Share your ideas with the larger group

1. Understanding and Teaching
Students with Anxiety and Depression
Rona Milch Novick, PhD
Rev 1/11

2. Erica’s Story
Erica is a middle school student, who has always been a
bit clingy, shy and nervous. This year, during a
school trip she got sick and threw up on the bus.
Ever since, she has refused to go on the school bus.
She will not take gym class, complaining that
running around makes her feel like she will be sick.
She refuses to go to school many mornings, and
spends a lot of time in the nurse’s office, saying she
thinks she is going to be sick.

3. Yossi’s Story
Yossi transferred to the all boy’s high school for 10th
grade saying he wanted a new start. He failed most
subjects in 9th grade and his parents say he became
really withdrawn, no longer hanging out with his
friends. When asked about it he said it’s just not
fun anymore. He says he hopes the change in school
will help but doubts it since he is not really good at
anything and will probably fail. His parents also
find him more angry and disrespectful, and he seems
to want to sleep constantly.

4. Think- Pair- Share
What Does This Have to Do With
School?
 List 3 ways anxiety could interfere with
school success
 List 3 ways depression could interfere with
school success

5. Stress/Anxiety-Performance
Curve
Performance
Anxiety

6. Anxiety and Avoidance
Stimulus Anxiety
Avoidance
Decreased
Anxiety

7. Components of Anxiety
Triple Response Mode:
 Physiological arousal
 Hypervigilance/worry
 Behavioral avoidance (as a result)

8. Impacts of Anxiety In School
Settings
 Negatively affects academic work and school
performance
 Impairments in social adjustment
 Decreased social acceptance
 Low global self worth
 Co-morbidity is significant
 12% depression
 15% oppositional defiant disorder
 17% ADHD
 50-75% another anxiety disorder

9. Psychiatric difficulties in youth
 American Academy of Pediatrics: 20% of children
aged 4-15 have psychological or behavioral problems
(2x increase since 1980)
 Estimates of actual psychiatric disorders:
 12 million American children and teens
 5-15% of 9-10 year olds
 15-20% of adolescents
 Adult comparison: 20%
 Criteria: DSM-IV, including symptom severity and
impairment in functioning (family school, peers)

10. Etiology
 Biological disorders of neurotransmitters
 Emergence of disorders precipitated by:
 genetic vulnerability
 deficient social supports
 family dysfunction
 trauma
 chronic environmental stress

11. How Prevalent Are Anxiety
Disorders?
 Most common psychiatric disorder in
children
 Estimated 10-20% incidence rate
 Anxiety symptoms are persistent over
time
 Prognosis poor if untreated
 More common in girls
 Up to 30% of all children may exhibit
subclinical levels of worry

12. Anxiety Interventions as
Resilience Builders
 Cognitive Behavioral Interventions
 Cognitive techniques
 Metacognitive lessons on healthy thinking
 Skill building
 Imagery, emotional literacy, other direct skills
 Relaxation training

13. Negative Thinking Exercise
 With your group of 4, review the common
negative thought patterns
 Create examples for three of these and,
without indentifying which type of negative
thought pattern they are, write them on your
paper
 Groups will rotate around the room and
attempt to indentify the negative thought
pattern in each example

14. Exercise Debrief
 Pedagogic technique – having students create
examples increases learning
 “Carousel” often involves movement,
possibility for non-verbal responding,
repeated practice

15. School Involvement in Treatment
 Majority of child’s time is in school
 School is child’s natural environment,
generalization is essential
 School requires intact cognitive and
social functioning
 School personnel are central in child’s
life

16. Interventions
 Behavioral and
Cognitive-Behavioral Treatments
 Exposure
 Response Prevention
 Relaxation/Imagery
 Reinforced practice/Operant techniques
 Cognitive Techniques
 Family Treatment
 Psychopharmacology
 Clomipramine
 SSRI’s

17. Need for Sensitivity:
Role of Schools
 Any and all school personnel can be part of
solution or problem
 All school personnel must understand disorder
and students’ needs
 All school personnel should respond sensitively
and therapeutically
 Communication between school, home and
outside professionals is essential

18. Intervention – Helping Those With
Special Needs
 Slow but steady movement
 Avoid avoidance
 Communication across settings
 Reinforcement of learned skills
 Generalization training

19. Reaction
Handling Anxious Reactions
 Match anxiety with calm
 Prompt for skill use
 Attempt not to go backwards – even if
forwards is impossible
 View as temporary crisis
 Reinforce non-anxious behavior but use
caution in penalizing anxious behavior

20. Anxiety Disorder Diagnoses
 Separation Anxiety Disorder
 Generalized Anxiety Disorder
 Social Phobia
 Selective Mutism
 Obsessive Compulsive Disorder
*School Phobia is not formal diagnosis

21. Generalized Anxiety Disorder
 Excessive and unrealistic worries
 About competence, approval, future, past
 Extreme self-consciousness
 Excessive need for reassurance
 Inability to relax
 Somatic complaints
 Trouble concentrating
 Sleep disturbance
 Fatigued
 Symptoms for 6 months or more

22. Separation Anxiety Disorder
Developmentally inappropriate & excessive anxiety concerning
separation from home or attachment figures, with 3 or more
 recurrent excessive distress at separation
 persistent and excessive worry about losing or harm befalling
attachment figures
 persistent reluctance or refusal to go to school or elsewhere
 persistent fearfulness at being alone
 persistent reluctance to go to sleep without being near major
attachment figure
 repeated nightmares about separation
 repeated c/o physical symptoms at separation or when
anticipated

23. Separation Anxiety - cont’d
 Duration of at least 4 weeks
 Onset before age 18
 Clinically significant distress
 Not PDD, Schizophrenia, Psychotic
disorder, or Panic Disorder in adolescents

24. Selective Mutism
 Rare, fewer than 1% of referrals
 Usually begins in preschool
 Many children reported as shy

25. School Phobia
 Not a formal diagnosis
 Variant of separation anxiety disorder,
social phobia or other anxiety disorder
 Rarely actual phobia to school setting
 Distinguish from truancy and school
refusal

26. Obsessive Compulsive Disorder
 Presence of obsessions or compulsion
 Obsessions are
 persistent ideas - intrusive
 unable to ignore
 Compulsions are
 repetitive behavior or thought driven to perform in
response to obsession
 Aimed at preventing distress
 Causes marked distress
 Child knows O/C are unreasonable

27. Video Watching Guide (Selective
Mutism)
 What is one thing you heard that you didn’t
know
 What is one thing you would do differently as
a result of watching the video

28. Depression in Children and
Adolescents
 How does depression effect learning?
 How does depression effect testing?
 How does depression effect other aspects of school
functioning?
 http://www.youtube.com/watch?v=S1PPCzRkBKQ

29. Depressed mood and depressive
disorders
 Depressed mood relatively common:
 10% school-age children
 40% adolescents
 If persistent and severe:
 Affective disorders, including Major Depressive Disorder,
Bipolar Disorder, Dysthymic Disorder
 Fewer than 1 in 5 young people who need tx for
depression get it

30. Historical trends
 “Parents are too stern, chide, brawl, whip and strike…
children are so disheartened they never have a merry
hour in their lives…” (Burton, 1621)
 Depression-like features in children whose
attachment was not initiated, interrupted, or lost
(Bowlby, Spitz, A. Freud, ’30s-’60s)
 “Masked depression” (’50s-’70s)
 Mood disorders of youth parallel adults (70s+)

31. Models of depression – with relevance
for school settings
 Learned helplessness (behavior independent of
reinforcement)
 http://www.youtube.com/watch?v
=gFmFOmprTt0
 Cognitive distortions (negative views of self,
environment and the future)
 Life stress (SES, family factors, poor social supports)
 Genetic/Biochemical (neurotransmitters)

32. Neurotransmitters
 Serotonin: low levels associated with
violence, suicidality (decreased CSF
concentration of 5HIAA)
 Dopamine: increase of dopamine activity
implicated in psychotic depression
 Norepinephrine: abnormalities found in
urinary MHPG of depressed patients

33. Assessment
 Need for multiple respondents
 Clinical interview (structured?)
 Rating scales (CDI, Beck, CBCL, BASC)
 Psychological testing
 Behavior observation
 DSM-IV

34. Mood disorders
 Major Depressive Disorder
 Dysthymic Disorder
 Depressive Disorder NOS
 Bipolar Disorder
 Mood Disorder NOS
 Mood Disorder due to Medical Condition
 Substance Induced Mood Disorder
 Adjustment Disorder w/ Depressed Mood

35. Major Depressive Disorder (MDD)
 Depressed or irritable mood
 Loss of interest or pleasure
 Weight loss or weight gain
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
 Fatigue, loss of energy
 Feelings of worthlessness, excessive guilt
 Poor concentration or indecisiveness
 Suicidality
 5 or more of above in same 2-week period

36. MDD: How common?
 Preschoolers: 1%
 School-age: 2%
 Adolescents: 4-9%
 Adults: 6-9%
 Relapse rates: 50-60%
 Recent cohort studies: increased incidence, earlier age
of onset, more severe sx (implications as aging
occurs)
 Sex differences: none for school-age; by teen years,
affects more females than males, across cultures

37. Dysthymic Disorder
 Insidious onset
 Chronic course
 Duration greater than one year
 High risk for MDD (“Double depression”)
 Prevalence: 4-8%

38. Bipolar Disorder
 No special DSM-IV provisions for children
 Complicated differential diagnosis (nonaffective
psychoses, unipolar depression, organic syndromes,
ADHD, and disruptive behavior disorders)
 Prevalence: 1-2% with no sex differences
 MDD, dysthymia as precursors

39. “Sub-threshold” Issues
 How depressed is depressed?
 Issue of criterion
 Determination of diagnosis especially difficult
in context of “adolescent turmoil”
 Even if formal criteria are not met, still
requires sensitivity to subclinical depressed
mood

40. Adolescent depression
 M:F=1:2, across cultures
 Greater frequency, intensity, earlier onset in each
generation since the ’40s
 May or may not parallel adult form
 Irritable, angry affect may predominate (different
from “typical” oppositionalism)
 More mood variability (can look fine at times)
 Course: episode duration in clinical samples: 7-9
months; 40-60% relapse in 2 yrs
 Less inclined to be referred for tx than disruptive
disorders

41. Treatment considerations
 Identifying teens who need professional help for
depression can be difficult
 Introversive teen can be overlooked, disruptive,
substance-abusing teens may not be seen as depressed
 Finding treatment can be difficult (7,000 child and
adolescent psychiatrists in US), especially in low-
income areas
 Demand outweighs resources

42. Treatments: Psychosocial
 Cognitive therapy (addresses negative views of self,
world and the future)
 Interpersonal therapy (emphasis on current
relationships; use of rehearsal, role play)
 Family therapy (communication skills, structural
realignment)
 Dialectical behavior therapy (DBT)

43. Suicidality
 A symptom, not a disorder itself
 Teen suicide: still a rare event
 Often (but not exclusively) associated with
depression
 3rd leading cause of death ages 15-19
 Threefold increase from ’50s to early ’90s
 Recent decreases across racial groups

44. Protective factors
 Family cohesion
 Social supports
 Religiosity
 Problem-solving skills
 Ability/willingness to verbalize
 Treatment

45. Prevention efforts
 In general, problematic
 School-based educational programs create more risk
than benefit
 Screenings: many false positives; also question of
available resources (600 calls/month at SCH)
 Crisis hotlines: mixed effects; most studies show no
significant effects; teens do not tend to use them

46. Exercise
 In your groups of 4:
 Consider a school activity that could either foster/
enhance depression, or help a student recover
 What could a teacher do to make the activity a
health-ful one
 Example: Standardized test – teacher could
berate students about need for excellence, or be
more supportive