Early detection of mental disorders in students can provide advantages. Schools provide a universal setting to observe students and identify issues early, as 20% of the US population can be found in schools. Common issues in students include depression, which affects 20-38% of youth and is characterized by symptoms like depressed mood, loss of interest, and impaired functioning. Early identification can help link students to needed support and treatment.

1. Advantages of EarlyAdvantages of Early
Detection of Mental DisordersDetection of Mental Disorders
in the Student Populationin the Student Population
Ronald Malave Ortiz, M.D.Ronald Malave Ortiz, M.D.
PsychiatristPsychiatrist
20162016

2. Psychosocial Crisis StagePsychosocial Crisis Stage Life StageLife Stage
age range, otherage range, other
descriptionsdescriptions
1. Trust v Mistrust1. Trust v Mistrust InfancyInfancy
0-1½ yrs, baby, birth to0-1½ yrs, baby, birth to
walkingwalking
2. Autonomy v Shame and2. Autonomy v Shame and
DoubtDoubt
Early ChildhoodEarly Childhood 1-3 yrs, toddler, toilet training1-3 yrs, toddler, toilet training
3. Initiative v Guilt3. Initiative v Guilt Play AgePlay Age 3-6 yrs, pre-school, nursery3-6 yrs, pre-school, nursery
4. Industry v Inferiority4. Industry v Inferiority School AgeSchool Age 5-12 yrs, early school5-12 yrs, early school
5. Identity v Role Confusion5. Identity v Role Confusion AdolescenceAdolescence 13-18 yrs, puberty, teens*13-18 yrs, puberty, teens*
6. Intimacy v Isolation6. Intimacy v Isolation Young AdultYoung Adult
18-40, courting, early18-40, courting, early
parenthoodparenthood
7. Generativity v Stagnation7. Generativity v Stagnation AdulthoodAdulthood 30-65, middle age, parenting30-65, middle age, parenting
8. Integrity v Despair8. Integrity v Despair Mature AgeMature Age 50+, old age, grandparents50+, old age, grandparents
Erik EricksonErik Erickson’’s Stages of Developments Stages of Development

3. OverviewOverview
• Developmental Stages; Review of NormalDevelopmental Stages; Review of Normal
versus Abnormal Child Developmentversus Abnormal Child Development
• Why Schools?Why Schools?
• DSM-5DSM-5
• Common Mental Health Issues, Review ofCommon Mental Health Issues, Review of
Symptoms and Practice SkillsSymptoms and Practice Skills
• Developing Healthy School EnvironmentsDeveloping Healthy School Environments
• Q and AQ and A

4. Mental Health Issue or Not?Mental Health Issue or Not?
Red Flags or Not?Red Flags or Not?
• If a child falls asleep every afternoon inIf a child falls asleep every afternoon in
class during the lesson?class during the lesson?
• If a child is late for school often?If a child is late for school often?
• If a child has frequent suspensions for notIf a child has frequent suspensions for not
following directions in class?following directions in class?
• If a child has a temper tantrum?If a child has a temper tantrum?
• If a child is unkempt?If a child is unkempt?

5. Lets Visit Ages 6 to 12Lets Visit Ages 6 to 12
Think about your experiences in 3Think about your experiences in 3rdrd
GradeGrade
• Where did you live?Where did you live?
• Who was your best friend?Who was your best friend?
• What games did you like to play?What games did you like to play?
• Where did you go to school? Who was your teacher?Where did you go to school? Who was your teacher?
What expression did he or she have on his or her face inWhat expression did he or she have on his or her face in
greeting you each day?greeting you each day?
• What game or technology was the newest thing?What game or technology was the newest thing?
• What was your favorite thing to eat at school?What was your favorite thing to eat at school?
• Was there a particular smell that you can remember toWas there a particular smell that you can remember to
your school? (pine sol? Mystery meat?....)your school? (pine sol? Mystery meat?....)

6. Developmental Goals (6 to 12)Developmental Goals (6 to 12)
• Ages 6 to 12Ages 6 to 12
– To develop industryTo develop industry
• Begins to learn the capacity to workBegins to learn the capacity to work
• Develops imagination and creativityDevelops imagination and creativity
• Learns self-care skillsLearns self-care skills
• Develops a conscienceDevelops a conscience
• Learns to cooperate, play fairly, and follow socialLearns to cooperate, play fairly, and follow social
rulesrules

7. Normal Difficult BehaviorNormal Difficult Behavior
Ages 6 to 12Ages 6 to 12
• Arguments/Fights with Siblings and/or PeersArguments/Fights with Siblings and/or Peers
• Curiosity about Body Parts of males and femalesCuriosity about Body Parts of males and females
• Testing LimitsTesting Limits
• Limited Attention SpanLimited Attention Span
• Worries about being acceptedWorries about being accepted
• LyingLying
• Not Taking Responsibility for BehaviorNot Taking Responsibility for Behavior

8. Cries for Help/More Serious IssuesCries for Help/More Serious Issues
Ages 6-12Ages 6-12
• Excessive AggressivenessExcessive Aggressiveness
• Serious Injury to Self or OthersSerious Injury to Self or Others
• Excessive FearsExcessive Fears
• School Refusal/PhobiaSchool Refusal/Phobia
• Fire Fixation/SettingFire Fixation/Setting
• Frequent Excessive or Extended EmotionalFrequent Excessive or Extended Emotional
ReactionsReactions
• Inability to Focus on Activity even for FiveInability to Focus on Activity even for Five
MinutesMinutes
• Patterns of Delinquent behaviorsPatterns of Delinquent behaviors

9. AdolescenceAdolescence

10. LetLet’’s Visit Ages 13-18s Visit Ages 13-18
Think about your experiences inThink about your experiences in
1010thth
gradegrade
• Who was your favorite teacher?Who was your favorite teacher?
• Were you dating or not dating?Were you dating or not dating?
• Who was your best friend?Who was your best friend?
• How would you have described your parent/caregiver?How would you have described your parent/caregiver?
• What did you do for fun?What did you do for fun?
• What was the latest and greatest technology?What was the latest and greatest technology?
• What was your favorite movie, song, or tv show?What was your favorite movie, song, or tv show?

11. Developmental GoalsDevelopmental Goals
• Developing Identity-the child developsDeveloping Identity-the child develops
self-identity and the capacity for intimacyself-identity and the capacity for intimacy
– Continue mastery of skillsContinue mastery of skills
• Accepting responsibility for behaviorAccepting responsibility for behavior
• Able to develop friendshipsAble to develop friendships
• Able to follow social rulesAble to follow social rules

14. Normal Difficult BehaviorNormal Difficult Behavior
• Moodiness!Moodiness!
• Less attention and affection towards parentsLess attention and affection towards parents
• Extremely self involvedExtremely self involved
• Peer conflictsPeer conflicts
• Worries and stress about relationshipsWorries and stress about relationships
• Testing limitsTesting limits
• Identity Searching/ExploringIdentity Searching/Exploring
• Substance use experimentationSubstance use experimentation
• Preoccupation with sexPreoccupation with sex

15. Cries for Help- Ages 13-18Cries for Help- Ages 13-18
• Sexual promiscuitySexual promiscuity
• Suicidal/homicidal ideationSuicidal/homicidal ideation
• Self-mutilationSelf-mutilation
• Frequent displays of temperFrequent displays of temper
• Withdrawal from usual activitiesWithdrawal from usual activities
• Significant change in grades, attitude, hygiene,Significant change in grades, attitude, hygiene,
functioning, sleeping, and/or eating habitsfunctioning, sleeping, and/or eating habits
• DelinquencyDelinquency
• Excessive fighting and/or aggression (physical/verbal)Excessive fighting and/or aggression (physical/verbal)
• Inability to cope with day to day activitiesInability to cope with day to day activities
• Lots of somatic complaints (frequent flyers)Lots of somatic complaints (frequent flyers)

16. DiscussionDiscussion
• How do you make the distinction betweenHow do you make the distinction between
normal versus abnormal development?normal versus abnormal development?
– How can you tell?How can you tell?

17. Why Schools?Why Schools?

18. ““Could someone help me with these?Could someone help me with these?
II’’m late for math class.m late for math class.””

20. Schools: The MostSchools: The Most
Universal Natural SettingUniversal Natural Setting
• Over 55 million youthOver 55 million youth
attend 114,700 schoolsattend 114,700 schools
(K-12) in the U.S.(K-12) in the U.S.
• 6.8 million adults work6.8 million adults work
in schoolsin schools
• Combining studentsCombining students
and staff, approximatelyand staff, approximately
20% of the U.S.20% of the U.S.
population can be foundpopulation can be found
in schools during thein schools during the
work week.work week.

21. Overview of ChildrenOverview of Children ’’ss
Mental Health NeedsMental Health Needs
• Between 20% to 38% of youth in the U.S. haveBetween 20% to 38% of youth in the U.S. have
diagnosable mental health disordersdiagnosable mental health disorders
• Between 9% to 13% of youth have serious disturbancesBetween 9% to 13% of youth have serious disturbances
that impact their daily functioningthat impact their daily functioning
• Between one-sixth to one-third of youth with diagnosableBetween one-sixth to one-third of youth with diagnosable
disorders receive any treatmentdisorders receive any treatment
• Schools provide a natural, universal setting for providingSchools provide a natural, universal setting for providing
a full continuum of mental health carea full continuum of mental health care

22. Workforce IssuesWorkforce Issues
• 15% of teachers leave after year 115% of teachers leave after year 1
• 30% of teachers leave within 3 years30% of teachers leave within 3 years
• 40-50% of teachers leave within 5 years40-50% of teachers leave within 5 years
(Smith and Ingersoll, 2003)(Smith and Ingersoll, 2003)

23. Opportunities in SchoolsOpportunities in Schools
• Can do observations of children in aCan do observations of children in a
natural settingnatural setting
• Can outreach to youth with internalizingCan outreach to youth with internalizing
disordersdisorders
• Can provide three tiers of serviceCan provide three tiers of service
(universal, selective, and indicated)(universal, selective, and indicated)
• Can be part of a multidisciplinary teamCan be part of a multidisciplinary team
involving school staff, families, and youthinvolving school staff, families, and youth

24. Activity-BrainstormingActivity-Brainstorming
• What is the mental health issue that youWhat is the mental health issue that you
find the most challenging in schools?find the most challenging in schools?

25. What is the DSM 5?What is the DSM 5?
• A reference guide for diagnosing mentalA reference guide for diagnosing mental
health concernshealth concerns
• Published by the American PsychiatricPublished by the American Psychiatric
Association in May 2013Association in May 2013
• For each Diagnosis provides specificFor each Diagnosis provides specific
criteria that needs to be metcriteria that needs to be met

26. DepressionDepression
EpidemiologyEpidemiology
• 2.5% of children, up to 5% of adolescents2.5% of children, up to 5% of adolescents
• Prepubertal-1:1/F:M; adolescence-4:1/F:MPrepubertal-1:1/F:M; adolescence-4:1/F:M
• Average length of untreated MajorAverage length of untreated Major
Depressive Disorder – 7.2 monthsDepressive Disorder – 7.2 months
• Recurrence rates-40% within 2 yearsRecurrence rates-40% within 2 years
Heredity
• Most important risk factor for the development
of depressive illness is having at least one
affectively ill parent

27. Major Depressive DisorderMajor Depressive Disorder
I.I. Five (or more) of the following symptoms have been present duringFive (or more) of the following symptoms have been present during
the same two-week period and represent a change from previousthe same two-week period and represent a change from previous
functioning. At least one symptom is either (1) depressed mood orfunctioning. At least one symptom is either (1) depressed mood or
(2) loss of interest or pleasure.(2) loss of interest or pleasure.
– Depressed mood most of the day, nearly every day, as indicated byDepressed mood most of the day, nearly every day, as indicated by
subjective report or based on the observations of others. In childrensubjective report or based on the observations of others. In children
and adolescents, this is often presented as irritability.and adolescents, this is often presented as irritability.
– Markedly diminished interest or pleasure in all, or almost all,Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every dayactivities most of the day, nearly every day
– Significant weight loss when not dieting or weight gain (change ofSignificant weight loss when not dieting or weight gain (change of
more than 5% of body weight in a month), or decrease or increasemore than 5% of body weight in a month), or decrease or increase
in appetite nearly every dayin appetite nearly every day
– Insomnia or hypersomnia nearly every dayInsomnia or hypersomnia nearly every day
– Psychomotor agitation or retardation nearly every day (observablePsychomotor agitation or retardation nearly every day (observable
by others)by others)
– Fatigue or loss of energy nearly every dayFatigue or loss of energy nearly every day
– Feelings of worthlessness or inappropriate guilt nearly every dayFeelings of worthlessness or inappropriate guilt nearly every day
– Diminished ability to think, concentrate, make a decision nearlyDiminished ability to think, concentrate, make a decision nearly
every dayevery day

28. Major Depressive DisorderMajor Depressive Disorder
II.II. Symptoms cause clinically significant distressSymptoms cause clinically significant distress
or impairment in social or academic functioningor impairment in social or academic functioning
III.III. Symptoms are not due to the direct physiologicalSymptoms are not due to the direct physiological
effects of a substance (drugs or medication) or aeffects of a substance (drugs or medication) or a
general medical conditiongeneral medical condition
Although there is a different diagnostic category forAlthough there is a different diagnostic category for
individuals who suffer from Bereavement, many of theindividuals who suffer from Bereavement, many of the
symptoms are the same and counseling techniquessymptoms are the same and counseling techniques
may overlap.may overlap.

29. Dysthymic DisorderDysthymic Disorder
• Major difference between a diagnosis of MajorMajor difference between a diagnosis of Major
Depressive Disorder and Dysthymia is theDepressive Disorder and Dysthymia is the
intensity of the feelings of depression and theintensity of the feelings of depression and the
duration of symptoms.duration of symptoms.
• Dysthymia is an overarching feeling ofDysthymia is an overarching feeling of
depression most of the day, more days than not,depression most of the day, more days than not,
that does not meet criteria for a Majorthat does not meet criteria for a Major
Depressive Episode.Depressive Episode.
• Impairs functioning and lasts for at least oneImpairs functioning and lasts for at least one
year in children and adolescents, two in adults.year in children and adolescents, two in adults.

30. DepressionDepression
Modifications in DSM- 5 for children:Modifications in DSM- 5 for children:
• irritable mood (vs. depressive mood)irritable mood (vs. depressive mood)
• observed apathy and pervasive boredom (vs.observed apathy and pervasive boredom (vs.
anhedonia)anhedonia)
• failure to make expected weight gains (rather thanfailure to make expected weight gains (rather than
significant weight loss)significant weight loss)
• somatic complaintssomatic complaints
• social withdrawalsocial withdrawal
• declining school performancedeclining school performance

31. What depression may look like:What depression may look like:
• Negative thinking –Negative thinking – ““I canI can’’t, I wont, I won’’tt””
• Social withdrawalSocial withdrawal
• IrritabilityIrritability
• Poor school performance (not just grades)Poor school performance (not just grades)
• Lack of interest in peer activitiesLack of interest in peer activities
• Muscle aches or lack of energyMuscle aches or lack of energy
• Reports of feeling helpless a lot of the time.Reports of feeling helpless a lot of the time.
• Lowering their confidence-level about intelligence,Lowering their confidence-level about intelligence,
friends, future, body, etc.friends, future, body, etc.
• Getting into trouble because of boredom.Getting into trouble because of boredom.

32. What Works for DepressionWhat Works for Depression
• PsychoeducationPsychoeducation
• Cognitive/CopingCognitive/Coping
• Problem SolvingProblem Solving
• Activity SchedulingActivity Scheduling
• Skill-Skill-
building/Behavioralbuilding/Behavioral
RehearsalRehearsal
• Social Skills TrainingSocial Skills Training
• Communication SkillsCommunication Skills

33. Cognitive/CopingCognitive/Coping
• Change cognitive distortionsChange cognitive distortions
• Increase positive self talkIncrease positive self talk
• Identify the type of event that willIdentify the type of event that will
trigger the irrational thought.trigger the irrational thought.
• Help students become aware ofHelp students become aware of
their thoughtstheir thoughts
• Recognize and get rid ofRecognize and get rid of
negative self talknegative self talk
• Counter negative thoughts withCounter negative thoughts with
realistic positive self talkrealistic positive self talk
• Believe the positive self talk!Believe the positive self talk!

34. Cognitive DistortionsCognitive Distortions
• ExaggeratingExaggerating -- Making self-critical or otherMaking self-critical or other
critical statements that include terms like never,critical statements that include terms like never,
nothing, everything or always.nothing, everything or always.
• FilteringFiltering - Ignoring positive things that occur to- Ignoring positive things that occur to
and around self but focusing on and inflating theand around self but focusing on and inflating the
negative.negative.
• LabelingLabeling - Calling self or others a bad name- Calling self or others a bad name
when displeased with a behaviorwhen displeased with a behavior
Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health
Curriculum - A Training Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of
Nursing, printed by the University of Colorado School of Nursing.

35. Cognitive DistortionsCognitive Distortions
• DiscountingDiscounting - Rejecting positive experiences as- Rejecting positive experiences as
not important or meaningful.not important or meaningful.
• CatastrophizingCatastrophizing - Blowing expected- Blowing expected
consequences out of proportion in a negativeconsequences out of proportion in a negative
direction.direction.
• Self-blamingSelf-blaming - Holding self responsible for an- Holding self responsible for an
outcome that was not completely under one's control.outcome that was not completely under one's control.
Adapted from: Walker, P.H. & Martinez, R. (Eds.) (2001) Excellence in Mental Health: A school Health
Curriculum - A Training Manual for Practicing School Nurses and Educators. Funded by HRSA, Division of
Nursing, printed by the University of Colorado School of Nursing.

36. AnxietyAnxiety
• Panic DisorderPanic Disorder
• Obsessive Compulsive DisorderObsessive Compulsive Disorder
• Specific PhobiasSpecific Phobias
• Separation Anxiety DisorderSeparation Anxiety Disorder
• Posttraumatic Stress DisorderPosttraumatic Stress Disorder
• Generalized Anxiety DisorderGeneralized Anxiety Disorder

37. Anxiety - PrevalenceAnxiety - Prevalence
• 13% of youth ages 9 to 17 will have an13% of youth ages 9 to 17 will have an
anxiety disorder in any given yearanxiety disorder in any given year
• Girls are affected more than boysGirls are affected more than boys
• ~1/2 of children and adolescents with~1/2 of children and adolescents with
anxiety disorders have a 2anxiety disorders have a 2ndnd
anxietyanxiety
disorder or other co-occurring disorder,disorder or other co-occurring disorder,
such as depressionsuch as depression

38. Panic Disorder - Diagnostic CriteriaPanic Disorder - Diagnostic Criteria
I. Recurrent unexpected Panic AttacksI. Recurrent unexpected Panic Attacks
Criteria for Panic Attack: A discrete period of intense fear or discomfort, inCriteria for Panic Attack: A discrete period of intense fear or discomfort, in
which four (or more) of the following symptoms developed abruptly andwhich four (or more) of the following symptoms developed abruptly and
reached a peak within 10 minutes:reached a peak within 10 minutes:
(1) Palpitations, pounding heart, or accelerated heart rate(1) Palpitations, pounding heart, or accelerated heart rate
(2) Sweating(2) Sweating
(3) Trembling or shaking(3) Trembling or shaking
(4) Sensations of shortness of breath or smothering(4) Sensations of shortness of breath or smothering
(5) Feeling of choking(5) Feeling of choking
(6) Chest pain or discomfort(6) Chest pain or discomfort
(7) Nausea or abdominal distress(7) Nausea or abdominal distress
(8) Feeling dizzy, unsteady, lightheaded, or faint(8) Feeling dizzy, unsteady, lightheaded, or faint
(9) Derealization (feelings of unreality) or depersonalization (being detached(9) Derealization (feelings of unreality) or depersonalization (being detached
from oneself)from oneself)
(10) Fear of losing control or going crazy(10) Fear of losing control or going crazy
(11) Fear of dying(11) Fear of dying
(12) Paresthesias (numbness or tingling sensations)(12) Paresthesias (numbness or tingling sensations)
(13) Chills or hot flushes(13) Chills or hot flushes

39. Specific PhobiasSpecific Phobias
• Marked and persistent fear of a specific object or situationMarked and persistent fear of a specific object or situation
with exposure causing an immediate anxiety responsewith exposure causing an immediate anxiety response
that is excessive or unreasonablethat is excessive or unreasonable
• In children, anxiety may be expressed as crying,In children, anxiety may be expressed as crying,
tantrums, freezing, or clinging.tantrums, freezing, or clinging.
• Animal phobias most common childhood phobia.Animal phobias most common childhood phobia.
• Also frequently afraid of the dark and imaginary creaturesAlso frequently afraid of the dark and imaginary creatures
• In older children and adolescents, fears are more focusedIn older children and adolescents, fears are more focused
on health, social and school problemson health, social and school problems
• Adults recognize that their fear is excessive. ChildrenAdults recognize that their fear is excessive. Children
may not.may not.
• Causes significant interference in life, or significantCauses significant interference in life, or significant
distress.distress.
• Under 18 years of age – symptoms must beUnder 18 years of age – symptoms must be >> 6 months6 months

40. Separation AnxietySeparation Anxiety
DisorderDisorder
Developmentally inappropriate and excessive anxiety concerningDevelopmentally inappropriate and excessive anxiety concerning
separation from home or from those to whom the individual isseparation from home or from those to whom the individual is
attached, as evidenced by three (or more) of the following:attached, as evidenced by three (or more) of the following:
(1)(1) Recurrent excessive distress when separation from home or majorRecurrent excessive distress when separation from home or major
attachment figures occurs or is anticipatedattachment figures occurs or is anticipated
(2)(2) Persistent and excessive worry about losing, or about possible harmPersistent and excessive worry about losing, or about possible harm
befalling, major attachment figuresbefalling, major attachment figures
(3)(3) Persistent and excessive worry that an untoward event will lead toPersistent and excessive worry that an untoward event will lead to
separation from a major attachment figure (e.g., getting lost or beingseparation from a major attachment figure (e.g., getting lost or being
kidnapped)kidnapped)
(4)(4) Persistent reluctance or refusal to go to school or elsewhere because ofPersistent reluctance or refusal to go to school or elsewhere because of
fear of separationfear of separation

41. Separation AnxietySeparation Anxiety
DisorderDisorder
(5)(5) Persistently and excessively fearful or reluctant to be alone or withoutPersistently and excessively fearful or reluctant to be alone or without
major attachment figures at home or without significant adults in othermajor attachment figures at home or without significant adults in other
settingssettings
(6)(6) Persistent reluctance or refusal to go to sleep without being near a majorPersistent reluctance or refusal to go to sleep without being near a major
attachment figure or to sleep away from homeattachment figure or to sleep away from home
(7)(7) Repeated nightmares involving the theme of separationRepeated nightmares involving the theme of separation
(8)(8) Repeated complaints of physical symptoms (such as headaches,Repeated complaints of physical symptoms (such as headaches,
stomachaches, nausea, or vomiting) when separation from majorstomachaches, nausea, or vomiting) when separation from major
attachment figures occurs or is anticipatedattachment figures occurs or is anticipated
• Duration of at least 4 weeksDuration of at least 4 weeks
• Causes clinically significant distress or impairment in social,Causes clinically significant distress or impairment in social,

42. Generalized Anxiety DisorderGeneralized Anxiety Disorder
• Excessive anxiety and worry for at least 6Excessive anxiety and worry for at least 6
months, more days than notmonths, more days than not
• Worry about performance at school, sports,Worry about performance at school, sports,
etc.etc.
• DSM 5 criteria less stringent for children (NeedDSM 5 criteria less stringent for children (Need
only one criteria instead of three of six):only one criteria instead of three of six):
(1)(1) Restlessness or feeling keyed up or on edgeRestlessness or feeling keyed up or on edge
(2)(2) Being easily fatiguedBeing easily fatigued
(3)(3) Difficulty concentrating or mind going blankDifficulty concentrating or mind going blank
(4)(4) IrritabilityIrritability
(5)(5) Muscle tensionMuscle tension
(6)(6) Sleep disturbance (difficulty falling or stayingSleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep)asleep, or restless unsatisfying sleep)

43. Obsessive CompulsiveObsessive Compulsive
DisorderDisorder
• Presence of ObsessionsPresence of Obsessions
(thoughts) and/or Compulsions(thoughts) and/or Compulsions
(behaviors)(behaviors)
• Although adults may haveAlthough adults may have
insight, kids may notinsight, kids may not
• Interferes with life or causesInterferes with life or causes
distressdistress
• One third to one half of all adultOne third to one half of all adult
patients report onset inpatients report onset in
childhood or adolescencechildhood or adolescence

44. Post-traumatic Stress Disorder (PTSD)Post-traumatic Stress Disorder (PTSD)
The person has been exposed to a traumatic event in whichThe person has been exposed to a traumatic event in which
both of the following were present:both of the following were present:
• (1) The person experienced, witnessed, or was confronted(1) The person experienced, witnessed, or was confronted
with an event or events that involved actual or threatenedwith an event or events that involved actual or threatened
death or serious injury, or a threat to the physical integritydeath or serious injury, or a threat to the physical integrity
of self or othersof self or others
• (2) The person's response involved intense fear,(2) The person's response involved intense fear,
helplessness, or horror. (Note: In children, this may behelplessness, or horror. (Note: In children, this may be
expressed instead by disorganized or agitated behavior.)expressed instead by disorganized or agitated behavior.)

45. Persistent Re-experiencing of eventPersistent Re-experiencing of event
(1 or more)(1 or more)
(1)(1)Recurrent and intrusiveRecurrent and intrusive distressing recollectionsdistressing recollections of the event,of the event,
including images, thoughts, or perceptions. (Note: In youngincluding images, thoughts, or perceptions. (Note: In young
children, repetitive play may occur in which themes or aspects ofchildren, repetitive play may occur in which themes or aspects of
the trauma are expressed.)the trauma are expressed.)
(2)(2)RecurrentRecurrent distressing dreamsdistressing dreams of the event. (Note: In children, thereof the event. (Note: In children, there
may be frightening dreams without recognizable content.)may be frightening dreams without recognizable content.)
(3)(3)Acting or feeling as if the traumatic event were recurringActing or feeling as if the traumatic event were recurring (includes a(includes a
sense of reliving the experience, illusions, hallucinations, andsense of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes, including those that occur ondissociative flashback episodes, including those that occur on
awakening or when intoxicated). (Note: In young children, trauma-awakening or when intoxicated). (Note: In young children, trauma-
specific reenactment may occur.)specific reenactment may occur.)
(4)(4)Intense psychological distressIntense psychological distress at exposure to internal or externalat exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic eventcues that symbolize or resemble an aspect of the traumatic event
physiological reactivity on exposure to internal or external cues thatphysiological reactivity on exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic eventsymbolize or resemble an aspect of the traumatic event

46. Avoidance and NumbingAvoidance and Numbing
(3 or more)(3 or more)
(1)(1) Efforts to avoid thoughts, feelings, or conversations associated withEfforts to avoid thoughts, feelings, or conversations associated with
the traumathe trauma
(2)(2) Efforts to avoid activities, places, or people that arouseEfforts to avoid activities, places, or people that arouse
recollections of the traumarecollections of the trauma
(3)(3) Inability to recall an important aspect of the traumaInability to recall an important aspect of the trauma
(4)(4) Markedly diminished interest or participation in significant activitiesMarkedly diminished interest or participation in significant activities
(5)(5) Feeling of detachment or estrangement from othersFeeling of detachment or estrangement from others
(6)(6) Restricted range of affect (e.g., unable to have loving feelings)Restricted range of affect (e.g., unable to have loving feelings)

47. Increased ArousalIncreased Arousal
(2 or more)(2 or more)
(1)(1) Difficulty falling or staying asleepDifficulty falling or staying asleep
(2)(2) Irritability or outbursts of angerIrritability or outbursts of anger
(3)(3) Difficulty concentratingDifficulty concentrating
(4)(4) HypervigilanceHypervigilance

48. Posttraumatic Stress Disorder (PTSD)Posttraumatic Stress Disorder (PTSD)
• At least one month duration.At least one month duration.
• Causes clinically significant distress or impairment inCauses clinically significant distress or impairment in
social, occupational, or other important areas ofsocial, occupational, or other important areas of
functioningfunctioning
• Many students with PTSD meet criteria for another Axis IMany students with PTSD meet criteria for another Axis I
Disorder (e.g., major depression, Panic Disorder) – bothDisorder (e.g., major depression, Panic Disorder) – both
should be diagnosedshould be diagnosed
• Prevalence in adolescentsPrevalence in adolescents
– 4% of boys and 6% of girls4% of boys and 6% of girls
– 75% of those with PTSD have additional mental health75% of those with PTSD have additional mental health
problemproblem
((Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995 )Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995 )

49. Impact of trauma on learningImpact of trauma on learning
• Decreased IQ and reading abilityDecreased IQ and reading ability
(Delaney-Black et al., 2003)(Delaney-Black et al., 2003)
• Lower grade-point averageLower grade-point average (Hurt et al., 2001)(Hurt et al., 2001)
• More days of school absenceMore days of school absence (Hurt et al., 2001)(Hurt et al., 2001)
• Decreased rates of high school graduationDecreased rates of high school graduation
(Grogger, 1997)(Grogger, 1997)
• Increased expulsions and suspensionsIncreased expulsions and suspensions
(LAUSD Survey)(LAUSD Survey)

50. Effective Practice StrategiesEffective Practice Strategies
• ModelingModeling
• RelaxationRelaxation
• Cognitive/CopingCognitive/Coping
• ExposureExposure

51. What isWhat is ModelingModeling??
• Demonstration of aDemonstration of a
desired behavior by adesired behavior by a
therapist,therapist,
confederates, peers,confederates, peers,
or other actors toor other actors to
promote the imitationpromote the imitation
and subsequentand subsequent
performance of thatperformance of that
behavior by thebehavior by the
identified youthidentified youth

52. What isWhat is RelaxationRelaxation??
• Techniques or exercises designed to induceTechniques or exercises designed to induce
physiological calming, including musclephysiological calming, including muscle
relaxation, breathing exercises, meditation,relaxation, breathing exercises, meditation,
and similar activities.and similar activities.
• Guided imagery exclusively for the purpose ofGuided imagery exclusively for the purpose of
physical relaxation is considered relaxation.physical relaxation is considered relaxation.

53. Relaxation: Deep BreathingRelaxation: Deep Breathing
• Breathe from the stomach rather than from theBreathe from the stomach rather than from the
lungslungs
• Can be used in class without anyone noticingCan be used in class without anyone noticing
• Can be used during stressful moments such asCan be used during stressful moments such as
taking an exam or while trying to relax at hometaking an exam or while trying to relax at home
• Children should breathe in to the count of 5, andChildren should breathe in to the count of 5, and
out to the count of 5. Adolescents should breatheout to the count of 5. Adolescents should breathe
in and out to the count of 8in and out to the count of 8
• Have them take 3 normal breaths in between deepHave them take 3 normal breaths in between deep
breathsbreaths
• Have them imagine a balloon filling with air, then totallyHave them imagine a balloon filling with air, then totally
emptyingemptying

54. Relaxation: MentalRelaxation: Mental
Imagery/Visualization TipsImagery/Visualization Tips
• Have the student close his/her eyes andHave the student close his/her eyes and
imagine a relaxing place such as aimagine a relaxing place such as a
beachbeach
• While they imagine this, describe theWhile they imagine this, describe the
place to them, including what they see,place to them, including what they see,
hear, feel, and smellhear, feel, and smell
• Younger students may use a picture orYounger students may use a picture or
drawing to help themdrawing to help them

55. Relaxation: Progressive MuscleRelaxation: Progressive Muscle
RelaxationRelaxation
• Alternating betweenAlternating between
states of musclestates of muscle
tension and relaxationtension and relaxation
helps differentiatehelps differentiate
between the twobetween the two
states and helpsstates and helps
habituate a process ofhabituate a process of
relaxing muscles thatrelaxing muscles that
are tensedare tensed
• Many goodMany good
tapes/c.d.tapes/c.d.’’s availables available
on relaxationon relaxation

57. ADHD PrevalenceADHD Prevalence
• Range from 1-16% depending onRange from 1-16% depending on
criteria usedcriteria used
• 3-5% prevalence in school-age3-5% prevalence in school-age
childrenchildren
• Male: female ratio is 3:1 to 10:1Male: female ratio is 3:1 to 10:1
• Occurs more frequently in lowerOccurs more frequently in lower
SESSES

58. ADHD DSM-5 DiagnosisADHD DSM-5 Diagnosis
• 6 or more inattentive items6 or more inattentive items
• 6 or more hyperactive/impulsive items6 or more hyperactive/impulsive items
• Persistent for at least 6 monthsPersistent for at least 6 months
• Clinically significant impairment in social,Clinically significant impairment in social,
academic, or occupational functioningacademic, or occupational functioning
• Inconsistent with developmental levelInconsistent with developmental level
• Some symptoms that caused impairment beforeSome symptoms that caused impairment before
the age of 7the age of 7
• Impairment is present in two or more settingsImpairment is present in two or more settings
(school, home, work)(school, home, work)

59. InattentionInattention
1)1) Often fails to give close attention to details or makesOften fails to give close attention to details or makes
careless mistakes in schoolwork, work or other activitiescareless mistakes in schoolwork, work or other activities
2)2) Often has difficulty sustaining attention in task or playOften has difficulty sustaining attention in task or play
activitiesactivities
3)3) Often does not seem to listen when spoken to directlyOften does not seem to listen when spoken to directly
4)4) Often does not follow through on instructions and fails toOften does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace (notfinish schoolwork, chores, or duties in the workplace (not
due to oppositionality or failure to understand instructions)due to oppositionality or failure to understand instructions)
5)5) Often has difficulty organizing tasks and activitiesOften has difficulty organizing tasks and activities
6)6) Often avoids, dislikes or is reluctant to engage in tasks thatOften avoids, dislikes or is reluctant to engage in tasks that
require sustained mental effortrequire sustained mental effort
7)7) Often loses things necessary for tasks or activitiesOften loses things necessary for tasks or activities
8)8) Is often easily distracted by extraneous stimuliIs often easily distracted by extraneous stimuli
9)9) Is often forgetful in daily activitiesIs often forgetful in daily activities

60. HyperactivityHyperactivity
1) Often fidgets with hands or feet or squirms in seat1) Often fidgets with hands or feet or squirms in seat
2) Often leaves seat in classroom or in other situations in2) Often leaves seat in classroom or in other situations in
which remaining seated is expectedwhich remaining seated is expected
3) Often runs about or climbs excessively in situations in3) Often runs about or climbs excessively in situations in
which it is inappropriate (in adolescents or adults, maywhich it is inappropriate (in adolescents or adults, may
be limited to subjective feelings of restlessness)be limited to subjective feelings of restlessness)
4) Often has difficulty playing or engaging in leisure4) Often has difficulty playing or engaging in leisure
activities quietlyactivities quietly
5) Is often5) Is often ““on the goon the go”” or often acts as ifor often acts as if ““driven by a motordriven by a motor””
6) Often talks excessively6) Often talks excessively

61. ImpulsivityImpulsivity
1)1) Often blurts out answers beforeOften blurts out answers before
questions have been completedquestions have been completed
2)2) Often has difficulty awaiting turnOften has difficulty awaiting turn
3)3) Often interrupts or intrudes on othersOften interrupts or intrudes on others

62. Make sure it is ADHD!Make sure it is ADHD!
Mood/Anxiety
Problems
PDD Spectrum

63. What DoesnWhat Doesn’’t Work for ADHD?t Work for ADHD?
• Treatments with little or no evidence ofTreatments with little or no evidence of
effectiveness includeeffectiveness include
– Special elimination dietsSpecial elimination diets
– Vitamins or other health food remediesVitamins or other health food remedies
– Psychotherapy or psychoanalysisPsychotherapy or psychoanalysis
– BiofeedbackBiofeedback
– Play therapyPlay therapy
– Chiropractic treatmentChiropractic treatment
– Sensory integration trainingSensory integration training
– Social skills trainingSocial skills training
– Self-control trainingSelf-control training

64. Basic Principles for EffectiveBasic Principles for Effective
Practice for ADHDPractice for ADHD
• Clear and brief rulesClear and brief rules
• Swift consequencesSwift consequences
• Frequent consequencesFrequent consequences
• Powerful consequencesPowerful consequences
• Rich incentivesRich incentives
• Change rewardsChange rewards
• Expect failuresExpect failures
• AnticipateAnticipate

65. PraisePraise
• Praising correctly increasesPraising correctly increases
compliance in youth with ADHDcompliance in youth with ADHD
– Praise can includePraise can include
• Verbal praise, EncouragementVerbal praise, Encouragement
• AttentionAttention
• AffectionAffection
• Physical proximityPhysical proximity

66. Giving Effective PraiseGiving Effective Praise
• Be honest, not overly flatteringBe honest, not overly flattering
• Be specificBe specific
• NoNo ““back-handed complimentsback-handed compliments”” (i.e.,(i.e., ““I likeI like
the way you are working quietly, why canthe way you are working quietly, why can’’tt
you do this all the time?you do this all the time?””))
• Give praise immediatelyGive praise immediately

67. Ignoring and DifferentialIgnoring and Differential
ReinforcementReinforcement
• Train staff and teachers toTrain staff and teachers to selectivelyselectively
– Ignore mild unwanted behaviorsIgnore mild unwanted behaviors
ANDAND
– Attend to and REINFORCE alternativeAttend to and REINFORCE alternative
positive behaviorspositive behaviors

68. How to ignoreHow to ignore
• Visual cuesVisual cues
– Look away once child engages in undesirableLook away once child engages in undesirable
behaviorbehavior
– Do not look at the child until behavior stopsDo not look at the child until behavior stops
• Postural cuesPostural cues
– Turn the front of your body away from the location ofTurn the front of your body away from the location of
childchild’’s undesirable behaviors undesirable behavior
– Do not appear frustrated (e.g., hands on hip)Do not appear frustrated (e.g., hands on hip)
– Do not vary the frequency or intensity of your currentDo not vary the frequency or intensity of your current
activity (e.g., talking faster or louder)activity (e.g., talking faster or louder)

69. How to ignoreHow to ignore
• Vocal cuesVocal cues
– Maintain a calm voice even after your child beginsMaintain a calm voice even after your child begins
undesirable behaviorundesirable behavior
– Do not vary the frequency or intensity of your voiceDo not vary the frequency or intensity of your voice
(e.g., don(e.g., don’’t talk faster or shout over the child)t talk faster or shout over the child)
• Social cuesSocial cues
– Continue your intended activity even after your childContinue your intended activity even after your child
begins undesirable behaviorbegins undesirable behavior
– Do not panic once childDo not panic once child’’s begins inappropriates begins inappropriate
behavior (i.e., do not draw more attention to child)behavior (i.e., do not draw more attention to child)

70. When to IgnoreWhen to Ignore
• When to ignore undesirable behaviorWhen to ignore undesirable behavior
– Child interrupts conversation or classChild interrupts conversation or class
– Child blurts out answers before questionChild blurts out answers before question
completedcompleted
– Child tantrumsChild tantrums
• DoDo notnot ignore undesirable behavior thatignore undesirable behavior that
could potentially harm the child orcould potentially harm the child or
someone elsesomeone else

71. Differential reinforcementDifferential reinforcement
Step OneStep One: Ignore (stop reinforcing) the child: Ignore (stop reinforcing) the child’’ss
undesirable behaviorundesirable behavior
Step TwoStep Two: Reinforce the child: Reinforce the child’’s desirable behavior in as desirable behavior in a
systematic mannersystematic manner
– The desirable behavior should be a behavior that is incompatibleThe desirable behavior should be a behavior that is incompatible
with the undesirable behaviorwith the undesirable behavior
Example:Example:
• Target behavior: InterruptingTarget behavior: Interrupting
• Desirable behavior: Working by himselfDesirable behavior: Working by himself
• Reward schedule: 5 minutesReward schedule: 5 minutes
– If child goes 5 minutes without interrupting, the child receivesIf child goes 5 minutes without interrupting, the child receives
reinforcementreinforcement
– If child interrupts before 5 minutes is up, the child does notIf child interrupts before 5 minutes is up, the child does not
receive reinforcement and the reward schedule is resetreceive reinforcement and the reward schedule is reset

72. Defining Disruptive BehaviorsDefining Disruptive Behaviors
• Types of Disruptive Behavior DisordersTypes of Disruptive Behavior Disorders
(DBD):(DBD):
– ADHDADHD
– Oppositional Defiant Disorder (ODD) – losesOppositional Defiant Disorder (ODD) – loses
temper, argues with adults, easily annoyed,temper, argues with adults, easily annoyed,
actively defies or refuses to comply with adults.actively defies or refuses to comply with adults.
– Conduct Disorder (CD) – aggression towardConduct Disorder (CD) – aggression toward
peers, destruction of property, deceitfulness orpeers, destruction of property, deceitfulness or
theft, and serious violation of rules.theft, and serious violation of rules.

73. Oppositional Defiant DisorderOppositional Defiant Disorder
“You left your D__M car in the driveway again!”

74. Oppositional Defiant DisorderOppositional Defiant Disorder
A pattern of negativistic, hostile and defiantA pattern of negativistic, hostile and defiant
behavior lasting greater than 6 months of whichbehavior lasting greater than 6 months of which
you have 4 or more of the following:you have 4 or more of the following:
• Loses temperLoses temper
• Argues with adultsArgues with adults
• Actively defies or refuses to comply with rulesActively defies or refuses to comply with rules
• Often deliberately annoys peopleOften deliberately annoys people
• Blames others for his/her mistakesBlames others for his/her mistakes
• Often touchy or easily annoyed with othersOften touchy or easily annoyed with others
• Often angry and resentfulOften angry and resentful
• Often spiteful or vindictiveOften spiteful or vindictive

75. Oppositional Defiant DisorderOppositional Defiant Disorder
(ODD)(ODD)
• Prevalence-3-10%Prevalence-3-10%
• Male to female -2-3:1Male to female -2-3:1
• Outcome-in one study, 44% of 7-12 year oldOutcome-in one study, 44% of 7-12 year old
boys with ODD developed into CDboys with ODD developed into CD
• Evaluation-Look for comorbid ADHD,Evaluation-Look for comorbid ADHD,
depression, anxiety & Learningdepression, anxiety & Learning
Disability/Mental RetardationDisability/Mental Retardation

76. Conduct DisorderConduct Disorder
(CD)(CD)
• Aggression towardAggression toward
people or animalspeople or animals
• Deceitfulness orDeceitfulness or
TheftTheft
• Destruction ofDestruction of
propertyproperty
• Serious violationSerious violation
of rulesof rules

77. Conduct DisorderConduct Disorder
(CD)(CD)
• Prevalence-1.5-3.4%Prevalence-1.5-3.4%
• Boys greatly outnumber girls (3-5:1)Boys greatly outnumber girls (3-5:1)
• Co-morbid ADHD in 50%, common to have LDCo-morbid ADHD in 50%, common to have LD
• Course-remits by adulthood in 2/3. OthersCourse-remits by adulthood in 2/3. Others
become Antisocial Personality Disorderbecome Antisocial Personality Disorder
• Can be diagnosed as early onset (before ageCan be diagnosed as early onset (before age
10) or regular onset (after age 10)10) or regular onset (after age 10)

78. Practices that Work with DBDPractices that Work with DBD
• PraisePraise
• Commands/limit settingCommands/limit setting
• Tangible rewardsTangible rewards
• Response costResponse cost
• PsychoeducationPsychoeducation
• Problem solvingProblem solving

79. Steps to Making EffectiveSteps to Making Effective
CommandsCommands
1.1. To make eye contact with the child beforeTo make eye contact with the child before
giving commandgiving command
2.2. To reduce other distractions while givingTo reduce other distractions while giving
commandscommands
3.3. To ask the child to repeat the commandTo ask the child to repeat the command
4.4. To watch the child for one minute after givingTo watch the child for one minute after giving
the command to ensure compliancethe command to ensure compliance
5.5. To immediately praise child when s/he starts toTo immediately praise child when s/he starts to
complycomply

80. Effective Commands/Limit SettingEffective Commands/Limit Setting
with Adolescentswith Adolescents
• Praise teens for appropriate behaviorPraise teens for appropriate behavior
• Tell teen whatTell teen what toto do, rather than whatdo, rather than what notnot to doto do
• Eliminate other distractions while giving commandsEliminate other distractions while giving commands
• Break down multi-step commandsBreak down multi-step commands
• Use aids for commands that involve timeUse aids for commands that involve time
• Present the consequences for noncompliancePresent the consequences for noncompliance
• Not respond to compliance with gratitudeNot respond to compliance with gratitude

81. Setting up a Reward System forSetting up a Reward System for
Children at SchoolChildren at School
• School staff tracks the childSchool staff tracks the child’’s behavior and reports it tos behavior and reports it to
the parent daily.the parent daily.
– Rewards can given at home or at schoolRewards can given at home or at school
• Choose a few target behaviors at schoolChoose a few target behaviors at school
– Choose one that the child will be successful with most of theChoose one that the child will be successful with most of the
timetime
– Set up a system for school report card or school/home noteSet up a system for school report card or school/home note
systemsystem
• Set up a daily report card targeting one to threeSet up a daily report card targeting one to three
behaviorsbehaviors
• Can also set up guidance counselor, tutor or peer asCan also set up guidance counselor, tutor or peer as
““coachcoach”” for organizational skills or other targetsfor organizational skills or other targets

82. Calm
Trigger
Agitation
Acceleration
Peak
De-escalation
Recovery
Acting Out CycleActing Out Cycle
Adapted from The Iris Center: http://iris.peabody.vanderbilt.edu

83. General StrategiesGeneral Strategies
• Use active listeningUse active listening
• DonDon’’t be afraid to show that you caret be afraid to show that you care
• Be a good role modelBe a good role model
• Take the time to greet students dailyTake the time to greet students daily
• Show genuine interest in their lives and hobbiesShow genuine interest in their lives and hobbies
• Find and reinforce the positivesFind and reinforce the positives
• Move beyond labels and leave assumptions at home!Move beyond labels and leave assumptions at home!
• Smiles are contagiousSmiles are contagious
• Take the time to problem solve with studentsTake the time to problem solve with students
• Involve families in a childInvolve families in a child’’s educations education
• Instill hope about the futureInstill hope about the future