Adolescent Mental Health:

Anxiety, Depression, and Stress: Coping Skills for Teens

David W. Holdefer

MCPS School Psychologist

Mental Health There is a straw that breaks the camel’s

back. Sometimes the “camel’s back” is another

name for our internal mental health. Our predisposition to coping or falling apart. Our ability to be resilient. Resilience is highly related to self-esteem, self-image, and self concept. In the school setting, academic success and resilience are highly correlated to cognitive and emotional intelligence, but…

COPING SKILLS

What are the major stressors facing adolescents?

What are positive coping skills adolescents use to alleviate stress? (How about the negative coping strategies?)

How do some teenagers manage their time, advanced classes, and friendships?

Instructional match? How can parents help students to have reasonable expectations?

How might anxiety,

depression, and stress affect a

teen’s academic performance?

Research suggests that anxiety and depression inhibits:AttentionMemoryLanguage skillsSocial skillsMental processes

Depression interferes with academic achievement

Anxiety Quote:

“ No sharp-witted judge knows how to interrogate, to examine the accused, as anxiety does, which never lets him escape, neither by diversion nor by noise, neither at work nor at play, neither by day nor by night.”

Soren Kiekegaard

The Stats: 40 million Americans suffer the gnawing

unease of anxiety in its many forms; more people seek treatment for anxiety than for back pain.

Anxiety is one of the most common experiences of children and adults with the primary characteristic of “worry”.

It is estimated that as many as 10% of all teens experience significant anxiety problems.

Anxiety Symptoms:

Concentration and Attention Problems Memory Problems Problem-Solving Difficulties Fear and Worry Restlessness and Fidgeting Irritability Withdrawal Perfectionism

Anxiety as an Impairment

Anxiety disorders can impair social, personal, and academic functioning. The frequency of anxiety disorders ranges from about 3% up to 20% of children and adolescents. With a 10% frequency rate, a high school class of 30 students could have as many as three students with an anxiety disorder and perhaps two of them would be girls who appear quiet and hard working.

Emotional Symptoms

The primary symptoms of depression are a sad mood and/or loss of interest in life. Activities that were once pleasurable lose their appeal. Patients may also be haunted by a sense of guilt or worthlessness, lack of hope, and recurring thoughts of death or suicide.

Anxiety is a feeling of apprehension and fear characterized by physical symptoms.

Depression Symptoms: Physical

Depression is sometimes linked to physical symptoms. These include:

Fatigue and decreased energy Insomnia, especially early-morning waking Excessive sleep Persistent aches or pains, headaches,

cramps, or digestive problems that do not ease even with treatment.

Anxiety Symptoms:

The main symptom of anxiety is a constant and exaggerated sense of tension and stress. A student may not be able to pinpoint a reason why he/she feels tense. Or the teen may worry too much about ordinary matters, such as grades, relationships, or his/her health. All this worrying can interfere with sleep and the ability to think straight. The teen may also feel irritable due to poor sleep or the illness itself.

Physical Symptoms of Anxiety

Body problems usually come along with the excess worry. They can include:

Muscle tension or pain Headaches Nausea or diarrhea Trembling or twitching

Self-Care for Anxiety Teens can support their treatment of anxiety

symptoms by making a few simple changes in habits. 1) Avoid caffeine, street drugs, and even some cold medicines, which can boost anxiety symptoms. 2) Try to get enough rest/sleep and eat healthy foods. 3) Try relaxation techniques, such as yoga or meditation. 4) And be sure to exercise; there's evidence that moderate physical activity can have a calming effect.

Depression can make other health problems feel worse, particularly chronic pain. Key brain chemicals influence both mood and pain. Treating depression has been shown to improve co-existing illnesses.

Depression Symptom: Appetite

Changes in appetite or weight are another hallmark of depression. Some students develop increased appetite, while others lose their appetite altogether. Depressed teens may experience serious weight loss or weight gain. Some medications can also contribute to weight gain.

Impact on Daily Life

Without treatment, the physical and emotional turmoil brought on by depression can derail grades in school, hobbies, and relationships. Depressed students often find it difficult to concentrate and make decisions. They turn away from previously enjoyable activities, including friends. In severe cases, depression can become life-threatening.

Suicide Warning Signs Suicide Warning Signs People who are depressed are more likely to

attempt suicide. Warning signs include talking about death or suicide, threatening to hurt people, or engaging in aggressive or risky behavior. Anyone who appears suicidal should be taken very seriously. Do not hesitate to call one of the suicide hotlines: 800-SUICIDE (800-784-2433) and 800-273-TALK (800-273-8255).

Causes of Depression Doctors aren't sure what causes depression,

but a prominent theory is altered brain structure and chemical function. Chemicals called neurotransmitters become unbalanced. What pushes these chemicals off course? One possibility is the stress of a traumatic event, such as losing a loved one or loss of a relationship. Endogenous combine with exogenous…internal predispositions (biochemical/genetic with stress).

Seasonal Depression

If your teen’s mood matches the season – sunny in the summer, gloomy in the winter – he/she may have a form of depression called seasonal affective disorder (SAD). The onset of SAD usually occurs in the late fall and early winter, as the daylight hours grow shorter. Experts say SAD affects up to 3% of the U.S. population, or about 9 million people, mainly in the northern part of the country.

Depression in Children Depression clouds the days of one in every

20 American kids. It interferes with the ability to play, make friends, and complete schoolwork. Symptoms are similar to depression in adults, but some children may appear angry or engage in risky behavior, called "acting out." Depression can be difficult to diagnose in children and both depression and anxiety are often misdiagnosed as ADHD in students of all ages.

Talk Therapy for Anxiety and Depression

Studies suggest different types of talk therapy can fight mild to moderate depression. Cognitive Behavioral Therapy aims to change thoughts and behaviors that contribute to depression. Interpersonal therapy identifies how your relationships impact your mood. Some patients find a few months of therapy are all they need, while others continue long term.

Exercise for Depression

Research suggests exercise is a potent weapon against mild to moderate depression. Physical activity releases endorphins that can help boost mood. Regular exercise is also linked to higher self-esteem, better sleep, less stress, and more energy. Any type of moderate activity, from swimming to housework, can help. Choose something your teen enjoys and let them aim for 20 to 30 minutes four or five times a week.

The Role of Social Support Loneliness goes hand-in-hand with

depression, students need to develop a positive social support network as an important part of treatment, similar to group counseling. This may include joining a support group, finding online support, or making a genuine effort to see friends and family more often. It is important to connect with people on a regular basis.

Did You Know…?8.5% of teens aged 12 to 17 (1 in 12)

experience depression in any given year.

Suicide is the 3rd leading cause of death among individuals ages 15-24 years old. In 2011, an average of 11.5 individuals in this age group completed suicide each day.

7.5% of Maryland youth attempted suicide in 2007. For every completed suicide, there are approximately 100-200 attempts.

As many as 200,000 individuals will be affected by the loss of a loved one or acquaintance to suicide.

Red Flags of Mental HealthDeep Sadness and/or HopelessnessLong-lasting irritability, anger and/or rageDepression can be anger turned inward

Dramatic Changes in Appearance, Personality, and/or BehaviorWithdrawal from friends, family and/or activitiesMajor changes in sleeping or eating habits, such

as unexpected gain or loss of weightMarked change in levels of energy, motivation

and/or concentration

Risky Behavior (promiscuity, substance abuse)

Red Flags of Mental HealthIncreased Physical Complaints

like Headaches or Stomachaches

Thoughts and/or Talk of Death Giving away of prized possessionsMorbid fascination revealed through

artwork, poetry, etc.

Drops in Academic PerformanceFrequent absences from school Increased frequency of incompletes or

bad grades

Ensuring Students’ Well-Being and Safety

One out of every 53 high school students report having made a

suicide attempt serious enough that it required treatment by a doctor or

nurse– Centers for Disease Control, 2010

Prevention

It is estimated that four of five suicide victims demonstrated identifiable warning signs before completing suicide. School personnel and parents need to be knowledgeable about warning signs of youth suicide and potential triggers.

Warning Signs for Suicide

Someone threatening to hurt or kill themselves

Someone looking for ways to kill themselves; seeking access to pills, weapons, or other means

Someone talking or writing about death, dying, or suicide, when these actions are out of the ordinary for the person

U. S. Dept. of Health and Human Services, 2012

Social-Emotional Learning Emotional intelligence/resilience relates to

our ability to cope with stress and anguish, pain and failure. Teenagers fall in love and break-ups can be emotionally devastating.

Low grades can eliminate the opportunity to play on a high school sports team. Low skills can cause students who have played a recreational sport their entire life to be cut from a team.

Bullying Unfortunately there are students who bully

and students who are bullied and now we have cyber-bullying where feelings get hurt and students fear coming to school.

Many parents take their anxious or depressed teen to a private psychologist for a comprehensive evaluation and we often see the diagnosis: ADHD? Let’s look a little further into this diagnosis:

ADHD Look-Alikes There are many psychological and medical

problems that look like ADHD, so children who present signs of ADHD need to be carefully evaluated. Look-alike ADHD children may meet the DSM-IV diagnostic criteria, but have a completely different primary problem.

Anxiety Disorders often go undetected, but they occur in 5-10% of school children.

Among children with ADHD, the rate of anxiety is 3 to 6 times greater (co-occuring).

One of main characteristics of an anxiety disorder is “inattention”.

Most of the Time Other Disorders Accompany ADHD A person with ADHD is six times more

likely to have another psychiatric or learning disorder than most other people. ADHD usually overlaps with other disorders.

Difficulties with learning, emotional regulation, executive functioning, social functioning, or behavior.

ADHD has extraordinarily high rates of co-morbidity with all psychiatric disorders.

A List of Common Look-Alikes Depression Stress-induced

Anxiety Biologically Based

Anxiety Child Abuse or

Neglect Bipolar Disorder Medical Conditions:

Chronic Fatigue, Thyroid dysfunction, etc.

Tourette’s Syndrome Autism Spectrum

Disorders Speech and Language

Impairments Sensory Integration

Disorders Auditory Processing

Disorders Other Affective Mood

Disorders

Multimodal Treatment Study (MTA Cooperative Group 1999) Children Ages 7 to 9 with ADHD: 70% were found to have at least one other psychiatric disorder:

Oppositional Defiant Disorder 40% Anxiety Disorder 34% Conduct Disorder 14 % Tic Disorder 11 % Affective Disorder (depression) 4% Mania (or hypomania) 2% Learning Disorders: Reading, Math, and

Written Expression

Additional Research Findings in Older Children and Adults Ages 9 to 16:

– Depressive Symptoms 48%

Adults: Combined Type InattentiveSubstance Abuse 69% 43%Major Depression 63% 63%Oppositional Defiant 40% 16% Anxiety Disorders 35% 23%Conduct Disorders 30% 20%Social Phobia 24% 31%

Study of Adults with ADHD:Rachel Milstein and others (1997) Combined Type

– Substance Abuse 69%

– Major Depression 63%

– Oppositional Disorder 40%

– Anxiety Disorders 35%

– Conduct Disorders 30%

– Social Phobia 24%

Inattentive Type– Substance Abuse 43%

– Major Depression 63%

– Oppositional Disorder 16%

– Anxiety Disorders 23%

– Conduct Disorders 20%

– Social Phobia 31%

ADHD Subtypes

Internalizing Inattentive Type:

– Anxiety– Affective Mood

Disorders– Depression– Somatic

Complaints– Child Abuse– Sleep Disorder

Externalizing Hyperactive-

Impulsive Type:– Conduct Disorder– Disruptive

Behavior Disorder– Mania– Aggression– Oppositional

Defiant Disorder

ADHD and Depressive Disorders

Children and adults referred for ADHD demonstrate a higher-than-chance incidence of depression and individuals referred for depression have elevated rates of ADHD.

Because the presence of an underlying or co-occurring mood disorder may complicate the treatment of ADHD, the mood disorder must be properly diagnosed and treated.

Depression in Youth

Irritability, social withdrawal, school dysfunction, negativity, and somatic disorders.

Approximately 30% of 237 youth with ADHD assessed could also be diagnosed with major depression (Beiderman).

After four years, the rate was more than

40% compared with approximately 5% of the control group.

ADHD and Depression

Youth with co-occurring disorders have high rates of a variety of mental health problems, including bipolar disorder and anxiety disorder.

Seventy percent of children referred for severe or mild depression had co-occurring ADHD. When classified by age, rates of ADHD were 84% in children up to seven, 66% in children 8-12 and 39% in children ages 13 to 18.

Treatment Options

Options that are most effective for ADHD (e.g. stimulants) do not significantly improve depression, and treatments for mood disorders are generally not helpful for ADHD.

When a co-occurring mood disorder exists, stimulants are less effective.

Mental Health Treatment

Appropriate levels of service need to be authorized:– Medication needs to be monitored– Intensive personal and family therapy – Environmental interventions– Special education services– Hospitalization and/or residential treatment

may be needed at some point in time

ADHD and Substance Abuse

ADHD, with or without co-occurrence, is a risk factor for substance abuse among adolescents and adults.

When an individual presents with both substance abuse and ADHD, clinicians should first stabilize and treat the substance abuse. They should then treat the depression and then the ADHD.

ADHD and Substance Abuse

Successful treatment of ADHD in either childhood or adolescence appears to offer some protection against later-life substance abuse.

In a four year study of ADHD and non-ADHD families, Biederman observed that patients whose ADHD was not treated had much higher rates of later substance abuse than either the treated ADHD patients or the controls.

Untreated ADHD is also associated with higher rates of alcoholism use at 15 year follow-up.

The Key

ADHD is frequently associated with coexisting psychiatric disorders such as depression and anxiety

The key to positive outcome is the correct and early diagnosis of all co-occurring disorders, followed by robust treatment.

Comprehensive multidisciplinary evaluation and proper diagnosis

Effective efficacious therapy– Ongoing monitoring

Points to Remember

Children with pure ADHD do not manifest mood disturbances, thus the presence of such instability is clear evidence of a co-occurring disorder.

Although co-occurrence complicates treatment it does not preclude successful intervention.

The key to a positive outcome is the correct and early diagnosis of all co-occurring disorders, followed by a robust regimen built around the most efficacious therapies.

Coping with Anxiety, Depression and Stress

Coping implies a camel with a ton of straws on his back or a juggler juggling a dozen balls in the air.

Counseling/Therapy, medication, activities, friendships, social activities are ways to take the straws off the camel’s back or take a few apples out of the juggle.

Reduce the stress, don’t worry about college

Thank You!

David W. HoldeferMCPS School PsychologistStudent Services OfficeRockville High School2100 Baltimore RoadRockville, Maryland 20851301-738-5733David_Holdefer@mcpsmd.org