Manifestations of Stress:
Recognizing the Warning Signs
All-Staff Training
Churchill High School
October 4, 2010
Montgomery County, MD:
• Montgomery County is one of the most affluent
counties in the US
• MC-Highest percentage(29.2%) of residents
over 25 who hold post-graduate degrees
• Parents expect their children to “be the best”
• Parents want to give their kids what they did not
have
• “Take as many as AP classes so you can so that
you get into good college.”
Churchill High School
• 98.6% graduates attend college
• Many are over-scheduled with extracurriculum activities: (art, music, athletics,
clubs, theatre, journalism.)
• Their talents are extremely impressive
• Some kids bite off more than they can chew
• >Academic stress is off the charts
• >Increasing % of school avoidance/refusal
The UPs and DOWNs of Adolescence
*Body Changes:
– Puberty
– Raging hormones/New sexual desires
– Separation/Individuation from Parents
– Schools /Friends Change
*Mood Changes:
It is normal for teen to feel moody, confused,
defiant, and reckless as they break rules, test
limits, and take risks >identity formation
Poor Impulse Control
• Teen’s judgment can be overwhelmed by the
urge for new experiences, thrill seeking, and
sexual and aggressive impulses.
• Seem driven to seek experiences that produce
strong feelings and sensations.
• In real life, adolescents compared to adults, find
it more difficult to:
– interrupt an action under way (stop speeding);
– to think before acting
– Choose between safer and riskier alternatives.
Neuroscience Explains the “WHY” *
• “Accidental deaths, homicides, and binge drinking
spike in adolescence.
• It’s when psychosis, eating disorders, and
addictions take hold.
• Surveys show that everyday unhappiness reaches
its peak in late adolescence.
• Scientific research reveals how teens’ unsettled
moods and unsettling behavior is rooted in uneven
brain development.” [Harvard Mental Health Letter]
Brain Development
• It’s not a question of intellectual maturity
• Studies show that by ages 15 or 16, a teen has
abstract reasoning, memory, and formal
capacity for planning.
• They can give the same answers as adults when
asked hypothetical questions about reward and
consequences.
• Yet, in real life, adolescents compared to adults,
find it more difficult to interrupt an action under
way (stop speeding.)
Prefrontal Cortex and the Amygdala
• Not mature until 20’s, last connections are
prefrontal cortex (which is seat of judgment
and problem solving) with the emotional
centers in the limbic system, especially the
amygdala.
• These links are critical for emotional learning
and high-level self-regulation.
The Power of Group
• Teens “find themselves” by identifying with a peer
group
• Teens make more risky decisions when friends were
watching.
• This dynamic is present in gang violence, reckless
driving and drinking that occurs in groups due to
group peer pressure.
• “Power in numbers”…..
Challenges ‘At-Risk’ Teens Face
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Anxiety
School Avoidance
Dropping Grades
Medical Illness
Pregnancy/STDs, HIV
Family Problems
Unemployed Parent
Separation/Divorce
Peer Pressure
Eating Disorder
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Substance Abuse
Sexual Orientation
Cyber-Bullying
Crime/Violence
Accidents
Running away/sneaking
out of house
• Depression
• Self Injury
• Suicide
2009 Study-Journal of Pain
• 382 high school students grades 8-12, mean age
14.4 yrs
• (223 female and 159 male) filled in
questionnaires
• Insecure adolescents feel more intense pain, and
are more likely to be anxious, depressed, and to
catastrophize.
• They have frequent headaches, stomach pain,
and joint pain.
• 20-25% experience chronic pain
Anxiety in Adolescents
*Generalized Anxiety:
persistent/excessive
worry, fears Worst Case
Scenario
*Panic Disorder-sweating,
pounding heart, difficulty
breathing, nausea,
stomach pains, dizziness,
lightheadedness, feeling
faint, fear of losing
control, going crazy, dying
*Phobia-dread and
avoidance of situations
*OCD-presence of recurrent,
persistent and unwanted
thoughts, impulses, or
obsessions; >performance
of repetitive behaviors:
washing, checking,
repeating.
*PTSD-experiencing a
traumatic causing fear,
horror, and hopelessness;
>recurring flashbacks,
dreams,+ startle reaction
Eating Disorders: Anorexia/Bulimia
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Obsessed with food/calorie intake
Withholding/Starving/Binging/Purging
Fear of food + fat/inability to stop once started
Excessive exercise
Avoidance of eating certain foods (i.e. fat)
Feels “in control” by starving/purging
Can cause Death/high suicide rate
Family history of eating disorders, bipolar,
alcohol/drug abuse
Drugs and Alcohol Abuse
• Many see using as a right of passage.
• “Everyone does it”=Peer pressure
• Using is an “instant ticket of acceptance” to
the “using/negative peer group.”
• Substance abuse is a form of anesthesia, a
way to not feel the anxiety that accompanies
aspects of a teen’s life.
Substances: Denial is a Symptom
*“It’s fun. It makes me feel better.”
• If Using Substances causes problems……..?
• Drugs/ alcohol is a central nervous system depressant
>“using” can cause depression. {Chicken or Egg?}
• A family history of alcohol /drug use increases the
probability for addiction for teen.
• Studies reveal how early drug use is correlated to
ongoing psychiatric conditions that develop later in
life.
Adolescent Depression
• Changes in eating habits
(weight loss/gain)
• Change in sleeping habits
• Loss of Interest in
activities
• Falling grades
• Poor concentration
• Withdrawal from family
and friends
• School refusal
• Crying/Irritability
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Chronic boredom
Drug/Alcohol abuse
Self Injury
Self Body Piercing
Increased sexual activity
Running Away
Grief
Guilt, shame, self
derogatory comments
• 20% of teens have
depression
Adolescent Self Injury
• Definition-Dr. Armando Favazza: 1987
author of ‘Bodies Under Siege’
* “a deliberate alteration of body tissue
without suicidal intent.”
• Daldin(1990): self-injury has aggressive as
well as sexual components.
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Teachers and Adolescent Self injury
• Classrooms of today are populated with
many teens who, to the untrained eye, may
appear to be emotionally healthy.
• Some of these seemingly well-adjusted
students tend to resort to maladaptive self
injury.
• High School Teachers must become more
aware of this growing problem.
Assessing Teacher’s Awareness/Knowledge of
S.I. + their Ability to Intervene
• 2004 Chicago Study seeks to address
• (a)the level of awareness and knowledge that teachers have about self
cutting behavior of adolescent studies and
• (b) how confident and prepared teachers feel they are to intervene with
a student with a self-injuring ,
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on, DeGeer, Deur, and Fenton
150 High School Teachers from 3 suburban Chicago high schools
Participants self-administered a questionnaire measuring current knowledge of adolescent self
injury
2004 Study Results
• The majority of the participants did not feel
knowledgeable or confident in their ability to
respond to self injury.
• Also, 85% felt that they would benefit from
more training
Adolescent Self Injury-[Galley, 2003)
• “It is crucial to be more alert to this behavior and
not accept without question flimsy explanations for
injuries like: “the cat scratched me, or I fell down
the stairs.”
• Teachers may be the first to notice symptoms of SI
and the first to approach a self injuring student.
• If teachers, who are on the front line, are made
aware of this growing problem, a move towards
preventing this “epidemic” will be made.”
Common Forms of Self Injury
• Cutting: most
common
• Burning
• Biting
• Scab picking
• Head Banging
• Hair-pulling
6/28/2016
• Scratching
• Self-hitting
• Interference with
wound healing
• Carving
• Breaking Bones
• (Briere & Gil, 1998; Ross &
Heath, 2002)
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Where do their body do they
self-harm?
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Arms
Legs
Wrists
Hands
Hips
Upper thighs
Areas within easy reach of dominant hand +
easily hidden with clothing
Functions of S.I:
• Control
• Distraction:“Physical Pain is Better than
Emotional Pain”
• Teen is DOING SOMETHING-focusing on
healing
• It proves they are alive
• “Every scar tells a story”
• Usually an attempt to stay alive, not die
Functions continued….
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Communication
Dissociation
Punishment
Proof that their pain is real
Proof of being alive-{Like George
Bailey in ‘It’s a Wonderful Life’}
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What are the warning signs of SI?
• Always wearing long
sleeves/pants>even in
hot weather
• Avoiding exposure to
body parts
• Refusal to wear shirtless,
shorts, bathing suit, or to
undress in front of others
• Wearing wrist bands.
wrist warmers, or sweat
shirts with thumb-hole
• Wearing inches of
bracelets to cover wrists
• New body piercings
appearing
• Frequent accidents
• Hiding knives, scissors,
pins, tacks, box cutters in
bedroom, purse,
backpack
• Unexplained bruises/cuts
with flimsy excuses
Typical SI Teen Profile
• Appear to be high performers: A’s, ace
athlete, actor, dancer, editor of paper, goal
oriented
• Perfectionists: one mistake is UNACCEPTABLE
• Always “FINE,” with smile on face
• “Its not OK for teen to NOT BE OK!”
• This student usually is THE LAST person that
teacher would have to worry about
Yet, Once Teen is ALONE
• No matter how many awards won, A’s achieved,
goals kicked, lead in plays given, field goals
kicked, newspapers edited, etc.
……..it is NEVER ENOUGH!
• Teen never feels good enough; because
comparing herself with others, she always falls
short.
• Since a picture is worth a thousand words……
They Fly Under the Radar
• They need to hide/deny their pain from adults
by literally “keeping it under wraps.”
• Always performing, teen has to prove their
value every day to the world, needing constant
validation.
• She is only as good as her last A.
• Getting a “B” means failure:
– Black and white thinking (all good/bad)
– Concrete thinking- “Needs to get the bad parts out”
Concrete Thinking
• Primitive Defenses:
– Splitting: black/white thinking, all good/bad
– If you don’t ask, she won’t tell
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(“I promise to not cut”)
Teen doesn’t trust self /own emotions
Unable to talk about /feel intense emotions
Speaks in “clipped fashion,” answers questions in one
word answers (yes/no)
• Feels empty-no object constancy, needs constant
reassurance >YOU feel THEIR emptiness
Making a Proper S.I. Risk Assessment
• “Have you ever in your life hurt yourself on
purpose?”
• “How old were you?” (when, where, what did
you use.)
• “Can you tell me about it?”
• “Why? What are your triggers?”
• “How many times in your life have you hurt
yourself on purpose?”
• “When was the last time you hurt yourself ?”
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Adolescent Suicide
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Suicide: The End Game
Many SI Teens flirt with the idea of suicide
3rd leading cause of death
Themes of death, dying, hopelessness, and
extreme violence can surface in suicidal’s
teens school work.
• Homosexual/gay/lesbian/transgender +
adopted teens have highest rates of suicide
Assessing for Acute Suicidality
• Assess for depression, helplessness,
hopelessness on a scale from 1-10.
• Suicidal ideation, plan and intent,
implementation and access to a means of
suicide, past suicide attempts
• Family history of suicide, depression, bipolar
disorder, alcoholism/drug abuse
• Recent stressors or losses that are triggers
What Should Teachers Do?
• This is real, not just a
teen being “emo.”
• Treat students with
respect and dignity
• Do NOT talk down or in
condescending manner
• Do NOT judge>LISTEN!
• They don’t want to be
treated like a baby or
with “kid gloves”
• Trust your gut feelings
• Make a referral to
school counselor
• Take this seriously , do
not minimize
• By reaching out and
caring, you could be
saving a life, yet you
might not ever know!
Be Aware of Counter-transference
• Be aware of your OWN emotional reactions
when listening to a student’s problems
• Common negative reactions (“I feel anger,
fear, confused, overwhelmed, manipulated.”)
• Reach out to colleagues, department head,
supervisor, counselor specialist for assistance
• Remember, teens who self injure are
“bleeding emotionally,”, but don’t have the
ability or words to tell you
Self-Monitoring
• White et al., 2003 suggested the importance for
school counselors to monitor their personal
reactions to disclosures of self injury and not
make decisions based on transference reactions
such as fear or a desire to control the student’s
behavior.
• Shame and embarrassment tend to accompany
this symptom, thus increasing the need to keep
their S.I. hidden & a “secret.”
• Avoid displaying shock, engaging in shaming,
punitive responses.
Whack-A-Mole
• Symptoms are addicting but move around
• Teen replaces s.i. with purging, with
pot/cough syprup (ROBO-ing)
• All are forms of “Self Medication”
• A way to Not FEEL PAIN!!!
• Anesthesia
Colored Bracelets
• Different colored bracelets make
announcements:
• Purple= pro-Bulimia (“Mia”)
• Red= pro-Anorexia (“Ana”)
• Orange=pro-Self-Injury
• Understand that these bracelets are
supporting illnesses that can result in death
“Can I Tell You a Secret?”
• If a Kid comes to you and says this……….
• Do NOT ENABLE THEM!!!!!!!
• Say: “It depends on what you tell me. I am here
to help you, so I can’t keep a secret that would
hurt you.”
• If they tell you they are suffering from any form
of SI or having suicidal ideation:
“Thank you for telling me. We are all here to help
you. Let’s go down to talk to your
counselor/school nurse.”
Who to Believe…….??
• A friend of Susie comes to you to express worry
about Susie, saying that Susie has been cutting
herself and is now having suicidal thoughts.
• You don’t know Susie. Susie gets great grades,
always has a smile on her face, and has a lot of
friends.
• When you ask Susie about it, she gets extremely
upset, seems to be insulted, and wants to know
who “ratted on her.”
• Who do you believe? What do you do?
ACCESS To GUNS:
Access to GUNS:
– ALWAYS ask high risk teen and (parents) if the teen has
ANY access to guns
• Tendency to assume that families in opulent Montgomery County
do not own guns, so we don’t usually ask.
• Depressed/bipolar teens who have access to guns are at high
risk for suicide.
• “The Washington Post 10/2007 study : nearly twice as many
people commit suicide in the 15 US states with the highest rates
of gun ownership than in the 6th states with the lowest rates of
gun ownership, although the population of the two groups is
about the same.
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Barriers to Effective Treatment:
Parental Denial
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My teen is “just going through a phase”
She will “grow out of it”
She “just wants attention”
‘Just Fix my kid, I’m NOT putting her on Medication!!!!….’
I am ‘letting my daughter stop the sessions because they
upset her too much. She’s always in a bad mood after.’
• Due to parent’s own fears, some will ‘refuse to support the
treatment or the use of medication’
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How Can You Help a Teen Who
Doesn’t Want Your Help?
• Create a Safe Environment for this hard to reach,
evasive population.
• If you see unexplained scars, ask open ended
questions in a calm and non-judgmental way.
• “What happened? Can you say more about
that? What was that like for you?”
• Be an active listener while “mirroring” their
emotions.
• Role model structure, consistency, and
predictability in your counseling relationship.
Barriers: Teen Denial
• It’s not a big deal……(I’m not worth it)
• Symptom of SI is ego-syntonic where teen is
wedded to it.
• “If it’s NOT BROKEN, WHY FIX IT?
• It’s my body, and I’m not hurting anybody.
[But you are hurting yourself]
– So what? I don’t care
– “BACK-OFF”…. “I DON’T NEED HELP!!!”
What IS the Definition of SUCCESS?
• In “Even Eagles Need a Push” the author
interviewed many famous people and asked
them if it was their fame or fortune that
made them feel successful?
• They gave a surprising answer:
• “To GIVE BACK to the Community.”
• “There are MANY ROADS that LEAD to
ROME.”
Make a Referral to Counseling Office
• Adolescent self injury is a “CRY FOR HELP”
• Teen is self-medicating when self injuring
• One episode of self injury is one time too
many
• Know resources for therapist/hospital who
specialize in the treatment of adolescent self
injury
ASIF
WWW.adolescentselfinjuryfoundation.
com
ASIF: Website began 2/2010
• Over 48,500 hits on the internet since 2/2010
• From 5 Countries
• This data shows how rates of Adolescent SI
are rising world-wide.
Spread the Word: How to Help
• Click on
www.adolescentselfinjuryfoundation.com
• Find ideas for: how to help S.I. teen, your SI
friend, first steps for parents to take, lists of
alternative behaviors to self injury!
• GOOD LUCK!