Other Mental Health Issues that Impact Learning Stephanie Eken, M.D. Child and Adolescent Psychiatrist David Causey, Ph.D. Clinical Child Psychologist.

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

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

• 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

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

• Neurobiology– Dysregulation of serotonin & norepinephrine in

CNS– Influence of sex hormones

• Personality– Negative cognitive style

• Environmental factors– Abuse & neglect– Stressful life events– Family dysfunction

Genetics

• 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• Irritability (more common than depressed

mood)

• Boredom (anhedonia)

• Somatic complaints– Stomachaches & headaches most common

• Anxiety

• Indecision

• Temper tantrums & disruptive behavior

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

• 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?

• 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

• Behavioral or emotional response to a identifiable cause or stress

• Symptoms occur within three months of the stressor

• Symptoms cause marked distress

Adjustment Disorder

• Associated with:– Anxiety– Mixed anxiety and depressed mood– Disturbance of mood and conduct– Disturbance of conduct

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

• 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 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

• Increasingly diagnosed in children– Lifetime prevalence = 1%

• Risk factors– Early onset depression– Psychosis– Mood lability– Seasonal pattern– Family history of BD

Bipolar Disorder

• Increasingly diagnosed in children

• Genetics

• If untreated, children/adolescents are at risk for substance abuse, school failure, accidents, incarceration and suicide

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• 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• 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?

• 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 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

• Psychological interventions– Individual therapy (CBT)– Parent guidance sessions– School-based counseling

• Biological interventions– Medications

• Side effects may impact learning or behavior when starting medication

Childhood 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

• 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• Genetics

• Biologic – Central Nervous System (brain)

• Abnormal neurotransmitter functioning– Serotonin, norepinephrine, GABA receptors

• Psychological– Internal and external stressors overwhelm

coping abilities

Fear

• Alarm and agitation

• Caused by expectation or realization of danger

• A state of dread or apprehension

Webster’s II Dictionary, Third Ed.

Fear • 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

Anxiety• 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?

• 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

• 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• 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

• 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 Anxiety

• Expression varies with age

• Prepubescent children (5-8 years)– Clinging/shadowing behavior– Nightmares– Fear of loss of loved ones– School refusal

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

• 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 Phobia

• Exposure causes significant anxiety/panic

• Fear excessive and unreasonable

• Avoidance or endurance with extreme distress

• Interference in functioning

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

• 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

• 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

• 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 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

• Anti - Worry Plan

• *What am I worried or afraid about?

• *How worried Am I? 2

• 0 1 2 3Not 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?

Defiance & Aggression

Defiance

• 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

• 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

• 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

• 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

• 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):

“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

• 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• 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

• 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

• 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 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• 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

• “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

Positive Attention Things

• PATs

Treatment of Mood & Anxiety Disorders

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

• 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

• 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

• 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• 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

Medications

• Depression/Anxiety– Antidepressants

• SSRIs• Atypical antidepressants• TCAs

• Bipolar Disorder/Mood dysregulation– Mood stabilizers– Antidepressants

Antidepressants Mechanism of Action

Modulation of neurotransmitters Increase serotonin at 5-HT receptor Atypical antidepressants may modulate serotonin,

norepinephrine and dopamine Indications

Depression (unipolar/bipolar) Anxiety disorders Obsessive Compulsive Disorder Panic Disorder PTSD Bulimia Nervosa

SSRIs• 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

SSRIs 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

• 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

• 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 Box• Children and adolescents must be

monitored closely• School officials should notify parent if

student’s work reflects suicidal themes

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• 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

Indications Early-onset bipolar Anxiety OCD Explosive aggression

Mechanism of Action Multiple

Enhance GABA Block glutamate Second messengers

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

• Weight gain or loss

• Change in appetite

• Stomachaches

• Sedation

• Cognitive impairment– Especially Topamax (processing speed)

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 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• Weight gain

• Sedation

• Dyspepsia

• Impaired glucose tolerance

• Dyslipidemia – elevated cholesterol

• Hyperprolactinemia – gynecomastia, menstrual irregularities

• Long-term effects to CNS in children?

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 • 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• American Academy of Child and

Adolescent Psychiatry (aacap.org)“Facts for Families” handouts on many topicsLatest news on hot topics

• ParentsMedGuide.org Question and answer material about depression, suicide and black box warningLinks for parents and physiciansUp-to-date, well-organized, English-Spanish

Internet Resources

• Massachusetts General Hospital School Psychiatry Program– www.schoolpsychiatry.org

Books

• One Mind at a Time by Mel Levine