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Other Mental Health Issues that Impact Learning. Stephanie Eken, M.D. Child and Adolescent Psychiatrist David Causey, Ph.D. Clinical Child Psychologist Square One: Specialists in Child and Adolescent Development. Mood Disorders:. Symptoms, Treatment, & Impact on Learning.

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other mental health issues that impact learning

Other Mental Health Issues that Impact Learning

Stephanie Eken, M.D.

Child and Adolescent Psychiatrist

David Causey, Ph.D.

Clinical Child Psychologist

Square One: Specialists in Child and Adolescent Development

mood disorders

Mood Disorders:

Symptoms, Treatment, & Impact on Learning

why should we care
Why Should We Care?
  • Mood disorders are prevalent and recurrent
  • May impact school performance
  • May present with physical symptoms
  • Poor psychosocial outcomes
  • High risk for suicide
  • High risk for substance abuse
epidemiology of depressive disorders
Epidemiology of Depressive Disorders
  • Preschool: <1%
  • School-age: 1-2%
    • Female-to-male ratio 1:1
  • Adolescence: 6%
    • Female-to-male ratio 2:1
  • Cumulative incidence by 18 yrs: 20%
  • Hospitalized children: 20%
  • Hospitalized adolescents: 40%
most common stressors leading to youth suicide in kentucky
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 6%

Family Problems 6%

Academic problems 5%

Substance abuse 4%

Homosexuality 3%

Recent abuse 4%

Other stressors 15%

etiology of depression
Etiology of Depression
  • Neurobiology
    • Dysregulation of serotonin & norepinephrine in CNS
    • Influence of sex hormones
  • Personality
    • Negative cognitive style
  • Environmental factors
    • Abuse & neglect
    • Stressful life events
    • Family dysfunction
  • Children with a depressed parent are 3 times more likely to have MDD
  • Children at high genetic risk may be more sensitive to adverse environmental experiences
depression in children
Depression in Children
  • Irritability (more common than depressed mood)
  • Boredom (anhedonia)
  • Somatic complaints
    • Stomachaches & headaches most common
  • Anxiety
  • Indecision
  • Temper tantrums & disruptive behavior
depression in adolescents
Depression in Adolescents
  • Irritable or sad mood
    • More likely to report a sad/depressed mood
  • Increased sleep and appetite
  • Increased suicidal ideation & attempts
  • Increased impairment of functioning
  • Increased behavioral problems
  • Decreased energy
  • Rejection sensitivity
psychosocial risk factors for depression
Psychosocial Risk Factors for Depression
  • Family problems
    • Conflict, maltreatment, parental loss/separation, parental mental illness
  • Comorbid psychiatric disorders
    • ADHD, anxiety d/o’s, conduct d/o, substance abuse
  • Recent adverse events
    • School, relationships, loss of social support
  • Personality traits
    • Anger, dependence, difficulty regulating affect
is he sad or depressed
Is he sad or depressed?
  • Feeling sad or “blue”
    • Temporary period in which a child feels sad in response to a major stressor
  • Children may have transient depressed mood states
  • Adjustment disorders to stressors
  • Depression is more severe, lasts longer and impacts functioning
adjustment disorder
Adjustment Disorder
  • Behavioral or emotional response to a identifiable cause or stress
  • Symptoms occur within three months of the stressor
  • Symptoms cause marked distress
adjustment disorder15
Adjustment Disorder
  • Associated with:
    • Anxiety
    • Mixed anxiety and depressed mood
    • Disturbance of mood and conduct
    • Disturbance of conduct
impact on learning
Impact on Learning
  • May change sleep or eating patterns
  • Difficulty concentrating/focusing
  • Social isolation
  • School behavior – fighting, arguments
  • Academic difficulties can lead to changes in mood
    • Consider an educational evaluation if treatment for depression does not resolve learning issues
school based interventions
School-based Interventions
  • Acknowledge the student’s feelings
  • Provide a place for students to regroup if they feel weepy or fatigued
  • Allow the student to stop an activity and resume it later when calm
  • Encourage positive self-talk and break tasks down
school based interventions18
School-based Interventions
  • Irritable Mood
    • Model appropriate responses to replace irritable responses
    • Allow the student to take him/herself out of a situation (self-timeout) when irritability is starting to disrupt others
    • May want to work independently
    • Provide opportunities for the student to "fix" problems or inappropriate classroom behaviors
  • Fatigue
    • Provide class notes to the student
    • Identify study partners who can support and assist with assignments
    • Grade the student based on work completed or attempted (rather than work assigned)
bipolar disorder
Bipolar Disorder
  • Increasingly diagnosed in children
    • Lifetime prevalence = 1%
  • Risk factors
    • Early onset depression
    • Psychosis
    • Mood lability
    • Seasonal pattern
    • Family history of BD
bipolar disorder20
Bipolar Disorder
  • Increasingly diagnosed in children
  • Genetics
  • If untreated, children/adolescents are at risk for substance abuse, school failure, accidents, incarceration and suicide
bipolar disorder21
Bipolar Disorder
  • Neurobiology
    • Neurotransmitters
    • Neuroimaging shows subtle differences in frontal lobe and amygdala volume
  • Genetics
    • One parent with BD = 25% risk
  • Environmental factors
    • May potentiate genetic predisposition
    • Stressors
    • Low maternal warmth
bipolar disorder in children
Bipolar Disorder in Children
  • Mood may shift rapidly
    • Minute-to-minute
    • Day-to-day
  • May present as chronic irritability or explosiveness with no discernible pattern or periods of wellness
  • Different from depression by the presence of mania
    • 20% of depressed children will go on to develop bipolar disorder
mania in children
Mania in children
  • Excessive irritability
  • Excessively giddy or silly
  • Aggressive behaviors
    • Extended, rageful tantrums
    • Physically aggressive
  • Restless or persistently active
  • Age-inappropriate sexual interests
  • Grandiosity
how does it impact school
How does it impact school?
  • Fluctuations in cognitive abilities
  • Impaired ability to plan, organize, concentrate and use abstract reasoning
  • Heightened sensitivity to perceived criticisms
  • Hostility or defiance with little provocation
  • Emotions disproportionate to situation
school based interventions26
School-based Interventions
  • Develop a simple explanation that the student and staff can use with peers and teachers
  • Accommodate tardiness
  • Allow the student to complete schoolwork or tests in a less stimulating environment
  • Seat the student where the teacher can monitor, but not where the student is the focal "center of attention"
  • Limit homework to a feasible amount during manic periods
  • Allow the student to have homebound instruction during manic periods
  • Allow children to discreetly and frequently accommodate needs caused by medication side effects
treatment for mood disorders
Treatment for Mood Disorders
  • Psychological interventions
    • Individual therapy (CBT)
    • Parent guidance sessions
    • School-based counseling
  • Biological interventions
    • Medications
      • Side effects may impact learning or behavior when starting medication
anxiety disorders
Anxiety Disorders
  • Medical condition that causes people to feel persistently, uncontrollably worried over an extended period of time
  • Limit children’s ability to engage in a variety of activities
epidemiology of anxiety disorders
Epidemiology of Anxiety Disorders
  • Most common emotional/behavioral disorder in childhood
  • Incidence 10-15% of children/adolescents
  • Female-to-male ratio
    • Equal in preadolescent children
    • Females are increasingly represented in adolescent years
etiology of anxiety
Etiology of Anxiety
  • Genetics
  • Biologic
    • Central Nervous System (brain)
      • Abnormal neurotransmitter functioning
        • Serotonin, norepinephrine, GABA receptors
  • Psychological
    • Internal and external stressors overwhelm coping abilities
  • Alarm and agitation
  • Caused by expectation or realization of danger
  • A state of dread or apprehension

Webster’s II Dictionary, Third Ed.

  • Immediate alarm reaction
  • Basic, normal emotion
  • Essential to alert to imminent danger
    • Focuses attention
  • Prepare to respond: Flight or Fight
    • Pounding heart, rapid breathing, muscle tension, sweating
  • Consolidate experience to memory
    • To learn appropriate response
  • Apprehension of danger and dread
  • Accompanied by
    • Restlessness
    • Tension
    • Rapid heart rate
    • Shortness of breath
  • Unattached to a clearly identifiable stimulus
when is anxiety pathologic
When is anxiety pathologic?
  • Intensity of anxiety
    • Out of proportion to threat
  • Frequency of anxiety
    • Increase in fear reaction and cannot be “reasoned away”
  • Content of anxiety
    • Seemingly innocuous situation or stimulus
children with anxiety disorders
Children with Anxiety Disorders
  • Risk for developing other types of anxiety disorders/or psychiatric disorders
  • Comorbid psychiatric disorders
    • Young children with GAD can also suffer from separation anxiety
    • Depression can accompany the feeling of generalized anxiety
    • Increased risk for adjustment difficulties in adulthood
generalized anxiety disorder
Generalized Anxiety Disorder
  • Worry, worry, and more worry
    • About – family, friends, health of others, natural disasters, school performance, etc.
  • Somatic concerns
    • Headaches, feeling shaky, sweating
  • Not easily reassured
  • May throw tantrums related to anxiety
  • Poor concentration and attention
    • May present for ADHD work-up
separation anxiety
Separation Anxiety
  • Excessive anxiety focused on separating from home or parent figure
  • Most commonly diagnosed in prepubertal children
    • More common in 5-7 and 11-12 year olds with transition into elementary and middle school
  • Typically occurs following a significant change or major life event
separation anxiety39
Separation Anxiety
  • Expression varies with age
  • Prepubescent children (5-8 years)
    • Clinging/shadowing behavior
    • Nightmares
    • Fear of loss of loved ones
    • School refusal
separation anxiety40
Separation Anxiety
  • Preadolescent (9-12 years)
    • Emotional distress of separation
      • Staying away from home overnight
  • Adolescents (13-16 years)
    • Somatic difficulties
    • School refusal
social phobia
Social Phobia
  • Excessive fear in social situations where child is exposed to unfamiliar people/evaluation by others
  • Excessively self conscious/shy
  • Tremendous concern about social failure/embarrassment/humiliation
social phobia42
Social Phobia
  • Exposure causes significant anxiety/panic
  • Fear excessive and unreasonable
  • Avoidance or endurance with extreme distress
  • Interference in functioning
selective mutism
Selective Mutism
  • Children either talk minimally or not at all in certain settings or situations that are part of their daily lives (e.g., school)
  • Reflects underlying problems with anxiety
  • Often inadvertently reinforced by other individuals (i.e., parents, friends) in the child’s daily life (e.g., speaking for the child, permitting the use of nonverbal communication, etc.).
  • Considered an extreme form of social phobia
panic attacks
Panic Attacks
  • Sudden, discrete episodes of intense fear
  • Intense desire to escape
  • Feeling of doom
  • Activation of autonomic nervous system
    • Fight or flight
  • Duration 20-30 minutes
panic disorder
Panic Disorder
  • Recurrent panic attacks
  • Inter-episode worry about having a panic attack
  • Worry about implications and consequences
  • Changes in behavior
  • More common in adolescents
anxiety at school
Anxiety at School
  • Frequent self-doubt and criticism
  • Seeking constant reassurance from the teacher
  • Difficulty transitioning between home and school
  • Avoidance of academic and peer activities
  • Poor concentration
school based interventions47
School-based interventions
  • Accommodate late arrivals
  • Shorter school days to transition children with separation anxiety
  • Allow extra time for transitions
  • Provide alternative activities for children with somatic complaints
  • Have a “safe” place if child develops increased anxiety or panic attacks
  • Have an anti-worry plan
components of a simple anti worry plan
Components of a Simple Anti-Worry Plan
  • Anti - Worry Plan
  • *What am I worried or afraid about?
  • *How worried Am I? 2
  • 0 1 2 3

Not at all A little worried A lot

  • *How do we know that things will be OK?
  • *What can I do to help myself not worry so much?
  • *What can I do to help myself not worry so much?
  • *Is this something that I should worry about?
  • When is defiant behavior not really defiance to an authority figure….Never
  • When is defiant behavior a result of something other than a defiant attitude?...When it’s a coping response to an underlying vulnerability, frustration, or disappointment (“solution” versus problem)
two types of aggression
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.
cognitive distortions in angry youth
Cognitive Distortions in Angry Youth
  • Appraisal of internal arousal
  • Cue Utilization
  • Attributions
  • Social Perceptions (self and others)
  • Generating problem-solving solutions
  • Considering Consequences
  • Implementing Solutions
  • Situational Appraisals
adult issues that may escalate an anger outburst
Adult Issues That May Escalate an Anger Outburst
  • The adult’s mood at that moment
  • Feelings of helplessness in managing difficult situations
  • Expectations (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.
specific adult behaviors that may increase the likelihood of an anger outburst
Specific adult behaviors that may increase the likelihood of an anger outburst
  • Too quick to say “no”
  • Quick to anticipate a conflict
  • Quick to raise voice or yell
  • Interpret behavior as intentional
  • Don’t set limits when necessary
  • Too strict with limits-can’t follow through
  • Coercive Process
situational factors possible anger triggers
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.

specific student issues that may increase the likelihood of an anger outburst
Specific student issues that may increase the likelihood of an anger outburst
  • Experiencing frustration and worry – interpret anger
  • The occurrence of a real or perceived threat and/or adverse event
  • Being teased, bumped in the hallway, threatened by another youth, etc.
  • Obstacles to getting or doing what they want or expect
  • Not feeling heard or understood
  • Denied requests – don’t like to hear “no”
  • Feeling unimportant and insignificant – such as being left out of something
  • Some injustice occurs – e.g., the youth gets into trouble for something they didn’t do or didn’t initiate.
other high risk situations
Other “High Risk” Situations
  • Medications wear off
  • Blamed unjustly
  • Academic frustration
  • Embarrassed over a grade
  • Picked on
  • *Angry from home (“Carry Over”)
purpose process in good anger control plans
Purpose / Process in good anger control plans
  • Better self-regulation
  • Effective use of language
  • “Interactive Coping” – working with the student while maintaining authority
  • “Firm Flexibility” – adult must be firm, clear, and consistent while ALSO being flexible, supportive, and collaborative with the student when appropriate.
things to consider explore or examine when developing an anger plan
Things to consider, explore, or examine when developing an anger plan
  • Clarification of the concerns or problems
  • What’s behind the anger (feelings, issues)
  • Ideal alternative attitudes and behaviors
  • Benefits to them of positive behaviors and attitudes
  • Costs to them of negative attitudes and behaviors
  • High risk situations, antecedents (people, places, times, etc.)
things to consider explore or examine when developing an anger plan60
Things to consider, explore, or examine when developing an anger plan
  • Things that can be done to prevent frustration when entering a high risk situation
  • Things that can be done when frustration is present and/or escalating (i.e., 3-7)
  • Calm down actions or de-escalation strategies that can and can’t be done
  • Ways the adult can help with high-risk times
  • Reinforcements and consequences if any
  • Regular time to review how things are going
  • Discussion of problem possibilities
  • Completion of problem-solving sheet
mistakes adults sometimes make
Mistakes adults sometimes make
  • Setting too many goals at one time
  • Setting goals that are too lofty; it is sometimes better to begin with smaller more attainable goals, than to start with the obvious problem that needs to be eliminated.
  • Measuring success by an absence of the problem, rather than recognizing a reduction in the problem.
  • Scrapping a plan because “its not working”.
  • Assuming the plan isn’t working because the youngster isn’t trying or doesn’t care about doing better.
key parts to a problem solving plan
Key Parts to a Problem-Solving Plan
  • “High risk” situations
  • Feelings when this happens
  • Angry thoughts that worsen my anger:
  • What to do:
    • Identify the problem
    • Use good self talk
    • Coping strategies
  • What others can do to help
  • Evaluate the process or how it could turn out
talking with parents
Talking with Parents
  • Need to involved parents when the student experiences significant academic, social or emotional difficulties that interfere with learning
  • Develop a shared understanding of child/adolescent
    • Ask parents if they see concerning emotional or behavioral problems at home
  • Parents may have effective strategies they use at home that can be implemented in the classroom
when to refer for further evaluation
When to refer for further evaluation
  • Impact on learning
  • Effecting social interactions
  • Safety concerns
    • Suicidal statements
    • Threats toward others
    • Concern for abuse/neglect
  • Typical interventions do not work
choosing initial treatment
Choosing Initial Treatment
  • Psychotherapy
    • Individual
    • Family – parental educations
  • Psychopharmacologic Intervention
    • Patients unable to participate in therapy due to severity of symptoms
    • Comorbidity with other psychiatric illnesses
    • Symptoms that do not respond to therapy
goals of treatment
Goals of Treatment
  • Safety
  • Build alliance & instill hope
  • Clarify diagnosis
  • Assess comorbidity (substance abuse, medical illness, other psych d/o’s)
  • Assess motivation for treatment
  • Availability of resources (e.g., partial hospital, day tx programs, outpt. tx)
  • Treatment is multimodal
  • Pharmacotherapy alone not effective due to psychosocial context of illness
  • Address family, school, peer issues
  • Psychotherapy for mild to moderate mood disorders (CBT, IPT, family therapy, psychodynamic)
  • Consider medications
  • Depression/Anxiety
    • Antidepressants
      • SSRIs
      • Atypical antidepressants
      • TCAs
  • Bipolar Disorder/Mood dysregulation
    • Mood stabilizers
    • Antidepressants
  • Mechanism of Action
    • Modulation of neurotransmitters
      • Increase serotonin at 5-HTreceptor
      • Atypical antidepressants may modulate serotonin, norepinephrine and dopamine
  • Indications
    • Depression (unipolar/bipolar)
    • Anxiety disorders
    • Obsessive Compulsive Disorder
    • Panic Disorder
    • PTSD
    • Bulimia Nervosa

First-line medication for depressive and anxiety disorders

No evidence that one SSRI is superior to another

SSRIs take 4-6 weeks to determine efficacy of dose

Fewer side effects than older antidepressants

  • FDA approved in children & adolescents
    • Fluoxetine
      • Depression (age 8 and over)
      • OCD (age 7 and over)
    • Sertraline (Zoloft) – OCD (age 6 & over)
    • Fluvoxamine (Luvox) – OCD (age 8 & over)
  • Significant portion of psychiatric medications are prescribed “off-label” for use in pediatric population
  • Off label use
    • Paroxetine (Paxil)
    • Citalopram (Celexa)
    • Escitalopram (Lexapro)
ssri side effects that may impact learning
SSRI Side Effects that May Impact Learning
  • Common
    • Gastrointestinal – dyspepsia, diarrhea
    • CNS – headache, anxiety, insomnia
    • Increased sweating
  • Uncommon
    • Akasthisia (inner feeling of restlessness)
    • Agitation
    • Mania (may occur in children with BD)
  • May need to add additional agent to manage side effects
antidepressant black box
Antidepressant Black Box
  • The most serious warning possible on drug packaging in the USA
  • To apply to ALL antidepressants for children and adolescents < 25 yrs old
  • Explicit about the increased risk of suicide especially during the early phase of tx
  • No completed suicides in studies reviewed
  • Review of studies showed increased suicidal thoughts (2% to 4%) through adverse event reporting
antidepressant black box78
Antidepressant Black Box
  • Children and adolescents must be monitored closely
  • School officials should notify parent if student’s work reflects suicidal themes
other antidepressants
Other Antidepressants
  • SNRIs
    • Modulate serotonin and norepinephrine transmission
  • Atypical Antidepressants
    • May modulate serotonin, norepinephrine, and dopamine
  • Can be used as single agent or as augmentation strategy with SSRI or other psychotropic
  • Fewer studies in children & adolescents
  • No FDA approved SNRIs in pediatric OCD
side effects
Side Effects
  • SNRIs
    • Venlafaxine (Effexor)
      • Elevated B/P - diastolic
    • Duloxetine (Cymbalta)
      • Blurred vision, mydriasis (dilated pupils – can affect vision)
  • Atypical Antidepressants
    • Mirtazapine (Remeron)
      • Sedation
      • Weight gain
      • No sexual side effects
mood stabilizers
Mood Stabilizers
  • Indications
    • Early-onset bipolar
    • Anxiety
    • OCD
    • Explosive aggression
  • Mechanism of Action
    • Multiple
      • Enhance GABA
      • Block glutamate
      • Second messengers
mood stabilizers83
Mood Stabilizers
  • Depakote
  • Lithium
  • Oxcarbazepine (Trileptal)
  • Gabapentin (Neurontin)
  • Topirimate (Topamax)
    • Migraine prophylaxis
    • Psychiatric indications
      • Mood stabilization
      • Augmenting agent for treatment resistant OCD
side effects that may impact school
Side Effects that may Impact School
  • Weight gain or loss
  • Change in appetite
  • Stomachaches
  • Sedation
  • Cognitive impairment
    • Especially Topamax (processing speed)
atypical antipsychotics
Atypical Antipsychotics
  • Mechanism of action
    • 5HT2A/D2 receptor antagonism
    • Less TD and EPS symptoms than 1st generation
  • Indications
    • Psychosis/psychotic depression
    • Mood stabilization – bipolar, mood dysregulation
    • Aggressive behaviors – autism, MR, DD
    • Augmenting agent for OCD
    • Conduct problems
    • Severe tic disorders
atypical antipsychotics86
Atypical Antipsychotics
  • FDA approved
    • Risperidone (Risperdal)
      • Treatment of irritability associated with autism in children 5 years of age and older
      • Schizophrenia (13 years and older) and bipolar disorder in children (10 years and older)
  • Off label use
    • Quetiapine (Seroquel)
    • Aripiprazole (Abilify)
    • Ziprasidone (Geodon)
    • Olanzapine (Zyprexa)
    • Paliperidone (Invega)
side effects of anti psychotics
Side Effects of Anti-psychotics

Weight gain



Impaired glucose tolerance

Dyslipidemia – elevated cholesterol

Hyperprolactinemia – gynecomastia, menstrual irregularities

Long-term effects to CNS in children?

serious side effects
Serious Side Effects
  • Acute Dystonia
    • Spastic contraction of discrete muscle groups
      • Most common – neck, tongue, eyes
    • Risk factors – young, male, medication initiation or dose increase
  • Extrapyramidal symptoms
    • Related to dopamine blockade in nigrostriatal pathway
      • Akathisia & parkinsonism
school role with medication
School Role with Medication
  • Part of treatment team
  • Observations of student during school invaluable
  • Dispense medication
  • Medication or side effects may impact behavior or learning
  • Impact on parent attitude toward medication
internet resources
Internet Resources
  • American Academy of Child and Adolescent Psychiatry (aacap.org)

“Facts for Families” handouts on many topics

Latest news on hot topics

  • ParentsMedGuide.org

Question and answer material about depression, suicide and black box warning

Links for parents and physicians

Up-to-date, well-organized, English-Spanish

internet resources91
Internet Resources
  • Massachusetts General Hospital School Psychiatry Program
    • www.schoolpsychiatry.org
  • One Mind at a Time by Mel Levine