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YOUTH

MENTAL

HEALTHA Whole-School

Approach

S C H O O LC L I M AT E

A M Y H I L L , S Y S T E M D I R E C T O R O F S C H O O L B A S E D S E R V I C E S

S H E L L Y F A R N A N , S Y S T E M D I R E C T O R O F D I V E R S I T Y A N D I N C L U S I O N

YOUTH MENTAL HEALTH: A WHOLE-SCHOOL APPROACH

WHAT IS SCHOOL CLIMATE?

Generally, school climate represents the shared norms, beliefs, attitudes, experiences, and

behaviors that shape the nature of interactions between and among students, teachers, and

administrators- PBIS Technical Brief

School climate refers to the quality and character of school life. School climate is based on

patterns of students', parents' and school personnel's experience of school life and reflects

norms, goals, values, interpersonal relationships, teaching and learning practices, and

organizational structures. –National School Climate Center


• 1. Safety

• 2. Relationships

• 3. Teaching and Learning

• 4. External Environment

• Positive School Climate = Academic Achievement and Positive Youth

Development

4 KEY COMPONENTS


SAFETY

• Rules- Clear communication about harassment, bullying, physical violence and adult

intervention

• Sense that students feel physically safe

• Sense that students feel emotionally safe


RELATIONSHIPS

• Connection with adults, engagement, high expectations

• Respect for student diversity

• Relationship with peers, friendships, involvement


TEACHING AND LEARNING

• Academic learning- individualized learning, varied ways to show achievement, academic

challenge, constructive feedback, encouragement, dialog and questioning

• Social learning- empathy, conflict resolution, decision making, responsibility, emotional

regulation, social skills, self-relection


ENVIRONMENT

• Opportunities to participate, extra curricular activities, school life, community involvement,

family connections

• Building readiness, cleanliness, access to resources/materials, adequate facilities


F O U R E L E M E N T S

O F F L O U R I S H I N G

The Person Brain Model- Paul

Baker


T H E E C O -

R E L AT I O N A L

F U N N E L

The Person Brain Model-Paul

Baker


• Survey Questions (never, sometimes, often, always)

• I like school

• I feel successful at school

• I feel my school has high standards for achievement

• My school sets clear rules for behavior

• Teachers treat me with respect

ASSESSING YOUR SCHOOL CLIMATE


• Survey Questions (never, sometimes, often, always)

• The behaviors in my class allow the teachers to teach

• Students are frequently recognized for good behavior

• School is a place at which I feel safe

• I know an adult at school that I can talk with if I need help



Survey Questions for teachers

I get along well with other teachers

I feel supported as a teacher

Teachers at my school have a high standard for success

Teachers at my school recognize student success

I feel safe at my school

Teachers at my school work hard to ensure student success

Students at my school show respect for others



5 STEPS TO POSITIVE SCHOOL CLIMATE

1. Make relationships a priority

• Students

• Staff

• Community

2. Provide a safe environment

• Teachers can’t teach when they don’t feel safe. Kids can’t learn with they don’t feel safe

3. Communicate well and often

• Students

• Staff

• Community


5 STEPS TO POSITIVE SCHOOL CLIMATE

4. Check assumptions, observe, and question

• Identify your own assumptions

• Catch yourself making an assumption and make an observation instead

• Ask questions and really listen to the response

5. Give everyone a voice

• Evaluate and re-evaluate

• Take action

• Monitor success


RESOURCES

• https://www.pbisapps.org/Resources/SWIS%20Publications/School%20Climate%20Survey%20Su

ite%20Manual.pdf

• https://safesupportivelearning.ed.gov/safe-and-healthy-students/school-climate

• https://www.schoolclimate.org/

• https://www2.ed.gov/policy/elsec/leg/essa/essaguidetoschoolclimate041019.pdf

https://www.pbisapps.org/Resources/SWIS Publications/School Climate Survey Suite Manual.pdf

https://safesupportivelearning.ed.gov/safe-and-healthy-students/school-climate

https://www.schoolclimate.org/

https://www2.ed.gov/policy/elsec/leg/essa/essaguidetoschoolclimate041019.pdf

Q U E S T I O N S ?C O M M E N T S ?

YOUTH

MENTAL


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THANK YOU

YOUTH

MENTAL


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YOUTH

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HELP! THIS CLASSROOM IS IN CHAOS

Potential Diagnoses Brewing Under the Surface

A D A M A N D R E A S S E N , P S Y . D

C H I E F O P E R A T I N G O F F I C E R

B U R R E L L B E H A V I O R A L H E A L T H


Objectives of Presentation

• Summarize the most common diagnoses underlying disruptive classroom

behaviors

• Identify the obvious and subtle differences in these diagnoses including

ADHD, PTSD, Disruptive Mood Dysregulation Disorder

• Explore contributors and conceptual frameworks for understanding why

these behaviors occur

• Apply this information to broad strategies for preventing and managing

disruptive classroom behaviors


May I have fries with that Ritalin?

Common Diagnoses Simplified


Common Diagnoses Influencing Disruptive Behaviors• Attention-Deficit/Hyperactivity Disorder (ADHD)

• Inattentive and/or Hyperactivity/Impulsivity

• Aka “ADD”

• Posttraumatic Stress Disorder (PTSD)

• Strong reactions to reminders of previous traumatic experiences

• Anything from avoidance/anxiety to anger outbursts and inattention

• Bipolar Disorder

• Mood Disorder including both energy increased moods (mania) and decreased energy

moods (depression)

• Historically overdiagnosed


Common Diagnoses Influencing Disruptive Behaviors• Oppositional Defiant Disorder

• Generally oppositional behaviors, especially to limit setting

• Considered relatively “mild” – anything BUT mild in the classroom

• Conduct Disorder

• Oppositional and/or indifference to normative expectations by authority

figures

• Includes conduct problems such as aggression, theft, deceitfulness,

lawbreaking, etc.

• Disruptive Mood Dysregulation Disorder (DMDD)

• Intended as a REPLACEMENT for many Bipolar Disorders

• Includes elements of ADHD, Depression, ODD, and Bipolar

• General moodiness and reactivity with distress


• Autism Spectrum Disorders

• Generally characterized by lack of awareness or interest in prosocial behaviors

• Often, but not always, influenced by low IQ

• Anxiety Disorders

• Depressive/Mood Disorders

• COMORBIDITY!

• ADHD & PTSD

• ADHD & Conduct Disorder

• ADHD & Mood Disorders

Other Factors and Diagnoses


700% increase of Ritalin

prescribed in the US since 1995Diller, 1998

Total stimulant usage has

doubled in the last decadePiper et al., 2016


Common Overlapping Symptoms in the Medical Field

Appendicitis

Strep Throat

Fever

Geller & DelBello, 2008


Common Overlapping Symptoms in Psychological Symptoms

Mania

(elated mood and grandiosity)

Major Depressive

Disorder

(low mood and

anhedonia)

Autism

(communication and social deficits)

ADHD

(no cardinal symptoms)

Irritability and Hyperactivity



Where are we heading?


Prevalence Rates

1% 8%

Barkley, 2006

Goldstein, 2012


History and Features of ADHD

• Around WWI ADHD symptoms were often associated with an outbreak

of encephalitis

• Clinicians began to see similar symptoms in other organic based

disorders (brain injured child, MBD)

• Also “spoiled child” syndrome

• 1930’s began to notice improved effects with amphetamine use to

control headaches

Barkley 2006


History and Features of ADHD

• 1950’s movement to hyperkinetic impulse disorder

• Later in the decade more specific learning problems were

identified rather than generalizing MBD

• 1970’s began to focus on impulsivity as well

• 1980’s focus on attention problems

• Later focus on educational needs

• 21st century continues to look at further subtypes

Barkley 2006


CONCEPTUALIZING

ADHD

Kolb & Whishaw (2003)

Halperin et al., 2012

• Exhibit poor and irregular sleep

• Colic

• Feeding problems

• Dislike being cuddled or held still for long

In Infancy

• Driven to run rather than walk

• Driven to handle everything

• Major problems as adults:

• Low self-esteem

• Poor social skills

Toddler


DISTINCTIVE ADHD FEATURES

• Demanding

• Oppositional

• Do not play well with others

• Poor tolerance of frustration, high level of activity, poor concentration, and poor self-esteem may lead to a referral

Elementary school

• May be failing school

• 25-50% have encountered legal problems

• Withdraw from school

• Fail to develop social relations and maintain steady employment

• Females with inattention often diagnosed with dysthymia (chronic mild depression) rather than ADHD

• Females with combined symptoms (impulsivity, hyperactivity, inattention) often diagnosed with Bipolar Disorder

Adolescence

Kolb & Whishaw (2003)

Quinn and Madhoo (2014)


Different Types of ADHD• ADHD, Inattentive Type

• ADHD, Sluggish Cognitive Tempo

• ADHD, Hyperactive-Impulsive Type

• ADHD, Combined Type


• Often fails to give close attention to details and make careless mistakes

• Difficulty sustaining attention

• Does not listen when spoken to directly

• Not following through on instructions

• Difficulty organizing tasks

• Often loses things

• Often forgetful in everyday activities

ADHD, Inattentive Type


ADHD, H-I TypeINATTENTIVE TYPE PLUS:

• Fidgets with hands or feet in seat

• Leaves seat in the classroom

• Runs or climbs about excessively

• Difficulty playing in leisure activity

• Is often “on the go” or appears “driven by a motor

• Often talks excessively


WHY IS IT

OVER

DIAGNOSED?

• Changing culture/Parenting styles

• One size fits all?

• Concept called comorbidity

• Relief Factor: “Have a name”

• Cultural medication solution

• Impact of schools

• Treatment of “spectrums”


Most Common School Problems & ADHD• High rates of disruptive disorders

• Low rates of engagement with academic instruction and achievement

• Inconsistent completion/accuracy of school work

• Poor performance on homework, tests & long-term assignments

• Difficulties getting along with peers


Concept of Executive Functioning and brain development

• The ability to plan and organize event in a sequential manner with

sound judgment

Also involves:

• Nonverbal and verbal working memory

• Emotional Self-Regulation

• Planning and Problem-Solving

ADHD & Executive Functioning


ADHD & Low Arousal TheoryTheory suggesting that ADHD (and Conduct, Antisocial, etc.)

individuals seek/require more stimulation to transcend their

excessively low arousal rate.

In one study ADHD individuals required more noise levels to establish the same

stimulation level (due to less dopamine).

-See Wikipedia – “Low Arousal Theory”


Interfacing Medical Issues

Sleep Apnea AsthmaInner Ear

Infections

Pervasive

Development

Disorders

Bipolar Disorder


Bipolar Disorder

• The word “manic” traces back to Ancient Greek

• Mania and melancholia have been tied together for centuries

• Biphasic Mental Illness causing recurrent oscillations between mania

and depression (1854 Jules Baillarger)

• Emil Kraepelin coined term manic depression (1900’s)

• 1952 placed in the Diagnostic Manual


BIPOLAR &

KINDLING

THEORY OF KINDLING• Somewhat controversial, but conceptually useful

• Important to assumptions of early psychosocial

interventions

• First applied to seizure disorders

• Combination of stress and genetic vulnerability

leads to greater destabilization until full onset

• Brain becomes further sensitized with each

episode until spontaneous occurrence without

stressors

• Will result in less inter-episodic recovery time and

treatment resistance



Manic EpisodeDistinct period of abnormally and persistently elevated, expansive, or irritable

mood for 1 week (unless hospitalization is necessary)

Three or more (4 if just irritable) and PRESENT TO A SIGNIFICANT DEGREE

1. Inflated self-esteem or grandiosity

2. Decreased NEED for sleep

3. More talkative than USUAL

4. Flight of ideas or racing thoughts

5. Distractibility

6. INCREASE in goal-directed activity or psychomotor agitation

7. Excessive involvement in pleasurable activities with a high potential for painful consequences

Disruptive Mood Dysregulation Disorder (DMDD)


A. Severe recurrent temper outbursts (verbal or physical)

B. Outbursts inconsistent with developmental level

C. Occur 3+ times per week (on average)

D. Mood at other times is largely irritable or angry most of the time

E. A-D have been present for 12 or more months with no 3 month remittance

F. A & D present in 2 of 3 settings

G. Don’t diagnose before age 6 or after 18

H. A-e onset prior to age 10

I. No mania or hypomania criteria for longer than a day

J. Not part of MDE

K. Not something else

DISRUPTIVE MOOD DYSREGULATION DISORDER


Disruptive Mood Dysregulation DisorderCAN’T COEXIST WITH:

• ODD (only dx DMDD if both criteria met)

• IED or Bipolar (don’t dx dmdd if mania or hypomania ever met)

CAN COEXIST WITH:

• MDD

• ADHD

• Conduct

• Substance Use Disorders


Disruptive Mood Dysregulation Disorder• Diagnosis invented to account for non-episodic mood problems

• Also to reduce number of children receiving bipolar dx due to chronic but not episodic

mood disruptions

• Prevalence

• Unknown (Brand new)

• Guess: 2% - 5%

• Rates expected to be higher in males and school-age children


Disruptive Mood Dysregulation DisorderMarked by low frustration tolerance – lots of functional

implications at school and elsewhere

Posttraumatic Stress Disorder (PTSD)


Posttraumatic Stress Disorder• First Challenge: PTSD is only ONE outcome of trauma

• Trauma = From a psychological perspective it’s an emotional response to a terrible

event

• Appraisal is important indicator

• All my fault?

• Totally helpless?

• SAMHSA’s 3 E’s of Trauma (Event, EXPERIENCE, Effects)


• High Arousal will look similar to ADHD even though ADHD is

triggered by a LOW arousal!

• Bipolar is more like organic arousal that will look like

triggered (PTSD) arousal AND low arousal response (ADHD)

• How to differentiate?

PTSD & Arousal


Trauma in the Classroom• Greater likelihood of performing below grade level (lower GPA)

• Higher rates of office referrals, suspensions, and expulsions

• Decreased reading ability

• Language and verbal processing deficits

• Delays in expressive and receptive language

• Greater tendency to be misclassified with developmental delays

• Decreased ability to focus and concentrate, recall and remember, organize and

process information, and plan and problem-solve

Differentiating the Diagnoses


• Destructiveness: ADHD careless destruction v. Bipolar occurs in anger

• Temper-tantrums: ADHD children calm down in 20-30 minutes; Bipolar for hours

• Regression during outbursts: Bipolar may lose memory of tantrum; regression more severe in Bipolar

• Triggers: ADHD-triggered by sensory and emotional overstimulation; Bipolar react more to limit setting

• ADHD does not show depressive as primary predominant symptom

• Arousal in morning: ADHD- arouse quickly and alert within minutes; Bipolar fuzzy thinking and irritable

Important Distinctions(Papolos & Papolos)


Profiling the DiagnosisBIPOLAR• Can you identify manic or mixed symptoms? (Required)

• How long are outbursts occurring? (more than an hour?)

• How intense are outbursts?

• Can increased energy be confirmed?

• Remember the brain! (ADHD – Executive Functioning; Bipolar – Emotional Dysregulation;

PTSD – Triggering events and external influence)


• PTSD

• Can triggering event be identified? If not, trauma can still be relevant

even if you don’t diagnose PTSD

• Attention Problems/Hyperactivity could be in fact keyed-up OVER-

ATTENTION (monitoring)

• Any subtle behavioral clues?

• How do they respond when you give them a focusing task?

• Many individuals with anxiety/PTSD focus well and actually calm themselves with

tasks

Profiling the Diagnosis


ADHD & PTSDUnderlying ADHD can increase risk of PTSD

• Problems gathering and using information can complicate appraisal of events which

heavily influences PTSD factors

• Can ADHD be identified prior to traumatic events


TESTING &

FORMAL

EVALUATION

ADHD is a performance-based

issue; may need performance-

based assessment alongside

full evaluation

• Bipolar – many mood factors are

easier to identify when paired with

test data

• PTSD – Residual effects of trauma

also easier to isolate with testing

• But sometimes time or resources don’t

allow this approach


• ADHD – Peeling back layer of the onion (what’s left)

• Degrees of certainty rather than “confirming”

• Additive: Sleep Problems? Sleep Apnea? Early Ear Infections, Asthma, etc.

• PTSD – Don’t rush to it as dx just because a trauma occurred

– it’s a very specific set of reactions

• One of the most effective ways of narrowing it down

• Bipolar – Is affect brain lighting up and flooding person?

• Genetics, etc.

• Assess mood upon awaking! (Cranky/Sluggish v. Good to go!)

Simplifying Further

Intervention


Outside the Classroom

Trauma Stressors Diet & Health Sleep!


Why is Sleep so Important?• Critical for affect regulation

• Important for cognitive functioning

• Impacts health

• Associated with substance use

• Contributes to impulsivity and risk taking


• 40% of children in some studies suffer from sleep problems

• 15% exhibit bedtime resistance

• 10% or more experience daytime drowsiness

• Students with C’s, D’s, and F’s went to bed on average 40

minutes later than A students

• Insufficient sleep leads to many other problems

National Sleep Foundation

Some Staggering Statistics


How Much Sleep is Enough?

AGE HOURS

3 to 5 10 to 13

6 to 13 9 to 11

14 to 17 8 to 10


What Works?ADHD

• Important: You can’t talk/discipline/train a child out of having ADHD!

• Regulate Environment

• Reduce Chaos and/or Increase Interest-level (stimulation) of activities

• Shorten/Breakup Instruction

• When to Medicate:

• When disruptions are not easily managed/redirected

• When there are secondary results causing distress

• Poor grades

• Social failures


Bipolar Disorder/DMDD

• Important: You can’t talk/discipline/train a child out of having a

manic episode

• In a general way, therapeutic interventions such as

therapy/counseling can improve mood management and reduce

likelihood of depressive episodes

• Mood stabilizers and antidepressants are first-line defense

• When encountering a manic reaction

• Reduce stimulation

• Avoid dogmatic limit-setting; be calm and offer options

• Remove from the situation and ensure safety

What Works?


What Works?POSTTRAUMATIC STRESS DISORDER (PTSD)

• Most responsive to environmental cues

• Reduce stimulation – especially intensity

• Be calm and reassuring – even when they are angry

• Remove from the situation and ensure safety

• Antianxiety medication has some, but limited, efficacy

• Therapeutic interventions are key

• Reduce associations

• Increase tolerance to exposure/reminders


Conduct/Oppositional Disorders

• Limited effectiveness of medication

• Limited effectiveness of short-term behavioral interventions

• Longstanding behavioral interventions and consistency shows some

results

• In the Classroom:

• Be consistent

• Avoid power struggles/Reactivity

What Works?


What Works?AUTISM SPECTRUM• Generally requires more intensive behavioral treatment such as Applied Behavioral

Analysis (ABA)


Regardless of Diagnosis, What Works?• Be empathetic and supportive

• Be aware of your own experiences, mood, stressors, etc.

• Seek support and treatment when necessary

• Communicate with parents/guardians

• Balance support and concerns

• Don’t wait until it gets bad

• Encourage assessment, detection, and prevention indicatives


General Classroom StrategiesMAINTAIN A TRAUMA-INFORMED LENS

TRADITIONAL PERSPECTIVE

• Challenging behaviors are the result of individual deficits

(e.g. what’s wrong with you?).

• Understands difficult behaviors as purposeful or personal.

• Focuses on changing the individual to “fix” the problem.

• Providers/school faculty need to uphold authority and

control.

• Punitive approaches are most effective.

• Support for people exposed to trauma is provided by

counseling professionals.

TRAUMA-INFORMED PERSPECTIVE

• Challenging behaviors may be ways of coping with trauma

(e.g. what happened to you?).

• Understands difficult behaviors may be an automatic stress

response.

• Focuses on changing the environment.

• Providers/school faculty need to offer flexibility and choice.

• Positive, strengths-based approaches are most effective.

• Support for people exposed to trauma is the shared

responsibility of all who provide support.


General Classroom Strategies6 PRINCIPLES OF COMPASSIONATE EDUCATION

1. Always empower, never disempower

• Avoid power struggles, Discipline must never resemble the trauma, Discipline should

be consistent, respectful, and non-violent

2. Provide unconditional positive regard

• Genuine respect, kindness, and empathy

3. Maintain high expectations

• Consistent expectations and limits, Set limits and rules that keep students safe and

protect their well-being using a calm and respectful voice


General Classroom Strategies6 PRINCIPLES OF COMPASSIONATE EDUCATION

4. Check assumptions, observe, and question

• Identify your own assumptions, Catch yourself making an assumption and make an

observation instead, Ask questions and really listen to the response

5. Be a relationship coach

• By helping students feel safe and supported, they can put more energy into learning,

By being a relationship coach, teachers can help students mend perceptions of

community and friends

6. Provide guided opportunities for helpful participation

• Carefully plan, model, and observe ongoing interactions

YOUTH

MENTAL


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Questions & Discussion

[email protected]

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MENTAL


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RS


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