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Effects of COVID on the mental health of adolescents

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Effects of COVID on the mental health of adolescents

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Mental health challenges, economic insecurity and parental abuse became a routine part of life for a staggering share of high school students during the pandemic, data released Thursday by the Centers for Disease Control and Prevention show.

More than a third of high school students reported experiencing poor mental health during the pandemic, more than half reported being subjected to emotional abuse at home and a quarter said a parent or another adult at home had lost their jobs, according to results from the first nationally representative survey of high school students' mental health and well-being during the pandemic.

Faced with sudden school closures, social isolation and the fear of family loss or illness, 66% of students reported that schoolwork became more difficult to complete after the pandemic shuttered campuses nationwide in March 2020.

Even before the pandemic, survey data suggests that youth mental health had grown bleeker and suicide was already a leading cause of death among teens. The new CDC data point to a situation that's grown even more dire, especially for LGBTQ youth and girls, two groups that reported particularly high levels of poor mental health during the pandemic.

In response, public health experts called on policymakers to act with urgency to reverse the trend.

"Young people and their families have been under incredible levels of stress during the pandemic," Kathleen Ethier, director of the CDC's division of adolescent and school health, said during a press call Thursday. "Our data exposes cracks and uncovers an important layer of insight into the extreme disruptions that some youth have encountered."

The results come from the Adolescent Behaviors and Experiences Survey, which was completed by a nationally representative sample of 7,705 public and private high school students. The CARES Act-funded questionnaire was conducted online between January and June 2021. Since then, the country has entered a new phase of the pandemic as mask mandates and other public health measures are lifted, but while the death toll approaches 1 million. Public health officials acknowledged it's unclear how youth well-being has fared since the survey was completed.

The figures are key to understanding the pandemic's effects on the health and well-being of American youth. Previous evidence has suggested the pandemic has had a deleterious effect on youth and contributed to trends like a surge in teen depression and anxiety, but the national survey is the first to asses the national prevalence of disruptions and adversities like parental job loss, personal job loss, homelessness, hunger and the extent of emotional or physical abuse at home.

They also reveal a promising strategy that school leaders can leverage to put youth on a better trajectory. Youth who feel connected to their school, the survey found, were significantly less likely than those who did not to report feeling hopeless or attempt suicide. Yet fewer than half - 47% - of teens reported feeling close to the people at their schools during the pandemic, when millions primarily experienced learning remotely.

"Although our latest findings present an often-grim picture and there is much work to be done, it is clear that right now young people need all the support we can give them," Ethier said.

During his State of the Union address earlier this month, President Joe Biden addressed the youth mental health crisis, declaring that students "lives and education have been turned upside-down." His budget proposal released this week seeks $1 billion to double the number of counselors and psychologists in schools.

Based on the CDC's survey data, these six charts show the challenges students faced during the pandemic - while also revealing promising strategies that could help them recover from more than two years of life-altering disruptions.

As the pandemic shuttered businesses, many teens were forced to live through the hardships of an economic crisis.

Nearly a third of students reported that a parent or another adult at home had lost their job while 22% of teens reported experiencing job loss themselves. A quarter of teens reported experiencing food insecurity. Among white students 18.5% reported experiencing hunger while 32% of Black students said they lacked enough food to eat. In total, 2% of students reported experiencing homelessness.

Teachers and other school officials are generally considered mandated reporters, putting them on the front lines of spotting issues like physical abuse at home. Remote learning heightened concerns that such abuse could go undetected at a moment when pandemic-induced stressors could exacerbate the problem. Indeed, the CDC data suggest that the physical and emotional abuse of teens has grown more alarming during the public health crisis.

More than half of respondents - 55% - reported that a parent or another adult at home had subjected them to emotional abuse and 11% said they faced physical abuse. Black students experienced the highest prevalence of physical abuse by a parent, at 15%, compared to 9.8% of white students.

Those figures are substantially higher than pre-pandemic levels, when 13.9% of students reported experiencing emotional abuse in a nationally representative survey and 5.5% reported being subjected to physical abuse by a caregiver. These differences, CDC researchers concluded, highlights a reality that "increased stress contributes to violence."

The pandemic's devastating emotional toll on high schoolers was clear in the data. Overall, 37.1% of students reported experiencing poor mental health during the pandemic and an even larger share - 44.2% - said they felt persistently sad or hopeless during the 12 months prior to completing the survey.

And while a teen suicide crisis has been billowing for years, the new CDC data show the extent of the problem. While 19.9% of students reported that they seriously considered dying by suicide, a staggering 9% had actually tried.

The pandemic-era mental health crisis was particularly grim for girls. Nearly half of girls reported having poor mental health during the pandemic compared to nearly a quarter of boys. Similarly, 5.3% of boys reported attempting suicide compared with 12.4% of girls.

A widely reported previous CDC report found an increase in youth emergency room visits due to suicide attempts during the pandemic. In February and March 2021, suicide-related emergency room visits were 50.6% higher for girls and 3.7% higher for boys than they were during the same period in 2019.

Even prior to the pandemic, youth mental health was a critical public health concern. Among high school students nationwide, 26.1% reported feeling persistent sadness or hopelessness in 2009. By 2019, that rate jumped more than 10 percentage points to 36.8%. During that same period, there was a 5 percentage point increase in students reporting having seriously considered attempting suicide and a 2.6 percentage point increase in youth reporting having attempted suicide.

CDC data suggest the pandemic has been particularly challenging for students who identify as gay, lesbian or bisexual. Perhaps more troubling, the data were released at a moment when Republican lawmakers have championed legislation that critics say would make life harder for LGBTQ youth. Just this week, Florida Gov. Ron DeSantis signed so-called "Don't Say Gay" legislation, a controversial law that bans educators from offering instruction about sexual orientation and gender identity to children in grades K-3.

Nearly three-quarters of gay, lesbian and bisexual teens reported experiencing emotional abuse at home, compared to roughly half of their straight classmates. Similarly, more than a quarter of gay, lesbian and bisexual teens reported an attempt to die by suicide in the last year compared to 5.2% of heterosexual youth.

Although the survey doesn't highlight the experiences of transgender youth, previous surveys suggest they also faced heightened risks during the pandemic compared to their cisgender peers, Ethier said.

Between January and June 2021, 31.6% of respondents reported using tobacco, alcohol or marijuana, or misusing prescription opioids. Nearly a third of students who said they'd used such substances before reported using more of them during the pandemic.

However, CDC survey data suggest that overall teen substance use decreased during the pandemic. It's possible, researchers concluded, that students who attended schools virtually had limited access and greater parental supervision.

Students who attended schools virtually, the survey revealed, were less likely than those who attended in-person to use substances like tobacco and alcohol. For example, a quarter of in-person students reported using tobacco compared to just 9% of remote learners.

Because youth get tobacco products from social sources such as friends, access to those products likely decreased during the pandemic, researchers concluded. However, more open alcohol policies like home delivery may have lowered barriers for youth attempting to purchase booze.

The CDC survey highlights the steep obstacles that teens have had to navigate during the pandemic, but it also recommends strategies that could offer a brighter future. While remote learning likely hindered students' feelings of connectedness at school, experts stressed it's not too late to make positive changes.

The CDC survey reveals that feelings of connectedness at school are critical to youth mental health. More than a quarter of youth who felt connected at school reported poor mental health during the pandemic compared to nearly half of those who said they did not feel close to others at their schools.

Youth who said they experienced racism during the pandemic and those who are gay, lesbian or bisexual were less likely than other student groups to report feeling connected at school.

To foster greater connectedness and promote positive school climates, the CDC recommended that districts implement programs that focus on social-emotional learning and professional development centered on classroom management and fostering positive relationships between students, their families and school staff. Districts should also analyze school disciplinary policies to ensure they're implemented equitably across racial and ethnic groups, researchers recommended.

"There is much that can be done to make sure that LGBTQ youth and youth from racial and ethnic minority groups feel safe, supported and connected in their schools," Ethier said, noting the importance of such school efforts specifically designed to improve the mental health of LGBTQ youth and reduce their risk of suicide. "When schools are less toxic for youth at increased risk for severe outcomes, schools are less toxic for everyone."

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centers for disease control and prevention

# data[].attributes.attachment_link.title
Youth Anxiety, Depression and Abuse Surged During COVID. 6 Charts from New CDC Data Show How Students Suffered - And Ways to Help Them Recover

# data[].attributes.attachment_link.description
Mental health challenges, economic insecurity and parental abuse became a routine part of life for a staggering share of high school students during the pandemic, data released Thursday by the Centers for Disease Control and Prevention show. More than a third of high school students reported experiencing poor mental health during the pandemic, more than [...]

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Abstract

Binge eating disorder (BED) represents one of the most problematic clinical conditions among youths. Research has shown that the developmental stage of adolescence is a critical stage for the onset of eating disorders (EDs), with a peak prevalence of BED at the age of 16-17 years. Several studies among adults with BED have underlined that it is associated with a broad spectrum of negative consequences, including higher concern about shape and weight, difficulties in social functioning, and emotional-behavioral problems. This review aimed to examine studies focused on the prevalence of BED in the adolescent population, its impact in terms of physical, social, and psychological outcomes, and possible strategies of psychological intervention. The review of international literature was made on paper material and electronic databases ProQuest, PsycArticles, and PsycInfo, and the Scopus index were used to verify the scientific relevance of the papers. Epidemiological research that examined the prevalence of BED in adolescent samples in accordance with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition showed a prevalence ranging from 1% to 4%. More recently, only a few studies have investigated the prevalence of BED, in accordance with the Diagnostic and Statistical Manual of Disorders, Fifth Edition criteria, reporting a prevalence of ~1%-5%. Studies that focused on the possible impact that BED may have on physical, psychological, and social functioning showed that adolescents with BED have an increased risk of developing various adverse consequences, including obesity, social problems, substance use, suicidality, and other psychological difficulties, especially in the internalizing area. Despite the evidence, to date, reviews on possible and effective psychological treatment for BED among young population are rare and focused primarily on adolescent females.

Keywords: binge eating, adolescence, prevalence, impact, treatment

Introduction

Binge eating disorder (BED) is an empirically validated eating disorder (ED), 1- 3 introduced in May 2013 in the Diagnostic and Statistical Manual of Disorders, Fifth Edition (DSM-5). 4 BED is characterized by recurrent episodes of unusually large amount of food intake without compensatory behaviors, and it is associated with subjective experience of feeling of loss of control (LOC) and marked distress. 5- 8 Originally, BED was introduced in the appendix of the Diagnostic and Statistical Manual of Disorders, 4th Edition, Text Revision (DSM-IV-TR), 9 as a subcategory of Eating Disorders Not Otherwise Specified (EDNOS). Criteria required binge eating episodes at least twice per week for 6 months, but the new DSM-5 changed this threshold to at least once a week for 3 months. 10 Generally, binge eating episodes are preceded by intense feeling of craving, 11 and several researchers have suggested that binge eating may serve as a maladaptive strategy for coping with negative mood states. 12- 16

BED is the most prevalent form of ED and one of the primary chronic illnesses among adolescents. 17 Adolescence is a transitional developmental stage characterized by rapid and deep physical, psychological, and neural development changes, and it represents a critical period for the onset of EDs, including BED. 18- 21 During this period, youths experience fast neurobiological and body modifications, which may be accompanied by increased concern and attention for body size and shape, 22- 24 as the awareness of societal pressures for thinness and relationships with peers becomes increasingly important, leading to a higher concern about peer acceptance. 25- 27 For these reasons, although EDs can affect individuals of all ages, adolescence represents a peak lifetime period of increased vulnerability for the onset of EDs. 28, 29 In particular, an increased prevalence of ED symptoms among youths aged 14-16 years has been evidenced, 30 with two peaks of onset of BED, the first immediately after puberty, at a mean age of 14 years, 31 and the second in late adolescence (19-24 years), between 18 and 20 years. 32

In the general population, international research has reported that 26% of female and 13% of male adolescents have experienced an episode of binge eating at least once in the last 12 months 33 and that subclinical symptoms of BED can be associated with a higher risk of developing BED 34 and/or other adverse outcomes, including lower self-esteem and higher body dissatisfaction. 35

It is noteworthy that binge eating episodes in adolescence could be difficult to differentiate from nonclinical behaviors, as youths could indulge in large food consumption due the developmentally specific growth spurts. 36 Consequently, it has been suggested that the criterion of LOC eating is the most salient marker of BED in this developmental phase, especially for early adolescents. 37 Furthermore, adolescents may also show less frequent episodes of binge eating than it is necessary to pose a diagnosis of BED according to the Diagnostic and Statistical Manual of Mental Disorders. 18, 38, 39 For these reasons, it is important for clinicians to consider subthreshold binge eating disorder (SBED) in adolescents. 32, 34, 37, 40

It has also been evidenced that female adolescents frequently report less overeating than male adolescents, 41 but more severe indicators of loss of control, 10, 42 and distress during binge eating episodes. 10, 41 Moreover, several studies among adults with BED have shown that this ED is associated with various adverse consequences, including higher distress and concern about shape and weight, 43 social impairment, 8, 44 and both clinical and subclinical forms of psychological difficulties, especially anxiety and depressive symptoms. 7

Based on these theoretical and empirical premises, the aim of this narrative review was to examine the current knowledge 45 of the prevalence of BED in adolescent population, outcomes associated in terms of physical, social, and psychological consequences, and possible psychological strategies of intervention.

Research methods

The methodological approach adopted in this paper consists of a narrative review, 45, 46 an interpretive-qualitative form of research that, when include some features of a systemic methodology, 47 can allow synthesizing the findings of literature about a specific theme and improve our knowledge on the topic. 48 Specifically, our methodological research ( Table 1 ) was inspired by the four steps provided by Egger et al 49 as follows: 1) formation of a working group, composed of three operators expert in BEDs; one of them has acted as a methodological operator and the other two as clinical operators; 2) formulation of the review questions on the basis of the state of the art of BED in adolescent population (in terms of its prevalence, impact, and possible psychological treatment strategies), as made in the abstract; 3) identification of relevant studies: the review of international literature was performed through an extensive search on paper materials in university libraries and through electronic databases such as ProQuest, PsycArticles, and PsycInfo and indexing papers published from January 2007 to June 2017, together with the use of Scopus index to verify the scientific relevance of papers. First, in order to examine the prevalence rates of binge eating in adolescent population, we were specifically interested in articles that reported the prevalence of both BED and SBED, in accordance with DSM-IV and DSM-5 criteria, and assessed diagnoses with self-report questionnaires and/or interview instruments. Despite self-report measurements have methodological limitations compared with interview-based assessments, we also included studies using report data to classify diagnoses, because epidemiological research of BED in adolescence is still scarce, and these studies may provide important preliminary data for future studies. This research was performed by using relevant combined keywords such as "binge eating disorder," "BED," "subthreshold BED," "adolescent," "youth," "prevalence," and "epidemiology."

Table 1

Step

General activities

Specific activities

1

Formation of a working group

Three psychologist experts in binge eating disorder:
1. One as a methodological operator
2. Two as clinical operators

2

Formulation of the review questions

Evaluation of the state of the art on the prevalence of BED in adolescence, its impact, and its possible psychological treatment strategies

3

Identification of relevant studies on ProQuest, PsycArticles, and PsycInfo

1. Identification of the keywords on the basis of the field of interest of the papers to be searched, grouped in inverted commas ("...") and used separately or combined
2. Use of the Boolean AND operator, in order to establish a logical relationship among concepts
3. Research modalities: advanced search
4. Limits: papers published in the last 10 years; languages: English; type of paper: peer-review
5. Manual search through the reference lists of articles, using the Scopus index to verify the scientific relevance of papers

4

Analysis and presentation of the outcomes

The data extrapolated from revised studies were collocated in tables and presented in the form of a narrative review

Second, to explore the possible impact of BED on adolescents' health and mental health, we searched for studies presenting physical, social, and psychological outcomes in female and male adolescents with BED and SBED, using the following combined search terms: "adolescence," "binge eating," "subthreshold BED," "outcomes," "long-term effects," "impact," "correlates," and "consequences."

Finally, to examine the research focused on possible psychological treatment strategies, we used the keyword search function by entering the following terms: "binge eating disorder," "adolescence," "youth," "psychological treatment," "psychotherapy," and "intervention."

Given that the criterion of LOC eating has been suggested to be a more appropriate indicator of binge eating in adolescence with respect to amount of food consumed, 37 we also included treatment studies specifically focused on the reduction of LOC.

We examined the title and screened abstracts of each identified article using these initial search strategies. Then, we also conducted a hand-search of the reference lists of published articles, and papers were inspected for their relevance in the review. On the basis of the evidence of two peaks of onset for BED 31, 32 (the first in early adolescence and the second in late adolescence), 50 we included in this review only articles in which sample of adolescents was aged between 10 and 24 years. Furthermore, we selected only papers in which sample or subsample of adolescents was diagnosed with BED or SBED, in accordance with either DSM-IV or DSM-5 criteria, or studies that examined binge eating symptoms and/or episodes without compensatory behaviors. Other inclusion criteria were that articles in English language and published in peer-reviewed journals. Thesis dissertations were excluded.

The final step is 4) the analysis and presentation of the outcomes; we identified a total of 25 articles, 00 for prevalence, 10, 18, 39, 40, 51- 53, 59- 62 11 for outcomes, 18, 39, 40, 59- 61, 64- 68 and 6 for psychological treatment. 79- 84 The data extrapolated from these revised studies were collocated in tables and carried out in the form of a narrative review. Table 1 shows the summary of the methodology used in the review. The flow diagram of the narrative review is shown in Figure 1 .

Results

Prevalence of BED in adolescence

Given that BED has only recently been introduced into the psychiatric nomenclature, epidemiological research is very limited, especially for adolescent populations. We found 13 prevalence studies specifically focused on youths, which have used different types of measurements to assess diagnoses ( Table 2 ). Five studies 18, 40, 51- 53 have examined the prevalence of BED in accordance with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and overall reported a rate of prevalence from 1% to 4%. For example, a study by Decaluwé and Braet 51 in a population of obese adolescents, using interview measurements, has reported a rate of ~2%. Two other studies 52, 53 have examined the rate of BED in general adolescent population, but using self-report questionnaires, reporting a slightly lower prevalence of 1.2%, with a higher rate among female adolescents. These studies 51, 52 have also underlined the presence of high percentage of youth who did not meet full-threshold criterion for an ED diagnoses, suggesting limitations of classification systems for epidemiological research among adolescent populations.

Table 2

Reference

Age (years)

Sample (N)

Methods

Prevalence (%)

Total

Female

Male

Screening

Criteria

Total

Female

Male

Stice et al 40

12-15
20

496

496

-

EDDI

DSM-IV

-

Swanson et al 18

13-18

10,123

-

-

CIDI

DSM-IV

Allen et al 59

14-17-20

1,383

715

668

ChEDE
EDE-Q

DSM-5

0.9
1.3
2.4

1.8
1.4
4.1

0
1.2
0.7

Smink et al 31

19

1,597

861

739

CIDI
EDE

DSM-5

1.5

2.3

0.7

Stice et al 32

12-15
20

496

496

-

EDDI

DSM-5

-

Micali et al 60

14-16

6,140
5,069

3,416
3,059

2,742
2,154

2-part question

DSM-5

0.5 a
0.03 b
1.15 a
0.42 b

0.61 a
0.03 b
1.15 a
0.72 b

0.33 a
0.04 b
0.6 a
0 b

Lee-Winn et al 10

13-18

9,336

4,738

4,598

EDDI

DSM-5

Finally, we considered two studies 18, 40 that, using interview-based assessments, have provided the prevalence rates also for SBED, evidencing a higher prevalence of this form in this phase of development. One study 40 was focused only on adolescent girls, finding a rate of 1% for BED and 4.6% for SBED. The second study 18 had considered both sexes of adolescent population, reporting a prevalence of 1.6% for BED and 2.5% for SBED and evidencing higher rates among girls for SBED also.

In particular, we found three studies 39, 59, 61 that have longitudinally examined the prevalence of BED in adolescent community samples and that suggested an increase of rate over time. For example, Field et al 61 found a BED prevalence of 2.5%, which tended to increase during the development, with a peak at 19-22 years of age.

Two other studies 39, 59 have confirmed these findings also among male adolescent samples. Interesting, a study by Allen et al 59 has reported that BED prevalence increased over time among female adolescents, starting from 0.7% in 14-year-old subjects, reaching 1.4% when they were 17 years, and finally growing up to 4.1% when they were 20 years old. In male adolescents, BED prevalence was estimated to be absent (0%) at 14 years of age and 1.2% at 17 years and was decreased to 0.7% at 20 years, suggesting that adolescent girls have a higher risk of maintaining BED over the course of life. However, another study 37 found that prevalence of BED generally increased over time among both female and male adolescents, peaked at ~3.3% at an age of 22 years for girls and 1.2% at 24 years for boys.

More recently, two cross-sectional studies 31, 62 have reported lower rates of prevalence (~1.5%), but among samples of younger adolescents with respects to previous studies in which an increase of prevalence has been evidenced over time.

Finally, we considered three studies 10, 32, 60 focused also on the prevalence of SBED. Interestingly, the study by Stice et al 32 has examined the prevalence of EDs in the same female adolescent samples of their previous study, 40 but considering the new DSM-5 criteria, finding an increased prevalence of BED of ~2%. Two other studies 10, 60 have replicated similar results but considering also male adolescents. One study 60 was consistent with the previous findings, underlining that female adolescents had a higher prevalence of BED and SBED with respect to their peer male adolescents. In contrast, another study 10 has evidenced a higher rate of BED among female adolescents, but male adolescents reported higher rate of SBED.

Impact of BED on physical, psychological, and social functioning

As seen in the above paragraph, epidemiological research has underlined that BED is common in adolescent population. Research that has focused on the possible consequences of BED on physical, psychological, and social functioning has evidenced that adolescents suffering from BED have an increased risk of developing a variety of adverse outcomes, which may persist into young adulthood. 63

Table 3

Reference

Age (years)

Sample (N)

Outcome

Results (OR; 95% CI) or (p-value) or (Cohen's d) or (%)

Field et al 61

16-24

859

Overweight/obesity
Use drugs
Binge drink
Depressive symptoms

BED was predictive of overweight/obesity (OR: 1.9; CI: 1.0-3.5) and depressive symptoms (OR: 2.3; CI: 1.0-5.0) in female adolescents. No association was found with binge drinking

Sonneville et al 39

12-24

14,166

Overweight/obesity
Use drugs
Binge drink
Depressive symptoms

Binge eating was significantly associated with incident overweight/obesity (OR: 1.73; CI: 1.11-2.69), starting to use marijuana (OR: 1.85; CI: 1.27-2.67) and other drugs (OR: 1.59; CI: 1.08-2.33), and with the onset of high depressive symptoms among both female adolescents (OR: 2.12; CI: 1.32-3.40) and male adolescents (OR: 3.21; CI: 0.68-15.27)

Micali et al 64

13-15

7,082

Overweight/obesity
Social impairment
Family burden
Emotional-behavioral disorders

Bingeing/overeating was predictive of higher BMI z scores at 15 years of age ( p<0.0001), both in adolescent girls and boys. Bingeing/overeating in girls was associated with social impairment ( p<0.0001), burden to parents ( p<0.0001), and both emotional ( p<0.01) and behavioral ( p<0.01) disorder In male adolescents, bingeing/overeating was associated with social impairment ( p<0.0001), family burden ( p<0.0001), and both emotional ( p<0.0001) and behavioral ( p<0.0001) disorder

Micali et al 60

14-16

6,140

Overweight/obesity
Depression
Anxiety
Alcohol use
Substance use
Self-harm

BED was prospectively associated with obesity (OR: 3.58; CI: 1.06-12.14), depression (OR: 2.00; CI: 1.06-3.75), anxiety (OR: 3.53; CI: 1.58-7.86), and drug use (OR: 3.39; CI: 1.35-8.48). SBED had prospective associations with depression (OR: 2.11; CI: 1.44-3.10), anxiety (OR: 7.90; CI: 2.53-24.67), drug use (OR: 2.15; CI: 1.14-4.04), and deliberate self-harm (OR: 2.32; CI: 1.43-3.75)

Ranzenhofer et al 65

12-17

158

Depressive symptoms
Health
Social/interpersonal functioning
Work/school
Mobility
Self-esteem
Activities of daily living

BED was associated with depressive symptoms ( p<0.05), health ( p<0.05), mobility ( p<0.05), and self-esteem ( p<0.01). Adolescent girls, compared to boys, reported lower levels of activities of daily living, mobility, self-esteem, and social/interpersonal functioning ( p<0.05), but not health or work/school

Swanson et al 18

13-18

10,123

Mental health
Social impairment
Suicidality

BED and SBED were associated, respectively, to mood disorder (OR: 4.6; CI: 2.7-7.7), a (OR: 2.0; CI: 2.2-3.4); b anxiety (OR: 5.0; CI: 3.0-8.1), a (OR: 1.7; CI: 1.1-2.6); b substance abuse (OR: 3.1; CI: 1.3-7.2), a (OR: 2.7; CI: 1.6-4.6); b and behavioral disorder (OR: 3.1; CI: 1.0-9.4), a (OR: 2.5; CI: 1.4-4.2) b 62.6% of adolescents with BED and 34.6% with SBED reported impairment in the last year, specifically in household chore (45%, a 23.5% b), school or work (46.2%, a 20.6% b), family life (45.7%, a 21.3% b), and social life (51.6%, a 20.9% b). 8.7% of BED and 2.8% of SBED reported several impairment in the domain of household chore (4.8%, a 2.2% b), school or work (1.9%, a 2.6% b), family life (3.7%, a 2.1% b), and social life (5.7%, a 2.1% b). 34.4% of BED and 18% of SBED reported suicidal ideation, 5.1% of BED and 5.1% of SBED declared suicidal plan, and 15.1% of BED and 5.3% of SBED showed suicidal attempt. Finally, they reported significant higher suicidal ideation ( p<0.5) a, b and attempt ( p<0.05) b than control did

Skinner et al 67

12-23

4,798

Depressive symptoms

Female adolescents with binge eating or overeating had a higher risk to develop depressive symptoms after 2 years (OR: 1.9; CI: 1.2-2.9 and OR: 1.9; CI: 1.1-3.4, respectively). Female adolescents with depressive symptoms at baseline had a higher risk to start binge eating (OR: 2.3; CI: 1.7-3.0) or overeating (OR: 1.9; CI: 1.4-2.5) at follow-up

Allen et al 59

14-20

1,383

Depressive symptoms
Physical quality of life
Mental quality of life

BED was longitudinally associated with depressive symptoms ( p<0.05) and poor mental health quality of life ( p<0.05), in both male and female adolescents

Allen et al 68

14-20

1,383

Depression
Anxiety
Psychological functioning

BED was significantly and longitudinally associated with depressive ( p<0.01; d=0.73), anxiety ( p<0.01; d=1.25), and stress ( p<0.01; d=1.31) symptoms and poor mental quality of life ( p<0.01; d=0.83) in adolescents with BED

Stice et al 40

12-20

496

Mental health service use
Functional impairment
Emotional distress

Adolescents with BED and SBED reported more mental health treatment ( p<0.01), functional impairment ( p<0.05), and emotional distress ( p<0.01) than the control group

Stice et al 32

15-23

496

Functional impairment
Emotional distress
Suicidality
Mental health service utilization

BED was significantly associated with functional impairment ( p<0.01; d=1.06), emotional distress ( p<0.01; d=1.22), suicidality ( p<0.01; d=1.14), and mental health treatment ( p<0.01; d=1.10). SBED was associated only with emotional distress ( p<0.01; d=0.94) and suicidality ( p<0.01; d=0.51)

Forrest et al 66

13-18

10,123

Suicidality

BED was associated with elevated odds of suicidal ideation (OR: 3.81; CI: 2.14-6.77; p<0.001) and attempting (OR: 5.01; CI: 1.62-15.48; p<0.01)

Regarding the impact of BED on physical health, four prospective cohort studies 39, 60, 61, 64 have underlined that BED was predictive of overweight and obesity, both in girls and boys. 39, 60, 64 In particular, in early adolescents with BED, it has been reported a body mass index (BMI) of ~23 kg/m ², 59 is indicative of a healthy weight. However, among this population, BMI tended to increase during later adolescence, with a mean score of 27 kg/m ² among youths with BED 59 and of 26 kg/m ² for SBED, 32 representative of a overweight condition (25 < BMI < 29.9 kg/m ²), up to a rate of 60% of obese (BMI >30 kg/m ²), 31 suggesting that binge eating might represent a crucial risk factor for obesity. A study by Field et al 61 has shown that 35.1% of female adolescents became overweight and/or obese over the following years, with a significant higher incidence compared with their peers with other EDs. Three other longitudinal studies 39, 60, 64 have reported similar findings for both female and male adolescents, evidencing that binge eating symptoms are predictive of negative physical consequences (such as obesity) among both sexes.

Furthermore, research has underlined that the impact of BED in adolescence reaches beyond physical adverse outcomes. In particular, we considered three studies 18, 64, 65 that have suggested that the presence of BED was predictive of a broad spectrum of negative social/interpersonal and outcomes and lower quality of life, in both obese and general adolescent population. A study by Ranzenhofer et al 65 focused on an obese adolescent population has shown that binge eating youths reported severe impairments in the domains of health, mobility, and self-esteem compared with their peers without binge eating, even after controlling for body composition. At the same time, two studies 18, 64 have replicated similar results also in population-based samples, evidencing that bingeing/overeating symptoms were significantly associated with both social impairment and family burden, in girls and boys. As regards possible different impact of BED and SBED on adolescents' quality of life, one study 64 has evidenced that 62.6% of adolescents with BED and 34.6% of adolescents with SBED reported impairment in the past year, especially in the domains of social life and household chore, respectively. About 9% of adolescents with BED had severe impairments, particularly in social life, while 2.8% of those with SBED reported severe school or work impairment. Although the research design did not allow causal links, it represented the first population-based study focused on the impact of both threshold and subthreshold of BED in a large population-based samples of female and male adolescents.

More recently, three studies 39, 59, 68 have confirmed these associations also for adolescent boys. One of them 39 has reported a higher power of prospective associations between BED and depressive symptoms among boys. Moreover, these studies have also evidenced an expanded range of adverse psychological health outcomes predicted by BED, including anxiety and stress symptoms, substance use, and a general low quality of life. However, associations with stress and anxiety symptoms had large effect size. 68

Psychological treatment strategies

Despite the high prevalence of BED in adolescent populations and the severe physical, social, and psychological associated outcomes, systematic studies on possible and effective psychological treatment for BED among young population are scarce.

Table 4

Reference

Age (years)

Psychological treatment

Control group

Sample (N)

Results (OR: 95% CI) or (p-value) or (Cohen's d) or (%)

EG

CG

DeBar et al 79

12-18

CBT (8 sessions over 6 months)

TAU-DT

13

12

CBT participants had a significant higher rate of abstinence from recurrent binge eating at 3 months ( p<0.01) and at 6 months ( p<0.01; d=1.467), a significant greater improvement in eating-related concerns ( p<0.05; d=0.80), shape-related concerns ( p<0.01; d=1.04), and weight-related concerns ( p<0.01; d=0.64) and significant higher reduction in depressive symptoms ( p=0.051; d=0.57) at both 3 and 6 months

Jones et al 80

15

Internet-facilitated CBT-self-help intervention (16 session over 16 weeks)

WLC

52

53

Internet-facilitated CBT-self-help intervention was associated with a significant reduction of BMI z scores ( p<0.01; d=0.80) and BMI ( p<0.01; d=0.60) at 9-month follow-up assessment, a significant decrease of objective and subjective binge episodes at both posttreatment assessment ( p<0.01) and follow-up assessment ( p<0.05) and a significant lower weight- and shape-related concerns ( p<0.05)

Tanofsky-Kraff et al 81

12-17

IPT (12 sessions over 12 weeks)

HE

19

19

IPT was associated with significant reduction in LOC episodes at 6-month follow-up ( p<0.05) and in BMI ( p<0.05) over 1 year

Tanofsky-Kraff et al 82

12-17

IPT (12 sessions over 12 weeks)

HE

56

60

Both IPT and HE were associated with a significant decrease in expected BMI gain ( p<0.001), BMI z score ( p=0.003), BMI percentile ( p<0.001), anxiety and depressive symptoms ( p<0.001), and the frequency of LOC episodes ( p<0.001) over 12-month follow-up. IPT was associated with a significant higher reduction of objective binge eating ( p<0.05) at the 12-month follow-up

Safer et al 83

16

DBT (30 sessions over 6 months)

None

1

0

DBT was associated with decreased binge eating episodes by the end of treatment and abstinence at 3-month follow-up

Mazzeo et al 84

13-17

DBT (12 sessions over 12 weeks)

BWT

28

17

DBT and BWT were associated with significant reductions in eating-related concern ( p<0.05), shape-related concern ( p<0.05), restraint ( p<0.05), global disordered eating attitudes ( p<0.05), and negative ( p<0.05) effect

With regard to CBT studies, DeBar et al 79 have used an adolescent adaptation of CBT in a sample of female adolescents with BED (52%), recurrent binge eating episodes (32%), or bulimia spectrum disorders (16%). Subjects in CBT group were compared with a usual-delayed treatment (TAU-DT) control group (N=13), in which adolescents received CBT 6 months later. All participants were assessed at baseline and at 3- and 6-month follow-up sessions. Female adolescents in CBT group showed significantly higher abstinence of binge eating episodes at 3- and 6-month follow-up than their peers of TAU-DT group, with a robust effect size. At follow-up, totality of participants of CBT was abstinent. Moreover, the intervention also produced significant improvements in other shape-, weight-, and eating-related concerns, although with a smaller effect size. Finally, girls in the CBT group showed a significant lower depressive symptoms at both the follow-up sessions. However, subjects of TAU-DT group, who were additionally followed up at 9 and 13 months, reported similar outcomes. Although this study provided a preliminary evidence of the efficacy of CBT in reducing binge eating symptoms and their secondary outcomes among adolescent population, homogeneity and small size of sample did not permit generalizability of these findings. Another study by Jones et al 80 has investigated the use of an Internet-facilitated CBT-self-help intervention along 16 weeks, compared to a 9-month-wait-list control (WLC) group, for weight maintenance and the reduction of binge eating episodes. In particular, the treatment program was composed by an integrated intervention in which behavioral weight loss (BWL) was combined with CBT. This choice was due to the evidence that in adolescence the specific increased focus on body weight, control of eating behaviors, and dietary that characterizes traditional weight loss programs 73 could produce the paradoxical effect of increasing the risk and/or severity of ED symptomatology. 85 Moreover, despite traditional BWL programs being found to be effective in the treatment of BED in adults, 74 they are specifically focused on the objective overeating episodes, neglecting the aspects of loss of control which are particularly central in BED in adolescence. 37 Subjects in CBT group showed significantly lower BMI and BMI z scores at follow-up assessment, a greater decrease in both objective and subjective binge episodes at both posttreatment and follow-up assessments, and a significant reduction of weight- and shape-related concerns than control did, supporting the effectiveness of this intervention also in female adolescents with BED.

Regarding IPT that has been suggested to be an important strategy to reduce binge eating and associated interpersonal problems, 69 we found only two studies 81, 82 that evaluated its effectiveness in adolescents with BED. A pilot study by Tanofsky-Kraff et al 81 focused on IPT in a sample of female adolescents who were at-risk for excessive weight gain, with and without LOC eating, and reported a significant reduction in LOC episodes at 6-month follow-up and in BMI over 1 year, compared with girls randomly assigned to a standard-of-care health education (HE) program group. However, as in most pilot studies, the absence of statistical power did not allow generalizable conclusions on the reported effectiveness. Consequently, more recently, the same authors 82 conducted an adequately powered clinical trial to verify the effectiveness of an adapted IPT group of girls compared to an HE control group. Adolescents of both the groups reported significant reduction of dimensions of BMI (expected BMI gain, BMI z score, and BMI percentile), anxiety and depressive symptomatology, and LOC episodes over 1-year follow-up, with no differences between groups. However, girls in IPT group have shown a significant decrease of binge eating episodes at 12-month follow-up.

Finally, we reported two studies 83, 84 specifically interested in examining the effectiveness of DBT in reducing binge eating symptoms. One of them, Safer et al's study, 83 was a case report of a 16-year-old girl, who has shown a significant reduction of binge eating episodes after treatment, and abstinence from binging at 3-month follow-up. Despite potential limitations of case-control studies, we considered this study because it provided a preliminary support for the utility of the adolescent modified version of DBT in reducing binge eating episodes. Finally, Mazzeo et al 84 examined the effectiveness of DBT in adolescent girls, compared to a BWL treatment control group, reporting a significant reduction in eating-related concern, shape-related concern, restraint, global disordered eating attitudes, and negative effect in both the groups.

Summary

What is the prevalence of BED in adolescence?

However, the validity of some of the reviewed studies can be questioned, because the prevalence rate and the definition itself of binge eating may differ depending on the assessment measurements used by researchers. In particular, studies that have used self-report assessments 52, 53, 59, 61 tended to report higher prevalence than interview-based studies. 10, 18, 31, 32, 39, 40, 62 This may depend on the fact that interviews may allow clarifying the subjective experience of "lack of control overeating" and objectively measure the "large food consumption," which represent two key criteria for the clinical diagnosis of BED. Other specific problems are the general tendency of individuals suffering from BED to hide their illness, the limited awareness of the clinical relevance of their disordered eating, and, consequently, the difficulty to seek for professional help. 18, 88 For these reasons, future studies on large sample of adolescents from the general population are needed.

What are the physical, social, and psychological outcomes of BED in adolescence?

Research in the last decade has documented the clinical significance of BED in terms of adverse physical, social, and psychological health problems commonly associated with this condition. In particular, with regard to physical outcomes, several studies have reported that BED and SBED, in both female and male adolescents, were predictive of high rates of overweight and obesity. 39, 60, 61, 64 This finding supports the view of clinical significance of binge eating, given the important consequences on health associated with obesity in adolescent and adult populations. Indeed, international research has evidenced that obesity is associated with an increased risk to develop severe medical conditions, such as type II diabetes mellitus (DM), hypertension, cardiovascular disease, fatty liver disease, and a higher risk for morbidity and mortality. 89

Moreover, the studies we reviewed have also evidenced a growing interest in examining possible associations of BED with psychiatric comorbidities. These studies have evidenced that BED in adolescence is a strong predictor of a large spectrum of mental health difficulties. Most of them showed prospective associations with internalizing problems, especially depressive (reported by ~45% of subjects with BED), anxiety, and distress symptoms (as displayed by about one third of adolescents with BED), 18, 59- 61, 64, 65, 67 and suggesting a higher impact on male adolescents. 39 Substance use also seems to affect one fourth of subjects with BED. 18, 39, 60

What is the effectiveness of existing psychological interventions for BED in the adolescent population?

To date, evidence for effective treatments for adolescents with BED is growing but yet scarce and inconsistent. This may be due to the fact that BED has only recently been included as a diagnostic category in DSM-5, and, consequently, attention of clinicians on specific intervention in this area is at its dawn.

Notwithstanding the studies we reviewed have evidenced some positive preliminary results in reducing binge eating episodes and associated psychopathological symptoms, all of them had small sample size and relatively short follow-up intervals, precluding definitive conclusions about their effectiveness and appropriateness, and suggesting the necessity of implementing long-term longitudinal studies to verify the persistence of clinical benefits over time. Furthermore, additional research comparing these different methodological interventions is needed.

Moreover, to the best of our knowledge, no study has yet been conducted to confirm the effectiveness of psychological treatment in male adolescents with BED.

Finally, it is important to emphasize that epidemiological studies have suggested that only a small percentage of adolescents with BED (specifically, 11.9%) tended to seek clinical help. 18 Moreover, the high rate of adolescents who do not meet full-threshold criteria, although they are affected by various severe physical and psychological negative consequences, makes it even harder to identify them, suggesting the importance of implementing primary prevention programs aimed at increasing awareness, reducing stigma, and promoting acceptance of intervention.

Conclusion

International research has underlined that adolescence is characterized by a high risk for the onset of BED, which represents the most common ED subtype among youths, posing severe risks to their physical and mental health. Several studies have evidenced the complex etiopathogenesis of BED, which seems to result from dynamic and reciprocal relationships between different type of variables, including biological (in particular, familial genetic predisposition and epigenetic processes), 95, 96 psychological (such as personality traits of perfectionism and impulsivity, negative effect or depressive symptoms, weight and eating concerns, and body dissatisfaction), 98- 100 and environmental risk factors, in terms of parental influences on childhood eating behavior, 95 parental psychopathology and psychopathological risk, 101 early adverse experiences, and the presence of traumatic experiences in the parents. 102 Among individual risk factor, it has also been reported that dietary restraint, a general rigid eating habits and maladaptive weight control behaviors represent significant risk factor for the onset of BED. 103 Moreover, many studies have reported the predictive role played by peer influences and perception of a lack of peer support, 104, 105 as well as by cultural influences (especially social pressure for thinness and the resulting body dissatisfaction) 97, 106 on the onset of BED. Overall, these findings suggest the importance of implementing longitudinal studies and randomized controlled trials to increase our knowledge of long-term outcomes of BED and support the planning of evidence-based prevention programs and treatment strategies targeted on the risk factors for the onset and maintenance of BED. Given the high prevalence of adolescents who reported SBED, early detection is needed in order to prevent the evolution and worsening of eating symptoms. Moreover, although it has been underlined that a high prevalence of BED may also be found in male adolescent population, there is a dearth of studies that have specifically focused on the possible effectiveness of intervention programs in boys with BED. Thus, future studies including both female and male adolescents with BED are needed.

Footnotes

Disclosure
The authors report no conflicts of interest in this work.

References

34. Tanofsky-Kraff M, Shomaker LB, Olsen C, et al. A prospective study of pediatric loss of control eating and psychological outcomes. J Abnorm Psychol 2011120 1108. [[ PubMed] PMC free article] [ Google Scholar]

93. IGuidelines CE.Eating Disorder: Recognition and Treatment, Version 1 Commissioned by theNational Institute for Health and Care Excellence; London, UK; 2016 [ Google Scholar]

Articles from Adolescent Health, Medicine and Therapeutics are provided here courtesy of Dove Press

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A narrative review of binge eating disorder in adolescence: prevalence, impact, and psychological treatment strategies

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Binge eating disorder (BED) represents one of the most problematic clinical conditions among youths. Research has shown that the developmental stage of adolescence is a critical stage for the onset of eating disorders (EDs), with a peak prevalence of ...

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Definition

Students with emotional disorders are a very heterogeneous group with a wide range of issues that are unique to each individual. However, there are some key characteristics that are used to define this disability category, mostly relating to issues of personal identity and emotional well-being. An emotional disorder may be present if a student responds to a situation with an inappropriate behavior or emotion, and particularly, if this emotion is depression or long term unhappiness. Students with emotional disorders typically have a very difficult time maintaining personal relationships with others, and these personal problems lead to physical symptoms in time. If the student has difficulty learning, but there is no intellectual or sensory cause of this difficulty, then an emotional disorder may be to blame. This disability category does include some mental illnesses such as schizophrenia.

It should be noted that one or more of the previously mentioned characteristics has to be present for an extended period of time, and must have a negative impact on the student's academic performance before being considered an emotional disorder. Signs of an emotional disorder need to be taken seriously, as they can lead to physical aggression and self-injurious behavior. However, care must also be taken to recognize the difference between emotional disturbance and general teenage angst. There are as many causes of emotional disturbance in children as there are children in this category, but they can generally be divided into either biological causes, environmental causes, or a combination of the two.

Prevalence

The U.S. Department of Education reports 5,971,495 students receiving special education services in the 2003-2004 school year. Of that number, roughly 7.7%, or 461,055 students, received special education services based on a classification of emotional disturbance. However, within this group of 461,055 students, there was a definite disproportionally between gender, race and socioeconomic background. African-American students were far more likely to be diagnosed as emotionally disturbed than white students, reflecting possible race bias in this category. Research has pointed to a direct correlation between low income status and emotional disorders, but the exact reasons for this correlation are unknown.

Characteristics

Each student with an emotional disturbance will have characteristics that are unique to that individual. However, these students will all share deficits in three specific areas, namely emotional development, behavioral development, and cognitive development.

These students may have specific emotional characteristics/conditions such as anxiety disorder, mood disorder, oppositional defiant disorder, conduct disorder, and schizophrenia. Not addressing any one of these disorders with the appropriate support system could have potentially tragic results. Behavioral characteristics of an emotional disorder include externalizing behavior and conversely internalizing behavior. The former can result in problem behavior and physical aggression while the latter results in depression and anxiety. Finally, students with emotional disorders have a number of academic issues as well, and each year half of the students in this category drop out of school entirely.

One intriguing possible contributing factor to emotional disturbance can be found in deficits in communication. An estimated 71% of students with emotional disorders also have expressive and receptive language disorders that impact their ability to understand and communicate with peers and adults.

Impact on Learning

Students with emotional disorders can be found at every level of cognitive functioning, but the majority of these students tend to have low average intelligence. Most achieve below grade level in academic achievement, with the greatest deficits in both math and spelling. Many have a coexisting learning disability of some type. Students that exhibit externalizing behaviors are at the greatest risk for continued deficits in academic functioning. Students with emotional disorders are less likely to attend post-secondary school than students in many other disability categories. An effective educational program for students with emotional disorders will provide emotional and behavioral supports that foster the replacement of problem behaviors with more appropriate behaviors. Positive behavior support systems are one especially effective strategy to achieve this goal, as are the implementation of wraparound services.

Teaching Strategies

Wraparound planning is a collaborative process that has shown great promise in supporting students with emotional disorders, both in research and in more practical application. This planning process brings all of the involved service providers (i.e., adult rehabilitation services, mental health services, guidance counselor) and individuals together to create a natural support system that is founded on the strengths of the individual student and the community in which that student lives. The family is an integral part of this process, and the overall goal is to devise a program that will capitalize on the strengths and interests of the student while utilizing community resources for placement and intervention.

Generally, academic achievement and problem behaviors often go hand-in-hand for students with emotional disorders. To put this another way, the more difficulty they have with a classroom task, the more likely that maladaptive behavior will result. Supporting the academic performance of these students will thus have the added benefit of decreasing externalizing and internalizing behaviors. Best practices for students with emotional disorders are often best practices for all students. A strategy such as allowing students to choose between classroom tasks, for example, is an effective way to decrease problem behaviors in general. Consistent and specific praise is also a great technique to utilize with all students in the classroom, but can be particularly effective with students with emotional disorders.

It is very important to not make assumptions about any family of a child with an emotional disorder. Many emotional disorders have an organic cause, and the parents of the child may well be loving and supportive in every way. However, some of these students have indeed been abused in some fashion in their young lives, and this too can be a cause of emotional or behavioral issues. Trust can be a very large issue for these children. Forming a relationship with these students that is built on empathy, trust, and mutual respect can often be the solution to many problem behaviors, and can have a lasting impact of the emotional development of the child.

Assistive Technology

Some modification in instruction will be necessary to allow a student with an emotional disorder to demonstrate mastery in a number of academic areas, and most especially in the area of writing. Word processing software can be an excellent supplementary aid for these students, allowing them to edit and revise their work as they produce it. These programs can strengthen spelling skills and writing cohesion simply by making the writing process easier overall. Of particular benefit are word processing programs that read the text as it is typed, providing an additional audio cue for the student.

Organizations

There are a number of excellent organizations that can help support classroom instruction for students with emotional and behavioral disabilities. The information presented in this module is intended as just a very brief description of emotional disorder and its impact on learning. Much more in-depth information and instructional strategies can be accessed through the following organizations:

American Academy of Child and Adolescent Psychiatry

The AACAP (American Academy of Child and Adolescent Psychiatry) is the leading national professional medical association dedicated to treating and improving the quality of life for children, adolescents, and families affected by these disorders. Composed of over 7,500 child and adolescent psychiatrists and other interested physicians, its members actively research, evaluate, diagnose, and treat psychiatric disorders and pride themselves on giving direction to and responding quickly to new developments in addressing the health care needs of children and their families.

Public Information Office
3615 Wisconsin Ave., NW
Washington, DC 20016-3007

Web: www.aacap.org

Center on Positive Behavioral Interventions and Supports

The OSEP-funded National Technical Assistance Center on Positive Behavior and Intervention Supports was established to address the behavioral and discipline systems needed for successful learning and social development of students. The Center provides capacity-building information and technical support about behavioral systems to assist states and districts in the design of effective schools.

5262 University of Oregon
Eugene, OR 97403-5262

Email: pbis@oregon.uregon.edu
Web: www.pbis.org

Center for Disability and Development

Dept. of Educational Psychology
4225 Texas A&M University
College Station, TX 77843-4225

Council for Exceptional Children

The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving educational outcomes for individuals with exceptionalities, students with disabilities, and/or the gifted. CEC advocates for appropriate governmental policies, sets professional standards, provides continual professional development, advocates for newly and historically underserved individuals with exceptionalities, and helps professionals obtain conditions and resources necessary for effective professional practice.

1110 North Glebe Road, Suite 300
Arlington, VA 22201-5704

Federation of Families for Children's Mental Health

This organization is dedicated exclusively to helping children with mental health needs and their families achieve a better quality of life. They provide leadership to develop and sustain a nationwide network of family-run organizations; focus the passion and cultural diversity of our membership to be a potent force for changing how systems respond to children with mental health needs and their families; help policy-makers, agencies, and providers become more effective in delivering services and supports that foster healthy emotional development for all children.

1101 King Street, Suite 420
Alexandria, VA 22314

Email: ffcmh@ffcmh.org
Web: www.ffcmh.org

National Alliance for the Mentally Ill (NAMI)

NAMI is the National Alliance on Mental Illness, the nation's largest grassroots organization for people with mental illness and their families. NAMI is dedicated to the eradication of mental illnesses and to the improvement of the quality of life for persons of all ages who are affected by mental illnesses. NAMI members and friends work to fulfill our mission by providing support, education, and advocacy.

Colonial Place Three
2107 Wilson Boulevard, Suite 300
Arlington, VA 22203-3754

Web: www.nami.org

Mental Health America

Mental Health America is dedicated to helping ALL people live mentally healthier lives. They work to fulfill this mission by education the public about ways to preserve and strengthen mental health; advocating for access to effective care; fostering innovation in research, practice, services and policy; and providing support to individuals and families.

2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311

Web: www.nmha.org

National Mental Health Information Center

The National Mental Health Information Center was developed for users of mental health services and their families, the general public, policy makers, providers, and the media. They provide free information about mental health via a toll-free number, their website, and more than 600 publications.

P.O. Box 42557
Washington, DC 20015

Web: www.mentalhealth.org

References

Hunt, N., and Marshall, K. (2006). Exceptional children and youth. Boston, MA: Houghton Mifflin Company.

National Dissemination Center for Children with Disabilities (2004). Fact Sheet 5. Retrieved February 1, 2008 from www.nichcy.org/pubs/factshe/fs5txt.htm.

Turnbull, A., Turnbull, R. & Wehmeyer, M. L. (2007). Exceptional lives. Special education in today's schools. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

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Students with emotional disorders typically have a hard time maintaining relationships, and these personal problems may lead to physical symptoms in time.

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Diagnostic Statistical Manual for Mental Disorders

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Diagnostic Statistical Manual for Mental Disorders

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Teaching Strategies for children with Bipolar Disorder

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Teaching Strategies for children with Bipolar Disorder

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Though children with bipolar disorder are often gifted, they require patience and new approaches to help them learn and grow. Here are eight teaching strategies to help these students excel in the classroom.

#1 Flexibility works best

It is best to adapt a more flexible lesson plan for children with bipolar disorder. Additional time for assignments and tests may be required and understanding given for missed classes due to appointments with health care professionals.

#2 Consistent schedules

Children who live with bipolar require flexibility with their schedules such as incorporating many breaks throughout the day to aid with focus and staying positive. It's important; however, that this routine stay consistent.

#3 Few distractions

Distractions can cause more disruptive behaviors and can negatively affect the student's ability to focus. Some students will need to be seated near the front of the room to help reduce the distractions.

#4 Practice patience

Understand that the child's grades may drop or he could participate less in class activities. Practice tolerance in dealing with minor problems and, instead of focusing on negative conduct, recognize and praise the positive behavior.

#5 Maintain good communication

There should be open lines between educators, the school and the child's parents/guardians, psychologist or other health care professionals. It is important to practice good communication and be ready to adapt and try different approaches for the child if something is not working.

#6 Have a plan

It's essential that teachers watch for extreme behavioral changes or any signs of suicidal thoughts. These signs should be taken seriously and a plan should be in place about how school staff should respond to such situations. The plan can be decided ahead between the child's parents, psychologist and teachers.

#7 Accommodate special needs

May children with bipolar disorder need to visit the school nurse regularly for medication or talk to a school psychologist. And, especially for children taking lithium, they may need to carry a water bottle and have unlimited access to restrooms.

#8 Agree on a safe place/person

Children suffering from bipolar can feel overwhelmed or anxious or they may be unsure of how to deal with their strong emotions and feel out of control. It's important to establish both a safe place and a safe person they can go to in times of distress. Allow them access to leave the classroom on their own.
code:bphopekids

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8 Things Every Teacher Should Know About Bipolar Disorder | bpHope.com

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It is best to adapt a more flexible lesson plan for children with bipolar disorder. Additional time for assignments and tests may be required and understanding given for missed classes due to appointments with health care professionals. Children who live with bipolar require flexibility with their schedules such as incorporating many breaks throughout the day to aid with focus and staying positive.

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Accurate Portrayal of Mental Disorders in Television-Shameless

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Accurate Portrayal of Mental Disorders in Television-Shameless

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“Shameless” - a Show That Actually Get Mental Illnesses Right

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Educational side of Shameless. Mentall illnesses portrayed in Shameless

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Teaching strategies for students with ADHD

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Teaching strategies for students with ADHD

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Centers for Disease Control and Prevention

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Children with attention-deficit/hyperactivity disorder (ADHD) experience more obstacles in their path to success than the average student. The symptoms of ADHD, such as inability to pay attention, difficulty sitting still, and difficulty controlling impulses, can make it hard for children with this diagnosis to do well in school.

To meet the needs of children with ADHD, schools may offer

ADHD treatments, such as behavioral classroom management or organizational training;

Special education services; or

Accommodations to lessen the effect of ADHD on their learning.

Classroom Treatment Strategies for ADHD Students

There are some school-based management strategies shown to be effective for ADHD students: behavioral classroom management and organizational training.

The behavioral classroom management approach encourages a student's positive behaviors in the classroom, through a reward systems or a daily report card, and discourages their negative behaviors. This teacher-led approach has been shown to influence student behavior in a constructive manner, increasing academic engagement. Although tested mostly in elementary schools, behavioral classroom management has been shown to work students of all ages.

Organizational training teaches children time management, planning skills, and ways to keep school materials organized in order to optimize student learning and reduce distractions. This management strategy has been tested with children and adolescents.

These two management strategies require trained staff-including teachers, counselors, or school psychologists-follow a specific plan to teach and support positive behavior.

The American Academy of Pediatrics (AAP) recommends that the school environment, program, or placement is a part of any ADHD treatment plan. AAP also recommends teacher-administered behavior therapy as a treatment for school-aged children with ADHD. You can talk to your child's healthcare provider and teachers about working together to support your child.

Special Education Services and Accommodations

Most children with ADHD receive some school services, such as special education services and accommodations. There are two laws that govern special services and accommodations for children with disabilities:

The Individuals with Disabilities Education Act (IDEA)

Section 504 of the Rehabilitation Act of 1973

The support a child with ADHD receives at school will depend on if they meet the eligibility requirements for one of two federal plans funded by IDEA and Section 504: an individualized education program (IEP) or a 504 Plan.

What are the main differences between the two Plans?

IEPs provide individualized special education services to meet the unique needs of the child.

A 504 Plan provides services and changes to the learning environment to meet the needs of the child as adequately as other students.
Learn more about IEP and 504 Plans [PDF - 2.75 MB]
Accommodations

IEP and 504 Plans can offer accommodations for students to help them manage their ADHD, including:

Extra time on tests;

Instruction and assignments tailored to the child;

Positive reinforcement and feedback;

Using technology to assist with tasks;

Allowing breaks or time to move around;

Changes to the environment to limit distraction; and

Extra help with staying organized.

There is limited information about which types of accommodations are effective for children with ADHD. However, there is evidence that setting clear expectations, providing immediate positive feedback, and communicating daily with parents through a daily report card can help.

What Teachers Can Do To Help

For teachers, helping children manage their ADHD symptoms can present a challenge. Most children with ADHD are not enrolled in special education classes, but do need extra assistance on a daily basis. The National Resource Center on ADHD provides information for teachers from experts on how to help students with ADHD.

Here are some tips for classroom success.

Communication

Give frequent feedback and attention to positive behavior;

Be sensitive to the influence of ADHD on emotions, such as self-esteem issues or difficulty regulating feelings;

Provide extra warnings before transitions and changes in routines; and

Understand that children with ADHD may become deeply absorbed in activities that interest them (hyper-focus) and may need extra assistance shifting their attention.

Assignments and Tasks

Make assignments clear-check with the student to see if they understand what they need to do;

Provide choices to show mastery (for example, let the student choose among written essay, oral report, online quiz, or hands-on project;

Make sure assignments are not long and repetitive. Shorter assignments that provide a little challenge without being too hard may work well;

Allow breaks-for children with ADHD, paying attention takes extra effort and can be very tiring;

Allow time to move and exercise;

Minimize distractions in the classroom; and

Use organizational tools, such as a homework folder, to limit the number of things the child has to track.

Develop a Plan That Fits the Child

Observe and talk with the student about what helps or distracts them (for example, fidget tools, limiting eye contact when listening, background music, or moving while learning can be beneficial or distracting depending on the child);

Communicate with parents on a regular basis; and

Involve the school counselor or psychologist.

Close collaboration between the school, parents, and healthcare providers will help ensure the child gets the right support.

Parent Education and Support

CDC funds the National Resource Center on ADHD (NRC), a program of Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD). The NRC provides resources, information, and advice for parents on how to help their child. Learn more about their services.

How to best advocate for your child

Understand your child's diagnosis, how it impacts their education, and what can be done at home to help.

Understand your child's IEP. If you have questions, don't be afraid to ask.

Speak with your child's teacher.

When possible, obtain written documentation from teachers, administrators, or other professionals working with your child.

Know your rights.

Play an active role in preparing your child's IEP or 504 Plan.

Keep careful records, including written documentation, communication between home and school, progress reports, and evaluations.

Try to maintain a good working relationship with the school while being a strong advocate for your child.

Communicate any concerns you may have about your child's progress or IEP or 504 Plan.

Encourage your child every day, and work with your child to create a system to help with homework and other school projects.

What every parent should know

More Information

Reference

1. Evans S, Owens J, Bunford N. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology 2014;43(4):527-551 [Read overview]

2. DuPaul GJ, Chronis-Tuscano A, Danielson ML, Visser SN. Predictors of receipt of school services in a national sample of youth with ADHD. Journal of Attention Disorders Published online December 10, 2018. [Read summary]

3. Harrison JR, Bunford N, Evans SW, Owens JS. Educational accommodations for students with behavioral challenges: A systematic review of the literature. Review of Educational Research 2013;83(4):551-97.

4. Moore DA, Russell AE, Matthews J, Ford TJ, Rogers M, Ukoumunne OC, et al. School-based interventions for attention-deficit/hyperactivity disorder: A systematic review with multiple synthesis methods. Review of Education. Published online October 18, 2018.

5. https://chadd.org/for-parents/individuals-with-disabilities-education-act/

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To meet the needs of children with ADHD, schools may offer ADHD treatments, special education services, or accommodations to lessen the effect of ADHD on their learning.

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Child Mind Institute resources for families

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Child Mind Institute resources for families

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Concerned about a child, but not sure where to start? Check off the issues you're noticing (you can choose as many as you want) and we'll show you a list of related resources.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares.

Schizophrenia is a mental health condition that can cause teenagers and young adults to lose touch with reality. They see, hear or believe things that aren't real or true. This is called psychosis. People with schizophrenia think and act in ways that don't make sense to other people. Many people with schizophrenia think that someone or something is reading their mind or trying to hurt them. These false beliefs are called paranoid delusions. Some also see things that aren't there, which are called hallucinations.

Schizophrenia is very rare in young children, but they can show some early signs. It is more often diagnosed in teenagers and young adults.

What are the symptoms of schizophrenia?

Kids with schizophrenia have strange thoughts and behaviors. Some signs include:

Ideas that don't make sense

Believing things that aren't true

Seeing, hearing or feeling things that aren't there

Seeming distracted

Speaking in ways that other people can't understand

Thinking that others want to hurt them

Hearing voices that tell them what to do

Thinking strangers know them or are talking about them

Believing that TV shows are sending them special messages

Trouble with regular tasks, such as eating, bathing and going to school

Withdrawing from friends and family

Not showing a lot of feelings

Moving around way too much or way too little

How is schizophrenia diagnosed?

Before diagnosing schizophrenia, a mental health professional will rule out other possible causes of the strange thoughts and behavior. This includes drug or alcohol abuse, medical issues and other mental health problems. Kids are only diagnosed with schizophrenia if they have had symptoms for at least six months. The symptoms also have to interfere with their regular lives.

It can be hard to tell schizophrenia apart from other mental health disorders. Sometimes, kids with schizophrenia are incorrectly diagnosed with conduct disorder because their delusions make them behave aggressively. It's important to get a thorough assessment that looks closely at the child's physical and mental health, as well as their family history.

What are the risk factors for schizophrenia?

Children are more likely to have schizophrenia if someone in their family has it or if there were problems during pregnancy or at birth. However, most children with these risk factors don't have schizophrenia.

How is schizophrenia treated?

Schizophrenia is usually treated with therapy and medication.

The recommended treatment is a special program called Coordinated Specialty Care. This should be done in the first two or three years after the child shows signs of schizophrenia. It can decrease symptoms in the future by a lot and help with many of the problems linked to this illness.

Coordinated Specialty Care teaches kids how to deal with their symptoms. It also helps them build a group of people who can help them. The treatment includes:

Low doses of antipsychotic medication

Cognitive behavioral therapy for psychosis (CBTp)

Family education and support

Learning skills for school and work

Children with schizophrenia are at risk of developing other disorders, including:

Obsessive-compulsive disorder (OCD)

Depression

Panic disorder

Post-traumatic stress disorder (PTSD)

Problems with drugs or alcohol, which can make symptoms of schizophrenia worse

We have over 60 guides and 700 articles available to help you (in Spanish too!).
Subscribe and get a curated selection weekly.

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Quick Guide to Schizophrenia - Child Mind Institute

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Schizophrenia is a mental health condition that can cause teenagers and young adults to lose touch with reality. They see, hear or believe things that aren't real or true.

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We can all help prevent suicide. The 988 Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States.

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The 988 Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week in the United States. We're committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness.

About The Lifeline

Anyone could be struggling with suicide. Find more specific resources below.

I'm Struggling With Individuals with Neurodivergence

We understand that every struggle is different. Experience the stories of people like you, and how they overcame crisis to find hope and recovery.
read stories of hope & recovery

First, you'll hear an automated message featuring additional options while your call is routed to your local 988 Lifeline network crisis center.

We'll play you a little music while we connect you to a skilled, trained crisis worker.

A trained crisis worker at your local center will answer the phone.

This person will listen to you, understand how your problem is affecting you, provide support, and get you the help you need.

988 Lifeline Center calls are free and confidential, and we're available 24/7.

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Skip to main content We can all help prevent suicide. The 988 Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States. 988 ¡Los servicios de texto y chat de 988 Lifeline ya están disponibles en español!

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Texas Model for Professional Guidance Counseling

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Texas Model for Professional Guidance Counseling

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How to help students with Oppositional Defiant Disorder

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How to help students with Oppositional Defiant Disorder

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Offering kids choices, safe spaces, and positive reinforcement can help teachers avoid problems-or manage them when they arise.

Elliott Golden / The iSpot

Most children will, at times, argue and test limits. Yet some kids are defiant and hostile to a degree that interferes with their daily lives-behavior that's sometimes diagnosed as Oppositional Defiant Disorder, or ODD, according to a story by WeAreTeachers.

"Students with ODD disrupt their own lives and often the lives of everyone nearby," write the report's authors. "[They] push the limits of defiance far beyond reason. Their problem behavior is much more extreme than that of their peers, and it happens much more often."

According to the American Academy of Child & Adolescent Psychiatry, kids with ODD exhibit "an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the child's day-to-day functioning," for six months or more. Symptoms like frequent temper tantrums, excessive arguing with adults, and mean and hateful speech when upset, are usually seen across multiple settings, but especially at home or school. While a direct cause remains unclear, "biological, psychological, and social factors may have a role," the academy notes. Up to 16 percent of children may have the disorder, and children with ADHD are especially prone.

Though a teacher's first reaction to ODD might be to react defensively, this can backfire and create a power struggle with the student, say experts. Instead, teachers who've worked with students with ODD recommend a set of strategies that will address challenging behavior, and help you start building relationships with hard-to-reach students.

"We all have the capacity to learn, change, and grow," writes special education teacher Nina Parrish. "When given the right tools and environment, students with problematic behavior can learn more productive strategies that will help them have positive and effective interactions with others."

1. Be Calm and Consistent: As a new teacher, Parrish says she quickly learned that reacting with anger when her students with ODD acted out made the behavior worse and students became "amused or encouraged by upsetting an adult." Instead, Parrish recommends trying to keep a positive tone to your voice, adopting neutral body language, and being "cautious about approaching the student or entering their personal space as this might escalate the situation."

Consistency with words and actions is also important when working with kids with ODD. Teacher Brandy T. tells WeAreTeachers she routinely uses the same set of "trigger words" so her students know she's serious. When students in her class begin to argue with her, "I simply say either, 'not now,' 'later,' or 'fix the issue.'" When her students hear 'fix the issue,' for example, she says that's the signal to "go to their chill-out space if they need to calm down."

2. Reinforce Positive Behavior: For all kids, but especially children with ODD, it's important to "switch your focus from recognizing negative behavior to seeking out demonstrations of positive behavior," writes Parrish. She sends home positive notes when students show behavior improvements, even if they're small gains.

Additionally, consider offering students the opportunity to earn certain privileges, suggests WeAreTeachers, rather than "taking those privileges away as punishment." For example, give kids the opportunity to earn rewards-like a bit of iPad time or lunch with a teacher.

3. Find Out What's Going On: Behaviors, notes Parrish, help students "obtain something desirable, or escape something undesirable." She suggests thinking about behavior as feedback, or a way of communicating, an approach that's "helped me work more effectively as a teacher with students who display problem behaviors." Figuring out factors that contribute to students with ODD acting out can help you develop a plan for addressing their difficult behaviors in the classroom.

Sometimes, it's a matter of picking up on a student's signals that their emotions are building long before things reach a breaking point. When students who've experienced trauma are beginning to feel upset, they often show physical signs of their mounting distress: balling up fists, withdrawing from classroom interaction, or clenching their jaw, writes Micere Keels, an associate professor at the University of Chicago and a trauma-informed educator.

"Many educators tend to ignore students' increasing signs of agitation, hoping they'll eventually calm down. But when disregarded, these minor behaviors can quickly escalate," writes Keels, who also recommends identifying students' triggers, like touch or emotionally difficult anniversaries, to avoid situations entirely.

4. Create a Safe Reset Space: Kids with ODD "can learn to recognize when they're feeling overwhelmed and getting ready to challenge or defy," according to WeAreTeachers. "Giving them a safe space to calm down and rethink their choices can be beneficial."

At Fall-Hamilton Elementary, a trauma-informed school in Nashville, Tennessee, for example, every classroom has a nook-called a peace corner-with a comfortable seat, a timer, and items like stuffed animals, sensory squeeze toys, and simple drawing and writing supplies. It's a spot where kids can take a break and reset. The school also recognizes that teachers may need a time out too. Using a strategy called Tap-in/Tap-Out, teachers can ask a colleague via text message to briefly cover their class if they are about to lose their cool.

"A dysregulated adult cannot regulate a dysregulated child," says school principal Mathew Portell. "Use strategies that honor the student's emotions and need for space while also getting their systems to calm in a safe way."

5. Offer Choices: It's important to "affirm your students' autonomy by giving them choices," writes Keels, about best practices for de-escalation. When kids feel respected, "their sense of belonging and mood will often improve."

She recommends avoiding ultimatums like "You better sit back down or I'll send you to the office." Instead, clearly communicate expectations and limits so kids understand. You might say, "I see you're upset, but it's not OK to yell at me. You can either go get a drink of water and come back in five minutes, or sit in the reading chair and I will check in with you in five minutes," says Keels.

In the heat of the moment, it's important to avoid an argument, teacher Holli A. tells WeAreTeachers. "State your choices, then walk away," she says. "Give the student time to process and decide which choice to make. If they don't like the choices, don't engage. When they try to argue, repeat the choices, and walk away again. If the student still will not choose, they do not get to participate in their preferred activity."

6. Build Connections: Often, kids with ODD "are looking for a relationship with a teacher who can help them deal with problems on their own, instead of making them stand out in a negative way," according to WeAreTeachers. "Building a connection with them will help get to the root of the behavior."

Though teachers can feel the need to create boundaries with students, simply talking with them informally can build invaluable connections that influence their behavior in the classroom, says middle school math teacher Cicely Woodard.

Woodard says she intentionally makes herself approachable to students and tries to learn interesting details about them. "Some of my students tell me stories about their lives during the five minutes between classes," Woodard says. "I stop what I am doing, look them in the eyes, and listen."

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Offering kids choices, safe spaces, and positive reinforcement can help teachers avoid problems-or manage them when they arise.

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Anxiety Disorders: Diagnosis and Treatment

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Anxiety Disorders: Diagnosis and Treatment

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Anxiety, Depression, OCD, and substance abuse in television

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Anxiety, Depression, OCD, and substance abuse in television

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HBO’s “Euphoria” on Teen Drug Use and Mental Health | Turnbridge

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The new HBO series, “Euphoria” touches on difficult topics like mental health, addiction, overdose, and sex – common experiences among teens today. Learn more.