Bringing Health Care to Schools for Student Success
Integrating Mental Health Into Your
Primary Care Practice
Margaret Bavis, DNP, FNP-BC
Sue Murray, RN, MPH
In collaboration with Sharon Stephan, PhD
Center for School Mental Health
NASBHC Training of Trainers
September 20-23, 2008
1
Ice-Breaker
2
Workshop Objectives
Participants will be able to:
• Name at least two strategies for improving primary
care-mental health collaboration in school-based
health centers.
• Identify at least one screening instrument to screen
for anxiety, depression, disruptive behavior
disorders, and strengths and difficulties.
• Identify possible mental health diagnoses based on
a list of presenting symptoms.
3
Workshop Objectives (continued)
Participants will be able to:
• Identify at least two core skills for treating
anxiety and depression.
• Identify at least two strategies to improve
mental health referrals and documentation.
4
Workshop Outline
Mental health and primary care integration
and collaboration
 Risk and protective factor assessment
 Mental health screening tools
 Diagnostic review
 Treatment, referrals and follow-up
 Resources

5
Definitions



Primary Care and Mental Health Integration integrating mental health practice into primary care
services
Collaborative Care – primary care and mental health
providers working collaboratively to provide quality
health and mental health care
Interdisciplinary Practice - mutual respect and
coordination of care between SBHC staff and other
health professionals practicing in schools, including
nurses, nutritionists, as well as mental health and other
counseling professionals, see position statement at:
http://www.nasbhc.org/atf/cf/{CD9949F2-2761-42FB-BC7ACEE165C701D9}/Advocacy%20interdisciplinary%20pos.%20s
tatement.pdf
6
Primary Care Providers –
Why should I be doing mental health?

I don’t have time

I’m not trained

I don’t like doing mental health work
7
Importance of Mental Health Services in
School-Based Health Centers
•
•
•
•
In studies of SBHC service utilization, mental health counseling is
repeatedly identified as the leading reason for visits by students.
Approximately 1/3 to 1/2 of all visits to SBHCs are related to
mental health problems.
Only 16% of all children receive any mental health services. Of
those receiving care, 70-80% receive that care in a school setting.
Schools are the “de facto” mental health system for children
and adolescents.
SOURCE: (1) National Assembly on School-Based Health Care. Creating Access to Care for Children and Youth: School-Based Health Center
Census 1998-1999. June 2000. (2) Jellinek M, Patel BP, Froehle MC, eds., Bright Futures in Practice: Mental Health—Volume II. Tool Kit.
Arlington, VA: National Center for Education in Maternal and Child Health. (4) Center for Health and Health Care in Schools, Children’s Mental
Health Needs, Disparities, and School-Based Services: A Fact Sheet.
8
SBHC Staffing Models
(N=1235)
Primary Care
Mental Health
Plus
31%
Unknown
4%
Primary Care
Only
31%
Primary CareMental Health
34%
9
Mental Health Services in SBHCs With (n=655)
and Without (n=277) Mental Health Providers
*Other
*Conflict Resolution/Mediation
*Tobacco Use Counseling
*Substance Use Counseling
*Referrals
*Skill-Building
*Case Management
*Medication Management/Administration
*Long Term Therapy
*Brief Therapy
*Mental Health Diagnosis
*Screening
*Assessment
*Psycho-education
*Grief and Loss Therapy
* P<.01
*Crisis Intervention
0
10
20
30
40
With Me ntal He alth Provide r
50
60
70
80
Without Me ntal He alth Provide r
90
100
10
Strategies for Improving
Collaborative Care in SBHCs








Collaborative screening and assessment
Chart/documentation
Information sharing between mental health and
primary care providers
Interdisciplinary case conferences
Multidisciplinary training
Co-facilitation of student groups
Joint presentation of in-services to school staff
Efficient, reliable, informative referral process
11
Mental Health Problem Identification

Comprehensive Risk and Protective Factor
Assessment

Mental Health Screening

Mental Health Diagnosis
12
Assessment and Screening
 Shouldn’t only mental health
providers assess and screen
for mental health?
13
Assessment of Risk and
Protective Factors
14
What assessment tools is your
SBHC using???
15
During an office visit…

Comprehensive
Risk Assessment

Asset Checklist

Stress/Risk Factor
Assessment
75
16
Risk Assessment
A
comprehensive annual risk
assessment and biennial
physical exam are essential to
detecting and addressing all
important health concerns of the
student.
-NASBHC CQI Tool
17
Risk Assessment
Must be developmentally appropriate and is
expected to cover:






injury
safety
violence
diet and exercise
dental
substance use and
passive exposure






abuse
family relationships
school
friends
mood and emotional
health
sexuality
- NASBHC CQI Tool
18
Risk Assessment Tools

Guidelines for Adolescent Preventive
Services (GAPS)
http://www.ama-assn.org/
ama/pub/category/1980.html

Bright Futures
http://www.brightfutures.org

American Academy of Pediatrics
http://www.aap.org/policy/periodicity.pdf
19
Risk Assessment Tools

Pediatric Symptom Checklist
http://www.massgeneral.org/psc

Child Health and Illness Profile
(CHIP)
http://chip.jhu.edu
20
HEADSS interview
 Home
 Education
 Activity
 Diet
 Safety
 Sexuality
21
The Asset Checklist
 Self-report
 40
developmental assets
 Identifies qualities in youth that can
be enhanced to promote resiliency.

http://www.searchinstitute.org/assets/assetlists.html
22
Stress-Risk Factor
Assessment

Ask
– “What 3 things do you think are causing you the most
stress lately?”;
– “What 3 things do you think are causing your family the
most stress lately?”
– “What 3 things do you think are most stressful about
your school?”
– “What 3 things do you think are most stressful about
your neighborhood?”
23
Considerations In Assessment
Selection








Be sensitive to age, sex, language, and
culture
Be relevant to their needs or risk factors
Practicality of implementing in your
practice
Instruments should be “user friendly”
Capture the information you need
Be measurable
Fit with your style of practice
There is no best way
24
How do you conduct the risk
assessment?




Paper and pencil – done by student
Computer based
Provider interview of student at the time
of the examination
Provider interview of student at a time
apart from the examination
What works in your setting?
25
Documentation of Risk and
Protective Factors

Documentation may take many
forms…
– Inclusion of strengths/assets/protective
factors in intake evaluation, progress
notes, and/or treatment plan
– Checklist of risk and protective factors
– Assessment instruments (e.g.,
comprehensive risk assessment, asset
checklist, etc.)
26
Getting the assessment done:
Distribution of work
Identifying components of the work
 Identifying team roles
 Shared Responsibility
 Staff Training

27
Screening Instruments
28
Screening Instruments –
public domain (aka FREE)
General Mental Health – Strengths and Difficulties
– Strengths and Difficulties Questionnaire
 Disruptive Behavior Disorders/ADHD
– Parent/Teacher Disruptive Behavior Disorders Rating Scale
– Vanderbilt Scales
– Disruptive Behavior Disorders Structured Parent Interview
 Depression:
– Center for Epidemiological Studies Depression Scale for
Children (CES-DC)
 Anxiety:
– The Spence Children’s Anxiety Scale (SCAS)

29
Strengths and Difficulties
Questionnaire


25-item self-report screening of strengths and
difficulties for 3-16 year olds
5 subscales:
–
–
–
–



Emotional symptoms
Conduct Problems
Hyperactivity/inattention
Peer relationship problems
Prosocial Behavior
Used as initial screener and/or measure of
treatment progress
FREE! – available at http://www.sdqinfo.com/
30
Parent/Teacher Disruptive
Behavior Disorders Rating Scale
Disruptive Behavior Disorders
 45 items
 FREE! – available at
http://128.205.76.10/DBD.pdf
 Parent and Teacher report
 Subscales for:

– ADHD, ODD, CD
31
Vanderbilt Scales
Parent and teacher versions
 Also screens ODD, Conduct
Disorder, and Anxiety/Depression
 Easy to score
 FREE! – available at
http://www.nichq.org/resources/tool
kit/

32
Disruptive Behavior Disorders
Structured Parent Interview
Based on DSM criteria
 FREE! – available at
http://128.205.76.10/DBDInterv.pdf
 Subscales for:

– ADHD, ODD, CD
33
Center for Epidemiological Studies
Depression Scale for Children
(CES-DC)

20-item self-report depression inventory

Used as initial screener and/or measure of
treatment progress
FREE! – available at
http://www.brightfutures.org/mentalhealth/pdf
/professionals/bridges/ces_dc.pdf

34
Center for Epidemiological Studies
Depression Scale for Children
(CES-DC)

Possible scores ranging from 0-60

Scale from 0 (Not at all) – 3 (A lot)

Developers indicate a cutoff score of 15 as
suggesting depressive symptoms in children
and adolescents.

Scores over 15 may be indicative of
significant levels of depression
35
The Spence Children’s Anxiety Scale
(SCAS)


38 anxiety items
Overall measure of anxiety with 6 subscales
tapping specific aspects of anxiety
–
–
–
–
–
–

Panic attack/agoraphobia
Separation anxiety
Physical injury fears
Social phobia
Obsessive compulsive
Generalized anxiety/overanxious disorder
FREE! – available at
http://www2.psy.uq.edu.au/~sues/scas/

Parent and Child versions available
36
Screening Discussion

In your SBHC, what factors would you
need to consider if you were to implement
mental health screening?
–
–
–
–
Who would do the screening?
When?
Who would score?
Who can diagnose?
37
Diagnosis
Who me?… Diagnose?
38
Diagnosis

DSM IV-TR (Diagnostic and Statistical manual,
fourth edition, text revised)
– Contains mental health diagnoses, as well as all the
criteria needed to make the diagnosis
– Created by a panel of experts who reach a consensus
on what makes a diagnosis - based on their experience
and evidence based research
– Often see a certain number of symptoms needed to
make a diagnosis, i.e. 5 of 9 for depression.
39
Diagnosis cont.

Need some sort of impairment in an arena
of patient’s life in order to make diagnosis
– So, need to see impairment in social
interactions, school functioning, interpersonal
interactions, etc.
DSM is updated every so often to indicate
any prevalent changes in the field of
psychiatry in regards to different diagnoses
 Good for “common language”

40
Diagnosis – Primary Care
 DSM-IV-PC
(Diagnostic and Statistical manual,
fourth edition, primary care)
 Primary Care Adaptation
– emphasizes only those psychiatric disorders
that regularly present in primary care settings
41
Diagnosis – Primary Care cont.
 Simplified
Diagnostic Technique
– Nine algorithms, headed by presenting
symptoms, for the most common psychiatric
concerns encountered in primary care
– concise description of disorders as they
clinically appear in primary care settings
– provides differential diagnoses as they relate
to general medical conditions, substance abuse
and more severe psychiatric disorders
42
Memorizing the DSM-IV
Daniel Carlat’s, “The Psychiatric
Interview”
 Memorize the 7 Major Diagnostic
Categories
 Organized by category for memorization
(not organized this way in DSM-IV)
 Focus on Positive Criteria

43
Anxiety

Panic Disorder
– Agoraphobia
Obsessive Compulsive Disorder
 Specific Phobias
 Separation Anxiety Disorder
 Posttraumatic Stress Disorder
 Generalized Anxiety Disorder
 Anxiety Disorder NOS

44
What type of anxiety???

Marcus has come for a follow-up
appointment at the School-Based Health
Center (SBHC). He reported several anxiety
symptoms during his comprehensive risk
assessment, and screened positively for
panic attacks during the Diagnostic
Predictive Scales. Marcus indicates that the
panic attacks are triggered by a fear of being
called on in class. He experiences
symptoms of panic (heart palpitations,
nervousness, sweating, etc) on the way to
school, while sitting in class, and even just
thinking about being in class.
45
Panic Disorder - Diagnostic Criteria
I. Recurrent unexpected Panic Attacks
Criteria for Panic Attack: A discrete period of intense fear or discomfort, in
which four (or more) of the following symptoms developed abruptly and
reached a peak within 10 minutes:
(1) Palpitations, pounding heart, or accelerated heart rate
(2) Sweating
(3) Trembling or shaking
(4) Sensations of shortness of breath or smothering
(5) Feeling of choking
(6) Chest pain or discomfort
(7) Nausea or abdominal distress
(8) Feeling dizzy, unsteady, lightheaded, or faint
(9) Derealization (feelings of unreality) or depersonalization (being detached
from oneself)
(10) Fear of losing control or going crazy
(11) Fear of dying
(12) Parenthesis (numbness or tingling sensations)
(13) Chills or hot flushes
46
Panic Disorder - Diagnostic
Criteria
II. At least one of the attacks has been
followed by 1 month (or more) of one (or
more) of the following:
(1) Persistent concern about having additional
attacks
(2) Worry about the implications of the attack
or its consequences (e.g., losing control,
having a heart attack, "going crazy")
(3) A significant change in behavior related to
the attacks
47
What type of anxiety???

Philip’s mother came to school to talk to
her son’s teacher (Ms. Chalk) because of
Philip’s recent absences from school.
Upon talking with Philip’s mother, Ms.
Chalk learned that Philip had a fear of
animals, and was increasingly scared to
go outside of his house because he did
not want to come into contact with any
animals. His mother reported that he
even gets nervous when seeing animals
on television, even though he knows they
cannot hurt him.
48
49
Specific Phobias





Marked and persistent fear of
a specific object or situation
with exposure causing an
immediate anxiety response
that is excessive or
unreasonable
In children, anxiety may be
expressed as crying, tantrums,
freezing, or clinging.
Adults recognize that their fear
is excessive. Children may not.
Causes significant interference
in life, or significant distress.
Under 18 years of age –
symptoms must be > 6 months
50
Specific Phobias

Animal phobias most
common childhood
phobia.

Also frequently afraid
of the dark and
imaginary creatures

In older children,
fears are more
focused on health,
social and school
problems
51
What type of anxiety???

Sally is brought to the school principal by her
parents, who are worried about her poor attendance
in school. Sally has had some difficulty leaving her
parents for the past several years, but her concerns
have grown increasingly more intense. She reports
having fears that if she goes to school, her parents
will abandon her or something very bad might
happen to them. She sometimes has dreams that
they have died, and she wakes up in a panic. Sally
has come to the office several times in the past few
months complaining of headaches and
stomachaches, requesting that she be sent home.
52
Separation Anxiety
Disorder
Developmentally inappropriate and excessive anxiety
concerning separation from home or from those to whom
the individual is attached, as evidenced by three (or more)
of the following:
(1)
(2)
(3)
(4)
Recurrent excessive distress when separation from home or
major attachment figures occurs or is anticipated
Persistent and excessive worry about losing, or about possible
harm befalling, major attachment figures
Persistent and excessive worry that an untoward event will lead
to separation from a major attachment figure (e.g., getting lost or
being kidnapped)
Persistent reluctance or refusal to go to school or elsewhere
because of fear of separation
53
Separation Anxiety
Disorder
(5)
Persistently and excessively fearful or reluctant to be alone
or without major attachment figures at home or without
significant adults in other settings
(6)
Persistent reluctance or refusal to go to sleep without being
near a major attachment figure or to sleep away from home
(7)
Repeated nightmares involving the theme of separation
(8)
Repeated complaints of physical symptoms (such as
headaches, stomachaches, nausea, or vomiting) when
separation from major attachment figures occurs or is
anticipated
54
Separation Anxiety Disorder

Duration of at least 4 weeks

Causes clinically significant distress or
impairment in social, academic
(occupational), or other important
areas of functioning
55
What type of Anxiety???

James walks into the school nurse’s office
for an appointment. He reports having great
difficulty concentrating in his classes
because of his increased worrying. He
cannot pinpoint his worries; Rather, he
reports being nervous about many things in
his life, including his relationships with
peers, his grades, and even his performance
in basketball. His worries are beginning to
impact his sleep, and he is finding himself
becoming more irritable than usual.
56
Generalized Anxiety Disorder



Excessive anxiety and worry for at least 6
months, more days than not
Worry about performance at school, sports,
etc.
DSM IV criteria less stringent for children
(Need only one criteria instead of three of
six):
(1) Restlessness or feeling keyed up or on
edge
(2) Being easily fatigued
(3) Difficulty concentrating or mind going
blank
(4) Irritability
(5) Muscle tension
(6) Sleep disturbance (difficulty falling or
staying asleep, or restless unsatisfying
sleep)
57
Generalized Anxiety Disorder:
Macbeth Frets Constantly Regarding
Illicit Sins
3/6 for 6 months…
Muscle tension
 Fatigue
 Concentration problems
 Restless, feeling on edge
 Irritability
 Sleep problems

58
What type of anxiety???

Shelley’s teacher calls Shelley’s parents because
he is concerned that her grades have been
declining, and he has noticed that she has not been
completing her homework. Shelley reports that she
is being plagued by distressing thoughts of doing
bad things, including hurting herself and others. In
order to get rid of the thoughts, Shelley often has to
engage in intricate routines, including counting to
100 and backwards, and touching her desk at home
in specific patterns. Although these routines
decrease her anxiety, they are causing her to skip
homework assignments and even lose sleep.
59
Obsessive Compulsive
Disorder




Presence of Obsessions
(thoughts) and/or
Compulsions (behaviors)
Although adults may have
insight, kids may not
Interferes with life or
causes distress
One third to one half of all
adult patients report
onset in childhood or
adolescence
60
What type of anxiety???

Ginny comes to the SBHC for a sports
physical. During her risk assessment, she
reveals that her parents have a history of
domestic violence, and that she witnessed
her father attack her mother on several
occasions. In the past few months, Ginny
has been having nightmares about the
abuse, and finds herself having flashbacks
even during class. Ginny has been avoiding
certain rooms in her house that remind her
of the incidents. She also reports having
difficult sleeping and concentrating in class.
61
Post-traumatic Stress Disorder (PTSD)
The person has been exposed to a traumatic event in which
both of the following were present:
 (1) The person experienced, witnessed, or was
confronted with an event or events that involved actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others
 (2) The person's response involved intense fear,
helplessness, or horror. (Note: In children, this may be
expressed instead by disorganized or agitated behavior.)
62
Persistent Re-experiencing of event (1+)
(1)
Recurrent and intrusive distressing recollections of the event,
including images, thoughts, or perceptions. (Note: In young
children, repetitive play may occur in which themes or aspects of
the trauma are expressed.)
(2)
Recurrent distressing dreams of the event. (Note: In children,
there may be frightening dreams without recognizable content.)
(3)
Acting or feeling as if the traumatic event were recurring (includes
a sense of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes, including those that occur on
awakening or when intoxicated). (Note: In young children, traumaspecific reenactment may occur.)
(4)
Intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event
physiological reactivity on exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
63
Avoidance and Numbing (3+)
(1)
Efforts to avoid thoughts, feelings, or conversations associated with the
trauma
(2)
Efforts to avoid activities, places, or people that arouse recollections of
the trauma
(3)
Inability to recall an important aspect of the trauma
(4)
Markedly diminished interest or participation in significant activities
(5)
Feeling of detachment or estrangement from others
(6)
Restricted range of affect (e.g., unable to have loving feelings)
(7)
Sense of a foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
64
Increased Arousal (2+)
(1)
Difficulty falling or staying asleep
(2)
Irritability or outbursts of anger
(3)
Difficulty concentrating
(4)
Hypervigilance
(5)
Exaggerated startle response
65
Posttraumatic Stress Disorder (PTSD)

At least one month duration.

Causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning

Note: Many students with PTSD meet
criteria for another Axis I Disorder (e.g.,
major depression, Panic Disorder) – both
should be diagnosed
66
Posttraumatic Stress Disorder:
Remembers Atrocious Nuclear Attacks



Re-experiencing the trauma via intrusive
memories, flashbacks or nightmares (one
required)
Avoidance of stimuli associated with trauma and
Numbing such as avoiding things associated with
trauma, amnesia, restricted affect and activities,
detachment, foreshortened future (one required)
Symptoms of increased Arousal such as
insomnia, irritability, hypervigilance, startle
response, poor concentration (two required)
67
Anxiety Disorder NOS

Disorders with anxiety symptoms BUT do not
meet criteria for any specific Anxiety Disorder,
Adjustment Disorder with Anxiety, or Adjustment
Disorder with Mixed Anxiety and Depressed
Mood

Example: mixed anxiety-depressive disorder

Also used in situations in which clinician has
concluded that an anxiety disorder is present,
but is unable to determine whether it is primary,
due to medical condition, or substance induced
68
Depressive Disorders

Major Depressive
Disorder

Dysthymic Disorder
69
Depression
Epidemiology




2.5% of children, up to 5% of adolescents
Prepubertal-1:1/M:F; adolescence-4:1/F:M
Average length of untreated MDD-7.2 months
Recurrence rates-40% within 2 years
Genetics
Most important risk factor for the
development of depressive illness is having at
least one affectively ill parent
70
What type of depression??

Tonya comes to health class looking “down in
the dumps,” as she had for past few weeks.
Tonya’s teacher asks to speak with her after
class, and finds out that Tonya has a number of
depressive symptoms, including suicidal
ideation. Tonya seems to display a lot of
negative thinking and cognitive distortions. For
example, she believes that “nobody” likes her
and that s/he will “never” be successful in
school. Her math teacher often compliments her
work, but Tonya dismisses the teacher’s
comments as him “just trying to be nice.” Tonya
has good grades in all classes except for one,
yet she only acknowledges her below average
Chemistry grade. Tonya has felt extremely sad
for about three weeks, which is a contrast from
her usually happy disposition.
71
Major Depressive Disorder
Major Depressive Episode:
Five (or more) of the following symptoms have been present during the same
two-week period and represent a change from previous functioning. At least
one symptom is either (1) depressed mood or (2) loss of interest or pleasure.

–
–
–
–
–
–
–
–
–
Depressed mood most of the day, nearly every day, as indicated by
subjective report or based on the observations of others. In children and
adolescents, this is often presented as irritability.
Markedly diminished interest or pleasure in all, or almost all, activities most
of the day, nearly every day
Significant weight loss when not dieting or weight gain (change of more than
5% of body weight in a month), or decrease or increase in appetite nearly
every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (observable by
others)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or inappropriate guilt nearly every day
Diminished ability to think, concentrate, make a decision nearly every day
Recurrent thoughts of death, recurrent suicidal ideation with or without a
specific plan, or an actual suicide attempt
72
Major Depressive Disorder
II. Symptoms cause clinically significant
distress or impairment in social or academic
functioning
III. Symptoms are not due to the direct
physiological effects of a substance (drugs
or medication) or a general medical
condition

Although there is a different diagnostic
category for individuals who suffer from
Bereavement, many of the symptoms are
the same and counseling techniques may
overlap.
73
Depression
Modifications in
DSM- IV for children:






irritable mood (vs.
depressive mood)
observed apathy and
pervasive boredom (vs.
anhedonia)
failure to make expected
weight gains (rather than
significant weight loss)
somatic complaints
social withdrawal
declining school
performance
74
Depressed Patients Sound
Anxious, So Claim Psychiatrists
Depression & Other Mood Disorders
 Psychotic Disorders
 Substance Abuse Disorders
 Anxiety Disorders
 Somatoform Disorders
 Cognitive Disorders
 Personality Disorders

75
Major Depression: SIGECAPS
4/8 with depressed mood or anhedonia for 2 weeks
Sleep disturbance (increased or decreased)
 Interest deficit (anhedonia)
 Guilt (worthlessness, hopelessness, regret)
 Energy deficit
 Concentration deficit
 Appetite disturbance (increased or
decreased)
 Psychomotor retardation or agitation
 Suicidality

76
Adolescent Development
77
Adolescent Development
•
•
Periods of transient milder problems
with low self-esteem, anxiety,
depressive feelings are quite common.
Needs to be differentiated from clinical
depression!
78
Suicide

Attempts- 3:1/F:M, Completions- 4:1/M:F

Most common means of completed suicide:
FIREARMS

Most often associated with depressive
disorder.

Risk factors: Age, sex, presence of
psychiatric illness, family history, isolation
from friends, substance abuse
79
Risk Factors for Suicide:
SAD PERSONS
•
•
•
•
•
Sex: Attempts- 3:1/F:M, Completions4:1/M:F
Age: teenagers and elderly at highest risk
Depression: 15% of people with
depression die by suicide
Previous Attempt: 10% of those who have
previously attempted die by suicide
Ethanol abuse: 15% of alcoholics commit
suicide
80
Risk Factors for Suicide:
SAD PERSONS cont.
•
•
•
•
•
Rational thinking loss: Psychosis is a risk
factor, 10% of those with chronic
schizophrenics die by suicide
Social supports are lacking
Organized plan: a well formulated plan is
a red flag
No spouse: being divorced, separated or
widowed. Having responsibility for
children is an important statistical
protector
Sickness: chronic illness
81
What type of depression??

Maria comes for a follow-up appointment to
the SBHC. Her risk assessment showed that
she has felt sad or blue for at least two
weeks. Upon further inquiry, Maria reports
that she generally feels sad, and finds little
enjoyment in activities. She reports having
felt this way for several years. In fact, she
can’t recall a time when she didn’t feel
mostly down. She denies suicidal ideation,
and is doing pretty well in school. She is not
very social, but does have a few friends.
82
Dysthymic Disorder

Major difference between a diagnosis of Major
Depressive Disorder and Dysthymia is the
intensity of the feelings of depression and the
duration of symptoms.

Dysthymia is an overarching feeling of
depression most of the day, more days than
not, that does not meet criteria for a Major
Depressive Episode.

Impairs functioning and lasts for at least one
year in children and adolescents, two in adults.
83
Dsythmia: ACHEWS
2/6 with depressed mood for 2 years
Appetite disturbance
 Concentration deficit
 Hopelessness
 Energy deficit
 Worthlessness
 Sleep disturbance

84
Depressive Disorder NOS

Disorders with depressive symptoms BUT do not
meet criteria for: Major Depressive Disorder,
Dysthymic Disorder, Adjustment Disorder with
Depressed Mood, or Adjustment Disorder with
Mixed Anxiety and Depressed Mood

Examples: premenstrual dysphoric disorder, minor
depressive disorder (at least 2 weeks, but < 5
symptoms)

Also used in situations in which clinician has
concluded that a depressive disorder is present, but
is unable to determine whether it is primary, due to
medical condition, or substance induced
85
Disruptive Disorders in Children




Attention Deficit
Hyperactivity
Disorder
Oppositional Defiant
Disorder
Conduct Disorder
Disruptive Behavior
Disorder NOS
86
What type of Disruptive Behavior
Disorder?

Joseph was referred to the main office by his
teacher for disrupting her class. Joseph’s
teacher reported that she cannot manage
him in class because he is constantly out of
his seat and will not concentrate on work.
He has a hard time completing tasks, and is
very disorganized. He talks back to her
occasionally when frustrated, but is not
frequently defiant. His peers are getting tired
of him constantly interrupting them, and he
is losing friends quickly.
87
Attention Deficit Hyperactivity Disorder



Symptoms for at least
six months to a
degree that it is
maladaptive and
INCONSISTENT with
developmental level
Some symptoms
present prior to age 7
years
Two or more settings
88
Attention Deficit Hyperactivity Disorder

Inattention





Poor organization
Does not seem to
listen when spoken
to
Loses objects
Easily distracted
Forgetful in daily
activities

Hyperactivity/Impulsivity







Fidget
Leaves seat often
Runs or climbs
excessively
Always “on the go”
Talks excessively
Blurts out answers
Can’t wait turn,
interrupts others
89
Attention Deficit Hyperactivity Disorder

Attention deficit disorder can occur
WITH and WITHOUT hyperactivity

Hyperactivity is more common in boys
than girls
90
Attention Deficit Hyperactivity
Disorder

ADHD can be a lifetime disorder with 30-50% having
symptoms as adults

Learning Disabilities are frequently seen in children
with ADHD

Behavior in a provider’s office does NOT always
reflect the situation at home or in school
91
What type of Disruptive Behavior
Disorder?

The principal of your school has called you to a
meeting with Jonathon’s parents and his teachers,
all of whom complain that Jonathon has been
“acting out” for over a year, and refuses to listen to
their direction. He is constantly arguing with all
authority figures, and will not take responsibility for
his actions. Jonathon’s teacher and mother say
that he is “always angry,” and that he lashes out at
everyone around him. He has been breaking more
rules at home and in school. He has not been
drinking alcohol or using drugs, nor has he broken
the law up until this point, but his parents are
worried that his behaviors are going to grow
steadily worse.
92
Oppositional Defiant Disorder
A pattern of negativistic, hostile and defiant
behavior lasting greater than 6 months of
which you have 4 or more of the following:








Loses temper
Argues with adults
Actively defies or refuses to comply with rules
Often deliberately annoys people
Blames others for his/her mistakes
Often touchy or easily annoyed with others
Often angry and resentful
Often spiteful or vindictive
93
Oppositional Defiant Disorder
(ODD)




Prevalence-3-10%
Male to female -2-3:1
Outcome-in one
study, 44% of 7-12
year old boys with
ODD developed into
CD
Evaluation-Look for
co morbid ADHD,
depression, anxiety
&LD/MR
94
What type of Disruptive Behavior
Disorder?

Matthew was referred to the school social worker
because he has been “going down the wrong path
for several years,” according to his mother.
Matthew’s negative behaviors began before puberty,
when he started hanging out with negative peers.
Matthew’s mother has caught him hurting their
family pet as well as other animals, and he was
recently arrested for vandalizing school property. He
has been getting into frequent fights at school
without apparent instigation. Matthew’s mother also
realized that he had stolen from her when she
noticed $50 missing from her purse and found it in
his pocket.
95
Conduct Disorder
(CD)

Aggression
toward people
or animals

Deceitfulness or
Theft

Destruction of
property

Serious violation
of rules
96
Conduct Disorder
(CD)




Prevalence-1.5-3.4%
Boys greatly
outnumber girls (35:1)
Co morbid ADHD in
50%, common to
have LD
Course-remits by
adulthood in 2/3.
Others become
Antisocial Personality
Disorder
97
Conduct Disorder
“You left your D__M car in the driveway again!”
98
Disruptive Behavior Disorder NOS

Disorders characterized by conduct or
oppositional defiant behaviors that do
not meet criteria for ODD or CD

Still must have impairment in
functioning
99
Substance Abuse/Dependence
* acknowledgement to Judith Rubenstein, Boston University, for
Substance Abuse slides
100
Epidemiology

Alcohol & drug abuse is of epidemic proportion in
adolescents and is a major public health problem

Highest prevalence of abuse in 18 to 22 y.o.

Greatest risk for abuse when onset before 15yo
&/or mental disorder present

Use of gateway drugs (alcohol, tobacco,
cannabis, inhalants) starting at younger ages

~50% of adolescents experiment with illicit
substances at some point
101
Underage drinking….

16% of all alcohol sales (2001)

3,170 deaths & 2.6 million harmful events

$62 billion in direct and indirect costs
Miller TR, Levy DT, Spicer RS, Taylor DM.
Societal costs of underage drinking.
J Studies on Alcohol 2006; 67: 519-528.
102
We have recently learned that early intervention
is more important than we thought….
Adolescents who begin drinking
before age 15 are more likely to:

binge drink

drive after drinking

ride with a drinking driver

be injured in fights or carry a weapon

use other illicit drugs

perform poorly in school

become alcohol dependent as a young adult
Data from a series of papers published from
The Boston University Youth Alcohol Prevention Center
103
Adolescent Brain Changes

Earlier drinking more likely to result in
alcohol dependence independent of family
hx (Grant 1998)

Exposure of alcohol may indeed cause
alterations in brain chemistry…. There are
studies indicating heaving drinking during
adolescence causes memory and
neuropsychological changes (Brown, et al)

Animal studies show that early exposure to
alcohol results in longer term problems
such as cognitive and behavioral problems
104
Adolescent Drug Use


Experimentation with substances is common,
particularly during adolescence.
Teenagers use alcohol and drugs for a variety of
reasons:
–
–
–
–

curiosity
to reduce stress
to fit in with a peer group
it feels good
Difficult to determine which
youths will experiment and stop and
which will develop more serious problems
with substances.
105
Now What?:
•
•
•
•
•
Family engagement
Treatment planning
Interventions/core skills
Referrals
Follow-up
106
Engaging Family in Services
Family engagement is crucial even for adolescents
 Interventions must take into account child’s
developmental needs
 Educate family about benefits of their participation
– improve emotional climate of family
– increase cohesion
– reduce conflict
 Help family with other things they need – be helpful
person in multiple ways

107
Family Interventions







Make services user-friendly to parents
Validate parent frustration and the fact that child is difficult
Never blame parents for child’s problems
Appeal to parent’s desire for things to be better
Address misperceptions about learning parenting skills
Utilize Behavior Management and Parent Training
Techniques
Involve youth in family decision making and rule-setting –
parents need to learn how to go “one down” to go “one up”
108
Mental Health Treatment Planning

What do you include in your treatment plan?
–
–
–
–
–
Identify Strengths
Identify Needs/Problems
Match interventions to needs/problems
Identify who will implement intervention
Identify short- and long-term goals with timeline
and make these clear to student/family
109
Training in
Core
Cognitive
Behavioral
Skills
110
What are “core skills”?

Based in cognitive behavioral theory

Buffer against the development of mental
health problems

Assist in coping with mental health
problems
111
What is Cognitive Behavior Therapy
(CBT)?
Relatively short-term, focused psychotherapy
 Focus:

– How you are thinking (your cognitions)
– How you are behaving and communicating
Emphasis on present rather than past
 Learn coping skills

112
Skills training for Anxiety






Deep Breathing
Progressive Muscle
Relaxation
Mental
Imagery/Visualization
General Stress Busters
Cognitive Restructuring
Systematic
Desensitization
113
Skills training for Depression





Thought Stopping
Activity Scheduling
Problem Solving
Relaxation Training
Cognitive
Restructuring
114
Substance Abuse Strategies and Skills
• Individual, family and classroombased interventions
• Substance Abuse screening
• Motivational Interviewing
• Refusal Skills
• Self-Esteem
• Education
• Referrals
115
“Core Skills” Resource

Stephan, S. H., & Marciante, W. (2007).
Quick Guide to Clinical Techniques for
Common Child and Adolescent Mental Health
Problems. Baltimore: University of Maryland
Center for School Mental Health
http://www.schoolmentalhealth.org/Resources
/Clin/QuickGuide.pdf
116
Medication Management
• Factors to consider:
–
–
–
–
–
–
Diagnosis and symptoms
Resources for referral
Provider competence
Provider availability for monitoring
Family support
School support for the administration of
psychotropic medication in the school
117
Medication Management
• Develop protocol for SBHC that includes
–
−
−
−
−
−
Referral for therapy
Full assessment
Consultation
Documentation
Education of student and family
Follow up, follow up, follow up!
118
Medication Resources

Psychotropic Drugs and Children
A 2007 Update
December 2007
The Center for Health and Health Care in Schools
http://www.healthinschools.org/News%20Room/Fact%20She
ets/Psychotropic.aspx

Facts for Families
American Academy of Adolescent and Child Psychiatry
http://www.aacap.org/cs/root/facts_for_families/psychiatric_
medication_for_children_and_adolescents_part_ihow_medica
tions_are_used
119
Strategies to Facilitate
Referrals

Internal referrals:
–
–
–
–
Referral log
Referral form with feedback form
Interdisciplinary case conferences
Follow-up documentation in charts
 External referrals:
– Community resource directory
– Established relationships with community mental health
providers/sponsoring organization
120
Referral Form







Students name, grade, homeroom
Date of referral
Name of person referring
Reason for referral
Urgency of referral
Have you talked to student or family about this
referral?
Date referral was received and reviewed
121
Referral Feedback



Get consent from student to provide feedback to
referral source
Feedback can be verbal or written
Feedback form can include:
–
–
–
–
–
–
student has not responded to appointment requests
student or parent declined counseling services
status of evaluation, type of service student is receiving
student was referred for outside evaluation/treatment
student’s difficulties appear to be resolved
student is receiving mental health services from another
provider
122
Interdisciplinary Case Conferences

Used for:
–
–
–
–
–
–
case management
referrals
problem-solving over difficult cases
information sharing
multi-disciplinary training
team-building
123
How To Set Up Case Conferences
Who will coordinate
 Which staff should participate
 Time and frequency
 Prioritization of cases
 Documentation
 Follow-up from previous conferences
 Identify additional training needs

124
Mental Health Progress Notes-What to include?
 Date, Time, Duration
 Diagnosis
 Type of Contact
 Content of Session
 Assessment Strategies
 Intervention Strategies (e.g. CBT)
 Progress on Objective Treatment Goals
 Family Involvement
 Plans for Future Intervention
125
Benefits of Good Mental Health
Documentation
Assists in monitoring of treatment progress
 Mindful of different components of
treatment – family involvement,
assessment, intervention (not just content)
 Structures intervention around treatment
goals/objectives
 Liability!

126
Resources
127
128
NASBHC Resources
www.nasbhc.org
 Mental
Health Section:
– Screening and assessment tools
– Mental Health Planning and Evaluation
Template
– Links to other school mental health resources
Technical Assistance Section:
– Training opportunities
– Professional Development
129
– Annual Convention!!
Home
About Us
Resources for
Clinicians
Resources for
Educators
Resources for
Families
Resources for
Students
FAQ
Welcome to the School Mental Health Connection!
This site offers school mental health resources not only for clinicians, but
also for educators, administrators, parents/caregivers, families, and
students. To efficiently find resources that fit your needs, just click the link to
the left that corresponds to your role in the school community. However,
since you may benefit from resources in numerous domains within this site,
we encourage you to explore many areas.
The resources on this site emphasize practical information and skills based
on current research, including prominent evidence-based practices, as well
as lessons learned from local, state, and national initiatives.
The School Mental Health Connection is designed for use by anyone who is
interested in school mental health. It is also a central feature of the
Baltimore School Mental Health Technical Assistance and Training Initiative.
What's New
View the newly-released Directory of Community Services for
Baltimore City.
Educators: Check out the user-friendly Mental Health Fact Sheets for
the Classroom, provided by the Minnesota Association for Children's
Mental Health.
Baltimore City
Resource Directory
Consultation &
130
Support Line
© 2006 The School Mental Health Connection. All Rights Reserved.
Other Helpful
School Mental Health Websites

Center for School Mental Health
http://csmha.umaryland.edu

Center for Health and Healthcare in
Schools
http://www.healthinschools.org

UCLA Center for Mental Health in
Schools
http://smhp.psych.ucla.edu
131
Other Helpful Resources

Adolescent Health Working Group
adolescent provider toolkit
http://www.ahwg.net/resources/toolkit.htm

Integrated Primary Care
Alexander Blount, Ed.D.
http://www.integratedprimarycare.com/
132

Questions?

Evaluations, please.
133
Contact Information
Sue Murray, MPH, RN
Program Consultant
Illinois Coalition for School Health Centers
smurray@ilmaternal.org
Margaret Bavis, DNP, FNP-BC
Instructor
Rush University College of Nursing
margaret_bavis@rush.edu
134