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addressing mental health in school crisis prevention and response_1_

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Definition

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

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

Prevalence

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

Characteristics

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

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

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

Impact on Learning

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

Teaching Strategies

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

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

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

Assistive Technology

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

Organizations

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

American Academy of Child and Adolescent Psychiatry

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

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

Web: www.aacap.org

Center on Positive Behavioral Interventions and Supports

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

5262 University of Oregon
Eugene, OR 97403-5262

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

Center for Disability and Development

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

Council for Exceptional Children

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

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

Federation of Families for Children's Mental Health

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

1101 King Street, Suite 420
Alexandria, VA 22314

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

National Alliance for the Mentally Ill (NAMI)

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

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

Web: www.nami.org

Mental Health America

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

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

Web: www.nmha.org

National Mental Health Information Center

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

P.O. Box 42557
Washington, DC 20015

Web: www.mentalhealth.org

References

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

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

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

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

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National Institute of Mental Health (NIMH)

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

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

What is bipolar disorder?

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental illness that causes people to experience noticeable, sometimes extreme, changes in mood and behavior. It is a common misperception that children cannot have bipolar disorder. Although most people are diagnosed with bipolar disorder in adolescence or adulthood, the symptoms can appear earlier in childhood.

Bipolar disorder is not the same as the typical ups and downs every child goes through. The mood changes in bipolar disorder are more extreme, often unprovoked, and accompanied by changes in sleep, energy level, and the ability to think clearly.

Children with bipolar disorder sometimes feel very happy or "up" and are much more energetic and active than usual. This is called a manic episode. Children with bipolar disorder sometimes feel very sad or "down" and are much less active than usual. This is called a depressive episode. Bipolar disorder is often episodic, but it usually lasts a lifetime.

Bipolar disorder symptoms can make it hard to perform well in school or get along with friends and family members. Some children and teens with bipolar disorder may try to hurt themselves or attempt suicide. Early diagnosis and treatment can lead to better functioning and well-being over the long term.

Signs and symptoms of bipolar disorder may overlap with symptoms of other disorders that are common in young people, such as attention-deficit/hyperactivity disorder (ADHD), conduct problems, major depression, and anxiety disorders.

Diagnosing bipolar disorder can be complicated and requires a careful and thorough evaluation by a trained, experienced mental health professional.

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

What causes bipolar disorder?

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

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

Research also suggests that people with a genetic risk of having bipolar disorder may be more likely to develop the disorder after experiencing trauma or other stressful life events.

Some research studies have found differences in brain structure and function between people with bipolar disorder and people without it. Researchers are examining these differences to learn more about possible causes and effective treatments.

What are the symptoms of bipolar disorder?

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

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

Children and teens having a manic episode may:

Show intense happiness or silliness for long periods of time.

Have a very short temper or seem extremely irritable.

Talk fast about a lot of different things.

Have trouble sleeping but do not feel tired.

Have trouble staying focused and experience racing thoughts.

Seem overly interested or involved in pleasurable but risky activities.

Do risky or reckless things that show poor judgment.

Have an inflated sense of ability, knowledge, and power.

Children and teens having a depressive episode may:

Feel frequent and unprovoked sadness.

Show increased irritability, anger, or hostility.

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

Start sleeping a lot more.

Have difficulty concentrating.

Feel hopeless and worthless.

Have difficulty communicating or maintaining relationships.

Eat too much or too little.

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

Think about death or have thoughts of suicide.

Can children and teens with bipolar disorder have other problems?

Young people with bipolar disorder can have several problems at the same time. For example, they may also be at risk of misusing alcohol or drugs. Sometimes extreme behaviors go along with mood episodes. During manic episodes, young people with bipolar disorder may take extreme risks that they wouldn't usually take or that could cause them harm or injury. During depressive episodes, some young people with bipolar disorder may think about running away from home or have thoughts of suicide.

If your child shows signs of suicidal thinking, take these signs seriously and call your child's health care provider.
If your child is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org . This service is confidential, free, and available 24 hours a day, 7 days a week.

How is bipolar disorder diagnosed?

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

Other disorders-such as ADHD, disruptive mood dysregulation disorder, oppositional defiant disorder, conduct disorder, and anxiety disorders-have symptoms like those of bipolar disorder. It can be challenging to distinguish bipolar disorder from depression that occurs without mania, referred to as "major depression." A health care provider who specializes in working with children and teens can carefully evaluate your child's symptoms to provide an accurate diagnosis.

How is bipolar disorder treated?

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

Several types of medication can help treat symptoms of bipolar disorder. Children respond to medications in different ways. They may need to try different types of medication to find the one that works best for them. Some children may need more than one type of medication because their symptoms are complex. Health care providers usually try to prescribe the fewest number of medications and the smallest doses possible to help treat a child's symptoms. Always tell your child's health care provider about any medication side effects. Do not stop giving your child a prescribed medication without speaking to a health care provider. Stopping medication suddenly can be dangerous and can make symptoms worse.

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

What can children and teens expect from treatment?

With treatment, daily functioning and well-being can improve over time. Treatment is more effective when health care providers, caregivers, and young people work together.

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

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

How can I help my child or teen?

Help begins with an accurate diagnosis and treatment. Talk to your child's health care provider about any symptoms you notice.

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

Be patient.

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

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

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

Help your child have fun.

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

Help your child understand that treatment can make life better.

How does bipolar disorder affect caregivers and families?

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

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

Where do I go for help?

If you're unsure of where to get help, your doctor, pediatrician, or other family health care provider is a good place to start. A health care provider can refer you to a qualified mental health professional, such as a psychiatrist or psychologist, who has experience treating bipolar disorder and can evaluate your child's symptoms.

Learn more about getting help on the NIMH website. The Substance Abuse and Mental Health Services Administration has an online treatment locator to help you find mental health services in your area.

What should I know about clinical trials?

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

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. Learn more about  participating in clinical trials.

Reprints

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

For More Information

MedlinePlus (National Library of Medicine) ( En español )

ClinicalTrials.gov ( En español )

NIH Publication No. 23-MH-8081
Revised 2023

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Information about bipolar disorder in children and teens including causes, signs and symptoms, diagnosis, treatment options, and how to help a child or teen who has bipolar disorder.

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Since adolescents are often moody, it can be difficult to recognize when your child has become depressed and might need help. The thing people tend to notice first is withdrawal, or when the teenager stops doing things they usually like to do. There might be other changes in their mood, including sadness or irritability. Or in their behavior, including appetite, energy level, sleep patterns, and academic performance. If several of these symptoms are present, be vigilant about the possibility of teen depression.

This is especially important because by the time family members and other people around a teenager note their lack of interest in most things-or what we call anhedonia-they've usually been depressed for some time. Depression is an internalizing disorder, i.e. one that disturbs a patient's emotional life, rather than an externalizing one, which takes the form of disruptive or problematic behavior. As such, it takes a while not only for others to recognize it but often for the patient themselves to realize that their thinking, and emotional responses, are disturbed.

Note that there are actually two kinds of depression. In major depressive disorder -the most familiar form of depression-the symptoms occur in what may be severe episodes that tend to last from seven to nine months. But there is also another form of depression called dysthymia, in which the symptoms are milder, but they last longer, even years. So while the experience of dysthymia may be less debilitating for the child at any given moment, the risk is that there is more accrued damage and more time in which the child is kept out of the healthy development process.

When a teenager is depressed, their suffering isn't the only reason it's important to get help. In addition to the disorder itself, there are add-on effects that may cause lifelong issues. With depression symptoms comes low energy and poor concentration, two factors that are likely to have a significant impact on social and academic functioning.

It's easy to see the effects of poor academic functioning: falling behind in school undermines a child's confidence and self-image and can impact their future if it's prolonged. But social learning is just as critical as academic learning in adolescence. Deficits in social skills not only put depressed teens behind their peers but in themselves can compound their depression.

It's important to understand that a teenager who is depressed may also develop anxiety and may need to be treated for two separate disorders. It may be that depression leads to anxiety-the negative state of mind of a depressed teenager lends itself to uncertainty. If you're not feeling good about yourself, confident, secure, or safe, anxiety may find fertile ground. It may also be because the regions of the brain affected by anxiety and depression are close together and mutually affected.

Two serious problems that are directly associated with teenage depression and anxiety are suicidal thinking (or behavior) and substance abuse. Suicide is the third leading cause of death among adolescents and young adults aged 15 to 24, and we know that most kids who commit suicide have been suffering from a psychiatric illness. Especially at risk are teenagers who hide their depression and anxiety from parents and friends. That's why it's important to be alert to signs of these disorders-withdrawal, changes in school performance, eating habits, sleeping patterns, things they enjoy doing-even when teenagers aren't forthcoming about how they feel.

Similarly, the majority of teenagers who develop substance abuse problems also have a psychiatric disorder, including, most commonly, anxiety or depression, which is another important reason to get treatment in a timely way.

Fortunately, early involvement of health care professionals can shorten the period of illness and decrease the likelihood of missing important life lessons.

The most common treatment a mental health professional is apt to use is some form of cognitive behavioral therapy, and depending on how young the child is, it may involve teaching the parents as well. Cognitive behavioral therapy is based on the idea that a person suffering from a mood disorder is trapped in a negative pattern of thought. Depressed kids tend to evaluate themselves negatively, interpret the actions of others in a negative way, and assume the darkest possible outcome of events. In CBT, we teach sufferers to challenge those negative thoughts, recognize the pattern and train themselves to think outside it. And in many cases, we see real improvement.

If the depression is moderate to severe, treatment may involve medications such as antidepressants. A combination of psychotherapy and medication usually works better than either alone.

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What Are the Symptoms of Depression in Teenagers? - Child Mind Institute

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What are teen depression symptoms? Child Mind Institute provides information on how to tell if your teenager is just moody or depressed, and how to address the issue.

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Student self-monitoring is an effective tool for behavior change. Self-monitoring has two components, measurement and evaluation (Loftin, Gibb, & Skiba, 2005): That is, the student (1) measures and records his or her own behavior (measurement), and then (2) compares that recorded behavior to a pre-determined standard (evaluation). Self-monitoring can take many forms. One student may use a paper form to rate her study skills at the end of each class period, for example, while another student might verbally rate his social behaviors when approached by his teacher at random times across the school day.

Self-monitoring takes advantage of a behavioral principle: the simple acts of measuring one's target behavior and comparing it to an external standard or goal can result in lasting improvements to that behavior. Self-monitoring is sometimes described as having 'reactive' effects (Kazdin, 1989), because students who measure and pay close attention to selected behaviors often react to this monitoring information by changing those target behaviors in the desired direction.

In classroom settings, self-monitoring offers several advantages. Self-monitoring requires that the student be an active participant in the intervention, with responsibility for measuring and evaluating his or her behaviors. Also, in order to accurately self-evaluate behaviors, the student must first learn the teacher's behavioral expectations. That ability of a child or youth to understand and internalize the behavioral expectations of others is a milestone in the development of social skills. Finally, student self-monitoring data is typically economical to collect, even in a busy classroom, and can often be used to document the success of a behavioral intervention.

There are many possible variations to student self-monitoring programs. In order to be most effective, however, self-monitoring programs will usually include the following 7 steps:

The teacher and student select and carefully define one or more behaviors that the student will monitor.

Targets for self-monitoring can include behaviors to increase (Webber et al., 1993), such as:

Focusing on the task or assignment (on-task).

Making positive statements to peers.

Completing work.

Complying with teacher requests.

Reading pages of text read during study periods.

Completing math computation problems.

Self-monitoring can also focus on behaviors to decrease (Dunlap, Clarke, Jackson, Ramos, & Brinson, 1995), such as:

Calling out.

Leaving one's seat.

Requesting teacher assistance.

The teacher should meet privately with the student to discuss the behavior(s to be monitored. For each goal behavior, the teacher and student write a clear, specific behavioral definition that provides observable 'look-fors' to indicate when the behavior is displayed. For example, 'on-task' can be made observable by defining it as "eyes on the teacher or desk-work".

Student self-monitoring does not necessarily require that monitoring data be written down. For example, a student who regularly consults a self-correction checklist before turning in math assignments or keeps a mental count of call-outs during large-group instruction may see behavioral improvements even if she does not commit her self-monitoring information to writing. However, creating a written record of self-monitoring data will allow the student to collect data over time to look for trends of improvement and to share self-monitoring information with teachers and/or parents.

Reviewed here are three convenient formats to structure the collection of self-monitoring data and to record the resulting behavioral data--rating scale, checklist, and frequency count (Chafouleas, Riley-Tillman, & Sugai, 2007):

Rating scale. A rating scale consists of one or more items that a student can use to complete a global rating of a corresponding number of behaviors (e.g., "How well did I: (1) stay in my seat?; (2) participate?; (3) avoid distracting others?; (4) follow directions?"). The rating scale usually has a qualitative, sliding-scale rating format (e.g., "poor...fair...good"). Rating scales are typically completed at the conclusion of a fixed observation period (e.g., after a class period; at the end of the school day). See the sample Behavior Rating Scale later in this article for an example of how to set up a rating scale to measure student behaviors.

Checklist. A checklist is a listing of behaviors (to be increased or decreased) that the student periodically reviews, checking off those behaviors actually displayed during the monitoring period. For example, a student may have a checklist for independent assignments that contains these 3 work-readiness items: (1) I have all work materials needed, (2) My desk workspace is organized, (3) I understand the directions of this assignment. Before beginning independent work, that student reviews and verifies that these preparatory actions have been carried out. Checklists are helpful for monitoring multi-step behaviors (e.g., the plan-write-revise-edit stages of the writing process) or for monitoring clusters of several related behaviors (e.g., as illustrated in the work-readiness example cited above). Investigate the sample Behavior Checklist elsewhere in this article as a guide for setting up a behavior checklist.

Frequency count. In a frequency count, the student keeps a running tally of the number of times that a he or she displays a target behavior (e.g., number of call-outs or requests for teacher assistance) during an observation period. Check out the example of a Frequency Count form further on in this article for advice on monitoring the frequency of student behaviors.

Because self-monitoring requires that the student periodically measure his or her behavior, the teacher and student must decide on what schedule the monitoring will occur (Rafferty, 2010; Webber et al. 1993). Here are options:

Start of period or day. The student monitors at the start of the class period or school day. Sample behaviors suitable for 'start' intervals include arriving to class on time and having all required work materials.

End of period or day. The student monitors at the end of the class period or school day. Sample behaviors suitable for 'end' intervals include copying homework assignments from the board and global ratings of the student's behavior during that classroom period or school day.

Scheduled transition points through period or day. The student monitors periodically during the class period or school day, with each monitoring episode tied to a scheduled, easily identified 'transition point' that naturally occurs in that classroom setting. A common transition point would be the student's moving from one learning activity to another (e.g., from independent seatwork to whole-class lecture). Sample behaviors suitable for 'transition point' intervals include the speed of the student's transition between activities and the student's general behavior during transition periods.

Start or end of assignments. As student academic work is often the focus of self-monitoring, a logical time-point for doing that monitoring is when beginning or finishing assignments. Sample behaviors suitable for 'start of assignments' include checking for the presence of all work materials and clearing the desk to create an uncluttered work space. Sample behaviors suitable for 'end of assignments' include ensuring that a writing assignment is legible and correctly formatted and applying a self-correction checklist to a math assignment to catch and correct common mistakes.

Fixed intervals through period or day. The student monitors at fixed periods during the class period or school day (e.g., every 15 minutes; at the top of each hour). Sample behaviors suitable for 'fixed' intervals include overall classroom behaviors, attention and focus, social interactions with other students, and compliance with adult requests.

Once the teacher and student have determined a monitoring schedule, they should decide on a cue to trigger student monitoring (Rafferty, 2010). Below are some options. (Note that most of these cuing methods can either be self-administered by the student or used by the teacher to cue one student, a small group, or even an entire class):

'Beep tape'. The student is given an audio tape (or electronic audio file) with beeps spaced at fixed intervals whose rate matches the student's self-monitoring schedule. For example, a student monitors his on-task behavior every 5 minutes on a self-rating scale using an MP3 player with an audio-file beep tape with tones at 5 minute intervals. NOTE: Schools can download free fixed-interval beep tapes in MP3 format and in a range of interval-lengths from: http://www.interventioncentral.org/free-audio-monitoring-tapes

Timer. The student or teacher sets a timer (e.g., kitchen timer, cell-phone timer, stopwatch) for a pre-set interval. When the timer rings, the student self-monitors behavior and then the timer is reset. For example, a student in a math class sets a cell-phone timer with vibration setting for 3-minute intervals during independent work. When the timer rings, the student counts up the number of math-computation problems completed during the interval.

Teacher-delivered cue. The teacher delivers a cue to the student to remind him or her to self-monitor. For example, at the end of an in-class writing assignment, an English instructor prompts the class to review their compositions using self-correction checklists before turning in their work.

Student-delivered cue. The student is given responsibility to initiate self-monitoring informally without use of a timer, beep tape, or other external cue. For example, a student monitoring her understanding of assigned texts during in-class independent reading is directed to use a rating scale at least 3 times during the activity to rate and record her comprehension of the text --with the student determining how to space those self-checks.

The teacher may want to choose suitable rewards to further motivate students to use self-monitoring to move toward positive behavior change (Loftin, Gibb, & Skiba, 2005). Teachers can increase the power of a self-monitoring program by rewarding students when they consistently achieve positive ratings. Remember, though, that students differ in what experiences, privileges, or objects they find positively reinforcing. Here are 3 ideas for figuring out what rewards will motivate a particular student:

Watch the student in action. Teachers can often get a very good idea of a student's preferred rewards, or reinforces, simply by observing the student across the school day. The locations where a student chooses to spend time, the people he or she chooses to interact with, and the activities the student engages in all provide hints about what the student finds rewarding. For example, one student may have a friend that he enjoys spending time with, suggesting that the student would view 'free time with a friend of your choice' as a motivating reward. Another student might frequently beg the teacher to be allowed to care for the class mascot, a pet rabbit-presenting the possible reward idea of 'five minutes petting the rabbit'.

Ask people who know the student well. Adults such as parents or past teachers who have interacted with the student regularly for months or years may be able to supply a list of ideas about rewards that will really motivate him or her.

Administer a reinforcer survey. Reinforcer surveys contain a list of possible rewards acceptable for use in a classroom. The teacher meets with the student to review each reinforcer item on the survey, and the student rates whether he or she finds the item to be a motivating reward. The teacher can then create a menu of possible rewards for the student using those reinforcers that the student rated as most motivating. (HINT: Teachers can conveniently create their own customized reinforcer surveys online at this web address: http://www.interventioncentral.org/teacher-resources/student-rewards-finder.)

Periodically, the teacher should check the student's self-monitoring data and procedures--particularly at the start of the monitoring--to ensure that the student is recording accurately (Webber et al., 1993). Random spot-checks tend to result in higher-quality student self-recording data.

As the student attains his or her behavioral goals, self-monitoring procedures should be faded--that is, gradually simplified or discontinued (Loftin, Gibb, & Skiba, 2005; Rafferty, 2010). The goals in fading are (1) to streamline self-monitoring so that it becomes sustainable over the long term, while (2) maintaining the student's behavioral gains. Specific methods used in fading will vary, depending on the elements that make up the self-monitoring plan. Fading strategies might include condensing the monitoring format (e.g., distilling a 6-item checklist for monitoring classwork-readiness into a single question: "Am I ready to work?"), changing the monitoring cue (e.g., moving from use of an external beep-tape to student-delivered cues); and monitoring less frequently (e.g., having the student shift down from a daily monitoring schedule to monitoring twice per week on randomly selected days).

References

Chafouleas, S., Riley-Tillman, C., & Sugai, G. (2007). School-based behavioral assessment: Informing intervention and instruction. New York: Guilford Press.

Dunlap, G., Clarke, S., Jackson, M., Ramos, E., & Brinson, S. (1995). Self-monitoring of classroom behaviors with students exhibiting emotional and behavioral challenges. School Psychology Quarterly, 10, 165-177.

Kazdin, A. E. (1989). Behavior modification in applied settings (4th ed.). Pacific Gove, CA: Brooks/Cole.

Loftin, R. L., Gibb, A. C., & Skiba, R. (2005). Using self-monitoring strategies to address behavior and academic issues. Impact, 18(2), 12-13. Retrieved from the Web site of the Institute on Community Integration, University of Minnesota (http://ici.umn.edu).

Rafferty, L. A. (2010). Step-by-step: Teaching students to self-monitor. Teaching Exceptional Children, 43(2), 50-58.

Webber, J., Scheuermann, B., McCall, C., & Coleman, M. (1993). Research on self-monitoring as a behavior management technique in special education classrooms: A descriptive review. Remedial & Special Education, 14(2), 38-56.

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How To: Teach Students to Change Behaviors Through Self-Monitoring

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Student self-monitoring is an effective tool for behavior change. Self-monitoring has two components, measurement and evaluation (Loftin, Gibb, & Skiba, 2005): That is, the student (1) measures and records his or her own behavior (measurement), and then (2) compares that recorded behavior to a pre-determined standard (evaluation).

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Parents Guide to ADHD - ChildMind.org

Children with attention-deficit hyperactivity disorder (ADHD) find it unusually difficult to concentrate on tasks, to pay attention, to sit still, and to control impulsive behavior. This guide offers parents the information you need to understand the behaviors associated with the disorder and make effective decisions for your child about symptoms, diagnosis, and treatment.

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Parents Guide to ADHD - ChildMind.org Children with attention-deficit hyperactivity disorder (ADHD) find it unusually difficult to concentrate on tasks, to pay attention, to sit still, and to control impulsive behavior. This guide offers parents the information you need to understand the behaviors associated with the disorder and make effective decisions for your child about symptoms, diagnosis, and treatment.

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Individuals with Disabilities Education Act

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The Individuals with Disabilities Education Act (IDEA) is a law that makes available a free appropriate public education to eligible children with disabilities throughout the nation and ensures special education and related services to those children.

The IDEA governs how states and public agencies provide early intervention, special education, and related services to more than 8 million (as of school year 2022-23) eligible infants, toddlers, children, and youth with disabilities.

Infants and toddlers, birth through age 2, with disabilities and their families receive early intervention services under IDEA Part C. Children and youth ages 3 through 21 receive special education and related services under IDEA Part B.

Additionally, the IDEA authorizes:

Formula grants to states to support special education and related services and early intervention services.

Discretionary grants to state educational agencies, institutions of higher education, and other nonprofit organizations to support research, demonstrations, technical assistance and dissemination, technology development, personnel preparation and development, and parent-training and -information centers.

Congress reauthorized the IDEA in 2004 and most recently amended the IDEA through Public Law 114-95, the Every Student Succeeds Act, in December 2015.

In the law, Congress states:

Disability is a natural part of the human experience and in no way diminishes the right of individuals to participate in or contribute to society. Improving educational results for children with disabilities is an essential element of our national policy of ensuring equality of opportunity, full participation, independent living, and economic self-sufficiency for individuals with disabilities.

Other Laws for Children with Disabilities

The U.S. Department of Education's Office for Civil Rights (OCR) provides additional resources of interest for individuals with disabilities and their families.

OCR does not enforce the IDEA; however, OCR does enforce the Rehabilitation Act of 1973, Section 504 and Americans with Disabilities Act of 1990, Title II rights of IDEA-eligible students with disabilities.

To learn more, visit the OCR's Frequently Asked Questions About Section 504 and the Education of Children with Disabilities.

Visit OCR's website for additional resources.

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About IDEA - Individuals with Disabilities Education Act

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The IDEA is a law that makes available a free appropriate public education to eligible children with disabilities throughout the nation and ensures special education and related services to those children.

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Centers for Disease Control and Prevention

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Learn about different types of mental disorders in children, including symptoms, treatment, and what can be done to prevent them.

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Centers for Disease Control and Prevention

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Mental health is an important part of children's overall health and well-being. Mental health includes children's mental, emotional, and behavioral well-being. It affects how children think, feel, and act. It also plays a role in how children handle stress, relate to others, and make healthy choices.

Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day. Among the more common mental disorders that can be diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety, and behavior disorders.

There are different ways to assess mental health and mental disorders in children. CDC uses surveys, like the National Survey of Children's Health, to describe the presence of positive indicators of children's mental health and to understand the number of children with diagnosed mental disorders and whether they received treatment. In this type of survey, parents report on indicators of positive mental health for their child and report any diagnoses their child has received from a healthcare provider. The information on this page provides data about indicators of positive mental health in children and mental health disorders that are most common in children.

Facts about mental health in U.S. children

National data on positive mental health indicators that describe mental, emotional, and behavioral well-being for children are limited. Based on the data we do have:

Facts about mental disorders in U.S. children

ADHD, anxiety problems, behavior problems, and depression are the most commonly diagnosed mental disorders in children. Estimates for ever having a diagnosis among children aged 3-17 years, in 2016-19, are given below.

ADHD 9.8% (approximately 6.0 million)

Anxiety 9.4% (approximately 5.8 million)

Behavior problems 8.9% (approximately 5.5 million)

Depression 4.4% (approximately 2.7 million)

Some of these conditions commonly occur together. For example, among children aged 3-17 years in 2016:

Having another mental disorder was most common in children with depression: about 3 in 4 children with depression also had anxiety (73.8%) and almost 1 in 2 had behavior problems (47.2%).

For children with anxiety, more than 1 in 3 also had behavior problems (37.9%) and about 1 in 3 also had depression (32.3%).

For children with behavior problems, more than 1 in 3 also had anxiety (36.6%) and about 1 in 5 also had depression (20.3%).

For adolescents, depression, substance use and suicide are important concerns. Among adolescents aged 12-17 years in 2018-2019 reporting on the past year:

Learn more about high-risk substance use among youth. Learn more about suicide.

Mental, behavioral, and developmental disorders begin in early childhood
1 in 6 U.S. children aged 2-8 years (17.4%) had a diagnosed mental, behavioral, or developmental disorder.

Prevalence of mental disorders change with age

Diagnoses of ADHD, anxiety, and depression become are more common with increased age.

Behavior problems are more common among children aged 6-11 years than younger or older children.

Adverse childhood events (ACEs) are associated with children's physical and mental health. In 2016-2019, among children aged 6-17 years:

Children who were discriminated against based on race or ethnicity had higher percentages of one or more physical health conditions (37.8% versus 27.1%), and one or more mental health conditions (28.9% versus 17.8%).

Racial/ethnic discrimination was almost seven times as common among children with three other ACEs compared to those with no other ACEs.

Note: The estimates reported on this page are based on parent report, using nationally representative surveys. This method has several limitations. It is not known to what extent children receive these diagnoses accurately. Estimates based on parent-reported diagnoses may match those based on medical records, but some children may also have mental disorders that have not been diagnosed, or receive diagnoses that may not be the best fit for their symptoms. Limited information on measuring children's mental health nationally is available.

Read more about children's mental health from a community study.

Access to mental health treatment

Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders. Access to providers who can offer services, including screening, referrals, and treatment, varies by location. CDC is working to learn more about access to behavioral health services and supports for children and their families.
View information by state describing the rates of different types of providers who can offer behavioral health services providers by county. Read a recent report describing shortages of services, barriers to treatment, and how integration of behavioral health care with pediatric primary care could address the issues. Read a policy brief on potential ways to increase access to mental health services for children in rural areas
Data sources for mental health and related conditions

There are many different datasets which include information on children's mental health and related conditions for children living in the United States.

Healthy People 2030
Healthy People 2030 sets data-driven national objectives to improve health and well-being over the next decade, including children's mental health and well-being.

National Survey of Family Growth (NSFG)
NSFG gathers information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and general and reproductive health.

National Health and Nutrition Examination Survey (NHANES)
NHANES assesses health and nutritional status through interviews and physical examinations, and includes conditions, symptoms, and concerns associated with mental health and substance abuse, as well as the use and need for mental health services.

National Health Interview Survey (NHIS)
NHIS collects data on children's mental health, mental disorders, such as ADHD, autism spectrum disorder, depression and anxiety problems, and use and need for mental health services.

National Survey of Children's Health (NSCH)
NSCH examines the health of children, with emphasis on well-being, including medical homes, family interactions, the health of parents, school and after-school experiences, and safe neighborhoods. This survey was redesigned in 2016.

For previous versions of this survey, see also:
National Survey of Children's Health (NSCH 2003, 2007, 2011-12)
National Survey of Children with Special Healthcare Needs (NS-CSHCN 2001, 2005-6, 2009-10)

National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome (NS-DATA)
NS-DATA collects information about children, 2-15 years old in 2011-2012, who had ever been diagnosed with ADHD and/or Tourette syndrome (TS), with the goal of better understanding diagnostic practices, level of impairment, and treatments for this group of children.

National Survey on Drug Use and Health (NSDUH)
NSDUH, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides national- and state-level data on the use of tobacco, alcohol, and illicit drugs (including non-medical use of prescription drugs), as well as data on mental health in the United States.

National Vital Statistics System (NVSS)
NVSS contains vital statistics from the official records of live births, deaths, causes of death, marriages, divorces, and annulment recorded by states and independent registration areas

National Youth Tobacco Survey (NYTS)
NYTS is a nationally representative school-based survey on tobacco use by public school students enrolled in grades 6-12.

School Associated Violent Death Study (SAVD)
SAVD plays an important role in monitoring trends related to school-associated violent deaths (including suicide), identifying the factors that increase the risk, and assessing the effects of prevention efforts.

School Health Policies and Programs Study (SHPPS)
SHPPS is a national survey assessing school health policies and practices at the state, district, school, and classroom levels. Collected data includes mental health and social service policies.

Web-based Injury Statistics Query and Reporting System (WISQARS)
WISQARS is an interactive database system that provides customized reports of injury-related data.

Youth Risk Behavior Surveillance System (YRBSS)
The YRBSS monitors health-risk behaviors, including tobacco use, substance abuse, unintentional injuries and violence, sexual behaviors that contribute to unintended pregnancy, and sexually transmitted diseases.

References

1. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, Hedden SL, Crosby AE, Visser SN, Schieve LA, Parks SE, Hall JE, Brody D, Simile CM, Thompson WW, Baio J, Avenevoli S, Kogan MD, Huang LN. Mental health surveillance among children - United States, 2005-2011. MMWR 2013;62(Suppl; May 16, 2013):1-35. [Read summary]

2. Bitsko RH, Claussen AH, Lichtstein J, Black LJ, Everett Jones S, Danielson MD, Hoenig JM, Davis Jack SP, Brody DJ, Gyawali S, Maenner MM, Warner M, Holland KM, Perou R, Crosby AE, Blumberg SJ, Avenevoli S, Kaminski JW, Ghandour RM. Surveillance of Children's Mental Health - United States, 2013 - 2019 MMWR, , 2022 / 71(Suppl-2);1-42. [Read article]

3. Ghandour RM, Sherman LJ, Vladutiu CJ, Ali MM, Lynch SE, Bitsko RH, Blumberg SJ. Prevalence and treatment of depression, anxiety, and conduct problems in U.S. children. The Journal of Pediatrics, 2018. Published online before print October 12, 2018 [Read summary]

4. Bitsko RH, Holbrook JR, Ghandour RM, Blumberg SJ, Visser SN, Perou R, Walkup J. Epidemiology and impact of healthcare provider diagnosed anxiety and depression among US children. Journal of Developmental and Behavioral Pediatrics. Published online before print April 24, 2018 [Read summary]

5. Cree RA, Bitsko RH, Robinson LR, Holbrook JR, Danielson ML, Smith DS, Kaminski JW, Kenney MK, Peacock G. Health care, family, and community factors associated with mental, behavioral, and developmental disorders and poverty among children aged 2-8 years - United States, 2016. MMWR, 2018;67(5):1377-1383. [Read article]

6. Hutchins HJ, Barry CM, Valentine V, Bacon S, Njai R, Claussen AH, Ghandour RM, Lebrun-Harris LA, Perkins K, Robinson LR (submitted). Perceived racial/ethnic discrimination, physical and mental health conditions in childhood, and the relative role of other adverse experiences. Adversity and Resilience Science published online May 23, 2022. [Read summary]

7. US Department of Health and Human Services Health Resources and Services Administration & Maternal and Child Health Bureau. Mental health: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health; 1999. [Read report]

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Data and Statistics on Children's Mental Health | CDC

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Read data highlights about children's mental health.