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The Texas Model for Comprehensive School Counseling 5th Ed.

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The Texas Model for Comprehensive School Counseling 5th Ed.

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The Responsibilities of School Counselors And Other Staff Members

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The Responsibilities of School Counselors And Other Staff Members

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Integrating a Multi-Tiered System of Supports With Comprehensive School Counseling Programs

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Integrating a Multi-Tiered System of Supports With Comprehensive School Counseling Programs

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Integrating a Multi-Tiered System of Supports With Comprehensive

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What is bipolar disorder? - Helen M. Farrell

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What is bipolar disorder? - Helen M. Farrell

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What is bipolar disorder? - Helen M. Farrell

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Finding balance in bipolar | Ellen Forney | TEDxSeattle

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Finding balance in bipolar | Ellen Forney | TEDxSeattle

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Finding balance in bipolar | Ellen Forney | TEDxSeattle

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Bipolar Disorder: Educational Implications for Secondary Students

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Bipolar Disorder: Educational Implications for Secondary Students

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How Your Child’s Bipolar Disorder Can Affect The School Day

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How Your Child’s Bipolar Disorder Can Affect The School Day

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With children struggling from bipolar disorder (and especially if they have a co-existing condition like ADHD or anxiety disorder), they also have to deal with the resulting issues that may affect their academic performance. The best thing is to talk to their teacher to explain the symptoms of this brain disorder. Here are some things to keep in mind:

Extra sensitivity

Children with bipolar may be extra sensitive to what they believe is criticism - and their mood will dominate how they perceive directions from a teacher. This may result in a defensive and defiant reaction.

Changes in cognition

Teachers and parents should be on the lookout for any fluctuations in the child's cognitive abilities, difficulty with organizing or using abstract reasoning. Changes in his concentration, alertness or processing speed may occur throughout the school week and may even reflect the overall mood stability of the child with bipolar. These symptoms can affect both his behavior and academic performance.

Easily frustrated

Because of these changes in cognition, children can be easily frustrated and discouraged because regular tasks can seem more difficult than for a child without bipolar. Along with irritation, their self-esteem can also suffer and this can easily lead to a spiral into depression.

Disproportionate emotions

When at school children with bipolar disorder may appear distressed that is out of proportion to actual events, crying for any real reason and could also be inconsolable when upset. Trying to reason with these children during this irrational period usually doesn't work.

Social isolation

Pay attention or talk to your child's teacher to find out if your son or daughter is having problems making or keeping friends and how he or she is getting along with schoolmates. Many times stigma of mental health issues can result in isolation for children with bipolar disorder. This can lead very quickly to anxiety or a depressive episode.

Higher than normal anxiety

Typically children with bipolar suffer from extremely high levels of anxiety. This usually interferes with their ability to make sense of a situation. This could then easily develop into frustration and an emotional outburst.

Over tired

Being exhausted, which in turn leads to anxiety and fragile moods, could be caused by either sleep issues from home or from side effects due to medication. Some common side effects of mood regulating medication can include tiredness, headaches, tremors or a change in appetite.

Meds at school

If your child needs to take his bipolar medication during the day, speak with the school's nurse to make him/her aware of this fact and also find out if there is someone available to administer the medication to your child if needed. You'll need to make his teachers aware of some of the medication's side effects, and ask for accommodations for your child to have access to something to drink and to a washroom when needed.
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How Your Child's Bipolar Disorder Can Affect The School Day | bpHope.com

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Children with bipolar may be extra sensitive to what they believe is criticism - and their mood will dominate how they perceive directions from a teacher. This may result in a defensive and defiant reaction. Teachers and parents should be on the lookout for any fluctuations in the child's cognitive abilities, difficulty with organizing or using abstract reasoning.

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Depression: Supporting Students at School

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Depression: Supporting Students at School

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Students with Depression Help Them Find Their Way Out

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Students with Depression Help Them Find Their Way Out

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Does your child go through extreme changes in mood and behavior? Does your child get much more excited or much more irritable than other kids? Do you notice that your child goes through cycles of extreme highs and lows more often than other children? Do these mood changes affect how your child acts at school or at home?

Some children and teens with these symptoms may have bipolar disorder, a brain disorder that causes unusual shifts in mood, energy, activity levels, and day-to-day functioning. With treatment, children and teens with bipolar disorder can get better over time.

What is bipolar disorder?

Bipolar disorder is a mental disorder that causes people to experience noticeable, sometimes extreme, changes in mood and behavior. Sometimes children with bipolar disorder feel very happy or "up" and are much more energetic and active than usual. This is called a manic episode. Sometimes children with bipolar disorder feel very sad or "down" and are much less active than usual. This is called a depressive episode.

Bipolar disorder, which used to be called manic-depressive illness or manic depression, is not the same as the normal ups and downs every child goes through. The mood changes in bipolar disorder are more extreme, often unprovoked, and accompanied by changes in sleep, energy level, and the ability to think clearly. Bipolar symptoms can make it hard for young people to perform well in school or to get along with friends and family members. Some children and teens with bipolar disorder may try to hurt themselves or attempt suicide.

Most people are diagnosed with bipolar disorder in adolescence or adulthood, but the symptoms can appear earlier in childhood. Bipolar disorder is often episodic, but it usually lasts a lifetime.

Signs and symptoms of bipolar disorder may overlap with symptoms of other disorders that are common in young people, such as attention-deficit/hyperactivity disorder (ADHD), conduct problems, major depression, and anxiety disorders. Diagnosing bipolar disorder can be complicated and requires a careful and thorough evaluation by a trained, experienced mental health professional.

With treatment, children and teens with bipolar disorder can manage their symptoms and lead successful lives.

What causes bipolar disorder?

The exact causes of bipolar disorder are unknown, but several factors may contribute to the illness.

For example, researchers are beginning to uncover genetic mechanisms that are linked to bipolar disorder and other mental disorders. Research shows that people's chance of having bipolar disorder is higher if they have a close family member with the illness, which may be because they have the same genetic variations. However, just because one family member has bipolar disorder, it does not mean that other members of the family will have it. Many genes are involved in the disorder, and no single gene causes it.

Research also suggests that adversity, trauma, and stressful life events may increase the chances of developing bipolar disorder in people with a genetic risk of having the illness.

Some research studies have found differences in brain structure and function between people who have bipolar disorder and those who do not. Researchers are studying the disorder to learn more about its causes and effective treatments.

What are the symptoms of bipolar disorder?

Mood episodes in bipolar disorder include intense emotions along with significant changes in sleep habits, activity levels, thoughts, or behaviors. A person with bipolar disorder may have manic episodes, depressive episodes, or "mixed" episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that often last for several days or weeks. During an episode, the symptoms last every day for most of the day.

These mood and activity changes are very different from the child's usual behavior and from the behavior of healthy children and teens.

Children and teens having a manic episode may:

Show intense happiness or silliness for long periods of time.

Have a very short temper or seem extremely irritable.

Talk fast about a lot of different things.

Have trouble sleeping but not feel tired.

Have trouble staying focused, and experience racing thoughts.

Seem overly interested or involved in pleasurable but risky activities.

Do risky or reckless things that show poor judgment.

Children and teens having a depressive episode may:

Feel frequent and unprovoked sadness.

Show increased irritability, anger, or hostility.

Complain a lot about pain, such as stomachaches and headaches.

Have a noticeable increase in amount of sleep.

Have difficulty concentrating.

Feel hopeless and worthless.

Have difficulty communicating or maintaining relationships.

Eat too much or too little.

Have little energy and no interest in activities they usually enjoy.

Think about death, or have thoughts of suicide.

Can children and teens with bipolar disorder have other problems?

Young people with bipolar disorder can have several problems at the same time. These include:

Misuse of alcohol and drugs. Young people with bipolar disorder are at risk of misusing alcohol or drugs.

Attention-deficit/hyperactivity disorder (ADHD). Children and teens who have both bipolar disorder and ADHD may have trouble staying focused.

Anxiety disorders. Children and teens with bipolar disorder also may have an anxiety disorder.

Sometimes extreme behaviors go along with mood episodes. During manic episodes, young people with bipolar disorder may take extreme risks that they wouldn't usually take or that could cause them harm or injury. During depressive episodes, some young people with bipolar disorder may think about running away from home or have thoughts of suicide.

If your child shows signs of suicidal thinking, take these signs seriously and call your child's health care provider.
If you think your child is in crisis and needs immediate help, call 911. You also can call the National Suicide Prevention Lifeline (Lifeline) at 1‑800‑273‑TALK (8255), or text the Crisis Text Line (text HELLO to 741741). The deaf and hard of hearing can contact the Lifeline via TTY at 1-800-799-4889. These services are confidential, free, and available 24/7.

How is bipolar disorder diagnosed?

A health care provider will ask questions about your child's mood, sleeping patterns, energy levels, and behavior. There are no blood tests or brain scans that can diagnose bipolar disorder. However, the health care provider may use tests to see if something other than bipolar disorder is causing your child's symptoms. Sometimes health care providers need to know about medical conditions in the family, such as depression or substance use.

Other disorders have symptoms like those of bipolar disorder, including ADHD, disruptive mood regulation disorder, oppositional defiant disorder, conduct disorder, and anxiety disorders. It also can be challenging to distinguish bipolar disorder from depression that occurs without mania, which is referred to as "major depression." A health care provider who specializes in working with children and teens can make a careful and complete evaluation of your child's symptoms to provide the right diagnosis.

How is bipolar disorder treated?

Children and teens can work with their health care provider to develop a treatment plan that will help them manage their symptoms and improve their quality of life. It is important to follow the treatment plan, even when your child is not currently experiencing a mood episode. Steady, dependable treatment works better than treatment that starts and stops.

Treatment options include:

Medication. Several types of medication can help treat symptoms of bipolar disorder. Children respond to medications in different ways, so the right type of medication depends on the child. This means children may need to try different types of medication to see which one works best for them. Some children may need more than one type of medication because their symptoms are complex. Children should take the fewest number of medications and the smallest doses possible to help their symptoms. A good way to remember this is "start low, go slow." Medications can cause side effects. Always tell your child's health care provider about any problems with side effects. Do not stop giving your child medication without speaking to a health care provider. Stopping medication suddenly can be dangerous and can make bipolar symptoms worse.

Psychosocial Therapy. Different kinds of psychosocial therapy can help children and their families manage the symptoms of bipolar disorder. Therapies that are based on scientific research-including cognitive behavioral approaches and family-focused therapy-can provide support, education, and guidance to youth and their families. These therapies teach skills that can help people manage bipolar disorder, including skills for maintaining routines, enhancing emotion regulation, and improving social interactions.

What can children and teens expect from treatment?

With treatment, children and teens with bipolar disorder can get better over time. Treatment is more effective when health care providers, parents, and young people work together.

Sometimes a child's symptoms may change, or disappear and then come back. When this happens, your child's health care provider may recommend changes to the treatment plan. Treatment can take time, but sticking with the treatment plan can help young people manage their symptoms and reduce the likelihood of future episodes.

Your child's health care provider may recommend keeping a daily life chart or mood chart to track your child's moods, behaviors, and sleep patterns. This may make it easier to track the illness and see whether treatment is working.

How can I help my child or teen?

Help begins with the right diagnosis and treatment. Talk to your family health care provider about any symptoms you notice.

If your child has bipolar disorder, here are some basic things you can do:

Be patient.

Encourage your child to talk, and listen to your child carefully.

Pay attention to your child's moods, and be alert to any major changes.

Understand triggers, and learn strategies for managing intense emotions and irritability.

Help your child have fun.

Remember that treatment takes time: sticking with the treatment plan can help your child get better and stay better.

Help your child understand that treatment can make life better.

How does bipolar disorder affect caregivers and families?

Caring for a child or teenager with bipolar disorder can be stressful for parents and families. Coping with a child's mood episodes and other problems-such as short tempers and risky behaviors-can challenge any caregiver.

It is important that caregivers take care of themselves, too. Find someone you can talk to or consult your health care provider about support groups. Finding support and strategies for managing stress can help you and your child.

Where do I go for help?

If you're not sure where to get help, your doctor, pediatrician, or other family health care provider is a good place to start. A health care provider can refer you to a qualified mental health professional, such as a psychiatrist or psychologist, who has experience treating bipolar disorder and can evaluate your child's symptoms.

You can learn more about getting help and finding a health care provider on the National Institute of Mental Health website. Hospital health care providers can help in an emergency. The Substance Abuse and Mental Health Services Administration (SAMHSA) has an online tool to help you find mental health services in your area.

I know someone who is in crisis. What do I do?

If you know someone who might be thinking about hurting themselves or someone else, get help quickly.

Do not leave the person alone.

Call 911 or go to the nearest hospital emergency room.

Call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or the toll-free TTY number at 1-800-799-4TTY (4889). You also can text the Crisis Text Line (text HELLO to 741741) or go to the National Suicide Prevention Lifeline website.

What should I know about clinical trials?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit the NIMH Clinical Trials webpage.

Reprints

This publication is in the public domain and may be reproduced or copied without permission from NIMH. Citation of NIMH as a source is appreciated. To learn more about using NIMH publications, please contact the NIMH Information Resource Center at 1-866‑615‑6464, email nimhinfo@nih.gov, or refer to our reprint guidelines.

For More Information

MedlinePlus (National Library of Medicine) ( En español)

ClinicalTrials.gov ( En español)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 20-MH-8081
Revised 2020

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Does your child go through extreme changes in mood and behavior? Does your child get much more excited or much more irritable than other kids? Do you notice that your child goes through cycles of extreme highs and lows more often than other children?

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Risk of Suicide and Self-harm in Kids: The Development of an Algorithm to Identify High-Risk Individuals Within the Children’s Mental Health System

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Risk of Suicide and Self-harm in Kids: The Development of an Algorithm to Identify High-Risk Individuals Within the Children’s Mental Health System

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Abstract

Suicide is the second leading cause of death in adolescents within Canada. While several risk factors have been found to be associated with increased risk, appropriate decision-support tools are needed to identify children who are at highest risk for suicide and self-harm. The aim of the present study was to develop and validate a methodology for identifying children at heightened risk for self-harm and suicide. Ontario data based on the interRAI Child and Youth Mental Health Screener (ChYMH-S) were analyzed to develop a decision-support algorithm to identify young persons at risk for suicide or self-harm. The algorithm was validated with additional data from 59 agencies and found to be a strong predictor of suicidal ideation and self-harm. The RiSsK algorithm provides a psychometrically sound decision-support tool that may be used to identify children and youth who exhibit signs and symptoms noted to increase the likelihood of suicide and self-harm.

Introduction

Suicide is a major public health concern that has devastating long-term effects on both families and communities. It has been estimated that suicide and self-harm costs Canadian society approximately $3.3 billion annually in both direct and indirect costs [ 1]. Notably, suicide is the second leading cause of death among adolescents in Canada [ 2]. Previous research suggests that effective prevention strategies for child and adolescent suicide should primarily be targeted at reducing suicide risk factors [ 3]. Furthermore, the risk factors and features of suicidality in youth are different than those found in adults, hence the urgent need to determine potential risk factors as well as develop decision-support tools to identify these young people at greater risk [ 4].

Self-harm: Nonsuicidal Self-injury and Suicidal Self-injury

Self-harm is defined as any deliberate and direct act that causes harm to one's body, encompassing both nonsuicidal self-injury (NSSI) and suicidal self-injury (SSI). NSSI is defined as intentional destruction of one's body tissue without lethal intent and has a prevalence rate in adolescents of approximately 30-40% in clinical samples and 13-29% in non-clinical samples [ 5, 6, 7]; SSI is deliberate self-directed harm to one's body with the intent to end one's life and has a lower prevalence by comparison of 24-33% in clinical samples and 4-8% in non-clinical samples [ 5, 7, 8]. Adolescence represents a period of heightened risk for the initiation and engagement in self-injurious behaviours, given that the average age of onset is 12-13 years [ 9].

Potential Risk Factors for Self-harm, NSSI, and SSI

Individual Factors

A prior history of self-injurious behaviour is one of the strongest predictors of future suicidal behaviour, both cross-sectionally and longitudinally [ 15]. The CASE study found that among those who self-harmed within the year before, more than 50% reported multiple events, suggesting that repetition of self-harm is quite prevalent in adolescents [ 16]. A review examining the link between NSSI and suicidal behaviour found that across studies, NSSI was consistently a robust predictor of suicidal thoughts and behaviour, above and beyond a number of well-studied factors including depression and family functioning [ 17, 18, 19]. It has also been reported that more frequent engagement of NSSI is predictive of more frequent suicide attempts [ 17]. Additionally, longitudinal studies have found that a previous suicide attempt increases the risk of a future suicide attempt threefold [ 20].

Self-harm and suicidal behaviour has also been linked to certain personality and character traits, such as perfectionism and neuroticism [ 21]. One trait that has become increasingly important in the literature is impulsivity, as it has been reported that 50% of adolescents start thinking about harming themselves less than an hour before performing the act [ 22]. Impulsivity is known to increase the risk of suicidal behaviour; moreover, adolescents who engage in both NSSI and SSI have significantly higher trait impulsivity compared to those who engage in NSSI only [ 23]. Self-injury has also been linked to compulsive behaviours, such that having one or more obsessive compulsive symptoms increases the odds of suicidality by 2.4 times [ 24].

Interpersonal Factors

A lack of family and social support is associated with a greater likelihood of engaging in self-harm. Research has found a number of family factors are related to adolescent self-harm, including maladaptive parenting, parental divorce, domestic violence, and child maltreatment [ 25, 26, 27]. Adolescents who have attempted suicide are more likely to report running away from home, stress related to parents, and lack of adult support outside the home [ 28]. Moreover, a longitudinal study found that even after controlling for depression, low family support predicted future suicide attempts into young adulthood, highlighting the persistent effect of low family support on suicidality [ 29, 30]. Finally, family discord has been reported as the most common precipitant of completed suicide in adolescents [ 31].

The present study sought to develop and validate a methodology that could identify children and youth who are at greater risk of suicide and self-harm within the Ontarian children's mental health system. A validated methodology to identify adults who are at risk for suicide and self-harm (SOS) has previously been developed [ 32]. Due to the fact that Ontario does not currently have an existing system specifically designed for children and youth, an effort was launched to develop a new decision-support algorithm for identifying those at greatest risk of self-harm in this younger population. Applying the same methodology utilized in the SOS, the Risk of Suicide and Self-Harm in Kids (RiSsK) algorithm was created to assist healthcare providers in determining whether a young person is at heightened risk of self-harm or committing suicide. The aim of this article is to describe the development and validation efforts undertaken as part of the development of the RiSsK algorithm.

Methods

Sample

The participants in this study consisted of children and youth who received services from mental health agencies in Ontario. Referrals were made to the agencies through their family physicians, pediatricians, school personnel, parents or other allied professionals. Derivation was conducted on a primary sample using screener records collected between September 1, 2015 and January 31, 2019, a total of 60,414 records on 54,280 unique individuals from 59 organizations. Males made up 49.8% of these observations and the mean age was 11.8 years (SD 3.74, range 4 to 18 years). A validation sample consisted of 2117 records on 2098 unique individuals that were completed in a subsequent time period in the same 59 organizations, between February 1, 2019 and March 5, 2019. Males made up 49.0% of these observations and the mean age was 11.7 years (SD 3.67, range 4 to 18 years). There were no differences in the methods or sources between the derivation and validation samples.

The derivation and validation data came from the implementation of the Child and Youth Mental Health Screener (ChYMH-S) [ 33], described below. Two additional related sources of data were also used in the post-scale development stage, the Child and Youth Mental Health (ChYMH) [ 34] and the Child and Youth Mental Health and Developmental Disability (ChYMH-DD) [ 35], also described below. A sample of 25,104 ChYMH and ChYMH-DD assessments on 13,899 unique individuals was used, completed between September 1, 2015 and January 31, 2019. Males made up 57.0% of these observations and the mean age was 12.1 years (SD 3.51, range 4 to 18 years). The ChYMH, ChYMH-DD, and ChYMH-S have been utilized as the standard of care in mental health agencies across the Province of Ontario. Therefore, the inclusion criteria were children and youth 4-18 years of age who presented at mental health facilities utilizing the interRAI child/youth suite of instruments as standard of care.

Measures

The ChYMH-S is a brief assessment tool used in assessing, triaging and prioritizing children and youth seeking mental health services [ 33]. Within the global interRAI Collaborative network, the ChYMH-S was developed to provide seamless screening and support decision-making related to triaging, placement, and service urgency for children and youth with mental health needs. It was also designed to be used in multiple settings, including schools, community programs, as well as inpatient and residential services [ 33].

Detailed manuals support the child/youth suite of instruments and provide coding rules for the items. The result is a valid and reliable set of information that can be used individually for case documentation and to inform program planning, as well as collectively for system reporting and secondary research purposes. All interRAI instruments and assessments are rigorously evaluated to ensure stringent psychometric properties suitable for international implementation for both adults [ 40, 41, 42], children and youth [ 38, 39, 43, 44, 45, 46].

Procedure

The interRAI ChYMH Screener (ChYMH-S) was administered as part of typical practice for children and youth seeking mental health services in 59 agencies across Ontario. All assessors completed a full-day training session regarding how to administer and score the ChYMH-S. The service providers that administered the ChYMH-S ranged in discipline and expertise and included psychologists, nurses, psychiatrists, speech and language therapists, child and youth workers, physiotherapists, resource teachers, developmental social service workers, and social workers. Through a semi-structured interview, either in person or over the phone, assessors gathered information from a variety of sources (i.e., family members, community members, document review, and clinical observations).

Assessment information was entered into a de-identified web-based software, password protected, encrypted, and stored on computers with no internet or USB ports to ensure confidentiality. This web-based software securely stores the data at interRAI Canada and provides each case a randomly assigned, study-specific participant number. Importantly, personal identifiers had been removed prior to the data being made available for analysis. Approval was granted through Western University's ethics board (REB #106415) for the secondary analysis of data collected in various agencies throughout the Province of Ontario.

Analysis

The goal was to develop an algorithm that would produce an ordinal scale of the individual's risk of suicide and self-harm. A single ordinal item records the assessor's perceived risk of the individual's "danger to self" scored as 0 (minimal) to 4 (very severe or imminent). The analytic approach was to use this estimate as the dependent measure and to use multiple measures from the screener items to predict it. An important purpose of this scale will be its use with the comprehensive ChYMH assessment, which shares many, but not all, items with the ChYMH-S. Therefore, all explanatory items used in the algorithm must be available in the ChYMH assessment as well.

Importantly, in the full ChYMH, the item "danger to self" is not recorded as it is in the ChYMH-S. The algorithm development therefore uses the availability of "danger to self" from the ChYMH-S as the dependent variable in order to model or predict this in the ChYMH where it is not available. This single item reflects the clinician's evaluation based on all available evidence as to the level of risk of the child's danger to self.

In developing the scale, all screener records were used because it represents the flow of assessments for which to establish the relationship between predictor variables and global risk; and so this is aptly influenced by a young person who may have been screened two or more times (e.g., within both inpatient and outpatient settings). Therefore, the sample population represents the properly balanced sample of cases for which the algorithm hopes to be applied to.

Exploratory work considered modeling dichotomous proportions (e.g., percentage 2 or greater) in addition to weighted and unweighted mean values. The simple unweighted mean was ultimately chosen. The independent or explanatory variables consisted of those that were judged to be acceptable from a face validity and practical perspective. For example, while age and sex might be associated with differential self-harm risk, it is more desirable that mental health symptoms and behaviours, some of which may be age or sex related, be used instead. Also, items related to school were avoided, as not all screened children and youth are in school.

Modeling was done utilizing an interactive decision tree tool supported by the SAS Enterprise Miner package. In this interactive decision tree approach, like other tree modeling approaches, the user starts with all cases and sequentially divides them at nodes to arrive at mutually exclusive and exhaustive classifications. The SAS program allows the analyst to control, based on presented options ranked by statistical strength, which variable is chosen (for statistical and clinical reasons) and to see the resulting groups before proceeding. This allows many alternative trees to be explored. Decision trees naturally handle interactions that are common in health data, such that the influence of a given variable is specific to subsets of the data, in contrast to regression modeling which uses the average effect across all subjects. In decision tree modeling, the first split is particularly important. In addition to the top-ranking variables, forced splits (age, sex) were also considered as the first splits, but were abandoned since they offered no additional explanatory power and resulted in some fragmentation and small cell sizes in some branches. The chosen tree was subsequently tested among sex and age groups.

A design goal was to have a final scale that had a compact range: 7 groups (labels of 0 to 6, higher values with higher risk). Because of the large sample with many variables, resulting trees could have 30 or more terminal nodes, requiring them to be combined after modeling. Group assignment was done using weighted k-means clustering, resulting in 7 groups with the largest overall differences across the group means. During modeling, this resulting assignment would often result in a part of the original tree being unnecessary (over-branched), for example, a final two-way split in a branch for which both resulting nodes were assigned to the same clustered group. In these cases, the tree would be pruned at these logical points with other splitting options explored before repeating the process, until a finished parsimonious tree was designed.

Multinomial logistic regression was applied to test model fit of the dependent variable, to provide odds ratios as well as the C-statistic (area under curve). Using the full sample of 25,104 ChYMH and ChYMH-DD assessments, the RiSsK scale was calculated, and additional descriptive analyses related to diagnoses were conducted. SAS 9.4 and SAS Enterprise Miner 14.1 were used for the analysis.

Results

Figure 1 provides a schematic representation of the final RiSsK algorithm, which categorizes assessed children and youth into levels of risk that suggest the need for heightened concern for suicide or self-harm based on criteria from the ChYMH-S. A tree with 20 terminal nodes was selected. It uses six items from the screener assessment, plus a scale of depression symptoms (the Depression Symptoms Scale, DSS) constructed from an additional nine items. All of these 15 items exist in the same form in both the ChYMH Screener and ChYMH full assessment.

Risk of Suicide and Self-harm (RiSsK) decision tree diagram. DSS depression symptoms scale

As shown in Table 1, groups were assigned from 0 (lowest) to 6 (highest) with higher scores indicating heighted risk of suicide or self-harm. The child or youth may fall into a given level via a number of pathways that represent different combinations of the criteria/risk factors. Higher risk was concentrated in a small minority of children, youth and their families [approximately 0.08% scored at the highest level (6)]. Specifically, Group 6 had 29 times the mean risk value as group 0, and 313 times the proportion rated as severe, very severe, or imminent risk. The C-statistic represents the area under the receiver operator characteristic (ROC) curve, and for the derivation dataset was 0.837. To validate the RiSsK score, data from 2117 new records were utilized. The C-statistic for the validation sample was 0.822. Table 2 presents the results for the validation sample.

Table 1 Derivation results of Risk of Suicide and Self-harm (RiSsK) algorithm (N = 60,414)

Table 2 Validation results of Risk of Suicide and Self-harm (RiSsK) algorithm (N = 2117)

For the derivation sample, three different cut-points were examined by further collapsing the RiSsK score into dichotomous groups (Mild +, Moderate +, and Severe +) to determine sensitivity and specificity for identifying high risk cases. Table 3 presents sensitivity and specificity as well as positive predictive and negative predictive values, for the severe, moderate, and mild groups. As can be seen from Table 3 (severe group), a RiSsK score of 3 + provides a sensitivity of 86% and specificity of 75%. However, given the importance of sensitivity rather than specificity in relation to clinical utility, a 2 + cut-point was chosen which provided a sensitivity of 93% and a specificity of 61%. While there is likely to be more false positives with the lower threshold, a lower cut-point will reduce the likelihood that a child or youth is at high risk but is not identified.

Tables 4 and 5 present the derivation sample by age group and sex, respectively. As can be seen from Table 4, older children scored higher on the RiSsK algorithm indicating that they were at higher risk of suicide and self-harm, than younger children. Specifically, at a cut-point of 2 + for children under 7 years of age, only 10.7% (vs. 7% for a cut-point of 3 +) were classified as high on the RiSsK algorithm compared to higher scores for children aged 8-11 years (23.3% vs. 14% for a cut-point of 3 +) and those over 12 years (58.1% vs. 38.5% for a cut-point of 3 +). Additionally, girls scored higher on the RiSsK algorithm than boys (51.4% vs. 30.3% for a cut-point of 2 + and 35.1% vs. 18.2% for a cut-point of 3 +) reflecting higher risk for self-injury in the former group than the latter one.

To examine diagnoses related to the RiSsK algorithm, data from the full ChYMH and ChYMH-DD assessments were utilized within the same time period as the derivation sample, comparing the diagnosis recorded as most important as well as if a diagnosis was prevalent at all. Table 6 (prevalence of suicide and self-harm by diagnosis) presents the proportions that scored with higher values of the RiSsK algorithm, among those with these diagnoses. The diagnoses with higher RiSsK values varies somewhat depending on the cut-point, here either 2 + or 3 + . However, the leading three diagnoses associated with higher RiSsK algorithm scores included Mood, Adjustment and Eating Disorders.

Discussion

Depressive symptomology was another factor that contributed to higher scores on the RiSsK algorithm. This finding is in accordance with previous studies that have shown higher levels of depressive symptoms are associated with increased likelihood of engaging in suicidal behaviour or self-harm [ 12]. Furthermore, a multi-national study examining the influence of various psychosocial factors on NSSI in adolescents found that depressive symptoms was the only factor associated with increased odds of engaging in NSSI across all countries included in the study [ 50].

The final contributing factor to the RiSsK algorithm is the family being overwhelmed by the child or youth's condition. There are a number of reasons the family may be feeling overwhelmed or stressed. Family members may have significant concerns about the safety of their child. Additionally, these families may not possess effective coping strategies needed to help navigate their child's difficult situation, or the child's condition may be compounded by other family stressors, resulting in feeling burdened or overextended. Research has shown a variety of familial factors are associated with suicidality and self-harm, such as poor family environment and low parental monitoring [ 51]. Interestingly, adolescents who are more likely to report a lack of family network availability have a higher likelihood of suicide attempts [ 52]. Families may feel overwhelmed because of the lack of outside help from family and/or friends, thus contributing to the child's increased risk of self-harm, a finding consistent with this study. Studies have also found that low family support predicts suicidal ideation and behaviours across both gender and ethnicity [ 53]. It can be postulated that when a family is feeling overwhelmed by the child, family members may not be capable of providing the necessary, ongoing support the child needs, thus resulting in the increased likelihood of the child engaging in self-harming behaviours. Overall, it appears that the predictive ability of the family feeling overwhelmed within our model can be understood within the greater context of the well-documented relationship between family stressors and increased risk of self-injurious behaviours among adolescents.

The current study also examined diagnoses related to the RiSsK algorithm, and identified mood, adjustment, and eating disorders among the top diagnoses associated with higher RiSsK scores. The association between these DSM-diagnoses and higher risk for self-harm and suicidal behaviour is well-supported by the literature. For example, one of the most common mood disorders in children and youth is major depressive disorder, and as evidenced by both the results of the current study and prior research, depressive symptomology is an important independent predictor of self-injurious behaviour [ 13, 14].

Other research has also reported that suicidal behaviour and self-harm is very prevalent in youth with eating disorders. Koutek and colleagues found suicidal behaviour to be present in 60% of patients with an eating disorder, and self-harm in 49% [ 54]. Furthermore, when examining the relationship between suicidality and eating disorders across the lifespan, it has been reported that approximately 16.9% of those with anorexia nervosa have attempted suicide at some point in their lives [ 55].

Past literature has also found a strong relationship between adjustment disorder and suicidality. A study conducted by Gradus and colleagues found that after controlling for a number of factors including marital status, income, and history of depression, individuals with adjustment disorder had 12 times the rate of completed suicide compared to those who had not received this diagnosis [ 56]. Furthermore, among adolescents who were admitted to a psychiatric hospital, adjustment disorder was more common in youth hospitalized for a suicide attempt compared to those without a history of suicide attempt [ 57].

Overall, a number of variables predict risk for suicidality and self-harm within childhood and adolescence, including factors related to a prior history of self-injurious behaviours, mental health concerns and family stressors. Furthermore, certain DSM-diagnoses are more strongly associated with a higher RiSsK score.

Use and Utility of RiSsK

Based on the findings, RiSsK is an empirically based decision-support tool that may be used to identify children and adolescents who exhibit symptoms that have been shown to increase one's likelihood of engaging in self-harm and suicidal behaviour. Given that the RiSsK algorithm was found to be a strong predictor of high-risk self-injurious behaviour, service providers utilizing this decision-support algorithm will be able to make more systematic evaluations in determining whether a child or adolescent is at heightened risk of committing suicide or engaging in self-harm.

The results of the RiSsK can be obtained automatically by the assessor who has completed the interRAI ChYMH-S assessment from the software in which the algorithm is embedded. The results are intended to help support service providers in selecting appropriate resources based on the child or youth's RiSsK score. Furthermore, the RiSsK algorithm is meant to be used in conjunction with other information obtained during the assessment process, for the purpose of assisting the clinical team in determining the level of risk of suicide or self-harm. Importantly, the RiSsK algorithm should not be used as an automated decision-making system, without any clinical judgment. Rather, the responsibility lies within the clinical team to use their professional judgment in making the decision as to whether the RiSsK score accurately reflects the child or youth's risk of committing suicide or engaging in self-harming behaviour, when all available information is considered holistically. Finally, the child or youth, along with his or her family, should be included in the decision-making process as necessary, as each unique case requires careful consideration of that individual's preferences, strengths, and needs.

Depending on whether the child's RiSsK score falls within the upper or lower range will help determine subsequent care planning steps. If the child or youth's score falls within the lower range, it is recommended that the clinical team engage in further discussion to determine whether the RiSsK level seems appropriate given all other assessment information. If the child or youth's score falls within the upper range, it is recommended that the clinical team consider the individual to be at high risk for self-harm or suicide. The Suicidality and Purposeful Self-Harm collaborative action plan (CAP) developed by interRAI can assist clinicians in care planning for higher risk children and adolescents [ 58, 59]. When the young person is at high risk of self-harm, immediate safety planning is required. When the young person is at moderate risk of self-harm, clinicians can consider referral to in-patient or out-patient treatment depending on the circumstances, such as whether the child has a supportive family relationship and stable home life, or whether the child is experiencing extreme levels of uncontrollable stress. Early detection and intervention are essential components of effective prevention efforts, which signifies the importance of the RiSsK algorithm in identifying children and youth who are at a greater risk of suicide or self-harm, as it enables clinicians to intervene earlier on.

Notably, proper assessment of self-harm is associated with increased resources and costs in the mental health field. This is evidenced by a study that examined predictors of service complexity in children's mental health, and found that suicidality risk and purposeful self-harm was an important contributor to increased resource costs [ 46]. Furthermore, other research has found that self-harm and suicidal ideation are associated with increased use of emergent and intensive services as a result of these behaviours being life-threatening by nature [ 11, 60]. Taken altogether, this finding emphasizes the need to properly assess and care plan around this critical issue, again pointing to the significant utility of the RiSsK algorithm.

While this study has numerous strengths, including its relatively large sample size, it is not without its limitations. First, this study is cross-sectional in nature. As a result of this, older children have had a longer opportunity to engage in suicidal and self-harming behaviours, and so it may not be unexpected that these children obtained higher RiSsK scores compared to younger children. In the future, longitudinal data are needed to examine risk of suicidality and self-harm as the child grows and develops. Second, the findings may not be generalizable to a community-based sample because the children and youth assessed were accessing outpatient or inpatient mental health services. Additional future research should examine whether this study's findings are consistent when participants comprise of a community sample.

Summary

Suicide is a major public health concern as it is the second leading cause of death among Canadian youth [ 2]. Although a number of risk factors have been previously identified, there continues to be a critical need for the development of appropriate decision-support tools to identify young persons who are at highest risk for suicide and self-harm. In this study, analyses were conducted using the interRAI ChYMH-S data collected within the province of Ontario to develop a decision-support algorithm to identify children and youth at risk for suicide or self-harm. The primary sample for the derivation of the algorithm was 60,414 records obtained from participants aged 4-18 years who had completed the ChYMH-S assessment. The algorithm was subsequently validated with additional data from 59 agencies. The independent or predictor variables that contributed to the RiSsK algorithm included having considered or attempted self-injury, attempted to kill him or herself, have previously engaged in any type of self-injurious behaviour, others being concerned about the youth partaking in self-injury, along with depressive symptomology and the family being overwhelmed by the child or youth's condition. Through the derivation and validation efforts, the RiSsK algorithm was found to be a strong predictor of suicide and self-harm. Therefore, the RiSsK algorithm provides a psychometrically sound decision-support tool that may be used to identify children and adolescents at heightened risk of engaging in suicide or self-harm. The main goal for the development and implementation of the RiSsK algorithm is to prevent future self-harming behaviours or suicidal acts through the earlier detection, and subsequent intervention, of children and youth at greatest risk.

Acknowledgements

The authors would like to sincerely thank the children, youth, and their families, along with the service providers within the agencies for their participation in the research.

Funding

Public Health Agency of Canada (#1617-HQ-000050).

Author information

Affiliations

1. Faculty of Education, Western University, London, ON, Canada

Shannon L. Stewart & Angela Celebre

2. Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada

John P. Hirdes & Jeffrey W. Poss

Corresponding author

Correspondence to Angela Celebre.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the ethics committee of Western University.

Informed Consent

For this study, consent was obtained as part of standard of care.

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Risk of Suicide and Self-harm in Kids: The Development of an Algorithm to Identify High-Risk Individuals Within the Children's Mental Health System

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Suicide is the second leading cause of death in adolescents within Canada. While several risk factors have been found to be associated with increased risk, appropriate decision-support tools are needed to identify children who are at highest risk for suicide and self-harm.

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A guide for parents and guardians

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Recognizing Mental Health Problems In Children

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Recognizing Mental Health Problems In Children

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Children's mental health problems are real, common and treatable. Although one in five children has a diagnosable mental health problem, nearly two-thirds of them get little or no help.

Untreated mental health problems can disrupt children's functioning at home, school and in the community. Without treatment, children with mental health issues are at increased risk of school failure, contact with the criminal justice system, dependence on social services, and even suicide.

Parents and family members are usually the first to notice if a child has problems with emotions or behavior. Your observations, along with those of teachers and other caregivers, can help determine whether you need to seek help for your child.
The following signs may indicate the need for professional help:

Decline in school performance

Poor grades despite strong efforts

Constant worry or anxiety

Repeated refusal to go to school or to take part in normal activities

Hyperactivity or fidgeting

Persistent nightmares

Persistent disobedience or aggression

Frequent temper tantrums

Depression, sadness or irritability

Early identification, diagnosis and treatment can help children reach their full potential. A first step may be to have your child complete our youth screening which is intended for young people (age 11-17) who are concerned that their emotions, attention, or behaviors might be signs of a problem. A complementary parent screening is also available for your use.

The information from the completed screenings can be helpful in starting a conversation with your child about their mental health, and may be useful when talking with your child's pediatrician or a mental health professional.

An evaluation may include consultation with a child psychiatrist, psychological testing and medical tests to rule out any physical condition that could be causing the symptoms. Children also must be carefully evaluated to distinguish possible mental health conditions from learning disabilities or developmental delays.

If your child is diagnosed with a mental health problem, a comprehensive treatment plan should include psychotherapy and, in some cases, may include medication. The plan should be developed with the family. Whenever possible, the child should be involved in treatment decisions.
Additional Resources Time to Talk: Tips for Talking About Your Mental Health
Youth Mental Health: Emotions Matter (Infographic)

Helpful vs Harmful: Ways to Manage Emotions (For Youth)
Helping at Home: Tips for Parents Learn about IEPs and 504 Plans Prevention and Early Intervention in Mental Health- Puberty to Early Adulthood ADHD and Kids Healthy Mental and Emotional Development Take the Youth Screen Take the Parent Screen
Treatment of Children with Mental Illness. National Institute of Mental Health.

# data[].attributes.attachment_link.title
Recognizing Mental Health Problems In Children

# data[].attributes.attachment_link.description
Children's mental health problems are real, common and treatable. Although one in five children has a diagnosable mental health problem, nearly two-thirds of them get little or no help. Untreated mental health problems can disrupt children's functioning at home, school and in the community.

# data[].attributes.headline
Psychosis (Schizophrenia) In Children And Youth

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Psychosis (Schizophrenia) In Children And Youth

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Psychosis (Schizophrenia) in Children and Youth

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Psychosis (Schizophrenia) Schizophrenia and other psychotic disorders are medical illnesses that result in strange or bizarre thinking, perceptions (sight, sound), behaviors, and emotions. Psychosis is a brain-based condition that is made better or worse by environmental factors - like drug use and…

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Clinical Practice Guidelines for the Management of Schizophrenia in Children and Adolescents

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Clinical Practice Guidelines for the Management of Schizophrenia in Children and Adolescents

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Your access to the NCBI website at www.ncbi.nlm.nih.gov has been temporarily blocked due to a possible misuse/abuse situation involving your site. This is not an indication of a security issue such as a virus or attack. It could be something as simple as a run away script or learning how to better use E-utilities, http://www.ncbi.nlm.nih.gov/books/NBK25497/, for more efficient work such that your work does not impact the ability of other researchers to also use our site. To restore access and understand how to better interact with our site to avoid this in the future, please have your system administrator contact info@ncbi.nlm.nih.gov.

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The challenge of early conduct disorder: Derek Patton at TEDxLaunceston

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The challenge of early conduct disorder: Derek Patton at TEDxLaunceston

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The challenge of early conduct disorder: Derek Patton at TEDxLaunceston

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The Neuropsychology of Conduct Disorder in Children | Kalina Michalska | TEDxUCR

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The Neuropsychology of Conduct Disorder in Children | Kalina Michalska | TEDxUCR

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The Neuropsychology of Conduct Disorder in Children | Kalina Michalska | TEDxUCR

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An overview of conduct disorder and ways to manage it in children

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Treatment works best when it involves and empowers parents.

All children and adolescents act out occasionally, but those with conduct disorder consistently behave in unusually aggressive ways - sometimes resulting in property damage or physical injury. Examples of such behavior include stealing from parents, threatening schoolmates to extract pocket change, breaking windows in cars, and setting fires. Although children with conduct disorder may have normal intelligence, they tend to disrupt or skip classes and fall behind in school.

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Options for managing conduct disorder - Harvard Health

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Treatment works best when it involves and empowers parents. All children and adolescents act out occasionally, but those with conduct disorder consistently behave in unusually aggressive ways - sometimes resulting in property damage or physical injury. Examples of such behavior include stealing from parents, threatening schoolmates to extract pocket change, breaking windows in cars, and setting fires.

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Oppositional Defiant Disorder (ODD) in Children

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Oppositional Defiant Disorder (ODD) in Children

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An overview of ODD in children.

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What is oppositional defiant disorder (ODD) in children?

Oppositional defiant disorder (ODD) is a type of behavior disorder. It is mostly diagnosed in childhood. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures. They are more troubling to others than they are to themselves.

What causes ODD in a child?

Researchers don't know what causes ODD. But there are 2 main theories for why it occurs:

Developmental theory. This theory suggests that the problems start when children are toddlers. Children and teens with ODD may have had trouble learning to become independent from a parent or other main person to whom they were emotionally attached. Their behavior may be normal developmental issues that are lasting beyond the toddler years.

Learning theory. This theory suggests that the negative symptoms of ODD are learned attitudes. They mirror the effects of negative reinforcement methods used by parents and others in power. The use of negative reinforcement increases the child's ODD behaviors. That's because these behaviors allow the child to get what he or she wants: attention and reaction from parents or others.

Which children are at risk for ODD?

ODD is more common in boys than in girls. Children with the following mental health problems are also more likely to have ODD:

Mood or anxiety disorders

Conduct disorder

Attention-deficit/hyperactivity disorder (ADHD)

What are the symptoms of ODD in a child?

Most symptoms seen in children and teens with ODD also happen at times in other children without it. This is especially true for children around ages 2 or 3, or during the teen years. Many children tend to disobey, argue with parents, or defy authority. They may often behave this way when they are tired, hungry, or upset. But in children and teens with ODD, these symptoms happen more often. They also interfere with learning and school adjustment. And in some cases, they disrupt the child's relationships with others.

Symptoms of ODD may include:

Having frequent temper tantrums

Arguing a lot with adults

Refusing to do what an adult asks

Always questioning rules and refusing to follow rules

Doing things to annoy or upset others, including adults

Blaming others for the child's own misbehaviors or mistakes

Being easily annoyed by others

Often having an angry attitude

Speaking harshly or unkindly

Seeking revenge or being vindictive

These symptoms may look like other mental health problems. Make sure your child sees his or her healthcare provider for a diagnosis.

How is ODD diagnosed in a child?

If you notice symptoms of ODD in your child or teen, you can help by seeking a diagnosis right away. Early treatment can often prevent future problems.

A child psychiatrist or qualified mental health expert can diagnose ODD. He or she will talk with the parents and teachers about the child's behavior and may observe the child. In some cases, your child may need mental health testing.

How is ODD treated in a child?

Early treatment can often prevent future problems. Treatment will depend on your child's symptoms, age, and health. It will also depend on how bad the ODD is.

Children with ODD may need to try different therapists and types of therapies before they find what works for them. Treatment may include:

Cognitive-behavioral therapy. A child learns to better solve problems and communicate. He or she also learns how to control impulses and anger.

Family therapy. This therapy helps make changes in the family. It improves communication skills and family interactions. Having a child with ODD can be very hard for parents. It can also cause problems for siblings. Parents and siblings need support and understanding.

Peer group therapy. A child develops better social and interpersonal skills.

Medicines. These are not often used to treat ODD. But a child may need them for other symptoms or disorders, such as ADHD.

How can I help prevent ODD in my child?

Researchers don't know what causes ODD. But certain approaches can help prevent the disorder. Young children be helped by early intervention programs that teach them social skills and how to deal with anger. For teens, talk therapy (psychotherapy), learning social skills, and getting help with schoolwork can all help reduce problem behaviors. School-based programs can also help to stop bullying and improve relationships among teens.

Parent-management training programs are also important. These programs teach parents how to manage their child's behavior. Parents learn positive reinforcement methods, and also how to discipline their child.

How can I help my child live with ODD?

Early treatment for your child can often prevent future problems. Here are things you can do to help:

Keep all appointments with your child's healthcare provider.

Take part in family therapy as needed.

Talk with your child's healthcare provider about other providers who will be involved in your child's care. Your child may get care from a team that may include counselors, therapists, social workers, psychologists, and psychiatrists. Your child's care team will depend on his or her needs and how serious the disorder is.

Tell others about your child's conduct disorder. Work with your child's healthcare provider and school to develop a treatment plan.

Reach out for support. Being in touch with other parents who have a child with ODD may be helpful. If you feel overwhelmed or stressed out, talk with your child's healthcare provider. He or she may direct you to a support group for caregivers of children with ODD.

When should I call my child's healthcare provider?

Call your child's healthcare provider right away if your child:

Feels extreme depression, fear, anxiety, or anger toward him or herself or others

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

Can't sleep or eat for 3 days in a row

Shows behavior that concerns friends, family, or teachers, and others express concern about this behavior and ask you to seek help

Call 911 if your child has suicidal thoughts, a suicide plan, and the means to carry out the plan.

Key points about ODD in children

Oppositional defiant disorder (ODD) is a type of behavior disorder. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures.

Developmental problems may cause ODD. Or the behaviors may be learned.

A child with ODD may argue a lot with adults or refuse to do what they ask. He or she may also be unkind to others.

A mental health expert often diagnoses ODD.

Therapy that helps the child interact better with others is the main treatment. Medicines may be needed for other problems, such as ADHD.

Next steps

Tips to help you get the most from a visit to your child's healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child's condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child's provider after office hours. This is important if your child becomes ill and you have questions or need advice.

# data[].attributes.attachment_link.title
Oppositional Defiant Disorder (ODD) in Children

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Oppositional defiant disorder (ODD) is a type of behavior disorder. It is mostly diagnosed in childhood. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures.

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Hidden Secrets: Eating Disorders | Rayo Cole | TEDxCrenshaw

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Hidden Secrets: Eating Disorders | Rayo Cole | TEDxCrenshaw

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Hidden Secrets: Eating Disorders | Rayo Cole | TEDxCrenshaw

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Eating Disorders in Schools: Prevention, Early Identification and Response

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Eating Disorders in Schools: Prevention, Early Identification and Response

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The School Counselor’s Role in Addressing Eating Disorder Symptomatology Among Adolescents

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The School Counselor’s Role in Addressing Eating Disorder Symptomatology Among Adolescents

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How Teachers and Coaches can Help in Preventing Eating Disorders

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How Teachers and Coaches can Help in Preventing Eating Disorders

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Lean sports such as running, swimming, wrestling, gymnastics and dance are sports that are judged on appearances and body shape and tend to have higher rates of eating disorders, but no sport is immune to an eating disorder. Athletics can be a great way to learn teamwork, self-discipline, mindfulness and the development of the importance of physical activity in daily living and therefore it is important that parents, teachers, coaches and athletes alike keep in mind these goals when competing in sports.

The relationship of a coach with an athlete can be especially important when trying to prevent an eating disorder. The athlete is influenced by the coach's motivation, their body image, and their relationship with the team, the training, and their competitiveness. Athletes and coaches spend a significant amount of time together during the week, especially if the coach is also one of the athlete's teachers. The coach or teacher can have a substantial influence on an athlete's beliefs, perceptions, and behaviors.

The relationship between motivation, conflict, and performance has also been shown to increase or decrease disordered eating in athletes. If the conflict is high between the coach and athlete, and there is little support then typically the athlete may begin to show signs of disordered eating. Additionally, if there is a performance-centered or judgment based environment, there is often a higher rate of disordered eating among athletes.

Teaching about mindfulness and body positivity in schools

Research at middle schools and high schools have shown that engaging in prevention programs like mindful eating can help in preventing eating disorders.

Middle school programs that incorporate mindfulness also work to integrate reframing techniques to help youth reframe their thoughts with the use of dietetics and food science teachers. Studies have shown that eating disorders are deeply rooted in past trauma, low self esteem, unhealthy coping skills, and poor interpersonal relationships and therefore developing a positive body image and high self esteem is important, especially in school-aged children and adolescents. Some schools bring in short-term prevention programs or leadership training such as The Body Positive, Girls on the Run and Girls in the Know that explore healthy lifestyles, body image, and self-care education. Professional therapists, dietitians, and physicians in local communities that volunteer their time to these organizations often lead these educational programs. Other programs have guest speakers who are recovering from an eating disorder and share their personal story.

Taking preventative steps in the classroom and on the field

Another way to prevent unhealthy social atmospheres is to change the conversations from performance and appearance driven to team and quality driven.

When coaches and teachers start to focus on the team or class as a whole, talents of the person, as well as performance, it enhances the student's or athlete's self-confidence and self-worth.

Inviting dietitians to talk at schools on a regular basis about nourishment for the athlete's body, mindful eating practices, and self-care are important for all students regardless of the age or if they are in athletics.

Being able to have the student and athlete focus all of their senses on how their body is feeling, what emotions they are sensing, and how their food tastes is a great tool to use in preventing disordered eating patterns.

Engaging a school counselor or a therapist to work with a student in school or on the team or the team as a whole can help with prevention efforts. School therapists can offer educational sessions on healthy versus unhealthy eating behaviors, and provide one-on-one counseling.

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How Teachers and Coaches can Help in Preventing Eating Disorders

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Lean sports such as running, swimming, wrestling, gymnastics and dance are sports that are judged on appearances and body shape and tend to have higher rates of eating disorders, but no sport is immune to an eating disorder.

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An overview of eating disorders , the signs, symptoms, risk factors, and therapies

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Overview

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people's eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Signs and Symptoms

Risk Factors

Treatments and Therapies

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There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people's eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder.

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Emotion-Focused Family Therapy for Eating Disorders Across the Lifespan: A Pilot Study of a2-Day Transdiagnostic Intervention for Parents

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Emotion-Focused Family Therapy for Eating Disorders Across the Lifespan: A Pilot Study of a2-Day Transdiagnostic Intervention for Parents

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Emotional FOcused Family Therapy for Eating Disorders

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Common Questions About Oppositional Defiant Disorder

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Common Questions About Oppositional Defiant Disorder

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Patient information: A handout on this topic is available at https://familydoctor.org/familydoctor/en/diseases-conditions/oppositional-defiant-disorder.html.

Author disclosure: No relevant financial affiliations.

Oppositional defiant disorder (ODD) is a disruptive behavior disorder characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness lasting for at least six months. Children and adolescents with ODD may have trouble controlling their temper and are often disobedient and defiant toward others. There are no tools specifically designed for diagnosing ODD, but multiple questionnaires can aid in diagnosis while assessing for other psychiatric conditions. ODD is often comorbid with attention-deficit/hyperactivity disorder, conduct disorder, and mood disorders, including anxiety and depression. Behavioral therapy for the child and family members improves symptoms of ODD. Medications are not recommended as first-line treatment for ODD; however, treatment of comorbid mental health conditions with medications often improves ODD symptoms. Adults and adolescents with a history of ODD have a greater than 90% chance of being diagnosed with another mental illness in their lifetime. They are at high risk of developing social and emotional problems as adults, including suicide and substance use disorders. Early intervention seeks to prevent the development of conduct disorder, substance abuse, and delinquency that can cause lifelong social, occupational, and academic impairments.

What Causes ODD?

The etiology of ODD is not clearly defined. Most experts think it is caused by the cumulative effect of multiple risk factors that stem from biologic, psychological, and social issues. Social support is a protective factor.

EVIDENCE SUMMARY

The etiology of ODD is multifactorial with a cumulative nature. Biologic factors associated with ODD may include nicotine use by parents, prenatal nutritional deficiencies, and developmental delay. 6- 9 Familial clustering suggests an underlying genetic component, but hereditary connections are variable. Psychological factors associated with ODD may include insecure attachment and unresponsive parents. 6 Parental psychopathology, including maternal aggression, is associated with ODD; abuse, harsh punishment, and inconsistent discipline are common correlates. 10 Newer studies confirm that parental behavior is likely causal rather than a response to the child's symptoms. 11 Additional social factors that may contribute to ODD include poverty, lack of structure, peer rejection, and community violence. 6 Protective factors are less clear but include social support, such as peer acceptance and time spent in supportive environments. 10

What Are the Diagnostic Criteria?

To meet the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5) diagnostic criteria for ODD, the child must have at least four symptoms of angry/irritable mood, argumentative/defiant behavior, or vindictiveness. Symptoms must be present for at least six months and have a negative impact on social, educational, or occupational functioning.

EVIDENCE SUMMARY

A number of changes in the diagnostic criteria for ODD were made in the DSM-5. Symptoms are now grouped by mood, behaviors, and vindictiveness, and the exclusion criterion for conduct disorder has been removed. Because many oppositional behaviors are a normal part of early childhood and adolescence, the DSM-5 now provides guidance on when these behaviors are a departure from normal development. For example, the DSM-5 notes that temper outbursts for preschool-aged children are common, but they may be abnormal if they occur on most days and are associated with significant impairment, such as being asked to leave school. 1

The DSM-5 also provides severity criteria depending on the number of settings in which symptoms are present. In contrast with attention-deficit/hyperactivity disorder (ADHD), in which impairment must be pervasive across multiple settings, ODD symptoms must be present in only one setting to make the diagnosis. 1 This means that a child who has no behavioral problems in school may be diagnosed with ODD as a result of oppositional issues at home. However, ODD more commonly causes impairment in multiple settings, and pervasiveness across settings indicates a more severe disorder. 12 Children with ODD who have symptoms in only one setting may still have significant problems with current and future adjustment, and warrant further evaluation and treatment.

Are There Tools for Diagnosing ODD?

No questionnaires are specifically designed for diagnosing ODD, but multiple tools can aid in diagnosis while assessing for other psychiatric conditions.

EVIDENCE SUMMARY

Diagnostic tools for ADHD, such as the Vanderbilt ADHD Diagnostic Parent Rating Scale and the Conners 3 scales, have comorbidity screening scales that can help identify ODD. 6, 13 One study of the Vanderbilt scale found that affirmative answers ("often" or "very often") to the items "Actively disobeys or refuses to follow adults' requests or rules" and "Is angry or bitter" had good sensitivity (55% to 88%) and specificity (85% to 94%) for diagnosing ODD. 13 Table 2 provides information on these and other tools for identifying behavior disorders; Table 3 lists the differential diagnosis of ODD. 1

What Are Common Comorbidities with ODD?

ODD is often comorbid with other mental health conditions. The most common are ADHD and conduct disorder, although mood disorders are also common. Substance use and other behavioral problems may also coexist with ODD.

EVIDENCE SUMMARY

ADHD is one of the most common comorbid conditions with ODD, occurring in 14% to 40% of children with the disorder. 14, 15 Symptoms of ADHD may precede those of ODD. Children with more predominant defiant and headstrong symptoms of ODD are more likely to have comorbid ADHD. 2, 16 Older studies suggested that conduct disorder may be a more severe, age-related progression of ODD, although more recent evidence suggests that they are distinct disorders. 2, 12, 14 Retrospective studies estimate that conduct disorder is comorbid in up to 42% of persons with ODD. 4, 14 Those with comorbid ADHD and ODD or conduct disorder and ODD tend to have more severe and persistent behavioral problems and are more likely to have additional comorbid mood disorders. 6, 17 They are also at higher risk of substance use and abuse. 17

Anxiety and depression are commonly associated with ODD, developing as early as preschool age. 2, 5, 14 One study found that up to 14% of persons with ODD also have anxiety, and 9% have a depressive disorder. 15 A more recent study found even higher rates; at least 50% of participants with ODD had comorbid anxiety or depression. 14 Those with angry and irritable symptoms of ODD are at higher risk of comorbid mood disorders, whereas those with argumentative, defiant, and vindictive symptoms are at higher risk of conduct disorder. 16

Which Behavioral Treatments Are Effective?

Individualized treatment plans by mental health professionals for both the child and family are the most effective. Behavioral parenting interventions are first-line therapy in younger children. In adolescence, individual therapy takes a more prominent role, but outcomes are better when parents are involved. Early intervention may help prevent other disorders, such as conduct disorder, substance abuse, and delinquency.

EVIDENCE SUMMARY

Child-based therapy often focuses on problem-solving skills, whereas parent training (parent management therapy) focuses on how to respond to the child's behavior. Parent management therapy aims to help parents manage disruptive behavior by decreasing unintentional positive reinforcement of disruptive behaviors, to help them understand appropriate consequences and punishments for disruptive behaviors, and to help them make their response timely, predictable, and appropriate. Overall, the goal is for parents to be more positive and less harsh. 6 A 2012 Cochrane review found that group parenting interventions based on behavioral therapy and cognitive behavior therapy (CBT) are effective and cost-effective for improving child conduct problems, parental mental health, and parenting skills in the short term. 18 Group CBT for children has also been found to decrease aggressive behaviors. 19

Collaborative problem solving, in which parents and children work together, is another effective technique for treating ODD. 20 A 2015 trial found collaborative problem solving to be as effective as parent management therapy. 21 In both treatment arms, 50% of children no longer met criteria for ODD after six months.

Can Pharmacologic Treatment Help?

Medications are not recommended as first-line treatment for ODD, but they may be helpful in some situations when used in conjunction with behavioral interventions. Treatment of comorbid conditions often improves symptoms of ODD. 6 Mood stabilizers and atypical antipsychotics may be helpful for aggressive behaviors, but have limited data for ODD.

EVIDENCE SUMMARY

Stimulants can help improve oppositional symptoms in persons with comorbid ADHD, whereas atomoxetine (Strattera) has mixed evidence for reduction of ODD symptoms. 22, 23 Clonidine has also proved effective in managing concomitant ADHD and ODD. 24

Antidepressant therapy in persons with concomitant depression and ODD can help both disorders. One study found that fluoxetine (Prozac), with or without CBT, improves comorbid ODD. 25 Fluoxetine plus CBT was superior to CBT alone, but ODD symptoms improved in all treated groups.

The broader literature on conduct disorder suggests that mood stabilizers and atypical antipsychotics may be helpful for managing aggressive behavior. A 2012 Cochrane review found limited evidence that atypical antipsychotics help with aggression and conduct problems in children five to 18 years of age. 26 The evidence was strongest for risperidone (Risperdal), and there was no evidence to support the use of quetiapine (Seroquel) in this population.

What Is the Natural History of ODD?

ODD does not have a consistent course. Symptoms often resolve by early adulthood, although other mental health problems, such as mood disorders and social impairment, may persist or develop.

EVIDENCE SUMMARY

The normal course of ODD is not well defined. One study showed that 70% of persons with ODD had symptom resolution by 18 years of age. 14 However, ODD can persist into adulthood, and earlier onset of symptoms and male sex predict more severe psychopathology. 6, 14

Environmental factors such as family instability, low may increase the risk of conduct disorder in persons with ODD. 2, 4 Because antisocial personality disorder is considered a more severe adult form of conduct disorder, children with ODD and comorbid conduct disorder are at risk of developing antisocial personality disorder. 6

Adults and adolescents with a history of ODD have a greater than 90% chance of being diagnosed with another mental illness in their lifetime. 14 They are at high risk of social and emotional problems as adults, including suicide. They also have a higher risk of mood disorders, such as anxiety, depression, and bipolar disorder, and high rates of substance use disorders. 2, 17, 27, 28 Early intervention is aimed at preventing the development of conduct disorder, substance abuse, and delinquency that can cause lifelong social, occupational, and academic impairments.

Can ODD Be Prevented?

Programs that improve social skills, conflict resolution, and anger management in preschool-aged children to adolescents can reduce the risk of ODD. These programs are often embedded in existing community programs that serve high-risk youth, such as Head Start, or in elementary or secondary school curricula.

EVIDENCE SUMMARY

Integrating behavioral programs for preventing conduct problems into existing programs such as Head Start has had a positive impact. One example, the Incredible Years program ( http://www.incredibleyears.com), has been found to improve social competence and emotional self-regulation and decrease conduct issues. This program has content for parents, children, educators, and clinicians. 29, 30 Other programs for adolescents concentrate on CBT-based interventions, skills training, vocational training, and academic preparation. A comprehensive list of programs and resources is available on the American Academy of Child and Adolescent Psychiatry's website ( https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Oppositional_Defiant_Disorder_Resource_Center/Home.aspx). 6, 31

Address correspondence to Margaret Riley, MD, FAAFP, University of Michigan, 2025 Traverwood Dr., Ste. A6, Ann Arbor, MI 48105 (e-mail: marriley@med.umich.edu). Reprints are not available from the authors.

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# data[].attributes.attachment_link.title
Common Questions About Oppositional Defiant Disorder

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Oppositional defiant disorder (ODD) is a disruptive behavior disorder characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness lasting for at least six months. Children and adolescents with ODD may have trouble controlling their temper and are often disobedient and defiant toward others.

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A pilot study of a school-based prevention and early intervention program to reduce oppositional defiant disorder/conduct disorder

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A pilot study of a school-based prevention and early intervention program to reduce oppositional defiant disorder/conduct disorder

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School Based Interventions for School-Aged Children with Oppositional Defiant Disorder: A Systematic Review

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School Based Interventions for School-Aged Children with Oppositional Defiant Disorder: A Systematic Review

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Bottom‑up and top‑down approaches to understanding oppositional defiant disorder symptoms during early childhood: a mixed method study

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Bottom‑up and top‑down approaches to understanding oppositional defiant disorder symptoms during early childhood: a mixed method study

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Pediatric Anxiety Epidemic: A New Approach to Treatment | Kathryn Boger | TEDxWalthamED

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Pediatric Anxiety Epidemic: A New Approach to Treatment | Kathryn Boger | TEDxWalthamED

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Pediatric Anxiety Epidemic:  A New Approach to Treatment | Kathryn Boger | TEDxWalthamED

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Tips to for parents/guardians to help their child manage anxiety at home.

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Here are things you can do at home to help your child manage his or her anxiety disorder:

Pay attention to your child's feelings.

Stay calm when your child becomes anxious about a situation or event.

Recognize and praise small accomplishments.

Don't punish mistakes or lack of progress.

Be flexible, but try to maintain a normal routine.

Modify expectations during stressful periods.

Plan for transitions (For example, allow extra time in the morning if getting to school is difficult).

Keep in mind that your child's anxiety disorder diagnosis is not a sign of poor parenting. It may add stress to family life, however. It is helpful to build a support network of relatives and friends.

It's important that you have the same expectations of your anxious child that you would of another child, according to psychologist Lynn Siqueland, PhD. She has specialized in treating children and adolescents with anxiety disorders for more than 15 years. She offers these parenting tips for anxious kids, as well as ways to manage siblings, whose lives are also affected.

SAMHSA Report: how to help children who have experienced traumatic events.

Other Resources

Keep reading about the important role of parenting at BetterHelp.

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Here are things you can do at home to help your child manage his or her anxiety disorder: Pay attention to your child's feelings. Stay calm when your child becomes anxious about a situation or event. Recognize and praise small accomplishments. Don't punish mistakes or lack of progress.

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Peer Victimization and Onset of Social Anxiety Disorder in Children and Adolescents

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Peer Victimization and Onset of Social Anxiety Disorder in Children and Adolescents

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Your access to the NCBI website at www.ncbi.nlm.nih.gov has been temporarily blocked due to a possible misuse/abuse situation involving your site. This is not an indication of a security issue such as a virus or attack.

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Anxiety disorders in children and adolescents: Need for early detection

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Anxiety disorders in children and adolescents: Need for early detection

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Anxiety is a normal human emotion and involves behavioral, affective, and cognitive responses to the perception of danger. It is considered to be excessive or pathological when it is out of proportion to the challenge or stress or when it results in significant distress and impairment.[ 1] It is viewed as a normal part of childhood. Children experience fear, nervousness, shyness, and avoidance of places and activities that persist at times despite the helpful efforts of parents, caretakers, and teachers. Anxiety disorders are one of the most common disorders seen among children and adolescents. The prevalence of anxiety disorders ranges from 4% to 20%.[ 2] Common anxiety disorders among children are specific phobia, social phobia, generalized anxiety disorder, and separation anxiety disorder having mean prevalence rates between 2.2% and 3.6%. Agoraphobia (1.5%) and post-traumatic stress disorder (1.5%) are less prevalent, whereas panic and obsessive-compulsive disorders are relatively rare (i.e., below 1%).[ 3]

The current study[ 4] found anxiety symptoms more in older children which was in contrast to European studies. Girls have higher prevalence compared to boys, and this difference gets accentuated with development and reaches 2-3:1 by adolescence.[ 5] This was not supported by the current study.[ 4] There is a need to conduct a wider survey taking samples from different types of schools to determine the exact role of age and gender in the prevalence of anxiety disorders.

The current data on the prevalence of anxiety disorders among school-going children and adolescents in India is lacking. This study[ 4] has done a commendable job in providing this data.

Social milieu also effects anxiety disorders as has been found in various studies. This study revealed a high prevalence of anxiety disorders among school-going children belonging to middle and upper classes in a metropolitan city emphasizing the need to conduct a study in different metropolitan cities as well as among children in rural areas.

The earliest report on psychiatric morbidity in pediatric population observed neuroses in approximately 18% of the study population.[ 6] Recently, a multidimensional ICMR study reported the prevalence of simple phobia as 1.98-2.9% and all other anxiety disorders at less than 1%.[ 7] Difficulty in coping with studies, concern about weight, having less friends, lack of intimacy with parents, and being treated differently from siblings were associated factors.[ 8] The current study[ 4] included only average students which helped in reducing bias by excluding outliers. There is a need to study the role of important variables such as school and board exams in the prevalence of anxiety symptoms as well as the impact of anxiety on the academic performance of children.

Hereditary and environmental factors and cognitive bias play a role in the etiology of anxiety disorders. Childhood anxiety disorders are transitory but in some they can be chronic and persistent often with a waxing and waning course and "syndrome shifts."[ 9] The pure form of anxiety disorder decreases with rise in secondary psychopathology such as depressive or substance use disorders by late adolescence or early adulthood. Depression is more than 8 times as likely in youths with anxiety disorders than in those without anxiety disorders.[ 10] The current study had a higher number of older children with obsessions; a previous history of anxiety symptoms in early ages needs to be evaluated to determine if this was a continuum to secondary psychopathology. Moreover, variables such as peer pressure, family dynamics, as well as history of psychiatric illness or history of any traumatic event can also be studied for better perspectives in a child's anxiety behavior.

The current practice recommends screening, rating severity, and assessing functional impairment among young for anxiety disorders, and to look for comorbid psychiatric conditions as well as for general medical conditions (e.g., hyperthyroidism) that may mimic anxiety symptoms.[ 11] This evaluation also differentiates from developmentally appropriate worries, fears, and responses to stressors and presence of stressors or traumas are considered to determine their contribution to the development or maintenance of anxiety symptoms.

Multidimensional Anxiety Scale for Children, Screen for Child Anxiety and Related Emotional Disorders (SCARED), and the Spence Children's Anxiety Scale (SCAS) (child self-report measures), Pediatric Anxiety Rating Scale (a clinician-rated measure), and Preschool Anxiety Scale (a parent report) are sensitive and specific tools for assessing anxiety as well as for monitoring treatment progress.[ 12, 13, 14] As suggested by the current study,[ 4] there is a need to develop standardized screening tools in India that are validated in local languages to include a wider range of sample.

Management strategies involve both nonpharmacological approach as well as pharmacotherapy. A large multicenter study observed that participants who were on combined treatment [cognitive behavior therapy (CBT) with sertraline] not only showed better response but also maintained the same at 24 and 36 weeks of follow-up.[ 15] CBT has now been examined in very young children (preschoolers) with anxiety disorders with better response. Pharmacotherapy can be employed especially during the acute phase or in very severe stage, or in poor response to CBT but otherwise nonpharmacological approach is still regarded as the treatment of choice for childhood anxiety disorders. In the current scenario, where continual performance is considered to be the key to success, parents and environment put a lot of pressure on a child resulting in anxiety; at times parents' anxiety is projected over their kids. This can be harmful in the long run, and in authors' experience, are major contributors towards increase in childhood mental health problems, which can be as severe as suicide. Probably, steps from the micron level to the national level to reduce this pressure can hold better future for these young children.

There is evidence that childhood anxiety disorders are at the outset of a "cascade of psychopathology," therefore, there is a need for early recognition and treatment. In addition to adverse long-term psychopathological outcomes, it also causes impairment in functioning as well hampers general health, resulting in financial, interpersonal, and educational difficulties. It is clear that an understanding of the pathways - how they develop, maintain, and remit - requires consideration. More longitudinal studies are needed to further expand our knowledge on this highly prevalent type of psychopathology.

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Anxiety disorders in children and adolescents: Need for early detection

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Anxiety is a normal human emotion and involves behavioral, affective, and cognitive responses to the perception of danger. It is considered to be excessive or pathological when it is out of proportion to the challenge or stress or when it results in significant distress and impairment.[ 1] It is viewed as a normal part of childhood.

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Depression and Anxiety among First-Generation Immigrant Latino Youth: Key Correlates and Implications for Future Research

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Depression and Anxiety among First-Generation Immigrant Latino Youth: Key Correlates and Implications for Future Research

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Abstract

We examined how the migration and acculturation experiences of first-generation Latino youth contributed to their psychological well-being. Data came from the Latino Adolescent Migration, Health, and Adaptation (LAMHA) study, which surveyed 281 first-generation Latino immigrant youth, ages 12-19. Using logistic regression, we evaluated how migration stressors (i.e. traumatic events, choice of migration, discrimination, and documentation status) and migration supports (i.e. family and teacher support, acculturation, and personal-motivation) were associated with depressive symptoms and anxiety. We found that migration stressors increased the risk of both depressive symptoms and anxiety. Time in the US and support from family and teachers reduced the risk of depressive symptoms and anxiety. Compared to documented adolescents, undocumented adolescents were at greater risk of anxiety, and children in mixed-status families were at greater risk of anxiety and marginally greater risk of depressive symptoms.

Keywords: Adolescent, Latino, Hispanic, Immigrant, First Generation, Mental Health

The dramatic increase in the Latino population across the United States is changing the face of the nation's youth. Currently, one in five public school children are Latino, compared to one in eight in the 1990s. By 2050, more Latino school-age children than non-Latino white school-age children will reside in the US ( Fry and Gonzales, 2008).

Latino youth face a multitude of challenges, including poor socioeconomic resources, risk for behavioral problems (e.g., drug use and early pregnancy), and low educational attainment ( Kuperminc et al., 2009; Rodriguez and Morrobel, 2004). Of particular concern is the mental and emotional health of Latino youth. The CDC's (2007) national survey found that Latino youth were more likely to feel sad or hopeless (36.3%), to seriously consider suicide (15.9%), and to attempt suicide (10.2%) than white (26.2%, 14.0%, and 5.6%, respectively) and African American (29.2%, 13.2%, and 7.7%) youth. Furthermore, studies have shown that both depression and anxiety are positively correlated with increased rates of suicidal behavior, and adolescents who are depressed are 35-50% more likely to attempt suicide ( Dopheid, 2006).

Major depression and anxiety disorders are two of the most prevalent mental health conditions affecting Latino youth. In one of the few existing national studies of Latino youth (age 11-15), Saluja and his colleagues (2004) found that Latino youth had higher rates of depressive symptoms (22%) than white (18%), Asian American (17%), and African American (15%) youth. Other studies also consistently find higher rates of depression among Latino youth-especially Mexican American and Afro-Latinos-than among other ethnic groups ( Choi et al., 2006; Mikolajczyk et al., 2007; Ramos et al., 2003). Although no national data are available on the prevalence of anxiety disorders or anxiety-related problems among Latino youth, studies also suggest that Latino youth experience significantly higher levels of anxiety than whites but not African Americans ( Glover et al., 1999; Roberts et al., 2006). Approximately, 8% of Mexican-American youth (age 11-17) have had an anxiety disorder in the past year ( Roberts et al., 2006).

As summarized by Gonzalez et al. (2009 Gonzalez et al. (2002) and Umaña-Taylor and Alfaro (2009), much of the research available on foreign-born and US-born Latino youth examines how acculturative stress, which stems from challenges related to adapting to life in the US (e.g., learning a new language, adjusting to new social norms and family dynamics, and experiencing discrimination), affect psychological well-being. These studies find a positive association between acculturative stress and a variety of internalizing behaviors, including low self-esteem, symptoms of depression, and greater suicidal alienation. But they also find that Latino youth rely on protective factors, such as strong family connections, active coping strategies, and social supports, to minimize the detrimental influences of acculturative stress.

Other studies of Latino youth compare mental health outcomes across immigrant generations and attempt to explain differences, if any, by adjusting for socio-economic risk and protective factors ( Gonzales et al., 2002). For example, Harker's (2001) and Harris' (1999) national-level assessments indicate that first-generation Latino youth (i.e. foreign-born youth with foreign-born parents; ages 12-18) experience fewer depressive symptoms than their later generation peers (i.e. US-born) and that a number of family influences (e.g., parental supervision and closeness) protect first-generation immigrant youth from experiencing the poor mental health outcomes commonly associated with low socio-economic and minority status. But, Rumbaut (1995) found that English language competence predicted lower levels of depressive symptoms among Latino youth and argues that, at least initially, the stresses of immigration negatively affect psychological well-being until youth become accustomed to their new home and learn how to navigate their new environment.

Although the previous literature makes an important contribution to understanding how acculturative stress and immigrant generational differences contribute to anxiety and depression among Latino youth (see Gonzalez et al., 2009; and Kuperminc et al., 2009 for detailed reviews), it does not provide an in-depth understanding of mental health etiologies among first-generation immigrant Latino youth. Unlike their US-born counterparts, first-generation youth undergo both a migration and acculturation process that includes experiences leading up to migration, experiences during migration, and initial settlement experiences ( Zuniga, 2002).

In addition, the voluntary or involuntary nature of migration can affect immigrants' mental health ( Ogbu, 1987). Voluntary immigrants have chosen to undertake the migration journey in the hopes that they will be able to improve their circumstances and futures. For them, migration is an opportunity that is worth the stress and sacrifices endured. For adolescents, who typically migrate in response to a decision made by their parents, migration may not be viewed as an opportunity or a voluntary decision ( Perreira et al., 2006). For them, it is only a stressor.

Though few studies contain data on legal status, a child's legal status and the status of their parents can also shape migration and acculturation experiences and influence the risk of depression and anxiety. The limited research available suggests that undocumented adult Mexican immigrants are more likely to experience a traumatic event, have fewer economic and social resources, and are more marginalized and vulnerable to exploitation ( Sullivan and Rehm, 2005). Immigration raids by US Immigration and Custom Enforcement agents and the fear of raids can further traumatize children and their parents ( Capps et al., 2007). Even children who are citizens but whose parents or siblings are undocumented (i.e. children in mixed status families) can suffer from the stresses associated with documentation status. Yet few studies have examined how the unique risks of undocumented immigrants-especially adolescents-affect mental health ( Rasmussen et al., 2007; Sullivan and Rehm, 2005).

Over time Latino immigrant youth learn how to navigate US social institutions and acculturate to life in the US. Though we classify acculturation as a measure of support, acculturation as measured by time in the US, English language usage, or adoption of Anglo-American customs, may either reduce or increase the stresses associated with acculturation and the subsequent risk of poor mental health. On the one hand, acculturation can increase immigrant youths' capacities to navigate social systems in the US ( Perreira et al., 2006; Ko and Perreira, in press) and reduce their risk of depression or anxiety. On the other, acculturation may alienate foreign-born Latino youth from their parents and ethnic communities, and consequently, increase their risk for depression or anxiety ( Umaña and Alfaro, 2009). Moreover, as youth acculturate, the challenges and every day realities of life in the US begin to trump the initial euphoria immigrants experience after having successfully migrated and re-united with their families ( Portes and Rumbaut, 1990).

In this paper, we examine the unique migration and acculturation experiences of first-generation Latino adolescents and how these experiences contribute to rates of anxiety and depression. As immigrant youth adapt and acculturate, they encounter a multitude of new challenges and stressors, but they also develop support systems to overcome these challenges ( Suárez-Orozco and Suárez-Orozco, 2001). Using data from the Latino Adolescent Migration, Health, and Adaptation (LAMHA) study, we examine how these stressors and supports influence rates of depression and anxiety. We conclude by discussing implications of our research.

Methods

Procedures and Sample

We use data from the Latino Adolescent Migration, Health, and Adaptation Project (LAMHA), the first population-based study of mental health, migration and acculturation among first-generation Latino youth living in an emerging Latino state, North Carolina. Between August 2004 and November 2006, the LAMHA research team employed a stratified cluster sampling design to collect survey data on 281 first-generation Latino youth and their primary caregivers. To ensure a representative sample, high schools located in high-growth (i.e. ≥ 394% growth between 1990 and 2000) Latino communities in North Carolina with a Latino population of at least 5,000 were divided into urban and rural strata. Then, high schools within these strata were randomly selected for participation in the study in proportion to the number of Latino students enrolled in the school. For each high school selected, all the middle schools feeding into that high school were also selected. A total of 11 high schools and 14 middle schools participated.

Each participating school prepared a roster of all youth who self-identified as Hispanic/Latino or had Hispanic/Latino surnames. These youth were then contacted and screened for eligibility. Only foreign-born Latino youth with foreign-born parents were eligible for inclusion and only one youth per household could participate. Our response rate was 69%. Those who refused to participate almost uniformly indicated that they did not have sufficient time. Adolescents and their parents completed an interview-administered survey in their preferred language (English or Spanish). Using scales that have been validated with Spanish-speaking populations, the LAMHA survey included questions on youths' immigration histories, family relationships, school and community experiences, and socioeconomic background.

After deleting missing observations on the dependent (N=4) and independent variables (N=22), the analytic sample for the analysis of anxiety consisted of 255 Latino immigrant adolescents of Mexican descent (70%) in mostly two-parent families (77%) in which few parents had more than a high school education (34%). In the typical family, both parents were the youth's biological parents (58%) and the youth lived in a household with an average of three siblings. The majority of youth in our sample also lived in an urban area (78%). An additional case was lost for the analysis of depression (N=254).

Measures

Mental Health

We identified two mental health outcomes: depression and anxiety. We used the 27-item Children's Depression Inventory (CDI) ( Kovacs, 1992). Scores on the CDI range from 0 to 54 and a cut point of 20 for a general screening identifies adolescents as at risk for a depressive disorder. Internal consistency was good (α = .85). Using the 10-item version of the Multidimensional Anxiety Scale for Children (MASC-10) ( March et al., 1997), we followed standard scoring protocols and classified adolescents as at risk for anxiety (i.e. above average anxiety levels) if they had a t-score of 56 or greater. Raw scores range from 0 to 30 and are converted into standard t-scores (mean=50; SD=10). Internal consistency was good (α = .72).

Migration Stressors

Mental health stressors measured in this study fall into two categories: migration experience and discrimination. We identified five migration experience stressors. First, we calculated the total number of years the adolescent was separated from their primary caregiver. Second, we classified adolescents as having experienced a stressful migration event if they reported that they had been robbed, physically attacked, accidentally injured and/or became sick during their migration to the US Third, we used adolescent self-reports of their involvement in the migration decision to classify adolescents as not at all involved (reference group), not very or somewhat involved, or very involved. Fourth, we derived the adolescent's level of dissatisfaction with the migration decision from agree/disagree responses to five statements about their move to the US (e.g., moving to the US was the best thing for my family, and I am happier in the US). We summed the responses to create a variable ranging from one to five with a higher score indicating greater dissatisfaction. Lastly, using parent reports of their and their child's documentation status upon entering the US we created three indicators of documentation status: the adolescent had documents (reference group), only the parent had documents, and neither the adolescent nor parent had documents.

To measure discrimination, we used adolescent self-reports on whether the adolescent had experienced discrimination in the US (1=experienced discrimination, 0=otherwise). In addition, we measured perceived discrimination using a 4-item instrument adapted from the Youth Adaptation and Growth Questionnaire ( Portes and Rumbaut, 2001). This measure ranged from one to four with an internal consistency of α =.58.

Migration Supports

We identified three categories of mental health supports: social support, acculturation, and personal motivation-optimism. To identify social support, we measured family support using the 7-item familism scale from Gil et al. (2000) (range: 1-5; α=.92), teacher support (range: 0-11) from the 11-item School Success Profile ( Bowen et al., 2005) and general social support (range: 0-8) from the 8-item Social Support Scale ( Richman et al., 1993).

Because there is little agreement about which measure(s) best capture acculturation ( Hunt, 2004), we constructed acculturation measures from three sources: years in the US, the Short Acculturation Scale for Hispanics (SASH) ( Marin et al., 1987), and the Psychological Acculturation Scale (PAS) ( Tropp et al., 1999). In our final results reported here, we used years in the US as our primary measure of acculturation because it produces more consistent and easily interpreted results than multidimensional acculturation scales ( Escobar and Vega, 2000). Years in the US was correlated with the SASH (r=.27) and the PAS (r=.60) and results using this variable were more robust to model specification. We include summary scores and unadjusted odds ratios on the PAS (α=.91) and SASH (α=.78) to verify that the acculturation trends detected are similar across measures. Both scales ranged from one to five with higher scores indicating greater acculturation. Lastly, as a proxy for immigrant optimism, we created a personal motivation variable indicating whether the adolescent aspired to some college or more (1=some college or more, 0=otherwise). The use of college aspirations as a proxy for immigrant optimism follows research by Kao and Tienda (1995).

Control Variables

We control for both age and gender. Parent education, family composition (i.e. living in a two-parent family), and Mexican heritage varied little within our sample. Therefore, these variables were never significant in unadjusted or adjusted models and were excluded from the final analysis for parsimony. Urban residence also did not significantly contribute to our model and was excluded in the final analysis.

Statistical Analysis

We began our analysis by examining the prevalence of anxiety and depression by gender. We then calculated the prevalence of mental health stressors and supports. Next, we estimated unadjusted logit models to obtain odds ratios and 95% confidence limits measuring the association between our mental health measures and each measure of mental health stressors and supports. Finally, we constructed three adjusted logit models controlling for gender and age to assess which mental health stressors and supports predicted depression and anxiety. For parsimony, we only included those mental health stressors and supports that were associated with depression or anxiety once we controlled for demographic differences and other stressors or supports, respectively. All analyses were weighted and adjusted for the stratification and clustering in the sample design.

Models were checked for robustness by conducting OLS regression analyses on CDI and MASC-10 scores. Results were consistent with results obtained through the logit specification and are available upon request. In our regression analyses, mental health stressors explained 15% of the variance in CDI scores and 13% of the variance in MASC-10 scores. Mental health supports explained 33% of the variance in CDI but only 2% of the variance in MASC-10 scores.

Results

Prevalence of Depression, Anxiety, and Mental Health Stressors and Supports

Among first-generation Latino adolescents nearly 7% were symptomatic for depression and 29% were symptomatic for anxiety (). Compared to males, females were slightly more likely to have symptoms of depression but less likely to have symptoms of anxiety. The difference, however, was not statistically significant.

Table 1

Mental health stressors were prevalent in the lives of the first-generation Latino immigrant youth in our study. Three-quarters of immigrant adolescents had been separated from their primary caregiver prior to their migration, and the average separation period lasted three years (). When the decision was made to migrate, a plurality (39.6%) of adolescents indicated that they were very involved in the decision, but a sizeable portion indicated little (28.7%) to no involvement (31.7%). During their journey to the US, nearly a quarter (24%) experienced a stressful migration event. After migration, undocumented status was a common stressor among first-generation Latino youth. The vast majority of both adolescents and their parent lacked documents upon entering the US (60.5%), and almost 11% of adolescents were undocumented though their parent had documents. Moreover, immigrant Latino adolescents both experienced (42%) and perceived (M=2.61, SD=.09) discrimination. Nevertheless, they did not express high levels of dissatisfaction with the migration decision (M=1.91; SD=.25).

Table 2

Though they confronted many stressors, the first-generation immigrant Latino youth in our study also benefited from several mental health supports including high levels of familism (M=4.2; SD=.05), teacher support (M=10.25; SD=.20), and general social support (M=6.05; SD=.12). On average, Latino adolescents in our sample had lived in the US for 4.5 years and showed signs of both acculturation to the English language, as measured by the SASH, and acculturation to Anglo customs and norms, as measured by the PAS (). These youth also benefited from strong immigrant optimism with 71% indicating some college aspirations.

Unadjusted Association between Mental Health and Mental Health Stressors and Supports

The unadjusted odds ratios demonstrate how each of these stressors and supports were associated with depression and anxiety (). Dissatisfaction with the migration decision increased the odds that an adolescent would have symptoms of depression (OR=1.44) and anxiety (OR=1.51), while experiencing a stressful migration event only increased the odds of anxiety symptoms (OR=2.43). Compared to documented adolescents, undocumented children with documented parents were significantly more likely to report symptoms of both depression (OR=7.88) and anxiety (OR=6.27), while undocumented children with undocumented parents were only more likely to report anxiety symptoms (OR=4.19). The influence of mental health supports differed across depression and anxiety. Social supports reduced the odds of depressive symptoms (Familism OR=.91; Teacher support OR=.69) but had no impact on anxiety symptoms. Conversely, years in the US reduced the odds of anxiety symptoms (OR=.91) but were only marginally related to depression. Personal motivation reduced the odds of both symptoms of depression (OR=.20) and anxiety (OR=.60).

Adjusted Association between Mental Health and Mental Health Stressors and Supports

To understand how both stressors and supports contribute to immigrant Latino adolescent mental health, we first estimated a logit model for the stressors measured (: Model 1a & 1b), then a model including only the support variables (: Model 2a & 2b), and finally a model combining the stressor and support variables (). These three models were estimated for both depression and anxiety controlling for gender and age. The results from these adjusted models were similar to those from the unadjusted models, with a few exceptions. For undocumented children with documented parents the odds of reporting depression and anxiety symptoms increased substantially once we controlled for other stressors - from 7.88 and 6.27 (respectively) in the unadjusted models to 55.09 and 11.18 in the adjusted models (: Model 1a & 1b). After controlling for the presence of multiple stressors, we also found that experiencing discrimination was significantly associated with an increased likelihood of depressive symptoms (OR=7.89). Similarly, after controlling for the presence of multiple supports (: Model 2a & 2b), we found that years in the US was significantly associated with decreased likelihood of depressive symptoms (OR=.66). However, college aspirations, our indicator of personal-motivation, was associated with neither depressive nor anxiety symptoms.

Table 3

Table 4

When we combined both measures of stressors and supports into a single model (), we observed that the effects of key stressors on our two mental health outcomes declined. In the fully adjusted models, we found that adolescents who were very involved in the migration decision had a lower likelihood of anxiety symptoms (OR=.28) than those with no involvement in the migration decision. The magnitude of the relationship between living in a mixed-status family and symptoms of depression and anxiety declined. Finally, ever experiencing discrimination was no longer associated with depression. In short, the presence of social supports reduced the influence of stressors on our two mental health outcomes. These social supports helped to mitigate the effects of involuntary migration for adolescents who were not involved in the migration decision, lacked legal status, or experienced discrimination.

Discussion

We examined how stressors and supports experienced during migration and acculturation influence risks for anxiety and depression among first-generation immigrant youth. In our study, the risk of anxiety (28.8%) was higher than DSM-III or DSM IV anxiety disorder estimates for a general population of youth - typically 13 to 20 percent ( DHHS, 2001; Shaffer et al., 1996). Our measure of anxiety, however, captured a wider range of anxiety levels. Our estimate of the risk of depression among first-generation Latino youth (6.8%) was within the range of DSM-III or DSM IV estimates of depression for youth in general - typically 5 to 10 percent ( DHHS, 2001; Dopheide, 2006; Shaffer et al., 1996). Rates of depressive symptoms were lower than estimates for all Latino youth, which include the 2 nd and 3 rd+ generations. Using a national sample of Latino adolescents and a shortened version of the CDI, Kleykamp and Tienda (2005) found higher rates of depression among Latino youth (11%) than we find in our first-generation only sample. Saluja's (2004) estimates of depressive symptoms in Latino adolescent populations are substantially higher (22%) than either our estimates or Kleykamp and Tienda's, but Saluja used only a 2-item measure which is not as robust as CDI-based measures.

Like refugees and asylees forced to migrate in the face of political violence ( Ogbu, 1987; Rumbaut, 1991), children not involved in the decision to migrate and compelled to migrate as a result of their parents' decisions and children exposed to violence during migration can be more vulnerable to anxiety and depression. Our results supported this hypothesis. High levels of involvement in the migration decision were associated with lower rates of anxiety symptoms. This finding suggests that parents who help youth understand the migration process by including them in discussions about moving to the US can help reduce their children's anxiety. Thus, parents can take steps to reduce the potential negative mental health consequences of migration prior to migrating. However, during migration, parents cannot always protect their children from stressful events, such as being robbed or injured. When these events occur, our study shows that they result in a higher risk of anxiety even an average of five years after migration occurred.

After arriving in the US, other stressors such as legal status and discrimination become important determinants of mental health outcomes ( Finch and Vega, 2003). Among the immigrant youth we surveyed, those who were undocumented were at high risk for anxiety and at even greater risk when they lived in mixed-status families with documented parents. These youth may fear being sent back to their home countries and being separated from their parents.

Most importantly, our results demonstrate that social support at home and in school can ameliorate the negative effects of discrimination and other stressors. These results complement previous research on youth showing that social acceptance by peers and teachers in youths' schools contributes to their psychosocial well-being ( DeGarmo and Martinez, 2006; Finch and Vega, 2003). Our results also echo findings from research on primarily US-born Latino youth, which emphasize the important role of familism and the maintenance cultural values in promoting the resilience of Latino youth and protecting them from a variety of negative health behaviors ( Coohey, 2001; Kuperminc et al., 2009; Umaña-Taylor and Alfaro, 2009).

Lastly, time in the US appears to reduce immigrant Latino youths' risk for anxiety and depression by protecting them from the deleterious effects of migration and acculturative stress, but the associations are only marginal in our final adjusted model. These results help to disentangle the mixed findings on the association between acculturation and Latino mental health ( Gonzalez et al., 2009). Our results indicate that acculturation can have positive psychological affects for (mostly) recent arrivals undergoing the initial process of adjustment ( Gil et al., 1994). As immigrant youth become more fluent in English as a second language, adapt to new social norms, and are better able to navigate US social systems, they experience fewer daily hassles and less stress. However, our results do not preclude the possibility that biculturalism, as found in previous studies ( Gonzales et al., 2002, 2009), can further promote the psychological well-being of first-generation youth. In a relatively recent first-generation immigrant population, some level of acculturation to the host society must occur prior to the development of bicultural competence. Those youth who do not ultimately develop bicultural competence in adulthood and their 2 nd and 3 rd+ generation children may experience increased risks for depression and anxiety.

Strengths and Limitations

Though our study has many strengths - our sample is a random sample of first-generation youth and we have more detail on the migration and acculturation experiences of youth than previous studies - the results of this study should be read with some caveats in mind. First our data are cross-sectional. Thus, we identify important associations that need to be further evaluated with longitudinal data. Second, because our sample is drawn from middle and high schools, we exclude first-generation youth who never enter into the US school system and those who drop out during high school ( Fry, 2003). These important subpopulations of first-generation immigrant youth may be at higher risk of mental health problems due to their limited economic opportunities ( Needham, 2009). Fourth, while we identified key migration supports and stressors future research needs to examine others. In particular, enculturation and the maintenance of ethnic identity could not be identified using the LAMHA data but have been previously found to be positively associated with psychological well-being ( Gonzales et al., 2009). Future research should also examine the role of key migration supports and stressors in the onset of depression among Latino immigrant parents and the role of parental mental health in shaping the health of Latino immigrant youth. Lastly, over seventy percent of the Latino youth in our study were of Mexican heritage. Thus, caution must be used in generalizing our results to all Latinos ( Guarnaccia et al., 2007).

Conclusion

Few studies have focused specifically on first-generation immigrant Latino youth and how their migration experiences contribute to their overall psychological well-being. This study examined how stressors that occur during the migration and acculturation process as well as immigrant support systems were associated with Latino immigrant youth's risk of depression and anxiety. Extending prior research, we found that the unique migration stressors (i.e. involuntary migration, exposure to traumatic events during migration, and discrimination) of immigrant Latino youth increased their risk for depression and anxiety. We have shown that documentation status, which is absent in most research, plays a significant role in the adaptation and acculturation process. Lastly, we found that migration supports (i.e. time in the US, and family and teacher support) minimized the stressors of migration.

Acknowledgments

The LAMHA Project was funded by a grant from the William T. Grant Foundation and directed by Krista M. Perreira and Mimi V. Chapman. Persons interested in obtaining LAMHA contract use data should see http://www.cpc.unc.edu/projects/lamha for further information. We greatly appreciate the assistance of all the schools, immigrant families, and adolescents who participated in our research project. For their support of this research, we would like to that the Russell Sage Foundation Visiting Scholar Program and the Population Research Training grant (5 T32 HD007168), awarded to the Carolina Population Center at The University of North Carolina at Chapel Hill by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

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Depression and Anxiety among First-Generation Immigrant Latino Youth: Key Correlates and Implications for Future Research

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We examined how the migration and acculturation experiences of first-generation Latino youth contributed to their psychological well-being. Data came from the Latino Adolescent Migration, Health, and Adaptation (LAMHA) study, which surveyed 281 first-generation Latino immigrant youth, ages 12-19. Using logistic regression, we evaluated how migration stressors (i.e.

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Understanding Anxiety and Depression for LGBTQ People

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Understanding Anxiety and Depression for LGBTQ People

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If you're lesbian, gay, bisexual, transgender, or questioning (LGBTQ) and you struggle with anxiety or depression, let's start by putting things into context. By that I mean let's think through powerful life experiences that fundamentally impact your sense of well-being.

Anxiety and Depression for Lesbians, Gay Men, Bisexuals, and Transgender People

Somewhere between 30 and 60 percent of lesbians, gay men, bisexuals, or transgender people deal with anxiety and depression at some point in their lives. That rate is 1.5 to 2.5 times higher than that of their straight or gender-conforming counterparts.

It's a strikingly high number, and it raises a lot of questions. While the entire answer is undoubtedly complex as to why you or your LGBTQ loved ones are more apt to struggle with anxiety or depression, here's where context is key to understanding it for yourself.

It's About Context

If you're LGBTQ I'd wager a bet that you're really good at reading a situation to determine how much you can safely be yourself. This skill, while adaptive, comes at a cost because it was developed in response to being subjected to high levels of persistent prejudice and discrimination.

For example, just ask any teenager who's attracted to people of the same sex (or think back to your own experiences) and you'll hear (or remember) vivid examples of the fear, shame, and ridicule that lead to learning how to read a situation.

Being highly attuned to context as a lesbian, gay man, bisexual, or transgender person shapes your internal world, too. It affects how you think and feel about yourself. In response to an outside world full of negative messages about what it means to be attracted to people of the same sex or gender nonconforming, many people come to view themselves as deeply flawed, unlovable, unworthy, and hopeless.

Minority Stress

Psychologists refer to this contextual process of dealing with persistent prejudice and discrimination as minority stress. Many studies have shown that it has powerful, lasting, and negative impacts on the mental health and well-being of LGBTQ people. Bottom line: It creates a situation ripe for struggling with anxiety and depression.

Your Life in a Larger Context

Coping with minority stress does not tell the whole story, though, in the lives of lesbians, gay men, bisexuals, or transgender individuals. There's way more to each person's life than that: Camaraderie, pride, strength, and sense of belonging are found in community, friendship, and the love of other LGBTQ people and their supportive allies. All of us, whether gay, straight, gender conforming or not - or somewhere in between - are more than a constellation of the difficulties that we've had to face.

If You're Searching for Help

The ways that anxiety and depression are part of your life are determined by many factors. Our bodies, predispositions, and life experiences all play a role. My advice for LGBTQ people seeking help with their anxiety or depression is this: Seek a professional who gets the larger contextual picture and what it means to be you.

Find a LGBTQ-Affirming Mental Health Care Provider
About the Author
Brad Brenner, PhD, is a counseling psychologist and the founder and Clinical Director of the Therapy Group of DC. He also cofounded The Capital Therapy Project, a community-based psychotherapy training institute.

# data[].attributes.attachment_link.title
Understanding Anxiety and Depression for LGBTQ People

# data[].attributes.attachment_link.description
If you're lesbian, gay, bisexual, transgender, or questioning (LGBTQ) and you struggle with anxiety or depression, let's start by putting things into context. By that I mean let's think through powerful life experiences that fundamentally impact your sense of well-being.

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Effectiveness of a Classroom Mindfulness Coloring Activity for Test Anxiety in Children

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Effectiveness of a Classroom Mindfulness Coloring Activity for Test Anxiety in Children

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The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians

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The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians