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The TEA Texas Model for Comprehensive School Counseling Programs

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The TEA Texas Model for Comprehensive School Counseling Programs

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International OCD Foundations - Great Spot for Resources

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International OCD Foundations - Great Spot for Resources

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There are various educational resources available for understanding and managing OCD. From expert articles, to books and multimedia, view our full list of resources below.

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Recommended OCD Resources | The OCD & Anxiety Center

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Online resources for OCD sufferers - support groups, organizations, and blogs.

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OCD Resources From the American Academy of Child & Adolescent Psychiatry (Includes Video Clips and Handouts)

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OCD Resources From the American Academy of Child & Adolescent Psychiatry (Includes Video Clips and Handouts)

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Obsessive Compulsive Disorder Resource Center

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Attention Deficit/Hyperactivity Disorder (ADHD) is a condition which includes difficulties with attention, increased activity, and difficulties with impulsivity.

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Approximately 1 in 100 children have a diagnosis of Obsessive Compulsive Disorder (OCD). For many, OCD is a silent battle, commonly underdiagnosed, leading to many individuals silently suffering for years. OCD greatly impacts a child's social, emotional, and academic functioning. Since children spend the majority of their time in school it is incredibly important for parents of children with OCD to team up with school personnel to develop a plan to reduce OCD impact on school performance.
Spread Awareness
Parents should make sure school personnel have a general understanding of how your child's OCD presents and what they can expect. Knowledge creates understanding; transparency between parents and school personnel will be incredibly vital in finding school success. Disclosure of your child's diagnosis not only reduces stigma but also creates a space for your child to receive needed academic accommodations that will level their playing field and decrease the likelihood of internalized feelings of not being "good enough", "stupid", and a "failure" due to OCD symptoms. The Federal Individuals with Disabilities Education Act (IDEA) provides special education and related accommodations for students with disabilities including children with a diagnosis of OCD. Section 504 of the American with Disabilities ACT (ADA) ensures students with disabilities will not be denied the same academic opportunities as peers due to their disability. Speak with your school's counselor to determine what documentation you may need from your specialized OCD provider or additional testing to begin the 504 or IEP process for your child.
How OCD Can Impact your Child's School Day
-Frequent class tardiness

-Inability to keep up with reading and writing responsibilities

-Increase in general school avoidance

-Decreased ability to concentrate during lectures

-Inhibit ability to complete regular homework assignments

-Impair normal social interactions

-Increased anxiety in speaking with teachers

-Withholding of turning in already completed assignments

-Unkind attention from peers due to repetitive externalized compulsions

-Heightened stress and delays during class transitions

-Increased frustration and outburst during class
Additional Signals for Teachers and Parents
-Persistent reassurance questions to teachers, nurses, or counselors

-Incessant calls home to leave school, "I don't feel well", "I can't be here", and "I hate it here"

-Prolonged and frequent bathroom visits and/or mysteriously clogged toilets

-Excessively dry, red, or chapped hands, arms, and face

-Intense fixation on completing a specific task ("just right")

-Consistent requests to be excused to nurse's office

-Repeating of body movements and phrases especially when interrupted

-Frequent erasing, rewriting, and throwing away of paper

-Incredibly behind in completing reading assignments due to repetitive need to "reread"

-Excessive ordering and organizing of book bag, school locker, and/ or desk
Commonly Requested Academic Accommodations
-Extension on deadlines for academic assignments

-Extended time for completing tests: 1.5x or 2x

-Reduced workload by 50%

-Separate classroom for reduced distraction for completion of tests and/or assignments

-Copy of class notes from a peer or teacher

-Approved fidgets in classroom

-Excused from written essays and ability to provide essay orally instead

-Additional breaks and identified "safe place" at school (guidance counselor office, library, etc..)

If your child is just starting their journey towards alleviating their OCD symptoms make sure your child's therapist is experienced in providing Exposure with Response Prevention, the gold standard treatment for Obsessive Compulsive Disorder.

Looking for treatment for your child with OCD? Get connected with Kelsi below.

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Find Your BASE- OCD in School: Impact And Accommodations

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Kelsi Libfraind, LCSW Is your child suffering silently from Obsessive Compulsive Disorder? If so, it is highly likely it is impacting their school day. Read on for tips on how to support your child and what schools can do to recognize these symptoms early.

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BodyWise Handbook for Eating Disorders in Middle School

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BodyWise Handbook for Eating Disorders in Middle School

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Warning Signs and Treatment for Tweens with Eating Disorders

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Warning Signs and Treatment for Tweens with Eating Disorders

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A 7-year-old states that she is vegetarian because she loves animals, and begins to eat a more restricted diet. A 10-year-old is concerned about starvation in the world and begins to feel guilty about their abundance of food, and slowly begins to eat fewer food choices. An 8-year-old eats less in response to stressful family dynamic and begins to lose weight.

Eating disorders are dangerous at any age, but when the symptoms go unnoticed in a child, it can be catastrophic. Children have lower percentage of body fat, and small amounts of weight loss can be medically detrimental to growth and physical health. Bodies and brains are continually developing at this age and eating disorders can affect development through limiting growth potential and damaging vital organs [1, 5].

Margaret Kelly, a clinical nurse manager at Children's Hospital Denver, states that their program has had to reduce the admittance requirements to age 9 for eating disorders. She states that the increase in males has gone up in the last decade, as well [1].

5 percent of adolescents are affected by an eating disorder, and at least 10 percent of adults first showed clear symptoms prior to age 10. According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD), 60 percent of elementary and middle school teachers report eating disorders are a problem.

Further statistics from the National Eating Disorders Association (NEDA) stated that 41 percent of children in first through third grade report they want to be thinner, and 81 percent of 10-year-olds are afraid of becoming fat. A further 51 percent of 9 and 10-year-olds say they would feel better about themself if they were on a diet.

Risk Factors for Children

Children are more vulnerable to eating disorders due to culture and personality traits [1, 3]. Common traits are high levels of anxiety, perfectionism, obsessive-compulsive tendencies, depression, and addiction. Children also have genetic risks that can compound when mixed with personality traits.

Cultural pressures, including messages at school around healthy eating and exercise, can be misheard and misperceived by many children. Magazine ads, commercials, and unhealthy family expectations and pressures all add to the vulnerability of the development of an eating disorder in children.

Sports can also play a role in the development of an eating disorder. Children are participating at a much younger age than before, and involved in competitive levels and/or on various levels of teams. Team uniforms and sports that have a higher emphasis on appearance can also increase the risk of an eating disorder.

Another factor is puberty. This can be a trigger due to rapid growth spurts and weight gain as their bodies change. Both boys and girls may have a wider body prior to the growth spurt, which may result in bullying by peers.

Types of Eating Disorders and Symptoms in Children

In children, eating disorders can overlap [2]. Some children may alternate between periods of anorexia, bulimia, and binge eating.

Children often struggle with feelings of distress around weight gain or mealtime situations, may feel helplessness around the disorder, and struggle with low self-esteem. Developing unhealthy eating habits may seem like an option to tweens to control their feelings or situation.

Physical issues are common with those who have an eating disorder and can lead to serious, sometimes fatal, medical complications.

Early symptoms to look out for in children are:

Skipping meals or making excuses to eat in secret

Excessive focus on food or healthy eating

Persistent worry or complaints of being fat

Frequent body checking

Repeatedly eating large amounts of sweets or high-fat foods

Regularly going to the bathroom after eating

Eating more than considered normal for a meal or snack

Expressing depression, disgust, shame, or guilt about eating habits [3].

Anorexia symptoms can include being thin or emaciated yet wanting to diet, being underweight but having an intense fear of becoming fat, menstruation that is infrequent or stops altogether, rapid weight loss, and strange eating habits.

Damage to major organs, such as brain, heart, and kidneys, can occur with significant weight loss. Irregular heartbeat or slowed heart rhythm, lowered blood pressure, pulse, and temperature, sensitivity to cold, and thinning of bones are all common results of weight loss.

The most common causes of death in children with anorexia are cardiac arrest, electrolyte imbalance, and suicide [2, 4].

Tweens can often struggle with fear of weight gain and feelings of distress around body shape and size. Often with eating disorder overlap, a child may overeat and feel a sense of lack of control. This leads to vomiting, laxative use, diet pills, diuretics, or enema use to rid the body of food consumed. Typically, purging behaviors bring a sense of relief to the child, reinforcing the eating disorder. Many times the purging behaviors are done in secret.

Symptoms of bulimia in children can include increased anxiety, binging on large amounts of food or food missing from cabinets and refrigerator, eating in secret, or noticing unusual eating habits.

Excessive exercise with sport, or practicing outside of scheduled games or practices, is also a sign. Some children will excessively play or fidget, as well, after mealtimes. Physical complications include damage and erosion of tooth enamel, inflammation of the esophagus, swelling of salivary glands in cheeks where they look puffy, and lower blood levels of potassium, which can lead to abnormal heart rhythms [2, 4].

Binge eating is similar to bulimia but without the purging aspect. It includes chronic, out-of-control eating of large amounts of food in a short period of time. It often brings discomfort physically to the child and causes guilt, shame, and distress. Typically a binge will occur in secret, is chaotic, and is done in a 2-hour period or less with an out-of-control feeling and inability to stop.

Children who binge eat are often overweight due to consumption of large amount of foods and non-compensating behaviors. These individuals may struggle with managing emotions, such as anger, worry, stress, sadness, or boredom. Depression and anxiety are also common with binge eating. Health problems include heart disease, high blood pressure, high cholesterol, and type 2 diabetes [2, 4].

Treatment of Eating Disorders

The first step in eating disorder treatment is often to have the child assessed by a coordinator of a hospital or higher level of care treatment facility. Once the assessment is complete, the determination of which treatment option is best will be decided and the child admitted to the program.

The primary goal, at first, is to restore weight and healthy eating patterns. If malnutrition is severe, or a concern, the child will be first admitted to hospital for refeeding until medically stable. In these cases, a feeding tube may be required for weight restoration. Psychological treatment may include medication treatment for co-occurring mood disorders, behavioral therapy, group support, psychotherapy and nutritional counseling.

Treatment for bulimia in children is multi-fold. The first step is to reduce and cease the binge-purge cycle. Treatment options may include hospitalization, depending on severity of cycles. It is also important to have the child evaluated by a medical physician who specializes in pediatric eating disorders. Further treatment can include medication for mood disorders, behavior modification, individual, family, and group therapy, and nutritional counseling.

Treatment for binge eating in tweens includes behavioral therapy, such as cognitive behavioral to address negative thinking and unhealthy behaviors, medication treatment, and psychotherapy, as well as nutritional counseling to establish healthy eating habits and cease binging behaviors.

In conclusion, with comprehensive treatment, children and teens can manage eating disorder symptoms and reach full recovery.

It is important to get an assessment and treatment for a child who is struggling. Treatment often includes the family, as both individual and group practices are highly effective. Research shows that early identification and treatment lead to successful results [5].
About the Author: Libby Lyons is a Licensed Clinical Social Worker and Certified Eating Disorder Specialist (CEDS). Libby has been practicing in the field of eating disorders, addictions, depression, anxiety and other comorbid issues in various agencies. Libby has previously worked as a contractor for the United States Air Force Domestic Violence Program, Saint Louis University Student Health and Counseling, Saint Louis Behavioral Medicine Institute Eating Disorders Program, and has been in Private Practice.
Libby currently works as a counselor at Fontbonne University and is a Adjunct Professor at Saint Louis University, and is a contributing author for Addiction Hope and Eating Disorder Hope. Libby lives in the St. Louis area with her husband and two daughters. She enjoys spending time with her family, running, and watching movies. References:
[1] Renkl, M. (n.d.). The scary trend of tweens with anorexia. Retrieved March, 2017, from http://www.cnn.com/2011/HEALTH/08/08/tweens.anorexia.parenting/index.htmlKam, K. (n.d.). Eating Disorders in Children and Teens. Retrieved March, 2017, from http://www.webmd.com/mental-health/eating-disorders/features/eating-disorders-children-teens#1Teen eating disorders: Tips to protect your teen. (2015, June 02). Retrieved March, 2017, from http://www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/teen-eating-disorders/art-20044635https://www.nationaleatingdisorders.org/sites/default/files/Toolkits/ParentToolkit.pdf
[2] [3]
[4] (n.d.) Retrieved March 2017, from
[5] A. (n.d.). Retrieved March, 2017, from https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_families_Pages/Teenagers_With_Eating_Disorders_02.aspx

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals. We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.
Published on May 4, 2017.
Reviewed By: Jacquelyn Ekern, MS, LPC on May 3, 2017.
Published on EatingDisorderHope.com

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Tweens with Eating Disorders: Warning Signs and Treatment Options

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A 7-year-old states that she is vegetarian because she loves animals, and begins to eat a more restricted diet. A 10-year-old is concerned about starvation in the world and begins to feel guilty about their abundance of food, and slowly begins to eat fewer food choices.

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Purging Disorder Symptoms and Treatements

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Purging Disorder Symptoms and Treatements

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Purging disorder is an eating disorder that involves "purging" behavior to induce weight loss or manipulate body shape. Purging can mean a number of things, including:

self-induced vomiting

misuse of laxatives or medications

excessive exercise

fasting

While it's not as well-known as other eating disorders, purging disorder is a recognized eating disorder. It's categorized as an "Other Specified Feeding or Eating Disorder."

It's critical to remember that eating disorders are among the deadliest mental health conditions. They can cause significant harm to both physical and mental health.

If you're experiencing symptoms of an eating disorder, remember that you aren't alone and help is always available.

Bulimia is a serious eating disorder that often occurs in a cycle of binge-eating behavior followed by a period of purging.

While bulimia and purging disorder can both share purging behaviors, the main difference between the two is that there's a compulsion to binge eat with bulimia.

Purging disorder is as engaging in purging behaviors without it being in response to a binge-eating episode.

As a recognized eating disorder, purging disorder can be identified by many of the same symptoms as other eating disorders. Symptoms might include:

recurring episodes of purging behaviors to lose weight, including:

self-induced vomiting

laxative or diuretic misuse

misuse of enemas

fasting

excessive exercise

significant emotional distress or disruption to social, work, or personal life

fear of gaining weight or obsession with losing weight

self-esteem issues heavily influenced by body shape or weight

You can be any shape or size and have an eating disorder. This is why it's important to recognize the symptoms before your health is damaged.

If you think you or a loved one may have an eating disorder, you can take an online-self assessment to determine if you have any behaviors that could potentially result in an eating disorder.

However, it's important to note that these assessments don't qualify as a diagnosis. If you think you have an eating disorder, speak with your doctor.

Eating disorders like purging disorder can affect anyone, regardless of:

Stereotypes that eating disorders only affect teenage girls are both incorrect and damaging. This idea can often discourage people from seeking treatment.

What the research says

There are certain factors that might contribute to higher rates of eating disorders among certain people.

Sexual and physical abuse, or participating in appearance or weight-focused sports, are potential risk factors.

While studies suggest that eating disorders are more common during late childhood and adolescence, it's possible for eating disorders to occur at any time in life.

Men are also at risk for eating disorders. A recent review concluded that at least of people with eating disorders are male. Plus, eating disorders like purging disorder are actually increasing at a faster rate among males than females.

People who have an eating disorder are also more likely to have another mood disorder at the same time. One study concluded that as many as 89 percent of individuals with eating disorders often have concurrent mood disorders, such as:

Eating disorders are a serious mental health condition, not a choice. There's no shame in getting help.

Treatment for purging disorder can vary based on each person. Some people may benefit from more intensive inpatient treatment and recovery programs, while others might prefer outpatient therapy options.

Inpatient treatment is more common in cases that require medical monitoring or daily assessments. Outpatient treatment might include psychotherapy and nutrition counseling.

Medications aren't used to treat purging disorder. Rather, they may be prescribed to treat concurrent mood disorders that may be causing additional stress or making it harder to cope with recovery. Talk with your doctor about medication options.

Purging disorder can cause many serious side effects to your health, including:

feeling faint

tooth decay

throat swelling

facial swelling

mood swings

irregular heartbeat and other heart problems

scarred hands

pregnancy complications

kidney failure

digestive issues or constipation

dehydration

nutrient deficiencies

electrolyte or chemical imbalances

Self-induced vomiting can also lead to severe damage to other areas of your body over time, including your:

If you or someone you know has purging disorder, you can:

Remember that eating disorders are serious mental health conditions, not a question of willpower. Don't feel ashamed to seek treatment or additional help, and know that you're not alone.

Recovering from an eating disorder is possible, but it takes time. Be patient with yourself over the course of your recovery. Everyone is different, and healing is an ongoing process.

Consider continuing therapy, journaling, or joining a support group to help as you recover. Relapses might happen, but you're not a failure if they do. Help is always there to get you back on track.

Purging disorder is a serious mental health condition caused by repeated cycles of purging in order to manipulate weight or body shape. Purging can take many different forms, which can cause serious nutritional and metabolic imbalances and lead to lasting damage to your health.

It's important to seek professional treatment for purging disorder as soon as possible, whether that's joining a support group or seeking more intensive therapy.

While recovery from an eating disorder is an ongoing process, it's absolutely possible to live a happy and healthy life. The goal is to restore your relationship with food and your body. Remember, the first step to breaking the cycle of purging is to reach out for help.

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Purging Disorder: Symptoms, Treatments, and More

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Purging disorder is an eating disorder characterized by the compulsion to purge after consuming food. It's different from bulimia, as purging episodes aren't triggered by binge eating. Learn about the treatments available to help you recover from this eating disorder.

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Binge Eating Disorder Information on Symptoms and Treatements

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Binge Eating Disorder Information on Symptoms and Treatements

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Adolescent Eating Disorders such as Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder are treatable.

Eating disorders are complex illnesses that affect people of all ages; the onset of eating disorders typically occurs during pre-adolescence or adolescence. Eating disorders affect millions of adolescents and young adults in the U.S. alone. Given the serious medical complications that may result from eating disorders, it is imperative to identify, diagnose and treat them as early as possible. With early diagnosis and proper treatment, recovery is possible.

Diagnosing Eating Disorders

The earlier eating disorders are diagnosed and treated, the more likely the probability of complete recovery. However, many adolescents go undiagnosed and do not receive treatment until their eating disorders are at an advanced stage. One reason is teenagers with eating disorders often try to hide their behaviors. Or teenagers (as well as family and friends) may be in denial about their eating disorders, or simply unaware of the signs and symptoms of an eating disorder.

It can be difficult to identify a teenager with an eating disorder, as they may appear to be a 'normal weight'. Yet teenagers can be very malnourished even at seemingly 'normal weights'. They may also appear to eat normally in front of peers or family while secretly restricting food intake, bingeing, purging, or over exercising.

Different types of eating disorders produce different warning signs, about which friends, family and patients themselves should become aware.

Types Of Eating Disorders

The most common eating disorders among adolescents are Anorexia Nervosa, Bulimia Nervosa and Binge-Eating Disorder. Even patients that do not meet all of the clinical criteria for an eating disorder can be at serious risk and should seek medical treatment.

Anorexia Nervosa

Teenagers with Anorexia Nervosa may take extreme measures to avoid eating and control the quantity and quality of the foods they do eat. They may become abnormally thin, or thin for their body, and still talk about feeling fat. They typically continue to diet even at very unhealthy weights because they have a distorted image of their body.

Signs of Anorexia Nervosa may include:

A distorted view of one's body weight, size or shape; sees self as too fat, even when very underweight

Restricting, hiding or discarding food

Obsessively counting calories and/or grams of fat in the diet

Denial of feelings of hunger

Developing rituals around preparing food and eating

Compulsive or excessive exercise

Social withdrawal

Pronounced emotional changes, such as irritability, depression and anxiety

Physical signs of Anorexia Nervosa include rapid or excessive weight loss; feeling cold, tired and weak; thinning hair; absence of menstrual cycles in females; and dizziness or fainting.

Teenagers with Anorexia Nervosa often restrict not only food, but relationships, social activities and pleasurable experiences.

Bulimia Nervosa

Teenagers with Bulimia Nervosa typically 'binge and purge' by engaging in uncontrollable episodes of overeating (bingeing) usually followed by compensatory behavior such as: purging through vomiting, use of laxatives, enemas, fasting, or excessive exercise. Eating binges may occur as often as several times a day but are most common in the evening and night hours.

Teenagers with Bulimia Nervosa often go unnoticed due to the ability to maintain a normal body weight.

Signs of Bulimia Nervosa may include:

Eating unusually large amounts of food with no apparent change in weight

Hiding food or discarded food containers and wrappers

Excessive exercise or fasting

Peculiar eating habits or rituals

Frequent tips to the bathroom after meals

Inappropriate use of laxatives, diuretics, or other cathartics

Overachieving and impulsive behaviors

Frequently clogged showers or toilets

Physical signs of Bulimia Nervosa include discolored teeth, odor on the breath, stomach pain, calluses/scarring on the hands caused by self-inducing vomiting, irregular or absent menstrual periods, and weakness or fatigue.

Teenagers with Bulimia Nervosa often have a preoccupation with body weight and shape, as well as a distorted body image. The clinical diagnosis commonly defines Bulimia Nervosa if they binge and purge on average once a week for at least three consecutive months.

Binge Eating Disorders

Binge Eating Disorder is characterized by a sense of uncontrollable excessive eating, followed by feelings of shame and guilt. Unlike those with Bulimia Nervosa, however, teenagers with Binge Eating Disorder typically do not compensate for their binges.

Teenagers with Binge Eating Disorder may feel like they have no control over their behavior and eat in secret when they are not hungry.

Signs of Binge Eating Disorder might include:

Eating an unusually large amount of food in a distinct period of time (within 2 hours)

Hiding food or discarded food containers and wrappers

Eating in secret because of feeling embarrassed by how much they are eating

Eating when stressed or when feeling uncertain how to cope

Feeling that they are unable to control how much they eat and disgusted with themselves afterwards

Experimentation with different diets

Most of the physical signs and symptoms associated with Binge Eating Disorder are long-term, including weight gain, high blood pressure, diabetes, irregular menstrual cycle, skin disorders and heart disease.

Similar to Bulimia Nervosa, Binge Eating Disorder is commonly diagnosed if teenagers binge on average once a week for at least three consecutive months.

Eating Disorder Treatment

Recommended treatment for adolescent eating disorders usually involves a multidisciplinary approach. Treatment should include medical; psychiatric; individual, group and, in particular, family therapy; along with nutritional rehabilitation aimed at restoring health and body weight and eventually modifying behaviors related to eating and exercise. Treatment should always be based on a comprehensive evaluation of the individual and family.

The frequency of medical complications during the course of treatment requires the close supervision of a medical professional. Medication may be required if certain psychiatric disorders are also present; most commonly depression and anxiety disorders. Teenagers may have obsessive-compulsive disorder or tendencies, and may also suffer from trauma or substance abuse, or engage in self-harming behavior, such as cutting or burning. It is important that eating disorder treatment works to identify and address these co-occurring disorders.

Individual therapy usually includes both behavioral and cognitive techniques. Group therapy allows individuals struggling with eating disorders to find a place where they can open up and be honest and real about their struggles, relate to others, and receive much needed support. Family therapy is initially focused on supporting the family in nutritional rehabilitation and later, offering the opportunity to navigate other challenges of adolescence and mental health.

Nutritional counseling includes a combination of nutrition education, meal planning and goal setting. It also may include hands-on experiential and skills work. Treatment helps the individual recovering from an eating disorder cultivate a healthier relationship with food in order to gain the skills and education needed to eventually feed oneself going forward.

Common Eating Disorder Myths

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About Eating Disorders - The Healthy Teen Project

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Eating disorders are complex illnesses that affect people of all ages; the onset of eating disorders typically occurs during pre-adolescence or adolescence. Eating disorders affect millions of adolescents and young adults in the U.S. alone. Given the serious medical complications that may result from eating disorders, it is imperative to identify, diagnose and treat them as early as possible.

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Anorexia nervosa is an eating disorder that makes people lose more weight than is considered healthy for their age and height.

Persons with this disorder may have an intense fear of weight gain, even when they are underweight. They may diet or exercise too much, or use other methods to lose weight.

Causes

The exact causes of anorexia nervosa are not known. Many factors probably are involved. Genes and hormones may play a role. Social attitudes that promote very thin body types may also be involved.

Family conflicts are no longer thought to contribute to this or other eating disorders.

Risk factors for anorexia include:

Being more worried about, or paying more attention to, weight and shape

Having an anxiety disorder as a child

Having a negative self-image

Having eating problems during infancy or early childhood

Having certain social or cultural ideas about health and beauty

Trying to be perfect or overly focused on rules

Anorexia usually begins during the teen years or young adulthood. It is more common in females, but may also be seen in males. The disorder is seen mainly in white women who are high academic achievers and who have a goal-oriented family or personality.

Symptoms

To be diagnosed with anorexia, a person must:

Have an intense fear of gaining weight or becoming fat, even when she is underweight

Refuse to keep weight at what is considered normal for her age and height (15% or more below the normal weight)

Have a body image that is very distorted, be very focused on body weight or shape, and refuse to admit the seriousness of weight loss

Have not had a period for three or more cycles (in women)

People with anorexia may severely limit the amount of food they eat, or eat and then make themselves throw up. Other behaviors include:

Cutting food into small pieces or moving them around the plate instead of eating

Exercising all the time, even when the weather is bad, they are hurt, or their schedule is busy

Going to the bathroom right after meals

Refusing to eat around other people

Using pills to make themselves urinate (water pills or diuretics), have a bowel movement (enemas and laxatives), or decrease their appetite (diet pills)

Other symptoms of anorexia may include:

Blotchy or yellow skin that is dry and covered with fine hair

Confused or slow thinking, along with poor memory or judgment

Depression

Dry mouth

Extreme sensitivity to cold (wearing several layers of clothing to stay warm)

Loss of bone strength

Wasting away of muscle and loss of body fat

Get Help

Learn how to talk about mental health or how to get help for yourself or someone you care about.

Last Updated: 03/01/2022

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Bulimia nervosa, also known as bulimia, is an eating disorder. It's generally characterized by eating large amounts of food in a short period of time, followed by purging.

Purging can occur through forced vomiting, excessive exercise, or by taking laxatives or diuretics.

Bulimia is a serious condition that can be life threatening.

People living with bulimia may purge or display purge behaviors, as well as follow a binge-and-purge cycle. Purge behaviors can also include other strict methods to maintain weight like fasting, exercise, or extreme dieting.

Bulimia nervosa may also cause an obsession with achieving an unrealistic body size or shape. A person living with this eating disorder might be obsessed with their weight and can often be self-critical.

Read on to learn more about bulimia, as well as the ways you may help yourself or a loved one with this eating disorder.

The symptoms of bulimia include eating large amounts of food at once and purging, along with a lack of control over these behaviors. A person living with bulimia may also experience feelings of self-disgust after eating.

While the precise list of symptoms may vary between individuals, bulimia may include the following symptoms:

fear of gaining weight

making comments about being "fat"

a preoccupation with weight and body

a strongly negative self-image

binge eating, usually within a 2-hour period

self-induced vomiting

misuse of laxatives or diuretics

use of supplements or herbs for weight loss

excessive and compulsive exercise

stained teeth (from stomach acid)

acid reflux

calluses on the back of your hands

going to the bathroom immediately after meals

not eating in front of others

constipation

withdrawal from typical social activities

Complications from bulimia can include:

Bulimia can affect anyone at any age or body weight.

Research indicates that roughly 1.5 percent of women and 0.5 percent of men in the United States will experience bulimia at some point during their life. It's more common in women, and the median age of onset is estimated to be around 12 years old.

Risk factors may include:

social factors

biological makeup

genetics

psychological well-being

Additionally, some people living with bulimia may also have a history of anorexia nervosa or another eating disorder.

If you suspect your loved one needs help, it's important to let them know that you're there for them without any judgment. They may need you to just listen, or they might need your help finding and going to appointments.

Any progress should also be addressed with further encouragement.

Bulimia has no single known cause. However, it's thought that a combination of certain factors can influence its development. These can include:

genes

family history

a past traumatic event

social or cultural influences

A 2019 review, as well as some older research, also suggests that bulimia may also be associated with serotonin deficiencies in the brain. This important neurotransmitter helps regulate mood, appetite, and sleep.

A doctor typically uses a variety of tests to diagnose bulimia. First, they may conduct a physical examination. They may also order blood or urine tests.

A psychological evaluation will help them understand your relationship with food and body image.

The doctor will also use criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 is a diagnostic tool that uses standard language and criteria to diagnose mental disorders.

The criteria used to diagnose bulimia include:

recurrent binge eating

regular purging through vomiting, excessive exercise, misuse of laxatives, or fasting

deriving self-worth from weight and body shape

binge eating and purging that happens, on average, at least once a week for 3 months

not having anorexia nervosa

The also categorizes bulimia from mild to extreme:

Mild: 1 to 3 episodes per week

Moderate: 4 to 7 episodes per week

Severe: 8 to 13 episodes per week

Extreme: 14 or more episodes per week

You may need further tests if you've had bulimia for a long period of time. These tests can check for complications that could include problems with your heart or other organs.

Treatment focuses on food and nutrition education as well as mental health treatment. It requires development of a healthy view of yourself and a healthy relationship with food.

Treatment options can include:

Antidepressants. Currently, fluoxetine (Prozac) is the only antidepressant approved by the Food and Drug Administration (FDA) to treat bulimia. This selective serotonin reuptake inhibitor may also help with depression and anxiety. Fluoxetine is only approved for treating bulimia in adults.

Psychotherapy. Also called talk therapy, this type of counseling can include cognitive behavioral therapy, family-based therapy, and interpersonal psychotherapy. The goal is to help you work through potentially harmful thoughts and behaviors that contribute to your condition. Group talk therapy may also be helpful.

Dietitian support and nutrition education. These can help you learn healthy eating habits and form nutritious meal plans. You may also learn to shift your attitudes toward food.

Treatment for complications. This may include hospitalization, especially for cases of severe dehydration, electrolyte imbalances, and organ damage.

Successful treatment usually involves a combination of the above treatments, along with a collaborative approach between your doctor, mental health professional, and family and friends.

Some eating disorder treatment facilities offer live-in or day treatment programs. Some live-in programs provide around-the-clock support and care.

If you don't already have a therapist, you can browse doctors in your area through the Healthline FindCare tool.

Bulimia can be life threatening if it's left untreated or if the treatment fails. Bulimia is both a physical and psychological condition, and it may be a lifelong challenge to manage it.

However, there are several treatment options available that can help. Often, the earlier bulimia is detected, the more effective treatment may be.

Effective treatments focus on:

These treatments can help you maintain healthy behaviors in the long term.

Bulimia is a type of eating disorder defined by eating large amounts of food in a short amount of time, followed by purging behaviors. While there are some known risk factors, there's no single cause of bulimia.

It's also important to know that this eating disorder can affect anyone.

If you suspect you or a loved one may be living with bulimia, it's important to seek help from both a medical doctor and mental health professional.

Seeking prompt treatment may not only improve your quality of life, but it may also help prevent potentially life threatening complications.

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Bulimia Nervosa: Signs, Causes, and Treatment

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Bulimia nervosa, also known as bulimia, is an eating disorder. It's generally characterized by eating large amounts of food in a short period of time, followed by purging. Purging can occur through forced vomiting, excessive exercise, or by taking laxatives or diuretics. Bulimia is a serious condition that can be life threatening.

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Strategies for Learning and Teaching Students with Conduct and Behavioral Disorders

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Strategies for Learning and Teaching Students with Conduct and Behavioral Disorders

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Working to deliver a better special education service

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Home - ADDA - Attention Deficit Disorder Association

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Empowering adults with adhd to live their best lives A Different Brain Requires a Different Approach Whether you're newly diagnosed, wondering if you have ADHD, or simply ready to take charge of your life - we're here to help. Have ...

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Oppositional defiant disorder (ODD) is a behavior condition in which a child displays a continuing pattern of uncooperative, defiant and sometimes hostile behavior toward people in authority.

What is oppositional defiant disorder (ODD)?

Oppositional defiant disorder (ODD) is a behavior condition in which your child displays a continuing pattern of uncooperative, defiant and sometimes hostile behavior toward people in authority. This behavior often disrupts your child's normal daily functioning, including relationships and activities within their family and at school.

It's common for children - especially those two to three years old and in their early teens - to be oppositional or defiant of authority once in a while. They might express their defiance by arguing, disobeying or talking back to adults, including their parents or teachers. When this behavior lasts longer than six months and goes beyond what's usual for your child's age, it might suggest that they have ODD.

The majority of children and teens who have ODD also have at least one other mental health condition, including:

About 30% of children with ODD develop a more serious behavior condition called conduct disorder. ODD behaviors can continue into adulthood if ODD isn't properly diagnosed and treated.

What is conduct disorder?

Conduct disorder (CD) is a condition in which your child or adolescent shows an ongoing pattern of aggression toward others. They also show serious violations of rules and social norms at home, in school and with peers.

These rule violations may involve breaking the law. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Signs of conduct disorder include:

Frequently breaking serious rules, such as running away from home, staying out at night when told not to or skipping school.

Being aggressive in a way that causes harm, such as bullying, fighting or being cruel to animals.

Lying, stealing or damaging other people's property on purpose.

What's the difference between ODD and ADHD?

Approximately 40% of children with attention-deficit/hyperactivity disorder (ADHD) also have oppositional defiant disorder or a related conduct disorder. While these two conditions commonly occur together, they're distinct conditions.

ODD is related to a child's conduct and how they interact with their parents, siblings, teachers and friends. ADHD is a neurodevelopmental disorder that causes a person to be easily distracted, disorganized and excessively restless.

Who does oppositional defiant disorder affect?

ODD most commonly affects children and teenagers, but it can also affect adults. It most commonly begins by age 8.

Some children outgrow ODD or receive proper treatment for it, while others continue to have symptoms through adulthood.

Children assigned male at birth (AMAB) are more likely to have ODD in their younger years than children assigned female at birth (AFAB). But teenagers who were AMAB and AFAB are affected equally.

Your child is more likely to develop ODD if they have the following risk factors:

A history of child abuse or neglect.

A parent or caregiver who has a mood disorder or who has substance or alcohol use disorders.

Exposure to violence.

Inconsistent discipline and lack of adult supervision.

Instability in their family, such as divorce, moving to different houses often and changing schools frequently.

Financial problems in their family.

Parents who have or have had ODD, attention-deficit/hyperactivity disorder (ADHD) or behavioral problems.

How common is oppositional defiant disorder?

Researchers estimate that oppositional defiant disorder affects 2% to 11% of children. This range is so wide because some children may be misdiagnosed as having conduct disorder, and teenagers, as a population, are often underdiagnosed.

The prevalence of ODD declines with increasing age.

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Oppositional Defiant Disorder (ODD): Symptoms & Treatment

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Oppositional defiant disorder (ODD) is a condition in which your child displays a pattern of uncooperative, defiant and angry behavior toward people in authority.

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A Good Handout for PMT/CBT Behavior Problems

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A Good Handout for PMT/CBT Behavior Problems

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https://childmind.org/guide/quick-guide-to-conduct-disorder/

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Quick Guide to Conduct Disorder - Child Mind Institute

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Download our free guide to conduct disorder. Children who have conduct disorder are unkind and often violent, and they don’t care about other people’s feelings. Conduct disorder can also involve crimes like theft and vandalism.

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What is oppositional defiant disorder (ODD) in children?

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

What causes ODD in a child?

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

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

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

Which children are at risk for ODD?

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

Mood or anxiety disorders

Conduct disorder

Attention-deficit/hyperactivity disorder (ADHD)

What are the symptoms of ODD in a child?

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

Symptoms of ODD may include:

Having frequent temper tantrums

Arguing a lot with adults

Refusing to do what an adult asks

Always questioning rules and refusing to follow rules

Doing things to annoy or upset others, including adults

Blaming others for the child's own misbehaviors or mistakes

Being easily annoyed by others

Often having an angry attitude

Speaking harshly or unkindly

Seeking revenge or being vindictive

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

How is ODD diagnosed in a child?

If you see symptoms of ODD in your child or teen, get a diagnosis right away. Early treatment can often prevent future problems.

Before a mental health referral is made, your child's healthcare provider will want to rule out any other health problems. Once this is done, a child psychiatrist or qualified mental health expert can diagnose ODD. He or she will talk with you and your child's teachers about your child's behavior. He or she may also watch your child. In some cases, your child may need mental health testing.

How is ODD treated in a child?

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

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

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

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

Peer group therapy. A child learns better social skills.

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

How can I help prevent ODD in my child?

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

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

How can I help my child live with ODD?

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

Keep all appointments with your child's healthcare provider.

Take part in family therapy as needed.

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

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

If ODD greatly interferes with your child's ability to succeed in school, he or she may be eligible for certain protections and reasonable accommodations under the Americans with Disabilities Act (ADA) or Section 504 of the Civil Rights Act. Talk with your your child's teacher and school principal about how to get more information.

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

When should I call my child's healthcare provider?

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

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

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

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

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

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

Key points about ODD in children

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

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

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

A mental health expert often diagnoses ODD.

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

Next steps

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

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

Before your visit, write down questions you want answered.

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

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

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

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

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

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

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

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Oppositional defiant disorder (ODD) is a type of behavior disorder. It is mostly diagnosed in childhood. Children with ODD are uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures. They are more troubling to others than they are to themselves. Experts don't know what causes ODD.

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American Psychological Association A Good Basic Overview

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American Psychological Association A Good Basic Overview

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Anxiety is an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure.

People with anxiety disorders usually have recurring intrusive thoughts or concerns. They may avoid certain situations out of worry. They may also have physical symptoms such as sweating, trembling, dizziness, or a rapid heartbeat.

Anxiety is not the same as fear, but they are often used interchangeably. Anxiety is considered a future-oriented, long-acting response broadly focused on a diffuse threat, whereas fear is an appropriate, present-oriented, and short-lived response to a clearly identifiable and specific threat.

Adapted from the Encyclopedia of Psychology and APA Dictionary of Psychology

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Anxiety is characterized by feelings of tension, worried thoughts and physical changes. Anxiety disorders such as panic disorder and obsessive compulsive disorder (OCD) cause recurring intrusive thoughts or concerns and physical symptoms such as sweating, trembling, dizziness or a rapid heartbeat.

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Panic Anxiety Disorders in Middle School

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Panic Anxiety Disorders in Middle School

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Informed educators can have a positive impact on students who are struggling

In her 1994 book of poetry, Something Permanent, writer/poet Cynthia Rylant gets inspiration from the photographs of Walker Evans, a photojournalist who documented rural America during the Great Depression in the 1930s for the Farm Security Administration. In one photo, a young boy sits barefoot on a chair in a small room of a struggling family. The thin wooden walls are decorated with pictures cut from magazines, and the furniture, curtains, and boy's clothing seem old and tired. The boy sits up in his chair, though, interested at the prospect of having his picture taken. The last line of Rylant's companion poem for this photograph reads:
It gave him, briefly, some sort of feeling of just being
There are volumes spoken in these spare, few lines. What are all those factors in his life that convinced him he wasn't enough, what is lost because he never felt like he was enough, and where will this lead as he grows up?

Leaping forward 80+ years, do our students today feel like they are never enough for those around them? Almost hourly our students wonder if they are pretty enough, smart enough, normal enough, connected online enough, Hispanic/Black/Muslim/Jewish/Christian enough, athletic/creative/funny enough, male/female enough, or whether or not they are worthy of friendship/trust/respect/love. And what do we do as teachers to assure students that they, as they are right now and without conditions, are enough, that no apologies are needed for who they are or where they've been, that they are ceaselessly valued, legitimate individuals in their own right?

Fear of being enough is one of the many concerns that students identified with anxiety and panic disorders feel intensely. And this fear is often accompanied by real depression, though it may not be immediately identified as such, which can lead to unnecessarily long and painful recovery if not treated. And here's the thing, anxiety and panic disorders among students in middle school through college years are on the rise nationwide, but mental health training for teachers and the number of counselors assigned per school has not kept pace with the increasing demand.

If we have not experienced severe anxieties or panic ourselves, we may not appreciate the level of despair and real fear our students feel. For some of our students, we're talking about the involuntary heart-wobbling, muscle trembling, chilled (or warming) skin, sweaty palms, nausea inducing, let me out of this plastic bag before I suffocate, my toddler brother just ran into the street in front of a speeding car and I'm too far away to save him with my cement legs, my mouth is open but no scream will come kind of fear. This is the kind of fear that is only abated by pulling our limbs into the center of our bodies, closing our eyes, placing our face against a cool surface, and talking ourselves down from the precipice.
Some research suggests that your body's natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared for a life-threatening situation. Many of the same reactions occur in a panic attack. But it's unknown why a panic attack occurs when there's no obvious danger present.
www.healthline.com/health/panic-attack-vs-anxiety-attack#takeaway

To this day, I still wake up at night from time to time with the willies and cold sweats, recalling the stories of my cousins growing up and caving in Texas. They would crawl face forward, then wiggle, inch by inch to the very end of severely narrowing crevices deep in the earth while their headlamps faded in the heavy darkness. Soon their arms were pinned to their sides due to the now tight confines of the shaft, their faces wedged against the floor of the crevice, inhaling ancient dirt, because their skulls were jammed tightly against the rock ceiling above, leaving only six inches of breathable volume before the solid stone wall they can barely see. And now, before the oxygen depletes and panic sets in, they have to somehow communicate with their toes to the three climbers who lay end to end on their bellies in the crevice directly behind them to start backing up, and to do it pretty darn fast. I imagine the welling anxiety and crossing threshold for panic in students is something akin to this.

The weird thing about panic attacks is that they occur any time and without cause, and they can last just a few minutes to something much longer. Imagine driving a car at 65 mph on a busy highway and such an attack occurs-heart-racing, sweaty hands, dissociation from reality, feeling complete incompetence at the task, sucking oxygen like it's your last, unable to assimilate all the incoming data into your mind, and feeling like you've missed something vital, and you're three lanes over from the shoulder. You pray someone will let you over quickly and that there's a safe place to stop and pull over to let the panic subside.

This actually happened to a member of my own family who suffers from panic-anxiety disorders. This person misses work from time to time, struggles to maintain some conversations, can be significantly challenged navigating the grocery store, suffers from depression, and is exhausted by all of it much of the time-yet the person is brilliant, happy, extremely capable, and contributes mightily to the world. What a trapped feeling! For others I know, they feel ashamed of this condition, living in fear others will find out, which in turn can trigger panic. Many, including my family member, have these attacks in moments of great happiness as well. Anything can trigger it, and that's scary. Many of our students become anxious to an unhealthy degree just worrying about whether or not they will become too anxious to function.

The International Board of Credentialing and Continuing Education Standards (IBCCES) reminds us that anxiety in students is quite normal. It becomes an issue, they say, when it prevents students from participation in class and extracurricular activities, and when it affects their learning, test performance, and social interactions. In their blog, they elevate a big concern, as well: "Often, anxiety in students goes unnoticed and their unpredictable behavior, such as missing class, might be assumed to be lazy or irresponsible (ibcces.org/blog/2019/05/08/signs-student-anxiety-classroom/).

IBCCES says that anxiety and panic disorder students can obsess over perfectionism, feel "on edge," irritate easily, make out-sized emotional responses to non-threatening comments, refuse to go to school, isolate themselves, ceaselessly procrastinate, have difficulty focusing on simple tasks, and experience, "...derealization or feeling as if they are dying or going crazy."

In their online piece, "Panic Disorder: When Fear Overwhelms," the National Institute of Mental Health (NIMH) includes the following as indicators of panic disorders:

Sudden and repeated panic attacks of overwhelming anxiety and fear

A feeling of being out of control, or a fear of death or impending doom during a panic attack

Physical symptoms during a panic attack, such as a pounding or racing heart, sweating, chills, trembling, breathing problems, weakness or dizziness, tingly or numb hands, chest pain, stomach pain, and nausea

An intense worry about when the next panic attack will happen

A fear or avoidance of places where panic attacks have occurred in the past
www.nimh.nih.gov/health/publications/
panic-disorder-when-fear-overwhelms/
index, downloaded December 4, 2019

Other indicators of anxiety and panic disorders include feeling helplessness in daily activities, insomnia, difficulty dealing with transitions, cutting one's skin, constantly feeling threatened, alcohol/drug use, unhealthy fear of failing, problems interacting with peers or family members. Doctors add that too much caffeine, thyroid problems, phobias, stressful work, financial worries, and experiencing or witnessing trauma can spark anxiety and panic attacks as well (www.healthline.com).

This is a lot for an already insecure middle school student to handle. Unfortunately, it's becoming more prevalent in our schools.

Anxiety and Panic Disorders on the Rise

I work with thousands of teachers each year to improve grading practices, and grading, of course, causes a lot of anxiety and sometimes panic in students. The number of teachers and principals-whether or not they work in urban, suburban, rural, affluent, underserved, well-served, diverse, homogeneous, faith-based, public, international, or charter schools-who report serious spikes in mental health referrals for anxieties and panic disorders in the past five years is stunning, disconcertingly so. They describe it as a tsunami.

Officially, the National Institute of Mental Health (www.nimh.nih.gov/health/statistics) reports that 31.9% of adolescents have some sort of anxiety disorder, with 8.3% having severe impairments as a result. They say that anxiety disorders are higher in females than in males.

In her March 28, 2018 (updated March 2019) NEA Today article, "The Epidemic of Anxiety Among Today's Students," Mary Ellen Flannery writes,
[A] Pew survey found that 70 percent of teens say anxiety and depression is a "major problem" among their peers, and an additional 26 percent say it's a minor problem... "Honestly, I've had more students this year hospitalized for anxiety, depression, and other mental-health issues than ever," said Kathy Reamy, school counselor at La Plata High School in southern Maryland and chair of the NEA School Counselor Caucus. "There's just so much going on in this day and age, the pressures to fit in, the pressure to achieve, the pressure of social media. And then you couple that with the fact that kids can't even feel safe in their schools-they worry genuinely about getting shot-and it all makes it so much harder to be a teenager."
neatoday.org/2018/03/28/the-epidemic-of-student-anxiety/

More disturbing still, Flannery cites a study published in Clinical Psychological Science declaring that between 2010 and 2015, "the number of teens who felt 'useless and joyless' surged 33 percent. The number of 13- to 18-year-olds who committed suicide jumped 31 percent." She follows these statements with reference to the work of San Diego State University Professor Jen Twenge, who says social media has played a significant factor here: "[Teens] say things to a screen that they would never say face to face, things like 'you should kill yourself.' And many studies have found that increased social media use actually makes people feel more socially isolated. It also disrupts sleep, which is related to mental health."

In her own article for The Washington Post in 2017, Twenge writes,
[W]hile conducting research for my book on iGen, I found that teens now spend much less time interacting with their friends in person. Interacting with people face to face is one of the deepest wellsprings of human happiness; without it, our moods start to suffer and depression often follows. Feeling socially isolated is also one of the major risk factors for suicide. We found that teens who spent more time than average online and less time than average with friends in person were the most likely to be depressed ... Teens are also sleeping less, and teens who spend more time on their phones are more likely than others to not be getting enough sleep. Not sleeping enough is a major risk factor for depression...
Interested educators can read more of Twenge's perspective here: www.washingtonpost.com/national/
health-science/teenage-depression-and-suicide-are-
way-up-and-so-is-smartphone-use/2017/11/17/
624641ea-ca13-11e7-8321-481fd63f174d_story.

While many middle school students can develop anxiety and panic disorders, it's becoming even more prevalent in our society as students move into high school and college. In their August 27, 2019, Harvard Health blog, "Anxiety in college: What we know and how to cope," Nicole J. LeBlanc and Dr. Luana Marques claim anxiety in colleges is widespread. They cite the American College Health Association Fall 2018 National College Health Assessment, stating that, "63% of college students in the US felt overwhelming anxiety in the past year ... 23% reported being diagnosed or treated by a mental health professional for anxiety in the past year." They continue their commentary, focusing on the biggest trigger for anxiety:
The sharpest increase in anxiety occurs during the initial transition to college. A recent study demonstrated that psychological distress among college students-that is, their levels of anxiety, depression, and stress-rises steadily during the first semester of college and remains elevated throughout the second semester. This suggests that the first year of college is an especially high-risk time for the onset or worsening of anxiety.
www.health.harvard.edu/blog/anxiety-in-college-what-we-know-and-how-to-cope-2019052816729

What might this mean with students transitioning to middle school, or from middle school to high school? For helpful articles on how to help students transition to middle school and from middle school to high school check out the sections on transitioning at amle.org, " Transitioning Young Adolescents from Elementary to Middle School - Research Summary" by Casey Dianna Gilewski and Monica L. Nunn, and " Preparing Students for the Transition to High School " by Vanessa Scanfeld, Sean Robertson, Leah Weintraub, and Vincent Dotoli. Also see my article, "The Middle/High Years/Movin Up to the Middle," (http://www.ascd.org/publications/educational-leadership/apr11/).

LeBlanc and Marques add that,
In the US, some research shows a decrease in psychological well-being among adolescents over the past several years. It's not entirely clear what is causing this trend, though research shows a strong association between time spent on electronic communication (social media, smartphones) and reduced well-being among adolescents. Electronic communication might interfere with adjustment to college if it replaces healthy coping behaviors like exercise, face-to-face social interactions, and studying.
How Do We Respond to Students Having a Panic Attack at School?

No one policy, program, or act will solve the problems of increasing rates of anxiety and panic disorders among our students or help those who currently experience them. Collectively, however, multiple responses from educators can have a positive impact. Let's look at some of the possibilities:

Conduct professional development for faculty on anxiety and panic disorders.

If rising anxiety and panic experiences are affecting learning, socialization, test performance, and self-efficacy, or limiting the student's success in significant ways, it is time to seek a professional's help. First, we contact our school counselors, if we have them, and from there, we may need to get the student to see a medical professional.

If a doctor diagnoses an anxiety or panic disorder, students may be treated with psychotherapy called, "cognitive behavioral therapy" which teaches students healthy ways to adjust thinking, behavior, and reactions as episodes begin or to keep them from happening in the first place. This may include exposure therapy, too, in which students spend short periods of time in the anxiety-inducing situations, but with support, then the time periods slowly increase over time until the anxieties in those situations subside. In severe cases, doctors may prescribe medications, including benzodiazepines (like Xanax) to calm students.

During the anxiety or panic attack, avoid the urge to comfort the student with the phrases, "It's not a big deal," "It's just part of being in middle school," or worse, "Everything is going to be fine." The student knows these are not true and that these attacks aren't normal. And now they've lost trust in you. Empty platitudes aren't balm; they don't comfort or respect the student.

Create a hotline texting app that connects the student directly to a school counselor, social worker, or psychologist as available, and promote it to students regularly. If they ever feel out of control, depressed, overly anxious, dysfunctional, suicidal, and need a listening ear and genuine support, they text a simple code to a particular number and a qualified adult advocate will respond within a few minutes.

As we can, we help students learn techniques to mitigate and control rising anxiety or panic attacks. We can provide a quiet, private space to do this, if needed, or help them use some of these techniques at their classroom desk as episodes rise. Some of those helpful techniques include:

Breathing deeply

Recognizing the panic attack and calling it what it is (this helps the person realize that it's temporary and will pass)

Closing eyes to minimize external stimulation

Practiced mindfulness, focusing on specific sensations in and around the body

Relaxing muscles, focusing on one muscle or small group of muscles at a time

Focusing on an object in the room

Thinking of a comfortable, soothing place

Some forms of light exercise (endorphins release into the bloodstream and calm the mind)

Repeating a mantra

Smelling lavender (this has a calming effect in some people)
Paraphrased from www.healthline.com/health/how-to-stop-a-panic-attack

In her article, "Anxiety in the Classroom - Another Learning Disability?" Paula Prentis, a licensed social worker specializing in child and adolescent health, wellness, and development suggests:
Instead of offering security, offer skills. For instance, if a student avoids school, create a context for him that values him being there. In one example, a student became known as the school pet expert. He never missed another day because he was valued for his knowledge of pets, something for which the teachers and many classmates counted on him. He felt "good enough."

We teach in a developmentally appropriate way. Middle schools aren't junior versions of high school (see, "Middle School, not Junior High," (amle.org/am/wormeli3), nor are they just extensions of elementary school. They are unique, and teachers should have specific expertise when teaching this age group. This means we spend considerable time and energy on teaming, exploratory programs, and teacher-advisory programs, even when they are not popular with those untrained in middle school research. All three have a strong, positive effect on student emotional growth and sense of belonging.

For students who need structure and regular procedures, provide them, but also sit with them ahead of time and talk through those moments in the day or days ahead that will not be as structured and normal. Identify specifically what irregular, unstructured thing is going to happen and the specific steps the student can take to navigate the irregularity constructively.

As mentioned above, build and maintain a robust and responsive transitioning program from elementary to middle school and from middle school to high school. Seriously, this is one of those times when thoughtful proactive work on the front end prevents all the unnecessary trauma on the back end for both students and their teachers. Schools with such programs never regret spending the time and energy in developing them.

Do not, do not, do not ask students to drop fine and performing arts classes, technology classes, or any other class or extracurricular activity in which they are passionately interested and feel safe in experiencing. Quite often, these are a collective oasis that gets them through the day feeling normal, capable, and invested in life. And yeah, that means we don't take students out of these experiences in order to double-up on math or reading classes in preparation for state or provincial exams.

Overtly teach students executive function skills (time management, impulsivity/distractibility control, decision making, moral and abstract reasoning, responding constructively in social situations, and more). Students can't use skills and tools they don't have, and wow, training in executive function sure does help in middle school. Among others you may find helpful, my article with suggestions on how to do this is on my website.

Invest the time and energy in all those positive school climate programs and elements, and make sure it's happening in all areas: hallways, classes, buses, bus stops, playgrounds/fields, locker rooms, cafeteria, and online. This includes social-emotional facets as well. Make sure teachers trained in their subject areas see the value of gaining expertise in the emotional development of their students. It's what professionals do, and given what we know about young adolescent development, it is educational malpractice to remain indifferent to it or incompetent in it.

Develop a dozen or more constructive descriptive feedback techniques and use them frequently instead of judgement or evaluation. Good descriptive feedback does not invoke ego or self-preservation; no one is threatened. It invites students into their own learning and builds self-efficacy. There are wonderful books just about feedback. Let's read them and assure hope and growth.

Pull back from the autocratic/didactic approaches as much as possible and facilitate more student choice. Choice feeds autonomy and the sense that what students want matters to the teacher.

Allow students to rehearse tests, speeches, conversations, and presentations a day or two ahead of time in order to visualize and experience what it will be like, where the rocky and smooth parts occur, what they will be seeing from their position in the room, what the materials will feel like in their hands as they recall the things they want to say, etc. It really helps.

We can't say this enough: Make recovering from mistakes and failures compelling and doable. Yes, allow re-do's and re-takes for full credit. If we're concerned about how to teach responsibility when we do this, I respond to that concern in Fair Isn't Always Equal, 2nd Edition (Stenhouse Publishers, 2018). I'd also suggest my articles on why students cheat and plagiarize (and how to recover from them), on redo's, on the fallacy of always preparing students for the levels above, and more at www.rickwormeli.com. All articles are free to download and share.

Confront and dismantle the systemic racism, sexism, classism, and gender orientation biases that are perpetuated by the unaware majority. Yeah, I know this is a big thing, but it makes you think: If we're spending all this focus on helping students cope with severe anxieties and panic disorders, we should also be thinking about what's at the root of many of those stresses instead of just telling students to deal with them. Looming huge among them are the micro and macroaggressions and structural limitations experienced daily by children of a different color/culture/gender/sexual orientation, or by children who are underresourced, overweight, or the sons and daughters of alcoholics and opioid abusers. What a devastating waste of everyone's time and student potential it is to slap a tiny band-aid on a forefinger when the real issue all along is the massive heart attack. To get started, consider faculty book studies with any of these books:

Gullo, Gina Laura; Capatosto, Kelly; Staats, Cheryl; Implicit Bias in Schools: A Practitioner's Guide, Eye on Education, 2019

Kay, Matthew R.; Not Light, But Fire: How to Lead Meaningful Race Conversations in the Classroom, Stenhouse Publishers, 2018

Mayorga, Edwin; Picower, Bree; What's Race Got to Do With It? How Current School Reform Policy Maintains Racial and Economic Inequity, Peter Lang Publishers, 2015

Oluo, Ijeoma; So You Want to Talk about Race, Seal Press (Hatchette Group), 2018

Pollock, Mica; SchoolTalk: Rethinking What We Say About - And To - Students Every Day (Laying a Foundation for Equity), The New Press, New York, 2017

Stevenson, Howard C.; Promoting Racial Literacy in Schools: Differences That Make a Difference, Teachers College, 2014

Finally, let's put information into the hands of students and their parents. If they want to know more, support others, or, if they are afraid they are developing serious issues with anxiety, panic, or depression, get them the support they need. In addition to what the school, district, county, and city services provide, remind them of the following:

Call 911 if they or someone they know is in immediate danger

National Suicide Prevention Lifeline - 1-800-273-TALK (8255). For Spanish speakers, use 1-888-628-9454

Crisis Text Line - Text "HELLO" to 741741

We breathe in and out, aspire to great things, stumble, get insight, learn to forgive, aspire again, stumble again, then rise to greet yet another day. We can do this because we have versatile skills honed from years of experience and the assurance that comes from having made it to our adult years relatively intact: There are grounds for optimism. Young adolescents aren't there yet, however, and their rocky, narrow path along the cliff's edge may fall away at any moment, or so it seems to them.

Let's respect those peaks and valleys of youth and remain empathetic to their journey. Where we cannot be empathetic, let's be informed and helpful, and at the very least, do no harm. At the very best, dismantle that which limits anyone. Let's prove to students daily through word, action, and culture that they are valued as they are, that they are enough. Then, let's show them that the dynamics among learning, anxiety, courage, doubt, happiness, and hope remain throughout life, and they are not alone as they make their way through it. Our belief in them and the power that comes from true connection with others in our lives, especially when we are struggling, never wane. Both are something permanent.

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Panic Anxiety Disorders in Middle School Students - AMLE

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In her 1994 book of poetry, Something Permanent, writer/poet Cynthia Rylant gets inspiration from the photographs of Walker Evans, a photojournalist who documented rural America during the Great Depression in the 1930s for the Farm Security Administration. In one photo, a young boy sits barefoot on a chair in a small room of a struggling family.

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Quick Guide to Panic Disorder in Children

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Quick Guide to Panic Disorder in Children

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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.

Panic disorder is a specific kind of anxiety disorder. Kids with panic disorder have sudden attacks of anxiety that come with intense feelings of dread and physical symptoms that can feel like a heart attack. These episodes are called panic attacks. Sometimes, the child might feel like they are dying during the panic attack.

Panic attacks also involve a strong desire to escape from the situation. Fear of having another panic attack can trigger a new one. Kids with panic disorder often avoid places where they have had an attack.

Panic disorder is rare in young children but often begins during the teenage years.

What are the symptoms of panic disorder?

Signs that a child or teenager might have panic disorder include:

Anxiety attacks that come with intense physical symptoms, including racing heart, chest pains, trouble breathing, dizziness, nausea and sweating

A sudden and terrible fear of death or losing control

A feeling that the world is not real

A strong desire to escape from wherever they are

Repeated anxiety attacks that come on fast and reach their worst point within about ten minutes

Intense fear of experiencing more attacks

Avoiding places where they have had panic attacks in the past or places that would be hard to escape, like crowds or enclosed spaces

How is panic disorder diagnosed?

To diagnose a child with panic disorder, an expert will rule out other possible causes of the panic attacks.These other causes could be medical, or they could be psychiatric disorders that share some symptoms with panic disorder, like post-traumatic stress disorder (PTSD) or obsessive-compulsive disorder (OCD).

Once other causes are ruled out, the professional will diagnose panic disorder if:

The child has experienced several panic attacks

The child worries a lot about having more attacks

The child fears what will happen to them if they have another attack, including feelings of dying or "going crazy"

There is a big change in the child, like avoiding places where they have had panic attacks or even places that reminds them of panic attacks

How is panic disorder treated?

There are very effective treatments available for kids with panic disorder. Treatment often involves a combination of therapy and medication.

Cognitive behavioral therapy (CBT) is aimed at lessening the fear that causes kids to avoid situations that remind them of panic attacks. Over time, changing that behavior can ease their anxiety.

Another common treatment is called exposure with response prevention. This therapy helps lessen anxiety by gently and slowly exposing kids to situations that remind them of panic attacks.

Drugs called antidepressants have been shown to successfully prevent panic attacks in some children. If those don't work, anti-anxiety drugs like Xanax are sometimes prescribed instead.

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 Panic Disorder - 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. Panic disorder is a specific kind of anxiety disorder. Kids with panic disorder have sudden attacks of anxiety that come with intense feelings of dread and physical symptoms that can feel like a heart attack.

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Great Information for Parents!

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Polaris Teen Center: Premier Adolescent Treatment Center in Los Angeles

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As human beings, our bodies have a natural, built in "fight-or-flight" response when danger is sensed. The brain activates adrenaline in the body to trigger the response to either "fight" the danger or to escape (the "flight"). Although this "fight-or-flight" response serves as a protective mechanism, it can also feel like panic. Unfortunately, some experience this "fight-or-flight" response when there is no actual threat. This means individuals experience panic attacks in the absence of any valid risk or danger. When this occurs, it often indicates the presence of panic disorder. Even though these panic attacks do not serve any real "survival" purpose, they can still cause significant distress. And that distress doesn't simply end when the actual attack does. Teens who suffer from panic attacks often anticipate the next episode of panic, which can sustain worry and anxiety long after the panic attack is over. The overall increase in anxiety almost always takes a significant toll on a person's mental health, daily functioning, and overall well-being.

More than 3 million Americans will experience panic disorder in their lifetime, and in most cases, onset is in the adolescent or teenage years.

Types of Panic Attacks

Individuals with panic disorder may experience two different types of panic attacks:

Unexpected (or uncued) - unexpected or uncued panic attacks are those that occur without causation. Essentially, unexpected panic attacks seem to occur "out of the blue."

Expected (or cued) - expected panic attacks, also referred to as "cued" panic attacks, are those that are situationally bound. This means the panic attack is triggered when the person either anticipates exposure to, or is actually exposed to a specific panic attack trigger.

Causes of Panic in Teens

Panic disorder is a condition marked by repeated, unpredictable panic attacks that can cause feelings of extreme fear, disconnection from reality, and even impending death. Panic disorder is classified in the anxiety disorder family. Panic disorder typically manifests in people somewhere between adolescence and early adulthood. Although there is not one specific cause of panic disorder in teenagers, doctors and researchers suggest certain possibilities.

Genetics - studies with identical twins have demonstrated the strong possibility of a genetic inheritance of panic disorder.

Brain chemistry - a suggested (and well-supported) potential cause of panic disorder is linked to chemical imbalances in the brain. Research indicates individuals with panic attacks and panic disorder tend to have reduced levels of the neurotransmitters serotonin, dopamine, and norepinephrine (which are all associated with mood regulation and emotion regulation). Additionally, when it comes to brain chemistry as a potential cause, there is a strong connection between those with an "overactive" amygdala (the part of the brain in control of the fight-or-flight response) and panic disorder.

Environment - some studies point to environmental factors, including one's upbringing and current levels of stress, as a potential cause of panic attacks in adolescents and teenagers.

Whether or not a teenager is pre-disposed to panic disorder due to genetics, stress, brain chemistry, or environment, there are some risk-factors that can increase one's chances of developing panic disorder including:

Being diagnosed with a mental health disorder - depression, anxiety, bipolar disorder

Certain health problems - various respiratory problems (i.e. - asthma) put a teen at an increased risk of developing panic disorder or suffering from panic attacks.

High levels of stress

Experiencing a traumatic event

Major loss or life transition

Signs and Symptoms of Panic in Teens

The signs and symptoms of panic disorder in teenagers tend to look quite similar to those in adults. There are many possible symptoms of panic disorder, manifesting physically, behaviorally, and mentally.

Physical symptoms

Increased heart rate

Feeling lightheaded or dizzy

Sweating

Shortness of breath

Chest pain

Choking sensation

Headaches

Nausea and/or vomiting

Muscle tension and tightness

Chills and/or hot flashes

Trembling/shaking

Numbness or tingling sensations

Fatigue

Behavioral symptoms

Changes in diet or sleep pattern

Isolation from friends and/or family'

Refusal to leave the home

Lack of interest in previously enjoyed activities

Inability to relax

Mental symptoms

Excessive worry

Feelings of hopeless and/or depression

Fear of losing control

Fear of dying

Suicidal thoughts

For teenagers, symptoms of panic disorder may be anywhere from mild to severe. They tend to arise quickly, and worsen with time. For most teenagers, an actual panic attack will only last for a brief period of time. Unfortunately, that panic attack can affect that teen for much longer even once it has ended.

Diagnosis of Panic Disorder in Teens

If an adolescent or teen is experiencing some of the symptoms of panic disorder, then getting evaluated by a mental health professional or healthcare provider may be the next step. An evaluation (or assessment) will consider many aspects of the teen, including medical history, family history, behavior, current medications and/or drug and alcohol use, and symptoms.

The criteria for diagnosing a teenager with panic disorder is:

Recurrent, unexpected panic attacks where four or more of the following symptoms occur:

Pounding heart

Sweating

Trembling/shaking

Shortness of breath

Chest pain

Feeling of choking

Light-headedness

Fear of losing control

Fear of dying

Chills

Nausea

Derealization or depersonalization

At least one of the attacks has been followed by one month of one (or both) of the following:

Ongoing worry/concern about having another panic attack

Significant change in behavior (in an effort to avoid another panic attack)

The disturbance is not better explained by another mental health disorder

The disturbance is not attributable to the effects of a substance (drug or alcohol) or other medical condition

Treatment for Teens with Panic Disorder

Various treatment approaches and modalities may be recommended depending on the severity to which a teen's life and daily functioning is being inhibited by panic attacks. Some common methods of treating panic include:

Medication - selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are the most common medications prescribed to adolescents and teenagers who suffer from panic attacks and/or panic disorder. Research has shown SSRIs success in treating panic disorder in teens, but they do take anywhere from three to six weeks to start being effective. Benzodiazepines provide immediate, short-term relief of panic symptoms. They are frequently prescribed "as needed" meaning the individual who is prescribed the medication can take it at his or her own discretion. Unfortunately, benzodiazepines do have the potential to be habit-forming. Typically, when medication is prescribed, it is in conjunction with the recommendation for psychotherapy.

Cognitive-behavioral therapy (CBT) - cognitive behavioral therapy is a common approach used in psychotherapy, especially in regard to panic attacks and panic disorder. Cognitive behavioral therapy uses cognitive restructuring paired with exposure and response techniques. This therapeutic approach can help a teenager become aware of, and begin to manage his or her thoughts that contribute to the panic experienced. CBT also provides healthy coping skills and tools for dealing with irrational fears.

Group therapy - group models of treatment for teens with anxiety and panic have been extensively studied. Group therapy is effective for a variety of reasons including peer-modeling opportunities, social support, and reinforcement of healthy behaviors and coping skills.

Biofeedback - also called applied psychophysiological feedback, biofeedback uses electronic monitoring to assist the client in learning to control bodily functions, such as heart rate. The individual receiving the biofeedback is connected to electrical sensors, which provide the information (feedback) about the body (bio). This process allows the person with panic to view his or her physiological responses to stress and fear. With that awareness, he or she is then able to control responses and brain activity. Biofeedback has been extensively researched in terms of treating anxiety disorders, and is a viable treatment option, especially for those who do not want to use medication.

Stress Management skills - whether or not your teenager seeks professional intervention for his or her panic attacks, it is important to incorporate stress management skills that can be used independent of any other treatment. Coping skills such as deep breathing, muscle relaxation, and catching and challenging unhealthy thoughts are a few examples.

Panic attacks and panic disorder are treatable. If you think your teenager might be struggling with excessive fear, worry or panic, contact Polaris Teen Center at (844) 836-0222 to find out more about residential treatment options.

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Panic Attacks in Teens - A Guide for Parents

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As human beings, our bodies have a natural, built in "fight-or-flight" response when danger is sensed. The brain activates adrenaline in the body to trigger the response to either "fight" the danger or to escape (the "flight"). Although this "fight-or-flight" response serves as a protective mechanism, it can also feel like panic.

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In the United States, epidemiological studies have recently pegged social anxiety disorder as the third largest psychological disorder in the country, after depression and alcoholism!

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by Thomas A. Richards, Ph.D. Google+
Psychologist/Director, The Social Anxiety Institute

Social anxiety is the fear of being judged and evaluated negatively by other people, leading to feelings of inadequacy, inferiority, self-consciousness, embarrassment, humiliation, and depression.

If a person usually becomes (irrationally) anxious in social situations, but seems better when they are alone, then "social anxiety" may be the problem.

*If you are seeking treatment for social anxiety, start here*

The Third Largest Mental Health Care Problem

Social anxiety disorder (formerly termed "social phobia") is a much more common problem than past estimates have led us to believe. Millions of people all over the world suffer from this devastating and traumatic condition every day, either from a specific social anxiety or from a more generalized social anxiety.

In the United States, epidemiological studies have recently pegged social anxiety disorder as the third largest psychological disorder in the country, after depression and alcoholism. It is estimated that about 7% of the population suffers from some form of social anxiety at the present time. The lifetime prevalence rate for developing social anxiety disorder is 13-14%.

Specific and Generalized Social Anxieties

A specific social anxiety would be the fear of speaking in front of groups (only), whereas people with generalized social anxiety are anxious, nervous, and uncomfortable in almost all social situations.

It is much more common for people with social anxiety to have a generalized type of this disorder. When anticipatory anxiety, worry, indecision, depression, embarrassment, feelings of inferiority, and self-blame are involved across most life situations, a generalized form of social anxiety is at work.

Symptoms of Social Anxiety Disorder

People with social anxiety disorder usually experience significant emotional distress in the following situations:

Being introduced to other people

Being teased or criticized

Being the center of attention

Being watched while doing something

Meeting people in authority ("important people")

Most social encounters, especially with strangers

Going around the room (or table) in a circle and having to say something

Interpersonal relationships, whether friendships or romantic

This list is certainly not a complete list of symptoms -- other feelings have been associated with social anxiety as well.

The physiological manifestations that accompany social anxiety may include intense fear, racing heart, turning red or blushing, excessive sweating, dry throat and mouth, trembling (fear of picking up a glass of water or using utensils to eat), swallowing with difficulty, and muscle twitches, particularly around the face and neck.
Constant, intense anxiety that does not go away is the most common feature.
People with social anxiety disorder know that their anxiety is irrational and does not make rational (i.e., cognitive) sense. Nevertheless, "knowing" something is not the same thing as "believing" and "feeling" something.

Thus, for people with social anxiety, thoughts and feelings of anxiety persist and show no signs of going away -- despite the fact that socially-anxious people "face their fears" every day of their lives.

Only the appropriate treatment works to alleviate social anxiety disorder, the largest anxiety disorder, and the one that few people know anything about.

Effective Therapy for Social Anxiety Disorder¹

The good news is that cognitive-behavioral therapy for social anxiety has been markedly successful. Research and clinical evidence alike indicate that cognitive-behavioral therapy, which should be comprehensive in nature, produces permanent changes in the lives of people.

Social anxiety disorder can be overcome, although it takes both consistency and persistence. But, barring cognitive problems (e.g., dementia, Alzheimer's Disease) everyone can make progress against social anxiety using the appropriate type of cognitive-behavioral therapy.

At The Social Anxiety Institute, we call cognitive-behavioral therapy for social anxiety disorder "comprehensive" cognitive-behavioral therapy, to differentiate it from the general idea that cognitive concepts are simplistic and can be addressed by using only a few strategies.

A successful therapy program for social anxiety disorder must address the dozens of cognitive methods, strategies, and concepts that will allow people's brains (i.e., their brain associations or neural pathways) to literally change. The brain is continually learning, and irrational thoughts and beliefs can change as a result of this cognitive process.

A good therapy program will supply the necessary and specific strategies as well as indicate to people how and why they need to practice, work on, and begin to accept rational thoughts, beliefs, emotions, and perceptions.

How To Find Help for Social Anxiety Disorder

Social anxiety, as well as the other anxiety disorders, can be successfully treated. In seeking support for this problem, search for a specialist -- someone who (a) understands this problem well and (b) knows from experience how to treat it.

Become an informed client and ask questions. For example, does the therapist understand that you feel very self-conscious and that others are watching and forming a negative evaluation about you? - or do they minimize what you're saying and just say, "No, No, No, you're fine ... you're just exaggerating...." or expect you to go out and do unreasonable "exposures"?

It is true that we who have lived through social anxiety do realize our mind is many times irrational and we over-exaggerate, but it still FEELS like others are watching and judging us. Our self-consciousness is a feeling and it is very real.

If your psychologist/mental health care worker does not understand this, you know more than they do about social anxiety. Under these circumstances, it is very doubtful they will be able to help you.

Also, remember that the professional should always welcome your questions. If someone seems unfriendly or too clinical, they should not be your choice of a therapist.

Those of us who have (or have had) social anxiety need support, encouragement, and a relatively stress-free environment while we are in therapy, so that our brain can absorb all the changes that are occurring without being damaged by external factors (i.e., negative environments, negative people). If our environment is relatively peaceful when undergoing treatment for social anxiety, then it is easier to learn new habits that will permanently change our thoughts, beliefs, feelings, and our lives.

Does your therapist say, "Face your fears and they'll go away?"

Sorry, but this therapist does not understand the dynamics of social anxiety. We, as people with social anxiety, have constantly faced our fears ever since birth - we've had to - and we feel more fearful now than we did in the past.

In this case, seek another therapist. It is imperative you find a psychologist who understands social anxiety disorder completely - because if they don't even know what it is - how will they know what to do to help you overcome it?

Getting over social anxiety disorder is not an easy task, nor is it a difficult one. Many thousands of people have already done it.

While you're in the middle of the social anxiety syndrome, it feels hopeless - it feels that you'll never get any better. Life is just one gut-wrenching anxiety problem after another.

But this can be stopped, quenched, and killed in a relatively short period of time - by finding a cognitive-behavioral therapist who understands and specializes in the treatment of social anxiety.

The most important elements in overcoming social anxiety

1. An understanding and awareness of the problem,

2. A commitment to carry through with cognitive-behavioral therapy even when it is repetitious and seems difficult,

3. Practice, practice, practice to get that information (i.e., cognitive methods, strategies, and concepts) deep down into your brain - so that these cognitive methods become habitual and automatic,

4. Participation in a social anxiety therapy group in which you can slowly and gradually work on problems that cause you anxiety in the real world.

That is, the person who feels anxious while reading in public uses specific strategies to meet his goal, whereas the person who wants to learn how to make introductions and engage in small talk during social activities slowly works toward her goals. We use role-plays, acting, the tape recorder and video camera, question and answer periods, mock job interviews, and doing foolish things deliberately as part of our behavioral therapy group for people with social anxiety.

Note: A ladder or "hierarchy" should be used as a flexible guide in planning. We want to practice, meet our goals, move up our expectations, meet our goals, move up our expectations, until our goal is finally met.

Groups

Social anxiety behavioral therapy groups should not pressure, push, or cajole people to do things. No negative tactic should be employed because the individual must choose to participate at her own pace. If she wants to sit there in group and not say a word, that's O.K. No one should be made to do anything.

You may be asking, "won't people never make progress if they choose to do nothing each group?" Here's the secret: This has never happened. People in the group understand why they are there and, despite an amount of anxiety that is naturally present, they voluntarily choose to work on their specific anxieties. This is much more practical and real-life than being forced to do something.

Therapy groups for social anxiety should always be encouraging, positive, and supportive. If the right atmosphere is set, people can make (and continue to make) progress up their "hierarchy" of social anxieties.

It is impossible to stop a motivated person who refuses to give up. The role of the therapist is to know specifically what to do and how quickly to do it. This sounds easy, but it is not. You must be practicing the right material and you must proceed at the correct pace for your own anxieties. You are more in control of this process than you think.

Today, cognitive-behavioral therapy is used to treat both forms of social anxiety. With cognitive-behavioral therapy, we do not wallow in the past and continually bring it up --- because it doesn't do us any good. Instead, we focus on present-day problems and symptoms and use many small techniques and methods to eradicate anxiety thinking, feelings, beliefs, and belief systems.

Here's where motivation and practice come in. The more you can practice these small anti-anxiety methods and techniques, the sooner anxiety can be reduced, and social anxiety can be overcome.

*If you are looking for help in overcoming social anxiety, start here*

1. Goldin, P.R., Ziv, M., Jazaieri, H., Hahn K., Heimberg, R. (2013, October). Impact of Cognitive-Behavioral Therapy for Social Anxiety Disorder on the Neural Dynamics of Cognitive Reappraisal of Negative Self-beliefs, JAMA Psychiatry, 2013;70(10):1048-1056.
References and Citations

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Social anxiety is the fear of social situations and the interaction with other people that can automatically bring on feelings of self-consciousness, judgment, evaluation, and inferiority. Social anxiety is the fear and anxiety of being judged and evaluated negatively by other people, leading to feelings of inadequacy, inferiority, embarrassment, humiliation, and depression.

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Social Anxiety Disorder or Social Phobia

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Social Anxiety Disorder or Social Phobia

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There's nothing abnormal about a child being shy, but children with social anxiety disorder experience extreme distress over everyday situations such as playing with other kids, reading in class, speaking to adults, or taking tests. Often, children with social phobia don't even want to go to schoo

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Do you get anxious in certain social situations? Learn about the signs and symptoms and how to overcome social anxiety disorder.

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IDEA and 504 Accommodations for Depressive Disorders

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IDEA and 504 Accommodations for Depressive Disorders

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Not all students who have disabilities require specialized instruction. For students with disabilities who do require specialized instruction in the United States, the IDEA controls the procedural requirements and an IEP is developed. "Special education" under IDEA means the child has been identified as having unique educational needs related to his/her disability and is entitled to an Individualized Education Program (IEP) to meet these needs.

The IDEA process is more involved than that of Section 504 of the Rehabilitation Act. The IDEA requires that measurable growth and progress towards written goals and objectives be documented.

For students with disabilities who do not require specialized instruction but need the assurance that they will receive equal access to public education and services, a document is created to outline their specific accessibility requirements. Section 504 is a federal civil rights law. The purpose of Section 504 is to protect persons with disabilities against discrimination for reasons related to their disabilities.

While students with a 504 plan do not require specialized instruction, and specific goals and objectives are not necessarily outlines nor is data tracked, the plan should be reviewed annually to ensure that the student is receiving the most effective accommodations for his/her specific circumstances.

Unlike IDEA, Section 504 does not guarantee that a child with a disability will receive an individualized educational program that is designed to meet the child's individual educational needs. Rather, it guarantees that accommodations will be made relative to their specific medical needs.

Eligibility for protections under Section 504 depends on the child in question having a physical or mental impairment which must substantially limit at least one major life activity. Major life activities include walking, seeing, hearing, speaking, breathing, learning, reading, writing, performing math calculations, working, caring for oneself, and performing manual tasks. Section 504 requires an evaluation that draws information from a variety of sources.

A child who receives Section 504 protections has fewer rights than the child who receives special education services under the IDEA. The child who receives special education services under the IDEA is automatically protected under Section 504.

Section 504 is designed to guarantee that children with disabilities will not be discriminated against. It is also important to understand that if your child does not qualify for special education services under IDEA, your child does not have the procedural protections that are available under the IDEA.

Under Section 504, the child with a disability may receive accommodations and modifications that are not available to children who are not disabled. These accommodations and modifications are also available under IDEA. For example; accommodations could include, but not be limited to, such things as:

Tests taken in a separate location with time limits waived or extended.

The use of a word processor due to fine motor, visual motor deficits.

Shortened assignments.

Standardized tests answers written directly in the test booklet and transferred onto answer sheet by teacher or assistant.

Class notes provided rather than having the student copy from the chalkboard or overhead.

Allowing the child to leave the classroom 2 to 3 minutes early to avoid crowded hallways.

Preferential seating in the classroom.

Provision of a daily assignment sheet to be filled out by the student and verified by the teacher for accuracy. The parent could then check to make sure that all the work is accomplished. This would assist with homework prioritizing and management.

Please note: These are simply examples. All or none of these may be suitable for your child.

Students with bipolar disorder may or may not have a need for specialized instruction provided within an IEP. For some students, simply being granted accommodations that make allowance for the side effects of medications, related anxiety issues, or results of mood changes is sufficient.

Students with bipolar disorder who are well-controlled on medication may or may not be plagued by racing thoughts, distracting thoughts, an inability to concentrate, decreased energy; all of which will require modifications in the teaching environment or instructional strategies.

For other students, the side effects of medications may be significant enough to require changes in instruction provided or curriculum modifications. Some of the common side effects of medications include: tremors (trembling of hands), blurred vision, loss of coordination, slurred speech, sedation, ataxia (unsteady movement), dizziness, seizures. Some students with bipolar disorder may also have one of a number of other disabilities that impacts their access to the general education curriculum; such as vision or hearing impairment, learning disability, processing problems, or other disability. The co-morbidity rates of ADHD, anxiety disorder, conduct disorder, oppositional-defiant disorder and learning disabilities in students with bipolar disorder tell us that we should explore all avenues available to meet the educational needs of our children.

The following accommodations are meant to serve as a resource for parents unsure of what possibilities exist:

Students on some medications may need:

increased access to water, unlimited access to restrooms (particularly students taking Lithium)

decreased reading assignments or having books on tape or computer screen-reading due to blurred vision

modified school arrival, shortened day, scheduling of core content during the student's most alert time, reducing homework and extending deadlines, providing notes, allowing longer or more frequent breaks, allowing exercise or other movement due to sleep impairment or to sedation of medications

provision of notes and listening guides, work monitoring, extended time on assignments, extra set of books for home use, breaking assignments into more manageable pieces, use of checklists, providing written instructions and/or other visual cues, use of word banks on fill-in types of tests and other modifications that aid retrieval/memory, testing in a separate room, or extended test time, use of multiple choice formats, use of oral exams rather than written demands, use of noise-canceling headsets, - all for impaired concentration, memory

reducing or discontinuing homework may be necessary for some students due to difficulties with concentration, sleep patterns, mood irritability. For these students it may be necessary to schedule a resource room period at the beginning of the day to get assignments ready for the day, or at the end of the day to complete assignments before leaving school

preferential seating can be used to help with vision, focus, reduce visual or auditory distraction, allow for discrete monitoring

and while a 504 plan will simply list the type of accommodation needed and the reasons for it/them, an IEP must contain objectives that are written with specific criteria; such as -Given a grade level reading assignment of 1 chapter with 4 comprehension questions, (name) will answer the questions with 60/70/80% accuracy. Or given an assignment containing 5 long division problems, (name) will complete 3/4/5 problems at 80% accuracy.

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Accommodations for Students with Bipolar Disorder and Related Disabilities - International Bipolar Foundation

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Error! You must specify a value for the Video ID, Width, Height and Anchor parameters to use this shortcode! Not all students who have disabilities require specialized instruction. For students with disabilities who do require specialized instruction in the United States, the IDEA controls the procedural requirements and an IEP is developed.

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Support for parents when talking to schools about Depressive Disorders

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Support for parents when talking to schools about Depressive Disorders

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Depression Fact Sheets for Teachers and Parents

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Depression Fact Sheets for Teachers and Parents

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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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A Great Site for Infographics on Depression and Mental Health

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A Great Site for Infographics on Depression and Mental Health

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Fact Sheet Library | NAMI: National Alliance on Mental Illness

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View NAMI's fact sheets that give clear, concise information on mental health topics.

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Juvenile Bipolar Research Foundation Website Full of Helpful Information for Families

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Juvenile Bipolar Research Foundation Website Full of Helpful Information for Families

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The Clinician's Pathway Program (CPP) and its assessment tools, the CBQ and JJ, were developed by Dr. Demitri Papolos. By clicking the links below you will leave www.jbrf.org and be redirected to the research site that contains the CPP and the CBQ & JJ assessments. If you have any questions or concerns regarding these tools please direct them to Dr. Papolos's system administrator at CPP@drpapolos.com To Set Up a New CPP Account To Access an Existing CPP Account
Scoring for assessments within the CPP is a fee-based service offered by the private practice of Demitri Papolos, M.D.; this service is independent of JBRF but may be accessed through the JBRF website. Dr. Papolos developed the CBQ & JJ measures and their automated scoring report with the support of JBRF. Questions and/or concerns with regard to the scored report should be addressed to CPP@drpapolos.com

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JBRF - Juvenile Bipolar Research Foundation

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The Clinician's Pathway Program (CPP) and its assessment tools, the CBQ and JJ, were developed by Dr. Demitri Papolos. By clicking the links below you will leave www.jbrf.org and be redirected to the research site that contains the CPP and the CBQ & JJ assessments.

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ASCA on the School Counselor and Discipline

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ASCA on the School Counselor and Discipline

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The School Counselor and Discipline - American School Counselor Association (ASCA)

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Ideas for School Counselors on Managing Behavior Referrals

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Ideas for School Counselors on Managing Behavior Referrals

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Managing behavior referrals often fall under the realm of school counseling. However, most school counseling programs have few, if any, behavior management components. Don't worry, we've got you covered! Confident Counselor authors are ready to share their best practices for managing behavior referrals. Heather will cover the details we need to know first when presented with a behavior. Carla has some tips for clarifying the problem with the teacher. Finally, Robyn has some solid advice on how to engage the parents.

Hey there! I'm Heather from The Helpful Counselor Blog & Counseling Resources . Over the past two decades, I've worked as a therapist, school counselor, and special education teacher for students with emotional impairments. I pride myself on my ability to develop rapport and engage the tougher "hard to help" students. There's just something about watching them grow into their full potential!

Has a teacher ever referred a student to you for being disruptive but you were unsure about how to help? Sometimes, uncertainty can leave counselors feeling less than the helpful superstar they are.

The term "disruptive behavior" is extremely broad. It can mean anything that interrupts the classroom. Sometimes teachers will give you a broad description like a student is "angry". But unless we know the details, we won't be able to pinpoint . In order to help, we need to what's behind their anger clarify the problem.

Description of disruptive behaviors.

When does it occur (e.g., time of day, day of the week, subject)?

When did the behavior first begin?

How frequently does the behavior occur?

How long the behavior lasts?

What happened right before the disruptive behavior?

Gathering all of these details will help you narrow down the behavior AND the cause of the disruptive behavior.

Example: A student is extremely argumentative and off-task for most of the day every Friday. Upon speaking with the student, we learn he started visiting his father over the weekend. Although it's not 100% conclusive, there could be a connection and it certainly warrants further exploration!

Another Example: A student talks to the student around him whenever the teacher uses the overhead projector. While speaking with the student, they admit that they can't read what's being projected. The words are blurry. The two examples both contained disruptive behavior, but one of them might be helped with a pair of glasses while the other student may need counseling to learn some coping or anger management skills to help process the changes in his home life.

Hello, I'm Carla Christian, the DIY Counselor. I am a wife to Bill, Mom to three daughters, and Nanna to four grands with one on the way. Spending time with family and advocating for my profession are two things that I am very passionate about. My twenty plus years of experience as an educator have enabled me to create resources for teachers and school counselors. I especially enjoy developing no prep lessons for middle level school counselors

Sometimes it seems my colleagues are saying, "Here, fix this!" When this happens, it is difficult to know how to support the teacher and help the student right at that moment. How does one handle these impromptu encounters? I have found that consultation and collaboration are essential in managing behavioral referrals and helping teachers manage disruptive behaviors in the classroom.

Strategies for those spur of the moment behavior referral conversations

Ask the teacher specific questions: "Where are you in your discipline plan with this student?" "Have you contacted the parent?" "What are the most disruptive behaviors?" The answers provide a starting point to determine how to proceed. (Our school has a uniform discipline plan that teachers are to follow. Parent contact is the first step.) If there has been no parent contact, the teacher should inform the parents of student behavior. After there has been parent contact, consult with the teacher and move to the next step.

Request the teacher fill out a referral form. (This form documents all that the teacher has done prior to the referral and is vital in determining a plan of action.)

Observe the student in different settings. (include classroom, cafeteria, hallway, gym)

Meet with the teacher to discuss information from the referral and observations.

Work with the teacher to develop strategies for addressing student behavior, including behavior goals, behavior tracking charts, positive rewards, seating arrangement, classroom management, etc.

After a designated time, evaluate strategies to determine effectiveness.

If there is no improvement in student behavior, follow-up may include a conference with the parent, referral to a counselor for individual counseling, conference with admin, or a functional behavior assessment and behavior intervention plan.

Hello, I am Robyn from the TPT store Mental Fills. I am a Licensed Clinical Social Worker in California with close to 20 years of experience in the field of Mental Health. I have worked with a broad range of children, teens, and adults in inpatient psychiatric hospitals, residential treatment facilities, and outpatient mental health clinics providing individual and group therapy. Currently, I work full-time in The Department of Mental Health at a military hospital and part-time in private practice. Although I specialize in evidenced based treatment for anxiety, depression, and interpersonal relationships, it is my experience as a parent of a child with special needs in elementary school that has inspired both my TPT resources and my tips on engaging parents of disruptive children.

Reach out to parents early on to share your interest and good intentions of working together. After speaking to a parent in person or over the phone, an online partnership might be a good next step. To promote parent reception and eliminate defensiveness, consider scheduled weekly or biweekly emails:

Review specific goal(s). Keep the email focused on the specific goal that is being worked on. This will help eliminate child blame and focus on strategies that are working or need tweaking. For example, instead of "I am emailing you about David's anger problem," try "I am emailing you today regarding our goal of anger management."

Use language that demonstrates partnership, such as "us, we, our, let's." Although this may show a looseness of boundaries, we want parents to understand we are equally invested in their child's goals and progress; and this avoids blaming statements. A helpful example of positive language is, " work on helping David with coping skills this week."

Invite parent expertise. A newbie mistake is assuming parents are at fault for their child's behaviors. Regularly ask the parent/s for their advice. Ask what has worked for their child before, what is working for the child at home, and what reasonable suggestions the school could try to help their child's behavior. This will not only provide strategies you may not have considered before but helps to improve the parent's feeling of value and connection.

Include positive behaviors and progress towards goals. Similar to children, parents need to feel encouraged and supported. Parents need to hear their children are moving in a positive direction and although there may be a temporary regression, reminders of the steps made forward are necessary to sustain hope. Although this may be a challenge, it will be a critical piece of gaining parent investment.

When sharing updates that include negative behaviors, avoid language that shows judgment or criticism. Simply state the facts. Instead of "David lost control again and rudely threw his pencil. He can't seem to control his anger," try, "David struggled with impulse control today and threw his pencil." Sticking to facts prevents emotional and finger-pointing responses.

Avoid reviewing the negative consequences to their child's behaviors, such as "the teacher and the classmates are tired of his behavior." This will only promote shame and resistance. Instead, focus on the positive consequences that include the both of you working together. For example, "I plan to review coping skills with David this week. I will send home a list of the skills he prefers to practice at home."

Offer help. Even the best of parents feel helpless and inadequate. Instead of imposing recommendations, when appropriate, gently offer solutions. For example, "If you are interested, I have found some useful tips that may work at home, I would be happy to email you." Other suggestions that help support the parent include collaborating with the student's outside therapist and providing updates as needed.

Lastly, although parents can have a negative influence at times, we do not want to take for granted the positive influences they have on your student's success. These emails may seem like a chore at first, but once you create a trusting connection with a parent, the fewer details need to be provided and most importantly, the alliance built aids in improved behaviors. Finally, when writing your email, always put yourself in the parent's shoes and ask yourself, what would I want to read if this was my child?

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Managing Referrals for Disruptive Behavior

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Managing behavior referrals often fall under the realm of school counseling. However, most school counseling programs have few, if any, behavior management components. Don't worry, we've got you covered! Confident Counselor authors are ready to share their best practices for managing behavior referrals.

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"School counselor" is a deceptively simple title. In reality, school counselors play many roles, including social and emotional educator, academic adviser, conflict mediator, wellness coach, mental health therapist, student champion, educational collaborator and family liaison.

Now, with the advent of the pandemic caused by the novel coronavirus, many school counselors have become connectors and comforters-in-chief - not just to students but to parents and school staff.

Last spring, schools began closing in response to the pandemic. According to Education Week, 48 states; four U.S. territories; Washington, D.C.; and the Department of Defense Education Activity eventually ordered or recommended school closures affecting at least 50.8 million public school students. Suddenly, students, families, counselors, teachers and administrators all had to find a way to virtually re-create their in-person school routines. This already-challenging shift was complicated by the significant number of students who lacked access to high-speed internet or desktop, laptop or tablet computers.

Even before the pandemic, civil rights and education groups had been decrying what they had dubbed the "homework gap" because many teachers were increasingly assigning work that required internet access. Already at a disadvantage, these disenfranchised students - many of whom were Black, Indigenous or people of color (BIPOC) - now faced being completely locked out of school academic activities for the rest of the year.

According to "Students of Color Caught in the Homework Gap," a recent report by organizations that include the Alliance for Excellent Education and the National Urban League, when the wave of school closures occurred, 16.9 million children lacked high-speed home internet access (a number that included 1 in 3 BIPOC families), and 7.3 million did not have a computer or tablet. Many schools spent the spring and summer scrambling to provide devices and internet access to students - a task that was still incomplete going into the new school year. Stories of students struggling to keep up with online instruction on cell phones are still not uncommon.

In addition, when the economy took a nosedive as the coronavirus spread, it made it hard to focus on anything but survival for many families. But even financially secure families found it challenging to provide the ideal learning environment as - in many cases - parents working from home with multiple children wrestled with carving out a physical space and a time for each person to be online. Students missed getting to see their friends and participating in extracurricular activities. Sports seasons were canceled. The theater curtains never went up on school plays. Rites of passage such as prom and graduation ceremonies largely fell by the wayside.

And now it is fall, meaning a brand new school year. Even so, in many parts of the country, the football fields and stands will remain empty, the marching band instruments will stay silent and there will be no homecoming dances. Things are decidedly not back to normal. For that matter, there is relatively widespread belief that "normal" will never return. No one knows what the future will hold.

So, it's not surprising that parents, students and school personnel are all feeling stressed and overwhelmed. Continuing to hold classes online while simultaneously ensuring that students and families have the needed technological resources - or, in some cases, the absolute basics, such as enough food to eat - continues to be a team effort.

Because safeguarding the mental, emotional and physical welfare of students is the essence of what school counselors do, these professionals have typically been at the center of the problem-solving process since the arrival of the coronavirus. They have conducted check-in phone calls to make sure students had the necessary equipment and internet access; helped parents (or grandparents) with technological troubleshooting; arranged for families in need to receive gift cards and community resources; responded to requests from teachers to find out why students weren't showing up for online class (and then worked to resolve whatever the barrier was); reassured stressed-out parents; coached families on how to set up a structured school day; made mental health referrals for students in crisis; and provided moral support to teachers, administrators and each other. All while finding ways to continue offering academic guidance, focusing on students' emotional and social learning, and giving specific support to children who were struggling with various personal and school-related issues.

Counseling Today spoke to several school counselors at the end of the 2019-2020 school year and as they prepared for the new 2020 fall semester to learn more about the challenges of performing their jobs in the midst of a pandemic.

Linda Colón
Counselor for prekindergarten and kindergarten students, Bancroft Elementary School, Washington, D.C.
Bancroft is a Title I school (i.e., a facility that receives financial assistance due to a high population of students from families with low incomes) with a majority Latinx student body that also includes children of Ethiopian immigrants. Many of the families in the district live in poverty and often share relatively small living quarters with extended family.
Under normal circumstances, American Counseling Association member Linda Colón gives Bancroft's youngest students their earliest lessons in social and emotional learning. By observing (and joining) students at play, reading aloud to them, incorporating toys, conversing with puppets and showing self-produced videos, Colón teaches prekindergartners and kindergartners basic social skills and how to recognize and regulate their emotions.

Getting to know students' families and getting them invested in their children's learning has always been an integral part of Colón's counseling approach. She says that she's "planting a seed" of awareness about the importance of education and attendance from an early age. Colón meets with parents to answer questions and, if requested, gives them advice on how to reinforce the social and emotional lessons that their children are learning.

Another benefit of establishing a relationship with families - and checking in regularly via phone or in person (during nonpandemic times) - is that Colón can get a better sense of the problems with which the families might be struggling. If they trust the counselors and teachers, she says, they will be more likely to reach out if they need help addressing emotional or mental health problems or accessing vital resources such as food and shelter.

Colón has been finding new ways to stay connected to her students and their families since March, when schools across the metropolitan region shut their doors and transitioned to online learning to finish out the school year because of the coronavirus. Schools in Washington, D.C., opted to begin the new year virtually as well, with an option to reevaluate in November.

"We can't just say, 'This isn't going to work,'" Colón says. "We have to figure it out. We owe it to the kids."

Before in-person learning ceased completely in March, Colón, knowing that the children were feeling anxious, created a lesson centered on "claiming strategies." She reminded the children that when they were really afraid, it was helpful to talk about it, and she provided them with some age-appropriate safety information.

But the most important piece was the practical activity: washing hands. "We want to keep the germs away, so we wash our hands for 20 seconds," Colón told the children, reinforcing the statement with videos and puppet demonstrations of hand-washing.

Colón also made videos so that the children's social and emotional learning could continue virtually. The videos covered topics such as keeping a positive mindset, practicing breathing techniques and exercising mindfulness.

Colón also spoke to some of her students and their families one-on-one, either on the phone or via Microsoft Meetings, to find out how they were coping, to offer a sympathetic ear to stressed-out parents and to provide a reassuring presence for anxious children. She has given her phone number to parents and encouraged them to call or text her if they need help. As distance learning continues, she has been encouraging teachers to reach out as much as possible too. In addition, Colón has worked directly with parents to help solve technological problems.

This year, one of her initiatives is to help parents find a way to provide a space for children to take a break from their surroundings - a relaxation bubble. Many of her students live in small spaces, so the "bubble" might be something as simple and small as a blanket draped over a chair to make a mini tent.

Even at a young age, children are more aware of what is going on around them than most people realize, Colón says. They know that people are sick and dying, and at this age, children are less able to process the fear, which leaves them at risk of getting stuck in fight-or-flight mode. When they are at school, they can see their friends on the playground and have other opportunities to get away, but at home, exposure to trauma - even if only through the television - may be inescapable.

Activities such as drawing, watching a fun video or escaping to their relaxation bubble can help relieve the agitation, Colón says. The staff at Colón's school has requested that markers, crayons and paper be sent to all the families.

Research also shows that when people are experiencing trauma, simply making a connection with a sympathetic presence can help, Colón says. So, she believes that keeping in contact with students and families is one of the most important things school staff can do right now.

"It's finding a way to establish that connectedness," she says. "When you're in school, you're waving to them [students and families], saying 'Hi, good morning,' singing a silly song. You're doing something to make a connection that doesn't have anything to do with academics."

"I think our [school counseling] services are needed more than ever," Colón says. "We're the ones who are getting the pulse [of the community]."
****
Natasha Griffith
Counselor for first through sixth grades and homeless coordinator, Dorothy I. Height Elementary School, Washington, D.C.
Height is also a Title I school, with many of its families living at or below the poverty level. Most of the students are Black - primarily first-generation Ethiopian. Approximately 20 to 30 percent of students are Latinx.
"I think this year, I'll feel proud and accomplished if I can master Microsoft Teams and have whole class sessions," says ACA member Natasha Griffith, whose school - like Colón's - will be all virtual until at least November. She has modest goals for kicking off the school year, including holding a few smaller group sessions with students in fourth through sixth grades. Griffith's role as the school's homeless coordinator - which involves helping families in transitional housing find financial and community resources - can make that goal challenging. "I have to focus on the barriers that children and their parents face," she says.

Griffith says she and her co-workers "hit the ground running" last spring when school buildings closed, distributing gift cards from the city's public services department and money from a GoFundMe campaign to the neediest families and making sure that students had computers. But there will be an ongoing need for assistance during the current school year. In fact, although Griffith wasn't officially working over the summer, she heard from families in search of additional gift cards and did some interpreting for the school's technology contact, who doesn't speak Spanish. Most of the students received computers or iPads in the spring, but stable internet access was a persistent problem, so the school has been setting families up with mobile hotspot devices (routers connected to a cellular data network that provides Wi-Fi connectivity).

Griffith will also continue to call families to check in on students who aren't showing up online. If their absence is due to technological problems, she will make sure they get the resources they need. If the absence is because the students and families aren't adapting well to virtual learning, then Griffith will do her best to help them navigate the unfamiliar territory and highlight how important it is for students to participate so that they don't fall behind. "So many students weren't participating [last spring]," she says. Even if families aren't experiencing technological difficulties, many of them still aren't sold on virtual learning, Griffith says.

Unfortunately, as is the case in many communities across the country, there will be cases in which Griffith isn't able to get in touch with families. The counseling staff at Height does work closely with a social worker from Washington's department of public health who is responsible for connecting families with resources, and Griffith says that she has been able to accomplish a lot. Even so, the reality is that educational continuity is incredibly difficult for schools to provide during the pandemic.

As she did last spring, Griffith will continue to help bridge the gap between parents and teachers. Many parents are feeling overwhelmed, and coping with online learning is yet another source of frustration for them. Griffith provides a listening ear and works toward helping families see that the school staff is there to help, not to judge. She is also concentrating on developing lesson plans that help students navigate the virtual landscape and encouraging them to ask for help when they need it.

Another challenge Griffith is facing is that she has no designated "classroom time" online. To present lessons, she has to be flexible and grab any spare time that teachers have in their class schedules. To supplement, she is planning on developing videos covering the social and emotional learning topics that make up the core part of her counseling curriculum, including managing anger, building self-esteem, learning to identify emotions, developing resilience and using tools for academic success. She has been rearranging her apartment to carve out a space for filming. The videos will be posted on Microsoft Teams for the students to access on demand.

In the spring, Griffith created a few virtual "lunch bunches" for small groups of students. She and the children would play games such as self-care bingo; squares included actions such as taking a shower, eating breakfast, listening to your body, taking a break, meditating, calling a friend and saying something good about yourself. She would also ask students about what they were doing outside of their classroom lessons. "It gave them a place to talk about missing their friends," she says. "It was also something social that wasn't related to school."

Griffith is starting up the virtual lunches again during the current school year. She would also like to find a way to virtually re-create the in-person restorative circles that she used to hold in school. The activity, which usually involved 20-22 students, was focused on building community. Griffith would ask open-ended questions (usually focused on having respect for fellow students) and present students with a talking piece to pass around the circle. Students could choose to keep the piece and speak, or pass it on.

"I think restorative circles work well because they allow students to express their feelings about various social and emotional learning topics," she says. "It allows students to take ownership and be an involved participant in the classroom community."

Griffith will continue to connect with students any way she can while her school is held online, but she believes there is no substitute for face-to-face interaction. "Especially for these kids," she says. "Saying in person, 'You've got this. You can do this.' That's what I live for as a school counselor ... [to] make a difference and tell them they matter."
****
Judy Trigiani
Counselor for kindergarten through sixth grades, Spring Hill Elementary School, McLean, Virginia.
Spring Hill has a large population of international students, many of them the children of diplomats and business people from around the world. Some of these families temporarily relocated to their home countries to wait out the pandemic and have not yet returned to the U.S.
The plan for ACA member Judy Trigiani's school district is to operate exclusively online through at least the first quarter of the school year and then to reevaluate. But as Trigiani noted at the end of the prior school year, one of the biggest burdens of the pandemic for people is not knowing when it will end. Or, in the case of schools, when bringing students back in person will not carry the threat of widespread community spread. "We are trying to plan for the unknown. We don't know when we'll go back yet," Trigiani says.

In the meantime, Trigiani and the rest of the staff at Spring Hill continue to try to keep things as "normal" as possible. Traditionally, the school's year starts with an open house and a new family and student orientation. This year is no exception; however, the events will all be virtual. Families and students will connect via Blackboard Collaborate, where staff will introduce themselves and talk about the school community, scheduling and resources available to parents. A question-and-answer session will follow. The school is also hosting town hall meetings and a kindergarten orientation to present new resources and answer questions.

This year, there will also be a technology orientation to demonstrate Blackboard features such as the icons for accessing the microphone and video and "raising" your hand; how to magnify the screen; agreeing, disagreeing and reacting to the teacher and fellow students with emojis; and where to find the chat box, Trigiani says. The technology orientation will also cover some of the other programs the school will be using. Blackboard Collaborate enables staff to post videos and PowerPoints and share their screens. The tech session will also demonstrate how to access the website and the asynchronous learning area (video sessions that students can watch on their own schedule). Trigiani has also been preparing PowerPoint presentations for parents on topics such as setting up their children's workspaces and how to talk to children about COVID-19.

Trigiani and the rest of the counseling staff will continue to visit the virtual classrooms every morning to check in and say, "We're here if you need anything." There are 18 classrooms per counselor, and counselors go into one classroom each day, she explains. Sometimes, they conduct a lesson. Other times, Trigiani will show up early just to chat with the kids, asking them to use the emojis to let her know how they are doing. If a student expresses distress or Trigiani hears or sees something that causes her concern, she meets with the student individually online and works to address the issue.

Individual counseling, social skills instruction, school counseling programs, parent meetings, the identification and sharing of resources - all of the normal work of school counselors also continues virtually. In addition, Trigiani works with parents who are struggling to cope with their children's behavioral, social and emotional issues. If necessary, the counseling staff makes referrals to outside mental health resources.

The key, Trigiani says, is something that one of her former bosses used to say: "Keep your community and people informed, and stay as positive and flexible as you can."

Trigiani believes that technology will continue to become more and more critical to school counseling, even after schools decide to return to the in-person model. Not only will retaining a virtual element allow medically fragile students better access to education, but it will also help counselors prepare students for 21st-century jobs by enabling them to give students training in online social skills, Trigiani asserts.
****
Randi Vogel
Counselor for sixth grade, Thomas Pyle Middle School, Bethesda, Maryland.

Pyle also has a significant number of international students, which means that the student population is somewhat transitory.

"This pandemic has really brought to light the social-emotional needs of our students," ACA member Randi Vogel says. "Even students who we considered very solid are having difficulties."

In the spring, several students who were already struggling with mental health issues deteriorated further with the loss of a structured school environment and ended up needing to be hospitalized, she says. But even students who had no history of mental health issues were experiencing anxiety and stress.

After school moved online, Vogel and her team put out an announcement on the school portal that they were available via email and Zoom. They also sent out regular surveys asking students how they were feeling, if they needed anything or whether they just wanted to share.

One girl replied that she needed a Chromebook laptop to keep up with her school assignments. Another student said, "I miss you - and I fell and broke my arm." Some students expressed that they just really wanted to talk, so Vogel and her team connected with them individually via video chats.

The surveys also asked students what they were doing to take care of themselves and to whom they had reached out. Every time that Vogel spoke to a student, she would ask them what they were doing for themselves.

Vogel's district is starting the new school year with virtual-only instruction and will reassess in November. Although many students may have initially enjoyed the novelty of learning from home, that sentiment generally seems to have worn off, Vogel says. "I have heard from several parents and students that they truly miss the school experience - chatting in the halls with their friends, switching classes, the cafeteria, after-school activities, the bus rides to and from school."

Although her school can't re-create those experiences, the days will be more structured and organized for students this year, she says. There will be more live and interactive instruction, in contrast to this past spring, when teachers primarily gave lessons via "asynchronous learning," which involved using previously recorded videos that students would watch on their own. Teachers then offered online "office hours" to field follow-up questions.

"Parents definitely want more 'live' instruction and for more of the day to mimic what occurs in the building," Vogel says. Although this may help virtual lessons to feel more like regular class, she anticipates that students will have difficulty being on their screens for so many hours, despite the breaks that have been built into the schedule.

"We, as counselors, will continue to reach out to our students to see how we can help them virtually," she says. "This might look like lunch bunches or initiating one-on-one Zoom calls as check-ins."

Vogel says her counseling department really prided itself on always being available to students during the day. In fact, they had several students who were issued "flash passes" so they could come to the counseling office anytime they needed a break. "Once we are back in the building, I expect that to resume," she says. "However, it is much more challenging to establish relationships with middle schoolers via Zoom."

Because so many students are struggling or just need a little extra help coping, Vogel and her colleagues will be incorporating more mindfulness and stress-reduction activities and class meetings into the virtual day for students. "I think it will be very beneficial to have the students hear from one another how they are managing and that they are not alone with their feelings," she says.
**** Additional resources
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

ACA School Counselor Connection (counseling.org/membership/aca-and-you/school-counselors/school-counselor)

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/)
Books & DVDs (imis.counseling.org/store)

A School Counselor's Guide to Small Groups: Coordination, Leadership, and Assessment edited by Sarah I . Springer, Lauren J. Moss, Nader Manavizadeh and Ashley Pugliese

Critical Incidents in School Counseling, Third Edition, by Tarrell Awe Agahe Portman, Chris Wood and Heather J. Fye

Developing and Managing Your School Guidance and Counseling Program, Fifth Edition, by Norman C. Gysbers and Patricia Henderson

Solution-Focused Counseling in Schools, Third Edition, by John J. Murphy

Acute and Severe Behavior Problems presented by Dave Scott

Bullying in Schools: Six Methods of Intervention presented by Ken Rigby

Managing Conflict in Schools: A New Approach to Disciplinary Offense presented by John Winslade

Quality Circle Time in the Secondary School presented by Jenny Mosley

****
Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.
**** Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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School counseling in the time of the coronavirus - Counseling Today

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"School counselor" is a deceptively simple title. In reality, school counselors play many roles, including social and emotional educator, academic adviser, conflict mediator, wellness coach, mental health therapist, student champion, educational collaborator and family liaison.

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Character Education - Shared Responsibility

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Character Education - Shared Responsibility

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Throughout time, societies have recognized the need to educate the coming generation of adults to pass on knowledge and skills. Recorded history from long before the present era emphasizes that education must also develop character.

One of the great education reformers, Horace Mann, in the 1840s, helped to improve instruction in classrooms nationwide, advocating that character development was as important as academics in American schools. The United States Congress, recognizing the importance of this concept, authorized the Partnerships in Character Education Program in 1994. The No Child Left Behind Act of 2001 renews and re-emphasizes this tradition-and substantially expands support for it. Indeed, one of the six goals of the Department of Education is to "promote strong character and citizenship among our nation's youth" (Strategic Plan 2002-2007). To reach this goal, the Department of Education joins with state education agencies and school districts across our country to provide vital leadership and support to implement character education.

Within the character of the citizen lies the welfare of the nation.
- Cicero

What is character education?

Throughout history, character education has been the shared responsibility of parents, teachers and members of the community, who come together to support positive character development.

...nothing is of more importance for the public weal, than to form and train up youth in wisdom and virtue.
- Benjamin Franklin

Character education teaches the habits of thought and deed that help people live and work together as families, friends, neighbors, communities and nations.

Character education is a learning process that enables students and adults in a school community to understand, care about and act on core ethical values such as respect, justice, civic virtue and citizenship, and responsibility for self and others. Upon such core values, we form the attitudes and actions that are the hallmark of safe, healthy and informed communities that serve as the foundation of our society.

What is the school's role in character education?

Students spend much of their young lives in classrooms. This time in school is an opportunity to explain and reinforce the core values upon which character is formed.

In school, character education must be approached comprehensively to include the emotional, intellectual and moral qualities of a person or group. It must offer multiple opportunities for students to learn about, discuss and enact positive social behaviors. Student leadership and involvement are essential for character education to become a part of a student's beliefs and actions.

To successfully implement character education, schools are encouraged to:

Take a leadership role to bring the staff, parents and students together to identify and define the elements of character they want to emphasize;

Provide training for staff on how to integrate character education into the life and culture of the school;

Form a vital partnership with parents and the community so that students hear a consistent message about character traits essential for success in school and life; and

Provide opportunities for school leaders, teachers, parents and community partners to model exemplary character traits and social behaviors.

State education agencies, through a collaborative community process, have chosen to incorporate character education into their school improvement plans and state standards. Some states have chosen to implement character education through official state policies such as the Michigan State Board of Education Policy on Quality Character Education. Many schools have chosen to incorporate character education into their plans for Safe and Drug-Free Schools and Communities.

From state to state, the following are common threads in character education agendas:

Involvement of the whole community in designing and implementing character education for its schools; and

Commitment to making character education an integral part of the education process.

Federal resources and support for character education

The United States Congress and the Department of Education have expanded support for character education for more than a decade, enabling schools across our nation to implement character education in a variety of ways. The Department of Education provides grants to state and local education agencies to support the development of character education. Since 1995, through the Partnerships in Character Education Program ( www.ed.gov/programs/charactered/index.html), the Department has awarded 97 grants to assist in designing, implementing and sustaining high-quality opportunities for students to learn and understand the importance of strong character in their lives.

Education at its best should expand the mind and build character.
- Secretary Margaret Spellings

Resources for parents and teachers in character education

Office of Safe and Drug-Free Schools
www.ed.gov/about/offices/list/osdfs/index.html

Character Education and Civic Engagement Technical Assistance Center
www.cetac.org

What Works Clearinghouse-Character Education
www.whatworks.ed.gov

Helping Your Child Become a Responsible Citizen
View the booklet online at: www.ed.gov/parents/academic/help/citizen/index.html
Order by calling (877) 4ED-PUBS.

Character Education-Our Shared Responsibility
View the brochure online at: www.ed.gov/admins/lead/character/brochure.html
Order by calling (877) 4ED-PUBS.

Character education teaches the habits of thought and deed that help people live and work together as families, friends, neighbors, communities and nations.

U. S. Department of Education
Office of Safe and Drug-Free Schools
400 Maryland Avenue, S.W.
Washington, DC 20202-6450
1-800-872-5327
www.ed.gov

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Throughout time, societies have recognized the need to educate the coming generation of adults to pass on knowledge and skills. Recorded history from long before the present era emphasizes that education must also develop character. One of the great education reformers, Horace Mann, in the 1840s, helped to improve instruction in classrooms nationwide, advocating that character development was as important as academics in American schools.

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Supporting Students Experience Early Psychosis in Middle School

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Supporting Students Experience Early Psychosis in Middle School

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Children's Mental Health Disorder Fact Sheet for the Classroom on Schizophrenia

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Children's Mental Health Disorder Fact Sheet for the Classroom on Schizophrenia

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Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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Clinical Points

■ Hallucinatory experiences and delusions are more common in our patients than we may realize and occur frequently in the pediatric population. While not a benign occurrence, psychotic symptoms do not necessarily portend the future development of schizophrenia.

■ Psychotic symptoms in children and adolescents can occur in the context of a bevy of psychiatric disorders other than schizophrenia (eg, depression, anxiety, attention-deficit/hyperactivity disorder, posttraumatic states, and autism spectrum disorders) or can be secondary to a wide variety of medical conditions.

■ The onset of psychosis is usually preceded by a period of nonpsychotic symptoms known as prodromal symptoms. In recent years, there has been substantial research in early intervention efforts (eg, with psychotherapy or antipsychotic medicines) focused on the early stages of schizophrenia and on young people with prodromal symptoms. At present, outcome data are insufficient to draw definitive conclusions.

■ The pharmacologic treatment of psychotic symptoms in a pediatric population is similar in many ways to the treatment of infection with antibiotics-the clinician needs to choose the proper medication at a sufficient dose and then await therapeutic results while monitoring for potential side effects.

Over the past decade, psychiatric illnesses and, in particular, psychotic disorders in children and adolescents have been recognized more frequently. This increase in recognition, combined with changing trends in the provision of mental health care, has led primary care physicians and pediatricians to increasingly serve as the principal treaters of psychiatrically ill youth and their families. Primary care providers and behavioral health services (eg, in colocated care, embedded care practices, patient-centered homes, and consultation) form the backbone of contemporary psychosis evaluation and management. It is unclear whether psychotic disorders in younger individuals are actually becoming more prevalent, or whether educational efforts directed at enhanced screening and treatment have improved case detection. Efficacious and safe interventions should be employed to maximize beneficial effects and to minimize medication-related complications, such as weight gain, diabetes, and heart disease.

The question for today's health care providers is not whether psychotic symptoms will be encountered in daily practice, but how to confidently and effectively diagnose and treat the conditions in which they manifest. In order to frame this discussion, several areas of inquiry will be explored: "Have you ever been unsure about whether a young person in your practice was psychotic or simply imaginative? Have you wondered how to evaluate such a patient (eg, with laboratory testing or with neuropsychological testing) and what resources to recommend? Have you been concerned about using antipsychotics in young people? Does the potential for adverse side effects of antipsychotics in the short-term or long-term concern you?" For practitioners faced with these concerns, the following discussion should prove useful.

WHAT IS PSYCHOSIS AND HOW COMMON IS IT IN YOUNG PEOPLE?

Narrowly defined, psychosis denotes the presence of either delusions (false implausible beliefs) or hallucinations (false perceptions involving any sensory modality). Broader definitions of psychosis include manifestations of thought disorders, behavioral disorganization, or catatonia. Family members, particularly parents, are often concerned that children who manifest delusions or hallucinations might have schizophrenia. Fortunately, most forms of psychosis in children and adolescents are not a result of schizophrenia.

Population-based surveys show that the prevalence of psychotic symptoms may be far greater than had been previously considered, with a meta-analysis suggesting a prevalence rate of 5%-8% in the general population (which is nearly 10 times higher than the prevalence of diagnosed psychotic disorders). Prevalence rates of such symptoms may be even higher among young people. In 2000, Poulton and colleagues reported that 14% of 11-year-old children endorsed psychotic symptoms upon interview and showed that these symptoms were associated with a 5-fold to 16-fold increased rate of psychotic illness in early adulthood (depending on the strength of the initial symptoms). Since then, large, population-based studies surveying psychotic symptoms among adolescents have found rates of 9%-14% in interview-based studies, and rates greater than 25% in some studies using self-report questionnaires. ⁻ Positive answers on self-report questionnaires have been validated on clinical interview. This emerging body of research suggests that a sizable minority of young people experience psychotic symptoms.

DOES THE PRESENCE OF PSYCHOTIC SYMPTOMS NECESSARILY PORTEND A DIAGNOSIS OF SCHIZOPHRENIA?

However, rather than being a harbinger of schizophrenia, psychotic symptoms in childhood and adolescence more likely accompany other psychiatric conditions (eg, major depression, bipolar disorder, or dissociative states). lists psychiatric disorders that can be accompanied by psychosis. Differentiating early-onset schizophrenia or childhood-onset schizophrenia from other psychiatric disorders has important treatment implications. For example, a pediatric patient with bipolar disorder often experiences hallucinations and delusions but also has the clinical characteristics of mania, depression, or both. In children with psychological trauma-related hallucinations (typically associated with nightmares and trance-like states), psychotic symptoms may quickly abate with psychotherapeutic and/or social interventions. Compared to traumatized children, children with schizophrenia are more apt to display a formal thought disorder, negative symptomatology (eg, apathy, social isolation), and impulsive aggression. Like children and adolescents with schizophrenia, those with autism spectrum disorders may also have odd beliefs (eg, believing that they are able to communicate with valued inanimate toys). Children with milder forms of autism (eg, Asperger's syndrome) may be misdiagnosed with psychosis due to their idiosyncratic beliefs, social awkwardness, and concrete thought process. Taking a comprehensive clinical history helps to disentangle diagnostic uncertainties.

Table 1

Psychotic symptoms have been associated with, or are secondary to, a wide variety of medical disorders as well. Psychosis may develop in response to central nervous system lesions, as a consequence of medical illness, or after traumatic injury or drug use. Recently, reports have linked a particularly severe form of new-onset psychosis-often associated with insomnia, catatonia, and autonomic instability-to antibodies against the glycine-binding NR ₁ subunits of the anti- N-methyl-d-aspartate (NMDA) receptor. Overall, studies from the adult literature show that about 3% of new-onset presentations of psychosis can be attributed to a medical condition., Therefore, before making a diagnosis of a primary psychotic disorder, secondary causes should be ruled out by a thorough-but not indiscriminate-medical workup.

WHAT ARE PRESENTING CHARACTERISTICS OF PSYCHOSIS IN CHILDREN AND ADOLESCENTS?

The most common manifestations in young people with psychosis are hallucinations, impaired functioning, flattened affect, and social withdrawal., Caregivers are more likely than the child patients themselves to report these problems to the clinician, as children often minimize, misinterpret, or avoid mentioning their symptoms. Hence, a comprehensive psychiatric assessment should include interviews with the child and his or her family members, review of records, information gathered from other involved adults (including a detailed description of the presentation and course of the psychotic symptoms), attention to developmental delays, a family psychiatric history, a history of abuse and/or neglect, and a mental status examination.,

Unlike adults, children with psychosis rarely demonstrate waxy flexibility or become catatonic. On the other hand, they can be emotionally reactive or agitated. The majority of children with childhood-onset schizophrenia often exhibit "soft" neurologic signs, including primitive reflexes, abnormal stereognosis, 2-point discrimination, and dysdiadochokinesia (impaired rapid alternating movements). Affected youth may manifest either a decreased or increased rate of eye blinking, as well as paroxysmal saccadic eye movements (inability to follow an object with smooth eye movements).

HOW ARE CHILDREN AND ADOLESCENTS DIAGNOSED WITH SCHIZOPHRENIA?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) made several changes to the category of schizophrenia, including raising the symptom threshold. A diagnosis of schizophrenia now requires 2 of the following conditions: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms such as affective flattening or paucity of thought or speech (in the manual's previous editions, the threshold was 1). To meet diagnostic criteria, symptoms must be present for at least 6 months (including at least 1 month of active symptoms); must result in deterioration in social, school-related, and self-care functioning; and should not be accounted for by a diagnosis of schizoaffective disorder, a mood disorder, a substance use disorder, or general medical conditions.

Additionally, an "attenuated psychosis syndrome" was included in the research section as a category for persons who do not meet criteria for a full-blown psychotic disorder but exhibit minor variations of relevant symptoms. This category seeks to identify individuals with an increased risk for developing a psychotic disorder, which may be significant for the implementation of effective early interventions.

Personality tests and projective tests should not be used to diagnose schizophrenia in youth; research indicates that tests, such as the Rorschach, do not increase the diagnostic accuracy in early-onset schizophrenia.

WHAT CAUSES SCHIZOPHRENIA IN CHILDHOOD AND ADOLESCENCE?

While there is no single confirmed etiology of childhood-onset or early-onset schizophrenia, it is likely that genetic, behavioral, and environmental factors all contribute to the development of this disease.

Genetic risk has been well-studied. First-degree relatives of patients with childhood-onset schizophrenia have a higher prevalence rate of schizophrenia and schizophrenia spectrum disorders, as well as impairment in smooth pursuit eye movements similar to those observed in patients with adult-onset schizophrenia. One study found that healthy siblings of patients with childhood-onset schizophrenia had decreased cerebral gray matter in the same pattern as was seen in the probands. In an investigation of youth identified as being at "high risk," the young relatives of patients with schizophrenia demonstrated an increased rate of Axis I psychopathology (eg, attention-deficit/hyperactivity disorder [ADHD], conduct disorder), soft neurologic signs, and a high level of outwardly expressed emotion. On neuropsychological examination, these "high-risk" nonprobands also demonstrated impairment in attention, spatial working memory, and executive function, as well as a volume reduction in the amygdala, hippocampus, and superior temporal gyrus.

WHICH NEURODEVELOPMENTAL AND NEUROBIOLOGICAL ABNORMALITIES ARE ASSOCIATED WITH YOUTH WHO DEVELOP SCHIZOPHRENIA?

Structural brain abnormalities are an established feature of schizophrenia, and recent evidence suggests a progressive nature of this pathology. Like adults with schizophrenia, youth with childhood-onset schizophrenia show bilateral enlargement of the lateral ventricles on neuroimaging. However, unlike adults, the abnormalities in brain morphology in patients with childhood-onset schizophrenia evolve during adolescence. Rapoport and associates, reported that adolescents with schizophrenia have significantly reduced frontal and temporal gray matter volumes compared with those observed in healthy age-matched controls. Moreover, youth with childhood-onset schizophrenia appear to lose more cortical gray matter compared to children who suffer from transient psychosis. Subsequent studies from this group have shown that the healthy siblings of afflicted patients also have reductions in cerebral volume and gray matter. Similar to patients with adult-onset schizophrenia, over the course of development, youth with childhood-onset schizophrenia appear to lose cortical thickness in prefrontal and temporal regions, regardless of their treatment with medications. In a systematic review of 66 articles comparing brain volume in patients with a first psychotic episode with the volume seen in healthy controls, a meta-analysis demonstrated that whole-brain and hippocampal volumes are reduced and that ventricular volumes are increased in affected patients compared to healthy controls. Future improvements in neuroimaging technology hold the potential to reveal more about neurobiological disturbances and their correlates in schizophrenia. Yet, at present, results of neuroimaging studies have not made the leap from bench to bedside.

WHICH NEUROTRANSMITTERS ARE THOUGHT TO BE INVOLVED IN SCHIZOPHRENIA?

The neurotransmitter most commonly implicated in the pathophysiology of schizophrenia is dopamine. Drugs that increase dopaminergic receptor activity (eg, cocaine, amphetamines) may induce an acute psychotic episode, whereas drugs that block postsynaptic D ₂ receptors help to alleviate psychotic symptoms. Furthermore, persons with schizophrenia also have fewer D ₁ receptors in the prefrontal cortex. Disturbances in a variety of other neurotransmitters such as glutamate, serotonin, and γ-aminobutyric acid (GABA) have been implicated in the pathophysiology of schizophrenia. Researchers are also interested in glutamate because phencyclidine (PCP or angel dust) is an NMDA/glutamine antagonist; NMDA receptor dysfunction can also cause psychotic symptoms. As mentioned earlier, anti-NMDA receptor antibodies, sometimes secondary to teratomas or autoimmune dysfunction, can cause psychosis in children, often in conjunction with autonomic instability and seizures. Serotonin may also be important; most second-generation antipsychotics share relatively potent antagonism of serotonin 5-HT 2A receptors coupled with relatively weaker antagonism of dopamine D ₂ receptors. Preliminary studies suggest that GABA may also play a role in the development of chronic psychotic syndromes. Overall, disrupted neurotransmission and cognitive functions are key components in the pathophysiology of schizophrenia; however, no single neurotransmitter is clearly responsible for the onset and progression of schizophrenia.

ARE THERE ENVIRONMENTAL RISKS FOR THE DEVELOPMENT OF SCHIZOPHRENIA?

It is clear now that "the grass is not greener," as data from 6 longitudinal studies in 5 countries have shown that regular cannabis use predicts an increased risk for schizophrenia and symptoms of psychosis. Cannabis use during early adolescence coupled with a specific genetic vulnerability and changes in brain development are correlated with risk for the development of schizophrenia and overall cognitive decline. However, the direction of the effect has been called into question. Some suggest that individuals with psychosis use cannabis to alleviate their psychotic symptoms or to improve their mood. Others, however, suggest that cannabis causes or exacerbates psychotic symptoms. A pooled analysis of 35 studies showed a dose-response effect, with greater risk of psychosis in people who used cannabis most frequently. Moreover, individuals with schizophrenia who are moderate to heavy cannabis users show a greater brain volume reduction over a 5-year follow-up compared with nonusers.

Despite the fact that fewer adolescents believe that regular cannabis use is harmful to their health and increasingly permissive state laws governing the use of medical marijuana, the medical literature presents clear evidence for a neurotoxic effect of cannabis on the adolescent brain. These findings highlight the importance of efforts targeting adolescent cannabis use, including policy measures and psychoeducation in the doctor's office.

HOW CAN ONE DISTINGUISH PRIMARY PSYCHOSIS FROM SECONDARY PSYCHOSIS?

A thorough medical workup is essential for distinguishing between primary and secondary psychotic disorders. lists medical disorders that have been associated with psychosis. Although there is no generally agreed-upon medical evaluation that every patient with psychosis should undergo,, screening tests should be ordered on the basis of a patient's personal and family history, as well as on the basis of one's clinical suspicion of conditions. Blanket testing for rare disorders may increase the risk of false-positive or false-negative results. On the other hand, the search for medical etiologies of psychosis may be expanded in the face of atypical presentations or when cases are refractory to standard treatments.

Table 2

Infections

Creutzfeldt-Jakob disease

Herpes encephalitis

Human immunodeficiency virus infection

Lyme disease

Subacute bacterial endocarditis

Sydenham's chorea

Metabolic disturbances

Adrenocortical insufficiency

Cushing's disease

Hypercalcemia or hypocalcemia

Hypermagnesemia or hypomagnesemia

Hypernatremia or hyponatremia

Hyperthyroidism

Hypoglycemia

Hypokalemia

Hypophosphatemia

Lactic acidosis

Panhypopituitarism

Parathyroid disease

Thyroid storm

Neurologic

Cerebral neoplasms

Cerebrovascular disease

Cerebral lipidoses

Complex partial auras or seizures

Creutzfeldt-Jakob disease

Encephalitis (including anti- N-methyl-d-aspartate receptor encephalitis)

Focal lesions of temporal and parietal lobe

Generalized seizures

Hepatic encephalopathy

Herpes encephalitis

Multiple sclerosis

Normal pressure hydrocephalus

Temporal arteritis

Postnoxic encephalopathy

Posttraumatic encephalopathy

Fragile X syndrome

Klinfelter's syndrome

Metachromic leukodystrophy

Prader-Willi syndrome

Velocardiofacial syndrome

Wilson's disease

Vitamin deficiencies

Folate deficiency

Niacin deficiency

Vitamin B ₁₂ deficiency

Vitamin D insufficiency

Medications

Drug classes that can cause hallucinations or delusions

Amphetamine-like drugs

Anabolic steroids

Angiotensin-converting enzyme inhibitors

Anticholinergics

Antidepressants (both tricyclic antidepressants and selective serotonin reuptake inhibitors)

Antiepileptics

Barbiturates

Benzodiazepines

β-adrenergic blockers

Calcium channel blockers

Cephalosporins

Corticosteroids (prednisone, cortisone, adrenocorticotropic hormone, others)

Dopamine receptor agonists

Fluoroquinolone antibiotics

Nonsteroidal antiinflammatory drugs

Procaine derivatives (procainamide, procaine, penicillin G)

Salicylates

Sulfonamides

Alcohol toxicity/withdrawal

Illicit use of drugs (including prescribed medications)

Amphetamines

Glue sniffing/ingestion

Lysergic acid diethylamide

Methamphetamine (crystal meth)

Phencyclidine hydrochloride (PCP)

Psilocybin (mushrooms)

Toxicologic causes

Carbon monoxide poisoning

Heavy metal poisoning (eg, mercury, lead)

Key tests in the pediatric population () may include drug screens (to rule out medication or substance-related psychosis), laboratory studies (to rule out infections, metabolic disturbances, certain genetic conditions, or vitamin deficiencies), an electroencephalogram (EEG), and structural neuroimaging (eg, magnetic resonance imaging [MRI] or computed axial tomography [CT] scanning). The clinical relevance of a given EEG tracing can be difficult to discern, as almost half of the patients with new-onset psychosis will have EEG abnormalities of unclear significance. Furthermore, EEGs read as "normal" may not capture an interictal psychosis. Likewise, incidental and non-clinically meaningful MRI findings are found in approximately 20% of the non-psychiatrically ill population. Recent guidelines suggest that structural neuroimaging should not be obtained routinely during an evaluation for a first episode of psychosis. Despite the low yield of neuroimaging, counter arguments supporting its judicious use emphasize that patients and families feel reassured by negative scans. Conversely, neuroimaging can rule out rare etiologies for psychosis (eg, brain tumors) and help patients and families understand and accept the psychotic symptoms as manifestations of a psychiatric disorder.

Table 3

Electroencephalogram

Imaging studies (eg, magnetic resonance imaging or computed tomography of the brain) in select patients based on clinical suspicion

Laboratory studies

Antinuclear antibodies

Blood urea nitrogen/creatinine

Calcium and phosphorus

Ceruloplasmin (for Wilson's disease)

Complete blood count

Electrolytes

Erythrocyte sedimentation rate

FTA-Abs (for syphilis)-preferred over rapid plasma reagin

Human immunodeficiency virus screening

Liver function tests

Thyroid-stimulating hormone

Urinalysis

Urine (and/or serum) drug screen

HOW SHOULD PSYCHOSIS DUE TO AN UNDERLYING MEDICAL CONDITION BE TREATED?

The optimal treatment for secondary psychosis is treatment of the underlying medical or neurologic condition. Concomitant treatment of the secondary psychosis (usually with an antipsychotic agent) can protect both the patient and the treatment team while medical treatment is administered. Notably, most guidelines for dosing antipsychotics are based on the treatment of patients with schizophrenia and bipolar disorder. Patients treated for psychosis related to medical causes are often antipsychotic naive and sensitive to the sedating properties of lower-potency antipsychotics and to the extrapyramidal effects of higher-potency antipsychotics.

WHAT DOES THE FIRST EPISODE OF PSYCHOSIS INVOLVE?

Once functionally impairing psychotic symptoms develop-defined in terms of symptom severity and duration-a patient is no longer considered to be in the prodromal phase of illness, but instead diagnosed with an episode of psychosis. Clinically, the demarcation between prodromal (or "attenuated") symptoms and frank psychosis is rarely clear-cut, particularly in a patient with brief or intermittent bouts of mild psychotic symptoms. Moreover, few patients receive emergency treatment for psychosis. The median duration of untreated psychosis refers to the lag between the development of symptoms and the initiation of treatment. This lag time can range from 4 to 50 weeks in first episodes, and can extend longer when mood symptoms or illicit drug use cloud the diagnostic picture. The availability of mental health resources, socioeconomic factors, and cultural attitudes toward mental illness can also affect the time to treatment. Most studies show that a longer duration of untreated psychosis is associated with worse clinical outcomes. This observation has spurred increased research interest into interventions that target the period prior to, or immediately after, the development of a psychotic disorder. The hope is that these targeted interventions might forestall the onset of psychosis or improve long-term outcomes.

WHAT PSYCHOSOCIAL TREATMENTS ARE AVAILABLE FOR YOUTH WITH PSYCHOSIS OR SCHIZOPHRENIA?

Cognitive-behavioral techniques that evaluate evidence for beliefs or thinking through explanations surrounding a patient's perceptions can help to alter dysfunctional behaviors. A consistent framework with similar words/techniques used at home, at school, and with friends may allow the patient to employ a standardized approach to events across settings and to diminish misperceptions of daily events and interactions.

Research data supporting psychosocial treatments in pediatric psychotic disorders are scant. There is a controlled study comparing cognitive-behavioral therapy (CBT) with no antipsychotic to a monitoring program in prodromal patients. CBT was associated with less progression to psychosis; however, the results of this study were limited by methodological flaws. The PACE (Personal Assessment and Crisis Evaluation) trial randomly assigned prodromal patients (aged 14-28 years) to risperidone plus CBT versus a needs-based intervention of supportive therapy and psychotropics other than antipsychotics. At 6 months, 3 of 31 patients in the risperidone plus CBT group converted to psychosis, whereas 10 of 28 patients in the supportive therapy and nonneuroleptic pharmacotherapy group converted to psychosis. Since the average risperidone dose used in this study was relatively low (1.3 mg/d), there is a suggestion that CBT was a vital ingredient to the protective effects seen in this study.

WHAT DOES THE PHARMACOTHERAPY OF SCHIZOPHRENIA IN YOUTH INVOLVE?

Pharmacologic treatment for schizophrenia in youth remains an area of active research, with several large multisite trials completed within the past few years. Six, 6-week, randomized, placebo-controlled studies of second-generation antipsychotics for early onset schizophrenia have been completed thus far. They showed that aripiprazole, olanzapine, paliperidone, quetiapine, and risperidone-but not ziprasidone-were superior to placebo. In these controlled studies, aripiprazole, olanzapine, paliperidone, quetiapine, and risperidone, were superior to placebo with regard to improvement in the Positive and Negative Syndrome Scale (PANSS) total score.

In terms of atypical antipsychotic dosing, typically, these medications are initiated at a low dose and gradually titrated upward to achieve efficacy. Risperidone, for example, is generally started at 0.25 mg twice a day and can be increased every 1 to 2 days in association with close observation. In general, olanzapine and quetiapine are more sedating; their dosing is usually started at 2.5 to 5 mg/d and 25 to 50 mg/d, respectively. As most antipsychotic medications have a relatively long half-life, they typically do not need be administered more than twice daily. For patients maintained on antipsychotics, clinicians should monitor weight, vital signs, and relevant laboratory results (eg, triglycerides, cholesterol, fasting glucose, and prolactin levels).

Newer atypical antipsychotics (eg, asenapine, iloperidone, lurasidone) may eventually have a role in the treatment of patients with childhood-onset or early onset schizophrenia and in patients deemed at-risk of developing schizophrenia due to genetic and/or environmental factors. However, at present, there is little evidence to support the safety, tolerability, or efficacy of these agents in the pediatric population.

In sum, current pharmacologic research for early-onset and childhood-onset schizophrenia focuses on the identification of antipsychotic agents that will provide optimal efficacy without also causing undue adverse events. Many typical and atypical antipsychotics have been shown (based on open trials, randomized clinical trials, and head-to-head comparisons) to be efficacious in the treatment of early-onset and childhood-onset schizophrenia; however, they are well known to cause side effects such as weight gain, extrapyramidal symptoms, and metabolic abnormalities.

WHAT IS THE ROLE OF LONG-ACTING (INJECTABLE) ANTIPSYCHOTICS IN CHILDHOOD-ONSET SCHIZOPHRENIA?

In the near future, as many as 4 new atypical antipsychotic long-acting therapy formulations may become available. In clinical situations wherein adherence with oral preparations has proven difficult, it is reasonable-especially in older adolescents-to consider using a long-acting medication. Risperidone long-acting therapy has been shown to be efficacious and well tolerated in the treatment of schizophrenia, including those with newly diagnosed schizophrenia. Short-term and long-term studies found that risperidone long-acting therapy was associated with low rates of discontinuation related to adverse events and few reports of pain from injections. Evidence for newer long-acting injectables (eg, olanzapine, paliperidone) remains limited. The available evidence suggests that long-acting injectable antipsychotics can be used safely and effectively in early stages of the illness and that they may be associated with better outcomes than with oral medications. However, this is largely supported by evidence from naturalistic cohort studies and by a small number of controlled trials of risperidone long-acting injection. Given the paucity of data of long-acting therapy in the adolescent population, the use of these preparations in adolescents remains empiric. provides the side effect risk profiles of common second-generation antipsychotic medications used in children and adolescents.,

Table 4

Second-Generation Antipsychotics
(trade name)

Anticholinergic

Diabetes

Hyperlipidemia

Hyperprolactinemia

Hypotension

Sedation

Tardive Dyskinesia

Weight
Gain

WHAT ARE THE ADVERSE EFFECTS OF ANTIPSYCHOTICS?

In reviewing the available randomized, controlled studies and head-to-head comparisons of antipsychotics, Schimmelmann and colleagues noted, "Antipsychotics are efficacious in the treatment of early-onset schizophrenia. The lack of evidence for efficacy differences between various antipsychotics (except for clozapine for treatment-refractory early-onset schizophrenia) suggests that a primum non nocere principle should be applied when choosing and antipsychotic."(p228) Therefore, the side effect profile of the antipsychotics often dictates the choice of pharmacologic agent for young people with psychotic symptoms. Antipsychotic therapy has been linked to a bevy of metabolic changes (eg, dyslipidemia, weight gain, plasma prolactin increases), sedation, extrapyramidal symptoms, and dyskinesias (see ). With the exception of tardive dyskinesia, young people with schizophrenia seem more likely to experience these side effects from atypical neuroleptics compared with their adult counterparts. Children and adolescents may gain weight, even when treated with antipsychotics that are considered "weight-neutral" in adults. Similarly, there are reports of prolactin elevations in youth treated with prolactin-sparing agents such as quetiapine.

Other common adverse effects of antipsychotics include drowsiness and anticholinergic effects (eg, dry mouth, nasal congestion, blurred vision), particularly with the low-potency phenothiazines. Caregivers can usually manage the short-term adverse effects of antipsychotics with adjustments of dose and timing of administration. One can avoid undue sedation by using less sedating agents and by prescribing most of the daily dose at bedtime. One should not confuse drowsiness with impaired cognition; drowsiness can usually be corrected by adjusting the dose and the timing of administration. Furthermore, there is no evidence that antipsychotics adversely affect cognition when used in low doses. One can minimize anticholinergic effects by choosing a medium-potency or high-potency antipsychotic.

Extrapyramidal Side Effects

Extrapyramidal side effects such as acute dystonia, akathisia (motor restlessness), and parkinsonism (bradykinesia, tremor, and lack of facial expressions) are more commonly seen with use of high-potency agents (eg, butyrophenones, thioxanthenes) and have been reported in up to 75% of children receiving these agents. The extent to which antiparkinsonian agents (eg, anticholinergic drugs such as benztropine, trihexyphenidyl, antihistamines, and the antiviral agent amantadine) should be used prophylactically when antipsychotics are introduced is controversial, although coadministration has been shown to reduce the incidence of extrapyramidal side effects by a factor of 7.

Other Movement Disorders

Abrupt cessation of antipsychotic drugs can cause withdrawal dyskinesias (typically benign, but occasionally more pronounced) and a syndrome of deteriorating behavior. As with adults, the long-term administration of antipsychotic drugs can produce tardive dyskinesia. Although children appear generally less likely to develop tardive dyskinesia than adults, the fact that tardive dyskinesia is potentially irreversible prompts caregivers to evaluate the benefits of such medications, including documenting a clear indication and identifying target symptoms; to periodically discontinue the drug to assess continued need; and to monitor closely to ensure early detection. Current practice parameters recommend monitoring neurologic side effects with standardized scales (eg, Abnormal Involuntary Movement Scale or Simpson Angus Scale) at baseline and periodically during any treatment regimen requiring antipsychotic agents.

Akathisia

Akathisia is a movement disorder characterized by anxiety and an inability to sit still; it can be a side effect of either antipsychotics or antidepressants. Akathisia may be particularly problematic in young patients because of underrecognition or misdiagnosis as ADHD or agitation. Caregivers should consider akathisia in the differential when a child or adolescent starts an antipsychotic and becomes acutely agitated with an associated inability to sit still (and/or with aggressive outbursts).

Treatment of akathisia involves reduction of the offending agent to the lowest effective dose and then using either a benzodiazepine (eg, lorazepam, 0.5 to 1 mg 3 times per day) or a β-blocker. Although all β-blockers are likely to be effective, propranolol, initiated at 10 mg 2 or 3 times per day with an increase every few days until the desired effect is achieved, is a good choice. Alternately, betaxolol hydrochloride, a long-acting β ₁-selective adrenergic antagonist with few medication interactions, may be useful.

Neuroleptic Malignant Syndrome

Little is known about the potentially lethal neuroleptic malignant syndrome in children and adolescents; however, preliminary evidence indicates that its presentation is similar to that in adults. This syndrome may be difficult to distinguish from primary central nervous system pathology, concurrent infection, anti-NMDA receptor encephalitis, or other, more benign, side effects of antipsychotic treatment, including extrapyramidal side effects or anticholinergic toxicity. Neuroleptic syndrome is a life-threatening medical emergency; treatment is largely supportive but can include dopamine reuptake inhibitors like amantadine, similar to strategies used in adults.

WHAT STRATEGIES ARE HELPFUL FOR NONRESPONDERS?

A unique head-to-head randomized controlled trial of olanzapine and clozapine in the treatment of patients with childhood-onset schizophrenia showed that clozapine led to a statistically significant reduction in all outcome measures (particularly negative symptoms of schizophrenia) even when compared to another atypical agent.

WHAT STRATEGIES ARE AVAILABLE FOR EARLY INTERVENTION AND PREVENTION OF CHILDHOOD-ONSET SCHIZOPHRENIA?

The notion of early intervention and perhaps even prevention of schizophrenia remains at the forefront of early-onset psychosis research. Further research in this area is ongoing. However, at present, the literature does not support clear treatment guidelines for these vulnerable patients.

CONCLUSION

Clinicians should be vigilant and consider psychotic illnesses when evaluating children and adolescents with emotional and behavioral disturbances. Given the high developmental, financial, and functional toll associated with chronic psychotic illness, clinicians should employ a variety of diagnostic and treatment modalities to mitigate the risks associated with this illness. These modalities may include performing careful psychiatric and physical examinations, relevant laboratory testing, neuropsychological testing, and employing relevant cognitive therapies, as well as the use of antipsychotic and other pharmacologic interventions. Advances in the understanding of childhood-onset and early-onset schizophrenia, as well as the elucidation of prodromal psychotic symptomatology, will benefit both children and adults.

Footnotes
LESSONS LEARNED AT THE INTERFACE OF MEDICINE AND PSYCHIATRY
The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Dr Stevens is physician-in-charge at Westpark (Dearborn), Henry Ford Health Systems, Dearborn, Michigan, and clinical assistant professor at Wayne State University, Detroit, Michigan. Dr Prince is director of child psychiatry at North Shore Medical Center in Salem, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Prager is director of the Child Psychiatry Emergency Service at Massachusetts General Hospital, Boston, and assistant professor of psychiatry (child psychiatry) at Harvard Medical School, Boston, Massachusetts. Dr Stern is chief of the Avery D. Weisman Psychiatry Consultation Service at Massachusetts General Hospital, Boston, and the Ned H. Cassem professor of psychiatry in the field of psychosomatic medicine/consultation at Harvard Medical School, Boston, Massachusetts.

Dr Prince has received honoraria from the American Physician Institute and has provided expert legal reviews in malpractice cases. Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Stevens and Prager report no conflicts of interest related to the subject of this article.

References

1. Freudenreich O. Psychotic Disorders: A Practical Guide. Philadelphia, PA: Lippincott Williams and Wilkens; 2008.

20. McDonell M, McClellan J. Early-onset schizophrenia. In: Mash E, Barkley R, editors. Assessment of Childhood Disorders. 4th ed. New York, NY: Guilford Press; 2007. pp. 526-550.

26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Press; 2013.

28. Kodish I, McClellan J. In: Handbook of Psychological Assessment, Case Conceptualization, and Treatment: Vol. 2, Children and Adolescents. Hersen M, Reitman D, editors. Hoboken, NJ: John Wiley & Sons; 2008. pp. 405-443.

42. Millichap JJ, Goldstein JL, Laux LC, et al. Ictal asystole and anti- N-methyl-d-aspartate receptor antibody encephalitis. Pediatrics. 2011;127(3):e781-e786.

49. Freudenreich O, Goff DC. Psychotic patients. In: Stern TA, Fricchione GH, editors. Massachusetts General Hospital Handbook of General Hospital Psychiatry. Amsterdam, The Netherlands: Elsevier Science Publishers; 2010.

52. Structural neuroimaging in first-episode psychosis. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Feb. 24 p. (technology appraisal guidance; no. 136) http://www.guideline.gov/content.aspx?id=12284. Accessed December 4, 2013.

54. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2011;(6):CD004718. [ PMC free article]

60. Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 2011;(6):CD002831. [ PMC free article]

61. Jones C, Cormac I, Silveira da Mota Neto JI, et al. Cognitive behaviour therapy for schizophrenia. Cochrane Database Syst Rev. 2004;(4)(CD000524)

71. Yan J. FDA advisors back additional antipsychotics for use in teens. Psychiatr News. 2009;44(13):1-29.

80. Celano CM, Beach SR, Huffman JC, et al. Side effects profiles of psychotropic medications from cardiovascular and other side effects of psychotropic medications. In: Stern TA, Herman JB, Gorrindo T, editors. The Massachusetts General Hospital Psychiatry Update and Board Preparation. 3rd ed. Boston, MA: MGH Psychiatry Academy Publishing; 2012.

# data[].attributes.attachment_link.title
Psychotic Disorders in Children and Adolescents: A Primer on Contemporary Evaluation and Management

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■ Hallucinatory experiences and delusions are more common in our patients than we may realize and occur frequently in the pediatric population. While not a benign occurrence, psychotic symptoms do not necessarily portend the future development of schizophrenia.

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Talking to students whose parents have had an experience with psychosis, what kids need to know. Great resource for counselors.

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Children have a lot of questions when someone in their family is sick. When children don't have answers to their questions, they tend to come up with their own, which can be incorrect and scary!

When a family member has had psychosis, it can easily become a secret that nobody talks about. All children need some explanation and support, geared to their age, to help them understand this disorder.

Each parent and child's first conversations about psychosis will be different. How you address the subject will depend on the child's age and ability to manage the information-you know your child best. This brochure will help prepare you to take the first step in discussing this disorder with your child.

Questions kids have

Psychosis is a loss of contact with reality. People with psychosis have trouble telling the difference between what is real and what is not. When this happens, it is called a "psychotic episode."

The brain contains many chemicals that help us think, feel and act. When a person has psychosis, his or her brain works differently because the chemicals are out of balance. This imbalance also happens with other disorders in the body, such as diabetes and high blood pressure.

Psychotic symptoms can occur in a number of illnesses. They include schizophrenia, schizoaffective disorder, bipolar disorder, major depression and post-traumatic stress disorder. Psychotic symptoms can also be caused by another medical condition in the body.

Some of the most common symptoms include:

Difficulties with perception (the way the person understands things). The person may feel and look confused. He or she may hear voices or see things that aren't really there, or that other people can't hear or see. These are called "hallucinations." People with psychosis may not be able to hear what someone else is asking or telling them.

Strange thoughts and beliefs. These are called "delusions." For example, people with psychosis may believe someone is following them or wants to harm them-this is called a "paranoid delusion."

Scary or confused talk. Sometimes the person may say things that are scary, or may make up an unbelievable story. He or she may say things that don't seem to make sense.

Difficulties with expressing feelings. The person may have a hard time talking about or showing their feelings to their children (for example, giving hugs or saying "I love you"). They may even say mean things. This can be scary and painful for children.

A person with psychosis may not have all of these symptoms.

When and how does psychosis start?

The child is not the cause of the parent's psychosis.

It's unclear why, but some people get psychosis more easily that others do. Scientists are doing research to try to find out why.

There are many possible causes of psychosis. Sometimes the causes are not known. The cause in one person can be different from the cause in someone else.

Psychosis can develop suddenly or gradually.

Sometimes, the symptoms seem to come after a life crisis, stress or other illness.

For other people, using certain street drugs can cause psychotic symptoms.

Can my mom or dad's psychosis ever be fixed?

Yes. The good news is that today, psychosis is treatable.

As the person gets treatment, the strange thoughts, feelings and behaviour gradually go away. For some people this happens quickly, and for others it takes longer.

Sometimes psychotic symptoms may remain or come back, and they can be treated again.

Some people have only one psychotic episode in their lifetime (for example, someone with major depression). Others may have many psychotic episodes over a long period (for example, someone with schizophrenia). It all depends on the person and the type of illness. Some people may have only a few symptoms, and may still be able to get on with their lives (for example, go to work or school, or housework).

How can my mom or dad get better?

A person with psychosis may be the most sick at the beginning of his or her illness. This can be a very confusing and frightening time, both for the ill person and for the family. Doctors, nurses and other health care workers will try to help the person with treatments that have helped other people with psychosis.

Different treatments are available. They include medication and talk therapy.

Medication helps the chemicals in the brain to work as usual. Then the person can begin to feel and act more like his or her usual self.

Talk therapy with a focus on feelings lets the person talk to a therapist about what it is like to have this illness and about finding ways to cope.

Talk therapy with a focus on managing everyday life teaches people to help themselves when they have early symptoms of psychosis. They learn how to get more control over the illness (for example, by talking to friends or to a therapist) and how to get back on track with their life (for example, how to handle money, make meals and stay healthy).

Is there anything I can do to make my mom or dad better?

Family support is really important, but it is the adults who are responsible for being the "helpers," not the kids.

Even though kids can't fix the illness, sometimes it will help your parent just to know that you are there (for example, by giving your parent a card or photo, or talking to him or her on the phone). It is best to talk with other adults in the family, or to the health care workers caring for your mom or dad, to see what will be most helpful.

Your dad or mom might have said or done strange things when he or she was ill. Remember that these things were related to the illness-not to anything you did wrong. It can be helpful for you to talk to someone about what this was like for you.

What if my mom or dad has to go to hospital? What happens there?

Sometimes people with psychosis may need to go to hospital. If this happens, people at the hospital will take care of your parent and make sure your parent gets the help he or she needs. Your parent will have a comfortable room where he or she can rest.

It is OK to ask questions about what is happening with your mom or dad. Kids have a right to have their questions answered.

What if my mom or dad is too sick to look after me?

Family members should try to have a plan in place so the child knows what will happen if his or her parent has to go to hospital. Review this plan with the child and ask the child what he or she thinks. Make arrangements with a "safe person"-someone the child feels comfortable talking to-who can support the child if the parent is not available.

If the parent can't take care of the child, the adults caring for the child should help the child understand why. They should help the child maintain contact with the parent as he or she gets better-even if only by phone or letter. Other parts of the child's life should be kept as normal as possible, including attending the same school and maintaining friendships. Children may feel guilty about playing, having fun and maybe laughing every now and then-it's important to talk about this.

Sometimes children live in a home with only one parent. If the parent becomes too sick to care for the child, the child may have to stay with other family members or, sometimes, with a foster family. This change can be very hard for the child, who will miss and worry about his or her parent.

Remember that your mom or dad is getting help. As he or she begins to feel better, you will be able to spend time together again.

What do I tell kids at school? Will they think bad things about my family?

Most people find it hard to talk about mental illness. It often makes people uncomfortable because they don't know much about it. Children sometimes feel sad, not only because their parent is ill, but also because their friends don't understand. When people learn more, their ideas often change.

Sometimes children are ashamed that their parent has a mental illness. They may find the illness hard to talk about, and may not want to talk about it. But it's important for kids to talk with people who understand how they feel. It helps kids to feel better and to see that it's OK to feel the way they do.

Some people look down on a family that has experienced a mental illness. Mental illnesses can make people think they are different. Sometimes kids will make mean jokes or pick on others because of this. The important thing is to help children deal with these comments. They can choose to ignore them. They can also tell an adult right away. Children can also practise saying something simple, like:

"My mom is sick and needs to be in hospital, so she can get better."

"When my dad gets sick, it affects what he says and how he acts."

Adults in the child's life should help children decide how much information to share, and with whom. The child needs to know that he or she does not have to share details. If a child decides to talk with a friend, it may help if an adult is present. Adults can teach children to stop conversations when they get uncomfortable. For example, kids can say, "Thanks for asking, but I don't want to talk about this any more."

Will it happen to me? Will I get it too?

Psychosis is a mental illness; it's not something you can "catch" from someone else, like a cold.

Psychosis is rare, but no one can know for sure if he or she will experience it at some point in life.

It's natural to worry about this. Psychosis is like other illnesses: if you have this kind of mental illness in your family, you might be at greater risk yourself. But it is still a very small chance-there is a much bigger chance that you won't get the illness.

To protect themselves against psychosis, kids should focus on what they can do to deal with stress and to lead a balanced life.

What should I do if I'm scared? What can I do when I'm really worried about my mom or dad?

Sometimes children feel better if they make an action plan with their parents. This helps them decide what to do when they are scared.

Action plans can include:

making a list of signs that tell the child that the parent is doing well, or is not doing well

having the name and number of an adult whom the child can call.

Children need an adult they can talk to if their parent isn't available. This could be another family member, a teacher, a friend's parent or the family doctor.

It can be hard for a child to live with a parent who has psychosis. The parent may do or say things that make the child feel scared, sad, angry or confused. For example, the parent may not know what he or she is saying, or may talk to an imaginary person while looking at the child. That can feel very strange to a child. Children need other important people in their lives to talk with, and to give them reassurance.

If the child is worried and has no one to talk to, he or she can call Kids Help Phone at 1 800 668-6868 to talk to an adult who can help. If there is an emergency, the child can call 911.

Brochures in the When a Parent series:

When a parent is depressed: What kids want to know

When a parent has bipolar disorder: What kids want to know

When a parent drinks too much: What kids want to know

Also available from CAMH:

Need more information or help?

If you want more information about psychosis and how it affects children and families, speak to your family doctor or call Access CAMH at 1 800 463-6273, or 416 535-8501 in Toronto.

Other resources include:

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When a parent has experienced psychosis ... What kids want to know

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Children have a lot of questions when someone in their family is sick. When children don't have answers to their questions, they tend to come up with their own, which can be incorrect and scary! When a family member has had psychosis, it can easily become a secret that nobody talks about.

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IDEA and 504 Accommodations for Students with Psychiatric Disabilities

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IDEA and 504 Accommodations for Students with Psychiatric Disabilities

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Achieving equal access through accommodations and universal design

Tens of thousands of students enrolled in American postsecondary institutions report having a mental illness. Recent increases in the size of this group are due in part to improved medications that result in symptoms mild enough for them to enjoy the benefits and meet the challenges of postsecondary education. Students with psychiatric disabilities are entitled to reasonable academic accommodations as provided by the American Disabilities Act (ADA) of 1990 and 2008 amendments. Providing effective accommodations allows students equal access to academic courses and activities. The presence of students with disabilities also contributes to the diversity of the student population.

What is a Mental Illness?

"Mental illness" refers to the collection of all diagnosable mental disorders causing severe disturbances in thinking, feeling, relating, and functional behaviors. It can result in a substantially diminished capacity to cope with the demands of daily life.

A mental illness is a hidden disability; it is rarely apparent to others. However, students with mental illness may experience symptoms that interfere with their educational goals and that create a "psychiatric disability." These symptoms may include, yet are not limited to:

heightened anxieties, fears, suspicions, or blaming others

marked personality change over time

confused or disorganized thinking; strange or grandiose ideas

difficulty concentrating, making decisions, or remembering things

extreme highs or lows in mood

denial of obvious problems and a strong resistance to offers of help

thinking or talking about suicide

Psychiatric Diagnoses

A student with a mental illness may have one or more of the following psychiatric diagnoses (American Psychiatric Association, 1994).

Depression. This is a mood disorder that can begin at any age. Major depression may be characterized by a depressed mood most of each day, a lack of pleasure in previously enjoyed activities, thoughts of suicide, insomnia, and consistent feelings of worthlessness or guilt.

Bipolar affective disorder (BAD, previously called manic depressive disorder). BAD is a mood disorder with revolving periods of mania and depression. In the manic phase, a person might experience inflated self-esteem, high work and creative productivity, and decreased need to sleep. In the depressed phase, the person would experience the symptoms of depression (see above).

Borderline personality disorder (BPD). BPD is a personality disorder which includes both mood disorder and thought disorder symptoms. This diagnosis has both biological and environmental determinants. Individuals diagnosed with BPD may have experienced childhood abuse and family dysfunction. They may experience mood fluctuations, insecurities and mistrust, distortion of perceptions, dissociations, difficulty with interpersonal relationships, and limited coping skills.

Schizophrenia. This is a mental disorder that can cause a person to experience difficulty with activities of daily living and possibly delusions, hallucinations, and paranoia. Schizophrenic individuals typically demonstrate concrete thought processing and appreciate structure and routines.

Anxiety disorders. These are mood disorders in which the individual responds to thoughts, situations, environments, or people with fear and anxiety. Anxiety symptoms can disrupt a person's ability to concentrate and focus on tasks at hand. Symptoms may be in response to real or imagined fears. Specific anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder (OCD), panic disorder, social and specific phobias, and post-traumatic stress disorder (PTSD).

Functional Limitations

The following functional limitations related to psychiatric disabilities may affect academic performance and may require accommodations (Center for Psychiatric Rehabilitation, 1997).

Difficulty with medication side effects: side-effects of psychiatric medications that affect academic performance include drowsiness, fatigue, dry mouth and thirst, blurred vision, hand tremors, slowed response time, and difficulty initiating interpersonal contact.

Screening out environmental stimuli: an inability to block out sounds, sights, or odors that interfere with focusing on tasks. Limited ability to tolerate noise and crowds.

Sustaining concentration: restlessness, shortened attention span, distraction, and difficulty understanding or remembering verbal directions.

Maintaining stamina: difficulty sustaining enough energy to spend a whole day on campus attending classes; combating drowsiness due to medications.

Handling time pressures and multiple tasks: difficulty managing assignments, prioritizing tasks, and meeting deadlines. Inability to participate in multi-task work.

Interacting with others: difficulty getting along, fitting in, contributing to group work, and reading social cues.

Fear of authority figures: difficulty approaching instructors or TAs.

Responding to negative feedback: difficulty understanding and correctly interpreting criticism or poor grades. May not be able to separate person from task (personalization or defensiveness due to low self-esteem).

Responding to change: difficulty coping with unexpected changes in coursework, such as changes in the assignments, due dates or instructors. Limited ability to tolerate interruptions.

Severe test anxiety: the individual is rendered emotionally and physically unable to take an exam.

Instructional Strategies

Students with a history of psychiatric disabilities can be intelligent, sensitive, creative, and interesting. You can employ strategies that will promote their success in your class. For example:

Address a variety of learning styles (e.g. auditory, visual, kinesthetic, experiential, or a combination of styles).

Incorporate experiential learning activities.

Be prepared to set behavioral expectations for all students in your class.

Embrace diversity to include people with psychiatric disabilities.

Accommodations

Some students with mental illness may require accommodations to allow them equal access to classes, programs, and coursework. An accommodation is the removal of a barrier to full participation and learning. The emphasis is on access, not outcome. This is done by providing the student with a disability equal access to the content and activities of a course, but not necessarily assuring their success.

Each student with a disability is encouraged to register with the office that supports students with disabilities in order to receive accommodations. Personnel from this office typically send instructors a letter documenting specific accommodations required for the student with the disability. It is the responsibility of the instructor to provide the accommodations. It is the student's responsibility to fulfill the academic requirements of the course. The best solutions result when the instructor, student, and disability support service professional work cooperatively. Meeting as a group may facilitate problem-solving alternatives. Respecting the privacy of the student by not discussing his or her disability or accommodations with others outside of this meeting is essential. Review accommodations periodically with the student to assess effectiveness and adjust to changing needs.

The following are typical classroom, exam, and assignment accommodations that may be recommended by the disability student service professional for a student with a psychiatric disability.

Classroom Accommodations

Preferential seating, especially near the door to allow leaving class for breaks.

Assigned classmate as volunteer assistant.

Beverages permitted in class.

Prearranged or frequent breaks.

Tape recorder use.

Notetaker or photocopy of another student's notes.

Early availability of syllabus and textbooks.

Availability of course materials (lectures, handouts) on disk.

Private feedback on academic performance.

Examination Accommodations

Exams in alternate format (e.g., from multiple choice to essay; oral, presentation, role-play, or portfolio).

Use of assistive computer software (e.g., Optical Character Recognition, allowing scanned text to be read aloud by the computer's sound card; or speech recognition for converting the spoken word to printed word on the computer screen).

Extended time for test taking.

Exams individually proctored, including in the hospital.

Exam in a separate, quiet, and non-distracting room.

Increased frequency of exams.

Assignment Accommodations

Substitute assignments in specific circumstances.

Advance notice of assignments.

Permission to submit assignments handwritten rather than typed.

Written assignments in lieu of oral presentations or vice versa.

Assignments completed in dramatic formats (e.g., demonstration, role-play, and sculpture).

Assignment assistance during hospitalization.

Extended time to complete assignments.

Not all requested accommodations are "reasonable." An accommodation is not reasonable if:

Making the accommodation or having the individual involved in the activity poses a direct threat to the health or safety of others.

Making the accommodation means making a substantial change in an essential element of the curriculum.

Making the accommodation would require a substantial alteration in the manner in which educational opportunities are provided, such as the course objectives being altered.

Making the accommodation would impose an undue financial or administrative burden to the institution.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Author.

Center for Psychiatric Rehabilitation. (1997). How does mental illness affect the way I function at school? Boston University. www.bu.edu/cpr/jobschool/functed.htm.

Additional Resources

DO-IT has created a collection of videos that can be freely viewed at www.washington.edu/doit/videos/index.php. Of particular relevance are the following titles: Building the Team: Faculty, Staff and Students Working Together, Equal Access: Universal Design of Instruction, and Invisible Disabilities and Postsecondary Education. You may also find the following resources useful as you explore this topic further.

National Alliance on Mental Illness (NAMI)

About DO-IT

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Acknowledgment

This publication was developed under a grant from the U.S. Department of Education, #P33A990042. However, these contents do not necessarily represent the policy of the U.S. Department of Education, and you should not assume endorsement by the federal government.

Copyright © 2012, 2009, 2008, 2006, 2001, University of Washington. Permission is granted to copy these materials for educational, noncommercial purposes provided the source is acknowledged.

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By: Alfred Souma, Nancy Rickerson, and Sheryl Burgstahler

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Academic Accommodations for Students with Psychiatric Disabilities | DO-IT

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Achieving equal access through accommodations and universal design Tens of thousands of students enrolled in American postsecondary institutions report having a mental illness. Recent increases in the size of this group are due in part to improved medications that result in symptoms mild enough for…

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Tips for Teachers and Counselors for Working with Students with Psychological Disabilities

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Tips for Teachers and Counselors for Working with Students with Psychological Disabilities

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The needs of students with psychological disabilities can vary widely and may change with the changing course of their disability. The most important way faculty can support these students is by being supportive and flexible.

Functional Limitations

The following functional limitations related to psychiatric disabilities may affect academic performance and may require accommodations (Center for Psychiatric Rehabilitation, 1997).

Difficulty with medication side effects: side-effects of psychiatric medications that affect academic performance include drowsiness, fatigue, dry mouth and thirst, blurred vision, hand tremors, slowed response time, and difficulty initiating interpersonal contact.

Screening out environmental stimuli: an inability to block out sounds, sights, or odors that interfere with focusing on tasks. Limited ability to tolerate noise and crowds.

Sustaining concentration: restlessness, shortened attention span, distraction, and difficulty understanding or remembering verbal directions.

Maintaining stamina: difficulty sustaining enough energy to spend a whole day on campus attending classes; combating drowsiness due to medications.

Handling time pressures and multiple tasks: difficulty managing assignments, prioritizing tasks, and meeting deadlines. Inability to participate in multi-task work.

Interacting with others: difficulty getting along, fitting in, contributing to group work, and reading social cues.

Fear of authority figures: difficulty approaching instructors or TAs.

Responding to negative feedback: difficulty understanding and correctly interpreting criticism or poor grades. May not be able to separate person from task (personalization or defensiveness due to low self-esteem).

Responding to change: difficulty coping with unexpected changes in coursework, such as changes in the assignments, due dates or instructors. Limited ability to tolerate interruptions.

Severe test anxiety: the individual is rendered emotionally and physically unable to take an exam.

Instructional Strategies

Students with a psychological disability can be intelligent, sensitive, creative, and interesting. You can employ strategies that will promote their success in your class. For example:

Address a variety of learning styles (e.g. auditory, visual, kinesthetic, experiential, or a combination of styles).

Incorporate experiential learning activities.

Be prepared to set behavioral expectations for all students in your class.

Embrace diversity to include people with psychiatric disabilities.

Accommodations

Some students with a psychological disability may require accommodations to allow them equal access to classes, programs, and coursework. An accommodation is the removal of a barrier to full participation and learning. The emphasis is on access, not outcome. This is done by providing the student with a disability equal access to the content and activities of a course, but not necessarily assuring their success.

The following are typical classroom, exam, and assignment accommodations that may be approved by SSD for a student with a psychological disability.

Classroom Accommodations

Preferential seating, especially near the door to allow leaving class for breaks.

Prearranged or frequent breaks

Permission to audio record lectures

Copy of notes from a volunteer notetaker

Permission to use a laptop for taking notes in class

Access to powerpoints or overheads shown in class

Student will raise hand to participate in class and/or will work with instructor to determine how participation will be assessed. Student should not be called upon at random

Permission to approach instructor to discuss flexible deadlines. Final determination will be made by instructor based on the structure of the course.

Attendance may be an issue

Examination Accommodations

Extended time for test taking.

Test location in a reduced distraction environment

Not all requested accommodations are "reasonable." An accommodation is not reasonable if:

Making the accommodation or having the individual involved in the activity poses a direct threat to the health or safety of others.

Making the accommodation means making a substantial change in an essential element of the curriculum.

Making the accommodation would require a substantial alteration in the manner in which educational opportunities are provided, such as the course objectives being altered.

Making the accommodation would impose an undue financial or administrative burden to the institution.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: Author.

Center for Psychiatric Rehabilitation. (1997). How does mental illness affect the way I function at school? Boston University. https://cpr.bu.edu/resources/reasonable-accommodations/jobschool/how-does-mental-illness-affect-my-school-performance/

Additional Resources

DO-IT has created a collection of videos that can be freely viewed at www.uw.edu/doit/Video/. Of particular relevance are the following titles: Building the Team: Faculty, Staff and Students Working Together, Equal Access: Universal Design of Instruction, and Invisible Disabilities and Postsecondary Education. You may also find the following resources useful as you explore this topic further.

The Center for Universal Design in Education
www.uw.edu/doit/CUDE/

About DO-IT

DO-IT (Disabilities, Opportunities, Internetworking, and Technology) serves to increase the successful participation of individuals with disabilities in challenging academic programs such as those in science, engineering, mathematics, and technology. Primary funding for DO-IT is provided by the National Science Foundation, the State of Washington, and the U.S. Department of Education. DO-IT is a collaboration of UW Information Technology and the Colleges of Engineering and Education at the University of Washington.

Acknowledgment

This publication was developed under a grant from the U.S. Department of Education, #P33A990042. However, these contents do not necessarily represent the policy of the U.S. Department of Education, and you should not assume endorsement by the federal government.

Copyright © 2012, 2009, 2008, 2006, 2001, University of Washington. Permission is granted to copy these materials for educational, noncommercial purposes provided the source is acknowledged.
Academic Accommodations for Students with Psychiatric Disabilities
For more general information about Psychological Disabilities, please click here.

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Tips for Working with Students with Psychological Disabilities - Disability and Access

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The needs of students with psychological disabilities can vary widely and may change with the changing course of their disability. The most important way faculty can support these students is by being supportive and flexible. Functional Limitations The following functional limitations related to psychiatric disabilities may affect academic performance and...

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Teaching a student with Schizophrenia can be a challenge for teachers. This is a great site with tons of suggestions!

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How to Teach Schizophrenic Students | Synonym

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Teaching a student with Schizophrenia can be a challenge for teachers. The student with this mental disability falls under the Educable Mentally Handicapped category of the Emotionally or ...

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A child's stage of development must be taken into account when considering a diagnosis of mental illness. ¹ Behaviors that are normal at one age may not be at another. Rarely, a healthy young child may report strange experiences-such as hearing voices-that would be considered abnormal at a later age. Clinicians look for a more persistent pattern of such behaviors. Parents may have reason for concern if a child of 7 years or older often hears voices saying derogatory things about him or her, or voices conversing with one another, talks to himself or herself, stares at scary things-snakes, spiders, shadows-that are not really there, and shows no interest in friendships. Such behaviors could be signs of schizophrenia, a chronic and disabling form of mental illness. ²

Fortunately, schizophrenia is rare in children, affecting only about 1 in 40,000, ³ compared to 1 in 100 in adults. The average age of onset is 18 in men and 25 in women. Ranking among the top 10 causes of disability worldwide, ⁴ schizophrenia, at any age, exacts a heavy toll on patients and their families. Children with schizophrenia experience difficulty in managing everyday life. They share with their adult counterparts psychotic symptoms (hallucinations, delusions), social withdrawal, flattened emotions, increased risk of suicide and loss of social and personal care skills. They may also share some symptoms with-and be mistaken for-children who suffer from autism or other pervasive developmental disabilities, which affect about 1 in 500 children. Although they tend to be harder to treat and have a worse prognosis than adult-onset schizophrenia patients, researchers are finding that many children with schizophrenia can be helped by the new generation of antipsychotic medications. ⁵

Symptoms and Diagnosis

While schizophrenia sometimes begins as an acute psychotic episode in young adults, it emerges gradually in children, often preceded by developmental disturbances, such as lags in motor and speech/language development. Such problems tend to be associated with more pronounced brain abnormalities. The diagnostic criteria are the same as for adults, except that symptoms appear prior to age 12, instead of in the late teens or early 20s. ⁶ Children with schizophrenia often see or hear things that do not really exist, and harbor paranoid and bizarre beliefs. For example, they may think people are plotting against them or can read their minds. Other symptoms of the disorder include problems paying attention, impaired memory and reasoning, speech impairments, inappropriate or flattened expression of emotion, poor social skills, and depressed mood. Such children may laugh at a sad event, make poor eye contact, and show little body language or facial expression.

Misdiagnosis of schizophrenia in children is all too common. It is distinguished from autism by the persistence of hallucinations and delusions for at least 6 months, and a later age of onset-7 years or older. Autism is usually diagnosed by age 3. ⁷ Schizophrenia is also distinguished from a type of brief psychosis sometimes seen in affective, personality, and dissociative disorders in children. Adolescents with bipolar disorder sometimes have acute onset of manic episodes that may be mistaken for schizophrenia. Children who have been victims of abuse may sometimes claim to hear voices of-or see visions of-the abuser. Symptoms of schizophrenia characteristically pervade the child's life, and are not limited to just certain situations, such as at school. If children show any interest in friendships, even if they fail at maintaining them, it is unlikely that they have schizophrenia.

Treatment

Treatments that help young patients manage their illness have improved significantly in recent decades. As in adults, antipsychotic medications are especially helpful in reducing hallucinations and delusions. The newer generation "atypical" antipsychotics, such as olanzapine and clozapine, may also help improve motivation and emotional expressiveness in some patients. They also have a lower likelihood of producing disorders of movement, including tardive dyskinesia, than the other antipsychotic drugs such as haloperidol. However, even with these newer medications, there are side effects, including excess weight gain that can increase risk of other health problems. The NIMH is conducting research studies to improve treatments (www.clinicaltrials.gov). Children with schizophrenia and their families can also benefit from supportive counseling, psychotherapies, and social skills training aimed at helping them cope with the illness. They likely require special education and/or other accommodations to succeed in the classroom.

Causes

Although it is unclear whether schizophrenia has a single or multiple underlying causes, evidence suggests that it is a neurodevelopmental disease likely involving a genetic predisposition, a prenatal insult to the developing brain, and stressful life events. The role of genetics has long been established; the risk of schizophrenia rises from 1 percent with no family history of the illness, to 10 percent if a first degree relative has it, to 50 percent if an identical twin has it. Prenatal insults may include viral infections, such as maternal influenza in the second trimester, starvation, lack of oxygen at birth, and untreated blood type incompatibility. Studies find that children share with adults many of the same abnormal brain structural, physiological, and neuropsychological features associated with schizophrenia. ⁶ The children seem to have more severe cases than adults, with more pronounced neurological abnormalities. This makes childhood-onset schizophrenia potentially one of the clearest windows available for research into a still obscure illness process.

For example, unlike most adult-onset patients, children who become psychotic prior to puberty show conspicuous evidence of progressively abnormal brain development. In the first longitudinal brain imaging study of adolescents, ⁸ magnetic resonance imaging (MRI) scans revealed fluid filled cavities in the middle of the brain enlarging abnormally between ages 14 and 18 in teens with early-onset schizophrenia, suggesting a shrinkage in brain tissue volume. ⁹ These children lost four times as much gray matter, neurons and their branchlike extensions, in their frontal lobes as normally occurs in teens. This gray matter loss engulfs the brain in a progressive wave from back to front over 5 years, beginning in rear structures involved in attention and perception, eventually spreading to frontal areas responsible for organizing, planning, and other "executive" functions impaired in schizophrenia. ¹⁰ Since losses in the rear areas are influenced mostly by environmental factors, the researchers suggest that some non-genetic trigger contributes to the onset and initial progression of the illness. The final loss pattern is consistent with that seen in adult schizophrenia. Adult-onset patients' brains may have undergone similar changes when they were teens that went unnoticed because symptoms had not yet emerged, suggest the researchers.

In addition to studies of brain structural abnormalities, researchers are also examining a group of measures associated with genetic risk for schizophrenia. Early-onset cases of illness have recently proven crucial in the discovery of genes linked to other genetically complex disorders like breast cancer, Alzheimer's, and Crohn's diseases. ³ Hence, children with schizophrenia and their families may play an important role in deciphering schizophrenia's molecular roots. Evidence suggests that the rate of genetically-linked abnormalities is twice as high in children as in adults with the illness. Similarly, schizophrenia spectrum disorders, thought to be genetically related to schizophrenia, are about twice as prevalent among first-degree relatives of childhood-onset patients. In one recent study, a third of the families of individuals with childhood onset schizophrenia had at least one first-degree relative with a diagnosis of schizophrenia, or schizotypal or paranoid personality disorder. ¹¹ This profile of psychiatric illness is remarkably similar to that seen in parents of adult-onset patients, adding to the likelihood that both forms share common genetic roots. Other anomalies associated with adult schizophrenia, such as abnormal eye movements, are also more common in families of children with the illness.

References

¹US DHHS. Children and mental health (Chapter 3). In: Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999; 123-220. http://www.surgeongeneral.gov/library/ mentalhealth/chapter3/sec1.html

² NIMH Schizophrenia publications.

³ Nicolson R, Rapoport JL. Childhood onset schizophrenia: rare but worth studying. Biological Psychiatry, 1999; 46: 1418-28.

⁴ World Health Organization. The World health report 2001-mental health: new understanding, new hope. Geneva: World Health Organization, 2001.

⁵ American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(10): 177S-93S.

⁶ Rapoport JL. Childhood onset of "adult" pathology: clinical and research advances. Washington, DC: American Psychiatric Press, Inc., 2000.

⁷ American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children, adolescents and adults with autism and other pervasive developmental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 1999; 38(12): 32S-54S.

⁸ Giedd JN, Blumenthal J, Jeffries NO, Castellanos FX, Liu H, Zijdenbos A, Paus T, Evans AC, Rapoport JL. Brain development during childhood and adolescence: a longitudinal MRI study. Nature Neuroscience, 1999; 2(10): 861-3.

⁹ Rapoport JL, Giedd JN, Blumenthal J, Hamburger S, Jeffries N, Fernandez T, Nicolson R, Bedwell J, Lenane M, Zijdenbos A, Paus T, Evans A. Progressive cortical change during adolescence in childhood-onset schizophrenia: a longitudinal magnetic resonance imaging study. Archives of General Psychiatry, 1999; 56(7): 649-54.

¹⁰ Thompson P, Vidal C, Giedd JN, Gochman P, Blumenthal J, Nicolson R, Toga AW, Rapoport JL. Mapping adolescent brain change reveals dynamic wave of accelerated gray matter loss in very early-onset schizophrenia. Proceedings of the National Academy of Sciences, 2001; 98(20): 11650-5.

¹¹ Asarnow RF, Nuechterlein KH, Fogelson D, Subotnik KL, Payne DA, Russell AT, Asamen J, Kuppinger H, Kendler KS. Schizophrenia and schizophrenia-spectrum personality disorders in the first-degree relatives of children with schizophrenia: the UCLA family study. Archives of General Psychiatry, 2001; 58(6): 581-8.
AASEP wishes to thank the National Institute of Mental Health for the information in this article.

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National Association of Special Education Teachers: Childhood-Onset Schizophrenia

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Emotional Disturbance Child Disturbance Emotional – National Association of Special Education Teachers

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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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Stop Bullying on the Spot!

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Stop Bullying on the Spot

When adults respond quickly and consistently to bullying behavior they send the message that it is not acceptable. Research shows this can stop bullying behavior over time.

Parents, school staff, and other adults in the community can help kids prevent bullying by talking about it, building a safe school environment, and creating a community-wide bullying prevention strategy.

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StopBullying.gov provides information from various government agencies on bullying, cyberbullying, prevention and response.

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The Role of the Middle School Counselor in Preventing Bullying

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The Role of the Middle School Counselor in Preventing Bullying

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Effects of Cyberbullying and How School Counselors Can Combat Bullying Today

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Effects of Cyberbullying and How School Counselors Can Combat Bullying Today

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A 2018 Pew Research Center survey of teens found 59 percent were targets of online abuse and harassment, also known as cyberbullying. Young students face the negative effects of cyberbullying in the real world - no matter the digital medium.

School counselors are essential in the ongoing fight against cyberbullying because they possess proven solutions to these challenges. They are important in mitigating the impact of cyberbullying by preventing long-term harm to students. Counselors also know how to engage teachers, parents and students against online abuse.

The quick rise of online bullying means that even veteran counselors are adjusting to problems emerging from new technology. You need to first understand the full scale of cyberbullying before helping students tackle its effects. Cyberbullying statistics and stories reveal the best way to combat online threats faced by students.

Learning the Basics of Cyberbullying

Cyberbullying is a relatively new trend in the grand scheme of student development. In the past decade, school stakeholders have played catch-up with students on bullying behaviors in the digital realm.

UNICEF defines cyberbullying as any threatening or negative behavior completed with digital devices. The Pew Research Center found the following cyberbullying behaviors were the most common among teenagers:

Offensive or inappropriate name-calling

Creating and distributing false information

Sending explicit photos or texts to others

Unwarranted requests for information about location or activity

The Cyberbullying Research Center asked 25,000 middle-school and high-school students over 12 years if they faced cyberbullying in their lifetimes. An average of 27.8 percent of students confirmed they had, with these cyberbullying statistics showing cyberbullying as commonplace across the United States:

School counselors need to equip themselves with next-level statistics to fully understand the aftermath of cyberbullying. The latest research on social media and gender disparities in cyberbullying is useful in turning student challenges into opportunities.

Cyberbullying Statistics on Social Media

The earliest forms of cyberbullying occurred in chat rooms and instant messaging services. Teens have migrated bullying behaviors to new frontiers like online gaming and social media accounts. Cyberbullying allows perpetrators more invasive and anonymous forms of abuse than in-person bullying.

Social media platforms and smartphones have become ubiquitous in recent years. Ninety-five percent of teenagers reported access to smartphones in a Pew Research Center survey. This survey reported the following percentages of teenagers using leading social media platforms:

The Annual Bullying Survey 2020 showed why victims of cyberbullying are targeted by perpetrators. Respondents noted the following reasons for targeted online aggression by their peers:

Physical appearance (47 percent)

Hobbies and interests (30 percent)

Recent behavior (24 percent)

Inaccurate description of gender or sexual identity (22 percent)

Cyberbullying based on sexual identity brings to light threats targeted at LGBTQ students. In fact, GLSEN's National School Climate Survey found 48.7 percent of LGBTQ respondents faced cyberbullying in the previous year.

These cyberbullying statistics can obscure how often students use multiple platforms every day. Bullied students may face hateful videos on YouTube, abusive comments on Facebook and sexually suggestive images on Instagram at the same time. Constant access to smartphones, laptops and tablets makes these threats loom larger in student minds.

Understanding Gender Disparities through Cyberbullying Statistics

Researchers have spent the past 20 years evaluating the frequency of cyberbullying based on gender. Male and female students develop on different timelines and the effects of cyberbullying can vary based on age.

A 2019 Statista study found 38.7 percent of female students reported being victims of cyberbullying in their lifetimes. This figure compares to 34.1 percent of male students indicating bullying behaviors toward them. Researchers also found 16.1 percent of male students cyberbullied others in their lifetimes compared to 13.4 percent of female students.

The Pew Research Center explored how this gender distinction manifested itself in specific cyberbullying behaviors. Female and male students experienced differing levels of the following threats:

School counselors familiar with the ins and outs of cyberbullying statistics understand the world navigated by students. The barrage of online images and messages isn't a short-term threat to young people. Physical, mental and academic harm are the effects of cyberbullying if not addressed.

Understanding the Effects of Cyberbullying with Data

Teens throughout the United States are well-aware of the aftermath of cyberbullying. Ninety percent told the Pew Research Center that cyberbullying is a problem. Sixty-three percent of this group considered online bullying a major problem.

Students who have faced years of online abuse know the potential mental health impacts. Consequences ranging from academic struggles to suicide are possible without help. School counselors develop interventions that prevent the following effects of cyberbullying on growing children.

Mental Health Effects of Cyberbullying

Researchers found that cyberbullying victims are more likely to commit acts of self-harm and suicide than victims of traditional abuse. The Cyberbullying Research Center built on this research by finding 60 percent of victims didn't feel safe at school or online. In short, cyberbullying adds a consistent layer of menace to a victim's life.

Mental health struggles can take many forms among victims of cyberbullying. Ditch the Label reported that 63 percent of respondents to its 2020 survey experienced moderate to extreme mental health consequences. These struggles resulted in:

Increased feelings of anxiety (44 percent)

Increased feelings of depression (36 percent)

Tardiness from school (18 percent)

The emergence of anti-social behaviors (12 percent)

School counselors can help identify signs of mental health impact of cyberbullying. The National Crime Prevention Council points to the following indicators of a bullied student:

A lack of intervention by school counselors, teachers and parents can have significant impacts on a student's academic prospects. The academic effects of cyberbullying include inattention to assignments, a lack of focus and testing struggles.

Stunted Relationships with People and Technology

K-12 students facing online abuse often struggle with interpersonal skills. Victims may become more aggressive or completely withdrawn based on their personalities. Another interpersonal aftermath of cyberbullying is a lack of trust even in close friends and family members.

Technology use has never been more critical in education and employment. Cyberbullying victims fall behind their peers in learning how to translate digital skills into post-graduate careers. Online abuse denies young victims the modern joys of collaborating, sharing and learning from others around the world.

Bringing Cyberbullying Statistics to Life

School counselors don't mentor and help statistics; they work every day with students facing real struggles. Cyberbullying statistics provide overviews of challenges facing students but real-life stories add dimension to this data.

We see in the following case studies how the effects of cyberbullying can vary significantly based on particular conditions. Counselors also see how they can achieve measurable success in confronting the cyberbullying scourge. Across all of these examples, though, we see the need for early and sustained intervention.

Cyberbullying at Surfside Middle School

The January 2018 suicide of 12-year old Gabriella Green wasn't initially attributed to the effects of cyberbullying. A Panama City Police Department (FL) investigation charged two fellow students for cyberbullying in connection with Green's death. The details of this case show how cumulative online abuse can lead to tragic endings.

One bully spread rumors to online groups frequented by classmates about Green hiding a sexually transmitted disease. This rumor also spread at the school, leading Green to attempt suicide but survive. The second bully video-chatted with Green and told her to try committing suicide again.

An onslaught of rumors and insensitive comments at a difficult time led Green to commit suicide. The school and local police found that the involved students accessed social media with little parental involvement. School counselors not only comforted classmates but educated students on the dangers of cyberbullying.

Digital Abuse of a Texas City Student

High school student Brandy Vela was subject to months of anonymous cyberbullying by fellow students. The 18-year-old received messages from an anonymous texting app mocking her weight. Cyberbullies created a fake social media page with Vela's phone number to amplify their abuse.

Vela changed her phone number multiple times but was found by cyberbullies after each change. She told her school and local authorities about the abuse shortly before her suicide in December 2016. The deputy who investigated the abuse encouraged a phone number change but couldn't pinpoint the source of the cyberbullying.

The stress of cyberbullying was so intense that Vela's family was unable to stop her suicide despite clear signs. Vela enjoyed good relationships with teachers, counselors and students at her school. Cyberbullying is often a private struggle as bullies use the anonymity of the online world to cover their tracks.

Surveying the Full Spectrum of Cyberbullying Stories

Teens across the United States have shared their experiences with cyberbullying through the Cyberbullying Research Center. A brief survey offers an open avenue for any teenager to share, in their own words, how they've been bullied. These stories are valuable because most online abuse cases are not reported by media outlets.

A full range of experiences emerged from the center's outreach to teens. These experiences include:

The common thread among these experiences is the isolation felt by its victims. Students often feel helpless against persistent bullies and adults unfamiliar with cyberbullying. School counselors can step into this void by intervening at the first signs of bullying.

Remediating the Effects of Cyberbullying: the Role of School Counselors

A school's counseling staff is often underutilized when responding to cyberbullying incidents. Parents, school administrators and law enforcement are key stakeholders responding to prolonged periods of abuse. However, school counselors are situated perfectly to counter the effects of cyberbullying whether the abuse happens in school or at home.

Each cyberbullying incident is unique and requires a student-centered approach. Counselors are trained in various techniques that navigate kids through difficult times. A good way to keep students out of cyberbullying statistics is to use the following tips as a checklist.

Developing Cyberbullying Prevention Procedures

Forty-nine states developed cyberbullying laws that applied to schools by 2018. These laws include civil and criminal penalties for digital abuse. Laws can only be enforced and improved with diligent adherence.

Individual school districts and schools can develop prevention policies that build on state laws. A counselor's day-to-day interactions with bullying behaviors can inform policy development by administrators. Schools can incorporate the following prevention techniques based on counselor feedback:

School counselors have proven crucial to enforcing state laws related to cyberbullying. Students may entrust counselors with emails, screenshots and texts as proof of bullying incidents. This profession's focus on accurate recordkeeping translates well to collecting details about bullying allegations.

Involving Parents in Mitigating the Effects of Cyberbullying

An important partner for any school counselor when dealing with cyberbullying incidents is the student's parents. Counselors only see the impact of cyberbullying when students are in their place of work. Parents see their children the rest of the time and observe behavioral changes crucial to a counselor's work.

Parent-counselor meetings usually focus on academic performance, college planning and school programs. An ongoing dialogue with parents outside of conferences reveals the often-hidden effects of cyberbullying. Parents and counselors use this dialogue to intervene early in students' experiences with bullies.

The relatively new nature of social media can mean a misunderstanding of these platforms by parents. School counselors can walk parents through social media safeguarding tools and techniques. Tools like the New York State Education Department's Response and Prevention tool also point out the dangers of unmonitored online time.

Engaging and Empowering Students

One-third of teen respondents to a Cyberbullying Research Center survey said blocking bullies stopped bullying behaviors. This solution does not work in most cases, however, as bullies use other platforms and tools to harass fellow students. Frequent contacts between counselors and students are necessary in cyberbullying cases.

Every school counselor is trained in mediation and group communications. Small-group sessions can respond to the impact of cyberbullying while building student resilience. These groups can deal with areas like:

Self-esteem building through shared experiences

Role-playing exercises for dealing with aggressive people

Learning to resolve conflicts and be assertive when necessary

Managing stress and channeling energy into healthier lives

Counselors can also nudge witnesses and perpetrators of cyberbullying to change their ways. Conversations about the dangerous effects of cyberbullying can turn bystanders into allies. Bullies confronted with their words and actions might be swayed to change their ways and make amends.

Students may be digital natives but they might also fail to understand the nuances of social media platforms. Counselors can show cyberbullying victims mechanisms for reporting inappropriate behavior within platforms. An understanding of community guidelines can also prevent microaggressions and slights from turning into aggressive acts.

Leveraging the School Community Against Cyberbullying

The ecosystem of a school means that there are many points of contact with students. Counselors talk to students all day but they do not hold the full picture of student behavior because of packed schedules. The signs of cyberbullying are witnessed by teachers, administrators and support staff.

Instructional staff and school counselors work closely to improve student outcomes. It only makes sense for counselors to partner with teachers when bullying incidents come to light. This collaboration can yield additional information, opportunities for student growth and a unified message.

School administrators also are important partners in the fight against cyberbullying. Principals and department heads can be vocal advocates for an anti-bullying campaign if engaged by counselors. Aggressive enforcement of school policies on cyberbullying also acts as a strong deterrent.

School staff are accustomed to continuing education and development over the course of their careers. Counselors can develop concise but effective training programs for staff unfamiliar with cyberharrassment. A simple way to reinforce these concepts is through informal conversations especially following reported bullying cases.

Countering the Effects of Cyberbullying with an MSED

School counselors develop the aforementioned skills and competencies through university programs. A bachelor's degree in education or psychology is a strong start toward a counseling career. A Master of Science in Education (MSED) not only builds undergraduate studies but meets licensing requirements in most states.

Reading about the aftermath of cyberbullying leads many counselors to ask how they can meet the needs of this moment. An MSED anticipates licensing requirements and provides practical experiences relevant to today's counseling positions. This graduate degree also raises the ceiling on a counselor's compensation with salaries commensurate with their specialized skills.

State Licensing Requirements for School Counselors

Every state maintains licensing requirements for educators including school counselors. These regulations ensure students are receiving instruction and assistance from qualified professionals. Varying licensing requirements can be confusing for new counselors and educators moving to new states.

The MSED is a valuable tool for any counselor in the new license and renewal process. Graduate hours often qualify as eligible experience for licensing purposes. In some states, school counselors are required to hold graduate degrees before achieving licensure.

New York's licensing process offers an example of how the MSED can open doors to counseling careers. Applicants qualify for licensing in the state of New York with any of the following:

An MSED from an exceptional school makes all three of these paths possible. Graduates of MSED programs are also prepared for the rigors of national programs like the National Certified School Counselors ( NCSC) exam. Licenses and certifications demonstrate the commitments of counselors to their professions.

The career outlook for school counselors is promising as well. School districts throughout the United States are seeking qualified counselors to help with issues like cyberbullying. BLS projected an 8 percent growth in counseling positions from 2019 to 2029 compared with 4 percent for all occupations. This estimate takes into account school enrollment growth, counselor retirements and an increasingly specialized field.

Completing a Master's in School Counseling at
St. Bonaventure University

St. Bonaventure University imparts decades of higher education excellence through its CACREP-accredited online MSED in School Counseling that prepares graduates for state licensing as school counselors. MSED candidates learn the skills to meet challenges like cybersecurity faced by students today and in the future.

Read more of St. Bonaventure University online's top school counseling blogs below:

1. Transitioning From School Teacher to School Counselor: Trading Your Classroom for a Counseling Office

2. School Counseling Advice: Earning an Online Master's Degre While Working

3. School Counselors: Overcoming 9 Key Challenges to a Rewarding Career

4. School Counselor: What Does the Future Hold?

5. Why Earn an MSED in School Counseling?

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Effects of Cyberbullying: How School Counselors Help | SBU Blog

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A 2018 Pew Research Center survey of teens found 59 percent were targets of online abuse and harassment, also known as cyberbullying. Young students face the negative effects of cyberbullying in the real world - no matter the digital medium. School counselors are essential in the ongoing fight against cyberbullying because they possess proven solutions to these challenges.

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7 Practical School Counseling Interventions for Bullying Prevention Month

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7 Practical School Counseling Interventions for Bullying Prevention Month

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7 Practical School Counseling Interventions for Bullying Prevention Month - Bright Futures Counseling

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It's October, and it's also Bullying Prevention Month! Being such a vital topic to cover, especially at the start of a new school year, chances are you're already teaching class lessons, organizing bullying prevention campaigns, and sending out newsletters to parents. I tend to start the year with

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Good research article on our roles and responsibilities

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School Counselors' Roles and Responsibilities in Bullying Prevention: A National Survey

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School Counselors' Roles and Responsibilities in Bullying Prevention: A National Survey

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Best Practices for School Counselors Working with Transgender Students

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Best Practices for School Counselors Working with Transgender Students

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Supporting Trans and Non Binary Middle School Students Through Inclusive Polices

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Supporting Trans and Non Binary Middle School Students Through Inclusive Polices

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The guide includes resources school counselors can use to create a gender inclusive student club, and as they advocate for more inclusive school policies and staff professional development.

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School Counselor Advocacy for Gender Minority Students

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School Counselor Advocacy for Gender Minority Students

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Jack D. Simons,

on behalf of the Simons Lab

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Abstract

One-thousand-one-hundred-and-ninety-one school counselors completed an online survey regarding advocacy for and with gender minority students comprising transgender and intersex students (school counselor gender minority advocacy competence). School counselors completed a battery of three competency-based assessments to assess their levels of gender identity counselor competence, intersex counselor competence, and school counselor gender minority advocacy competence. They also completed a demographic form so that competency levels could be examined with demographic variables. Attitudes, school level placement, gender, sexual orientation, gender identity counselor competence, and intersex counselor competence were significantly related to advocacy for and with gender minority students. These findings have implications for the application of identity behavior theory to examine the experiences and behaviors of minoritized individuals and those who advocate for them. These advocates include school counselors and other helping professionals who work with gender minority students.

Citation: Simons JD, on behalf of the Simons Lab (2021) School counselor advocacy for gender minority students. PLoS ONE 16(3): e0248022. https://doi.org/10.1371/journal.pone.0248022

Editor: H. Jonathon Rendina, Hunter College, UNITED STATES

Received: September 27, 2020; Accepted: February 16, 2021; Published: March 17, 2021

Copyright: © 2021 Simons, on behalf of the Simons Lab. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying this study is available in the openICPSR data repository ( https://doi.org/10.3886/E122501V1).

Funding: Research reported in this article is part of a Faculty Development Grant supported by Mercy College under IRB protocol number 17-75. The College funders did not a play a role in the study design, data collection and analysis, decision to publish, and preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

A paucity of research exists on school counselor gender minority advocacy competence, the extent to which school counselors effectively advocate for and with transgender and intersex students [ 1]. This lack of research is concerning because gender minority youth are becoming more visible in society, and, although the American School Counselor Association has called for respect and equal treatment of these students, many still report negative school experiences [ 2, 3]. Gender minority youth attending unsafe schools report being bullied, harassed, and victimized [ 2, 3]. Concurrent with major changes in society concerning attitudes toward gender minorities, and a need for more scholarship in this area, the adults who are expected to support them are encouraged to look more closely at their ability to advocate for gender minorities [ 1].

In this study gender minority youth comprise those who identify as transgender and intersex. Scholars estimate 150,000 adolescents in the United States identify as transgender [ 4]. Transgender youth experience incongruent feelings between birth sex and gender identity [ 5]. Intersex individuals account for one to two percent of the population [ 6]. Intersex youth possess a normal variation in hormone levels or chromosomes and may experience differences in body characteristics [ 7]. Some will undergo genital surgery [ 8]. Some transgender and intersex youth also identify as gender non-binary. Gender non-binary youth, also referred to as genderqueer youth, possess non-dichotomous gender identities that are neither male nor female; the identities of gender non-binary youth may be fluid or fixed, or exist somewhere between female and male (e.g., neutral) [ 9, 10].

Examining counselor advocacy for transgender and intersex youth is warranted because the needs of these youth appear to overlap [ 2, 3]. The two groups experience a wide array of feelings; face challenges (e.g., being bullied); and cope with identity development [ 2, 3]. This is also the case for gender non-binary students. As a result, the aim of this quantitative study is to assess the school counselor role as an advocate for transgender and intersex students. However, more research is needed to understand counselor advocacy for gender non-binary youth. The decision was made not to include assessment of advocacy for these students because prior to this study, the research team had only conducted studies to examine the school experiences of transgender and intersex students, not the school experiences of gender non-binary students [ 2, 3]. Additionally, school counselor gender minority advocacy competence comprising transgender and intersex advocacy competence (together) was examined to develop and norm the School Counselor Transgender Intersex Advocacy Scale, an online self-administered training tool that is used by school counselors and other school stakeholders to examine their ability to advocate for gender minority students [ 11]. This scale is an important tool because the amount of time that school counselors have for training may be limited due to high caseloads and other work responsibilities. By combining gender minority related training content together (transgender and intersex), school counselors may learn about how effective they are at meeting the needs of these students in a shorter amount of time. A review of the current body of research suggests the following regarding the need for more effective training of school counselors and other helping professionals who work with gender minority youth:

1. We do not know how counselor competence to provide services to transgender students relates to counselor competence to provide services to intersex students. A review of the research literature indicates that no studies have empirically examined these advocacy areas together. To the best of our knowledge, this study appears to be the first.

2. We have limited knowledge about how to train school counselors to most effectively support gender minority students, but what we do know, most notably from Australia, informs the research area [12-16]. Jones et al. [12] assessed mixed research data to learn more about the experiences and identities of both transgender and intersex students in Australia. The sample consisted of 189 gender diverse students who were 14 to 25 years of age. All were surveyed and 16 participated in qualitative interviews. Findings indicated that the needs of the participants varied widely, and their identities were not fixed. Transgender students reported that they did not display gender(s) congruent with the expectations of others. The students, therefore, valued learning about human development. As a result, it appears administrators and counselor educators should prioritize teaching current and future school counselors about how to discuss these areas with students and other school stakeholders, including parents. McGuire et al. [15] analyzed mixed data from 67 transgender students. The students reported that it was common for them to experience harassment and feel unsafe unless they were enrolled in schools with gender-inclusive curricula. As compared to cisgender students, they were less likely to have adequate academic and familial support, and some thought of suicide. Riggs et al. [16] analyzed survey data retrieved from 28 school stakeholders comprising cisgender school counselors, psychologists, and parents. The findings suggested that counselors were uniquely situated in schools to advocate for transgender students but needed more education to effectively do so [16]. Findings from the studies of McGuire et al. [15] and Riggs et al. [16] suggest that school counselors should be taught about how transgender students benefit from having teachers who have knowledge of transgender issues such as social and familial support, mental health, and inclusivity. For example, regarding the latter, school counselors should call for and run gender minority and ally groups and promote policies to assist gender minority students to transfer schools if needed (e.g., due to ongoing physical assault) [2].

3. We do not know how counselor competence to provide counseling services for and with transgender and intersex students within a comprehensive model of school counseling relates to counselor competence to provide counseling services to transgender and intersex individuals in a traditional model of one-on-one individual counseling. For example, with even controlling for gender and religious affiliation, would those who provide comprehensive model school counseling to the parents of gender minority youth be as effective as those who provide traditional individual counseling services to the parents of gender minority youth? [16].

Competency-based assessment

Training school counselors to self-reflect over who they are and how it influences the services they provide may be facilitated by use of competency-based assessments (CBAs). According to Lurie [ 17], CBAs illustrate models of competency that can be developed and refined by individuals. Educators in the health professions (e.g., counselors) and those who train them (e.g., counselor educators) use CBAs to gather empirical data to examine and improve best practices. Use of CBAs remain widespread despite the belief by some that CBAs overemphasize the development of individual skills to the detriment of not learning how to remain open to gaining knowledge from the totality of one's learning experience (holism). Brightwell and Grant [ 18] have argued that this inability to remain open to totality of experience weakens the role of trainees and hurts professions. One way to address these concerns might be to emphasize to students why making a commitment to holistic lifelong learning early in their careers is important [ 18]. More research, however, is warranted to develop more holistic and reflexive approaches to using CBAs in training and research. According to Bajis, Chaar, and Moles [ 19], the inclusion of lifelong learning into CBAs recognizes that competencies change over time due to ethical, social, clinical, and technological considerations. Addressing lifelong learning in CBAs is newer; highlighting the need for lifelong learning in CBAs has the ubiquitous goal of advancing competency paradigms over the entire lifespan in an ever-changing, dynamic world [ 19].

CBAs are used as part of educational practices, including accreditation, and to globalize behavioral expectations (e.g., advocating for gender minority students throughout the world). Individuals who effectively develop and modify CBAs to use in training consider historical, current, and future trends as well as try to strike a balance between use of prescriptive and descriptive language. To norm CBAs, Lurie [ 17] recommended framing constructs in terms of data‐based hypotheses, multiple situations, and reliability so that results from CBAs can be compared. Researchers and counselor educators have used CBAs to teach about multicultural counseling, group counseling, and internship training, to name just a few. More recently, counselor competencies concerning gender have been identified, assessed, and taught using CBAs [ 11].

Identity behavior theory

Simons [ 20] proposed Identity Behavior Theory as an alternative to Planned Behavior Theory (PBT). PBT has been widely used to predict behavior resulting from others' expectations, one's attitudes, self-efficacy, and behavior plans (intention) [ 20]. Behaviors examined using PBT have included, but are not limited to, health and food choices, educator effectiveness, and knowledge sharing; however, despite being developed over three decades ago, few changes have been made to PBT to improve its predictive validity. Moreover, the model does not explicitly recognize the role that identity plays in influencing behavior, nor does it emphasize the emancipatory nature of people, particularly sexual and gender minorities and their allies [ 20]. Identity Behavior Theory (IBT), in contrast to PBT, posits that individuals enact behavior based upon their attitudes, resilience, and identities (see Fig 1). Identity and resilience (personal strength and support) serve as a foundation for behavioral enaction (preparing to act, trying to act, and successfully acting).

Conceptual representation of the elements of Identity Behavior Theory described by Simons.

In this study, we examine the underpinnings of school counselor gender minority advocacy in light of IBT using three CBAs: the School Counselor Transgender Intersex Advocacy Competence Scale, the Gender Identity Counselor Competence Scale, and the Intersex Counselor Competence Scale [ 11]. Each of these measures will be further discussed and are comprised of subscale measures that assess attitudes, resilience, and enaction. Additionally, we examine how school counselor advocacy for gender minority students is related to several demographic variable (see S1 File). The research questions are:

Is gender identity counselor competence related to school counselor gender minority advocacy competence?

Is intersex counselor competence related to school counselor gender minority advocacy competence?

Are school counselor characteristics (age, attitudes, race/ethnicity, gender, sexual orientation, and school level placement) related to school counselor gender minority advocacy competence?

Given the tenets of CBAs and IBT, we hypothesized that school counselor gender minority advocacy competence would relate to gender identity counselor competence, intersex counselor competence, and school counselor characteristics (age, attitudes, race/ethnicity, gender, sexual orientation, and school level placement). In addition, we believed that findings would show: (a) a significant positive relationship between intersex counselor competence and school counselor gender minority competence; (b) a significant positive relationship between gender identity counselor competence and school counselor gender minority advocacy competence; and (c) significant differences between school counselors' characteristics (age, attitudes, race/ethnicity, gender, sexual orientation, and school level) on school counselor gender minority advocacy competence.

Methods

The Mercy College IRB approved the study with an approval number of 17-75. Study participants gave consent to participate via electronic REDCap survey form. A national survey study was conducted with a sample of school counselors. A nonprobability sample was sought to increase the likelihood of response. Participants were not exposed to any more risk than an average person in the general population would be exposed to when going about daily activities. We recruited school counselors throughout the United States by distributing a study announcement using email addresses, social media platforms, and contacts at state certification departments and state counseling associations. To learn more about recruitment procedures and geographical data, refer to Simons [ 11] and Simons, Bahr, and Ramdas [ 21].

The three CBAs and a demographic form were self-administered by 1,191 school counselors during the 2018-2019 school year. Data were gathered from school counselors and then downloaded from REDCap survey platform. Thereafter, data were cleaned, and reliable simulated values were created to impute missing data. All scale items had some missing data except for the demographic items. Forty-five percent of participants had at least 1 value missing. Eight percent of values had missing data. Five percent were missing completely at random, and three percent were missing based on sexual orientation. This latter missing data were on intersex topics. This suggests that one's sexual orientation might be related to attitudes, knowledge, and skills concerning the intersex community. This might also suggest that participants had more knowledge and exposure to transgender topics than intersex topics. The items with the greatest amount of non-response were the following two items: (a) Prejudicial concepts and intersexism (i.e., oppression towards intersex people) have permeated the mental health professions, and (b) Personally, I think being intersex is a mental disorder or a sin and can be treated through counseling or spiritual help. The average mean was used to replace all missing data.

Instruments

The demographic form included items on age, race/ethnicity, gender, sexual orientation, and school level. It was completed along with the School Counselor Transgender Intersex Advocacy Competence Scale (SCTIACS), the Intersex Counselor Competence Scale (ICCS), and the Gender Identity Counselor Competence Scale (GICCS). The SCTIACS is a 70-item scale comprising Likert-type scale items: a 22-item attitudes subscale and a 48-item advocacy subscale [ 11]. Items on the scales range from 1 (not at all true) to 6 (totally true). The SCTIACS is a CBA used to self-assess the degree to which one effectively advocates for gender minority students based upon attitudes, resilience, and identity. This is referred to as school counselor gender minority advocacy competence. Sample items include: (a) I have reflected over my own attitudes, beliefs, and transgender and intersex advocacy practices, (b) I have knowledge of the transgender identity developmental models, and (c) I am knowledgeable of the American School Counselor Association's (2016) position statement on counseling transgender and gender non-conforming students [ 22]. Scores on the SCTIACS range from 70 to 420. School counselors who scored above 245 were deemed to have had high levels of gender minority advocacy competence, and school counselors who scored below were deemed to have had low levels of gender minority advocacy competence. The attitudes subscale, the Awareness of Transgender and Intersex People Scale (ATIPS), assesses how one views gender minority individuals. Scores on the ATIPS range from 22 to 132. School counselors who scored above 77 were deemed to have held more positive attitudes toward gender minority individuals, and school counselors who scored below 77 were deemed to have held fewer positive attitudes toward gender minority individuals. The advocacy subscale, the Transgender Intersex Advocacy Activity Scale (TIAAS), assesses school counselors' knowledge and skills. Scores on the TIAAS range from 48 to 288. School counselors who scored above 168 were deemed to have held more knowledge and skills about advocating for gender minority individuals, and school counselors who scored below 168 were deemed to have held less knowledge and skills about advocating for gender minority individuals. Examples of knowledge assessed included knowledge of stereotypes, the coming out process, transgender identity developmental, and how to assist with gender transition. Examples of skills assessed include promoting anti-bullying policies, providing training and awareness programs, consulting with parents and guardians, and evaluating the strengths and weaknesses of school counseling programs.

The Intersex Counselor Competence Scale (ICCS), another CBA, is a 27-item scale comprising Likert-type scale items: a 9-item skills subscale (ICCS-S) and a 7-item knowledge and beliefs scale (ICCS-KB). Items on the scales range from 1 (not at all true) to 7 (totally true). The ICCS measures the self-perceived competence of one concerning ability to provide individual counseling services to individuals who identify as intersex [ 23]. Sample items include: (a) I have experience counseling female-to-male transgender clients, (b) I have been to in-services, conference sessions, or workshops, which focused on transgender issues in counseling, and (c) There are different psychological/social issues impacting transgender men versus transgender women. Scores on the ICCS range from 16 to 112. School counselors who scored above 64 were deemed to be more effective as counselors working with intersex individuals, and school counselors who scored below 64 were deemed to be less effective at counselors working with intersex individuals. The ICCS-S assesses the skills of counselors who work with intersex individuals. Scores range from 9 to 63. School counselors who scored above 36 were deemed to have possessed more skill at counseling intersex individuals, and school counselors who scored below 36 were deemed to have possessed less skill at counseling intersex individuals. The ICCS-KB assesses the knowledge and beliefs of counselors who work with individuals who identify as intersex. Scores on the ICCS-S range from 7 to 49. School counselors who scored above 28 were deemed to have possessed more knowledge and favorable beliefs about counseling these individuals, and school counselors who scored below 28 were deemed to have possessed less knowledge and favorable beliefs about counseling these individuals.

The Gender Identity Counselor Competence Scale (GICCS) is a 29-item CBA that measures the self-perceived competence of one's ability to provide individual counseling services to individuals who identify as transgender [ 24]. Likert-type scale items range from 1 (not at all true) to 7 (totally true). Sample items include: (a) Currently, I do not have the skills or training to do a case presentation or consultation if my client was intersex (b) I feel that gender differences between counselor and client may serve as an initial barrier to effective counseling of intersex individuals, and (c) Being born a non-intersex person in this society carries with it certain advantages. Scores on the GICCS range from 29 to 203. School counselors who scored above 116 were deemed to be more effective as counselors working with transgender individuals, and school counselors who scored below 116 were deemed to be less effective as counselors working with transgender individuals. Information about the psychometric properties of the SCTIACS, ICCS, and GICCS, along with the characteristics of participants are found in Simons [ 11] and Simons and Bahr [ 25].

Data analysis

We analyzed data that were gathered from participants who were full time employees, indicated working at a particular school level, were at least 18 years of age, and who reported gender, race/ethnicity, and sexual orientation. We conducted analyses with a high level of confidence despite using a nonrandom sample because approximately 92% of the response data were completed in full by the participants. Data were analyzed using Spearman's correlations, MANOVAs, ANOVAs and post hoc tests. Spearman's correlations were calculated to assess the strength and direction of the monotonic associations between ordinal variables. MANOVAs were run to measure the associations between two or more dependent variables at the continuous level. This was done after confirming the following: (a) there were not any relationships between the observations in each group of the independent variables or between the groups themselves, (b) outliers were not related to data entry or measurement error, (c) multivariate normality was met and multicollinearity was not present, (d) linear relationships existed between the dependent variables for each group of the independent variables, and (e) homogeneity of variance-covariance matrices and variances were present. If the last assumption was not met, follow-up ANOVAs were conducted.

Results

To test hypotheses one to three, bivariate correlation analyses were utilized to assess the relationships between ordinal variables and levels of school counselor gender minority advocacy competence: attitudes, gender identity counselor competence, and intersex counselor competence. Spearman's bivariate correlations were calculated, and significant strong positive relationships were found between school counselor gender minority advocacy competence and (a) attitudes toward gender minority students, (b) gender identity counselor competence, and (c) intersex counselor competence. To further test hypothesis three, MANOVAs, ANOVAs, and post hoc tests were used to examine the relationships between school counselor gender minority advocacy competence and age, race/ethnicity, gender, sexual orientation, and school level. Race/ethnicity, gender, sexual orientation, and school level were significantly related to gender minority advocacy competence (see Table 1). However, no relationship was found to exist between age and gender minority advocacy competence, meaning that age was not related to advocacy for and with gender minority students.

Analyses for hypothesis testing

Attitudes were found to have a strong positive relationship with school counselor gender minority advocacy competence, meaning that more positive attitudes were related to more competence to advocate for gender minority students (see Table 2). School counselors' levels of gender identity counselor competence were found to have a strong positive relationship with gender minority advocacy competence, meaning that more gender identity counselor competence was related to more competence to advocate for gender minority students. School counselors' levels of intersex counselor competence were found to have a strong positive relationship with gender minority advocacy competence, meaning that more intersex counselor competence was related to more school counselor gender minority advocacy competence. Additionally, a strong significant correlation existed between intersex counselor competence and gender identity counselor competence ( r = .63). Thus, more intersex counselor competence was related to more gender identity counselor competence.

MANOVA analysis for age

Responses were assigned to five categories: (a) 20 to 29, (b) 30 to 39, (c) 40 to 49 (d) 50 to 59, and (e) 60 to 69. One-hundred-fifteen school counselor were between 20 and 29 years old, 359 were between 30 and 39 years old, 390 were between 40 and 49 years old, 243 were between 50 and 59 years old, and 84 were between 60 and 69 years old. Significant differences, however, were not found between the five groups of school counselors' mean scores on age, F(4, 1191) = 1.549, p = .186, ω ² = .482. These results suggest that age is not related to gender minority advocacy competence, and school counselors can become more effective at helping gender minority students at any age. As a result, counselor educators should teach current and future school counselors about learning from the totality of one's work; use of competency-based assessments can be a part of this education [ 18, 19].

MANOVA analysis for gender

Responses were assigned to three categories: (a) male, (b) female, and (c) other comprising transgender respondents. One-hundred-sixty-one school counselors identified as male, 1,025 school counselors identified as female, and five identified as transgender. Significant differences on gender were found, F(20, 2360) = 4.265, p < .0005; Pillai's Trace = .070; partial η ² = .035. Subsequently, ANOVAs were calculated. School counselors who identified as female ( M = 3.96, SD = 0.85) and male ( M = 4.03, SD = 0.85) scored lower on gender minority advocacy competence than school counselors who identified transgender ( M = 5.40, SD = 0.55). These results suggest that gender is related to gender minority advocacy competence; however, these findings of significant differences between members of different gender identity groups based on levels of school counselor gender minority advocacy competence should be interpreted with caution. The sample consisted of 1,191 participants and only five identified as transgender, yet the number of transgender participants outnumbered the number of gender identity groups. As a result, some would argue that cell size was insufficient to conduct analysis whereas others would not.

MANOVA analysis for race/ethnicity

Responses were assigned to four categories: (a) African American, (b) European American, (c) Hispanic, and (d) Multiracial. Sixty-four counselors identified as African American, 1,043 identified as European American, 30 identified as Hispanic, and 54 identified as Multiracial. Significant differences were found on race/ethnicity, F(30, 3540) = 2.613, p < .0005; Pillai's Trace = .065; partial η ² = .022. Subsequently, ANOVAs were calculated. School counselors who identified as African American ( M = 3.56, SD = 0.79) scored lower on gender minority advocacy competence than school counselors who identified as European American ( M = 4.01, SD = 0.86) and Multiracial ( M = 4.00, SD = 0.85). However, those in the Hispanic counseling subgroup ( n = 30) did not differ significantly on school counselor gender minority advocacy competence when compared to other counseling subgroups. Additional research is warranted. These results suggest that race/ethnicity is related to gender minority advocacy competence. School counselors who identified as African American reported lower levels of gender minority advocacy competence than those who identified as European American and Multiracial.

MANOVA analysis for sexual orientation

Responses were assigned to four categories: (a) exclusively heterosexual, (b) mostly heterosexual, (c) exclusively lesbian and gay, and (d) other. Nine-hundred-ninety-seven school counselors identified as exclusively heterosexual, 99 identified as mostly heterosexual, 47 identified as exclusively lesbian or gay, and 48 identified as other. Significant differences were found on sexual orientation, F(30, 3540) = 9.633, p < .0005; Pillai's Trace = .226; partial η ² = .075. Subsequently, ANOVAs were calculated. School counselors who identified as exclusively heterosexual ( M = 3.88, SD = 0.84) scored lower on gender minority advocacy competence than school counselors who identified as mostly heterosexual ( M = 4.35, SD = 0.75) and exclusively lesbian or gay ( M = 4.49, SD = 0.75). These results suggest that sexual orientation is related to gender minority advocacy competence. School counselors who identified as exclusively heterosexual indicated having lower levels of gender minority advocacy competence than those who identified as either mostly heterosexual or exclusively lesbian or gay.

MANOVA analysis for school level placement

Responses were assigned to seven categories: (a) kindergarten and elementary school, (b) elementary school, (c) middle school, (d) high school (e) middle and high school, (f) all levels, and (g) other. Thirty-seven school counselors reported working at the kindergarten and elementary school levels, 214 reported working at the elementary school level, 248 reported working at the middle school level, 506 reported working at the high school level, 18 reported working at all school levels, and 130 reported working at a combination of all other levels. Significant differences were found, F(60, 7080) = 2.597, p < .0005; Pillai's Trace = .129; partial η ² = .022. Next, ANOVAs were calculated. School counselors who were working in middle schools ( M = 4.13, SD = 0.82) and high schools ( M = 4.06, SD = 0.83) scored higher on gender minority advocacy competence than school counselors who were working in elementary schools ( M = 3.69, SD = 0.83). These results suggest that school level is related to gender minority advocacy competence. School counselors who worked at the elementary school level did not perceive themselves as being as competent concerning gender minority advocacy as middle and high school counselors.

Discussion

By having utilized CBAs to measure school counselor gender minority advocacy competence, gender identity counselor competence, and intersex counselor competence in light of IBT and particular demographic variables, we found that attitudes toward gender minority students (transgender and intersex), gender, sexual orientation, and school level placement significantly related to either higher or lower levels of school counselor gender minority advocacy competence. The findings have implications for school counselors, counselor educators, researchers, public policy officials, and others who aim to support gender minority youth. Our findings provide corroborating evidence to support findings from earlier studies. School counselor gender minority advocacy competence was found to relate to positive attitudes, race/ethnicity, and minority sexual orientation [ 26, 27]. Sexual orientation and gender were also associated with attitudes. School counselors who identified as exclusively gay or lesbian or mostly heterosexual had more favorable attitudes and perceived higher levels of gender minority advocacy competence than school counselors who identified as exclusively heterosexual. School counselors who identified as transgender and nonbinary indicated having the highest levels of gender minority advocacy competence which suggests that these individuals might serve as valuable resources and role models to school counselors who aim to make their school settings more inclusive for gender minorities.

Educators who offer gender minority advocacy training should include elementary school teachers in their training. Training should allow time to complete the SCTIACS self-assessment followed by time to self-reflect over the results. The results may be discussed with others who report having higher levels of gender minority advocacy competence. Thus, while reflection over and discussion of SCTIACS self-assessment results may be easy for some, it may be more difficult for others with lower scores, especially if they have not been exposed to or trained regarding the needs of gender minorities. Research findings suggest that when school counselors try to help themselves and others, they may come to empathize more with students [ 28]. They may also eventually report higher levels of both intersex and gender identity counselor competence, two areas of counselor competence that were found to positively relate to school counselor gender minority advocacy competence. This suggests that in addition teaching about school counselor gender minority advocacy competence, educators should teach about intersex counselor competence and gender identity counselor competence. This is relevant for two reasons: (a) delivering a comprehensive form of gender minority advocacy is different from delivering counseling services to gender minority students one-on-one, and (b) delivering counseling services to gender minority students, whether within a traditional one-on-one model or a comprehensive form, varies depending on if one is counseling intersex students, transgender students, or another category of gender minority students (e.g., gender non-binary) [ 1]. For example, unlike transgender students, intersex students may be more likely to undergo a series of genital surgeries. Resultantly, in the future, we hope to see more school counselors and helping professionals in schools self-identify as advocates for gender minority students and come out of the closet if they are also gender minorities. This outcome supports the tenets of IBT and increases the likelihood that more school counselors will outwardly identify as gender minority advocates which increases the likelihood that they will plan and try to actually effectively advocate for gender minority students. In turn, they may be perceived by gender minority students as acting with resilience tied to personhood-proactive, inclusive, and supportive of gender minority students at an individual level and institutional level, about both personal and academic matters. Examples of this can be implicit or explicit and include, for example, talking about being one who identifies as a minority or ally to students; using correct titles, names, and pronouns when trying to motivate and challenge students; and consulting with others who are trustworthy regarding students' needs [ 11, 29].

Training implications

Findings inform training implications because school counselors may indicate higher levels of gender minority advocacy competence if they perceive transgender and intersex students favorably, identify as sexual and gender minorities, work with older youth, and indicate higher levels of gender identity and intersex counselor competence. Thus, counselor educators should have school counselors self-administer and complete the GICCS and ICCS, along with the SCTIACS. As aforementioned, scores on the GICCS and ICCS significantly positively correlated with scores on the SCTIACS. Therefore, by teaching school counselors how to provide counseling services to gender minority students effectively at a traditional, one-on-one level, the training may positively affect how school counselors advocate for these students in school settings where they implement comprehensive model (systemic) counseling. Additionally, counselor educators may ask school counselors the following questions: (a) How do you believe your attitudes toward gender minority students influence your willingness to help these students? (b) What knowledge do you need to become more effective at meeting the needs of gender minority students? (c) What skills do you need to become more effective at meeting the needs of gender minority students? (d) How and to what extent are you a personal agent in your position as a school counselor who wants to effectively advocate for gender minority students? (e) How and to what extent are you positively supported as a school counselor who advocates for gender minorities? (f) Which aspects of your personhood as a school counselor relate to your work in this understudied area and why?

In addition to having school counselors self-administer the SCTIACS, GICCS, and ICCS as part of training, counselor educators facilitate discussion after administration and scoring by asking trainees the above questions. This is important because the impact of education might be limited to those who self-administer the scales but do not take time to process the results with others who have more expertise or who identify as gender minorities. Our findings support this outcome and recommendation. Moreover, given that attitudes are also tied to personhood, school counselors should always be prepared to debunk myths commonly associated with gender minority people and topics [ 6]. For example, some people believe that all transgender people have undergone sex reassignment surgery, which is not true.

Counselor educators share accurate information about gender minority people. Items on the SCTIACS, GICCS, and ICCS that may be reviewed as part of this are: (a) Transgender and intersex students should be accepted completely into our society, (b) Transgender and intersex students should not be allowed to cross-dress at school, (c) Transgender and intersex individuals must choose to live as male or female in order to lead healthy lives, (d) I think that my clients should accept some degree of conformity to traditional gender identities, and (e) It is obvious that a relationship involving an intersex person is not as strong as one involving a non-intersex person. We recommend use of these items in trainings as a starting point for reviewing baseline attitude scores on the SCTIACS, GICCS, and ICCS. Next, counselor educators are encouraged to review (a) counselors' knowledge about transgender and intersex communities and (b) school-based advocacy plans that counselors have in place, if any, to limit the impact of minority stress on health and academic success of gender minorities [ 1, 11, 30]. Counselor educators should also familiarize themselves with Identity Behavior Theory and the position statements from the World Professional Association for Transgender Health; the American School Counselor Association; and the Society for Sexual, Affectional, Intersex, and Gender Expansive Identities [ 18, 19].

Counselor educators should teach elementary school counselors about childhood gender identity development [ 30]. Further, they should inform trainees that models of intersex identity development and models of identity development among transgender people of color are only in the early stages of development [ 2]. More theoretical models are needed to inform practices and policies. This is an area for future research. In addition to the need for more theoretical models, there is also a need for more role models who demonstrate an ability to promote greater levels of gender minority advocacy competence in schools and society at large. These role models include school counselors but also other educators who self-identify as advocates and members of gender minority communities [ 30- 33]. Part of training homework should include requesting school counselors to observe and help gender minority individuals and allies, both in- and outside of their school communities. This is done to practice undertaking initiatives to promote more gender-inclusive education.

In this study, school counselors mostly identified as cisgender, heterosexual, White, and female. This demographic is reflective of the national body of school counselors in the United States. Counselor educators, therefore, should recruit a more diverse school counselor workforce that includes sexual and gender minorities, as well as racial and ethnic minorities, and encourage more school counselors to participate in cross cultural events where they interview individuals who are culturally different from themselves. School counselors ask these individuals about their family of origin, career, socioeconomic status, and wisdom. Then, after the interview is conducted the counselors write out, reflect over, and discuss their reactions to the interviewees' responses. Events and best times of the year to interview gender minority individuals include Intersex Awareness Day, Intersex Day of Solidarity, and Transgender Days of Remembrance and Solidarity [ 11]. School counselors and other helping professionals also may learn about gender minorities by volunteering for the World Professional Organization for Transgender Health, the Intersex Society of North America, El/La Para TransLatinas, Trans Student Educational Resources, the Organisation Intersex International, and interACT Advocates for Intersex Youth [ 11].

Limitations

Since correlational data were analyzed, we cannot presume that causation existed between examined variables. We used a nonrandom sample, and the study was conducted online and relied on assistance from presidents of state school counselor associations and state boards of education to recruit participants. Some school counselors, therefore, may not have heard about this study nor were able to access and complete the online survey because they did not have a computer or internet access. Another limitation was that counselors might have participated in the study because they were interested in the topic or they wanted to receive the Amazon gift card. This could have skewed the sample. Last, we did not collect any data on the formal training of school counselors to examine how this training might relate to levels of self-perceived competence in counseling gender minorities. In some jurisdictions, counseling credentials can be granted to individuals in other disciplines such as psychology and social work. Additionally, unlike school level placement, school level training was not assessed as a demographic variable. School level placement, however, was; it was found to significantly correlate with levels of gender minority advocacy competence. Consequently, more research is warranted to see if school level training would significantly correlate with levels of gender minority advocacy competence.

Future research

Today, some gender minority people report that others, including counseling professionals, interact with them as though they have mental disorders. This is unfortunate, especially for those gender minorities who are not affected by mental disorders. Counselor educators and counselors should teach about this. Counselors educators should also teach about gender non-binary people. Future lessons and studies might explore to degree to which school counselors understand the experiences of gender non-binary students. Last, research is needed to refine and strengthen the construct of school counselor gender minority advocacy. This may involve assessing other demographic variables (e.g., advocacy and gender identities) and including new items on training tools that address the needs of gender non-binary students, along with the needs of transgender and intersex students. To do this, gender non-binary people should be interviewed about their experiences with stress, health, and resilience. Their responses will help to develop gender non-binary advocacy competencies which will serve as a resource for educators, helping professionals, researchers, and public policy officials. This is the next chapter of research in education, counseling, and health related to sex, gender, and gender identity.

Conclusion

The aim of this national survey study conducted considering IBT using CBAs has been to examine gender identity counselor competence, intersex counselor competence, and variables related to school counselor agency to enact gender minority advocacy: attitudes, gender, sexual orientation, and school level placement. All variables but age significantly correlated with school counselor gender minority advocacy competence. As a result, our findings have filled a gap in the literature. We now know more about the makeup of school counselors who are likely to advocate for gender minorities comprising transgender and intersex students who may or may not also identify as gender non-binary. Findings also suggest that more exposure to effective training may help current and future counselors recognize how where they work, along with their backgrounds and personhood, relate (or not relate) to their levels of gender minority advocacy competence. Some counselors choose to participate in additional training to gain more exposure to gender minority topics and communities. It may also be beneficial for them to learn how to promote more gender-inclusive education by participating in events where gender minority people and their allies are present.

Last, both school counselors and counselor educators should stive to raise awareness about events and activities (or lack thereof) in professional organizations to advance the interests of gender minorities. These organizations include, but are not limited to, the American School Counselor Association, the American Counseling Association, the American Psychological Association, the National Association of Social Workers, and the Council on Social Work Education. Our study has extended research findings to mainly the experiences of school counselors [ 12, 15, 16]. Despite this, however, our understanding of school counselor gender non-binary advocacy competence remains limited. While school counselor advocacy for transgender and intersex students might be similar, this may not be the case regarding advocacy for gender non-binary youth. Therefore, we believe that future researchers should also examine a forms of gender minority advocacy competence that includes gender non-binary advocacy competence. Additionally, researchers should examine how school counselor gender minority advocacy competence may be improved considering Identity Behavior Theory and the influence of other demographic variables that were not assessed as part of this study.

Acknowledgments

The author thanks the participants and recognizes Mercy Simons Lab counseling students Matthew Gallo, Jorge Figuereo, and Melissa Williams for assisting with data collection and analysis. The Simons Lab is dedicated to scholarship on counseling, students' and educators' experiences, academic and career development, and health and wellness.

References

1. 22. American School Counselor Association. Position statement on counseling transgender and gender non-conforming students. Alexandria (VA): The Association; 2016. https://www.schoolcounselor.org/asca/media/asca/PositionStatements/PS_Transgender.pdf

2. 28. Carkhuff RR. Helping & Human Relations, Volume 2. Boston, MA: Thomson Learning; 1969.

3. 29. Simons JD, Russell ST. Educator interaction with sexual minority youth. J. Gay Lesbian Soc. Serv. Forthcoming 2021.

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School counselor advocacy for gender minority students

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One-thousand-one-hundred-and-ninety-one school counselors completed an online survey regarding advocacy for and with gender minority students comprising transgender and intersex students (school counselor gender minority advocacy competence). School counselors completed a battery of three competency-based assessments to assess their levels of gender identity counselor competence, intersex counselor competence, and school counselor gender minority advocacy competence.

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Active Listening & Allyship:  How School Counselors Can Uplift Their LGBTQ Students

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Active Listening & Allyship:  How School Counselors Can Uplift Their LGBTQ Students

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This challenging experience made me realize just how important it is that school counselors are trained in supporting and affirming LGBTQ students. I've also had some great experiences with school counselors and therapists. In fact, I love going to regular counseling sessions and think it's a great way to maintain mental well-being and process certain challenges. I was also lucky to have a high school counselor who was a member of the LGBTQ community, so she was able to understand my obstacles and provide me with useful and culturally responsive resources. One time, I was having a rough day and she bought me lunch and talked to me for almost an hour. It impacted me in profound ways to have a trusted adult in my life who really seemed to understand and care about my well-being.

When students go to their school counselor about issues, they don't just need empathy - they're also letting the counselor know about issues happening within the school that they have the power to address, ameliorate and prevent, especially when it comes to identity-based harassment and bullying that so many LGBTQ young people face.

NC: One of my former school counselors didn't make it clear whether they were accepting of LGBTQ students, so I sadly didn't seek out support when I needed it. How do the LGBTQ students at your school recognize you as LGBTQ affirming?

LR: As a straight, cisgender woman, I ensure that my students know that I am LGBTQ affirming by having safe space stickers and affirming artwork inside and outside my office. Now that school has started back and most of our students are learning virtually, I have made sure my safe space sticker is visible on my Zoom videos and that the school counseling online platform has a safe space sticker posted on our homepage as well.

In addition, I always interrupt when I observe homophobic, transphobic or anti-LGBTQ language or behavior. I make sure students see how I interrupt so they know I am an ally and LGBTQ affirming and so I can model for other students how to do so.

NC: How have you successfully advocated for the safety and inclusion of LGBTQ students at your school, and can you share examples of how your efforts have positively impacted school climate?

LR: Our students are aware that we still have many people in our community who are not LGBTQ affirming, so they often do not know who or what people or spaces are safe and inclusive in our school. I buy and offer safe space stickers for any educators in our building so students are aware. Feeling included and safe helps our students stay engaged and participate. The creation of our Gender and Sexuality Alliance last year (the first middle school GSA in our district) sent a message to our school community that ALL students are a valuable part of our school family. The GSA allows students who join to have a space to be vulnerable and authentic with supportive peers. We've seen GSA members grow in leadership skills, create positive peer relationships and become more motivated and engaged in academic work. For those students who wanted to join but faced a barrier, at least they saw there are folks (adults and peers) at our school who are also LGBTQ identifying or LGBTQ allies.

Making it known that I am LGBTQ affirming allows students to open up and share with me their needs so I can advocate effectively for them, whether it be to address mistreatment, asking teachers to use their preferred name and pronouns or seeking private areas to dress for PE class.

NC: Have you encountered complaints from colleagues, parents/guardians or community members around your advocacy for LGBTQ inclusion? How did you overcome these challenges and do you have any advice for other school counselors on this topic?

LR: I have encountered concerns, complaints and behaviors that are not supportive of our LGBTQ inclusion efforts. I remind myself and others that many of these things are a first to have in our school, such as multiple classrooms with safe space stickers and a GSA. We have had to make compromises in some areas but I remain relentless and persistent in ensuring that LGBTQ inclusion and support is still very much visible and apparent. Having a supportive administration is helpful as we take smaller, yet important steps forward in our advocacy for LGBTQ inclusion. For other school counselors, I think it is important to be grounded in our American School Counselor Association Ethical Standards and follow the guidance from ASCA's position statements on School Counselors and LGBTQ Youth, Transgender/Gender-nonconforming Youth, & Gender Equity.

It is important for school counselors to continue to learn about the importance and practices of advocacy for LGBTQ inclusion. There are are a variety of educational opportunities from HRC, Gay, Lesbian, & Straight Learning Network, GSANetwork, PFLAG, The Trevor Project, Hope in A Box and so many more.

NC: Sometimes school is a safe haven for LGBTQ students. I have a few close friends who were open about their LGBTQ identity at school but didn't want their parents/guardians to find out because they feared being rejected. Have you worked closely with a student who was open about their LGBTQ identity at school but not at home? If so, what advice do you have for school counselors who encounter similar situations?

LR: Absolutely, I have had students who were open about their LGBTQ identity at school but not at home and I can tell it's a difficult and scary space for them to be in. Our ASCA Ethical Standards for School Counselors not only tell us the just and respectful manner to support LGBTQ students, but it also delineates the importance of maintaining confidentiality. ASCA position statements on LGBTQ youth and Transgender/Gender Non-conforming youth explicitly states the rights of LGBTQ students in deciding when and with whom to share private information.

My decision making and responsibility is always about what is right for students, and putting my students in a situation that could be harmful, dangerous or humiliating by outing them to a parent/guardian is not right.

I often have LGBTQ students who are exploring exactly what their identity is and they are not even at a point to put a name or label to that identity, so sharing that information with a parent/guardian can add more stress and pressure. In addition, if a student has trusted a school counselor as a safe person to confide in and then that school counselor outs them to anyone else, that school counselor is creating a traumatic experience for that student. Sadly, many LGBTQ youth are rejected by parents/guardians and sometimes even kicked out of the home with no place to go.

NC: What suggestions do you have for school counselors to advocate for safe and inclusive schools for LGBTQ students? Can you name at least three actions they should take starting today?

LR:

1. Start with student voice. It is so important to ask LGBTQ students how they want and need to be supported.

2. Educate Yourself. Know the ethical standards and position statements that support the affirmation of LGBTQ students. Learn about LGBTQ identity development, LGBTQ+ identities and what they mean and ways to support LGBTQ students starting with the use of non-heteronormative and gender-inclusive language. I think it is so important that school counselors educate themselves so that the burden and pressure of education is not solely on the student. A professional whose focus is supporting ALL students has the responsibility to understand the definitions of pansexual, gender non-conforming, genderfluid, Two-Spirit, etc.

3. ACT: Advocate; Create; Team Up. After gaining awareness, school counselors must act. Acting means we have to advocate for the needs of our LGBTQ students with other educators and students, we have to be intentional and create spaces around the school that show that there are safe and affirming spaces for LGBTQ students and school counselors need to team up with other educators so that advocacy for LGBTQ students and creating safe spaces for students is not just being done by one educator.

NC: Many LGBTQ students also have other marginalized identities, which create obstacles and challenges to thriving in and outside of school. How do you address intersectionality in your advocacy efforts around LGBTQ inclusion in your school?

LR: I always try to be mindful of and help students explore the multiple identities that create their unique and authentic selves. I facilitate students' exploration of their multicultural self in classroom lessons for all students and with individual students.

We hold virtual student processing circles to help address equity and inclusion for all vulnerable student populations.

Our student leaders of GSA have also set goals to support and champion their peers of color. In leading staff development with our teachers this year, our primary focus is on anti-racism but these discussions and education cannot and will not be held without discussion of the intersectionality of students' identities that compound the discrimination, hate and anti-bias treatment that our LGBTQ students face.
Click here for more information about HRC's Click here for more information about Click here for more information about Click here for more resources from the Youth Well-Being Team. HRC's Welcoming Schools. Project THRIVE. Youth Ambassador Initiative.

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Active Listening & Allyship: How School Counselors Can Uplift Their LGBTQ Students - HRC

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This challenging experience made me realize just how important it is that school counselors are trained in supporting and affirming LGBTQ students. I've also had some great experiences with school counselors and therapists. In fact, I love going to regular counseling sessions and think it's a great way to maintain mental well-being and process certain challenges.

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Are you a school counselor or thinking of becoming one? What are the most important attributes an effective school counselor should have? This week, in honor of National School Counseling Week (February 7 though 11), Education World asked school counselors to reflect on what makes them effective. We are pleased to share their thoughtful and illuminating -- and often heartwarming -- responses.
National School Counseling Week -- February 7 through 11 -- is a time to celebrate the unique contributions that school counselors make to their school communities. The week also affords school counselors an opportunity to feature their on-going efforts and to highlight their visions for their schools. As school counselors take stock of their visions and accomplishments this week, Education World wondered

What attributes do effective school counselors have?

To learn the answer to that question, we enlisted the help of Barbara Muller-Ackerman, chairwoman of the American School Counselor Association's (ASCA) public relations committee. She asked leaders in the counseling field to share their thoughts with Education World. The answers were as diverse as the counselors themselves, but one common theme came through -- counselors care deeply about their work and the students and schools they serve.

FIRST AND FOREMOST

Most elementary school teachers know Margaret Wise Brown's The Important Book. Teachers recognize the book as a great tool for honing students' observation skills. When one teacher at Kreeger Elementary School in Fowlerville, Michigan, recently challenged kids to create their own Important Books, one student wrote a page dedicated to her school counselor. Counselor Judy Standley shared with Education World the heart-tugging sentiment that the student wrote:

"The important thing about our counselor is that she listens. I do know that lots of other people listen, but she listens the most. She does B.A.B.E.S. and lots of other things. She tells stories with important morals. She listens to you and tells no one. She is an important counselor. But the important thing about Mrs. Standley is that SHE LISTENS!!"

In the Important Book attributes of school counselors, listening ability is right there at the top of the list! It was the most common -- and perhaps least surprising -- response we received. The insight that counselors shared about that choice tells us even more!

Last year, Shaftsburg (Michigan) Elementary School counselor Teresa Severy met a new fourth grader for the first time. The bright and resilient little girl's life had been colored by the horrors of neglect, substance abuse, and family incarcerations. "I met her as I do all my new students, and she shared much of what was in her heart," said Severy. Then, one morning, Severy found on her desk a box -- clearly wrapped by a young person -- and a card, addressed in the beautiful awkward cursive of a child.

"The box contained a wind chime for my office, to add special music to my day," Severy related. "The card touched my heart. It read

Thank you for being a special person who really cares to listen and hear me. I wish you a very happy Mother's Day. Your friend...

"I wept when I read her words. Her mom was incarcerated, and [the child] was living with another family. One never knows that what we say or do can be significant in the life of a child."

The gift and the note were reminders of the importance of listening, of the importance of being "on top of my game when I work with children," Severy told Education World.

Larry Steele thinks often about the importance of listening too. "Many times, I get only one chance to work with a situation, crisis, student, or family," said Steele, Southern California area director for the California School Counselors Association. "I need to be right on the button the first time out of the gate, so listening skills are essential."

"Our children might not always say out loud what they are feeling, and school counselors need the ability to listen -- to words, body language, unspoken words, and attitudes," added Carol Turner. She is a counselor at Center Street Middle School in Birmingham, Alabama. "School counselors can effectively help students by really listening to them whether they are talking or not."

LISTENING'S CLOSE COMPANION

Listening and empathy go hand in hand as the two most frequent responses to the question we posed to school counselors. "The ability to experience as one's own the feelings of others" is key, said Deborah Bilzing, a school counseling consultant in Wisconsin.

"The ability to understand why others do what they do and think the way they do takes precedence over all other characteristics," agreed Robert B. Cormany, executive director of the Pennsylvania School Counselor Association. "Unless one has that quality of understanding, skill in technique is useless and knowledge is less than meaningless."

Helen A. Hatridge, past president of the Missouri School Counselor Association, goes along with that. "Without the ability to understand what the student is experiencing, a counselor cannot truly do an effective job. Empathy leads to good listening and a better ability to help the client come up with solutions. It also helps the student feel more comfortable and willing to open up to a counselor."

RELATIONSHIP BUILDING IS KEY

Key to the success of any school counselor is the person's ability to build trusting relationships with students and other members of the school community. That should be a prerequisite for anyone who is going to serve as a student advocate, said Beckie Meyer, an assistant professor in the school counseling department at Millersville (Pennsylvania) University.

Meyer reflected recently for Education World on her 23 years as a teacher and an elementary school counselor. "Student referrals to the counselor have greatly increased from teachers, parents, and the students themselves in recent years," said Meyer. "A counselor simply must be approachable, inviting, trustworthy and, yes, just plain fun at times. Students must want to seek out that person when in need."

"Most counseling cannot begin until that initial 'ice' is broken," concluded Meyer. "Once people feel trust, comfort, and acceptance, the possibilities for getting the work of counseling done are greatly enhanced."

"Our students need to sense that they have professional caregivers among the adults that they can turn to [and that the counselor] will be there for them in non-judgmental fashion," added Julie A. Kruk. She is a counselor at Bay Port High School in Green Bay, Wisconsin. "This accepting nature is enmeshed in our reputation, which builds student by student and is shared by word of mouth and experiences with others. Students can tell if we are warm and inviting and whether or not they can entrust us with their stories. I feel that this trait is the singular skill that counselors need to build their practice around. We can then do the good work that we have been trained to deliver."

Andrea Meyer, a counselor at Milbank (South Dakota) Middle School and no relation to Beckie Meyer, agreed. "You have to be able to develop rapport and you must be genuine! You have to understand the kid culture -- not try to be a part of it but know what the students are interested in, what's important to them. If you don't have a caring relationship of trust and understanding, nothing else is going to happen with children or adults. The old saw -- Kids don't care how much you know until they know how much you care -- still rings true today!"

COUNSELORS MAKE A DIFFERENCE

When Kim Haloway thought about our question, many characteristics raced through her mind -- empathy, honesty, ethics, sensitivity, accountability. "But if I don't think I will really make a difference -- if I don't believe in myself and in the student's ability to succeed, to overcome all odds -- then all those qualities are diminished."

The belief that we can make a difference has got to be the most important attribute of an effective school counselor, concluded Haloway, a counselor in the Marana (Arizona) Unified School District.

Jackie M. Allen, a counselor at Blacow Elementary School in Fremont, California, and past-president the ASCA, came to the same conclusion. "Commitment to the belief that counseling makes a difference in student lives and futures must be a foundational belief held sacred by that counselor -- a belief that will guide his or her relationships, responses, actions, program development, and counseling practice. Without that commitment to the process of change, a school counselor will not be able to effectively serve as a catalyst in student lives and a significant change agent in the educational community."

FLEXIBILITY IS KEY

Flexibility is another key to success in the school-counseling field. "Time is not yours" in counseling, Rich Downs, a school counseling consultant for the Florida Department of Education, told Education World. "When your expertise is needed to deal with a problem, you must make yourself available to assist others. Although your daily schedule has just been [interrupted] by someone else's need, you must be supportive and place your needs and concerns second. An effective school counselor must make the individuals of our attention believe that, at that particular point in time, they are the most important person in the world."

"You just never know what is going to come up next," agreed Linda Lueckenhoff, a counselor at Palmyra (Missouri) Elementary School and president-elect of the Missouri School Counselor Association. "You might finish presenting a classroom lesson on friendship, and on the way back to your office, the school secretary gives you a message to return a call from a concerned parent. But before you have a chance to pick up the phone, the school nurse steps in to discuss concerns about a student who might have been physically abused. While you are talking with the nurse, the superintendent calls to invite you to a meeting on developing a district crisis response plan...."

"A rigid person just couldn't survive very well in this type of setting!" added Lueckenhoff. "You must be able to switch gears and think fast."

KNOW YOURSELF -- AND TAKE CARE OF YOURSELF!

Each semester, Zark VanZandt gives students in his School Counseling and Services class at the University of Southern Maine an assignment he calls Beyond Mediocrity. "In that assignment, I ask students to create a personal mission statement in which they identify the ten most significant competencies they must possess to be an effective school counselor and how they personally plan to stay committed to professional excellence," he told Education World.

Students' responses to the assignment often impress VanZandt, and this semester was no exception. One response that stands out came from a student whose number one competency was

To possess self-knowledge: This is a crucial competency that includes a deep understanding of my own paradigms, my biases, my strengths and weaknesses, and my theoretical perspective on counseling. For me to create a career that is beyond mediocrity, I must first look inward. The vision that will lead me to effectiveness, my mission statement, is both personal and professional. It would feel false to separate the two, for I don't change my inner being depending on the circumstance.

"You cannot be an effective counselor if you are not physically, mentally, emotionally, and spiritually healthy," added Crystal Asche, a counselor at Wahpeton (North Dakota) Middle School. "Many times we are so busy taking care of others that we forget about taking care of ourselves. We then not only fail ourselves but [also lack] the energy to take care of our clients."

"I think that the most important characteristic for me is balance -- balance between professional and personal life, between giving and renewing, between helping and empowering." Tom Wiggins, president of the New York School Counselor Association, told Education World. "I have seen too many school counselors lose their effectiveness because they have lost their balance. They may still be effective at creating relationships, but they lose some of their effective edge either because they can't say no when they need to or because their own unattended-to needs surface. I regularly attend to my own needs so that I feel balanced between giving and receiving."

MORE COUNSELOR COMMENTSMORE COUNSELOR TRAITS

Good listening skills. Empathy. The ability to build strong relationships. Flexibility. Self-knowledge. A strong belief in the ability to make a difference. Those are some of the attributes of an effective school counselor. There are many others. School counselors shared with Education World some of the other characteristics that a good school counselor might possess. Following are four more:

On Laughter and Humor
With all of the tragic issues our youth must deal with, it is important for them to have someone they can turn to who will support them and also help them to find ways in which to laugh. The healing power of laughter and humor (not malicious) helps to give hope and healing. Humor also assists in building resiliency in children.

Julie Dillehay, school counselor
Crossroads Middle School
Meridian, Idaho

On the Ability to Advocate
The school counselor needs to be able to advocate on behalf of the students and the counseling program. The counselor also needs to be able to teach others to advocate for themselves and for those who cannot advocate for themselves.

Jo Hayslip, professor emerita
Plymouth (New Hampshire) State College

On Humility
The best help we can give is to be a person who knows that we have our own personal issues to address, works on them as best we can, and makes it possible for others to work on theirs too. As a school counselor, I am a fellow traveler who has the awesome privilege to walk with someone else on his or her journey. My job is to be a role model for someone who does not have all the answers but who is not afraid to look in the very dark places to find them.

Suzan Nolan, elementary counselor
Rapid City (South Dakota) School System

On Smiling
After 30 years of counseling, I think the most important attribute is a consistent, every day smile. I notice how students respond to my smile. Although many might not think of it as a skill in the traditional sense, it is very important.

Ned W. Toms
Tri Village Local School District
New Madison, Ohio

LAST BUT NOT LEAST

Finally, we asked ASCA president Janice Gallagher to respond to our question, and she did.

"I believe a school counselor must be able to see and understand the multifaceted potential of children. Counseling children is like working with an array of different gems and stones. Some are perfect as they are. Others need a little polish to shine, and still others need to be examined for preparation before they are shaped to be most beautiful and functional. One may be most lovely alone, another may be best as part of a small grouping or arrangement, and others need to be surrounded by a crowd. Each is different, each is beautiful in its own right and, most important, each has value."

Article by Gary Hopkins
Education WorldÂ® Editor-in-Chief
Copyright Â© 2005 Education World

RELATED ARTICLES FROM EDUCATION WORLD

Updated 1/31/2005

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School Counselors Reflective On What Makes Them Effective | Education World

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Are you a school counselor or thinking of becoming one? What are the most important attributes an effective school counselor should have? This week, in honor of National School Counseling Week (February 7 though 11), Education World asked school counselors to reflect on what makes them effective.

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Eight Counseling Techniques Educators Can Use

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Eight Counseling Techniques Educators Can Use

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Taking the time to help your students navigate the highs and lows of adolescence

By the time Catie, 14, stormed out of her last class of the day, she felt disconnected from her emotions. She had no idea how deeply she'd been impacted by a minor fight with her mother on the way to school. In homeroom, she took offense when her friend Trevor made an innocuous comment about her weekend plans. At lunch, she felt rejected when friends turned her away from their full table. As the day went on, she was increasingly irritable. When her teacher chastised her for being chatty during seventh period, she yelled out to no one in particular that she always got blamed for everything, then ran out of class.

I counseled Catie that evening, and it took a while for her to identify the precipitating event. It's easy for middle schoolers to get derailed by an argument, rescinded invitation, or ambiguous comment, but hard for them to connect the dots between their thoughts, feelings, and behaviors. Tweens may think bad feelings stick around forever, struggle to interpret feedback, or have no idea how to make themselves feel better. All of this can interfere with their functioning at school, but educators can use the following eight counseling techniques to help kids navigate the highs and lows.

Perfect the artful reframe.

Middle schoolers think in polarities. There's nothing more humiliating than making a mistake in class or clocking the slowest time in a relay. Getting disinvited from a sleepover, bombing a test, or getting excluded from a gift exchange all can feel like catastrophes. If you're able to reframe a situation-to help a child see it from a different angle-they'll experience it differently. Maybe that student who got disinvited from the sleepover knows deep down that they were spared discomfort and drama. Maybe no one intended to leave that kid out of the gift swap. Ask them how they'd reframe the situation for a friend or encourage them to pretend they're in a hot air balloon looking down on the situation. Do they see it any differently from that vantage point? Consider asking them to play it out. What's the evidence that the worst will happen? What's the evidence it won't happen? What would they need to cope with the worst-case scenario?

Challenge distorted thinking.

Students think they wouldn't lie to themselves, but they do. They catastrophize, think in black and white, overgeneralize, and discount the positive. For instance, they may get dozens of compliments on their presentation, but fixate on one snide comment about their voice cracking. If they bomb a quiz, they may conclude they'll fail at life. If they don't know the answer to #7 on the worksheet, they may feel they might as well bag the whole assignment. If a teacher changes their seat because they're disruptive, they may believe the relationship is irreparably damaged. Point out their faulty thinking and ask them to come up with alternative possibilities.

Validate them.

When a student makes a comment like, "I'm the worst writer," or "You never call on me," or "No one ever wants to be my lab partner," your instinct will be to refute the comment. Instead, validate it. That doesn't mean you agree or approve, it simply means you understand and empathize. You might say, "If I thought no one wanted to be my lab partner, I'd be pretty upset too. What makes you feel that way?" Consider sharing a time you felt similarly. Once a child feels heard, they'll be more open to problem-solving. Even if they behave inappropriately, start with validation. After saying, "If I thought everyone was laughing at me, I'd want to throw a chair, too," follow up with, "But here's why it's not okay."

Be an active and reflective listener.

Active listening is hard; it requires concentrating, matching a student's body language, turning toward them, eliminating distractions, making eye contact, and ensuring your tone, gestures and words are all in alignment. You'll lose credibility if there's inconsistency between what you say and what they perceive. It's tempting to multi-task when time is limited, but resist the urge to organize papers or glance at your computer. Make sure you listen reflectively, which requires repeating back what the student has just told you. That eliminates the potential for misunderstanding and increases the odds they'll feel heard. Bonus points if you reference any of their comments in a future conversation.

Provide psychoeducation.

Counselor-to-student ratios are absurdly high; students don't necessarily relate to their counselor, if they know them at all; and mental illness is skyrocketing among middle schoolers. Educators can help by taking the time once a semester to define depression and anxiety and explain the difference between mental illness and the normal mood fluctuations associated with puberty. You don't need to be a therapist or school counselor to self-identify as someone who wants to help. If you need to involve the student's counselor, consider walking them there to help them tell their story.

Extinguish phobias with small exposures.

You don't want to shield students from all anxiety, but you don't want to traumatize them either. If a kid is anxious taking tests and has been taking them in another room, for example, focus on incremental progress. The next step might be having them take the test in the classroom, but with their back to peers. Similarly, if a student fears public speaking, try to avoid having them opt out altogether. Instead, scaffold the risk-taking. Perhaps they start by presenting to a few trusted friends or read from a script. Collaborate on any solutions.

Ask open-ended questions and make time to relate.

Lead with curiosity and open-ended questions. You'll improve the relationship if you use any one-on-one time to focus on learning about your student rather than delivering content or hammering home behavioral expectations. Even if you only can carve out five minutes a week, ask them how they learn best or what excites them. What progress do they hope to make in your class? If you notice a sports logo on their shirt, ask if they're a fan. Solicit their opinions, treat them as the expert in their lives and speak above their maturity level to convey respect.

Connect thoughts to feelings and behaviors.

Students concentrate better when you help them label feelings. Some teachers ask kids to fill out charts to indicate their mood or have them hang their nametag on a "mood clothesline" in the spot that best corresponds to their emotions. You can have your students share why they're in a bad mood, then exchange ideas with classmates about what they can proactively do to feel better. Don't forget to acknowledge their joy as well. If a student seems exuberantly happy, encourage them to savor the pleasant feeling for as long as possible. Tweens experience intense lows and are wired to remember the negative, and that makes middle school the perfect time to reinforce positivity and optimism. In fact, that might be one of the most enduring, impactful lessons you can impart.

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Eight Counseling Techniques Every Middle School Educator Can Use - AMLE

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It's easy for middle schoolers to get derailed by an argument, rescinded invitation, or ambiguous comment, but hard for them to connect the dots between their thoughts, feelings, and behaviors. This can interfere with their functioning at school, but educators can use these eight counseling techniques to help kids navigate the highs and lows.

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Features - American School Counselor Association (ASCA)

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The role and professional identity of the school counselor has been an ongoing discussion throughout the history of the profession. With the growing need for more support to address the mental health needs of students and improve their well-being, the confusion about school counselor role and identity has heightened.

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How School Counselors Make a World of Difference

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How School Counselors Make a World of Difference

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The multifaceted work of school counselors helps prepare students academically and emotionally for life beyond school.

Long considered an integral part of a school’s support system, school counselors bring a wealth of insight and resources to a variety of student-centered issues. As part of a team of mental health experts, school counselors work with students individually and collectively to create a school climate that leads to healthy learning, living, and growth.

The specific roles that a school counselor takes on vary, depending to some extent on needs within the school and the presence of other professionals with overlapping roles and areas of expertise, such as psychologists and social workers. But, in general, as the American School Counselor Association (ASCA, 2014) explains, counselors’ work today falls into three domains:

Career and college development. Historically, school counselors’ primary responsibility has been to help students prepare for the transition to college and/or careers, and this continues to be a central part of their mission. In fact, given the expanding array of learning options available after high school and the fast-changing demands of the workforce, students are coming to rely on counselors more than ever before to provide accurate, comprehensive, and personalized guidance for postsecondary planning.

Academic development. By working alone with students or teaming with classroom teachers and other education professionals, school counselors help students build the curiosity and academic skills needed to be the best learners possible. For example, counselors are often responsible for overseeing individual student planning. A growing interest in personalization has made this role especially important in recent years, with school counselors working closely with students to explore potential avenues of study and create individual goals for deepening their knowledge in areas of interest.

Social and emotional development. As an integral part of their schools’ student support system, counselors tend to work hand in hand with psychologists, social workers, and nurses to create a school climate that promotes healthy learning, living, and personal growth. And shouldthe need arise, they respond to students who are facing personal challenges and steer them toward appropriate services at school or in the community.

The amount of time school counselors devote to each of these domains largely depends on the individual needs of the students they serve and the availability of other mental health professionals to offer direct services to students. Ideally, the school counselor is part of a building-wide team that includes a school psychologist and social worker. Typically, school psychologists administer psychological evaluations for individual students and oversee the creation of individualized learning plans for students with special needs, while social workers tend to focus on student needs outside school. Under this arrangement, the school counselor would then focus on student services within the building, devoting not less than 80% of their time to offering direct student services in the three domains combined.

By building in proactive strategies, including small-group counseling activities and discussions, counselors provide positive examples of behavior students can incorporate in their lives, leading to healthier decisions and more positive actions.

In the 2014-15 school year, 104,306 school counselors served more than 50 million U.S. students, with an average student-to-counselor ratio of 482 (ASCA, n.d.-d). They are required to have at least a master’s degree in school counseling and to meet the certification and licensure standards for their state. To meet students’ needs across the three domains, these counselors oversee the school counseling curriculum, which, like the academic curriculum, tends to be arranged by grade level. Unlike an academic curriculum, school counseling activities aren’t always delivered in classroom settings. While classroom instruction is a part of a counselor’s work, other services are best delivered with small groups of students and in one-on-one meetings. And since this curriculum touches on a broad range of skills and content — including activities related to study skills, conflict resolution, and college and career exploration — counselors often reach out to and collaborate with people who have expertise in these areas, such as local college faculty, healthcare professionals, and employers.

The difference school counselors make

Research suggests that school counselors can and often do have positive influences in all three domains of their work. For example, a study of counseling practices in six states shows that effective counseling strategies tend to have positive effects on classroom attendance, discipline, and overall achievement (Carey & Dimmitt, 2012). Likewise, counseling interventions have been shown to help close the achievement gap between student groups, as found in a program in which counselors delivered lessons specifically designed to support Latina and Latino students in math and science (León et al., 2011). These studies suggest that school counseling programs are most successful when counseling services include more than a response to a situation that already exists. By building in proactive strategies, including small-group counseling activities and discussions, as well as classroom presentations on topics that promote academic and social-emotional growth, counselors provide positive examples of behavior students can incorporate in their lives, leading to healthier decisions and more positive actions.

Further, a wealth of anecdotal evidence shows how counselors have helped teachers and other school leaders support student learning. For instance, a counselor-led initiative at a Sunnyside, Washington, high school boosted graduation rates by nearly 30 percent (Salina et al., 2013). Similarly, the 2018 Counselor of the Year, Kirsten Perry of Lawndale Community Academy in Illinois, has been credited with helping reduce chronic absenteeism by 61% over two years and raise her school’s academic standing. Her multifaceted approach to her work also addressed students’ emotional needs by bringing them together in “peace circles” to discuss and resolve their conflicts (Wegner, 2018).

When it comes to social and emotional development, counselors can play a significant role in everything from reducing negative student behaviors (Curtis et al., 2010) to reducing the spread of gossip among students (Cross & Peisner, 2009) to increasing awareness of depression and suicide risk (Erickson & Abel, 2013). Counselor support can also make a tremendous difference for students from low-income families and students from underrepresented groups, as in the examples of counselors helping students of Mexican descent build stronger relationships at school (Malott et al., 2010) and increasing the sense of empowerment and aspiration among Black males (Wyatt, 2009).

The effect school counselors have on young people’s career and college plans is well known, but the results of a statewide counseling initiative in Colorado (Johnson, 2016) is especially notable. Fueled by a state start-up grant, Colorado created 220 new school counseling positions over eight years and provided counselors with training in dropout prevention and college access strategies. The affected schools saw the dropout rate decline from 5.5% to 3.7%, while college attendance and persistence increased by 13 percentage points. And, in an important unintended consequence, student participation in career and technical education more than doubled. With more students attending high school, the schools’ total funding base increased enough for the new counseling positions to pay for themselves once the grants expired. By investing $16 million up-front in new counseling positions, Colorado created counseling positions that more than paid for themselves and saved the state over $300 million in the social costs associated with supporting high school dropouts.

Maximizing school counselor effectiveness

Given the differences school counselors can make in everything from school climate to classroom achievement to individual behavior, what are some of the conditions that need to be present for schools to make the most of the expertise and training of their school counselor?

Counselor caseloads

The success of the Colorado initiative offers insights into something school counselors have long known — they can do more when they have manageable caseloads. The American School Counselor Association recommends a ratio of not more than 250 students per counselor, but the average caseload nationally for 2014-15 was 482, with just three states having ratios at or below the recommended ratio, and 11 states reporting a ratio of 500 or more students per counselor (ASCA, n.d.-c).

The Colorado initiative succeeded in part by reducing counselor ratios at the participating schools from 363 students per counselor to 216. Given the financial savings the state has realized as a result of adding school counselors, it is understandable why several states are considering providing funding for new school counselor positions (see, for example, Bisaha, 2018).

Use of counselor time

Regardless of the number of students on their caseloads, school counselors often find themselves limited in their effectiveness because they are assigned administrative duties that have little to do with their role as a counselor. Although counselors recognize the importance of taking their turn with obligations like lunch duty and supporting the safe start and end of a school day, tasks like changing student schedules, administering building-wide tests, and constructing the school’s master schedule take them away from the student-centered tasks that should be the core of their work.

Administrators can support counseling efforts by sitting down with their building counselors before the start of each school year to develop a clear understanding of the counselors’ role. The ASCA Agreement Template (ASCA, n.d.-a) provides counselors and administrators with a starting point for this discussion, outlining the goals of the school counseling curriculum for the year and the appropriate allocation of the counselor’s time to achieve those goals. This template also serves as a source for creating assessment data to measure the effectiveness of the school counseling curriculum and to build plans for future years based on those results.

Counselors looking to improve the results of their college access curriculum may want to review the time they allocate to this task, as well as their college expectations for their students. A study by the Education Commission of the States (Zinth, 2014) shows that 73% of high schools with a high college-going rate have counselors who devote 20% or more of their time to college counseling, while only 25% of the high schools with a low college-going rate have counselors who spend that much time on the task. At the same time, 72% of the counselors at the high college-going high schools place college access as their first goal, while the low college-going high schools list college access as their first goal only 32% of the time.

Access to community resources

The American School Counselor Association recommends all school counselors convene a counseling advisory committee (CAC) as part of its counseling curriculum. Separate from the school improvement committee, the CAC’s goals are to “foster a collaborative partnership with community stakeholders, educate the advisory members about the school counseling program’s strengths, demonstrate the program’s unique needs and communicate the program’s outcomes” (ASCA, n.d.-b). By engaging local business leaders, clergy, mental health specialists, and leaders of community organization, CACs help broaden awareness of the school counseling program and widen the potential resources the program can draw on.

Although an engaged, effective CAC can foster greater recognition of the school counseling program and establish community ties to improve counseling services, school counselors report challenges in convening regular meetings of their CAC and an inability to direct their activities due to lack of time. High caseloads can prevent school counselors from making the most of their CAC, but with the right amount of administrative support, counselors can begin to engage their CACs actively and create student-centered goals for the committee that members can fully support.

Review of counselor training

Some school counselors have expressed a desire for their graduate school training in school counseling to align more with the duties and activities they experience on the job. This need was highlighted in a survey conducted by the National Consortium for School Counseling and Postsecondary Success:

The survey discovered a strong discrepancy between school counselors and school counselor educators on the content covered in counselor education programs, with counselor educators reporting much more effective coverage of topics than practitioners. This gap in perceptions suggests that counselor educators may need to pay closer attention to the demands of those in the field as well as emerging responsibilities such as a greater need to support career and college readiness. (Brown et al., 2016, p. 12)

In light of the ever-changing needs of students in all three school counseling areas, counselor training and continuing education programs need to be fine-tuned to ensure counselors are providing students and families with the latest in research-based programming and advice. A bill passed by the Michigan legislature in November 2017 requires all counselors in that state to receive such updates as part of their regular recertification requirements. Other states would do well to consider the best path they can take to support counselors’ desires for current training.

School counselors have a long record of working effectively with students, parents, fellow educators, and community members to create new paths of learning, achievement, and self-discovery. While much of this work is done behind the scenes, it has been empirically shown to make a difference in the lives of our students and our schools. More important, that difference resides in the hearts and minds of students who are leading stronger, healthier lives, thanks to the school counselor who supported them and showed them more of what their lives could be.

References

American School Counselor Association. (n.d.-a). Annual agreement template. Alexandria, VA: Author. www.schoolcounselor.org/asca/media/asca/
ASCA%20National%20Model%20Templates/AnnualAgreementTemplate.pdf

ASCA. (n.d.-b). ASCA national model FAQs. Alexandria, VA: Author. www.schoolcounselor.org/school-counselors/asca-national-model/asca-national-model-faqs

ASCA. (n.d.-c). The role of the school counselor. Alexandria, VA: Author. www.schoolcounselor.org/asca/media/asca/Careers-Roles/RoleStatement.pdf

ASCA. (n.d.-d). Student-to-school-counselor ratio 2014-15. Alexandria, VA: Author. www.schoolcounselor.org/asca/media/asca/home/Ratios14-15LowestToHighest.pdf

ASCA. (2014). Mindsets and behaviors for student success: K-12 college-and career-readiness standards for every student. Alexandria, VA: Author.

Bisaha, S. (2018, January 18). Kansas looks at hiring school counselors, if they can be found. KCUR Radio. http://kcur.org/post/kansas-looks-hiring-school-counselors-if-they-can-be-found

Brown, J., Hatch, T., Holcomb-McCoy, C., Martin, P., Mcleod, J., Owen, L., & Savitz-Romer, M. (2016). The state of school counseling: Revisiting the path forward. Washington, DC: National Consortium for School Counseling and Postsecondary Success.

Carey, J. & Dimmitt, C. (2012). School counseling and student outcomes: Summary of six statewide studies. Professional School Counseling, 16 (2), 146-153.

Cross, J.E. & Peisner, W. (2009). RECOGNIZE: A social norms campaign to reduce rumor spreading in a junior high school. Professional School Counseling, 12 (5), 365-377.

Curtis, R., Van Horne, J.W., Robertson, P., & Karvonen, M. (2010). Outcomes of a school-wide positive behavioral support program. Professional School Counseling, 13 (3), 159-164.

Erickson, A. & Abel, N.R. (2013). A high school counselor’s leadership in providing school-wide screenings for depression and enhancing suicide awareness. Professional School Counseling, 16 (5), 283-289.

Johnson, N. (2016, August 2). Colorado spends $16 million on h.s. counselors and saves $300 million in safety net services. The 74 Million. www.the74million.org/article/colorado-spends-16-million-on-hs-counselors-and-saves-300-million-in-safety-net-services

León, A., Villares, E., Brigman, G., Webb, L., & Peluso, P. (2011). Closing the achievement gap of Latina/Latino students: A school counseling perspective. Counseling Outcome Research and Evaluation, 2 (1), 73-86.

Malott, K.M., Paone, T.R., Humphreys, K., & Martinez, T. (2010). Use of group counseling to address ethnic identity development: Application with adolescents of Mexican descent. Professional School Counseling, 13 (5), 257-267.

Salina, C., Girtz, S., Eppinga, J., Martinez, D., Blumer Kilian, D., Lozano, E., . . . Shines, T. (2013). All hands on deck: A comprehensive, results-driven counseling model. Professional School Counseling, 17 (1), 63-75.

Wegner, R. (2018, February 5). Michelle Obama presents Counselor of the Year award to Chicago educator. Education Week. http://blogs.edweek.org/edweek/high_school_and_beyond/
2018/02/michelle_obama_presents_2018_school_counselor_of_the_year_award.html

Wyatt, S. (2009). The Brotherhood: Empowering adolescent African-American males toward excellence. Professional School Counseling, 12 (6), 463-470.

Zinth, J. (2014). College counseling in high schools: Advising state policy. The Progress of Education Reform, 15 (6).

Originally published in April 2018 Phi Delta Kappan 99 (7), 35-39. © 2018 Phi Delta Kappa International. All rights reserved.

PATRICK J. O’CONNOR (poconnor@cranbrook.edu; @collegeisyours) is associate dean of college counseling at Cranbrook Schools in metropolitan Detroit. He is also the inaugural School Counselor Ambassador Fellow at the U.S. Department of Education and the author of College Counseling for School Counselors (Outskirts Press, 2015).

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How school counselors make a world of difference - kappanonline.org

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The multifaceted work of school counselors helps prepare students academically and emotionally for life beyond school.

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Life Changing Self-Care Tips For School Counselors

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Life Changing Self-Care Tips For School Counselors

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Quick read to recharge!

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Self-care for school counselors is an important aspect of your routine as a helping professional. Holding yourself accountable is key to building the resiliency you need to care for others. Unfortunately, caring for yourself is often placed on the back burner because you might feel like there's not enough time or energy, for self-care.

You may even feel selfish for taking the time to focus on yourself.

But what if you looked at it from a different perspective?

Think of it like this: if you're in your best mental and physical shape, you can show up for your students and school staff when they need you the most.

In other words, the quality of care you give will be much better if you're feeling good yourself.

When you put it that way, self-care is non-negotiable. Yay for you!

But it's easier said than done, right?

There's a lot more to self-care than just a day at the spa. In fact, there are six facets of self-care that need your attention. Implementing self-care activities from each of these facets will help you produce a holistic self-care regime. Once you've mastered these for yourself, you will be ready to educate staff with these tips!
Don't worry, these tips are easy to implement in everyday life!
Mental Health Self-Care Tips for School Counselors

When we're talking about mental self-care, we're talking about activities that stimulate your mind and encourage cognitive growth (two things that keep your mind in tip-top shape).

All this leads to better brain function, and of course, better problem-solving skills-which we all know is important when managing a classroom or helping a student 1:1.

All you need, to keep your mind firing on all cylinders, is a few moments of time to spend on yourself doing something mentally stimulating.

Here are a few easy ways to incorporate mental health self-care into your daily routine:

1. Keep a personal journal (on your computer or with one of these handy journals).

2. Read a book or magazine simply for pleasure. Nope, you don't have to be learning a new professional skill...but you can if you'd like!.

3. Become more mindful about your thoughts and take note of the negative ones ... and then release them.

4. Play old school board games again. Pick the ones that challenge your thinking and problem solving.

Physical Self-Care Tips For School Counselors

Not surprisingly, physical self-care includes activities that promote a healthy lifestyle, like exercising, eating right, going to the doctor regularly for routine checkups.

These activities are no-brainers, but the following additional ways to take care of your physical self often go overlooked:

1. Taking breaks.

2. Sleeping when you need it. Yes, nap if you're tired. (You have my permission).

3. Putting routine wellness checks on your calendar and then sticking to them.

4. Combining something you like to do with a physical activity that you don't normally enjoy. Examples: bird watching while taking a jog or making up new dance moves to your favorite songs.

Emotional Self-Care

While this facet of self-care may coincide with mental self-care, it focuses specifically on your emotions by allowing them to exist without judging yourself for how you feel.

When you allow yourself to feel emotions as they surface, not only will you feel relieved instead of a pressure pot of emotions, but you'll also prevent your emotions from interfering with your day-to-day responsibilities.
Ways to practice emotional self-care:

1. When you feel sad, allow yourself to cry. Loudly if necessary, no shame in the ugly cry.

2. If you're angry, use exercise to release the negativity or invest in a legit punching bag.

3. Prevent overwhelm by saying no when you're simply too busy.

4. Meditate and become more mindful of your thoughts and emotions.

Practical Self-Care Tips for School Counselors

Getting your life in check is an easy way to reduce stress and enhance feelings of accomplishment, especially if you're feeling overwhelmed by disorganization.

Keeping a clean house, record-keeping, and checking things off your to-do list are all ways you can clear the clutter from your life so you can get ahead of all those seemingly little things that cause disorder.

Examples of practical self-care for school counselors:

1. Organize to be more efficient in day-to-day life.

2. Use a calendar to remind yourself of important dates. It'll let your brain relax.

3. Keep your workspace and home clutter-free.

4. Pay your bills ahead of time to prevent panic and feel accomplished.

5. Collaborate with other professionals to relieve some of your workload.

6. Hold yourself accountable for self-care with this free habit tracker.

Relationship Self-Care for School Counselors

When we think of relationship self-care we often think about what we are, or aren't, doing for others close to us. But the truth is, when you foster healthy relationships with loved ones, you're also gifting yourself a strong support system to reach out to when needed.

Examples of relationship self-care activities may include:

1. Being social in the teachers' lounge or going to school events for FUN.

2. Be intentional about fostering your friendships. Be the friend you would like to have.

3. Setting boundaries with coworkers and family members to protect your time and privacy.

4. Be helpful to others. Seek out ways to help.

Spiritual Self-Care for School Counselors

As humans, it's only natural to experience feelings of hopelessness and dread, and that's why spiritual self-care is important to your routine. For example, connecting with nature and meditating can promote self-reflection, help you feel more connected, grounded, as well as provide emotional clarity.

Here are some spiritual self-care activities:

1. Believe in a set of moral standards.

2. Spend time in nature.

3. Meditate regularly.

4. Pray, if you're religious.

5. Keep a daily gratitude or self-care journal.

If you can start implementing these six facets of self-care into your daily routine, they'll become habitual. And even though it may feel like you're spending a lot of time on yourself at first, you're actually freeing up your mind and your energy, so you can be your best self for yourself, your loved ones, and your students.

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Life Changing Self Care Tips for School Counselors

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Self-care for school counselors is an important aspect of your routine as a helping professional. Holding yourself accountable is key to building the resiliency you need to care for others. Unfortunately, caring for yourself is often placed on the back burner because you might feel like there's not enough time or energy, for self-care.

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Self care is always a hot topic, especially in the helping professions. We as school counselors know that self care is important, especially when we give so much throughout the day. We need boundaries, we need to care for ourselves, and we need to preserve our own mental space. Sometimes we hear quotes like, "A good teacher/counselor is like a candle - it consumes itself to light the way for others." When I hear this, I cringe because it promotes the idea that we have to give all of ourselves for our students. In fact, we need healthy boundaries and we need to preserve our own well being by engaging in daily, weekly, and monthly self care practices so that we can experience balance and peace. For this reason, I take time every summer to make a self care plan and engage in those daily practices to make sure I am creating a routine that I can stick to once the year starts. Keep reading to find out why and how you can make a self care plan to set yourself up for success too.

Why I Make a Self Care Plan

What is Self Care?

Self care isn't all bubble baths and manicures. While those things are nice if you enjoy them, they aren't necessarily tasks that help you care for your basic needs and boundaries. Self care should fill your tank, not empty it more. In your self care practice, think about those activities that support your own emotional, mental, physical, and spiritual health.

How I Do My Self Care Plan

I know that I am prone to let self care tasks fall off of my radar if I don't have a specific plan in place. The act of writing out my self care plan helps me to be accountable to myself (do you also love checking things off of a list? it's so gratifying to me). First, I identify what I call the "daily non-negotiables." These are the things that I absolutely must do every day to feel like I'm taking care of myself. This might look like:

taking any prescribed medication

flossing

drinking enough water

spending time reading to my kids

washing my face before bed

being outside for at least 15 minutes

putting my phone away 30 minutes before bed

This might look different for you but think about those daily things you absolutely must do to feel like you. Do I have a basic human need to read to my kids? No, but my day feels complete and full when I do so I put it in there. Once you have your non-negotiables, write them down. Build them into your calendar. If your schedule is anything like mine, it fills up quickly and sometimes feels chaotic. Having those daily self care tasks built it reminds me to actually do them.

I also fill in weekly tasks - like emptying my email inbox, cleaning my desk, or filing all necessary paperwork - and long term things that I can look forward to. Those go in the calendar too so I can keep myself accountable and look forward.

Check In With Yourself

I build in a weekly and monthly check in with myself. I take some time to reflect on how I'm feeling and if I'm actually doing those self care tasks that I need to do. I'm not perfect at this, so I need to spend time reflecting and being honest with myself about my own self care practice. If I notice that I'm not doing great with self care follow through, I think about how I can help myself do better or things I can do to make sure I'm getting in that vital self care.

What about you?

How do you make sure you're taking care of yourself? How do you make a self care plan? If you're looking for a first step to get yourself started with a self care routine, check out my free school counselor self care summer challenge (it's okay if it's not summer!) for some ideas of self care activities to build into your routine.

More on summer planning...

If you're looking for more ways to prepare yourself for your school year during the summer, head over to The New School Counselor Survival Guide to see everything I'm doing during the summer to prepare for a year at a new school and everything I'll be doing along the way.

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Self care is always a hot topic, especially in the helping professions. We as school counselors know that self care is important, especially when we give so much throughout the day. We need boundaries, we need to care for ourselves, and we need to preserve our own mental space.

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Let's address the elephant in the room. School counselors are natural helpers. Not checking email at home is actually counselor self-care! My biggest argument for not checking email during off-time is for YOUR own sanity and mental health. Disconnecting is hard, and it goes against our grain to turn our backs on our students and families even when we're not AT work.

I, personally, took work email off of my phone about 2 years into being a school counselor, and I've never looked back. We are the ones teaching our students that they need to care for themselves before they can care for others. School counselors tell each other to fill their own buckets, so they can fill others' buckets. We need to practice what we preach and take care of ourselves emotionally and mentally, and this includes "leaving work at work."

I don't know about you, but I am on the same contract time as teachers. I am not contracted to work in the summer. If I do not take a break for myself in the summer, I don't get emotionally recharged, and it's like the school year never ends!
Here are 5 myths you're believing about work email causing you to fail at counselor self-care.
Counselor Self-Care Myth #1- "What if my families can't get the information they need when they need it?"

Does your eye start to twitch just at the thought of NOT checking work email? Are you worried about how students and parents will adjust without you? Well... how did they do it before you? I think it's prideful to think you are their only lifeline.

Keep your resources and website up-to-date. Educate your families on where to get community resources and other information. If they can expect to find timely information in the same place, you can offload a lot of the same questions by directing them to where they can find the answers themselves. Students should practice this regularly as it is vital to their independence!

Your counselor self-care can be an example that you're setting for your students!

Counselor Self-Care Myth #2- "A student might have a deadline coming up, so I need to be available."

As you let students and parents know you are not available outside of work hours, they start understanding and respecting boundaries. When I talk to juniors and seniors about letters of recommendation, I stress the importance of not waiting until the last minute. ( What happens if I'm out sick or on vacation on Friday before your letter is due on Saturday? I'm sorry- I can't write that letter for you.)

Sometimes students need to make mistakes and miss deadlines before they know how serious you are. It sounds harsh, but sticking to your boundaries will teach everyone that you are respecting yourself and your family. It will also train them to plan ahead and be resourceful on their own when needed.

Counselor Self-Care Myth #3- "I'll just sneak a peek at my email so that I know what I'm stepping into in the morning."

I would also go as far as to argue not even PEEKING at your email even if "I'm not going to respond... I'm just going to check, so I know what I am walking into on Monday morning." This has caused my stress about the volume of emails I have awaiting me and anxiety about a parent email that is awaiting my response. My mind ends up racing at night about all that is to come the next day!

Counselor Self-Care Myth #4- "What if my administrators expect me to answer emails at all hours?"

How do your administrators handle your established boundaries for your own counselor self-care? This (oftentimes) requires teaching and conditioning. Our administrators have district phones, and they work more evening hours with sports and other events than we do. Their hours are often blurred (or they're getting PAID for those hours), and I think it's easy for them to rope us in with any after-hours issues.

Some things you could consider having a conversation with your administrator(s) about:

what constitutes an emergency and what does not (student death, direct communication from someone higher up than principal that MUST be specifically communicated to counselor in the most timely manner and requires action immediately)

healthy boundaries to prevent emotional burnout (if I want to stay in this job for the long-term, I have to have boundaries)

my family needs my energy outside of school

not having a district phone (and, even if I did... I would have to have clear boundaries on expectations and work hours)

BE FIRM- this may take some practice both rehearsing what you may say in this conversation and some practice for your admin to understand this as your norm especially if it is not the norm already

Counselor Self-Care Myth #5- "This is so hard. I could never do it."

Checking your email ONLY at work takes practice, practice, practice. Many counselors have told me it has taken them years to get better at this and to finally feel comfortable with it. (Especially once we've added in eLearning/distance learning/digital learning, the need to practice this comes with extra necessity. Otherwise, we will be CONSTANTLY connected, and we will never be able to completely tune out or turn work off.)

If you work with a team of counselors, encourage your department to join in this endeavor with you! Of course, you can't change everyone. It's up to them to decide how they spend their time outside of the office, but I do think it's helpful if everyone can be on a similar page.

I do not put up an away message every night or weekend. I do put an away message up in the summer, but it is very simple. This is one practical and personal way I have adding in some counselor self-care during my time off in the summer.

You could try something like: "Thank you for reaching out. I will be answering emails and voicemails periodically over the summer when I am in the office. Please check our school counseling website for the answers to many of your questions (link to the website). If this is an emergency, please call 911 immediately. I look forward to working with you when I am back in the office in August. Have a great summer!"

Consider the Legalities and Ethical Issues of "Around-the-Clock Availability"

Not only is counselor self-care a major issue, but there are legalities and ethical issues associated with checking your work email outside of work. That's why I loved this article from Dr. Carolyn Stone (2016) called Legal and Ethical Technology Imperatives that discusses the importance of not blurring your work and school hours. What happens when someone reaches out to you with a safety concern? Dr. Stone says, legally, it is best practice to not have a pattern of "around-the-clock availability."

Things you might have to consider depending on the circumstance:

you have seen an email/report/text and ethically have to act on it and get help

you are out of town and not able to respond appropriately or in a timely manner

you are making contact from your own personal phone line

you may be somewhere with spotty to no internet

you may not have access to the student or parents' contact information

student has a safety concern but you know family history and the immediate family may not be the best ones to address this concern

I'd love to hear your thoughts on work/home life boundaries. How have you established them? Have you been successful in adhering to them? If your lines between work and home are blurred, how do you manage your own counselor self-care?
Download this free Self-Care Goal Sheet, and set a self-care goal in six different categories! We discussed counselor self-care inside the Clique Collaborative as one of our monthly topics! Join the waitlist for my monthly membership for high school counselors to hear about when doors open next!

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Counselor Self-Care: The 5 Myths You're Believing About Work Email Causing You to Fail at It - Counselor Clique

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My biggest argument for not checking email during off-time is for YOUR own sanity and mental health. Not checking email at home is actually counselor self-care! Disconnecting is hard, and it goes against our grain to turn our backs on our students and families even when we're not AT work.

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Cedar Barstow, MEd, CHT, GoodTherapy.org Topic Expert Contributor

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A Guided Self-Care Assessment for Helping Professionals - GoodTherapy.org Therapy Blog

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In order to help others effectively, therapists and other helping professionals must make self-care a priority. How do you rate your self-care in these areas?

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Self-Care for Counselors and a Self-Care Plan

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Self-Care for Counselors and a Self-Care Plan

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In the world of mental health, caring for others who are emotionally stressed or distressed may create a stressful environment for therapists themselves.

It begs us to ask: who cares for the mental health carer?

Dunne (2015) looks into Carl Jung's wounded healer concept, in which the analyst must acknowledge pain from patients so the analyst can heal themself from personal pain experienced. To do this, Jung faced a decision in his work: does he see himself as part of the drama or cloak himself in his own authority (Dunne, 2015, p. 119)?

But why must we even ask these questions in the first place? To answer this, we explore why self-care is exceptionally important to those working in the mental health field.

Before you continue, we thought you might like to download our three Stress & Burnout Prevention Exercises (PDF) for free. These science-based exercises will equip you and those you work with, with tools to manage stress better and find a healthier balance in your life.

Why Is Self-Care Important for Mental Health Practitioners?

Mental health problems can be prevalent and persistent among psychologists and other therapists working in healthcare services.

There are many common problems therapists face when engaged in this line of work, including increased depression, psychosocial isolation, decreased job satisfaction, reduced self-esteem, disrupted personal relationships, and loneliness (Shapiro, Brown, & Biegel, 2007).

How is this happening? The wounded healer concept may play a role.

A recent survey of clinical psychologists (Tay, Alcock, & Scior, 2018) in the United Kingdom found that 63% of respondents reported having experienced self-defined mental health problems at some point in their lives, including issues around anxiety and depression.

Compare this to the 43% lifetime prevalence of mental health problems experienced by the general population in the UK (Mental Health Foundation, 2016), and we see how important it is for therapists to take care of themselves.

Stress and burnout seem to be key issues for therapists. In a systematic review of 8,808 therapists, 55% reported having moderate to high work-related stress and burnout (Simionato & Simpson, 2018).

Among the professional challenges therapists experience is "compassion fatigue" from emotional labor that is often part of working with clients (Mann, 2004).

While therapists enter the mental health field to help those in need, it does not make them invulnerable to feeling overly exhausted from the issues brought in by their clients.

Benefits of self-care plans for therapists

Engaging in self-care for therapists has many benefits (Bradley, Whisenhunt, Adamson, and Kress, 2013) including:

Self-awareness
By acknowledging their pain to themselves, therapists are better placed to understand client experiences and reactions to pain.

Further appreciation of the therapeutic value of the process
Once therapists are more aware of their feelings and issues, engaging in strategies or techniques can be more effective.

Externalizing the problem
When devising strategies to cope with their own stress, anxiety, or burnout, therapists can feel overwhelmed. Self-care creates a protective distance between themselves and the problems they face.

Containing the problem
With the problem externalized, therapists feel more prepared to contain negative emotions and facilitate healing.

4 Real-Life Examples of Self-Care Plans

With the obvious benefits of self-care plans in mind, how should a self-care plan be created?

It is best to start with a quick self-care assessment (Kottler, 2012) with the following questions:

Does a therapist believe they deserve self-care?

Does the therapist have a go-to list of activities?

Has the therapist made self-care a habit?

The responses will reveal different areas where engagement is needed when creating self-care plans.

Physical health

Caring for patients has been known to affect therapists on a physical level. Stress can increase body weight and fatigue (Barnett & Cooper, 2009).

A self-care plan that addresses therapists' physical health concerns while delivering therapy may include setting up a regular exercise schedule.

Whether it would be more prudent to exercise every day or three days per week, a self-care plan that involves physical activity may be best aided by consulting with a trainer at a gym or a nutritionist.

Furthermore, a self-care plan may be at its best when shared. When deciding to engage in exercise and having a plan for it, sharing with family, friends, and even a physician may help therapists stick to the plan.

Cognitive

Therapists can feel stressed when helping clients sift through thoughts and emotions. It is important for therapists to feel as if they can clear their minds of thoughts that may inhibit not only their ability to administer therapy, but also their personal lives (Lomas, Medina, Ivtzan, Rupprecht, & Eiroa-Orosa, 2019).

To help address therapists' cognitive concerns, a self-care plan may include setting aside time each day to practice meditation, whether that is documented in a schedule or a note to themselves.

Attuning to the world around them may be able to help therapists improve their cognitive functioning to help clients. In the Helpful Worksheets and Tips section below, we will detail recommended resources, including being aware of one's own five senses.

Emotional

When working with patients, therapists might feel as if boundaries are being crossed. They may feel overwhelmed in processing another's emotions while trying to balance issues in their personal lives (Bennett-Levy, 2019).

A good self-care plan for therapists who encounter emotional difficulties includes creating a gratitude journal to note down at least one aspect of their personal lives they appreciate each week.

In the Helpful Worksheets and Tips section below, we discuss a journal that therapists can use to get in touch with aspects of their lives they appreciate and goals they wish and hope for in the future.

Understanding these aspects of themselves and knowing there is a path for them outside of the therapy space may help therapists feel less overwhelmed by emotions while working with clients.

Spiritual

Sometimes, it can help therapists to have an escape mechanism that removes them from the therapy room and issues that clients present with. Being involved with their spiritual side can provide this escape mechanism (Boellinghaus, Jones, & Hutton, 2013).

An example of how therapists can address their spiritual needs is setting aside time to listen to spiritual music.

12 Self-Care Strategies and Techniques

Building a self-care plan within the areas of therapists' physical health, cognitive, emotional, and spiritual needs is important. The following strategies and techniques can be added to a schedule or journal that is part of the plan itself:

Physical

1. Maintain a healthy and nutritious diet. Ideally with the help of a nutritionist, planning your diet can be vital.

2. Drink plenty of water. Therapists often forget how much energy is being spent listening and talking to patients. Therapists have water set aside for patients, why not for themselves as well?

3. Get enough sleep. Without proper sleep, fatigue may make therapists less able to exert the needed concentration in sessions with patients.

Cognitive

1. Read for leisure. Taking thoughts away from sessions and redirecting them toward things to relax with and enjoy, such as books, can help.

2. Being aware of self-talk, inner thoughts, judgments, and feelings can reduce stress and burnout (Lomas et al., 2019).

3. Participate in personal therapy. It is important to have a separate space for therapists to discuss stressful thoughts and behaviors brought on by delivering therapy.

Emotional

1. Find things that oppose the negative emotions experienced during a session. For example, if a session was particularly sad, watch a funny movie.

2. Practice using positive affirmations such as praising yourself. As a therapist, you may not feel as if positive praise is warranted for your work, but what you do is important. Positive affirmations can benefit emotional wellbeing, lowering stress and rumination (Koole, Smeets, van Knippenberg, & Dijksterhuis, 1999; Wiesenfeld, Brockner, Petzall, Wolf, & Bailey, 2001).

3. Allow yourself to cry. All therapists can feel overwhelmed by emotions; a need to cry can be prevalent. Crying in personal therapy, as well as on your own time and in your own home, can be appropriate.

Spiritual

1. Make time for self-reflection at home, in nature, in a journal, or with a therapist.

2. Be open to not knowing. Therapists ground themselves in research and evidence-based work, but that does not mean therapists always have the answer. Not knowing can be stressful, but accepting that you don't know everything and releasing yourself from this pressure are important parts of self-care.

3. Spend time in nature. The commute to the office, interactions with many people, and day-to-day administrative tasks can feel like too much at times. Escaping to nature is a key aspect of a self-care break.

Helpful Worksheets and Tips

Further tips for effective self-care, with a few very useful worksheets.

The world around you

As Kottler (2012) discussed, before deciding what to include in a self-care plan, therapists can assess if they are open to self-care in the first place.

Being open means being knowledgeable and knowing that what can be used on themselves can also be used with clients.

Therapists may benefit from their own self-care by getting in touch with the world around them. What do we mean by this? In thinking about things one can see and hear, therapists gain a sense of relaxation they can use with those they work with. The Five Senses Worksheet can be helpful for this.

Muscle relaxation

Being familiar with muscle relaxation exercises is highly beneficial for therapists, as it also helps them apply this exercise with their clients.

Progressive muscle relaxation is a technique used to disrupt feelings of anxiety by tensing specific muscle groups. This progressive muscle relaxation worksheet guides therapists through the basics of the exercise.

Self-love

When feeling stressed, it can be easy for therapists to forget reasons to love themselves and appreciate their positive qualities.

What makes you unique? What is one personality trait that makes you proud? What are three compliments you received, and how did they make you feel?

A sense of accomplishment (or lack of it) can often be overlooked, adding to stress. When engaging in self-care, writing down these positive aspects can help therapists help themselves and, in turn, help clients.

Here is a Self-Love Journal to help you get started.

Positive qualities

If keeping a journal is not for you, an alternative tip is to create a series of cards listing positive qualities.

Write down positive affirmations and qualities about yourself on a series of cards as a way to engage in self-care. To explain more about this strategy, we have a worksheet called Stacking the Deck that therapists can use daily.

Awareness

Further to the self-love and positive qualities exercises, it's important to note other positive aspects, such as how you handle criticism and the goals on your agenda. These can be outside of the therapy room.

Therapists who know their goals beyond those of their career understand that goals are an important part of self-care. To help you realize this, check out our My Beliefs worksheet.

Tips

Other ideas for self-care include:

Letting light in a room

Engaging in physical exercise

Limiting media consumption around negative news topics

Practicing breathing exercises

Dancing

Learning a new skill using online learning programs, drawing, or even a different language

Playing brain games such as word or jigsaw puzzles

Cleaning around the home

Scheduling me-time with a relaxing bubble bath

Lighting scented candles

Listening to relaxing music

Books on the Topic

These books are great reads for enhances self-care.

1. Carl Jung: Wounded Healer of the Soul - Claire Dunne

This book is an illustrated biography of Carl Jung.

It details his history from childhood through self-discovery and professional success.

Claire Dunne (2015) comments throughout and touches on influences of Carl Jung's ideas about therapists being wounded healers.

Find the book on Amazon.

2. Counselor Self-Care - Gerald Corey, Michelle Muratori, Jude T. Austin II, and Julius A. Austin

Counselor Self-Care offers realistic perspectives on how to achieve work-life balance and personal wellness for counselors from graduate school to retirement.

Seasoned counselors, new professionals, and graduate students share their thoughts and experiences, contributing to a practical self-care action plan all in one book.

Find the book on Amazon.

3. Creativity as Co-Therapist: The Practitioner's Guide to the Art of Psychotherapy - Lisa Mitchell

In Creativity as Co-Therapis t, Lisa Mitchell (2016) guides therapists through a five-stage process to help them understand therapy as an art form.

This book guides the reader through the five stages so they are better able to identify areas where they may get stuck with patients.

Find the book on Amazon.

PositivePsychology.com's Relevant Resources

A Take-Home Message

In the mental healthcare profession, working with patients can be overwhelming and lead to mental health concerns and fatigue that therapists may not have expected when embarking on their professional journey.

After all, therapists are also people, and stress and burnout can happen to anyone, even the helpers.

So, who then helps the helpers? Who cares for them during times of burnout?

Self-care provides the ability for therapists to look after themselves, but it does not have to be done by themselves.

It can be done with the help of other therapists, friends, family, and the community at large.

Self-care begins by realizing you have to take care of yourself and develop a self-care plan. Use the resources provided, and keep in mind why you are doing this.

Clients depend on us. But we depend on ourselves just as much.

We hope you enjoyed this article; don't forget to download our three Stress & Burnout Prevention Exercises for free.

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Self-Care for Therapists: Tools & Counselor Self-Care Plan

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In the world of mental health, caring for others who are emotionally stressed or distressed may create a stressful environment for therapists themselves. It begs us to ask: who cares for the mental health carer? Dunne (2015) looks into Carl Jung's wounded healer concept, in which the analyst must acknowledge pain from patients so the analyst can heal themself from personal pain experienced.