Advantages of Early Advantages of Early Detection of Mental Detection of Mental

Disorders in the Student Disorders in the Student PopulationPopulation

Ronald Malave Ortiz, M.D.Ronald Malave Ortiz, M.D.PsychiatristPsychiatrist

20162016

  Psychosocial Crisis Psychosocial Crisis Stage Stage Life Stage Life Stage age range, other age range, other

descriptionsdescriptions

  1. Trust v Mistrust1. Trust v Mistrust Infancy Infancy 0-1½ yrs, baby, birth to 0-1½ yrs, baby, birth to walkingwalking

  2. Autonomy v Shame and 2. Autonomy v Shame and Doubt Doubt

Early Early ChildhoodChildhood

1-3 yrs, toddler, toilet 1-3 yrs, toddler, toilet trainingtraining

  3. Initiative v Guilt3. Initiative v Guilt Play Age Play Age 3-6 yrs, pre-school, 3-6 yrs, pre-school, nurserynursery

  4. Industry v Inferiority4. Industry v Inferiority School Age School Age 5-12 yrs, early school 5-12 yrs, early school   5. Identity v Role Confusion 5. Identity v Role Confusion Adolescence Adolescence 13-18 yrs, puberty, teens*13-18 yrs, puberty, teens*

  6. Intimacy v Isolation6. Intimacy v Isolation Young Adult Young Adult 18-40, courting, early 18-40, courting, early parenthoodparenthood

  7. Generativity v Stagnation7. Generativity v Stagnation Adulthood Adulthood 30-65, middle age, 30-65, middle age, parentingparenting

  8. Integrity v Despair8. Integrity v Despair Mature Age Mature Age 50+, old age, 50+, old age, grandparentsgrandparents

Erik EricksonErik Erickson’’s Stages of Development s Stages of Development

OverviewOverview• Developmental Stages; Review of Normal Developmental Stages; Review of Normal

versus Abnormal Child Developmentversus Abnormal Child Development• Why Schools?Why Schools?• DSM-5DSM-5• Common Mental Health Issues, Review of Common Mental Health Issues, Review of

Symptoms and Practice SkillsSymptoms and Practice Skills• Developing Healthy School EnvironmentsDeveloping Healthy School Environments• Q and AQ and A

Mental Health Issue or Not? Mental Health Issue or Not? Red Flags or Not? Red Flags or Not? • If a child falls asleep every afternoon If a child falls asleep every afternoon

in class during the lesson?in class during the lesson?• If a child is late for school often?If a child is late for school often?• If a child has frequent suspensions If a child has frequent suspensions

for not following directions in class?for not following directions in class?• If a child has a temper tantrum?If a child has a temper tantrum?• If a child is unkempt? If a child is unkempt?

Lets Visit Ages 6 to 12Lets Visit Ages 6 to 12Think about your experiences in 3Think about your experiences in 3rdrd Grade Grade• Where did you live?Where did you live?• Who was your best friend?Who was your best friend?• What games did you like to play?What games did you like to play?• Where did you go to school? Who was your teacher? Where did you go to school? Who was your teacher?

What expression did he or she have on his or her What expression did he or she have on his or her face in greeting you each day? face in greeting you each day?

• What game or technology was the newest thing?What game or technology was the newest thing?• What was your favorite thing to eat at school?What was your favorite thing to eat at school?• Was there a particular smell that you can remember Was there a particular smell that you can remember

to your school? (pine sol? Mystery meat?....)to your school? (pine sol? Mystery meat?....)

Developmental Goals (6 to 12)Developmental Goals (6 to 12)

• Ages 6 to 12Ages 6 to 12– To develop industryTo develop industry

•Begins to learn the capacity to workBegins to learn the capacity to work•Develops imagination and creativityDevelops imagination and creativity•Learns self-care skillsLearns self-care skills•Develops a conscienceDevelops a conscience•Learns to cooperate, play fairly, and follow Learns to cooperate, play fairly, and follow

social rulessocial rules

Normal Difficult Behavior Normal Difficult Behavior Ages 6 to 12Ages 6 to 12• Arguments/Fights with Siblings and/or PeersArguments/Fights with Siblings and/or Peers• Curiosity about Body Parts of males and Curiosity about Body Parts of males and

femalesfemales• Testing LimitsTesting Limits• Limited Attention SpanLimited Attention Span• Worries about being acceptedWorries about being accepted• LyingLying• Not Taking Responsibility for BehaviorNot Taking Responsibility for Behavior

Cries for Help/More Serious Cries for Help/More Serious IssuesIssuesAges 6-12Ages 6-12• Excessive AggressivenessExcessive Aggressiveness• Serious Injury to Self or OthersSerious Injury to Self or Others• Excessive FearsExcessive Fears• School Refusal/PhobiaSchool Refusal/Phobia• Fire Fixation/SettingFire Fixation/Setting• Frequent Excessive or Extended Emotional Frequent Excessive or Extended Emotional

ReactionsReactions• Inability to Focus on Activity even for Five Inability to Focus on Activity even for Five

MinutesMinutes• Patterns of Delinquent behaviorsPatterns of Delinquent behaviors

AdolescenceAdolescence

LetLet’’s Visit Ages 13-18s Visit Ages 13-18Think about your experiences in Think about your experiences in 1010thth grade grade

• Who was your favorite teacher?Who was your favorite teacher?• Were you dating or not dating?Were you dating or not dating?• Who was your best friend?Who was your best friend?• How would you have described your How would you have described your

parent/caregiver?parent/caregiver?• What did you do for fun?What did you do for fun?• What was the latest and greatest technology?What was the latest and greatest technology?• What was your favorite movie, song, or tv show?What was your favorite movie, song, or tv show?

Developmental GoalsDevelopmental Goals• Developing Identity-the child Developing Identity-the child

develops self-identity and the develops self-identity and the capacity for intimacycapacity for intimacy– Continue mastery of skillsContinue mastery of skills

•Accepting responsibility for behaviorAccepting responsibility for behavior•Able to develop friendshipsAble to develop friendships•Able to follow social rulesAble to follow social rules

Normal Difficult BehaviorNormal Difficult Behavior• Moodiness!Moodiness!• Less attention and affection towards parentsLess attention and affection towards parents• Extremely self involvedExtremely self involved• Peer conflictsPeer conflicts• Worries and stress about relationshipsWorries and stress about relationships• Testing limitsTesting limits• Identity Searching/ExploringIdentity Searching/Exploring• Substance use experimentationSubstance use experimentation• Preoccupation with sexPreoccupation with sex

Cries for Help- Ages 13-18Cries for Help- Ages 13-18• Sexual promiscuitySexual promiscuity• Suicidal/homicidal ideationSuicidal/homicidal ideation• Self-mutilationSelf-mutilation• Frequent displays of temperFrequent displays of temper• Withdrawal from usual activitiesWithdrawal from usual activities• Significant change in grades, attitude, hygiene, Significant change in grades, attitude, hygiene,

functioning, sleeping, and/or eating habitsfunctioning, sleeping, and/or eating habits• DelinquencyDelinquency• Excessive fighting and/or aggression (physical/verbal)Excessive fighting and/or aggression (physical/verbal)• Inability to cope with day to day activitiesInability to cope with day to day activities• Lots of somatic complaints (frequent flyers)Lots of somatic complaints (frequent flyers)

DiscussionDiscussion• How do you make the distinction How do you make the distinction

between normal versus abnormal between normal versus abnormal development?development?– How can you tell?How can you tell?

Why Schools?Why Schools?

““Could someone help me with these? Could someone help me with these? I I’’m late for math class.m late for math class.””

Schools: The Most Schools: The Most Universal Natural SettingUniversal Natural Setting

• Over 55 million youth Over 55 million youth attend 114,700 schools attend 114,700 schools (K-12) in the U.S.(K-12) in the U.S.

• 6.8 million adults work 6.8 million adults work in schoolsin schools

• Combining students Combining students and staff, and staff, approximately 20% of approximately 20% of the U.S. population can the U.S. population can be found in schools be found in schools during the work week.during the work week.

Overview of ChildrenOverview of Children’’s s Mental Health NeedsMental Health Needs• Between 20% to 38% of youth in the U.S. have diagnosable mental health Between 20% to 38% of youth in the U.S. have diagnosable mental health

disordersdisorders

• Between 9% to 13% of youth have serious disturbances that impact their daily Between 9% to 13% of youth have serious disturbances that impact their daily functioningfunctioning

• Between one-sixth to one-third of youth with diagnosable disorders receive any Between one-sixth to one-third of youth with diagnosable disorders receive any treatmenttreatment

• Schools provide a natural, universal setting for providing a full continuum of Schools provide a natural, universal setting for providing a full continuum of mental health caremental health care

Workforce IssuesWorkforce Issues• 15% of teachers leave after year 115% of teachers leave after year 1• 30% of teachers leave within 3 years30% of teachers leave within 3 years• 40-50% of teachers leave within 5 40-50% of teachers leave within 5

yearsyears(Smith and Ingersoll, 2003)(Smith and Ingersoll, 2003)

Opportunities in SchoolsOpportunities in Schools

• Can do observations of children in a Can do observations of children in a natural settingnatural setting

• Can outreach to youth with internalizing Can outreach to youth with internalizing disordersdisorders

• Can provide three tiers of service Can provide three tiers of service (universal, selective, and indicated)(universal, selective, and indicated)

• Can be part of a multidisciplinary team Can be part of a multidisciplinary team involving school staff, families, and youthinvolving school staff, families, and youth

Activity-BrainstormingActivity-Brainstorming• What is the mental health issue that What is the mental health issue that

you find the most challenging in you find the most challenging in schools? schools?

What is the DSM 5?What is the DSM 5?• A reference guide for diagnosing A reference guide for diagnosing

mental health concernsmental health concerns• Published by the American Published by the American

Psychiatric Association in May 2013Psychiatric Association in May 2013• For each Diagnosis provides specific For each Diagnosis provides specific

criteria that needs to be met criteria that needs to be met

DepressionDepressionEpidemiologyEpidemiology

• 2.5% of children, up to 5% of adolescents2.5% of children, up to 5% of adolescents• Prepubertal-1:1/F:M; adolescence-4:1/F:MPrepubertal-1:1/F:M; adolescence-4:1/F:M

• Average length of untreated Major Average length of untreated Major Depressive Disorder – 7.2 monthsDepressive Disorder – 7.2 months

• Recurrence rates-40% within 2 yearsRecurrence rates-40% within 2 years

Heredity

• Most important risk factor for the development of depressive illness is having at least one affectively ill parent

Major Depressive DisorderMajor Depressive DisorderI.I. Five (or more) of the following symptoms have been present Five (or more) of the following symptoms have been present

during the same two-week period and represent a change during the same two-week period and represent a change from previous functioning. At least one symptom is either (1) from previous functioning. At least one symptom is either (1) depressed mood or (2) loss of interest or pleasure.depressed mood or (2) loss of interest or pleasure.

– Depressed mood most of the day, nearly every day, as Depressed mood most of the day, nearly every day, as indicated by subjective report or based on the observations of indicated by subjective report or based on the observations of others. In children and adolescents, this is often presented as others. In children and adolescents, this is often presented as irritability.irritability.

– Markedly diminished interest or pleasure in all, or almost all, Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every dayactivities most of the day, nearly every day

– Significant weight loss when not dieting or weight gain Significant weight loss when not dieting or weight gain (change of more than 5% of body weight in a month), or (change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every daydecrease or increase in appetite nearly every day

– Insomnia or hypersomnia nearly every dayInsomnia or hypersomnia nearly every day– Psychomotor agitation or retardation nearly every day Psychomotor agitation or retardation nearly every day

(observable by others)(observable by others)– Fatigue or loss of energy nearly every dayFatigue or loss of energy nearly every day– Feelings of worthlessness or inappropriate guilt nearly every Feelings of worthlessness or inappropriate guilt nearly every

dayday– Diminished ability to think, concentrate, make a decision Diminished ability to think, concentrate, make a decision

nearly every daynearly every day

Major Depressive DisorderMajor Depressive DisorderII.II. Symptoms cause clinically significant distress Symptoms cause clinically significant distress

or impairment in social or academic or impairment in social or academic functioningfunctioning

III. III. Symptoms are not due to the direct Symptoms are not due to the direct physiological physiological effects of a substance (drugs effects of a substance (drugs or medication) or a or medication) or a general medical conditiongeneral medical condition

Although there is a different diagnostic category Although there is a different diagnostic category for individuals who suffer from Bereavement, for individuals who suffer from Bereavement, many of the symptoms are the same and many of the symptoms are the same and counseling techniques may overlap. counseling techniques may overlap.

Dysthymic DisorderDysthymic Disorder• Major difference between a diagnosis of Major difference between a diagnosis of

Major Depressive Disorder and Dysthymia is Major Depressive Disorder and Dysthymia is the intensity of the feelings of depression the intensity of the feelings of depression and the duration of symptoms.and the duration of symptoms.

• Dysthymia is an overarching feeling of Dysthymia is an overarching feeling of depression most of the day, more days than depression most of the day, more days than not, that does not meet criteria for a Major not, that does not meet criteria for a Major Depressive Episode.Depressive Episode.

• Impairs functioning and lasts for at least one Impairs functioning and lasts for at least one year in children and adolescents, two in year in children and adolescents, two in adults. adults.

DepressionDepressionModifications in DSM- 5 for children:Modifications in DSM- 5 for children:

• irritable mood (vs. depressive mood)irritable mood (vs. depressive mood)• observed apathy and pervasive boredom (vs. observed apathy and pervasive boredom (vs.

anhedonia)anhedonia)• failure to make expected weight gains (rather failure to make expected weight gains (rather

than significant weight loss)than significant weight loss)• somatic complaintssomatic complaints• social withdrawalsocial withdrawal• declining school performancedeclining school performance

What depression may look What depression may look like:like:

•Negative thinking – Negative thinking – ““I canI can’’t, I wont, I won’’tt ””•Social withdrawalSocial withdrawal• IrritabilityIrritability•Poor school performance (not just grades)Poor school performance (not just grades)•Lack of interest in peer activitiesLack of interest in peer activities•Muscle aches or lack of energyMuscle aches or lack of energy•Reports of feeling helpless a lot of the time.Reports of feeling helpless a lot of the time.•Lowering their confidence-level about Lowering their confidence-level about

intelligence, friends, future, body, etc.intelligence, friends, future, body, etc.•Getting into trouble because of boredom.Getting into trouble because of boredom.

What Works for DepressionWhat Works for Depression

• PsychoeducationPsychoeducation• Cognitive/CopingCognitive/Coping• Problem SolvingProblem Solving• Activity SchedulingActivity Scheduling• Skill-building/Skill-building/

Behavioral RehearsalBehavioral Rehearsal• Social Skills TrainingSocial Skills Training• Communication SkillsCommunication Skills

Cognitive/CopingCognitive/Coping• Change cognitive distortionsChange cognitive distortions• Increase positive self talk Increase positive self talk • Identify the type of event that Identify the type of event that

will trigger the irrational will trigger the irrational thought.thought.

• Help students become aware Help students become aware of their thoughtsof their thoughts

• Recognize and get rid of Recognize and get rid of negative self talknegative self talk

• Counter negative thoughts Counter negative thoughts with realistic positive self talkwith realistic positive self talk

• Believe the positive self talk!Believe the positive self talk!

Cognitive DistortionsCognitive Distortions

•ExaggeratingExaggerating - - Making self-critical or Making self-critical or other critical statements that include terms other critical statements that include terms like never, nothing, everything or always.like never, nothing, everything or always.

•FilteringFiltering - Ignoring positive things that - Ignoring positive things that occur to and around self but focusing on and occur to and around self but focusing on and inflating the negative.inflating the negative.

•Labeling Labeling - Calling self or others a bad - Calling self or others a bad name when displeased with a behaviorname when displeased with a behavior

Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health Curriculum - A Training Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of Nursing, printed by the University of Colorado School of Nursing.

Cognitive DistortionsCognitive Distortions

• DiscountingDiscounting - Rejecting positive - Rejecting positive experiences as not important or meaningful.experiences as not important or meaningful.

• CatastrophizingCatastrophizing - Blowing expected - Blowing expected consequences out of proportion in a negative consequences out of proportion in a negative direction.direction.

• Self-blamingSelf-blaming - Holding self responsible for - Holding self responsible for an outcome that was not completely under an outcome that was not completely under one's control.one's control.Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health Curriculum - A Training Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of Nursing, printed by the University of Colorado School of Nursing.

AnxietyAnxiety• Panic DisorderPanic Disorder• Obsessive Compulsive Disorder Obsessive Compulsive Disorder • Specific PhobiasSpecific Phobias• Separation Anxiety DisorderSeparation Anxiety Disorder• Posttraumatic Stress DisorderPosttraumatic Stress Disorder• Generalized Anxiety DisorderGeneralized Anxiety Disorder

Anxiety - PrevalenceAnxiety - Prevalence• 13% of youth ages 9 to 17 will have 13% of youth ages 9 to 17 will have

an anxiety disorder in any given yearan anxiety disorder in any given year• Girls are affected more than boysGirls are affected more than boys• ~1/2 of children and adolescents with ~1/2 of children and adolescents with

anxiety disorders have a 2anxiety disorders have a 2ndnd anxiety anxiety disorder or other co-occurring disorder or other co-occurring disorder, such as depression disorder, such as depression

Panic Disorder - Diagnostic CriteriaPanic Disorder - Diagnostic CriteriaI. Recurrent unexpected Panic Attacks I. Recurrent unexpected Panic Attacks Criteria for Panic Attack: A discrete period of intense fear or Criteria for Panic Attack: A discrete period of intense fear or

discomfort, in which four (or more) of the following symptoms discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: developed abruptly and reached a peak within 10 minutes:

(1) Palpitations, pounding heart, or accelerated heart rate (1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (2) Sweating (3) Trembling or shaking (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (4) Sensations of shortness of breath or smothering (5) Feeling of choking (5) Feeling of choking (6) Chest pain or discomfort (6) Chest pain or discomfort (7) Nausea or abdominal distress (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, lightheaded, or faint (8) Feeling dizzy, unsteady, lightheaded, or faint (9) Derealization (feelings of unreality) or depersonalization (being (9) Derealization (feelings of unreality) or depersonalization (being

detached from oneself) detached from oneself) (10) Fear of losing control or going crazy (10) Fear of losing control or going crazy (11) Fear of dying (11) Fear of dying (12) Paresthesias (numbness or tingling sensations) (12) Paresthesias (numbness or tingling sensations) (13) Chills or hot flushes (13) Chills or hot flushes

Specific PhobiasSpecific Phobias• Marked and persistent fear of a specific object or Marked and persistent fear of a specific object or

situation with exposure causing an immediate anxiety situation with exposure causing an immediate anxiety response that is excessive or unreasonableresponse that is excessive or unreasonable

• In children, anxiety may be expressed as crying, In children, anxiety may be expressed as crying, tantrums, freezing, or clinging.tantrums, freezing, or clinging.

• Animal phobias most common childhood phobia.Animal phobias most common childhood phobia.• Also frequently afraid of the dark and imaginary Also frequently afraid of the dark and imaginary

creaturescreatures• In older children and adolescents, fears are more In older children and adolescents, fears are more

focused on health, social and school problemsfocused on health, social and school problems• Adults recognize that their fear is excessive. Children Adults recognize that their fear is excessive. Children

may not.may not.• Causes significant interference in life, or significant Causes significant interference in life, or significant

distress.distress.• Under 18 years of age – symptoms must be Under 18 years of age – symptoms must be >> 6 6

monthsmonths

Separation Anxiety Separation Anxiety DisorderDisorder

Developmentally inappropriate and excessive anxiety Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom concerning separation from home or from those to whom the individual is attached, as evidenced by three (or the individual is attached, as evidenced by three (or more) of the following:more) of the following:

(1)(1) Recurrent excessive distress when separation from home or Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipatedmajor attachment figures occurs or is anticipated

(2)(2) Persistent and excessive worry about losing, or about possible Persistent and excessive worry about losing, or about possible harm befalling, major attachment figuresharm befalling, major attachment figures

(3)(3) Persistent and excessive worry that an untoward event will lead Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost to separation from a major attachment figure (e.g., getting lost or being kidnapped)or being kidnapped)

(4)(4) Persistent reluctance or refusal to go to school or elsewhere Persistent reluctance or refusal to go to school or elsewhere because of fear of separation because of fear of separation

Separation Anxiety Separation Anxiety DisorderDisorder

(5)(5) Persistently and excessively fearful or reluctant to be alone or without Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other major attachment figures at home or without significant adults in other settings settings

(6)(6) Persistent reluctance or refusal to go to sleep without being near a Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home major attachment figure or to sleep away from home

(7)(7) Repeated nightmares involving the theme of separationRepeated nightmares involving the theme of separation

(8)(8) Repeated complaints of physical symptoms (such as headaches, Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated attachment figures occurs or is anticipated

• Duration of at least 4 weeksDuration of at least 4 weeks

• Causes clinically significant distress or impairment in social, Causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioningacademic (occupational), or other important areas of functioning

Generalized Anxiety Generalized Anxiety DisorderDisorder • Excessive anxiety and worry for at least 6 Excessive anxiety and worry for at least 6

months, more days than notmonths, more days than not• Worry about performance at school, Worry about performance at school,

sports, etc.sports, etc.• DSM 5 criteria less stringent for children DSM 5 criteria less stringent for children

(Need only one criteria instead of three of (Need only one criteria instead of three of six):six):(1)(1) Restlessness or feeling keyed up or on Restlessness or feeling keyed up or on

edge edge (2)(2) Being easily fatiguedBeing easily fatigued(3)(3) Difficulty concentrating or mind going Difficulty concentrating or mind going

blankblank(4)(4) IrritabilityIrritability(5)(5) Muscle tensionMuscle tension(6)(6) Sleep disturbance (difficulty falling or Sleep disturbance (difficulty falling or

staying asleep, or restless unsatisfying staying asleep, or restless unsatisfying sleep) sleep)

Obsessive Compulsive Obsessive Compulsive DisorderDisorder

• Presence of Obsessions Presence of Obsessions (thoughts) and/or (thoughts) and/or Compulsions (behaviors)Compulsions (behaviors)

• Although adults may have Although adults may have insight, kids may notinsight, kids may not

• Interferes with life or causes Interferes with life or causes distressdistress

• One third to one half of all One third to one half of all adult patients report onset adult patients report onset in childhood or adolescencein childhood or adolescence

Post-traumatic Stress Disorder Post-traumatic Stress Disorder (PTSD)(PTSD)

The person has been exposed to a traumatic event in The person has been exposed to a traumatic event in which both of the following were present: which both of the following were present:

• (1) The person experienced, witnessed, or was (1) The person experienced, witnessed, or was confronted with an event or events that involved confronted with an event or events that involved actual or threatened death or serious injury, or a actual or threatened death or serious injury, or a threat to the physical integrity of self or others threat to the physical integrity of self or others

• (2) The person's response involved intense fear, (2) The person's response involved intense fear, helplessness, or horror. (Note: In children, this may helplessness, or horror. (Note: In children, this may be expressed instead by disorganized or agitated be expressed instead by disorganized or agitated behavior.) behavior.)

Persistent Re-experiencing of event Persistent Re-experiencing of event (1 or more)(1 or more)

(1)(1)Recurrent and intrusive Recurrent and intrusive distressing recollectionsdistressing recollections of the event, of the event, including images, thoughts, or perceptions. (Note: In young including images, thoughts, or perceptions. (Note: In young children, repetitive play may occur in which themes or aspects children, repetitive play may occur in which themes or aspects of the trauma are expressed.)of the trauma are expressed.)

(2)(2)Recurrent Recurrent distressing dreamsdistressing dreams of the event. (Note: In children, of the event. (Note: In children, there may be frightening dreams without recognizable content.) there may be frightening dreams without recognizable content.)

(3)(3)Acting or feeling as if the traumatic event were recurringActing or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (Note: In those that occur on awakening or when intoxicated). (Note: In young children, trauma-specific reenactment may occur.) young children, trauma-specific reenactment may occur.)

(4)(4)Intense psychological distressIntense psychological distress at exposure to internal or at exposure to internal or external cues that symbolize or resemble an aspect of the external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the or external cues that symbolize or resemble an aspect of the traumatic event traumatic event

Avoidance and Numbing Avoidance and Numbing (3 or more)(3 or more)(1)(1)Efforts to avoid thoughts, feelings, or conversations associated Efforts to avoid thoughts, feelings, or conversations associated

with the traumawith the trauma

(2)(2)Efforts to avoid activities, places, or people that arouse Efforts to avoid activities, places, or people that arouse recollections of the traumarecollections of the trauma

(3)(3) Inability to recall an important aspect of the trauma Inability to recall an important aspect of the trauma

(4)(4)Markedly diminished interest or participation in significant Markedly diminished interest or participation in significant activitiesactivities

(5)(5)Feeling of detachment or estrangement from othersFeeling of detachment or estrangement from others

(6)(6)Restricted range of affect (e.g., unable to have loving feelings)Restricted range of affect (e.g., unable to have loving feelings)

(7)(7)Sense of a foreshortened future (e.g., does not expect to have a Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) career, marriage, children, or a normal life span)

Increased Arousal Increased Arousal (2 or more)(2 or more)(1)(1)Difficulty falling or staying asleep Difficulty falling or staying asleep

(2)(2)Irritability or outbursts of angerIrritability or outbursts of anger

(3)(3)Difficulty concentrating Difficulty concentrating

(4)(4)Hypervigilance Hypervigilance

(5)(5)Exaggerated startle response Exaggerated startle response

Posttraumatic Stress Disorder Posttraumatic Stress Disorder (PTSD)(PTSD)• At least one month duration.At least one month duration.

• Causes clinically significant distress or impairment in Causes clinically significant distress or impairment in social, occupational, or other important areas of social, occupational, or other important areas of functioningfunctioning

• Many students with PTSD meet criteria for another Axis Many students with PTSD meet criteria for another Axis I Disorder (e.g., major depression, Panic Disorder) – I Disorder (e.g., major depression, Panic Disorder) – both should be diagnosedboth should be diagnosed

• Prevalence in adolescentsPrevalence in adolescents– 4% of boys and 6% of girls4% of boys and 6% of girls– 75% of those with PTSD have additional mental health 75% of those with PTSD have additional mental health

problemproblem((Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel,

1995 )1995 )

Impact of trauma on learningImpact of trauma on learning• Decreased IQ and reading ability Decreased IQ and reading ability (Delaney-(Delaney-

Black et al., 2003)Black et al., 2003)

• Lower grade-point average Lower grade-point average (Hurt et al., 2001) (Hurt et al., 2001)

• More days of school absence More days of school absence (Hurt et al., 2001) (Hurt et al., 2001)

• Decreased rates of high school graduation Decreased rates of high school graduation (Grogger, 1997)(Grogger, 1997)

• Increased expulsions and suspensions Increased expulsions and suspensions (LAUSD (LAUSD Survey)Survey)

Effective Practice StrategiesEffective Practice Strategies• ModelingModeling• RelaxationRelaxation• Cognitive/CopingCognitive/Coping• ExposureExposure

What is What is ModelingModeling??• Demonstration of a Demonstration of a

desired behavior by a desired behavior by a therapist, therapist, confederates, peers, confederates, peers, or other actors to or other actors to promote the imitation promote the imitation and subsequent and subsequent performance of that performance of that behavior by the behavior by the identified youthidentified youth

What is What is RelaxationRelaxation??

• Techniques or exercises designed to Techniques or exercises designed to induce physiological calming, including induce physiological calming, including muscle relaxation, breathing exercises, muscle relaxation, breathing exercises, meditation, and similar activities. meditation, and similar activities.

• Guided imagery exclusively for the Guided imagery exclusively for the purpose of physical relaxation is purpose of physical relaxation is considered relaxation.considered relaxation.

Relaxation: Deep BreathingRelaxation: Deep Breathing• Breathe from the stomach rather than from the Breathe from the stomach rather than from the

lungslungs

• Can be used in class without anyone noticingCan be used in class without anyone noticing

• Can be used during stressful moments such as Can be used during stressful moments such as taking an exam or while trying to relax at home taking an exam or while trying to relax at home

• Children should breathe in to the count of 5, and Children should breathe in to the count of 5, and out to the count of 5. Adolescents should breathe out to the count of 5. Adolescents should breathe in and out to the count of 8in and out to the count of 8

• Have them take 3 normal breaths in between deep breathsHave them take 3 normal breaths in between deep breaths

• Have them imagine a balloon filling with air, then totally Have them imagine a balloon filling with air, then totally emptying emptying

Relaxation: Mental Relaxation: Mental Imagery/Visualization TipsImagery/Visualization Tips• Have the student close his/her eyes Have the student close his/her eyes

and imagine a relaxing place such and imagine a relaxing place such as a beach as a beach

• While they imagine this, describe While they imagine this, describe the place to them, including what the place to them, including what they see, hear, feel, and smellthey see, hear, feel, and smell

• Younger students may use a picture Younger students may use a picture or drawing to help themor drawing to help them

Relaxation: Progressive Muscle Relaxation: Progressive Muscle RelaxationRelaxation

• Alternating between Alternating between states of muscle states of muscle tension and tension and relaxation helps relaxation helps differentiate differentiate between the two between the two states and helps states and helps habituate a process habituate a process of relaxing muscles of relaxing muscles that are tensedthat are tensed

• Many good Many good tapes/c.d.tapes/c.d.’’s available s available on relaxationon relaxation

ADHD PrevalenceADHD Prevalence•Range from 1-16% depending Range from 1-16% depending

on criteria usedon criteria used•3-5% prevalence in school-age 3-5% prevalence in school-age

childrenchildren•Male: female ratio is 3:1 to 10:1Male: female ratio is 3:1 to 10:1•Occurs more frequently in lower Occurs more frequently in lower

SESSES

ADHD DSM-5 DiagnosisADHD DSM-5 Diagnosis• 6 or more inattentive items 6 or more inattentive items • 6 or more hyperactive/impulsive items6 or more hyperactive/impulsive items• Persistent for at least 6 months Persistent for at least 6 months • Clinically significant impairment in social, Clinically significant impairment in social,

academic, or occupational functioningacademic, or occupational functioning• Inconsistent with developmental levelInconsistent with developmental level• Some symptoms that caused impairment Some symptoms that caused impairment

before the age of 7before the age of 7• Impairment is present in two or more settings Impairment is present in two or more settings

(school, home, work)(school, home, work)

InattentionInattention1)1) Often fails to give close attention to details or makes Often fails to give close attention to details or makes

careless mistakes in schoolwork, work or other careless mistakes in schoolwork, work or other activitiesactivities

2)2) Often has difficulty sustaining attention in task or play Often has difficulty sustaining attention in task or play activitiesactivities

3)3) Often does not seem to listen when spoken to directlyOften does not seem to listen when spoken to directly4)4) Often does not follow through on instructions and fails Often does not follow through on instructions and fails

to finish schoolwork, chores, or duties in the to finish schoolwork, chores, or duties in the workplace (not due to oppositionality or failure to workplace (not due to oppositionality or failure to understand instructions)understand instructions)

5)5) Often has difficulty organizing tasks and activitiesOften has difficulty organizing tasks and activities6)6) Often avoids, dislikes or is reluctant to engage in Often avoids, dislikes or is reluctant to engage in

tasks that require sustained mental efforttasks that require sustained mental effort7)7) Often loses things necessary for tasks or activitiesOften loses things necessary for tasks or activities8)8) Is often easily distracted by extraneous stimuliIs often easily distracted by extraneous stimuli9)9) Is often forgetful in daily activitiesIs often forgetful in daily activities

HyperactivityHyperactivity1) Often fidgets with hands or feet or squirms in seat1) Often fidgets with hands or feet or squirms in seat2) Often leaves seat in classroom or in other situations 2) Often leaves seat in classroom or in other situations

in which remaining seated is expectedin which remaining seated is expected3) Often runs about or climbs excessively in situations 3) Often runs about or climbs excessively in situations

in which it is inappropriate (in adolescents or adults, in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)may be limited to subjective feelings of restlessness)

4) Often has difficulty playing or engaging in leisure 4) Often has difficulty playing or engaging in leisure activities quietlyactivities quietly

5) Is often 5) Is often ““on the goon the go”” or often acts as if or often acts as if ““driven by a driven by a motormotor””

6) Often talks excessively6) Often talks excessively

ImpulsivityImpulsivity1)1) Often blurts out answers before Often blurts out answers before

questions have been completedquestions have been completed2)2) Often has difficulty awaiting turnOften has difficulty awaiting turn3)3) Often interrupts or intrudes on Often interrupts or intrudes on

othersothers

Make sure it is ADHD! Make sure it is ADHD!

Mood/Anxiety Problems

PDD Spectrum

What DoesnWhat Doesn’’t Work for t Work for ADHD?ADHD?• Treatments with little or no evidence of Treatments with little or no evidence of

effectiveness includeeffectiveness include– Special elimination dietsSpecial elimination diets– Vitamins or other health food remediesVitamins or other health food remedies– Psychotherapy or psychoanalysisPsychotherapy or psychoanalysis– BiofeedbackBiofeedback– Play therapyPlay therapy– Chiropractic treatmentChiropractic treatment– Sensory integration trainingSensory integration training– Social skills trainingSocial skills training– Self-control trainingSelf-control training

Basic Principles for Effective Basic Principles for Effective Practice for ADHDPractice for ADHD

• Clear and brief rulesClear and brief rules• Swift consequencesSwift consequences• Frequent consequencesFrequent consequences• Powerful consequencesPowerful consequences• Rich incentivesRich incentives• Change rewardsChange rewards• Expect failuresExpect failures• AnticipateAnticipate

PraisePraise

•Praising correctly increases Praising correctly increases compliance in youth with ADHDcompliance in youth with ADHD– Praise can include Praise can include

•Verbal praise, EncouragementVerbal praise, Encouragement•AttentionAttention•AffectionAffection•Physical proximityPhysical proximity

Giving Effective PraiseGiving Effective Praise• Be honest, not overly flatteringBe honest, not overly flattering• Be specificBe specific• No No ““back-handed complimentsback-handed compliments”” (i.e., (i.e.,

““I like the way you are working I like the way you are working quietly, why canquietly, why can’’t you do this all the t you do this all the time?time?””))

• Give praise immediatelyGive praise immediately

Ignoring and Differential Ignoring and Differential ReinforcementReinforcement• Train staff and teachers to Train staff and teachers to

selectivelyselectively– Ignore mild unwanted behaviorsIgnore mild unwanted behaviors

ANDAND

– Attend to and REINFORCE alternative Attend to and REINFORCE alternative positive behaviorspositive behaviors

How to ignoreHow to ignore• Visual cuesVisual cues

– Look away once child engages in undesirable Look away once child engages in undesirable behaviorbehavior

– Do not look at the child until behavior stopsDo not look at the child until behavior stops

• Postural cuesPostural cues– Turn the front of your body away from the Turn the front of your body away from the

location of childlocation of child’’s undesirable behaviors undesirable behavior– Do not appear frustrated (e.g., hands on hip)Do not appear frustrated (e.g., hands on hip)– Do not vary the frequency or intensity of your Do not vary the frequency or intensity of your

current activity (e.g., talking faster or louder)current activity (e.g., talking faster or louder)

How to ignoreHow to ignore• Vocal cuesVocal cues

– Maintain a calm voice even after your child begins Maintain a calm voice even after your child begins undesirable behaviorundesirable behavior

– Do not vary the frequency or intensity of your Do not vary the frequency or intensity of your voice (e.g., donvoice (e.g., don’’t talk faster or shout over the child)t talk faster or shout over the child)

• Social cuesSocial cues– Continue your intended activity even after your Continue your intended activity even after your

child begins undesirable behaviorchild begins undesirable behavior– Do not panic once childDo not panic once child’’s begins inappropriate s begins inappropriate

behavior (i.e., do not draw more attention to child)behavior (i.e., do not draw more attention to child)

When to IgnoreWhen to Ignore• When to ignore undesirable behavior When to ignore undesirable behavior

– Child interrupts conversation or classChild interrupts conversation or class– Child blurts out answers before question Child blurts out answers before question

completedcompleted– Child tantrumsChild tantrums

• Do Do notnot ignore undesirable behavior ignore undesirable behavior that could potentially harm the child or that could potentially harm the child or someone elsesomeone else

Differential reinforcementDifferential reinforcementStep OneStep One: Ignore (stop reinforcing) the child: Ignore (stop reinforcing) the child’’s s

undesirable behaviorundesirable behaviorStep TwoStep Two: Reinforce the child: Reinforce the child’’s desirable behavior s desirable behavior

in a systematic mannerin a systematic manner– The desirable behavior should be a behavior that is The desirable behavior should be a behavior that is

incompatible with the undesirable behaviorincompatible with the undesirable behaviorExample:Example:• Target behavior: InterruptingTarget behavior: Interrupting• Desirable behavior: Working by himselfDesirable behavior: Working by himself• Reward schedule: 5 minutesReward schedule: 5 minutes

– If child goes 5 minutes without interrupting, the child If child goes 5 minutes without interrupting, the child receives reinforcementreceives reinforcement

– If child interrupts before 5 minutes is up, the child does If child interrupts before 5 minutes is up, the child does not receive reinforcement and the reward schedule is not receive reinforcement and the reward schedule is resetreset

Defining Disruptive Defining Disruptive BehaviorsBehaviors• Types of Disruptive Behavior Types of Disruptive Behavior

Disorders (DBD):Disorders (DBD):– ADHDADHD– Oppositional Defiant Disorder (ODD) – loses Oppositional Defiant Disorder (ODD) – loses

temper, argues with adults, easily annoyed, temper, argues with adults, easily annoyed, actively defies or refuses to comply with actively defies or refuses to comply with adults. adults.

– Conduct Disorder (CD) – aggression toward Conduct Disorder (CD) – aggression toward peers, destruction of property, deceitfulness peers, destruction of property, deceitfulness or theft, and serious violation of rules.or theft, and serious violation of rules.

Oppositional Defiant Oppositional Defiant DisorderDisorder

“You left your D__M car in the driveway again!”

Oppositional Defiant Oppositional Defiant DisorderDisorderA pattern of negativistic, hostile and defiant A pattern of negativistic, hostile and defiant

behavior lasting greater than 6 months of behavior lasting greater than 6 months of which you have 4 or more of the following:which you have 4 or more of the following:

• Loses temperLoses temper• Argues with adults Argues with adults • Actively defies or refuses to comply with rulesActively defies or refuses to comply with rules• Often deliberately annoys people Often deliberately annoys people • Blames others for his/her mistakesBlames others for his/her mistakes • Often touchy or easily annoyed with othersOften touchy or easily annoyed with others• Often angry and resentfulOften angry and resentful• Often spiteful or vindictiveOften spiteful or vindictive

Oppositional Defiant Oppositional Defiant DisorderDisorder(ODD)(ODD)• Prevalence-3-10%Prevalence-3-10%• Male to female -2-3:1Male to female -2-3:1• Outcome-in one study, 44% of 7-12 year Outcome-in one study, 44% of 7-12 year

old boys with ODD developed into CDold boys with ODD developed into CD• Evaluation-Look for comorbid ADHD, Evaluation-Look for comorbid ADHD,

depression, anxiety & Learning depression, anxiety & Learning Disability/Mental RetardationDisability/Mental Retardation

Conduct DisorderConduct Disorder(CD)(CD)

• Aggression Aggression toward people toward people or animalsor animals

• Deceitfulness or Deceitfulness or TheftTheft

• Destruction of Destruction of propertyproperty

• Serious violation Serious violation of rulesof rules

Conduct DisorderConduct Disorder(CD)(CD)

• Prevalence-1.5-3.4%Prevalence-1.5-3.4%• Boys greatly outnumber girls (3-5:1)Boys greatly outnumber girls (3-5:1)• Co-morbid ADHD in 50%, common to have Co-morbid ADHD in 50%, common to have

LDLD• Course-remits by adulthood in 2/3. Others Course-remits by adulthood in 2/3. Others

become Antisocial Personality Disorderbecome Antisocial Personality Disorder• Can be diagnosed as early onset (before Can be diagnosed as early onset (before

age 10) or regular onset (after age 10)age 10) or regular onset (after age 10)

Practices that Work with DBDPractices that Work with DBD• PraisePraise• Commands/limit settingCommands/limit setting• Tangible rewardsTangible rewards• Response costResponse cost• PsychoeducationPsychoeducation• Problem solvingProblem solving

Steps to Making Effective Steps to Making Effective CommandsCommands1.1. To make eye contact with the child before To make eye contact with the child before

giving commandgiving command2.2. To reduce other distractions while giving To reduce other distractions while giving

commandscommands3.3. To ask the child to repeat the commandTo ask the child to repeat the command4.4. To watch the child for one minute after To watch the child for one minute after

giving the command to ensure compliancegiving the command to ensure compliance5.5. To immediately praise child when s/he To immediately praise child when s/he

starts to complystarts to comply

Effective Commands/Limit Effective Commands/Limit Setting with AdolescentsSetting with Adolescents

• Praise teens for appropriate behaviorPraise teens for appropriate behavior• Tell teen what Tell teen what toto do, rather than what do, rather than what notnot to do to do• Eliminate other distractions while giving Eliminate other distractions while giving

commandscommands• Break down multi-step commandsBreak down multi-step commands• Use aids for commands that involve timeUse aids for commands that involve time• Present the consequences for noncompliancePresent the consequences for noncompliance• Not respond to compliance with gratitudeNot respond to compliance with gratitude

Setting up a Reward System Setting up a Reward System for Children at Schoolfor Children at School• School staff tracks the childSchool staff tracks the child’’s behavior and reports s behavior and reports

it to the parent daily.it to the parent daily.– Rewards can given at home or at schoolRewards can given at home or at school

• Choose a few target behaviors at schoolChoose a few target behaviors at school– Choose one that the child will be successful with most of Choose one that the child will be successful with most of

the timethe time– Set up a system for school report card or school/home Set up a system for school report card or school/home

note systemnote system• Set up a daily report card targeting one to three Set up a daily report card targeting one to three

behaviorsbehaviors• Can also set up guidance counselor, tutor or peer Can also set up guidance counselor, tutor or peer

as as ““coachcoach”” for organizational skills or other targets for organizational skills or other targets

Calm

Trigger

Agitation

Acceleration

Peak

De-escalation

Recovery

Acting Out CycleActing Out Cycle

Adapted from The Iris Center: http://iris.peabody.vanderbilt.edu

General StrategiesGeneral Strategies• Use active listeningUse active listening• DonDon’’t be afraid to show that you caret be afraid to show that you care• Be a good role modelBe a good role model• Take the time to greet students dailyTake the time to greet students daily• Show genuine interest in their lives and hobbiesShow genuine interest in their lives and hobbies• Find and reinforce the positivesFind and reinforce the positives• Move beyond labels and leave assumptions at home!Move beyond labels and leave assumptions at home!• Smiles are contagiousSmiles are contagious• Take the time to problem solve with studentsTake the time to problem solve with students• Involve families in a childInvolve families in a child’’s educations education• Instill hope about the futureInstill hope about the future