Mental Health in Schools

Jen Fielder, M.A.

Overview
Intro to mental health Mental health problems & disorders

Symptoms Educational implications and instructional strategies

Role of schools in addressing mental health Resources

Mental health definitions

Mental health

The achievement of expected developmental cognitive, social, and emotional milestones (NASP, 2003) The successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity (USDHHS, 2001)

Mental health on a continuum (Skalski & Smith, 2006)

Mental health definitions

Mental health problems: conditions for which signs and symptoms (are) of insufficient intensity or duration to meet the criteria for any disorder (USDHHS, 1999) Mental disorders: characterized by abnormalities in cognition, emotion or mood, or the highest integrative aspects of behavior (USDHHS, 1999)

Prevalence
About 20% of children are believed to have a mental disorder associated with at least mild impairment (USDHHS, 1999) Fewer than 1 in 5 children with some impairment receive needed treatment (USDHHS, 2001)

Surgeon Generals Conference on Childrens Mental Health

By 2020, childhood neuropsychiatric disorders will rise by over 50% internationally to become one of the 5 most common causes of morbidity, mortality, disability There is no mental health equivalent to the federal governments commitment to childhood immunization

Causes of mental health problems

Seen as an interaction between many factors

Biological

Biological (e.g., genes, toxins, temperament) Family (e.g., family relationships, parents with mental health problems) Psychological stress and life events (e.g., death, abuse, disasters/ traumatic events) Cognitive (e.g., attributions, cognitive distortions)

Cognitive

Mental Health Problems

Stress/ Traumatic Event

Family/ Social

Important factors affecting mental health today

Recession

Loss of job Tight budget Increased family stress

Family Illness Bullying Homelessness

Maslows heirarchy of needs

Homeless and At-Risk Youth

Homeless children between the ages of 617 struggle with high rates of mental health problems 1 in 3 homeless children have at least one major mental disorder compared to 1 in 5 children who are not homeless. More than one-fifth of homeless preschoolers have emotional problems serious enough to require professional care, but less than one-third receive any treatment

Homeless and At-Risk Youth

Almost half of children who are homeless have anxiety, depression or withdrawal compared to less than one in five other school-age children. And more than one in three children who are homeless manifest delinquent and aggressive behavior compared to less than one in five other school-age children.

Multicultural Differences in Mental Health

Ethnic minorities tend to be more wary of mental health services Minorities with mental health problems tend to experience more physical symptoms such as headaches or stomachaches

Consequences of mental health problems

Disruption of family life Decreased self-esteem Increased risk of emotional and/or physical abuse Disruption of normal development (e.g., delayed acquisition of social skills) Academic problems Poor attendance; increased risk of drop out Conflict with adults and peers, poor social relationships Increased risk of chemical abuse Increased risk of suicide attempts and suicide

(MACMH, 2004; Merrell, 2001; Skalski & Smith, 2006)

How are disorders diagnosed?

Licensed mental health professional Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR) Distinct from county and education classifications

Children/adolescents with psychiatric diagnoses may:

Severe Emotional Disturbance (SED): legal term, state and county classification Emotional Behavior Disorder (EBD): education term

be classified as having EBD or OHD receive accommodations from a 504 plan need no educational assistance

Symptoms vs. disorders

Symptoms: the behavioral or emotional characteristics associated with problems or disorders Syndrome: collection of symptoms Disorder: collection of symptoms meeting specific diagnostic criteria (DSM-IV)

(Merrell, 2001)

Mood disorders
Includes all types of depression, bipolar disorders Symptoms in children:

occur over an extended period of time interfere with daily life and impair functioning may vary across ages may differ from symptoms in adults

Depression
Prevalence: estimated 4-6% of children and youth (syndrome or disorder) Associated with other disorders besides major depressive disorder

Symptoms of depression in children and youth

(Merrell, 2001)

Depressed mood or excessive sadness Loss of interest in activities Failure to make expected weight gains Sleep problems Psychomotor retardation (or agitation) Fatigue or lack of energy Feelings of worthlessness or excessive guilt Difficulty thinking or making decisions Preoccupation with death Irritability Physical/somatic complaints

Age-related differences in symptoms of depression

Birth-3
-

feeding problems - apathy tantrums - lack of playfulness failure to thrive (with no known cause)
accident-prone - fearful, subject to phobias delays or regression in developmental milestones excessively apologetic for minor mistakes and problems

Ages 3-5
-

(Cash, 2004)

Age-related differences in symptoms of depression

Ages 6-8
-

aggression - clinginess avoidance of new people and experiences frequent vague physical complaints morbid thoughts - insomnia extreme worry about schoolwork frequent self-blaming

Ages 9-12
-

(Cash, 2004)

Educational implications
Decreased interest in schoolwork and activities Grades may drop due to lack of interest, motivation, or absences Withdrawal and refusal to socialize

Instructional strategies

(MACMH; Huberty, 2008)

Break tasks into smaller components Reassure students they can catch up and detail the steps necessary Encourage social interaction Avoid punishment, sarcasm, disparagement, negative techniques Adjust assignments without lowering expectations or standards Provide opportunities for success via peer mentoring, leadership Help students recognize and acknowledge positive contributions and performance

Cutting and Self-Harm

Occurs more often with young teenage girls Way to get relief from bad feelings Can be habit-forming Usually not a suicide attempt http://www.youtube.com/watch?v=mkiZZ HmW9f8

Surgeon Generals Suicide Data 1997

Rate for ages * 10-14 - 1.6 /100,000

* 15-19 - 9.7 /100,000

* 20-24 - 14.5 /100,000

For young people 15-24, suicide is third leading cause of death In 1996, more youth and young adults died from suicide than cancer, heart disease, AIDS, stroke, pneumonia, & birth defects COMBINED

Suicide Risk Factors

Mental health disorders Substance abuse Incarceration Family history of suicide Previous suicide attempts Feelings of hopelessness or loss Severe life stress

Suicide Prevention Plan

Important questions to ask:

Have you been thinking about killing yourself? Do you have a plan? Do you have the means to carry out your plan? Have you thought about where you might carry out the plan?

Notify parents immediately and ask that the child be taken to the hospital

Bipolar disorders

Disturbance in mood, behavior, energy, and sleep Characterized by alternating depressive and manic episodes

Distinguished from normal child development Significantly impair normal functioning in areas of selfcare, getting along with others, learning Rapid cycling: frequent alternating between periods of depression and mania

Controversy and uncertainty regarding diagnostic criteria and presentation of disorder in children

Bipolar disorders

http://www.youtube.com/watch?v=kKm5 26pnMSg

Symptoms of bipolar disorders

Manic episode: period of excessively elevated or irritable mood

inflated self-esteem - grandiosity increased distractibility - racing thoughts decreased need for sleep rapid, loud, uninterrupted speech increased goal-directed activity/psychomotor agitation excessive involvement in pleasurable or dangerous activities

Symptoms of bipolar disorders

Episode of depression: period of sad or irritable mood or clearly decreased interest/pleasure in activities
- significant appetite change - sleep problems - feelings of worthlessness - fatigue - concentration problems - excessive guilt - restlessness or slowed movement - preoccupation with death and/or suicide thoughts, plans, or attempts

Educational implications

(MACMH)

Fluctuations (e.g., hourly, daily, seasonally) in mood, energy, and motivation Difficulty concentrating, remembering assignments Difficulty understanding assignments with complex directions and comprehending long texts Intense emotions (i.e., sadness, embarrassment) Difficulty in social situations

Instructional strategies

Be flexible

Be prepared for episodes of intense emotion

Modify academic expectations based on fluctuations in mood, energy, attention Find a safe and private place for the student to go if/when she needs a break Create a private signal to communicate the need for a break during class Identify triggers to episodes and create a behavior plan to teach ways to deal with stress/frustrations

Recognize social skills difficulties

(Lofthouse et al., 2004)

Social skills instruction

Anxiety

General reaction to vague situation/stimulus (vs. fear & phobia) 3 areas of symptoms

subjective feelings (e.g., discomfort, fear) overt behaviors (e.g., avoidance, withdrawal) physiological responses (e.g., sweating, nausea)

Prevalence: estimated 3-4% Many disorders with anxiety as main feature http://www.youtube.com/watch?v=rUDjkEmHu0&feature=related

Symptoms of anxiety in children and youth

(Merrell, 2001)

Negative and unrealistic thoughts Misinterpretation of symptoms and events Panic attacks Obsessions and/or compulsive behavior Physiological arousal Physical/somatic complaints Fears and anxieties regarding specific situations or events Excessive worries in general

Educational implications

Excessive worry about homework and grades Difficulty completing work-- taking longer to finish or refusing to begin School avoidance Frequent absences Difficulties with concentration, memory, attention, organization of work, performance on tests Social difficulties

(MACMH; Hubert, 2008)

Instructional strategies

(Hubert, 2008)

Establish predictable routines post the daily schedule Set clear and reasonable expectations Break tasks into small, more manageable components Provide specific evaluation criteria Provide opportunities for practice and rehearsal Pair students with confident, supportive peers Give special responsibilities Provide time to relax when anxiety increases Decrease or avoid unexpected situations Relaxation exercises in the classroom Consider modifying the curriculum to match the learning style

Anorexia/Bulimia
Obsessive compulsive behavior associated with the fear of gaining weight Anorexia affects one in every 100 to 200 adolescent girls Reported rates of bulimia vary from one to three of every 100 young people

Post-Traumatic Stress Disorder

Can develop as a result of:

Abuse (physical, sexual, emotional) Neglect Homelessness Witnessing domestic violence

http://www.youtube.com/watch?v=5yq_Js MTypI&feature=related Symptoms can look like ADHD symptoms:

Restlessness/Hyperactivity Inability to concentrate

Attention-Deficit/Hyperactivity Disorder

Inattention and/or hyperactivityimpulsivity

AD/HD, Combined Type AD/HD, Predominantly Inattentive AD/HD, Predominantly Hyperactive-Impulsive

2 or more settings Causes impairment in social, academic, or occupational functioning Present before age 7

AD/HD

Inattention (6+ months)

-

Easily distracted - Frequently misplaces things Often forgetful - Makes careless mistakes Has difficulty sustaining attention in work or play Does not appear to listen when spoken to Does not follow through on instructions; fails to finish schoolwork, chores, etc. Has difficulty organizing tasks and activities
Blurts out answers before question is asked Has difficulty waiting for a turn Frequently interrupts or intrudes on others

Impulsivity (6+ months)

-

AD/HD

Hyperactivity (6+ months)

-

Often leaves seat during class - talks excessively Runs about or climbs in inappropriate situations On the go or appears driven by a motor Often fidgets with hands or feet

Educational implications
Difficulty staying on task and completing assignments Frequently lose books, supplies, homework May blurt out answers May be irritable, impatient, Accident-prone Lower self-esteem Disruptive behavior Poor social relationships; difficulty making friends Poor relationships with adults Poor academic performance (MACMA; Barkley, 2006)

Instructional strategies & interventions

(MACMA; DuPaul, Stoner, & OReilly, 2008)

Provide consistent structure and clearly defined expectations Break down tasks or directions into smaller steps and only give 1-2 steps at a time Take every opportunity to reinforce positive behavior Use a secret code to communicate to the student that she is off-task and needs to refocus Give the student numerous opportunities to move around Computer-assisted instruction Peer tutoring Token reinforcement programs Time-out from positive reinforcement Consider functional assessment-linked strategies

Disruptive Behavior Disorders

Includes Conduct Disorder, Oppositional Defiant Disorder Difficulty of diagnosis http://www.youtube.com/watch?v=_0jgX Dlf4rM&feature=related

Conduct Disorder

DSM-IV-TR: A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated Four types of behavior

Aggression to people and animals (e.g., bullying, frequent physical fights) Destruction of property (e.g., fire setting) Deceitfulness or theft (e.g., lying to teachers, stealing from peers, breaking into homes or businesses) Serious violations of rules (e.g., chronic truancy, frequently running away)

Educational implications
Frequent power struggles Consistently challenge class rules and expectations Refusal to complete assignments Impaired academic functioning Impaired social functioning; may argue and fight with other students

Instructional strategies

(MACMH)

Provide work at instructional level Avoid power struggles stay calm, respectful, detached Avoid escalating prompts (e.g., shouting, touching, nagging) Provide options avoid direct demands or statements (you must) Establish clear classroom rooms and enforce consistently Systematically teach social skills, such as anger management and conflict resolution Maintain neutral impressions communicate positive regard for the student

Self-Medication/Substance Abuse
Youth dealing with undiagnosed or untreated mental health problems are at greater risk for self-medicating and abusing illegal drugs The highest rates of substance use and abuse are seen in street youth, followed by sheltered youth and runaways, then housed youth

Early Identification and Treatment of Psychiatric Disorders as Prevention

ADHD Pharmacotherapy reduces risk for later substance use disorder (Biederman, et al, 1999) Bipolar disorders early identification of Bipolar Disorder in younger children reduces risk of later substance abuse over adolescent identification (Wilens et al, 1999) Opposition Defiant/Conduct Disorders early treatment of child, parent, family all decrease later substance abuse risk

Why should schools address mental health issues?

Mental health is essential to learning as well as to social and emotional development.

School systems are not responsible for meeting every need of their students. But when the need directly affects learning, the school must meet the challenge (Carnegie Task Force on Education of Young Adolescents, 1989) There is a wide gap between number of students who need services and the number who actually receive treatment

Because of this, schools must be partners in the mental health care of children (Presidents New Freedom Commission on Mental Health, 2003)

Why Put Mental Health Services in Schools?

Improve access: Its where the students are! Families more comfortable in school setting Minimize stigma issues Opportunities to observe and intervene directly in setting where most students time is spent Ability to collaborate and advocate directly for education needs of students

Schools: The Most Universal Natural Setting

Over 52 million youth attend 114,000 schools

Over 6 million adults work in schools Combining students and staff, one-fifth of the U.S. population can be found in schools

Role of schools
Addressing mental health needs on a continuum (UCLA)

Promote healthy social and emotional development and prevent problems for everyone Respond to psychosocial and mental health problems promptly Provide intensive care for severe, pervasive, and chronic problems

School Mental Health Programs and Special Education

Currently most school mental health professionals work only with special education students SBHCs may have a critical role to play in evaluation, recommendations, interventions, IEPs for special education On-site school mental health professionals are a resource for administrators struggling with difficult discipline issues School mental heath providers may give direct guidance to teachers in meeting student classroom needs

Promoting mental health for all

Whelley et al., 2004

Build protective factors

Sense of belonging, adapting to change, recognition, making a difference, resiliency and accomplishment

Implement evidence-based programs/curricula that target social/emotional issues and skill development

e.g., bullying prevention, social skills, conflict resolution

Mental health screening (natural vs. formal) See Childrens Mental Health: Strategies for Educators

Addressing mental health problems

Whelley et al., 2004

Know the signs

Educate staff Integrate mental health professionals in the school environment

Develop procedures for addressing potential problems Establish a crisis response team Provide evidence-based interventions to students with mental health needs Know community mental health resources

Find Children and Adolescents with Behavioral Health Problems Early and Treat Them
Prevent later special education referrals Reduce primary care and urgent care over utilization Decrease high risk behaviors including violence and substance abuse Improve educational outcomes Decrease the accidents, suicides, and homicides that are the public health mortalities for our children

School Mental Health Program Outcomes

Improved grades, attendance, and behavior in students Decreased inappropriate referrals to special education Improved school climate

Mental Health System Recommendations

All interventions should be school-based to increase access and decrease stigma Outreach and training in schools to identify youth with mental health problems Screening and assessment system within schools that includes a seamless link to services Evidencebased models of intervention

Recommendations
Skalski & Smith, 2006
Step 1: Build the capacity of staff members to respond to the mental health needs of students All staff interact positively with all students Staff are familiar with early warning signs of mental health problems Staff know what to do when students share sensitive personal information School policies and procedures help teachers and students respond to mental health needs

Recommendations
Skalski & Smith, 2006
Step 2: Hire adequate numbers of school mental health professionals and empower them to take leadership roles in the provision of mental health services in the school Consider recommended staff ratios School administrators and school-based mental health professionals work collaboratively to support students

Recommendations
Skalski & Smith, 2006
Step 3: Promote a continuum of services that includes school-wide mental health prevention programming and intensive interventions Prevention programs reach all students and target at-risk students Psychologists, counselors, social workers support students with significant needs and identified mental health conditions Schools partner with community professionals to address needs that exceed the capacity of school staff

Recommendations
Skalski & Smith, 2006
Step 4: Create opportunities to regularly assess the mental health needs of students and the effectiveness of school-based services Assess the mental health needs of students using both informal and formal methods School administrators and school-based mental health professionals work collaboratively to support students

Hennepin County Childrens Mental Health

Services for resident kids (under 18) with Severe Emotional Disturbance (SED) Front Door Access: (612) 348-4111

Info and referrals to mental health & social services Parents, guardians, school staff, community providers can call On-site crisis assessment and intervention services When in doubt, call!

Child Crisis Services: (612) 348-2233

Ramsey County Childrens Mental Health Services

Early Intervention Services/Project Assist

Project Enhance

651-266-4042 or 651-266-4045 Home-based mental health assessments and brief case management to infants, toddlers, and school age youth Referrals accepted from schools Eligibility based on mental health screening 651-639-4016 Assess, plan, arrange and monitor mental health services and supports for children and their families Resident kids with SED

Ramsey County Childrens Mental Health Services

Case Management

Childrens Crisis Services

651-266-4500 Develop treatment plans, make referrals, provide support to families Families of children with SED

Ramsey County Childrens Mental Health Collaborative

651-774-7000 On-site response to children in homes, schools, or institutions

http://www.rccmhc.org

Other resources

National Institute of Mental Health

www.nimh.nih.gov Information, resources smhp.psych.ucla.edu Training aids and tutorials www.macmh.org Fact sheets, parent & teacher workshops www.mentalhealth.samhsa.gov/child/childhealth.asp Mental health articles

UCLA Center for Mental Health in the Schools

MN Association for Childrens Mental Health

SAMHSA Child & Adolescent Mental Health Information

Other resources

National Association of School Psychologists (NASP)

www.nasponline.org Mental health articles, handouts for teachers and parents, other resources

Collaborative for Academic, Social, & Emotional Learning (CASEL)

www.casel.org SEL info, research support, program reviews www.search-institute.org/assets Developmental assets http://ies.ed.gov/ncee/wwc

Search Institute

What Works Clearinghouse

References

Cash, R.E. (2004). Depression in adolescents: When it really hurts to be a teenager. In A.S. Canter et al. (Eds.), Helping children at home and school II: Handouts for families and educators. Bethesda, MD: NASP. Cash, R.E. & Cowan, K.C. (2006). Mood disorders: What parents and teachers should know. Retrieved on 9/10/08 from www.nasponline/org/publications. DuPaul, G.J., Stoner, G., & OReilly, M.J. (2008). Best practices in classroom interventions for attention problems. In A. Thomas and J.Grimes (Eds.), Best Practices in School Psychology V (pp.1421-1437). Bethesda, MD: NASP. Huberty, T.J. (2006). Depression: Helping students in the classroom. In A.S. Canter et al. (Eds.), Helping children at home and school II: Handouts for families and educators. Bethesda, MD: NASP. Huberty, T.J. (2008). Best practices in school-based interventions for anxiety and depression. In A. Thomas and J.Grimes (Eds.), Best Practices in School Psychology V (pp.1473-1486). Bethesda, MD: NASP. Lofthouse, N., Mackinaw-Koons, B., & Fristad, M.A. (2004). Bipolar spectrum disorders: Early onset. In A.S. Canter et al. (Eds.), Helping children at home and school II: Handouts for families and educators. Bethesda, MD: NASP.

References

Merrell, K.W. (2001). Helping students overcome depression and anxiety. New York: Guilford Press. Minnesota Association for Childrens Mental Health (MACMH). Childrens mental health disorder fact sheet for the classroom. Retrieved on 9/10/08 from www.macmh.org. Minnesota Association for Childrens Mental Health. (2004). Unlocking the mysteries of childrens mental health: An introduction for future teachers. (Rev.Ed.). St. Paul, MN. Author. Skalski, A.K. & Smith, M.J. (2006). Responding to the mental health needs of students. Principal Leadership. U.S. Department of Health and Human Services (USDHHS). (1999). Mental health: A report of the Surgeon General, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. U.S. Department of Health and Human Services. (2001). Surgeon General releases a National Action Agenda on childrens mental health. Whelley, P., Cash, R.E., Bryson, D. (2004). Childrens mental health: strategies for educators. In A.S. Canter et al. (Eds.), Helping children at home and school II: Handouts for families and educators. Bethesda, MD: NASP.