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Navigating a Mental Health Crisis (Photo)

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Navigating a Mental Health Crisis (Photo)

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National Alliance on Mental Illness. (n.d.). Navigation a mental health crisis. https://www.nami.org/Support-Education/Publications-Reports/Guides/Navigating-a-Mental-Health-Crisis

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What Teachers Should Know

It's normal for students to feel sad, angry, or moody at times. But when a sad or bad mood lasts for weeks, months, or even longer - and when it affects a student's ability to do well in school and with peers - it might be depression.

Depression is not uncommon among students. But it can go unrecognized or undiagnosed. Many students with depression don't receive the care they need.

Depression can get better with the right treatment and support. Mental health professionals treat depression with therapy, medication, or both. Effective early treatment can reduce the risk of future episodes of depression.

Teachers can help by knowing the signs of depression, taking steps to guide students toward the help they need, and by being a source of support and encouragement.

Teachers should know the signs that could mean a student is depressed. Students with depression may:

seem sad or irritable more often than not

seem tired, lack energy, give up easily

put little effort into schoolwork

have trouble concentrating in class

fail to turn in work, get lower grades

seem not to enjoy things

withdraw from friends or activities

miss school days, or be frequently late

Some students with depression may:

have experienced trauma or adverse life events

have other mental health issues, such as anxiety

engage in risky or self-harming behaviors (for example, be reckless or turn to alcohol, drugs, or self-injury)

talk about death or suicide

Teachers should know student behaviors that can be warning signs for suicide, including:

talking about suicide or death

hinting that they might not be around anymore

writing songs, poems, or letters about death

giving away treasured possessions

losing interest in school, classmates, sports, or other activities

engaging in risky behaviors

Teachers should be aware of suicide prevention methods, and follow their school's protocol for how to:

notify parents if a student appears suicidal

get help for a student at risk of suicide

supervise an at-risk student

work with the school's crisis team to set up a support system at school and at home

Students with depression may need:

treatment from mental health professionals

emotional support from a school counselor or school psychologist

a 504 plan for accommodations at school

short breaks throughout the day to avoid feeling overwhelmed

extra time or extra help to complete assignments

to take medication

treatment for other mental health issues or healing for trauma they've faced

What Teachers Can Do

Offer support and encouragement. Help students with depression feel welcome and included. Let them know you're available to help. Encourage their strengths and their interests. Look for opportunities for them to succeed in the classroom. Let them know you see their efforts - even the small steps.

Give extra time to complete assignments. Offer extra help. Consider having students work with a supportive peer to work on assignments or to study for tests.

Make physical activities a part of your daily classroom routine. This can help ease mild depression symptoms. It can energize all of your other students, too.

Make brief mindfulness practices a part of everyday instruction. At random or scheduled times, invite your class, "Let's all pause and take a few slow, calm breaths." This helps students learn and practice this simple but effective self-calming skill.

Use trauma-informed education approaches. Create and maintain an environment where every student can feel a sense of safety and inclusion. This helps every student thrive.

Date reviewed: April 2022

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What teachers should know about depression and how to help a student who is depressed.

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Depression, Anxiety, and Stress of School Aged Children

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Depression, Anxiety, and Stress of School Aged Children

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Abstract

BACKGROUND:

The depression, anxiety, and stress is a major educational problem among students all around the world. The purposes of this study were to determine the depression, anxiety, and stress among the high school adolescent children in public and private schools in Rangareddy district, Telangana state.

MATERIALS AND METHODS:

The present study was a cross-sectional study. The study sample considered 120 children from private schools and 259 children from public schools were studied. The study tool used was a questionnaire containing DASS (Depression, Anxiety, and Stress scale and sociodemographic characteristics. The data were expressed as proportion and mean values (Analysis of variance, independed t-test, and Pearson correlation) spatially tests were used at a significance level of P < 0.05).

RESULTS:

The overall prevalence of depression in children from the public school was found to be only 5%, that of anxiety was 20.8%, and that of stress was 15.8%; the overall prevalence of depression in children from private schools was found to be 1.9%, that of anxiety was 20.5%, and that of stress was 20.1%.

CONCLUSION:

In both schools, anxiety and atress were found to be more among study participants. Depression was observed to be less. But if they have more anxiety and stress and if not taken proper care at this point of time, it might get converted into a state of Depression.

Keywords: Anxiety, comparative study, depression, high schoolchildren, stress

Introduction

Adolescents and young adolescents' academic stress emerge as a significant mental problem in recent years. Depression is a common psychiatric disorder that presents with depressed mood, loss of interest or pleasure, felling of guilt or low-self -worth, disturbed sleep or appetite, low energy and poor concentration.[ 1] Anxiety is defined as an emotional reaction or state of stress that occurs before examinations and continues through the examination period.[ 2] Stress is the nonspecific response of the body to any demand. Stress is the most often as an over physical reaction or defensive outbursts, rocking and self-comforting behaviors, headache, and stomach ache, nervous fine motor behaviors. [Hair twirling or pulling, chewing and sucking biting of skin and finger nails, toileting accidents and sleep disturbances].[ 3] The symptoms of these three disorders can lead to poor academic performance, low mood, interest is lost of communication with friends and family members, substances abuse, feeling of abandonment, homicidal ideation, and suicidal tendency sadness feeling.[ 4, 5, 6]

The prevalence rates of anxiety disorders in community samples, based on clinical interviews (child and parent interviews respectively) vary between 21% and 29%, 10.5% and 16.5%, 9.7% and 10.8%, and 3.9% and 9.9%[ 7]

In epidemiological studies, the sex ratio is approximately 2/3 females endorsed significantly high levels of anxiety than males from Grade 1 through 12 and in college.

Scant literature is available on the prevalence of depression, anxiety, and stress in adolescents studying 8 th, 9 th, and 10 th class, and none were available for Rangareddy district.

Hence, the present study was carried to assess depression, anxiety, and stress among schoolgoing children in public and private schools and to impact health education to improve their mental disorders.

Materials and Methods

A cross-sectional study Questionnaire study was conducted among higher secondary schoolchildren in Rangareddy district, Telangana state, India, for a period of 3 months from December 2018 to February 2019. A total of 120 children from private schools and 259 children from public schools were studied. A quasi-experimental design was adopted for the present study.

Study participants and criteria

Students were selected randomly from grades VI to XII of the total sample, there were 180 boys and 199 females participated in this study. All government and private schools present in Rangareddy district, students studying in 8 th, 9 th, and 10 th of both genders, no history of psychological problems, and use of psychiatric drugs were included in the study. These students who did not give consent and the students who were absent for class on the day of data collecting were excluded from this study.

Sampling technique

The sampling procedure involved multistage sampling procedure was used for the sampling selection, where the Rangareddy district was divided into three groups, namely government senior secondary schools, government-aided senior secondary schools, and private senior secondary schools. Then from each stratum, 2 were selected randomly by lottery method.

Eligible children were selected randomly from a list obtained from school records. Age eligibility requires that the children fall into the appropriate age at the children sampling.

Sample size determination

Expected proportion = 0.5594 (55.94% prevalence), precision (%) = 5, desired confidence level (%) = 95, sample size ( n) = 379 should be taken with 5% alpha error,

Where Z = standard normal variate value ( Z = 1.96 at 5% error).

P = proportion (or) % of interest = 55.94%, q = proportion (or) % of interest = 55.94%, q = (1 − p) or 100- p (alternation proportion) = 100-55.94, d = clinically acceptable error = 5%.

Data collection instrument

The data were collected using a self-administered structured questionnaire. The questionnaire consists of three components that included socio-demographic profile like age, gender, class, parents, education was collected. The socioeconomic data include parental martial status, total family income per month. A previously validated and standardized survey instrument DASS (Depression, Anxiety, Stress Scale)-42 was used. Each one has different questions and some score is given for each question. There were 11 questions on depression, 12 for anxiety, and 19 stress.[ 8]

The score is given as 0 - never, 1 - some times, 2 - often, and 3 - always.

Data were collected for a period of 7 days. Four days in private and 3 days in public schools before the start of the study we took permission from principals of both the schools. We explained to the study participants about the purpose of study. Informed assent was obtained from every participant and informed consent was obtained from parents and schools teachers. They were assured about confidentially regarding the sensitive questionnaire. One-to-one interview was taken using a questionnaire. They were interviewed by interacting in English or any other comfortable language they wish. The response was marked in the questionnaire given.

Ethical consideration

The ethical clearance was obtained from the Ethical committee at the dental college and hospital. The official permission was obtained from the D.E.O Rangareddy district, Government of Telangana state.

Results

The acquired data were tabulated and subjected to statistical analysis. Descriptive statistics were explained by frequency, mean, and standard deviation. The measures of dispersion were analyzed using a t-test at a level of significance of 5% ( P < 0.05).

Table 1 shows that in public schools, the female proportion was more compared to males 58.3% versus 42%, respectively, while in private schools, both sexes were equally distributed. The reason for more girls in the public school shows the male predominance in the society. Parents wants their boys to study in private schools and girls are neglected so they are given the option of public schools. In public schools, majority of the children were in tenth class, while in private schools, majority were in the ninth class at the time of the study.

Table 1

Variable

Public school (%)

Private school (%)

Total (%)

Table 2 shows that the overall prevalence of depression in the children from the public schools was found to be only 5%, that of anxiety was 20.8%, and that of stress was 15.8%; the overall prevalence of depression in children from private schools was found to be 1.9%, that of anxiety was 20.5%, and that of stress was 20.1%.

Table 2

Grade

Public school (%)

Private school (%)

Depression

Anxiety

Stress

Depression

Anxiety

Stress

Table 3 shows that 19% restored TV watching, 8.4% used Internet, 17.4% reported playing, 13% engaged themselves in music, 37% spent time with friends, and 6% said they were busy with some or the other hobbies to cope with the depression, anxiety, and stress.

Table 3

Coping mechanism

Public school (%)

Private school (%)

Total (%)

Table 4 shows that the mean score of depression and anxiety was found to be similar in children from public and private schools. However, the stress score was significantly higher in children from public schools, i.e., 21.6% compared to children from private schools, i.e., 16.9 ( P < 0.05).

Table 4

Variable

Type of school

n

Mean±2SD

t

P

Discussion

The present study observed that the prevalence of depression and anxiety was slightly more in children from public schools compared to children from private schools, i.e., 5% and 21% versus 2% and 20%, respectively. However, the prevalence of stress was more in children from private schools, i.e., 20% compared to children from public schools, i.e., 16%.

Singh et al.[ 9] conducted a study on prevalence and factors associated with depression among schoolgoing adolescents in Chandigarh, North India. The proportion of students with depression was more in government schools compared to private schools in this study. This difference can be explained by the socio-economic difference between the students of two types of schools.

Vadageri[ 10] conducted a study on the knowledge and awareness about mental health among adolescents. A comparative study of government and private schools adolescents of Kalaburagi city. It shows that government schools' respondents are more known to the mental illness but having lay mean perspectives, whereas private schools' respondents are more toward scientific relevant knowledge about mental illness.

Sandal[ 11] conducted a study on the prevalence of depression, anxiety, and stress among schoolgoing adolescents in Chandigarh, North India. Extremely severe depression was very less. The prevalence of DASS was very higher in females for depression and anxiety, the peak age was 18 years.

Chauhan et al.[ 12] in their study conducted in the public schools of Noida in 2014 found that the prevalence of depression was 38% which is very high compared to the what we found, i.e., 5% only in the children from the public schools. This might be related to the fact that Noida is very near to Delhi, and hence, people are more aware of the tough competition.

Bansal et al.[ 13] while conducting a study in public schools reported a prevalence of depression of 18.4%. This is still high when compared to the present study where we observed that the prevalence of depression was 5% among children who hailed from public schools and still lower, i.e., only 2% among children who hailed from private schools.

Deb S et al.[ 14] conducted a study on the prevalence of anxiety among schoolchildren from Kolkata among private schools in 2015. They found a very high prevalence of anxiety, i.e., 63.5%, while we observed that the prevalence of anxiety was only 20% among the children who were studying in the private schools. Again, the reasons for these differences may be due to differences in the geographical areas and the study questionnaire used. Hence, it seems that children from either public schools or private schools but from metro areas are under more stress compared to children from nonmetro areas or from villages.

Mohanraj and Subbaiah[ 15] conducted a study with the objective to study the prevalence of depression among private schoolchildren. They noted that the prevalence of depression among schoolchildren from private schools was 57% in 2010. This was very high compared to the present study findings where we found that the prevalence of depression among children from private schools was only 2%.

Several Indian studies conducted on adolescents have found a prevalence of depression ranging from 10% to 27%, which is much higher than our findings which can be attributed to different instruments used for measurements and different time duration.[ 16, 17, 18]

Limitations and recommendation

A larger sample size over a larger geographical area would have been desirable; one of the limitations of this study was the lack of use of various data collections tools along with self-assessment questionnaire. Since this was a school-based study, we do not know the effect of excluding nonschoolgoing children. As the data were self-reported, under- or overreporting of data may have taken place due to stigma related to mental disorders.

More over, further studies are recommended to find out the factors leading to these mental disorders. There is a need for greater attention to the psychological well being of students to improve their quality of life.

Conclusion

In both the schools, anxiety and stress were found to be more among study participants. Depression was observed to be less. But if they have more anxiety and stress and if not taken proper care at this point of time, it might get converted into a state of depression. Most of the students in private school said they are anxious and stressed out because of exam fear as well as parents' pressure. Hence, teachers and parents should be educated not to put pressure on their children. They should also be told about the consequences of depression, anxiety, and stress on their children's life.

Ethical statement

Permission from the office of the director public instructions, Hyderabad, for understanding the study in selected schools was obtained. The approval and consent for this study was obtained from the Institutional Review Board. We haven taken written permission for this study from the principals of selected schools explaining them aim and objectives of the study. In case of minor participants, consent was obtained from their parents and the students. Verbal consent was obtained from each participant. There is no conflict with ethical considerations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The authors would like to thank the research department of pedodontics and preventive dentistry and hospital.

References

1. World Health Organization.W.H.O Definition of health. Geneva: WHO; 2013. [ Google Scholar]

8. Lovin Bond SH, Lovinbond PF. Mannual for Depression, Anxiety, Stress Scales. 2nd ed. Sydney: Pychology Foundation of Ausstrallia; 1995. [ Google Scholar]

Articles from Journal of Education and Health Promotion are provided here courtesy of Wolters Kluwer -- Medknow Publications

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The prevalence of depression, anxiety, and stress among high school adolescent's children in public and private schools in Rangareddy district Telangana state: A cross-sectional study

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The depression, anxiety, and stress is a major educational problem among students all around the world. The purposes of this study were to determine the depression, anxiety, and stress among the high school adolescent children in public and private schools ...

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How School Counselors Can Help Students with Depression

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How School Counselors Can Help Students with Depression

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When U.S. Surgeon General Vivek H. Murthy issued a public health advisory this month on protecting youth mental health, he brought attention to the widespread challenges facing today's young people. But he also emphasized that these challenges are surmountable - and often preventable.

One of his recommendations, as part of what he calls a "whole-of-society" effort to mitigate the pandemic's corrosive effects on mental health, is to support students' mental health in schools.

What kind of support systems do students have there? What can parents rely on school counselors to handle, and when does an issue become something that requires extra assistance? Debra Duardo, the superintendent of schools for Los Angeles County; Loretta Whitson, executive director of the California Assn. of School Counselors; and staff from the Santa Ana Unified School District explain.

How does it all work?

Schools have a combination of counselors, social workers, psychologists and nurses who work together as a mental health team on campus, Duardo said.

The team's No. 1 priority is making sure students can learn. This includes identifying and removing (or at least reducing) any barriers that are preventing a child from receiving or absorbing instruction.

But it's important to understand that all school employees are trained in how to identify distress in children, Duardo said.

"Because sometimes children won't go to a counselor," she said. "Maybe the first person they're going to talk to is their teacher or custodian, someone else that they connect with."

If a parent is concerned, Duardo recommends talking to the teacher first. "They spend so much time with the children in their classroom that they can see when something is off and a child is behaving differently than they typically do."

The teacher will know what resources are available at the school and be able to refer parents to the appropriate person.

Here are the main roles on campus

Duties may vary - and blur together - depending on the school and district. Middle and high schools tend to have more support than elementary schools, but that gap is narrowing.
School counselors
There are many different types of school counselors.

Some are academic or college counselors who help students set up classes and plan for the future. There are also attendance counselors, who try to figure out why some kids aren't showing up in school. And there are counselors who are more clinically oriented. They may work in campus wellness centers and give short-term care to students struggling with depression, anxiety or other mental health challenges.

Counselors can also provide support for parents and caretakers. Sometimes a parent needs advice on how to deal with a kid who refuses to attend school. Sometimes students need help communicating something that they're scared to tell their parents - for example, if a student is pregnant or HIV-positive.

"You can't help a child without addressing the parent," Duardo said.
School psychologists
Though one might assume psychologists are the ones providing therapy at schools - and they can be - school psychologists are usually the ones working with students with special needs. They help special education teachers develop individualized education plans and monitor progress.
School social workers
The role of school social workers can vary as well. They are trained in counseling and crisis intervention. They could also be working to help with a child's living situation, assisting kids with disabilities or developing trauma-informed programs.
School nurses
Though nurses deal with physical ailments, these symptoms can often be tied to mental health. If children are getting sick because they aren't sleeping enough or eating enough, this could be a sign of a mental health issue.

The goal is for all these providers to collaborate and understand the fuller picture of what a child's struggles are. Then they can pass the baton - what schools call "warm handoffs" - to the appropriate person at each stage of a student's need.

According to Sonia Llamas, assistant superintendent at Santa Ana Unified School District, that process starts with the early identification of the problem and continues to intervention and coordination of care and services. And if a student requires hospitalization, the school needs to provide support to help the child's transition back to campus.
What are the limitations of school-based mental health systems?
School counselors have extremely high caseloads. Though the American School Counselor Assn. recommends a ratio of 250 students per counselor, the national average for the 2019-20 school year was 424 students per counselor. California had a ratio of 601 to 1.

When school counselors have such a high caseload, they're forced to try to identify students' issues very quickly so they can figure which cases they need to prioritize, Duardo said.

Many schools use a framework called Multi-Tiered System of Supports. There are three tiers that correspond to different levels of student need. The majority of kids are in Tier 1, which focuses on prevention. Tier 2 is for kids who require early intervention, which can come in the form of group sessions. And Tier 3 is for kids who need individualized care.

For the most part, schools provide short-term counseling, and if students need extra support, schools refer them to an agency or work with the parents to see what kind of therapy or other assistance is covered by their insurance. Care Solace, for example, works with 300 school districts to help connect families with mental health providers.
What are some of the goals moving forward?
Schools have been working over the years to offer more assistance to students and caregivers who reach out for help. But they're also trying to do more to head off problems by integrating social and emotional learning lessons into the classroom. This includes teaching kids such fundamental skills as how to make friends, encouraging them to talk about their feelings and showing them the importance of being resilient.

Referring to the pandemic's numerous disruptions, Whitson said: "Kids have been thrown a real hard curve here. What we're working on is trying to help them understand that this is not permanent. And help them cope with it."

One reason schools are advocating for more counselors is because it makes it easier to be proactive in tackling the youth mental health crisis.

Just this year, the Santa And Unified School District successfully met the nationally recommended ratio of 250 students per counselor. This has made a world of difference in counselors being able to build trust with students, said Rebecca Pianta, the district's coordinator of college and career readiness.

There is more time for one-on-one connection, and counselors can build relationships with students - with fun activities in the quad or surveys to learn what topics they are curious about - before they need assistance.

This is especially important in communities where there is stigma associated with asking for help, said Káty Castellanos, the district's director of college and career readiness. Their district serves a majority Latino population.

"Because the mentality is that if you have a problem at home, you don't talk about it, you don't discuss it with anybody," she said. "And if you go to a school counselor and social worker, you're 'crazy.' So we're trying to demystify that."

View the news story in the LA Times here.

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how counselors and other school staff can help students with their mental health - caresolace.org

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care solace is a mental health care coordination service for education systems on a mission.

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How counselors and other school staff can help students with their mental health - CareSolace.org

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When U.S. Surgeon General Vivek H. Murthy issued a public health advisory this month on protecting youth mental health, he brought attention to the widespread challenges facing today's young people. But he also emphasized that these challenges are surmountable - and often preventable.

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Quick Guide to Bipolar Disorder - Child Mind Institute

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Download our free guide bipolar disorder in kids. Kids with bipolar disorder have periods of time where they are extremely happy and energetic, called mania, and other periods where they are very depressed.

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Educating the Child with Bipolar Disorder

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Educating the Child with Bipolar Disorder

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Bipolar Disorder in Children: School Issues

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Even with treatment, symptoms of bipolar disorder can be difficult to manage and can make school challenging. Regular and honest communication with your child and his or her teachers, guidance counselors, coaches, and school administrators can be the most important way to help your child succeed. Education professionals...

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The School Counselor and Student Mental Health

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The School Counselor and Student Mental Health

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The School Counselor and Student Mental Health

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Students' unmet mental health needs can be a significant obstacle to student academic, career and social/emotional development and even compromise school safety. Even so, most students in need do not receive adequate mental health supports (Centers for Disease Control and Prevention [CDC], 2013).

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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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The adjective "schizophrenic" needs to be removed from counselors' vocabulary, says Elizabeth Prosek, a counselor and assistant professor at the University of North Texas (UNT).

Schizophrenia has a great deal of stigma and negative connotations associated with it, and referring to clients in the first person can lessen these, she says.

"I encourage counselors to advocate for what clients with schizophrenia can do rather than [focusing on] the limitations of experiencing psychosis," says Prosek, who has counseled clients with severe mental health disorders and served on a support team for individuals with schizophrenia living independently. "I once heard someone discuss the 'aggressive nature' of those diagnosed with schizophrenia. I could not help but wonder where that perception evolved. In my experience, clients did not demonstrate aggressive behavior or language."

Counselors, as part of a multidisciplinary treatment team of helping professionals, can play a critical role in the lives of people diagnosed with schizophrenia, say Prosek and Kara Hurt, a licensed professional counselor who works with clients with schizophrenia at an inpatient psychiatric hospital.

Prosek and Hurt, who is also a doctoral student at UNT, recently collaborated to write a practice brief on schizophrenia for the American Counseling Association's Center for Counseling Practice, Policy and Research (see sidebar below).

In the brief, the duo describes schizophrenia as a lifelong illness characterized by negative symptoms, including "delusions, hallucinations (most commonly auditory), disorganized thinking or speech and disorganized or abnormal motor behavior." The estimated prevalence rate for schizophrenia is 1 percent of the population in Western, developed countries.

For counselors, empathy should play a big part in therapy - from knowing the many side effects of schizophrenia medications to fully understanding what it is like to live with hallucinations and psychosis, say Prosek and Hurt. Special training and workshops can help counselors understand the nuances of the disorder, as can materials from mental health agencies (see "for more information" below).

Prosek once attended a seminar at which participants sat through the experience - virtually - of living with hallucinations, experiencing paranoia and hearing voices intertwined with the dialogue of another person.

Prosek and Hurt led a course this past year in which they showed videos of clients with schizophrenia explaining their own experiences.

"When the students in the class debriefed after the video, many confirmed that hearing firsthand from a client decreased their misperceptions about the disorder," says Prosek. "Watching a video of a client with schizophrenia who was articulate and successful in a career reduced stigma of the disorder. Also, I noticed that when person-first language is used when discussing clients with schizophrenia [as opposed to using the term "schizophrenic"], negative connotations are immediately lessened."
What do counselors need to know about schizophrenia?
Elizabeth Prosek: Living with psychosis can be scary and challenging. When working with those diagnosed with schizophrenia, demonstrating empathic concern is essential to build a therapeutic relationship. In my experience, clients appreciated my willingness to embrace their perspective of psychosis. I think all of the clients I worked with experienced their psychosis uniquely, and it was imperative that I understood their lived experience.

Kara Hurt: Schizophrenia affects the client's support system, not just the client. In my experience, it is just as important to provide counseling and support to family members and loved ones of people diagnosed with schizophrenia as it is to provide support and counseling to clients with schizophrenia. All of us counselors can help provide services in some way that help clients diagnosed with schizophrenia and those that love them.

EP: Counselors may provide family members and friends with psychoeducation on the symptoms and treatment options for schizophrenia. Furthermore, counselors may assist family members and friends to build empathy for the experiences of those diagnosed with schizophrenia. There are support groups for family members through the National Alliance on Mental Illness (NAMI). Find a local NAMI support group through nami.org.

For those clients who do not have a familial support system, encouraging the development of a community support network may be essential for the social and emotional well-being of clients diagnosed with schizophrenia. Regardless of diagnosis, humans in general seek "belongingness" in their community, and those diagnosed with schizophrenia are no different.
What advice would you give about working with clients diagnosed with schizophrenia?
EP: Recognizing strengths can be a great first step to creating an appropriate treatment plan. Several of the clients I counseled had creative interests, such as art and music, and we developed interventions to promote participation in those activities.

Also, I recommend communication with all professionals working with the client. In my experience, collaborating with the client's psychiatrist and case manager allowed for a holistic approach when addressing current therapeutic needs. Having a multidisciplinary team also allows for clients to more easily transition in and out of inpatient psychiatric hospitalization when necessary. With the appropriate releases of information, all professionals involved can be aware of how the client's psychosis presented, any medication changes and any changes in treatment recommendations after an inpatient hospitalization stay.

It did not take long after beginning my work with clients diagnosed with schizophrenia for me to recognize the need for socialization. Several of my clients lived in isolation but longed for social relationships. In collaboration with case managers, I organized social outings for clients, which allowed for a more genuine community-living experience. There are several community resources for clients diagnosed with serious mental health disorders, such as supported-work programs. Having knowledge of such programs in the community will serve as great referral sources for clients diagnosed with schizophrenia.
With what other types of issues can clients diagnosed with schizophrenia present?
KH: One of the presenting issues that I had not expected when I started working with clients diagnosed with schizophrenia was substance abuse. One client in particular stands out in my mind because of the extent of his illicit drug use, which worsened his paranoia and other delusions. When working with clients with schizophrenia, you may need to reconsider your assumptions to appreciate that these clients have many of the same kinds of problems as other clients.

EP: I agree. Substance misuse was prevalent among the clients diagnosed with schizophrenia that I worked with as well. I also observed many secondary diagnoses, including anxiety and depression. I connect the anxiety and depressive symptoms back to the potential isolation clients experienced. Furthermore, it seems to me hearing voices and feeling out of touch from reality would lead to feelings of anxiety. Helping my clients accurately explain symptoms to their psychiatrists allowed for more precise medication prescriptions.
What are some common misperceptions about schizophrenia?
EP: One of the common misperceptions I hear frequently when describing a client with schizophrenia is the term "medication noncompliance." I advocate for this phrase to be removed from counselor language. From my observations, when clients did not take medications regularly or as prescribed, it was not with intentional noncompliance, but rather there was confusion when medication regimens became complex or changed with frequency. Moreover, several antipsychotic medications have uncomfortable side effects. On a bad day, when a client is not feeling well, he or she might not feel inclined to perpetuate the experience by taking medications that may worsen physical symptoms. In counseling sessions, taking time to hear clients' concerns or complaints about side effects may help clients feel validated in their experience.

What challenges do counselors face in this area?

EP: I think there may be a perception that clients with schizophrenia only need a case manager and psychiatrist. From my perspective, counselors can play a vital role in the treatment team. Never underestimate the power of a space in which a client's experience is heard and valued.

KH: I think it is absolutely critical to have good supervision when working with a client diagnosed with schizophrenia. I have felt frustrated with my perceptions of clients' lack of progress or insight, but with supportive supervision, I have been able to be more flexible with my therapeutic expectations and shift my perspective to be a better counselor for my clients. I cannot underestimate the value of good supervision. It can help you gain awareness of potential burnout and the need for regular self-care.

EP: Supervision is helpful. I often felt frustrated with the mental health care system and how clients with schizophrenia became victims of gaps in continuity of care. I agree with Kara that there is a greater potential for burnout when working with clients in and out of crisis.

Another challenge for counselors might be understanding the differences in antipsychotic medications most commonly prescribed for clients with schizophrenia. Actually, Kara introduced me to an app (named Epocrates) that provides names, descriptions and side effects for medications. I remember when I first started working with this population, I had a hard time differentiating the medications the clients were prescribed. There are several research studies published outlining effectiveness and common side effects of antipsychotic medications which may be helpful to read.

Going back to one of Kara's original statements about the importance of family supports, it may be challenging to help family understand the experience of schizophrenia. Counselors can serve as a good source of information to help educate and support family members. Consequently, family members can better support the client diagnosed with schizophrenia.

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For more information
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ACA Center for Counseling Practice, Policy and Research practice briefs
Prosek and Hurt's information sheet on schizophrenia is one of 30 practice briefs available to American Counseling Association members through the Center for Counseling Practice, Policy and Research.

The briefs, which range from working with victims of domestic violence to animal-assisted therapy to posttraumatic stress disorder, are written by ACA members who are experts on that particular topic. New practice briefs are being added regularly.

The practice briefs are designed to be practical, evidence-based resources for ACA members, says Victoria Kress, executive editor of the ACA center's practice briefs project and a professor at Youngstown State University in Ohio.

Counselors can use the practice briefs as a refresher on topics they may not encounter very often, such as schizophrenia, or as a jumping-off point for further research. Each brief contains links to in-depth sources and data on a topic, as well as therapy models and other tools.

Kress says each practice brief is written and edited to be practical and succinct, with focused bursts of information on topics that counselors in all works settings may encounter, from divorce and autism to perfectionism and suicide prevention.

The plan is to post 15 to 20 new briefs each year, Kress says, including on each of the new disorders added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Kress began soliciting practice briefs from ACA members, then editing and posting the briefs on the ACA website, close to two years ago. The idea grew out of ACA past president Bradley Erford's focus on counselor use of evidence-based practices, Kress says.

"Counselors don't always have access to, or the time to read, journal articles," she says. "We wanted to provide an outlet for ACA members to sit down and get a quick overview. ... It was really born out of this idea that counselors should be using evidence-based practices. We know that counselors are busy and have competing demands. ... The ultimate idea is that it will improve their practice. It's better for their clients and the profession."

****

Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

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What counselors need to know about schizophrenia - Counseling Today

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The adjective "schizophrenic" needs to be removed from counselors' vocabulary, says Elizabeth Prosek, a counselor and assistant professor at the University of North Texas (UNT). Schizophrenia has a great deal of stigma and negative connotations associated with it, and referring to clients in the first person can lessen these, she says.

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In the mental health world, I am best known as a parent advocate for children with mental illness. But in my professional life as an instructor at an open-access community college, I've had multiple opportunities to connect students in mental health crisis with the right resources. In this article, I'll share some things I've learned about managing psychosis in the classroom and explain why it's so important for educators to know the signs and be ready to help. In fact, teachers at all levels are on the front lines of mental health care. Education, empathy and advocacy are critical to ensuring that your students are able to succeed in the classroom and beyond.

Education

Students with serious mental illness face special challenges in the academic environment. Not only can the illness impede their cognitive function, but they may also face the fear and stigma that too often accompany diagnoses like schizophrenia and bipolar disorder. While these illnesses are rare - schizophrenia occurs in just 1 percent of the population - the first serious symptoms often occur right at the age when students are leaving home for the first time and attending college. This is why it's so important for educators to learn about psychosis and how it can manifest in the classroom.

My school has instituted mental health awareness training for all faculty members, but not everyone is so fortunate. I recommend that all educators take a Mental Health First Aid Course. You'll learn how to recognize the signs of mental illness and explore effective strategies for connecting students with appropriate resources.

Some signs that educators can watch for include:

Social withdrawal and isolation.

Sudden decline in school performance.

Expression of extreme fear (perhaps refusing to attend class or other school functions).

Odd behaviors or statements.

Sudden preoccupation with a narrow topic.

Clear changes in personal hygiene.

Difficulty in attending class and completing assignments (Back to School, p. 9).

You may also want to participate in some form of psychosis simulation. If you have not experienced psychosis, it can be hard to imagine how frightening and disorienting this condition can be for a young person who is experiencing it for the first time. The Mental Health First Aid course includes a simulation exercise, and I have linked to some in the Resources section below.

Empathy

If you see one or more warning signs, don't be afraid to approach the student. Ask open-ended questions, and be willing to listen. When I notice that a student is behaving in an uncharacteristic way, I try to take the student aside and ask a few questions using a communication model developed by Dr. Xavier Amador, who has dedicated his professional life to helping caregivers to communicate with people in psychosis. His LEAP model is a good guideline for educators: Listen-Empathize-Agree-Partner.

Educators who can recognize symptoms and connect students with mental healthcare have a unique opportunity to promote better outcomes for their students. The RAISE project in the United States has focused on getting help to patients after the first episode of psychosis. Early intervention can be critical to long-term positive outcomes, and in fact, many people can and do live in recovery.

Some educators may wonder about the potential risks of working with students who experience psychosis. While it seems like our social media feeds are filled with stories of violence and mental illness, most people experiencing psychosis, especially in the early stages, are not violent toward others. The risk of self-harm, however, is much greater. I keep my office stocked with National Suicide Prevention Hotline cards, and I am never afraid to ask a student, "Are you thinking about hurting yourself?" and "Do you have a plan?"

Advocacy

Advocating for your students is critical to their - and your - success.

A few years ago, I worked at a small college where my duties included managing paperwork for students with documented disabilities. I have to confess that as a mother of a child (now in college) who lives with bipolar disorder, I was often frustrated by the reactions of a few instructors who felt that students were getting "special treatment."

Accommodations are not "special treatment." They are designed to level the field so that students with special needs can succeed along with their peers. A SAMHSA toolkit on inclusion for students experiencing psychosis notes the following: "As is true for many other disabilities, psychosis can lead to multiple additional challenges and obstacles for students, but with the right resources and supports these can almost always be addressed" ( Back to School, p. 13).

Over my teaching career, I have seen students successfully complete my courses while managing conditions that range from schizophrenia to bipolar disorder to major depressive disorder. However, it's also important to realize that as with any illness, health should always come first. Sometimes, I have worked with students to connect them with mental healthcare and encouraged them to return to class when they are better able to manage their illness along with the inevitable stressors of an academic environment. In all cases, I advocate for what the student and I think will best serve their educational and health needs.

I also try to design both my on-ground and online courses with universal design principles in mind. This encompasses everything from closed captioning for hearing-impaired students to make-up work policies and classroom management and attendance policies that benefit all students but can be especially helpful for people who have mental illness.

Resources

If you're ready to make a difference in the lives of your students, you may be wondering where to start. Here are a few resources for educators that I have collected over the years:

I always keep a stack of contact cards from the National Suicide Prevention Lifeline in my office; their phone number is 1-800-273-8255. As many as 10 percent of people with psychosis attempt suicide within the first year of treatment. Don't be afraid to ask students if they are having thoughts about harming themselves. It's the first step to connecting them with help.

For more information about Mental Health First Aid and to find trainings in your area, visit https://www.mentalhealthfirstaid.org/.

For an overview of schizophrenia written with educators in mind, see this article from the National Association of Special Education Teachers.

This SAMHSA publication about including students who are showing signs of early psychosis includes a practical toolkit with accommodations examples and inclusive best practices for higher education.

Dr. Xavier Amador has dedicated his professional career to promoting positive and effective communication with people in psychosis. You can watch his TEDx Talk here, and learn more about his LEAP communication model at the LEAP Institute website.

Watch journalist Anderson Cooper as he attempts to work while experiencing a schizophrenia simulation to learn more about how psychosis can affect cognitive function.

Watch a schizophrenia simulation produced by Jannsen Pharmaceuticals (warning: the experience can be intense).

Open Mind of British Columbia, Canada, has collected a variety of resources for educators about mental illness in the classroom.

Schizophrenia and Related Disorders Alliance of America ( https://sardaa.org/ SARDAA) is a wonderful resource for anyone who wants to learn more about these illnesses.

The International Bipolar Foundation offers a variety of supports and resources, including webinars and local education events (full disclosure: I'm a board member).

The Child Mind Institute is involved in cutting-edge research and provides a variety of educational articles like this one about signs of psychosis in teens.

Find more information on Universal Design and inclusive learning in college courses here.

For more information on RAISE (Recovery After an Initial Schizophrenic Episode), see the National Institute of Mental Health's website.

One of my favorite books about managing mental illness in college students is Perfect Chaos: A Daughter's Journey to Survive Bipolar, A Mother's Struggle to Save Her by Cinda and Linea Johnson. Cinda is a special education professor, but her experience with her daughter's illness took her knowledge and empathy to a new level. The book is both personal and practical, and it provides a valuable glimpse at the struggles college students and teachers face.

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How Educators Can Help Students Experiencing Psychosis | Clarity CGC

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In the mental health world, I am best known as a parent advocate for children with mental illness. But in my professional life as an instructor at an open-access community college, I've had multiple opportunities to connect students in mental health crisis with the right resources.

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Integrating Children with Psychiatric disorders in the Classroom

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Integrating Children with Psychiatric disorders in the Classroom

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Giulia Cossu, 1,* Elisa Cantone, ¹ Mirra Pintus, ¹ Michela Cadoni, ¹ Anna Pisano, ¹ Roy Otten, ² Rowella Kuijpers, ² Elisa Pintus, ¹ Federica Sancassiani, ¹ Maria Francesca Moro, ¹ Anita Holzinger, ³ Alessandra Mereu, ¹ Antonio Preti, ¹ and Mauro Giovanni Carta ¹

Abstract

Background : The school setting may be the optimal context for early screening of and intervention on child mental health problems, because of its large reach and intertwinement with various participants (child, teacher, parent, other community services). But this setting also exposes children to the risk of stigma, peer rejection and social exclusion. This systematic literature review investigates the efficacy of mental health interventions addressed to children and adolescents in school settings, and it evaluates which programs explicitly take into account social inclusion indicators. Method : Only randomized controlled trials conducted on clinical populations of students and carried out in school settings were selected: 27 studies overall. Most studies applied group Cognitive Behavioural Therapy or Interpersonal Psychotherapy. Results : Findings were suggestive of the effectiveness of school-based intervention programs in reducing symptoms of most mental disorders. Some evidence was found about the idea that effective studies on clinical populations may promote the social inclusion of children with an ongoing mental disorder and avoid the risk of being highly stigmatized. Conclusion : School programs are still needed that implement standardized models with verifiable and evidence-based practices involving the whole school community.

Keywords: Educational context, mental health, school

INTRODUCTION

Schools are considered the ideal setting for the implementation of mental health treatment interventions, for several reasons.

Since the vast majority of children attends school and spends a considerable amount of time in school, the school is not only a setting for the early detection of children at risk of mental health disorders, but it also creates numerous possibilities to target these children with early interventions. Furthermore, the school provides a complex, far-reachingnetwork of community, parents, teachers and peers who,when involved, have a large potential of influencing childdevelopment.

School-based screening or treatment programs for common mental disorders can raise complex issues as well. One often feared risk is the potential over-diagnosing of students with the risk of stigmatizing them with a life-long label, damaging their social interactions and peer acceptance. Indeed, stigma and discrimination behaviour towards mental health disorders have been observed in even the youngest school children [ 1, 2].

To avoid the risk of stigmatization, there is some agreement that school-based screening and intervention programsshould not merely address clinical or cognition-based problems, but also include experiential social activities, engage students' feelings and behaviour thus facilitating their interaction with others, and develop their social skills [ 3, 4]. Within the worldwide call to eliminate and prevent mental health stigma and its antecedents [ 5], programs aimed at facilitating integration of children with psychiatric problems in the community were developed and tested.

Social competence is an important aspect in youth development and can be defined as the ability to form and maintain positive relationships and pro-social styles of interaction, and the ability to read social situations and to interpret them correctly. The absence of pro-social strategies often leads to dislike by peers, hence social exclusion. For children with a mental disease, peer-rejection at school can prompt or exacerbate antisocial development, while acceptance by peers could buffer the effects of dysfunctional behaviors [ 6, 7]. Interventions effectiveness could therefore benefit from the inclusion of strategies that strengthen social competence and stimulate peer acceptance in the school setting and in the community [ 6, 8, 9], and vouch for a functional network and community.

To create efficient functional networks and communities, school-based mental health activity and intervention programs increasingly involve families and school personnel in treatment. There is some evidence that positive interaction of families and school staff helps to achieve an overall functional school climate. Providers and families who work collaboratively for a student are more likely to win the student's collaboration, which can result in positive role modelling [ 10, 11]. Whole-school interventions have been emphasised recently. Sugai and Horner (2002) [ 12] described this system-based approach as a model that incorporates research-validated procedures and outcomes, consistent with international policies and guidelines about the best school practices. It also includes positive reinforcement and skill building approaches, prevents stress, and integrates all the elements of the school culture engaging students, teachers, administrators, and parents in practices.

Research and practices demonstrate that whole-school discipline programs, involving the school and its surrounding community as a unit of change, can be effective in reducing dysfunctional behaviours, preventing mental health problems, and contributing to a better students' performance [ 12- 16].

Educational achievement can materialize as academic success, and also in successful social relationships and integration at school. Engaging teachers into proactive and cooperative classroom management can produce positive environments that encourage and reinforce functional classroom behavior [ 4, 11, 17- 19]. To reduce the risk for children with a mental illness to have poor performance and a stressful social experience at school, resulting in potential exacerbation of the mental illness, practices need to improve their everyday psychosocial functioning in both school and home settings, involving the pupil's parents, teachers and community in school interventions [ 8].

OBJECTIVES

The main purpose of this study was to conduct a systematic review of school-based treatments or programs focusing on the integration of students with psychiatric diagnosis in the classroom. The concept of Integration comprises social inclusion dimensions, social skills, the sense of belonging to a group, inclusion in the school network, and quality relationships with peers: this dimension was labelled as "ingroup" [ 20]. Its opposite, conceived as a dichotomous construct, could be constituted by discrimination, the presence of stigmas, peer dysfunctional relationships, social exclusion, social anxiety, and low participation in school and recreational activities. The effectiveness of the interventions will be evaluated, while social outcome or social skills will be assessed as well as possible indicators of social inclusion/exclusion variables. Given the low number of studies specifically aimed at integration, authors decided to review all the studies involving clinical populations of students, ensuring the overall effectiveness of the interventions and assessing social outcomes and their changes after treatments apart.

METHODS

Inclusion and Exclusion Criteria

As a requirement of the search criteria, all the selected studies were based on randomized controlled trials (RCTs), which is considered the gold standard methodology to assess a program's effectiveness. More specifically, to be included studies had to involve a school-age (3-18 years old) clinical sample; they must have been carried out in school settings and verified through clinical, psycho-social, learning or academic skills outcomes. Only studies written in English and published from 2000 to 2014 were included. Primary and secondary prevention programs on at-risk populations chosen according to socio-demographic variables, and interventions focusing on addictions and substance abuse were excluded.

Search Strategy and Study Selection

We searched PubMed, and the Google Scholar databases using the following key words: "mental health, educational context, school"; no additional filters were used. This initial search yielded 17,700 hits, while seven additional studies were retrieved by searching on included articles' references or following indication by expert authors. Eventually, 1,090 abstracts written in English were examined to determine whether they met the specific inclusion and exclusion criteria. Overall sixty full-text articles were assessed for eligibility. Out of these, five studies were excluded because they were preliminary protocol descriptions or feasibility studies; one study was a psychometric validation of a questionnaire; nineteen studies did not refer to a randomized controlled trial; two studies referred to prevention programs applied to non-clinical samples; four studies referred to treatment other than school-based; two studies were reports of pharmacological treatments and did not refer to a psychosocial intervention (Fig. (​1 1 ): the flowchart according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PRISMA).

RESULT

General Description of Included Studies

Overall, 27 RCT papers met the inclusion criteria and were included in the qualitative synthesis.

These school-based interventions differed among them in terms of the role played by teachers and parents in the treatment. In some studies, treatment was targeted at parents or teachers and the outcomes were measured on school children. In other studies, students, teachers and parents were equally involved in the treatment; other studies instead delivered treatment to pupils only. Presentation of results and interpretation of findings was divided in two parts: school-based programs that actively involved parents or teachers in the interventions, and interventions aimed at students only. The main outcomes that revealed a statistical significance were reported (see Table , ). Table describes more in detail the psychometric instruments used to test social variables of social inclusion and their variation in relation to the intervention.

Table 1

Study

Country

Diagnosis

Type of
program/FU

Sample size
and group

Measures/outcome

Result

Social outcome

Ostberg
et al.
2012

Sweden

Attention deficit hyperactivity disorder
(ADHD)

Parent and teacher manual-based group training
Program
3-month T3

(Assessed by parents and Teachers) ADHD
Rating Scale
TG ↓ p <0.01 at T3
ODD
symptoms
TG ↓ p <0.05 at T3
SDQ
TG ↓ p <0.05. at T3
Stronger efficacy assessed by parents

Sayal et al.
2010

United KingdomUni

Attention deficit hyperactivity disorder
(ADHD)

Early school-based screening and educational intervention
5-year follow-up

The Strengths and
Difficulties Questionnaire (SDQ)

(Assessed by parents and Teachers) SDQ "
Stronger efficacy assessed by Teachers

Murray
et al.
2011

United States

Attention deficit hyperactivity disorder (ADHD)

Teacher Management Practices for children with ADHD
No follow-up

Teacher Management Questionnaire
(TMQ)

(Assessed by Teacher)
TMQ subscales:
Environmental modification
TG ↑ p < 0.001
Behavior modification
TG ↑ p < 0.05
Assignment modi-fication
TG ↑ p <0 .001
Structure and organization "
Instructional modifications "

Drugli
et al.
2006

Norway

Oppositional defiant disorder
(ODD)

Parent training combined with child therapy on positive discipline strategies, coping and social skills, conflict resolution, playing and cooperation with peers.
1-year follow-up

(Assessed by parents and Teachers)
TRF
Aggression problems at post-treatment
PT+CT vs PT ↓ p<0.05
PT+CT vs t WLC ↓ p<0.01
Aggression problems across post-treatment and follow-up
PT+CT ↑ p<0.01
PBQ
clinical level at post-treatment
PT+CT ↓ p<0.05
clinical level at follow-up
PT+CT ↑ p<0.05
WALLY
social strategies at post-treatment PT+CT ↑ p<0.001
social strategies at follow-up PT ↑ p<0.05
SCBE "
STRS "

WALLY
SCBE
STRS

Drugli
et al.
2007

Norway

Parent training combined with child therapy on positive discipline strategies, coping and social skills, conflict resolution, playing and cooperation with peers.
1-year follow-up

(Assessed by parents and Teachers)
CBCL (father reports)
from post-treatment and maintained across follow-up
PT + CT ↑ p < 0.01
PT ↑ p < 0.05
CBCL (mother ratings)
from post-treatment and maintained across follow-up
PT + CT ↑ p < 0.05
WALLY
Number of pro-social strategies used and maintained across follow-up
PT+CT ↑p < 0.01
SCBE "
LSC "

Hand, et al.
2013

Ireland

ID
Intellectual Disability

Evidence-based parenting programs based on social learning models
No follow-up

(Assessed by parents)
SDQ: (Time × Group)
Total difficulties subscales
TG ↓ p<0.007
Conduct problems subscales
TG ↓ p < 0.027
Hyperactivity "
Emotional problems "
Peer problems "
Pro-social behaviour "
Time factor
Total difficulties
TG ↓ p =0.003
Conduct problems
TG ↓ p = 0.009
PSI stress Index (Time × Group)
total score
TG ↓ p <0. 01
Total
TG ↓ p< 0.01).
(Time factor)
PSI Total score
TG ↓ p < 0.001
Parent Distress
TG ↓ p= 0.002
Parent-child relationship difficulties
TG ↓p= 0.004
Difficult child measure "
KPS Satisfaction Scale "
Parent defined child-related goals
(Time × Group)
child-related goals
TG↑ p < 0.001.
(Time effect)
TG v sCG ↑ p < 0.001

Jorm, et al.
2010

Australia

Mental disorders (Depression,Anxiety Psychosis, Behavioural disorders

Teachers educational programs on common mental disorders in
Adolescents and student welfare
6 months follow-up

Teacher outcomes:
mental health knowledge
Personal stigma items: %
strongly disagree
Perceived stigma items: % ≥ agree
Help given towards students: % ≥ occasionally
Confidence in helping students and staff with mental health problems % ≥ quite a bit
School policies on student mental health
Interacting with colleagues: % ≥
occasionally
Seeking Additional Mental health information: % ≥ occasionally
Teacher mental health
Student outcome:
Mental health knowledge
Beliefs and intentions about where to seek help for depression
Personal stigma: % strongly disagree
Perceived stigma: % ≥ agree
Help received from teacher
Student Mental Health

(Assessed by Clinicians) (Teacher)
knowledge
TIG ↑ p <0.001 and maintained at follow-up P < 0.001.
Perceived stigma (OR)
TIG ↑ p = 0.031 and maintained at follow -up
See other people as reluctant to disclose
TIG ↑ p= 0.041 and maintained at follow -up
Intentions towards helping students (OR)
Teachers more likely to discuss their concerns with another teacher
TIG ↑ p = 0.013 and maintained at follow -up
Discuss their concerns with a counsellor (OR)
TIG ↑ p = 0.023 and maintained at follow -up
Have a conversation with the student (OR)
TIG ↑ p = 0.162 and maintained at follow -up
School policy of mental health (OR)
TIG ↑ p=0.019 and maintained at follow -up
Policy had been implemented in the previous month (OR) TIG ↑ p= 0.070 and maintained at follow-up (Student) Mental health knowledge
Report that they received information about mental health problems
SIG ↑ P < 0.001 Beliefs and intentions about where to seek help for depression (Student outcome) "
Personal stigma: % strongly disagree (Student outcome) "
Perceived stigma: % ≥ agree
Stigma perceived in others (OR)
SIG ↑ p= 0.006.
Help received from teacher " Student Mental Health "

Mifsud, et al.
2005

Australia

Anxiety

( Assessed by Clinicians)
SCAS
TG ↓ p < 0.005 and maintained at follow-up
CATS
TG ↓ p = .001 and maintained at follow-up
SCAS-P↔
CBCL ↔

SCAS:
sub-scale s
Social phobia
CATS:
(9 items)
CBCL:
Social problems

Masia et al.
2005

United States

Anxiety

Skills training intervention on adolescents and participation of parents and teachers on psychoeducation groups
9-month
follow-up

Self-Report Inventories (ADIS-PC) Severity
Social Phobic Disorders Severity and Change Form (SPDSCF)
Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA)
Children's Global Assessment Scale(CGAS)
Social Phobia and Anxiety Inventory for Children
(SPAI-C)
Social Anxiety Scale for Adolescents (SAS-A)
Self-Report Inventories
Loneliness Scale
Parent Report:
Social Anxiety Scale for Adolescents (SAS-AP)

(Assessed by Clinicians) ADIS-PC Severity (Group × Time) TG ↓ p < .0001
SPDSCF (Group × Time)
TG ↓ p < .0001
LSAS-CA (Group × Time)
Total score, TG ↓ p = .03,
Total Avoidance subscale TG ↓ p = .03,
Social Avoidance subscale TG ↓ p = .04.
Performance Anxiety TG ↓ , p = .053
Total Anxiety TG ↓ p = .056.
CGAS (Group × Time interaction)
TG ↑ p < .0001
SPAI-C
Social phobia symptoms TG ↓ p = .052.
SAS-A(significance was found in one subscale out of three)
(Group × Time effect)
social anxiety in new situations
TG ↓ p = .03.
SAS-AP(parent reports)
Social anxiety in new situations
TG ↓ p = .02.
FNE ↔
SAD-General subscales. ↔
(CDI) ↔ (interpersonal Problems)

SPDSCF
LSAS-CA
SPAI-C
SAS-A (AP)
CDI:
(interpersonal Problems)
Self-Report Inventories
Loneliness Scale
ADIS-PC:
social phobia items
C-GAS: Children's global assessment scale
(the area of interaction with with friends)

Bernstein, et al.
2005

United States

Anxiety

Group cognitive-behavioral therapy (CBT) for children Group
6-month follow-up.

(Assessed byParentand Clinicians) ADIS
Composite CSR TG+TPP ↑ p= .03
TPP ↑ p= .06 Child-Interview
TG+TPP ↑ p = .045
CGI
TG+TPP ↑ p = .06
TPP ↑ p= .02).
MASC (group × time)
TG+TPP ↑ p= .006
SCARED(group × time)
TG+TPP↓ p= .001
MASCTotal TPP ↑p= .02.
SCARED indic. TPP ↑ p= .000.

Table 2

Study

Country

Diagnosis

Type of program/FU

Sample size
And group

Measures/outcome

Result

Social
outcome

Hong,
etal. 2011

China

Behavioral problems

Child Cognitive-behavioral intervention
6-month follow
Up

(Assessed by Parents) CBCL Total behavior problem scores
TG ↓ p = .024
TG ↓ p = .001 at 6-month follow up
The levels of reported total behavior problems declined in response to the intervention and remained lower than those in the control group 6 months later

CBCL:
Social problem scale

Leff,
et al. 2009

United States

CD
(Conduct problems)

Culturally-adapted social problem solving/social skills intervention
No follow-up

Intervention group TG
(n = 21)
Control
Group CG
(n = 11)
Age m=12

(Assessed by Peer, Teachers and Clinicians) CSB
Teacher reports of relational aggression
TG ↓ (moderate to large effect size of .74, Cohen, 1988)
Teacher ratings of peer likeability
TG ↑( very large effect size of 1.73, Cohen, 1988)
HAB
TG ↓ (very large effect size of .61, Cohen, 1988)
ALS
TG ↓ (moderate effect size of .45. Cohen, 1988

Owens et al. 2005

United States

Behavioral treatment intervention
9 months follow-up

(Assessed by Parents and Teachers) DBD Rating Scale, severity of hyperactivity and impulsivity TG ↓ p < .05
oppositional defiant behaviour TG ↓ p < .05
impairment in their peer relationships TG ↓ p < .05
CBCL,
aggressive symptomatology TG ↓ p < .10,
externalizing behavior problems TG ↓ p < .05
CD symptoms TG ↓ p < .10
total behavior problems TG ↓ p < .10

Cooper,
etal. 2010

United Kingdom

Emotional distress

School-based
humanistic counselling intervention
no follow-up

The Self-Report Strengths and Difficulties Questionnaire
(SDQ)
(The emotional symptoms subscale of the SDQ)

(Assessed by Clinicians) SDQ-ES ↔

Mufson, et al. 2004

Unites States

Depression/Anxiety

Interpersonal psychotherapy intervention
16 week follow-up

Hamilton Rating Scale for Depression (HAMD)
Children's global assessment scale
(C-GAS )
Clinical Global Impressions (CGI)
Social adjustment scale-self report
(SAS-SR)

(Assessed by Clinicians) HAMD
TG ↓ p=.04 and maintained at follow-up
C-GAS
TG ↑p=.04 (C-GAS trend to improvement at 16 weeks, p=0.06)
CGI
Global functioning
TG ↑p=0.03
mean CGI scores (improvement)
TG ↑p=0.03
At 16 weeks slight effect size in global functioning 0.51 (95% CI 0.003 to 1.02)
SAS-SR
social functioning mean TG ↑p=0.01

O'Leary-Barrett, et al. 2013

United Kingdom

Depression, Anxiety,
Conduct disorders

Cognitive behavioral therapy intervention
2 years follow-up

Treatment group TG ( n=694)
Control group CG (n=516)
Age m=13.5

(Assessed by Clinicians)
SURPS "
BSI
depressive symptoms
TG ↓ p<.05 (over two years)
Suicidal ideation
TG ↓ p<.02 (over two years)
Anxiety symptoms
TG ↓ p<.01 (over two years)
Panic attacks "
SDQ (conduct subscale)
TG ↓ p=.01 (over two years)

Stallard et al. 2012

United kingdom

Depression

Cognitive behavioural therapy
12 months follow-up

Short mood and
feelings questionnaire
(SMFQ)

(Assessed by Clinicians)
SMFQ"

Stallard, et al. 2013

United kingdom

Depression

Classroom based cognitive behavioural therapy
12 months follow up

s
et al. 2010

United States

Depression

Cognitive behavioural therapy group TG (n=78),
Contrast treatment at usual CG (n=70)
Age m=9,5

Multidimensional Anxiety Scale for
Children (MASC)
Children's Depression Inventory (CDI)

Gunlicks
etal. 2010

United States

Depression

Rose
et al 2014

Australia

Depression

(Assessed by Clinicians) RADS-2
↔ (TG1)
TG2 ↓ p =.008 (no at follow-up) CDI
↔(TG1)
TG2 ↓ p =.026 (not at follow-up)
PSSM
school connectedness
TG2 ↑ p= .061) (not at follow-up)
↔(TG1)
But no difference on follow-up between TG1 and TG2 MSLSS
TG2 ↑ p = .061
CAIR ↔
DISCAP↔

Tze-Chun Tang
et al. 2009

Taiwan

Depression

Interpersonal psychotherapy Intervention (IPT-A)
no follow-up

Intensive interpersonal psychotherapy TG (n=35)
Treatment as usual (psychoeducation) (TAU) CG (n=328)
Age m=15

(Assessed by Clinicians) BAI
TG ↓ p < 0.05 BDI
TG ↓ p< 0.001 BHS
TG ↓ p < 0.01 BSS
TG ↓ p < 0.01

Chemtob
et al. 2002

Hawaii

PTSD
post traumatic stress
disorders

School-based screening and psychosocial treatment
1 year
follow-up

Kauai Recovery Inventory (KRI)
Child PTSD Reaction Index (CPTS-RI)

(Assessed by Clinicians) KRI
TG ↑ p<.001 (maintained at follow-up)
CPTS-RI
TG ↓ p=.01

Stein,
etal. 2003

United States

PTSD post traumatic stress
disorders

Child Cognitive-behavioral program

Child Ptsd Symptom Scale (CPSS)
Child Depression Inventory
(CDI)
Parents report Psychosocial dysfunction
Teacher-Child Rating Scale
(TCRS)

(Assessed by Clinicians, Parents and Teachers) CPSS
TG ↓ p < 0.05
CDI
TG ↓ p < 0.05
Parents report Psychosocial dysfunction
TG ↓ p < 0.05
TCRS ↔

CPSS: item relationships with friends and item relationships with family CDI:
Subscale interpersonal Problems
Parents report Psychosocial dysfunction

Tol WA, et al. 2010

Sri Lanka

PTSD
post traumatic stress
disorders

Manualized intervention of cognitive behavioral
Techniques and creative expressive elements
3-month follow-up

Child PTSD Symptom Scale (CPSS)
Depression Self-Rating (DSRS)
Screen for Anxiety Related Emotional Disorders (SCARED-5)

Kataoka et al.2011

United States

PTSD
post traumatic stress
disorders

Cognitive behavioral therapy skills intervention in a group
format (5-8 students/group)

Academic performance
(math and language arts)
grades were extracted from school records and coded as A=4, B=3, C=2, D=1, and F=0 for use as an outcome variable

(Assessed by Teachers) Math grade TG ↑ p=0.048)
Language Arts ↔

Galla
et al.2011

United States

Anxiety

Modular Cognitive Behavioral
Therapy Treatment
1-year follow-up

Treatment group TG (n=14) Control group CG (n=10)
Age m=8.51,

MASC:
The Social Anxiety scale
Humiliation / Rejection subscale

Table 3

Study

Social Measure

Construct

Results

Ostberg et al. (2012)

The Strengths and Difficulties Questionnaire (SDQ)
social sub-scale

SDQ
Assess children pro-social skills and quality of peer relations
No separate presentation of data

Murray et al. (2011)

Not reported

Not reported

Drugli etal. (2006)

Drugli et al. (2007)

CBCL
Assess prosocial and antisocial behaviour (subscales)
Wally
Assess problem-solving ability in hypothetical social problem situations
LSC
Assess children's feelings of loneliness, appraisal and peer relationships, perceptions of the degree to which important relationship needs are met, and perceptions of their own social competence.
SCBE
Assess patterns of social competence (isolated-integrated aspects in peer interactions), affective expression, and adjustments difficulties in children

CBCL (father reports)
from post-treatment and maintained across follow-up
PT + CT (composite group) ↑ p < 0.01
PT ↑ p < 0.05
CBCL (mother ratings)
from post-treatment and maintained across follow-up
PT + CT (composite group) ↑ p < 0.05
WALLY
Number of pro-social strategies used and maintained across follow-up
PT+CT (composite group) ↑p < 0.01
SCBE ↔
LSC ↔

Hand et al. (2013)

The Strengths and Difficulties Questionnaire (SDQ)

SDQ
Assess children pro-social skills and quality of peer relations

No statistical significance was found

Jorm et al. (2010)

Student/Teachers
Personal Stigma Items: % (Strongly Disagree)
Perceived Stigma Items: % (Agree)

Student/Teachers
Personal Stigma and
Stigma perceived

Students Stigma perceived in others Perception that others believe in unpredictability TG ↑ p = 0.006
Teachers Personal Stigma Items:
See depression as due to personal weakness
TG ↓ p = 0.024; and p= 0.077 at follow-up
Be reluctant to disclose depression to others TG ↓ p = 0.012 and p = 0.029 at follow-up
Teachers Perceived Stigma Items
Believe that other people see depression as due to personal weakness
TG ↑ p=0.848 and p = 0.031 at follow-up
See other people as reluctant to disclose
TG ↑ p= 0.041 and p = 0.555 at follow-up

Mifsud et al. (2005)

No separate presentation of data

Masia Warner et al. (2005)

ADIS-PC Assess social phobia, social
anxiety disorder (subscales)
SPDSCF Assess Social Phobic Disorders
LSAS-CA Assess Social Anxiety
SPAI-C Assess Social Phobia
SAS-A/AP Assess Social phobia symptoms and
Social anxiety in new situations (subscales)
CDI Assess Loneliness Scale

ADIS-PC: No separate presentation of data SPDSCF (Group × Time effect)TG ↓ p < .0001
LSAS-CA (Group × Time effects)Total score
TG ↓ p = .03
Total Avoidance,
TG ↓ p = .03
Social Avoidance,
TG ↓ p = .04
SPAI-C (Group × Time effects)
Performance Anxiety,
TG ↑, p = .053
Total Anxiety,
TG ↓ p = .056.
SASS social phobia symptoms
TG ↓ p = .052.
SAS-A (Group × Time effect)
subscales social anxiety in new situations
TG ↓ p = .03.
SAS-AP (parent reports)
social anxiety in new situations
TG ↓ p = .02.

Bernstein et al. (2006)

Child and Parent Interview Schedules (ADIS) social phobia items
Multid. Anxiety Scale for Children (MASC-C) social anxiety, humiliation-rejection subscale

ADIS Assess social phobia, social
anxiety disorder (subscales)
MASC-C Assess social anxiety, humiliation-rejection (subscales)

No separate presentation of data

Hong et al. (2011)

Child Behavior Checklist-(CBCL)
social problems subscale

CBCL Assess social problems (subscale)

No separate presentation of data

Leff et al. (2009)

The Children's Social Behavior Questionnaire (CSB)
Asher and Wheeler Loneliness Scale (ALS)

CSB Assess Peer relations, how children think about the social world, and how children think and feel about themselves
ALS Assess feelings of Loneliness

CSB Relational aggression
TG ↓ moderate to large effect size of .74 (Cohen, 1988)
Peer likeability
TG ↑ very large effect size of 1.73. (Cohen, 1988)
ALS Feelings of loneliness
TG ↓ moderate effect size of .45.(Cohen, 1988)

Owens et al. (2005)

DBD Assess quality of peer relationships and impairment in peer relationships
IRS Assess quality of Peers relations and with parents
CBCL Assess social problems (subscale)

DBD peer relationships
TG ↑ p < .05
impairment in peer relationships
TG ↓ p < .06
IRS Peers relations
TG ↑ p < .06

Sayal et al. (2010)

The Strengths and Difficulties Questionnaire (SDQ)
peer relationship problems

SDQ Assess children pro-social skills and quality of peer relations

SDQ Parental and Teacher Peer problems
TG ↓ p<.001
Prosocial behaviour
TG ↑ p<.001

Cooper et al. (2010)

SDQ
Assess children pro-social skills and quality of peer relations SIQ
Assess Social Inclusion

SDQ-PS
prosocial subscale
TG ↑ p<.001

Mufson et al. (2004)

Children's global assessment scale (C-GAS) interaction with friends
Social adjustment scale-self report (SAS-SR)

O'Leary-Barrett
et al. (2013)

Not reported

Not reported

Stallard et al. (2012)

Secondary outcomes:
Revised child anx. and dep. scale (RCADS)

Stallard et al. (2013)

Manassis et al. (2010)

Multidimensional Anxiety Scale for Children (MASC) social Anxiety scale, humiliation/rejection subscale
Children's Depression Inventory (CDI)
Interpersonal Problems subscale

No separate presentation of data

Gunlicks-Stoessel et al. (2010)

No statistical significance was found

Kirsten et al. (2014)

Tze-Chun Tanget
et al. (2009)

Not reported

Not reported

Chemtob et al. (2002)

Not reported

Not reported

Stein et al. (2003)

Tol WA et al.(2012)

Secondary outcome:
The Strengths and Difficulties Questionnaire ( SDQ)
prosocial subscale

SDQ
Assess children pro-social skills and quality of peer relations

No statistical significance was found

Kataoka et al. (2011)

Not reported

Not reported

Brian et al. (2012)

Multidimensional Anxiety Scale for Children (MASC)
(The Social Anxiety scale Humiliation/Rejection subscale)

MASC-C
Assess social anxiety, humiliation-rejection (subscales)

No separate presentation of data

School-based Interventions on Clinical Samples with Active Participation of Teachers and/or Parents

Three of the parent- and teacher-training program treatments concerned children samples with Attention Deficit Hyperactivity Disorder (ADHD) (Table ). Two studies concerned Disruptive, Impulse-Control, and Conduct Disorders; more specifically, one dealt with oppositional defiant disorder (ODD) and the other with both Conduct Disorder (CD) and ODD children samples. One study followed a parenting program for the management of children with Intellectual Disability, one was a Teachers' educational program on common mental disorders (including Depression, Anxiety, Psychosis, Behavioural disorders) and three studies concerned Psycho-educational and Cognitive Behavioural Therapy (CBT) group treatments on a sample of children with Anxiety disorders, with participation of both parents and teachers.

School-based Interventions on Clinical Samples Targeting Pupils Only

Two studies concerned Disruptive, Impulse-Control, and Conduct Disorders, specifically one was on Conduct Disorder (CD), and the other had a children sample with behavioural problems as a specification of Conduct Disorders (Table ).

One study investigated the efficacy of school-based interventions on a sample of ADHD pupils; two studies investigated the effectiveness of treatment on both Anxiety and Depression disorders in a clinical sample of school children, seven studies focused solely on mood disorder school programs, six studies focused on the treatment of Depression disorder, and one on Emotional distress; four studies were about Post-Traumatic Stress Disorder (PTSD) programs; and one study was a treatment focused on Anxiety Disorders in a clinical school children sample.

Treatment Effectiveness of School-based Interventions on Clinical Samples with Active Participation of Teachers and/or Parents

The overall findings on school-based treatment of clinical samples with the active participation of teachers and/or parents were suggestive of the effectiveness of these programs in reducing the symptoms of most mental disorders. Only two studies out of ten were not associated with improved outcomes in children. Three studies investigated training for teachers that specifically focused on improving the knowledge and management of school children's mental disease, and on decreasing attributional bias and stigma towards mental illness. The aim of these interventions was to improve school policies [ 21- 23]. Effectiveness was assessed in terms of increased knowledge and more positive attitude towards talking about mental health (decrease of stigma) for both teachers and students. As depicted in Table , one study reported positive results; two interventions did not show improved outcomes in children [ 22, 23]. The other seven studies did not set integration as their main goal. Two of these studies evaluated and confirmed the effectiveness of Cognitive Behavioral Therapy (CBT) with the participation of parents in a clinical sample of children with anxiety disorders. Both studies used clinical measures as outcome measures: Clinical Global Impressions (CGI), and Spence Children's Anxiety Scale (SCAS) [ 24, 25]. Two studies investigated the positive results of two combined manualized programs: Basic Incredible Years Parenting Programme and Dinosaur School Programme for children with Conduct Disorders (ODD). The two mixed programs included: positive discipline strategies, effective strategies for coping with stress, and social skills. They shared The Wally Child Social Problem-Solving Detective Game (WALLY) as main outcome, as shown in Tables and [ 8]. Finally, three studies were heterogeneous on clinical sample type (ADHD, Anxiety, ID) and verified the effectiveness of school programs that combine different techniques: CBT, behavioural techniques, skills training, family systems interventions and psycho-education: Barkley's programme; Social Effectiveness Therapy for Children (SET-C), Parents Plus Children's Programme. They all used the Strengths and Difficulties Questionnaire (SDQ) as main outcome measure, as shown inTables and [ 26- 28].

Treatment Effectiveness of School-based Interventions on Clinical Samples Targeting Pupils Only

The overall findings about school-based treatment on clinical samples targeting pupils only were suggestive of the effectiveness of these programs in reducing the symptoms of most mental disorders. Only three studies were not associated with improved outcomes, and none of these specified integration as their specific goal. Most of the retrieved studies concerned a school-based intervention on a clinical sample with a target on pupils only (n=10), and consisted of a mixture of CBT techniques. Some studies were manualized and concerned verified interventions in a school setting. One study, in particular, used the Resourceful Adolescent Program (RAP) [ 29] (Rose et al., 2014) that incorporates CBT and Interpersonal Psychotherapy (IPT-A) principles, including stress management skills, cognitive restructuring, problem solving, and conflict resolution within families. However the results of this study revealed that adolescents completing RAP did not report significantly reduced depressive symptoms. The preponderance of studies based on CBT concerned samples of school children with Depression Disorder (n= 4), one included treatment of Anxiety and Depression Disorders and Behavioural problems, one focused on Anxiety Disorder only, one on Behavioural problems, and three studies targeted Post-Traumatic Stress Disorder (PTSD) symptoms [ 29- 38]. One of them did not identify any major effect on primary outcomes [ 36].

Three Interpersonal Psychotherapy (IPT-A) school-based interventions focused on Depression symptoms using Hamilton Rating Scale for Depression (HRSD) and Beck Depression Inventory (BDI) as main outcome. They reported signiﬁcantly higher effects on reducing the severity of depression symptoms [ 39- 41]. One intervention was performed as culturally-adapted social problem solving Intervention for Conduct problems (CD) in girls with relational aggression (GRAs) style. Greater decrease in teachers' reports about relational aggression from pre-treatment to post-treatment was found for students under treatment than for students in the control group. The main outcome measure in this study was derived from Asher and Wheeler Loneliness Scale Children's Depression Inventory [ 42]. One Behavioral Treatment intervention was performed on Attention deficit hyperactivity disorder (ADHD), Oppositional defiant disorder (ODD), Conduct problems (CD) and Disruptive Behavior Disorders (DBD) symptoms in a sample of schoolchildren. The study used the Disruptive Behavior Disorders Structured Interview (DBD) as main outcome measure and showed significant improvement [ 43]. Another study describing a school-based humanistic counselling intervention focused on the presence of Emotional distress symptoms in a sample of school-children using The Self-Report Strengths and Difficulties Questionnaire (SDQ), but showed non-significant results on the primary outcome measure [ 44].

Finally one study reported results from a specific psychosocial treatment for children who showed symptoms of Post Traumatic Stress Disorder (PTSD) after Hurricane exposure. Data showed significant differences on the Kauai Recovery Inventory (KRI) after treatment and at follow-up (X months) [ 45] in treatment-group children, as compared to children in the control group.

Social Outcome and Effectiveness of School-based Interventions on Clinical Samples

As stated above, only a few studies had a specific focus on investigating the integration of students with psychiatric diagnosis in the classroom; therefore all the studies that involved a clinical population in a school setting were included and changes in social outcome as a main or secondary outcome measure were reviewed. Five studies out of twenty-seven did not report a main outcome or secondary outcome measures as far as social inclusion or exclusion variables were concerned. It was not possible to extrapolate data from six studies, because for instance social variables were part of a subscale of the outcome measure that was used (are reported in Table as No separate presentation of data).

Considering all the reviewed studies, the most frequently used measures of social variables were subscales of instruments such as the social subscale of The Strengths and Difficulties Questionnaire (SDQ), the Social Anxiety subscale and Humiliation/rejection subscale of the Multidimensional Anxiety Scale for Children (MASC), and the interpersonal problems subscale of the Children's Depression Inventory (CDI). The chosen instruments (though not always as the main outcome) that seemed to specifically focus on treatment effectiveness in relation to social dimensions were: Personal and Perceived Stigma Items, The Social Inclusion Questionnaire' (SIQ), Asher and Wheeler Loneliness Scale (ALS), the Psychological Sense of School Membership (PSSM), The Wally Child Social Problem-Solving Detective Game (WALLY) and the IRS (Peers relation, Sibling relation, Parental relation). Overall, as shown in Table , out of sixteen studies that reported indicators of social values ​​or dimensions, thirteen studies reported positive results of social variables,while three studies found no effects on these outcomes.

DISCUSSION

This study assessed the literature on implemented and verified school-based practices addressed to clinical populations of students, and targeting specific mental disorders to improve the integration of pupils with specific mental health problems in the classroom and the school system. Of all the studies including clinical populations that were screened, only few concerned randomized controlled trials, which is the golden standard methodology to assess a program's effectiveness. In particular, this study evaluated the effectiveness of twenty-seven interventions on clinical populations. A larger amount of programs implementing standardized models with verifiable and evidence-based practices is still needed. Indeed in almost all the assessed studies, the main outcome, the effect size and the number required for treatment are not always clearly or fully indicated: it was therefore not possible to include these data in the tables. There is a clear call for the use of evidence-based practice (EBP) in schools. It is necessary to identify, better understand and define the potential barriers to the use of empirical interventions in school settings. This information could be used to guide strategies that promote EBP among school-based staff and clinicians [ 46]. A complicated issue in school interventions may involve the question on how all the elements of known evidence-based programs can ﬁt in the complex network of a specific school community, and how these programs can be successfully and effectively implemented and coordinated [ 11]. Evidence-based practice has shown that through involvement in interventions, the whole school and its surrounding community as a unit of change produce better performance in promoting and reinforcing students' health behaviors [ 17, 18, 47]. Engaging teachers in proactive and cooperative classroom management may produce positive environments that encourage and reinforce health classroom behavior. School practices and interventions need to improve psychosocial functioning of school children in both school settings and at home, by involving parents, teachers, and pupils [ 47, 18, 11, 8] However, out of the twenty-seven studies included in this review only 37% involved the active participation of parents and teachers in school treatment. Therefore, the practices that proved to be the most effective are not always concretely implemented [ 11]. Very few studies have also involved parents as well as teachers and clinicians as evaluators in the assessment phase. Several evidences indicate significant differences between the different types of evaluation observers. This approach would make it possible to assess differences in effectiveness between different studies in a more reliable manner [ 48]. School-based treatments for mental disorders can also raise the risk of stigmatizing and over-diagnose students, and subsequently violate their social interactions and peer acceptance [ 1, 2]. Social interactions can prevent the development of stigma towards mental disease, and young people's social networks are influential [ 49- 51]. A lack of pro-social strategies is often disliked by peers and could result in social exclusion. For children with a mental disease, peer-rejection could exacerbate antisocial development, while acceptance by peers could buffer the effects of dysfunctional behaviours. For this reason interventions should also target peer acceptance and strengthen social competence in the school setting and in the community [ 8, 6, 7, 52].

To avoid the danger of stigmatization, there is some agreement that school-based programs should involve children in experiential activities, engage students' feelings and behaviour, and facilitate students' interaction with others. However, out of the twenty-seven studies included, only 59% considered social values or dimensions after treatment, 48% reported positive results on prosocial behaviors and quality of interactions as an outcome of the program, and maintained them at follow-up. More programs are needed that involve clinical populations of schoolchildren and implement standardized models of intervention, taking into account social inclusion outcome in the school setting. It would be necessary to monitor if these values and indicators of integration ​​remain stable or change during the whole educational experience of students with mental disorders.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

REFERENCES

10. Weist MD, Evans SW, Lever NA, Lowie JA, Lever NA, Ambrose MG, Tager SB, Hill S. Partnering with families in expanded school mental health programs. Handbook of School Mental Health Advancing Practice and Research. 2003:135-147. [ Google Scholar]

50. Pescosolido BA, Martin JK. Stigma and the sociological enterprise. In: Avison WR, Pescosolido BA, Mcleod JD, editors. Mental Health, Social Mirror. NY:: Springer; 2007. pp. 307-28. [ Google Scholar]

Articles from Clinical Practice and Epidemiology in Mental Health : CP & EMH are provided here courtesy of Bentham Science Publishers and BioMed Central

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Integrating Children with Psychiatric Disorders in the Classroom: A Systematic Review

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Giulia Cossu, 1, * Elisa Cantone, 1 Mirra Pintus, 1 Michela Cadoni, 1 Anna Pisano, 1 Roy Otten, 2 Rowella Kuijpers, 2 Elisa Pintus, 1 Federica Sancassiani, 1 Maria Francesca Moro, 1 Anita Holzinger, 3 Alessandra Mereu, 1 Antonio Preti, 1 and Mauro Giovanni Carta 1 Background : The school setting may be the optimal context for early screening of and intervention on child mental health problems, because of its large reach and intertwinement with various participants (child, teacher, parent, other community services).

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Children with OCD have intrusive thoughts and worries that make them extremely anxious, and they develop rituals they feel compelled to perform to keep those anxieties at bay. This guide explains the often confusing behaviors that can be associated with OCD, and the treatments most effective for hel…

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Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry. These are called obsessions. To alleviate the anxiety caused by their obsessive thoughts, they perform repetitive, ritualized actions called compulsions. A child with OCD might need to line things up, touch things in a certain order when leaving the room or wash his hands repeatedly.

Obsessions Common in Kids With OCD

Contamination: Kids with this obsession are sometimes called "germaphobes." In schools, this plays out with kids worrying about other kids sneezing and coughing, touching things that might be dirty or getting sick in many different ways. This is the most common obsession seen in children.

Magical thinking: This is a kind of superstition, like "step on a crack, break your mother's back," taken to extremes. For example, kids might worry that their thoughts can cause someone to get hurt, or get sick. A child might think, "Unless my things are lined up in a certain way, mom will get in a car accident."

Catastrophizing: Some kids easily jump to the conclusion that something terrible has happened. For example, if her parents are five minutes late picking her up, a girl who is catastrophizing might tell herself that they've decided to abandon her.

Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.

What ifs: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

The "just right feeling": When OCD first develops, from about 6 to 9 years of age, kids may not know why they are doing something, but just that they need to do it until they get what we call the "just right feeling." So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time - in the 9- to 12-year-old range - it evolves into magical thinking and becomes more superstitious in nature.

Behaviors You Might See in Students With OCD

Frequent requests to go to the bathroom: This could be to wash hands, if someone near the child was coughing or sneezing, or if she touched something that she perceives as contaminated. She could be washing items-pens, pencils, backpacks, books. It could also be an excuse to get out the classroom and just be away from everyone, and have some respite.

Constant reassurance-seeking: This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" Checking doors, windows, lockers, desks. Over and over and over again.

Getting stuck on tasks: Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if a child is working out what he did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," he's not going to be able to shift gears.

Retracing: If a child leaves the classroom and worries that she left a pencil behind, she'll go back into the classroom and go to her desk and check. If she had a bad thought as she went through the doorway, she might have to "fix it" by going back through the doorway again saying a good word. If she had a bad thought when she went down a flight of stairs on the way to class, she might need to go back up that same stairway at the end of the period, even if it means being late to her next class.

Obsessive erasing: A child could be erasing a lot because the letters have to look perfect. Or he could have used a word that disturbs him. For example, if he has a fear of vomiting and he's written the word vomit, he might not be able to stand seeing that word, so he erases it. Kids start having erasers worn down to the metal. Teachers start to see holes in the paper. Words will be drawn over on the back of the page. A lot of different areas of writing become problematic.

Behaviors Often Confused With Another Disorder

Some behaviors associated with OCD are easy to confuse with ADHD, learning problems or being oppositional.

Distraction: If a child is busy thinking that if she doesn't turn the pen cap and count to four the right way then her mom is going to get sick, she's not going to be paying attention in class. And if her teacher calls on her to answer a question, her distraction might look like ADHD, but it isn't.

Slowness on exams, papers and tasks: Sometimes when kids take a long time, they're struggling with the perfectionism of needing to do things the right way. This could look like learning problems, or inattention, but it isn't.

Avoidance: Teachers might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. He may avoid a lot of playground activities - kids with germ fears will view the playground the way some adults view the subway: it's gross. Why touch anything there?

Tapping and touching symmetrically: If a child sits down at her desk and she accidentally kicks the chair of the kid next to her with her right foot, she's going to have to then kick it with her left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but actually it's OCD.

Complaints of anxiety and fatigue: There's one interesting theory that kids with OCD are smarter than other kids. And if you consider how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

How to Help Students With OCD

For children struggling with OCD, functioning in school can be complicated and very difficult. Here are some things you can do to help them, and the class as a whole, focus on learning:

Seating arrangement: If the school has noisy hallways, you might not want to have a child with OCD sit by the door. You might have her sit in the front, where she's less able to hear the noise and can stay more focused on her work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see her fidgeting with her hands, rocking or getting up a lot, might be better off closer to the door, toward the back of the room.

Extended time for tests and papers: If writing is a problem for a child who needs to find the perfect way to say something, he's going to need more time to finish those essay questions or papers.

Laptops for writing: If writing and rewriting/erasing is really problematic for a child, consider letting her use a laptop for taking notes, and having all assignments be typed instead of handwritten.

Private testing rooms: Research is quite clear that kids with OCD do better, are less overwhelmed and are more in control of their thoughts and their reactions if they're in a quiet place away from the other kids.

Skip reading out loud: Kids who feel they need to read perfectly may have to go back and reread sentences or whole paragraphs over and over to make sure they've got them right. So reading becomes a very laborious task, and reading in front of the class can become a nightmare. So if we know doing this is a problem for children, we can spare them.

Books on tape: If kids get so hung up reading that it takes forever, listening to the books can be a solution.

Break homework into chunks: If looking at a whole page of math makes kids feel overwhelmed and anxious - think of the potential for mistakes! - the problems can be broken up over four pages. It helps kids stay focused on doing the problems instead of worrying.

How to Minimize Behavioral Problems

Plan an escape route: Try working out a communication system so that if the student feels symptoms coming on, she can signal to you and leave the classroom, or go to a protected place in the classroom, without interrupting the class. It can prevent an embarrassing and disruptive blowup of symptoms in the classroom, and the other kids picking on or bullying her about it.

Be aware of triggering events: It's very important for teachers to know what kind of things might trigger the symptoms. Fatigue is a huge piece of OCD, and it can be exacerbated by medication. So it's important to know that if a child is drowsy in class, and maybe he's putting his head down, it's not because he's being oppositional or disrespectful, but because he's overwhelmed with fatigue.

Advance notice: Irritability and frustration are two of the longer-lasting things that kids with OCD are feeling on a daily basis. Changes in schedule can be very disruptive for a child with OCD, so it can be helpful for teachers to give advance notice of things. Kids who know what to expect are less likely to be thrown by the change.

Children with OCD are often teased and bullied because of their symptoms. Kids feel very uncomfortable about their rituals, knowing that they're being watched. It can be helpful to educate the whole class about what's going on, especially if a child is going to be in the same school for a number of years, and it can inspire a surprising amount of support from other children.

Peer understanding program: A peer understanding program includes a presentation in the classroom that explains (with the child participating) what OCD is. The child might say, "Listen, I have OCD. It's an anxiety disorder. It makes me think that my hands are dirty and I have to wash my hands a lot, so if you see me getting up and going to the sink to wash my hands, that's why." Psychologists can role-play with the teacher and child ahead of time, to anticipate questions his classmates might ask, and how to answer them.

A buddy system: A buddy is like a peer coach who sits next to the child and prompts him to keep up with note taking and staying on task. It can be great for the buddy, to foster a sense of confidence and pride and to be able to help someone in need, and great for fostering friendship.

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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. Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry.

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What comes to mind when you hear OCD? Do you picture TV detective Adrian Monk refusing to touch door handles because of germs? Or maybe super-nerd Sheldon Cooper, who absolutely has to use the bathroom at the same time each day? These characters often get played for laughs, but living with Obsessive-Compulsive Disorder, often called OCD, is no joke. The obsessions these people experience, and the compulsions they develop to deal with them, can keep them from leading satisfying lives. Students with OCD often struggle academically and socially. Here's how teachers can help.

What is OCD?

According to Child Mind, OCD is an anxiety condition that plagues a person with unwanted thoughts, images, or impulses called obsessions. The International OCD Foundation estimates that as many as 1 in 200 children have OCD. In an average elementary school, there are at least four or five kids with OCD and as many as 20 in a high school.

People with OCD have unreasonable fears that disrupt their daily lives. They might worry about contamination or fear that they'll suddenly become violent and hurt themselves or others. To cope with these anxieties, they develop repetitive and ritualized actions. These could include counting, locking and re-locking doors, lining up objects, hand-washing, or skin-picking. Those with OCD can get so involved in those behaviors that they're unable to focus on other tasks or function normally.

Children as young as five can develop OCD. It's most commonly diagnosed between the ages of 10 and 12 or between the late teens and early adulthood. To be diagnosed, someone must experience both obsessions and compulsions so strong that they disrupt normal life.

What does OCD look like in students?

For students with OCD, school can be a challenging and stressful place. They may appear to be daydreaming, distracted, uninterested, or lazy. In reality, they're hyper-focused on nagging urges and obsessive thoughts. Here's what that might look like specifically in your classroom. ( See a complete list here.)

Repetitive behaviors

This is one of the classic OCD behaviors. Those with OCD believe their behaviors are absolutely essential to their safety or the safety of others. They might believe that if they don't line up their pencils from smallest to largest, something terrible will happen to all their friends. They develop rituals like checking locks multiple times or reading a paragraph three times out loud before going on to the next one.

If a student with OCD has a bad thought when going through a door, for example, they may want to go back and "fix it." They will retrace steps and attempt to right the wrong of a bad thought or an item left in a room. Attempting to disrupt or deny these behaviors can lead to complete meltdowns.

Frequent bathroom breaks

The bathroom is a safe space for lots of students. Those with OCD may go there to be alone with their anxieties. If they have fears of contamination, they might be washing their hands or even school supplies obsessively. They might also retreat there to perform repetitive behaviors like skin-picking.

Focus on perfection

There's a difference between wanting to do your best and never feeling something is good enough. Students with OCD often focus on perfection. This leads them to spend an excessive amount of time on assignments and especially tests. They may also resist leaving a task unfinished and moving on to something else.

Compulsive erasing

Given that need for perfection, students with OCD especially struggle with writing. They may write and re-write something over and over, erasing it until there are holes in the page. Or, a minor error may cause them to scribble all over the page, trying to make the problem disappear.

Lack of focus

There are many reasons students can appear distracted. But those with OCD are usually dealing with intrusive and obsessive thoughts. For instance, they may be counting the number of red objects in the room, and fear if they miss one, a family member could die. Not surprisingly, those sorts of thoughts make it very hard to concentrate on schoolwork.

Fear of contamination

Many people with OCD have a severe fear of germs and dirt. This leads to compulsive hand-washing (sometimes to the point that their hands bleed). It also means kids might avoid doing things like sitting on the floor, touching books in the library, or even joining in on a messy art project.

Difficulty with transitions

For many kids, moving from one subject or class to the next is as easy as scooping up their stuff and moving on. For kids with OCD, it's not that simple. Their items may need to be arranged just so. They might not want to leave unfinished work behind. And when they start the next subject or class, everything has to be arranged exactly right all over again.

Need for constant reassurance

To quell their anxieties, students with OCD seek constant assurance that everything is okay. They might ask the same question about how to complete an assignment over and over again, interrupting the teacher when everyone else has moved on. They'll straighten their books, check their backpack again and again to make sure everything is there, or apologize profusely for breaking a very small rule.

How can teachers support students with OCD?

Understanding OCD and its behaviors is a good first step. Students who are diagnosed with OCD often undergo cognitive behavioral therapy (CBT). An IEP/504 plan developed with their therapist may outline specific actions for schools and teachers to take.

Tip: Remember, accommodations aren't treatment. Sometimes you may be asked to do something that seems to be allowing behavior that you feel ought to be stopped. But that's up to a student and their doctor or therapist. As a teacher, you want to focus on how they can succeed in your classroom. Some of these actions might help. ( See more ideas here.)

Choose their place in the classroom carefully

Finding the right place for a student with OCD can be tricky. They might need to sit facing away from an object that causes obsessive thoughts. Eliminating distractions like noise or movement might help. Many students need a safe space to fidget, rock, or perform another calming behavior (unless they're actively working to overcome that action).

Make assignments manageable

Students with OCD see any assignment as a chance to make endless mistakes, and longer assignments are even worse. Help younger students by breaking assignments into shorter tasks (read just one paragraph or page at a time, or give them just one math problem rather than a whole worksheet). Teach older students to do the same for themselves.

Reduce test-taking anxiety

Tests are enough to raise anxiety in any kid, but they're a disaster for those seeking perfection. Ensure the test focuses on what you need to assess, and eliminate unnecessary distractions. If a student takes too long to write, let them type their answers. Some students with OCD have trouble with bubble sheets, feeling the need to fill in each circle perfectly. Is there another way to take the test? Can an aide fill in the sheet for them, allowing them to focus on the questions themselves?

Provide separate supplies

For students with fears about germs and contamination, shared supplies are a nightmare. Even when schools make special efforts to keep things clean, a person with OCD may not trust or believe. Give them their own set of supplies when possible. Hand them their worksheet first, so they know other students haven't touched it, and make sure they have books marked for their own particular use.

Give alternatives to writing

When writing isn't the focus, don't make it necessary for success. Let them provide information orally or use a computer to type their answers. Whenever possible, don't grade work on neatness or nitpick about items that don't apply to the learning at hand. (For instance, don't correct spelling on a science paper if it really doesn't make much of a difference.)

Consider audiobooks

When reading proficiency isn't the goal, audiobooks can be an excellent tool for students with OCD. Reading often takes them longer, as they obsessively go back over a paragraph again and again, so they don't miss anything. Audiobooks continue on their own, providing information at a more regular pace.

Set limits

Compulsive behaviors can continue on and on. Let a student know that you'll be limiting what's acceptable. Do they often disappear to the bathroom to perform a repetitive behavior? Limit their visits to a certain number per day, with a set number of allowed minutes. (Of course, you can make exceptions for illness, etc.) For students who ask questions repeatedly, give them a maximum number of times (say, 3) that you'll answer. When a student feels the need to check their supplies obsessively or wash their hands again and again, try limiting that to certain times of day. Communicate these limits clearly, and stick to them.

Acknowledge their fears

You might feel the need to attempt to reassure students their fears aren't really a problem. After all, you know perfectly well that the student won't get into a car accident on the way home if they accidentally step on a line in the tile floor. But that doesn't really help students with OCD. It's okay to acknowledge and validate their feelings, without agreeing that their fears are true. Knowing that you understand and accept them can make a big difference.

Don't use "OCD" lightly

It's become common for us to joke about being "so OCD" about something, like wanting desks to be lined up straight or grading with your favorite pen. But OCD is no joke to the people who have it. Consider your words carefully when you speak.

How can I connect with students with OCD?

Kids with OCD want to succeed and can get very frustrated that their own behavior is getting in the way. According to Denise Egan Stack, a behavioral therapist from the International OCD Foundation, building a relationship is the key to a successful learning experience. Some students with OCD seek teachers out for approval and reassurance. Others, though, may hide because they feel ashamed or don't want to cause trouble. In that case, a teacher may need to be the one to reach out.

Egan Stack notes that these students do well with set check-ins. Set aside time to meet and talk about how things are going. This can help students cross the barrier when they're tempted to hide and avoid dealing with their OCD. Instead, you can work together to make plans.

Build a team to support the student and make them a part of regular meetings as well. This team could include parents, school counselors, the student's therapist, and, of course, the student themselves.

OCD Resources for Teachers

The more you understand about OCD, the more you can help and support your students affected by it. Try these resources for more information.

Online

Books

How do you support students with OCD in your classroom? Come share your thoughts and ask for advice on the WeAreTeachers HELPLINE group on Facebook.

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How To Support Students With OCD (Obsessive-Compulsive Disorder)

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What comes to mind when you hear OCD? Do you picture TV detective Adrian Monk refusing to touch door handles because of germs? Or maybe super-nerd Sheldon Cooper, who absolutely has to use the bathroom at the same time each day? These characters often get played for laughs, but living with Obsessive-Compulsive Disorder, often called OCD, is no joke.

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Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

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DuPaul, G. J., Weyandt, L. L., & Janusis, G. M. (2011). ADHD in the classroom: Effective intervention strategies. Theory Into Practice. 50(1). P. 35 – 42. https://www.tandfonline.com/doi/abs/10.1080/00405841.2011.534935

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Attention Deficit Hyperactivity Disorder (ADHD)

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Attention Deficit Hyperactivity Disorder (ADHD)

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The Response Ability Initiative. (2015). Attention deficit hyperactivity disorder. www.responseability.org

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Stargell, N. A., Barker, L. A., Kress, V. E., & Bullock, M. L. (2017, April). Counseling youth with attention-deficit/hyperactivity disorder (ADHD). The Center for Counseling

Practice, Policy, and Research.

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Reid, R., Trout, A. L., & Schartz, M. (2005). Self-regulation interventions for children with attention deficit/hyperactivity disorder. Exceptional Children. 71(4). P. 361 – 377.

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The Texas Model for Comprehensive School Counseling Program

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The Texas Model for Comprehensive School Counseling Program

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Texas Education Agency. (2018). The Texas model for comprehensive school counseling programs (5th ed.). Texas Counseling Association.

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Buser, J. K. (2012). The school counselor's role in addressing eating disorder symptomatology among adolescents. VISTAS Online.

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Quick Guide to Anorexia Nervosa - Child Mind Institute

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Learn how anorexia nervosa affects children and teenagers. Kids with anorexia have an eating disorder that causes them to starve themselves. They believe they are too fat, yet everyone else sees them as way too thin.

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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.

What is bulimia nervosa?

Bulimia nervosa is an eating disorder in which a child has periods of out-of-control eating called binging. After eating way too much, the child tries to reverse the binging by doing what's called purging: throwing up on purpose, using laxatives, not eating, or exercising too much. Unlike kids with anorexia nervosa (who are usually extremely thin), kids with bulimia are usually normal weight or somewhat overweight. But the way they maintain their weight is very unhealthy. Bulimia is diagnosed more often in girls than boys and it usually starts in adolescence.

What are the symptoms of bulimia nervosa?

Children with bulimia often hide their binging and purging, so it can be hard to spot.

Common signs of bulimia include:

Eating a lot of food in a very short time

Making up for eating a lot by vomiting, using laxatives, not eating at all, or exercising too much

Having a self-image that is mostly focused on body weight

Missing a lot of meals

Rushing to the bathroom right after eating

Long periods of not eating

Being secretive about eating

Physical effects of vomiting, including sore throat, swollen glands, acid reflux, and teeth damaged by stomach acid

How is bulimia diagnosed?

To be diagnosed with bulimia, a child must eat large amounts of food in a short amount of time (binging) and be unable to control their binge eating. They must also try to make up for the binge eating by throwing up on purpose, using laxatives, not eating, or exercising too much. These behaviors are known as purging. Kids who are diagnosed with bulimia binge and purge at least once a week on average for three months.

The first goal of treatment for bulimia is always to help the child stop binging and purging, which can endanger their health. Two kinds of therapy are most commonly used to treat bulimia nervosa:

Cognitive behavioral therapy (CBT) can help kids understand what causes their binging and purging, develop a more positive body image, and change unhealthy eating habits.

Interpersonal therapy focuses on how the child's relationship with others affects their feelings and eating habits.

If therapy alone isn't working, anti-depressant medications are sometimes prescribed to children experiencing bulimia. Education about nutrition can also help kids learn about the health effects of bulimia and feel motivated to change their behavior.

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Quick Guide to Bulimia Nervosa - Child Mind Institute

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Download our free guide to bulimia nervosa in children and teenagers. Kids with bulimia nervosa have periods of out-of-control eating called binging. After eating way too much, they try to reverse the binging by throwing up, using laxatives, not eating, or exercising too much.

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Binge eating, which involves consuming an unusually large amount of food in a short time, has long been associated with weight problems and psychological distress. But it's only since 2013 that repeated binge eating has been classified as an eating disorder. Binge-eating disorder is usually first diagnosed in teenagers or young adults, but it can also occur in children.

It's not just the unusual amount of food eaten that defines binge eating. People with the disorder also report feeling a loss of control while eating. And when it comes to children and adolescents who struggle with binge eating, experts say it's more useful to focus on the "loss of control" experience than the amount of food consumed in an eating binge.

That's in part because when you're talking about kids, it's hard to be clear what "large amount" means - it varies for different ages, genders and developmental stages, explains Marian Tanofsky-Kraff, PhD, a researcher of binge eating in youth and a professor at the Uniformed Services University School of Medicine. "If you have a 14-year-old boy going through a burst of puberty, he could easily eat a whole pizza. Is that large?" asks Dr. Tanofsky-Kraff. "What about an eight-year-old girl who's eating four slices of pizza? Is that too much?"

But it's also important to focus on the loss of control (LOC) experience because it's a behavior that often appears in kids before they have developed full-blown binge-eating disorder (BED). Kids who have episodes of LOC eating - regardless of the amount eaten - have been shown to be at higher risk for developing BED and adult obesity. So interventions that treat LOC eating in kids may be an important way to prevent BED.

Most young people who are diagnosed with BED are identified because they are seeking treatment for obesity, explains Andrea Goldschmidt, PhD, an associate professor of psychiatry at the University of Pittsburgh School of Medicine whose research focuses on LOC. They often don't know they have an eating disorder.

"When I ask kids and their families where they want to start, often times it will be weight loss," Dr. Goldschmidt says. "And we have to help them understand that the thing they need to work on before they can lose the weight is managing their binge eating."

Binge-eating disorder is rarely flagged by pediatricians and other doctors. That is in part because doctors don't think of eating disorders when they see a patient at an above average or higher weight, notes Dr. Tanofsky-Kraff. But more broadly, doctors often avoid talking to kids about their weight, for fear of undermining their self-esteem.

Drs. Goldschmidt and Tanofsky-Kraff report seeing LOC eating in kids as young as eight years old. And they've seen kids with the full-blown BED as young as 12 or 13.

The primary symptoms of BED are recurring episodes of binge eating. Those episodes are defined by eating more food than most people would consume in a discrete period of time - for instance, within a 2-hour period - and a sense of lack of control over eating during the episode. A person with BED feels unable to stop.

The episodes may also be characterized by:

Eating much more rapidly than normal

Eating until feeling uncomfortably full

Eating large amounts of food when not feeling physically hungry

Eating alone because of feeling embarrassed by how much one is eating

Feeling disgusted with oneself, depressed or very guilty afterward

For a BED diagnosis, these episodes must occur at least once a week, have continued for 3 months, and be causing serious distress. Individuals with the disorder are typically ashamed of their eating problems and often eat in secret to hide their symptoms.

While adults who have BED tend to say their episodes are triggered by negative feelings, younger kids generally don't connect them to feeling bad. That may be because they're not able to articulate their feelings, Dr. Tanofsky-Kraff notes. "A lot of children talk about feeling like they're zoning out or paralyzed. They describe a sort of numbing out when they're eating. We're not 100 percent sure why, but we think part of it is because they're using food to cope, to deal with aversive feelings."

Unlike adults with the disorder, kids don't tend to plan for binges. Instead, the episodes happen when there is an opportunity.

Often kids report that they don't eat regularly during the school day. "I will often hear that they don't want to bring a packed lunch and say the food at school is gross, so they're coming home from school very hungry," explains Dr. Tanofsky-Kraff. "Maybe nobody else is home, or their parents are busy doing something else. Those after-school hours can be the prime risk period for loss-of-control eating."

Like other eating disorders, girls are more likely to develop BED than boys. And the disorder is highly heritable.

Young people who have been engaging in unhealthy dieting to lose weight are also at higher risk for BED. They restrict their eating so much that they become famished, and they feel deprived. Then they end up overeating and feeling out of control later.

Research led by Dr. Tanofsky-Kraff published in American Psychologist proposes that there are several factors that, combined, may increase the development of BED and high weight among youth who report LOC eating behaviors. They are:

Negative mood: experiencing depression, anxiety, stress or interpersonal difficulties

Responsiveness to foods: being particularly sensitive to food as rewarding

Executive functioning issues: poor impulse control and self-regulation skills

Research has also found that a greater percentage of kids with ADHD have recurring LOC incidents than kids without ADHD.

Treatment for BED has been studied more in adults than teenagers. For adults, several forms of therapy have been shown to be effective.

Cognitive behavior therapy (CBT): CBT is the most studied and well-established form of therapy for BED. CBT works with patients to normalize eating patterns, develop self-control and modify negative views of themselves in order to reduce binge eating.

Interpersonal psychotherapy (IPT): IPT focuses on improving interpersonal skills to foster healthy relationships and a positive self-image, and helps individuals manage negative feelings without turning to food.

Dialectical behavior therapy (DBT): DBT focuses on improving emotional regulation skills to avoid using binge eating as a way of responding to painful emotional experience.

There are three kinds of medicine that have been found to help reduce BED in adults, sometimes in conjunction with therapy:

Stimulant medications developed for ADHD, which may reduce impulsiveness (Vyvanse is FDA-approved for BED in adults).

Antidepressants, including SSRIs, which may reduce binges by boosting mood.

Anti-seizure drugs like Topamax, which help stabilize mood and reduce impulse control problems.

Drs. Goldschmidt and Tanofsky-Kraff are both involved in adapting adult treatments for use with teenagers. They emphasize that there is not yet enough research to establish a gold standard treatment for kids with the disorder.

Dr. Goldschmidt uses CBT to help young people reset their eating habits to reduce extreme dieting and prioritize regular eating and flexibility with respect to food choices. There is also a big focus on helping kids improve their self-regulation around eating, and strengthening self-regulation skills in general.

Dr. Goldschmidt sees promise in web-based interventions for teenagers, given how much they are online already, and because issues like access and stigma might limit their willingness to engage in face-to-face therapy. In her work, she uses smartphones to collect data on how kids are feeling and what they're doing, including eating. It's called "ecological momentary assessment."

"We ping them throughout the day, or they respond to surveys at the time that they have an eating episode," Dr. Goldschmidt explains, "and they're answering a series of questions about where they are, who they are with, how they are feeling, and what they are doing."

This allows clinicians to offer guidance in real time. "We can identify the momentary factors, as they're occurring, that are going to trigger a binge-eating episode, and we can intervene in the moment to tell them, 'It looks like you're heading into a party with your friends. Let's think about the ways that you're going to avoid overeating at the buffet table,'" Dr. Goldschmidt adds.

Once patterns are established, Dr. Goldschmidt says, teens can be sent periodic reminders for high-risk situations, or when they're likely to be experiencing a trigger, to remind them to practice skills they have learned. Dr. Goldschmidt calls this technology-based treatment "CBT augmented by self-regulation interventions."

Dr. Tanofsky-Kraff advocates using IPT, which is focused on helping the child to understand relationship issues that may make them turn to overeating.

Kids who are binge eating are usually struggling with relationships, she says. You might assume that their biggest concerns would be friendships and acceptance by peers, she adds, but it's usually stressors with their parents. "We did a study where we looked at all the problem areas to see what was it that was prompting their loss of control episodes, and it was most frequently difficulties with their parents."

IPT helps kids focus on interpersonal issues that are related to their eating. "For instance," she notes, "if every day when you come home from school you're having a battle with your mom, you feel badly, and you use food to cope."

Dr. Tanofsky-Kraff stresses that IPT improves not only kids' eating habits but also their lives. "It goes deeper, to what is promoting the loss of control. It also improves relationships and mood symptoms, and loss of control is highly comorbid with things like anxiety and depression."

Dr. Goldschmidt notes the importance of developing scalable interventions that could be used to get care to kids who may have poor access to mental health professionals. "We know that binge eating affects kids who are under-resourced, maybe come from minority populations, like racial and ethnic minority youth, and don't have adequate insurance coverage."

She sees hope in the use of technology like smartphones that could enable short-term treatment that targets the eating behaviors and starts to address the mechanisms, though she recognizes that this kind of treatment "is not going to cover all of the bases in terms of what's underlying the eating disorder."

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What Is Binge-Eating Disorder? - Child Mind Institute

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Binge eating, which involves consuming an unusually large amount of food in a short time, has long been associated with weight problems and psychological distress. But it's only since 2013 that repeated binge eating has been classified as an eating disorder. Binge-eating disorder is usually first diagnosed in teenagers or young adults, but it can also occur in children.

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UNDERSTANDING STAGES OF CHANGE IN THE RECOVERY PROCESS

Recovery from an eating disorder can be a long process that requires not only a qualified team of professionals, but also the love and support of family and friends. It is not uncommon for someone who suffers with an eating disorder to feel uncertain about their progress or for their loved-ones to feel disengaged from the treatment process. These potential roadblocks may lead to feelings of ambivalence, limited progress, and treatment drop out. Therefore, knowing about the Stages of Change Model, as defined by Prochaska and DiClemente, will help everyone involved better negotiate the road to recovery.

The Stages of Change in the process of recovery from an eating disorder are a cycle rather than a linear progression. The person may go through this cycle more than one time or may need to revisit a particular stage before moving on to the next. They may also go through the stages for each individual eating disorder symptom. In other words, if they are recovering from anorexia, they could be in the Action Stage for restrictive eating (e.g., eating three meals a day along with snacks, engaging in social eating, and utilizing support system) while, at the same time, they could be going through the Contemplation Stage for body image and weight concerns (e.g., becoming aware of how body image is tied to self-esteem and self-worth, defining oneself as a body or number, and identifying the negatives of striving for the "perfect body"). This is precisely why recovery from an eating disorder is complex and individualized.

The table below is a general breakdown of the Stages of Change for someone who is recovering from an eating disorder. If you are a parent or friend of someone struggling, you no doubt suffer right along with them, so it is crucial for you to pay attention to your own needs as well as be present for your child or friend during her recovery process.

WHAT ARE THE STAGES OF CHANGE?

There are five Stages of Change that occur in the recovery process: Pre-Contemplation, Contemplation, Preparation, Action, and Maintenance.

PRECONTEMPLATION STAGE

The Pre-Contemplation Stage is evident when a person does not believe they have a problem. Close family and friends are bound to pick up on symptoms such as restrictive eating, the binge/purge cycle, or a preoccupation with weight, shape, and appearance even before the individual admits to it. They may refuse to discuss the topic and deny they need help. At this stage, it is necessary to gently educate the individual about the devastating effects the disorder will have on their health and life, and the positive aspects of change.

Do not be in denial of your child or friend's eating disorder.

Be aware of the signs and symptoms.

Avoid rationalizing their eating disordered behaviors.

Openly share your thoughts and concerns with your child or loved one.

CONTEMPLATION STAGE

The Contemplation Stage occurs when an individual is willing to admit that they have a problem and are now open to receiving help. The fear of change may be very strong, and it is during this phase that a psychotherapist should assist the individual in discovering the function of their eating disorder so they can understand why it is in their life and how it no longer serves them. This, in turn, helps the individual move closer toward the next stage of change.

If your child is under the age of 18, insist that they receive professional help from a qualified eating disorder specialist.

Educate yourself about the disorder.

Be a good listener.

Do not try to "fix" the problem yourself.

Seek your own encouragement from a local eating disorder support group for family and friends.

Find a support group >
PREPARATION STAGE

The person transitions into the Preparation Stage when they are ready to change, but are uncertain about how to do it. Time is spent establishing specific coping skills such as appropriate boundary setting and assertiveness, effective ways of dealing with negative eating disorder thoughts and emotions, and ways to tend to their personal needs. Potential barriers to change are identified. This is usually when a plan of action is developed by the treatment team, (i.e. psychotherapist, nutritionist, and physician) as well as the individual and designated family members. This generally includes a list of people to call during times of crisis.

If supporting a loved one in their recovery, identify what your role is in the recovery process.

Explore your own thoughts and beliefs about food, weight, shape, and appearance.

Ask your child/loved one and the treatment team how you can be best involved in the recovery process and what you can do to be supportive.

Visit Where Do I Start? >
ACTION STAGE

The Action Stage begins when the person is ready to implement their strategy and confront the eating disorder behavior head on. At this point, they are open to trying new ideas and behaviors, and are willing to face fears in order for change to occur. Trusting the treatment team and their support network is essential to making the Action Stage successful.

Follow the treatment team's recommendations.

Remove triggers from your environment: no diet foods, no scales, and no stress.

Be warm and caring, yet appropriate and determined with boundaries, rules, and guidelines.

Reinforce positive changes without focusing on weight, shape, or appearance.

MAINTENANCE/RELAPSE

The Maintenance Stage evolves when the person has sustained the Action Stage for approximately six months or longer. During this period, they actively practice new behaviors and new ways of thinking as well as consistently use both healthy self-care and coping skills. Part of this stage also includes revisiting potential triggers in order to prevent relapse, establishing new areas of interests, and beginning to live their life in a meaningful way.

Applaud your loved one's efforts and successes.

Continue to adjust to new developments.

Redefine the boundaries at home as necessary.

Maintain positive communications.

Be aware of possible recovery backsliding.

Learn more about recovery and relapse >
A possible Sixth Stage

The Termination Stage & Relapse Prevention. Relapse is sometimes grouped with the maintenance stage since recovery in nonlinear and it is not uncommon to return to old behaviors during the overall recovery process.

So, how do you know when it is time to discontinue treatment? With the understanding that this decision is best made in consultation with your treatment team, ask yourself the following questions:

Have I mastered the Stages of Change in the major areas of my eating disorder?

Do I have the coping skills necessary to maintain these changes?

Do I have a relapse prevention plan in place?

Am I willing to resume treatment in the future if necessary?

To prevent relapsing do not forget to ask for help, communicate your thoughts and feelings, address and resolve problems as they arise, live a healthful and balanced life, and remember that you would not have made it this far if it were not for your strong determination and dedication toward recovery.

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UNDERSTANDING STAGES OF CHANGE IN THE RECOVERY PROCESS Recovery from an eating disorder can be a long process that requires not only a qualified team of professionals, but also the love and support of family and friends.

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National Institute of Mental Health (NIMH)

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Overview

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

Signs and symptoms

Risk factors

Treatments and therapies

Join a study

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Learn about eating disorders, including types (e.g., anorexia nervosa, bulimia nervosa), signs and symptoms, risk factors, and treatments and therapies.

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https://childmind.org/guide/anxiety-in-children-quick-guide/

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Anxiety is a very general term used to describe a feeling of extreme worry or unease. Feeling anxious is natural after something upsetting happens. But when a child feels anxiety that lasts a long time and prevents them from doing things like going to school or seeing friends, then it becomes an anxiety disorder. Children can be diagnosed with several different anxiety disorders. The specific disorder depends on what the child is struggling with most, but many of the symptoms overlap.

What are the symptoms of anxiety in children?

Anxiety has many symptoms and can look very different from child to child. Here are some common signs that a child might have an anxiety disorder:

Trouble sleeping

Complaining about stomachaches or other physical problems

Avoiding certain situations

Being clingy around parents or caregivers

Trouble concentrating in class or being very fidgety

Tantrums

Being very self-conscious

Children can be diagnosed with different kinds of anxiety depending on what they are most worried about.

What kinds of anxiety disorders can children experience?

Separation anxiety disorder: Children feel extremely upset when they have to be away from parents or caregivers. This anxiety goes beyond what other kids their age normally feel.

Symptoms of separation anxiety include:

Children with separation anxiety disorder show symptoms for at least four weeks.

Social anxiety disorder: Children with social anxiety disorder feel extremely self-conscious around other people. They are so afraid of being embarrassed that they avoid social situations and even speaking in class.

Symptoms of social anxiety disorder in children include:

Avoiding most social situations or feeling terrible when they have to participate in them

Physical symptoms like shaking, sweating or trouble breathing in social situations

In young children, tantrums and crying in social situations

Fear of others seeing their anxiety and judging them for it

For a child to be diagnosed with social anxiety disorder, their worry must be so extreme that it interferes with daily life.

Selective mutism: Children with selective mutism have a hard time speaking in some situations, like at school. These kids aren't just shy. Their anxiety is so bad that they feel frozen and are not able to speak.

To get a diagnosis of selective mutism, the child must:

Be able to speak in some situations but not others

Have had the problem for at least a month

Have problems with school and social activities as a result

Children are not diagnosed with selective mutism if their trouble speaking is caused by a communication disorder or language barrier.

Generalized anxiety disorder: Children with generalized anxiety disorder worry about a lot of everyday things. Their worry is not caused by anything specific and it is bad enough to get in the way of daily life.

Symptoms of generalized anxiety disorder in children include:

Restlessness

Feeling on edge

Feeling tired much of the time

Problems concentrating

Feeling angry

Trouble sleeping

To be diagnosed with generalized anxiety disorder, children must experience symptoms most days for at least six months.

Panic disorder: Children with panic disorder have frequent, unexpected panic attacks. Panic attacks cause physical feelings that can make kids think they are dying or having a heart attack.Children are diagnosed with panic disorder when they experience at least one panic attack and show other signs including:

Constant fear of more panic attacks

A big change from normal behavior after the panic attacks, like avoiding places that remind them of an attack

When diagnosing a child with panic disorder, a professional also rules out medical causes and other disorders like PTSD.

Obsessive-compulsive disorder (OCD): Children with OCD have thoughts and worries that make them very anxious. They develop rules for themselves that they feel they must follow to control the anxiety.

Obsessions are the unwanted thoughts that make kids feel upset and anxious.

Compulsions are the rules kids feel they have to follow to get rid of their anxiety.

Children can be diagnosed with OCD when they have obsessions, compulsions or both.

Specific phobia: Kids with specific phobias are very afraid of one or more specific things. This fear is of something that isn't normally considered dangerous. Phobias disrupt kids' lives when they go out of their way to avoid the things they're afraid of.

Common phobias in children include:

Anxiety is a very general term used to describe a feeling of extreme worry or unease. Feeling anxious is natural after something upsetting happens. But when a child feels anxiety that lasts a long time and prevents them from doing things like going to school or seeing friends, then it becomes an anxiety disorder. Children can be diagnosed with several different anxiety disorders. The specific disorder depends on what the child is struggling with most, but many of the symptoms overlap.

What are the symptoms of anxiety in children?

Anxiety has many symptoms and can look very different from child to child. Here are some common signs that a child might have an anxiety disorder:

Trouble sleeping

Complaining about stomachaches or other physical problems

Avoiding certain situations

Being clingy around parents or caregivers

Trouble concentrating in class or being very fidgety

Tantrums

Being very self-conscious

Children can be diagnosed with different kinds of anxiety depending on what they are most worried about.

What kinds of anxiety disorders can children experience?

Separation anxiety disorder: Children feel extremely upset when they have to be away from parents or caregivers. This anxiety goes beyond what other kids their age normally feel.

Symptoms of separation anxiety include:

Children with separation anxiety disorder show symptoms for at least four weeks.

Social anxiety disorder: Children with social anxiety disorder feel extremely self-conscious around other people. They are so afraid of being embarrassed that they avoid social situations and even speaking in class.

Symptoms of social anxiety disorder in children include:

Avoiding most social situations or feeling terrible when they have to participate in them

Physical symptoms like shaking, sweating or trouble breathing in social situations

In young children, tantrums and crying in social situations

Fear of others seeing their anxiety and judging them for it

For a child to be diagnosed with social anxiety disorder, their worry must be so extreme that it interferes with daily life.

Selective mutism: Children with selective mutism have a hard time speaking in some situations, like at school. These kids aren't just shy. Their anxiety is so bad that they feel frozen and are not able to speak.

To get a diagnosis of selective mutism, the child must:

Be able to speak in some situations but not others

Have had the problem for at least a month

Have problems with school and social activities as a result

Children are not diagnosed with selective mutism if their trouble speaking is caused by a communication disorder or language barrier.

Generalized anxiety disorder: Children with generalized anxiety disorder worry about a lot of everyday things. Their worry is not caused by anything specific and it is bad enough to get in the way of daily life.

Symptoms of generalized anxiety disorder in children include:

Restlessness

Feeling on edge

Feeling tired much of the time

Problems concentrating

Feeling angry

Trouble sleeping

To be diagnosed with generalized anxiety disorder, children must experience symptoms most days for at least six months.

Panic disorder: Children with panic disorder have frequent, unexpected panic attacks. Panic attacks cause physical feelings that can make kids think they are dying or having a heart attack.Children are diagnosed with panic disorder when they experience at least one panic attack and show other signs including:

Constant fear of more panic attacks

A big change from normal behavior after the panic attacks, like avoiding places that remind them of an attack

When diagnosing a child with panic disorder, a professional also rules out medical causes and other disorders like PTSD.

Obsessive-compulsive disorder (OCD): Children with OCD have thoughts and worries that make them very anxious. They develop rules for themselves that they feel they must follow to control the anxiety.

Obsessions are the unwanted thoughts that make kids feel upset and anxious.

Compulsions are the rules kids feel they have to follow to get rid of their anxiety.

Children can be diagnosed with OCD when they have obsessions, compulsions or both.

Specific phobia: Kids with specific phobias are very afraid of one or more specific things. This fear is of something that isn't normally considered dangerous. Phobias disrupt kids' lives when they go out of their way to avoid the things they're afraid of.

Common phobias in children include:

Almost all types of anxiety are best treated with cognitive behavioral therapy (CBT). CBT is based on the idea that how we think and act both affect how we feel. By learning to change negative thoughts and unhealthy actions, kids can change their bad feelings.

An important part of CBT in treatment for anxiety is called exposure and response prevention. In exposure and response prevention, the therapist helps the child face the thing they're afraid of a little at a time. By dealing with their fear in small amounts in a safe space, kids learn to deal with the big feelings that come up.

For some children, taking medication for anxiety in addition to going through therapy makes treatment more effective.

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Quick Guide to Anxiety in Children - Child Mind Institute

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Download our free guide to different kinds of anxiety in children. Anxiety causes an extreme feeling of unease in kids. While some anxiety in stressful situations is normal, it becomes a disorder if it lasts a long time or gets in the way of daily life.

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https://www.mayoclinic.org/diseases-conditions/agoraphobia/symptoms-causes/syc-20355987

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Overview

Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed. You fear an actual or anticipated situation, such as using public transportation, being in open or enclosed spaces, standing in line, or being in a crowd.

The anxiety is caused by fear that there's no easy way to escape or get help if the anxiety intensifies. Most people who have agoraphobia develop it after having one or more panic attacks, causing them to worry about having another attack and avoid the places where it may happen again.

People with agoraphobia often have a hard time feeling safe in any public place, especially where crowds gather. You may feel that you need a companion, such as a relative or friend, to go with you to public places. The fear can be so overwhelming that you may feel unable to leave your home.

Agoraphobia treatment can be challenging because it usually means confronting your fears. But with psychotherapy and medications, you can escape the trap of agoraphobia and live a more enjoyable life.

Symptoms

Typical agoraphobia symptoms include fear of:

Leaving home alone

Crowds or waiting in line

Enclosed spaces, such as movie theaters, elevators or small stores

Open spaces, such as parking lots, bridges or malls

Using public transportation, such as a bus, plane or train

These situations cause anxiety because you fear you won't be able to escape or find help if you start to feel panicked or have other disabling or embarrassing symptoms.

In addition:

Fear or anxiety almost always results from exposure to the situation

Your fear or anxiety is out of proportion to the actual danger of the situation

You avoid the situation, you need a companion to go with you, or you endure the situation but are extremely distressed

You experience significant distress or problems with social situations, work or other areas in your life because of the fear, anxiety or avoidance

Your phobia and avoidance usually lasts six months or longer

Panic disorder and agoraphobia

Some people have a panic disorder in addition to agoraphobia. Panic disorder is a type of anxiety disorder in which you experience sudden attacks of extreme fear that reach a peak within a few minutes and trigger intense physical symptoms (panic attacks). You might think that you're totally losing control, having a heart attack or even dying.

Fear of another panic attack can lead to avoiding similar circumstances or the place where it occurred in an attempt to prevent future panic attacks.

Signs and symptoms of a panic attack can include:

Rapid heart rate

Trouble breathing or a feeling of choking

Chest pain or pressure

Lightheadedness or dizziness

Feeling shaky, numb or tingling

Excessive sweating

Sudden flushing or chills

Upset stomach or diarrhea

Feeling a loss of control

Fear of dying

When to see a doctor

Agoraphobia can severely limit your ability to socialize, work, attend important events and even manage the details of daily life, such as running errands.

Don't let agoraphobia make your world smaller. Call your doctor if you have signs or symptoms listed above.

Causes

Biology - including health conditions and genetics - temperament, environmental stress and learning experiences may all play a role in the development of agoraphobia.

Risk factors

Agoraphobia can begin in childhood, but usually starts in the late teen or early adult years - usually before age 35 - but older adults can also develop it. Women are diagnosed with agoraphobia more often than men are.

Risk factors for agoraphobia include:

Having panic disorder or other phobias

Responding to panic attacks with excessive fear and avoidance

Experiencing stressful life events, such as abuse, the death of a parent or being attacked

Having an anxious or nervous temperament

Having a blood relative with agoraphobia

Complications

Agoraphobia can greatly limit your life's activities. If your agoraphobia is severe, you may not even be able to leave your home. Without treatment, some people become housebound for years. You may not be able to visit with family and friends, go to school or work, run errands, or take part in other normal daily activities. You may become dependent on others for help.

Agoraphobia can also lead to or be associated with:

Depression

Alcohol or drug abuse

Other mental health disorders, including other anxiety disorders or personality disorders

Prevention

There's no sure way to prevent agoraphobia. However, anxiety tends to increase the more you avoid situations that you fear. If you start to have mild fears about going places that are safe, try to practice going to those places over and over again before your fear becomes overwhelming. If this is too hard to do on your own, ask a family member or friend to go with you, or seek professional help.

If you experience anxiety going places or have panic attacks, get treatment as soon as possible. Get help early to keep symptoms from getting worse. Anxiety, like many other mental health conditions, can be harder to treat if you wait.

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Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed. You fear an actual or anticipated situation, such as using public transportation, being in open or enclosed spaces, standing in line, or being in a crowd.

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http://www.worrywisekids.org/node/28

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A panic attack is a sudden rush of uncomfortable physical symptoms and a feeling of imminent danger (doing something embarrassing such as fainting or throwing up; having a heart attack, or not being able to breathe). Unlike other anxiety subtypes, the first panic attack is not triggered by any specific event, it occurs out of the blue. Following this, children may fear and attempt to avoid the situation or setting where the first panic attack occurred in order to prevent it from happening again.

A sudden surge of anxiety symptoms that appear out of the blue and peak within 10 minutes

Surge of physical symptoms- dizziness, feeling faint, heart racing, tingling in extremities, stomach ache

Fear that you are going to have a heart attack or go crazy or lose control in some way children may fear crying hysterically, throwing up, losing control of bowels

Feeling unreal as if in a movie, or detached from one's body

Avoidance of situations for fear of having a panic attack

In treatment, children learn that a panic attack is a completely harmless (though frightening) testing of the emergency response system in the body. All the uncomfortable symptoms a child experiences can be explained by specific actions of the sympathetic nervous system. Once the child understands how panic occurs, he or she learns how to control worries about the panic itself, as well as control the physical symptoms through breathing techniques. Panic symptoms may be simulated through hyperventilation, spinning in a chair, running up and down stairs, so that the child can practice breathing techniques and constructive interpretation of the physical sensations that these activities trigger. Once confident that they can stop the panic spiral, the child next begins to approach the situations (often open situations-church, supermarket, auditorium, movie theater) which have been avoided due to fear of having a panic attack.

Brought to you by The Children's and Adult Center for OCD and Anxiety.

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A panic attack is a sudden rush of uncomfortable physical symptoms and a feeling of imminent danger (doing something embarrassing such as fainting or throwing up; having a heart attack, or not being able to breathe). Unlike other anxiety subtypes, the first panic attack is not triggered by any specific event, it occurs out of the blue.

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http://www.worrywisekids.org/node/29

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Children with social phobia are not just a little "shy," rather they are painfully uncomfortable in any situation where they could be embarrassed or feel they are being evaluated. They may see these threats even in relatively safe situations. These children often wish they had more friends but find it hard to do the things that are required to make new friends or maintain these'friendships. Often time adolescents will say they like being alone and don't need friends. For some kids it's better not to know than take the risk they will be rejected.

Children with social anxiety appear uncomfortable and may choose to withdraw or not talk to prevent the risk of embarrassment. They are often successful at being invisible, in that while they may not actually incur the social rejection that they fear, they may be unnoticed by their peers and have a socially neglected status because of their voluntary isolation, (eating lunch in the bathroom or alone at a table, avoiding recess by going to the library or helping the teacher).

Fears being humiliated, embarrassing or laughed at in everyday situations

Avoid social contact or endures with great distress

Physical symptoms of anxiety- racing heart, sweaty palms, difficulty concentrating, stomachaches

Avoid eye contact, conversation with others

May be terrified of using the telephone, ordering in a restaurant, eating in a cafeteria

May be unable to raise a hand in class, do book reports or presentations, or ask for help which would require being the focus of attention

Avoidance of gym class or using school or public bathroom

Hesitant to go to friend's houses or talk to friend's parents

Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally based panic. In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from contact. Persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.

Clinically significant distress or impairment in important areas of functioning.

Duration of at least 6 months

The treatment focus for Social Phobia is similar to GAD with focus on addressing physical symptoms, identifying anxious thoughts and development of coping thoughts, and problem solving. Children learn that the worry voice is a disruptive internal critic, by devaluing that voice and "firing the judge," they can learn to turn attention away from self and toward others and focus on the task rather than who is watching. The early in vivo experiences may be smiling and making eye contact with a familiar peer, later making a phone call to a peer to invite them over, and moving up to giving a presentation in front of others.

Brought to you by The Children's and Adult Center for OCD and Anxiety.

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Children with social phobia are not just a little "shy," rather they are painfully uncomfortable in any situation where they could be embarrassed or feel they are being evaluated. They may see these threats even in relatively safe situations.

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https://childmind.org/guide/quick-guide-%20to-specific-phobia/

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Specific phobia is a mental health condition in which a child has an extreme and uncontrollable fear of something that is not actually dangerous. Common specific phobias include dogs, clowns, bugs, the dark and loud noises. Being around the thing they are afraid of or even thinking about it causes the child severe anxiety. These children are not anxious in general. It's just the thing they're afraid of that upsets them.

Adults and teenagers with specific phobia usually understand that their fears aren't logical, but children often don't understand that. They will put a lot of effort into avoiding the thing they're afraid of, which can interfere with their daily lives.

Specific phobia is more common in girls than boys.

What are the symptoms of specific phobia?

Signs that a child may have specific phobia include:

Extreme fear of a certain object or situation

Having anxiety attacks when they see or even think about the thing that scares them

Crying or throwing tantrums to avoid the thing that scares them

Trembling, dizziness, or sweating in reaction to the thing that scares them

It's common for children to have more than one specific phobia. For example, a child might be scared of both dogs and heights.

How is specific phobia diagnosed?

To be diagnosed with specific phobia, a child must show extreme fear of something not normally considered dangerous. Avoiding the thing they fear must cause problems with daily life. The fear or anxiety must happen nearly every time the child comes into contact with the thing they fear, but the amount of fear can they show can vary.

Specific phobias usually fall into one of five categories:

Animal Type (dogs, bugs, snakes, etc.)

Natural Environment Type (storms, heights, water, etc.)

Blood-Injection-Injury Type (getting shots, seeing blood or injuries)

Situational Type (flying, driving, small spaces)

Other Type (anything else)

How is specific phobia treated?

The best treatment for specific phobia is called exposure and response prevention. This means that the child is slowly exposed to the thing they are afraid of over and over, until their fear is not as bad. This treatment works very well for most kids with specific phobia.

For example, a child who is afraid of dogs would first look at a picture of a dog, then play with a stuffed dog. Eventually they would spend a few minutes with a real small dog.

Cognitive behavioral therapy (CBT) that teaches skills to deal with anxious thought patterns can also help older kids with specific phobia. Medication is not usually used to treat specific phobia.

This guide was last reviewed or updated on September 7, 2021.

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Quick Guide to Specific Phobia - Child Mind Institute

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Download our free guide to specific phobia in children. Specific phobia is when a child has an extreme fear of something that is not actually dangerous, like dogs, clowns, bugs, the dark or loud noises. Being around the thing they are afraid of or even thinking about it causes severe anxiety.