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
End of a relationship
Financial problems
Fight with a significant other
Recent move, social isolation
Legal problems
Family Problems
Academic problems
Substance abuse
Homosexuality
Recent abuse
Other stressors
20%
12%
10%
8%
7%
6%
6%
5%
4%
3%
4%
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
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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
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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 (selftimeout) 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
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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
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Anti - Worry Plan
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*What am I worried or afraid about?
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*How worried Am I?
2
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0
Not at all
1
A little
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*How do we know that things will be OK?
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*What can I do to help myself not worry so much?
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*What can I do to help myself not worry so much?
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*Is this something that I should worry about?
2
worried
3
A lot
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
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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
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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
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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
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“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
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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
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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
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Early-onset bipolar
Anxiety
OCD
Explosive aggression
 Mechanism of Action
 Multiple
 Enhance GABA
 Block glutamate
 Second messengers
Mood Stabilizers
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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
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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
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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
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Quetiapine (Seroquel)
Aripiprazole (Abilify)
Ziprasidone (Geodon)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Side Effects of Anti-psychotics
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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 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 Resources
• Massachusetts General Hospital School
Psychiatry Program
– www.schoolpsychiatry.org
Books
• One Mind at a Time by Mel Levine
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Psychopharmacology in pediatric OCD