Schools and Mental Health Schools promote mental health and act as a “protective” factor for...

Schools and Mental Schools and Mental HealthHealth

Schools promote mental health and act as a Schools promote mental health and act as a “protective” factor for children“protective” factor for childrenConnection, academic success, positive relationships, Connection, academic success, positive relationships,

caring interactions, stability, positive approaches to caring interactions, stability, positive approaches to disciplinediscipline

Schools can also be a “risk factor” Schools can also be a “risk factor” Alienation, academic failure, negative relationships with Alienation, academic failure, negative relationships with

adults and peers, bullying, gangs, harsh disciplineadults and peers, bullying, gangs, harsh discipline

Students perform better on tests when they Students perform better on tests when they believe that their teachers care about thembelieve that their teachers care about them

Success in school is clearly associated with Success in school is clearly associated with positive mental health and well-being for studentspositive mental health and well-being for students

Facts and FiguresFacts and Figures 21% of US children ages 9-17 have a 21% of US children ages 9-17 have a

diagnosable mental or addictive disorder diagnosable mental or addictive disorder that causes at least, minimal impairment that causes at least, minimal impairment and behavioral challenges (US Surgeon and behavioral challenges (US Surgeon General and NAMI).General and NAMI).

Students with mental illness have the Students with mental illness have the highest dropout rate of any disability group.highest dropout rate of any disability group.

Teacher-student relationships promote Teacher-student relationships promote student engagement, positive attitudes and student engagement, positive attitudes and a sense of belongings toward school, a sense of belongings toward school, motivation and academic achievement.motivation and academic achievement.

Facts and Figures-Facts and Figures-Anxiety Anxiety

13% of US children suffer from 13% of US children suffer from anxiety disorders (US Surgeon anxiety disorders (US Surgeon General).General).

Most common emotional problem Most common emotional problem among children and adolescentsamong children and adolescents

Teachers, school nurses and school Teachers, school nurses and school secretaries may be the first to see the secretaries may be the first to see the early signs and signals of childhood early signs and signals of childhood anxiety.anxiety.

Understanding AnxietyUnderstanding Anxiety

Starts with awareness Ends in someone getting help and

treatment Brains get sick too, with treatment

they get better 1 of 5 Families is impacted by

mental illness

Barriers Barriers Scarce mental health resourcesScarce mental health resources Obstacles: time, transportation, prioritiesObstacles: time, transportation, priorities Previous negative experiences with Previous negative experiences with

mental health treatmentmental health treatment Concerns about confidentialityConcerns about confidentiality IsolationIsolation Lack of insurance coverageLack of insurance coverage Family stressFamily stress Attitudes/stigma/shameAttitudes/stigma/shame

TermsTerms

Nut case/nutsNut case/nuts LooneyLooney CrazyCrazy Off his rockerOff his rocker PsychoPsycho BonkersBonkers

Reflect lack of acceptance and understanding;

contributes to stigma!!

StigmaStigma

2/3 of all people with diagnosable 2/3 of all people with diagnosable mental illness do not seek treatment mental illness do not seek treatment (Surgeon General)(Surgeon General)

What is Anxiety?What is Anxiety? Fear and worry are common, especially in Fear and worry are common, especially in

childhoodchildhood Many childhood fears are developmental and Many childhood fears are developmental and

self limitingself limiting Anxiety is a feeling everyone experiences: the Anxiety is a feeling everyone experiences: the

emotional uneasiness associated with emotional uneasiness associated with anticipation of danger/loss-anticipation of danger/loss-

Safety mechanism-”fight or flight”-shift of Safety mechanism-”fight or flight”-shift of blood flow to muscles, away from gut, blood flow to muscles, away from gut, increases oxygen where needed and heart rateincreases oxygen where needed and heart rate

A continuum from mild to moderate, useful A continuum from mild to moderate, useful and adaptiveand adaptive

Extreme=debilitating and maladaptiveExtreme=debilitating and maladaptive

Stress and AnxietyStress and Anxiety

Multiple physical symptoms:Multiple physical symptoms:

Cardiovascular-palpitations, Cardiovascular-palpitations, increased HR, BPincreased HR, BP

Respiratory-SOB, increased Respiratory-SOB, increased respiratory raterespiratory rate

Skin-blotching, rash, hot flashes, Skin-blotching, rash, hot flashes, sweating, numbness sweating, numbness


Musculoskeletal-shaky, muscle Musculoskeletal-shaky, muscle tension and crampstension and cramps

Gastrointestinal-diarrhea, nausea Gastrointestinal-diarrhea, nausea and abdominal painand abdominal pain

Other physical symptoms-headache, Other physical symptoms-headache, chestpain, insomnia, nightmares, chestpain, insomnia, nightmares, fainting, urinary frequencyfainting, urinary frequency


Cognitive-verbalization of specific Cognitive-verbalization of specific fears, ruminative negative thinking fears, ruminative negative thinking (ANTs) nightmares (ANTs) nightmares

Emotional-feeling scared, tense, Emotional-feeling scared, tense, nervous, stressed, fretful. In states nervous, stressed, fretful. In states of panic-fear of dying or impending of panic-fear of dying or impending doomdoom


Social Behavioral-Social Behavioral- Behaviors most likely seen by you:Behaviors most likely seen by you:

clingy, shy, withdrawnclingy, shy, withdrawn Under or over reactiveUnder or over reactive Reluctant to participate in activities Reluctant to participate in activities

with any possible dangerwith any possible danger Easily startles, hyper arousal/over alertEasily startles, hyper arousal/over alert

Causes of AnxietyCauses of Anxiety

Genetic-higher incidence if parent, Genetic-higher incidence if parent, sibling has anxietysibling has anxiety

Biologic-malfunctioning of norepi, Biologic-malfunctioning of norepi, serotonin and GABA; malfunctioning serotonin and GABA; malfunctioning of serotonin and at GABA receptorsof serotonin and at GABA receptors

Medical-illnesses, infections, Medical-illnesses, infections, endocrine disorders (thyroid) and endocrine disorders (thyroid) and other neurologic disordersother neurologic disorders

Why so many kids??Why so many kids?? Larger social environment-decreased social connectednessLarger social environment-decreased social connectedness Facebook?Facebook? Environmental dangersEnvironmental dangers

Physical (violent crime) Physical (violent crime) psychological (threat of nuke war)psychological (threat of nuke war)

Suicide rates and divorce: correlation with higher levels of Suicide rates and divorce: correlation with higher levels of anxietyanxiety

Geographical mobility-increased isolation and lonelinessGeographical mobility-increased isolation and loneliness Family stress related to domestic violence or threat of Family stress related to domestic violence or threat of

divorcedivorce Societal shift toward extrinsic goals, away from intrinsic Societal shift toward extrinsic goals, away from intrinsic

goalsgoals Lack of unsupervised, free play?Lack of unsupervised, free play? NCLBNCLB ISAT stressISAT stress

Why so many?Why so many?

Media creates high expectations-Media creates high expectations-appearance, jobs, wealth and appearance, jobs, wealth and relationshipsrelationships

Video games-scary or adult situations, Video games-scary or adult situations, high levels of violence increase anxiety high levels of violence increase anxiety in some children.in some children. Playing game stimulates adrenalin/fight or Playing game stimulates adrenalin/fight or

flight response, elevated stress homones flight response, elevated stress homones not expended and lead to anxiety issues not expended and lead to anxiety issues

Nature vs NurtureNature vs Nurture

Can’t change genetics or society ….Can’t change genetics or society ….

Can change media that children are Can change media that children are exposed toexposed to

Can help with the quality of Can help with the quality of relationshipsrelationships

The The impactimpact of society on individual family of society on individual family can be controlledcan be controlled

Monkey BusinessMonkey Business UW-Madison study 200+ genetically UW-Madison study 200+ genetically

related rhesus monkeysrelated rhesus monkeys Confirmed anxiety temperament was Confirmed anxiety temperament was

inheritedinherited Predicted individual’s degree of Predicted individual’s degree of

temperamenttemperament Increased activity in anterior hippocampus Increased activity in anterior hippocampus

(memory) genetically linked, anxious (memory) genetically linked, anxious temperamenttemperament

Increased activity in amygdala (emotion Increased activity in amygdala (emotion and fear) not inheritedand fear) not inherited

ImplicationsImplications

Suggests opportunity to modify Suggests opportunity to modify environment to prevent full blown environment to prevent full blown anxiety in children with anxious anxiety in children with anxious temperaments (extreme shyness, temperaments (extreme shyness, persistent worry and increased bodily persistent worry and increased bodily responses to stress)responses to stress)

Potential for improved diagnostic tools Potential for improved diagnostic tools for early detection, intervention and for early detection, intervention and prevention. prevention.

Sugar BabiesSugar Babies

Theory-junk food, high sugar diet Theory-junk food, high sugar diet triggers pancreas to “oversecrete” triggers pancreas to “oversecrete” insulin followed by a sudden fall in insulin followed by a sudden fall in blood sugar (glucose)blood sugar (glucose)

Drop in blood sugar causes adrenal Drop in blood sugar causes adrenal glands to secrete adrenalineglands to secrete adrenaline

Fight or flight response triggered Fight or flight response triggered which simulates anxiety which simulates anxiety

Summary of “Why so Summary of “Why so many?”many?”

““Interactive Model”:Interactive Model”: Genetic vulnerability (7 times more Genetic vulnerability (7 times more

likely if parent suffers from anxiety likely if parent suffers from anxiety disorder)disorder)

Environmental vulnerabilityEnvironmental vulnerability Protective factors….Protective factors….

TreatmentTreatment

Often delay-loooong delay-in correct Often delay-loooong delay-in correct diagnosisdiagnosis

Anxiety disorders respond very well to Anxiety disorders respond very well to treatmenttreatment

Often relapses as in many other Often relapses as in many other illnessesillnesses

Combination of medication and Combination of medication and cognitive behavioral therapy is most cognitive behavioral therapy is most effective long term treatmenteffective long term treatment

Antidepressant-Anxiety Antidepressant-Anxiety MedicationsMedications

Fluoxetine (Prozac)Fluoxetine (Prozac)Fluvoxamine (Luvox)Fluvoxamine (Luvox)Escitalopram) (Lexapro)Escitalopram) (Lexapro)Citalopram (Celexa)Citalopram (Celexa)Venlafaxine (Effexor)Venlafaxine (Effexor)Sertraline (Zoloft)Sertraline (Zoloft)Duloxetine (Cymbalta)Duloxetine (Cymbalta)Clomipramine (Anafranil)Clomipramine (Anafranil)

Common side effects: nausea, headache, stomach upset nervousness, weight gain, drowsiness

black box warnings

Augmentation for anxiety Augmentation for anxiety

Add an Atypical Antipsychotic Add an Atypical Antipsychotic (Seroquel) sleep and anxiety(Seroquel) sleep and anxiety

Add Trazodone (sleep and acute Add Trazodone (sleep and acute anxiety)anxiety)

Add Atarax (sleep and anxiety)Add Atarax (sleep and anxiety) Mirtazapine (Remeron) sleepMirtazapine (Remeron) sleepAnxiolyticsAnxiolytics BuspironeBuspirone Clonazepam Clonazepam

Side effects: abnormal movemnts, dry mouth, sedation, dizziness.

Side effects: sedation, dry mouth, dizziness

What’s normal? What’s What’s normal? What’s not?not?

Anxiety becomes a problem when it Anxiety becomes a problem when it begins to affect a child’s ability to begins to affect a child’s ability to engage in the three main engage in the three main responsibilities of childhood:responsibilities of childhood:

1.1. To learnTo learn

2.2. To make friendsTo make friends

3.3. To have funTo have fun

What’s normal? What’s What’s normal? What’s not?not?

Normal=age expected, justifiable and Normal=age expected, justifiable and reasonable to the circumstancesreasonable to the circumstances

Problematic-crosses the threshold when it Problematic-crosses the threshold when it becomes:becomes: ExcessiveExcessive DetrimentalDetrimental UncontrollableUncontrollable ParalyzingParalyzing PervasivePervasive ChronicChronic Age-mismatchedAge-mismatched

Anxiety? Anxiety?

Out of character behaviors-Out of character behaviors-”not ”not acting his age”; sudden unexpected acting his age”; sudden unexpected resistance from an otherwise resistance from an otherwise compliant child; sudden rigidity, compliant child; sudden rigidity, stubbornness (comes across as stubbornness (comes across as defiant/disobedient); child becomes defiant/disobedient); child becomes afraid and unduly cautious when afraid and unduly cautious when used to be bold and curiousused to be bold and curious

Other reasons for behavior?Other reasons for behavior?

Anxiety?Anxiety?

Agitation and easily triggered distress: unusual tearfulness, clinging, fear of being alone/left at school; pacing, restlessness, agitation, crying, irritability, “meltdowns”, general unhappiness, withdrawal.

Other reasons for behavior?

Anxiety?Anxiety?

“What if” – Constantly asks “But what if?” more than the average child. Questions pertain from the trivial to the profound and cover topics such as friends, grades, performance, family safety, the pet, natural disasters or the weather.

Other reasons for behavior?

Anxiety?Anxiety?

Reassurance seeking:Reassurance seeking: Incessant Incessant and insatiable need for reassurance. and insatiable need for reassurance. “Am I going to be OK? Am I going “Am I going to be OK? Am I going blind? Am I going to throw up? Can blind? Am I going to throw up? Can you feel my forehead to see if I have you feel my forehead to see if I have a fever? Are you sure there’s no a fever? Are you sure there’s no paper in my desk?”paper in my desk?”


Anxiety?Anxiety? Decline in attention, concentration Decline in attention, concentration

and organization:and organization: Distraction, Distraction, preoccupation, difficulty focusing or preoccupation, difficulty focusing or disorganization.disorganization.

Frequent physical complaints:Frequent physical complaints: Nausea, vomiting, many aches and Nausea, vomiting, many aches and pains, feeling on edge, “need to see the pains, feeling on edge, “need to see the nurse”.nurse”.


Anxiety?Anxiety?

Perfectionism:Perfectionism: High and High and unattainable self-imposed standards unattainable self-imposed standards with regard to schoolwork, behavior with regard to schoolwork, behavior or socialization. Repeats tasks or socialization. Repeats tasks endlessly, easy frustration with endlessly, easy frustration with perceived imperfection, refusal to perceived imperfection, refusal to accept parents/teachers satisfaction accept parents/teachers satisfaction with quality of work.with quality of work.


Anxiety?Anxiety?

Inability to complete tasks:Inability to complete tasks: Assignments or tasks that are clearly Assignments or tasks that are clearly within the child’s capability are not within the child’s capability are not completed due to perfectionism, or completed due to perfectionism, or other repetitive rituals such as other repetitive rituals such as checking, re-reading or counting. checking, re-reading or counting. Sometime a child may get “stuck” Sometime a child may get “stuck” and unable to proceed.and unable to proceed.


Anxiety?Anxiety?

Reluctance or school refusal:Reluctance or school refusal: Difficulty getting to school Difficulty getting to school (absent/tardy) due to avoidance of (absent/tardy) due to avoidance of anxiety triggers or inability to cope anxiety triggers or inability to cope with expectations and demands of with expectations and demands of schoolwork.schoolwork.


Anxiety?Anxiety?

Sleep problems: Sleep problems: Insomnia, Insomnia, nightmares and frequent nightmares and frequent awakenings, followed by exhaustion awakenings, followed by exhaustion and drowsiness during the day. May and drowsiness during the day. May be the result of staying up late, be the result of staying up late, absorbed in rituals or obsessions, absorbed in rituals or obsessions, trying to get homework done to trying to get homework done to perfection or procrastination.perfection or procrastination.


Anxiety?Anxiety?

Illogical thoughts:Illogical thoughts: The child is The child is seemingly impervious to common seemingly impervious to common sense. Logic, reassurance, sense. Logic, reassurance, explanations and distraction do not explanations and distraction do not appease the child’s anxiety.appease the child’s anxiety.


When anxiety is a When anxiety is a “disorder”:“disorder”:

Anxiety is at extreme end of the Anxiety is at extreme end of the continuum continuum

Must meet 4 criteria:Must meet 4 criteria:

DisproportionDisproportion DisruptionDisruption DistressDistress DurationDuration

DisproportionDisproportion

Anxiety is excessive, unreasonable Anxiety is excessive, unreasonable and out of proportion to trigger or and out of proportion to trigger or contextcontext

Child has an exaggerated sense of Child has an exaggerated sense of threat and danger in situations threat and danger in situations where most people would not be where most people would not be concernedconcerned

Child is unable to control the worry Child is unable to control the worry or fear or fear regardless of effort (A.N.T.s)regardless of effort (A.N.T.s)

DisruptionDisruption Interferes substantially with child’s Interferes substantially with child’s

ability to function normallyability to function normally

Can’t accomplish things he/she Can’t accomplish things he/she should be able to get through a should be able to get through a normal daynormal day School, homework or sleep disruptedSchool, homework or sleep disrupted Attendance problemsAttendance problems

DistressDistress The child is distraught and easily upset The child is distraught and easily upset

(younger=tantrums, outburts, crys)(younger=tantrums, outburts, crys)

The anxiety has become burdensome and The anxiety has become burdensome and bothersome to the child, may experience bothersome to the child, may experience physical ailments/somatizationphysical ailments/somatization

Parent reports emotional and irritable Parent reports emotional and irritable when gets home from school, meltdownswhen gets home from school, meltdowns

DurationDuration

To meet criteria for a diagnosis of To meet criteria for a diagnosis of anxiety disorder, a significant level anxiety disorder, a significant level of anxiety should be consistent over of anxiety should be consistent over a period of time, usually at least a a period of time, usually at least a month.month.

Thoughts on anxiety Thoughts on anxiety (from a parent who is also a teacher)(from a parent who is also a teacher)

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