For more information on this topic, see this release from the CDC Newsroom: Centers for Disease Control and Prevention. (2022). "New CDC data illuminate youth mental health threats during the COVID-19 pandemic." https://www.cdc.gov/media/releases/2022/p0331-youth-mental-health-covid-19.html.

New Mexico 988 Crisis Lifeline

Is someone you know experiencing a mental health crisis? Please call or text 988 for 24/7 assistance.

The Substance Abuse and Mental Health Services Administration (SAMHSA) through the Department of Health and Human Services developed and launched 988 in July of 2022. This line is identified as a “988 Suicide and Crisis Lifeline” (samhsa.gov, 2022).

The New Mexico Crisis Access Line (NMCAL) alongside the Division of Human Services Department (HSD), Behavioral Health Services Division (HSD) developed a webpage titled, “988: The 24/7 Lifeline for Emotional, Mental, or Substance Misuse Support.” NM 988 eliminated the word suicide from its webpage and marketing as it is promoting working with the individual in crisis and connection to services rather than sending the message of a suicide hotline. NM 988 utilizes the “Crisis Now” approach which was brought in by Dr. Bowen.

The “Crisis Now” (Crisis Now BHSD, 2022) is an approach that utilizes NMCAL “Care Traffic Control.” The goal is to work with the individual in crisis to resolve the crisis; however, if the crisis cannot be resolved they remain on the line with the individual until they receive the appropriate connection to mental health services. New Mexico has started to establish mobile crisis response teams. The mobile crisis response will send two individuals to the individual in crisis to assist them to obtain the appropriate level of care. The goal is to limit a law enforcement or hospital setting unless determined needed for the safety of the individual and others. In rural areas of New Mexico where a mobile crisis team may not be available, NM 988 will work to have a space, i.e. a hospital, where an individual will work with a licensed mental health professional in a private setting. The “COVID Awareness” grant is working with designated individuals of Indigenous Tribes/Clans on a response to individuals who reside on Native land. A Mobile Response Stabilization Services (MRSS) is being developed to work for families directly connected to the Children, Youth and Families Department (CYFD).

A few key points to consider: an individual can call or text 988, option one is for Veterans and option two is for Spanish, the call will be routed to a licensed mental health professional based on the area code of the phone and routed back to the county of residence if different. Per data from SAMSHA (2022) the average answer time is 28 seconds and 80-90% of the calls with the individual are resolved without the need for a more intense emergency service.

“Help is Three Numbers Away 988: The 24/7 Lifeline for Emotional, Mental or Substance Misuse Support.” (988nm.org, 2022)

School's Role

Mental health problems have a variety of causes and can be made worse if the student has a learning disability or physical health problem. While some may have a physiological base, others may be a result from trauma, familial dysfunction, social stresses, or other problems. Whatever the cause, there is a compelling reason for the school to be alert to the issues and respond accordingly. It is important for schools to encourage, support and participate in community of care that includes parents, mental health providers, law enforcement, and any other vested community partner to ensure proper care and action is taken when needed. School professionals such as guidance counselors, school psychologists, nurses, social workers, and school-based health center providers can educate and bridge the gap between these groups to obtain a successful working relationship in integrated care for every student in need.

Every school staff member has a crucial role in promoting healthy emotional development for adolescents. A healthy emotional and social development, including a sense of self-worth, contributes to their success in and outside the classroom. School staff spend every day in the company of students, who are profoundly affected by the world in which they live. Developing a deep awareness of the importance of the positive influence they have on those students at school is of utmost importance.

Developmental Stages

Developmental stages are a set of functional skills, “benchmarks” or age-specific tasks that most children develop by a certain age range. Understanding these stages of a child or adolescent’s social emotional development is helpful in distinguishing between behavior that is typical of the development phase and what behaviors may need observation and treatment by professionals. The following are general milestones children reach within each stage of development based on Piaget’s Cognitive Development, Erikson’s Psychological Development, Freud’s Psychosexual Development and Kohlberg’s Moral Development. These stages are broad with the primary focus on achieving general developmental milestones, however, they may differ based on the child’s gender, cultural background, and other individual characteristics. It is important to note that social emotional development can be disrupted and/or halted if a child or adolescent experiences significant or prolonged trauma.

Birth to 2 Years of Age

• Develop basic trust
• Oral stage, the mouth, tongue, and gums are the focus of sensations
• Most action is reflexive, like sucking and grasping
• Objects are extensions of self
• Cry to have needs met
• Self-comforts

2 to 3 Years of Age

• Develops autonomy (toileting, feeding, walking, & talking)
• Associates words with objects (language development)
• Explores and asks many questions
• Self-centered, requires sharing/cooperation to help move beyond self-centeredness
• Parallel without much interaction or sharing play themes, toys, or activities

4 to 6 Years of Age

• Explores limits
• Very active, enjoys things that involve movement
• Speech becomes more social
• Following rules of a game not developed
• Plan and engages in symbolic play/activities with others
• Curious about body parts and genitalia differences

7 to 12 Years of Age

• Learn to be competent and productive in mastering new skills
• Learn to make good choices and exercise self-discipline
• Solves concrete problems
• Form relationships with peers
• Engage in activities/play with mutually agreed upon rules
• Becomes aware of wider rules of society/viewpoints

13 to 18 Years of Age

• Develop crushes on peers
• Explores self-identity
• Uses rational thinking
• Develops moral reasoning
• Handle competitive play-winning and losing relatively well
• Rely more on peer’s evaluation, approval & direction opposed to parents
• Self-conscious and sensitive to physical development
• Exercises independency from parents

Prevention Activities

The major causes of mortality and morbidity among children and adolescents (accidents, homicide, suicide, substance abuse, and sexually transmitted diseases) are preventable. Other risk factors may be related to poverty or lack of adequate nutrition, shelter, and clothing. There are many useful intervention techniques that can be used for each type of prevention. Some techniques can be applied at any level; for example, all students can be taught social skills. Small groups focusing on social skills training can be useful as secondary prevention for children at risk. Social skills taught to a group of students having difficulty with peers can provide tertiary prevention for those children. Obviously, different problems may call for different interventions. It is important to match different problems with the appropriate interventions.

Primary Prevention (Skill Building)

Primary prevention consists of providing children with resources and skills necessary to cope with complex life situations. Such skills can help students gain a sense of competence and self-worth, which is critical to social and emotional well-being. Teachers, in concert with other school staff, such as the principal, guidance counselor, and health staff, have an important role to play in building a positive and a safe learning environment for all students. Topics and activities might include the following: improving problem-solving skills, coping skills, communication skills; teaching cooperation; anger management skills and other life skills that promote tolerance; helping students resolve conflicts with other students and with adults; and providing opportunities for positive emotional expression.

In addition to organizing and facilitating student-focused prevention activities, mental health professionals may play an important role as organizational consultants to schools. They might be involved in helping the school maintain a nurturing and a safe learning environment, providing consultation to teachers and staff about positive management of different behavioral concerns, and assisting schools to develop policies and procedures to deal with social and emotional related issues.

Secondary Prevention (Resource Building)

Secondary prevention efforts focus on identifying and providing services for children who are at risk of developing social and emotional concerns that may disrupt their academic gains. Children at risk may include those with family issues, learning disabilities and/or those affected by a significant loss or effects from prolonged trauma. Teachers are in daily contact with students, and they may be able to identify these children. A typical example of secondary prevention is educational support groups with a trained professional that focuses on helping children learn positive coping strategies.

Tertiary Prevention (Linking to Appropriate Services)

The third level of prevention consists of providing services to children who are actively demonstrating social and emotional concerns that warrant further assessment and/or appropriate referral. Schools may provide tertiary services in-house or make the necessary referral needed to a licensed mental health professional in the community to provide the appropriate behavioral health care services. Trained school staff may also provide the appropriate support and follow-up services for students in need of outpatient care or transitioning from out-of-home treatment facilities. Students may be seen for individual or group counseling to maintain continuum of care.

Common Mental Health Concerns

It is extremely important for helping professionals to understand the dynamics of each individual child’s situation to help that child effectively. Physiological problems, such as chemical imbalances in the brain, neurological disorders, or environmental discord, may be underlying factors in any given case. Effective intervention depends on comprehensive assessment, appropriate diagnosis, and treatment planning. The parents or guardians of children who are withdrawn or overly aggressive, those having significant problems interacting with peers or adults, and those encountering serious academic problems should be contacted and the student referred for an assessment.

Anxiety

What is it?

Anxiety is the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event. It's important to note that everyone feels anxiety to some degree regularly throughout their life. Fear and anxiety are helpful emotions that can function to help us notice danger or threats that keep us safe and help us adapt to our environment. Anxiety disorders occur when significant distress impairs your ability to function in important facets of life, such as work, school, or relationships. There are many potential risk factors for anxiety disorders, and most people likely experience multiple different combinations of risk factors, such as neurobiological factors, genetic markers, environmental factors, and life experiences.

Why should we know about it?

Approximately 15 to 20% of children and adolescents meet the criteria for an anxiety disorder but estimates as high as 31.9% have been cited among youths aged 13–18 years. Despite the public health burden of anxiety, many youths with anxiety are untreated. Identifying anxiety as the underlying cause of dysfunction is often complicated because common behavioral manifestations of anxiety (e.g., inattention, outbursts) can often mimic features of other disorders present in childhood, such as mood and externalizing problems. Anxiety disorders may also be under-recognized because the evidence base for the treatment of anxiety disorders among youth is relatively new. (National Library of Medicine, National Institutes of Health)

What does it look like?

Children with anxiety are hypervigilant. They are typically tense and on guard. They scan their environments for signs of perceived danger and are reactive to even slight changes to their environment because of a heightened sensitivity to threat. Compared with nonanxious children, anxious children are more likely to selectively attend to threatening information and interpret more information in a situation as threatening. Youths with anxiety avoid their fears as a primary coping strategy and may engage in tactics (i.e., negotiating, whining, dragging their feet to delay, crying) in attempts to avoid these situations. Somatic or physical symptoms are another core clinical feature of anxiety and are often used as effective excuses for avoidance. For example, it is common for children to report somatic symptoms before or during a feared situation (i.e., school) but to not complain of these same symptoms at other times (i.e., weekend or holidays). Physical complaints have been found to be more common among children with anxiety disorders relative to their nonanxious counterparts. Higher levels of somatic symptoms are also associated with greater anxiety severity and interference with family relationships. Common somatic complaints include tension headaches, stomachaches, dizziness, nausea, hyperventilation, palpitations, muscle tension, sweating, shaking, tingling in extremities, bladder or bowel urgency, chest pain or discomfort, problems swallowing, difficulty falling or staying asleep, and chills or hot flashes. Catastrophic reactions to novel or specific stimuli are another clinical feature of anxiety among youths. When initial attempts to avoid fears are unsuccessful, youths may escalate and behave in extreme ways that appear disproportionate to the situation. These behaviors may include explosive outbursts, clinging, negotiating, crying, whining, freezing, repeated questioning, excessive need for reassurance, yelling, and refusal to enter the situation, among others. On the surface, these behaviors may mimic disruptive behavior and appear to come out of nowhere. As opposed to overreacting indiscriminately across situations, however, youths with anxiety typically exhibit problems most prominently in anticipation of situations that scare them. As a result, catastrophic reactions tend to be triggered and context dependent when anxiety is the underlying cause and are “preemptive strikes” or desperate attempts by youths to avoid an impending feared situation (Chiu, A., Falk, A., & Walkup, J. T. (2016). Anxiety Disorders Among Children and Adolescents. Focus (American Psychiatric Publishing), 14(1), 26–33. https://doi.org/10.1176/appi.focus.20150029).

What schools can do

Adapted from "School Anxiety: 8 Strategies to Help Students Cope"

• Daily Check-In and Check-Out: A typical teacher will generally take the time to check in with their students. However, Ghetti suggests creating a more formalized system such as a daily check-in and check-out sheet for students who have high anxiety. According to the University of Nebraska-Lincoln, students who are at-risk would benefit from a more formalized system where caring adults can provide students with positive reinforcement. Meghan Ghetti, a school psychologist based in Cleveland, Ohio says, "Building relationships with one trusted adult in the school makes a student more likely to be successful." Therefore, a daily check-in/check-out sheet can assist students in forming positive relationships with school staff as well as supporting students' mental health needs.
• Support Students with Internalizing Behaviors: Research shows that we always notice the externalizers, the students whose behavior demands attention. School staff should be on the lookout for the internalized signs and symptoms. These are the students that try to be perfect, not make a fuss, and worry excessively. According to Hanover Research, "Teachers should be prepared to appropriately identify and respond to internalizing behaviors to support students." They can do so by using the traits listed in the "Student Risk Screening Scale-Internalizing and Externalizing Overview" created by Michigan's Integrated Behavior and Learning Support Initiative (MIBLSI). Teachers rate the frequency of the students' displayed behaviors and scores are calculated and used for interpretation of risk.
• Normalize Counseling: Teach for America says it's important to normalize and prioritize students' mental health. One way to do so is for teachers to begin to normalize mental health through daily classroom practices (journaling, check-ins, etc.). In addition to that, Ghetti suggests we also normalize referring students to the guidance counselor or mental health support person for counseling. She says, "Learning strategies early is the best way to prevent future problems from interference with a child's life."
• Create a Safe Environment: The CDC says, "School environments that are safe and supportive connect adolescents to a network of caring peers and adults, including parents, other primary caregivers, and teachers." It also says feeling connected can help reduce mental health issues. Ghetti thinks it's important to "have a safe way for students to message you privately about what they need or are having difficulty with. It can be electronic or a secure paper location where others cannot access it. This allows the quiet students to express their needs without drawing attention."

Depression

What is it?

Feelings of sadness, discouragement, and moodiness are normal responses to failure or distress; however, depression is different from sadness. Depression is an illness that evolves from a normal emotional reaction to a disorder typified by feelings and behaviors that last longer than a few days and are so intense that they require treatment. Depression can range from transient (short-term) feelings to mood disorders. Depression is more than the blues or the normal everyday ups and downs. When that “down” mood, along with other symptoms that lasts for more than a couple of weeks, then it may be clinical depression. Clinical depression is a serious health problem that affects all aspects of the person. It can change the way a person feels, behaves, their physical health and appearance, academic performance, social activity, and the ability to handle everyday decisions and pressures. The most common symptom is a persistent change in mood, often characterized by sadness, helplessness, and hopelessness. However, some depressed individuals have a persistent mood state characterized by anxiety and agitation. It is important to be aware that some depressed children may be identified by acting out, restlessness, and general agitation. Depression may also be cyclical in nature, characterized by both a depressed mood and agitation.

Why should we know about it?

According to the National Institute for Mental Health (NIMH), an estimated 3 million adolescents aged 12 to 17 in the United States had at least one major depressive episode in the past year. This number represented 12.5% of the U.S. population aged 12 to 17. Indicators for depression could include low self-esteem, the tendency to self-blame, feelings of powerlessness and hopelessness, and loss of pleasure in living. Although, these indicators may be difficult to identify depression in children because children may not express their feelings or feel sad at all. Instead, they feel angry, irritable, aggressive, and/or hostile. Children and teens may exhibit symptoms of depression through absenteeism, various forms of acting out (aggressive and/or violent behavior) or somatic complaints (frequent stomach aches, headaches, etc.).

While mental health professionals continue to debate the exact causes of depression, onset appears to be associated with a complex mix of multiple factors including stress and emotional loss. One widely held theory suggests that there is a genetic component that may make people (including children) biologically vulnerable to depression. In reaction to stressful situations, biologically vulnerable people are thought to experience changes in their body chemistry that may result in their becoming depressed. Poverty, divorce, death, illness, family discord, abuse, sexual identity, and neglect are examples of stressful events that may make children more vulnerable and at risk for depression. Some children are more resilient to these traumas than others. Two children who are vulnerable to depression may react differently to the same experience. For example, if both experience the death of a significant person, one’s reaction may be short-lived grief, while the other may develop a major depressive episode. Another contributing factor is substance abuse. Some youth who are depressed may begin to self-medicate with drugs or alcohol. Any signs of drug or alcohol use could warrant a co-occurrence disorder assessment.

What does it look like?

According to the National Alliance on Mental Illness (NAMI), a child or adolescent diagnosed with major depression typically exhibits at least five of the following symptoms, including either the first or second symptom, for at least two weeks. Look for sudden changes in behavior that are significant, last for a long time, and are apparent in all or most areas of his or her life (pervasive).

• Depressed or irritable mood for most of the day.
• Aggression toward self and others.
• Diminished interest or pleasure in almost all activities most of the day.
• Marked decline in school performance, skipping classes and opting out of school activities.
• Withdrawing from friends and social involvement.
• Significant increase or decrease in weight or appetite or failure to gain expected weight.
• Inability to sleep or excessive sleepiness.
• Slowed body movements or hyperactivity/agitation.
• Fatigue or loss of energy.
• Feelings of worthlessness or excessive or unnecessary guilt.
• Inability to concentrate or indecisiveness.
• Recurrent thoughts of death, thoughts of suicide, with or without a suicide plan.

What schools can do

Educators can support the mental health of all students in the classroom and school, not just individual students who may exhibit behavioral issues, including signs of depression. Here are recommendations from the U.S. Department of Health and Human Services:

• Educate staff, parents, and students on symptoms of and help for mental health problems
• Promote social and emotional competency and build resilience
• Help ensure a positive, safe school environment
• Teach and reinforce positive behaviors and decision-making
• Encourage helping others
• Encourage good physical health
• Help ensure access to school-based mental health supports
• Promote the healthy social and emotional development of all children and youth
• Recognize when young people are at risk for or are experiencing mental health problems
• Identify how to intervene early and appropriately when there are problems

Bipolar Disorder (Previously Called Manic-Depressive Illness)

What is it?

Bipolar disorder is a serious form of mental illness that affects perceptions, thoughts, moods, and behavior. Bipolar Disorder affects mood more than other functions. The person may have recurrent manic episodes or manic episodes alternating with depressive episodes or primary depressive episodes. Highs may alternate with lows, or the person may feel both extremes at close to the same time. Bipolar disorder may begin with either manic or depressive symptoms. Mania affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For depressive episodes of any age group, signs are like those that occur in depressed teens. Bipolar disorder must be diagnosed by a professional using a series of psychiatric, psychological, psychosocial, and other evaluations. Diagnosis should not be attempted by untrained school staff, the student or a family member. Diagnosis is clinically based on patient report and observation of behavior.

Why should we know about it?

Although less common in young children, bipolar disorder does occur in teenagers and young adults. This illness can affect anyone. However, if one or both parents have bipolar disorder, the chances are greater that their children will develop the disorder.

With proper treatment, a person with bipolar disorder can live a productive life. However, this diagnosis is associated with a high mortality rate; the risk for suicide is increased for an adolescent with bipolar disorder.

What does it look like?

Manic Episode

• Perceptual Disturbances - may see self as having special powers or abilities and others as admiring and adoring; may have auditory and/or visual hallucinations.
• Cognitive Disturbances - has increased thinking speed; may have delusions of grandeur; has difficulty concentrating; have flight of ideas and/or rapid shifting of thoughts and ideas.
• Mood Disturbances - is usually in elevated, euphoric mood; self-esteem may be extremely inflated; has decreased need for sleep.
• Behavioral Disturbances - uses loud, rapid speech that is difficult to interrupt; talks of or acts out involvement in grandiose projects; demonstrates psychomotor agitation, (pacing, twitching, gross gesturing, inability to sit still); may change appearance and dress; exhibits sexual acting out.

Depressive Episode

• Depressed or irritable mood for most of the day.
• Aggression toward self and/or others.
• Diminished interest or pleasure in almost all activities most of the day.
• Significant increase or decrease in weight or appetite or failure to gain expected weight.
• Inability to sleep or excessive sleepiness.
• Slowed body movements or hyperactivity/agitation.
• Fatigue or loss of energy.
• Feelings of worthlessness or excessive or unnecessary guilt.
• Inability to concentrate or indecisiveness.
• Recurrent thoughts of death, thoughts of suicide without a suicide plan.

What schools can do

Children and adolescents who are at risk for bipolar symptoms may be helped by consistent nurturing from trusted adults. The following are suggestions for school personnel to help children who are at risk:

• Reducing the amount of homework and extending deadlines and time limits on assignments and tests.
• If the bipolar student is having difficulty sleeping at night or fatigue is a problem, allow them to start school an hour or two later.
• Provide assistance if the bipolar disorder is making it difficult for the student to focus or sit still in the classroom.
• Ensure that there is constant communication between teachers and parents concerning the student’s progress and behavior in class.
• Have tutoring in place if the student’s bipolar disorder symptoms result in extended absences.
• Record lectures in class when the student isn’t able to concentrate due to their bipolar disorder symptoms.
• Allow the student to have full access to the bathroom and water fountain at school. This can be especially helpful in preventing classroom disruptions during a manic episode.
• In consultation with the student’s parents/guardians refer any student who exhibits symptoms of bipolar disorder to the school’s identified mental health professional. Ideally, these students should be assessed by a primary health provider as well as a provider with mental health expertise.
• There should be a procedure established for school personnel to obtain immediate professional help for students exhibiting symptoms of bipolar disorder, especially if the student exhibits suicidal ideation.

Disruptive Behavioral Disorders

What are they?

These are behavioral and emotional disorders characterized by being socially disruptive and may display aggressive, destructive, deceitful, or annoying behavior towards others. The essential feature has been identified as a persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms or rules are violated. There is no clear cause identified but it is believed that a combination of biological, genetic, and/or environmental factors may contribute to disruptive behavior disorders:

• Biological: Defects or injuries to specific areas in the brain can lead to behavioral problems as indicated in the results of some studies. It is also linked to abnormal levels of chemicals called neurotransmitters in the brain. The neurotransmitters assist nerve cells in the brain to communicate with one another and when this is disrupted or not working properly the messages are not delivered correctly in the brain resulting in disruptive behavior disorders or other mental illnesses.
• Genetics: These children tend to have close family members that have mental illness such as mood disorders, anxiety disorders, and personality disorders. This may create a genetic predisposition for disruptive behavior disorders.
• Environmental: A dysfunctional family, a family history of mental illness and/or substance abuse, a traumatic experience and inconsistent discipline by parents can contribute to the development of behavior disorders.

Disruptive Behavior Disorders include, but are not limited to Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Intermittent Explosive Disorder (IED), Disruptive Mood Dysregulation Disorder (DMDD), and Conduct Disorder.

Why should we know about them?

Estimates show that disruptive behavior disorders occur in about 6% of children in the United States. Many children and teens with disruptive behavior disorders may also suffer from other mental illnesses, such as, learning disorders, depression, substance abuse or an anxiety disorder which may also be contributing factors to their behavior problems.

Puberty and emerging independence are a part of any adolescent’s life. Navigating these issues with ADHD may be more challenging. Research suggests that teens with ADHD may have higher rates of “risky” sexual behaviors, suicidal thoughts, incarcerations, car crashes, job problems, illegal drug use, smoking, or obesity. Additionally, lower self-esteem and social functioning can lead to trouble with relationships with peers, getting along with family, and/or academic performance.

What does it look like?

ADHD - There are three different types of ADHD - predominantly inattentive, predominantly hyperactive/impulsive, and combined, each with their own set of symptoms. No one has all the signs and symptoms of ADHD, but here are 16 ways that ADHD can show itself in an adolescent:

• Lack of focus - An adolescent with ADHD might have trouble staying on task. They may start on a project only to end up starting another before finishing. Being easily distracted can lead to careless mistakes at school, work, or home.
• Disorganization - Everyone misplaces the house keys on occasion. But this can be a common occurrence in an adolescent with ADHD. They may spend a lot of time searching for their possessions. Time mismanagement can lead to missed appointments and deadlines.
• Self-focused behavior - It can be difficult for an adolescent with ADHD to recognize what other people want or need. They can have a hard time waiting for others or taking turns.
• Fidgeting - Restlessness is a common sign of ADHD. Someone with ADHD might find it difficult to sit still without squirming or getting up.
• Heightened emotionality - Research suggests that people with ADHD may not reach the emotional maturity of a typical 21-year-old until their late 20s or early 30s. Adolescence is an emotional rollercoaster. With ADHD in the mix, angry outbursts and overly dramatic scenes may play out in inappropriate circumstances.
• Fear of rejection - Rejection sensitive dysphoria is common in people with neurodevelopmental disorders such as ADHD. High emotions can be triggered by rejection, teasing, or criticism.
• Daydreaming- A person with ADHD may find themselves lost in daydreams for long periods.
• Impulsivity - Adolescents in general tend to be more impulsive than adults. For an adolescent with ADHD, resisting temptation may be particularly difficult, potentially leading to dangerous decisions.
• Difficulty following a conversation - ADHD can interfere with conversational skills in the following ways: appearing not to listen, even when someone is speaking directly to them, interrupting, talking too much, leaving mid-conversation, and/or butting into others’ conversations
• Procrastination - Procrastination is a byproduct of lack of focus. It’s especially noticeable in things that take a long time. Your adolescent might put off homework or other duties so long that they completely miss deadlines.
• Trouble working quietly - Quiet activities are generally not easy for a adolescent with ADHD. They may find it difficult to sit and read or work on a project by themselves.
• Always “on the go”- Adolescents tend to have fewer hyperactive symptoms than younger children with ADHD. But some are a flurry of activity. They may be set on playing their favorite video game one minute and going to a friend’s house the next.
• Trouble reading social cues - They may not realize it when they’ve interrupted or annoyed someone. It may be difficult to make or keep friends.
• Trouble compromising with others - Lack of focus, difficulty following a conversation, and trouble with social cues can make it hard to compromise with others.
• Personal hygiene issues - It’s not true of every adolescent with ADHD, but some have a problem keeping up with personal hygiene. It may have to do with disorganization and procrastination.
• Difficulty following directions - Lack of focus, restlessness, and mind-wandering can make detailed instructions nearly impossible to follow.

ODD- Some of the common symptoms associated with ODD are:

• Frequent temper tantrums
• Excessive arguing with adults
• Never obeys adults’ requests and question rules
• Attempting to annoy adults or upset people
• Easy provocation to anger/annoyance
• Frequent anger/irritation
• Spiteful attitude and revenge seeking

IED- There are a variety of symptoms that people who have intermittent explosive disorder will display based upon individual genetic makeup, development of social skills, coping strategies, presence of co-occurring disorders, and use or addiction to drugs or alcohol. The following are some examples of various signs and symptoms that a person suffering from IED may exhibit:

• Behavioral symptoms: Physical aggressiveness, verbal aggressiveness, angry outbursts, physically attacking people and/or objects, damaging property, road rage
• Physical symptoms: Headaches, muscle tension, chest tightness, palpitations, tingling, feelings of pressure in the head, tremors
• Cognitive symptoms: Low frustration tolerance, feeling a loss of control over one’s thoughts, racing thoughts
• Psychosocial symptoms: Feelings of rage, uncontrollable irritability, brief periods of emotional detachment

DMDD-A relatively new psychiatric disorder known as disruptive mood dysregulation disorder, or DMDD for short, may be the proper diagnosis for a teen with a combination of mood symptoms and highly disruptive and intense behaviors.

• Presence of persistent irritable or angry mood practically throughout much of the day almost every day, and occurs between anger outbursts (see below)
• The irritability and anger are noticeable to others who interact with your teen, such as family members, friends, and teachers
• Explosive outbursts of rage or anger expressed either verbally (e.g. screaming or yelling) or physically (e.g. becoming physically aggressive towards others or towards property such as hitting, punching, throwing or breaking things)
• These outbursts are excessively disproportionate in terms of their duration and intensity with regards to the situation that triggered them
• The outbursts have been occurring for at least 12 consecutive months and an average of at least 3 times a week during that 12-month period (with no more than a 3-month period of relief from symptom occurrence)
• The anger or temper outbursts don’t fit with the child’s developmental age (i.e. they might be considered normal in a younger child)
• The symptoms mentioned above aren’t caused by alcohol, drugs, or any other substances
• The irritability and anger outbursts don’t occur exclusively in the presence of another psychiatric disorder and can’t be better explained by another psychiatric disorder or a neurological disorder
• The symptoms above first appeared prior to the age of 10
• Family members often feel as if they must “tiptoe” around the individual so as not to “set” him or her off
• Symptoms occur in more than one setting (e.g. both home and school); if they occur in only one setting then DMDD is not the proper diagnosis
• There are no indicators of mania or hypomania lasting for more than one day

What schools can do

• Write Daily Schedule on the Board - Knowing what comes next helps school staff plan their day, but it also provides students who have disruptive behavior disorder with much-needed structure. By knowing where they are in their daily schedule and how much time remains in each block, children with DBD can gain a sense of control over their environment, thoughts and behaviors.
• Establish Clear Rules - Having clear rules in the classroom helps set appropriate expectations for each student. The standards serve as unambiguous guideposts for the student with a DBD to follow for the day and entire school year. Rules should be simple and easy to understand. Some examples include: Be on time, Be kind, Do your best, Show respect. Rules help the students, but they also support the teachers as well. When teachers are consistent with their expectations, their ability to manage their classrooms improves dramatically.
• Reward Positive Behaviors - Students with disruptive behavior disorders receive a lot of attention when they behave in aggressive or disrespectful ways. By shifting the emphasis to positive behaviors, a teacher can change a child’s life. This positive reinforcement encourages children with a DBD to practice desirable behaviors and helps them gain self-esteem. It also helps them realize that they can receive just as much attention for good behavior as bad behavior.
• Allow Mini Breaks - Forcing a person with a DBD to sit still and focus for long periods is like asking a person in a wheelchair to climb a flight of stairs. Ultimately, such a request is unfair and unproductive. By building small breaks into their daily schedule, teachers give students something to look forward to and an opportunity to expend excess energy.
• Have a Plan Ready - Having a disruptive student in class means an outburst will happen eventually, no matter how much focus there is on prevention. Prepared teachers do not react spontaneously to these instances because they already have a well-orchestrated plan prepared to control risk. Successful plans include ways to keep other students safe while de-escalating the behavior of students with DBDs. A teacher can even share details of the plan with the class to ensure everyone plays their role during times of trouble.
• Utilize Timeouts - Timeouts are excellent behavior modification strategies because they are a mild form of punishment. Other punishments apply unwanted consequences after an undesirable behavior, while timeouts work by subtracting all rewards from the environment the moment a child misbehaves.
• Provide Immediate Feedback - Based on the laws of conditioning, behavior is more likely to change when an adult provides feedback for an action immediately after it is completed. Without an immediate response, the link between behavior and response gets lost. If a child performs a desirable action but receives no verbal or tangible reinforcement, there is no motivation to repeat the behavior. Instead, notice positive behaviors and shower the student with praise, rewards or tokens they can exchange for a prize in the near future.
• Use Motivational Strategies- One of the best ways to manage disruptive behavior disorder in school is to use motivational strategies to encourage wanted behaviors. Teachers and school staff can encourage all students, but they must understand what motivates children for this encouragement to be effective. Too often, adults assume they know what a child wants as reinforcement but miss the mark. To eliminate this disconnect, teachers can have a conversation with the student to establish target behaviors and ask what rewards they’d want when they practice these behaviors. Understanding what encourages a student with DBD will make them more likely to exhibit positive behaviors.

When a behavioral health professional diagnoses a child with disruptive behavioral disorders, it is important to gather information from multiple sources to make an accurate diagnosis. A pediatrician, trained psychologist, neurologist, psychiatrist or trained clinical social worker can make the diagnosis in conjunction with input from parents, other caregivers, teachers, and other school staff that know the child. It is important to complete a comprehensive assessment with the parents and child on the child’s overall functioning and family situation.

Parent Management Training (PMT) emphasizes changing how the child responds in interpersonal situations at home, at school, and in the community and with teachers, parents, peers, siblings, and others. The treatment uses learning -based procedures to develop behavior and includes modeling, prompting and fading, shaping, positive reinforcement, practice and repeated rehearsal, extinction, and mild punishment. The treatment sessions develop skills that the parents use to implement behavior change programs in the home.

In-service training for school staff on symptoms of disruptive behavioral disorders, specifically conduct disorder and oppositional defiant disorder, with appropriate behavioral interventions and the importance of communicating and working with the family will support the academic success of the child. Teachers, parents, and mental health professionals coordinating and communicating with one another to teach the child healthy relationship skills and pro-social behaviors, with appropriate consequences, in a consistent manner is essential to classroom management.

Conduct Disorder

What is it?

Conduct disorder is a serious behavioral and emotional disorder that can occur in children and teens. A child with this disorder may display a pattern of disruptive and violent behavior and have problems following rules. Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Why should we know about it?

Conduct disorder affects 1 to 4% of 9- to 17-year-olds in the United States. The disorder is more predominate in boys than girls and more common in cities than in rural areas. Between 6 to 16 percent of boys and 2 to 9 percent of girls meet the criteria to be diagnosed with conduct disorder. It is estimated 40% of these children will grow up to be adults with antisocial personality disorder.

What does it look like?

Examples of CD behaviors include:

• Aggression to People and Animals - Often bullies, threatens, or intimidates others, often initiates physical fights, has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun), has been physically cruel to people, has been physically cruel to animals, has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery), has forced someone into sexual activity.
• Destruction of Property - Has deliberately engaged in fire setting with the intention of causing serious damage, has deliberately destroyed others’ property (other than by fire setting)
• Deceitfulness or Theft- Has broken into someone else’s house, building, or car, often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others), has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).
• Serious Violations of Rules- Often stays out at night despite parental prohibitions, beginning before age 13 years, has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period, is often truant from school, beginning before age 13 years, yhe disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

What schools can do

• Engage the family - Any family coming to a mental health service is likely to have some fear of being judged ‘bad’ and possibly ‘mad’. Families of children with conduct problems are more likely to be disadvantaged and disorganized, to have had arguments with official agencies such as schools and welfare officers, and to be suspicious of officialdom.
• Select which treatment to use and who should deliver it - If possible, interventions should specifically address each context, as it cannot be assumed that successful treatment in one area will generalize to another. Medication is controversial and generally best avoided; possible indications are discussed below. Generally speaking, in light of the strong evidence for its effectiveness, the first line of treatment should be parent training.
• Develop strengths - Identifying the strengths of both the child and the family is crucial. This helps engagement and increases the chances of effective treatment. Encouraging their abilities helps the child spend more time behaving constructively rather than destructively – more time spent playing football is less time spent hanging round the streets looking for trouble. Encouraging prosocial activities – for example to complete a good drawing or to play a musical instrument well – may lead to increased achievements, heightened self-esteem and greater hope for the future.
• Treat comorbid conditions - A child's antisocial behavior often affects others so strongly that comorbid conditions can easily be missed. Yet in clinical referrals, comorbidity is the rule rather than the exception. Common accompaniments are depression and attention-deficit hyperactivity disorder (ADHD); a number have post-traumatic stress disorder (PTSD), for example having been beaten by their father or witnessing his physical violence against their mother.
• Promote social and scholastic learning - Treatment involves more than the reduction of antisocial behavior – stopping tantrums and aggressive outbursts, while helpful, will not lead to good functioning if the child lacks the skills to make friends or to negotiate – positive behaviors need to be taught too. Specific intellectual disabilities such as reading retardation, which is particularly common in these children, need to be addressed, as do more general difficulties such as planning homework.
• Treat the child in their natural environment - Psychiatric hospitalization is very rarely necessary: there is no evidence that in-patient admissions lead to gains that are maintained after the child goes home.

Eating Disorders

What are they?

Eating disorders are complex clinical conditions that arise from a combination of long-standing behavioral, biological, emotional, psychological, interpersonal, and social factors. They can include, but are not limited to, the following behaviors: incessant dieting, compulsive overeating, repetitive binging and purging and/or compulsive exercising. While eating disorders may begin with preoccupations with food and weight, they are most often about much more than food. People with eating disorders often use food and the control of food to compensate for feelings and emotions that may otherwise seem overwhelming. Eating disorders often develop in the teen and young adult years, although they can develop at other ages. With treatment, one can return to healthier eating habits and sometimes reverse serious complications caused by the eating disorder.

Why should we know about them?

Young people between the ages of 15 and 24 with anorexia have 10 times the risk of dying compared to their same-aged peers. Female high school athletes reporting disordered eating were twice as likely to incur a musculoskeletal injury as athletes who did not report disordered eating. Three out of ten individuals looking for weight loss treatments show signs of a binge eating disorder. Up to 40% of overweight girls and 37% of overweight boys are teased about their weight by peers or family members. Weight teasing predicts weight gain, binge eating, and extreme weight control measures. 32 to 39% of people with anorexia nervosa, 36 to 50% of people with bulimia nervosa, and 33% of people with binge eating disorder are also diagnosed with major depressive disorder. Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.

What do they look like?

Anorexia Nervosa (Anorexia)- Not eating enough food and over consciousness of physical appearance is the first sign of Anorexia. The other symptoms include: Extreme weight loss, thin appearance, intense fear of gaining weight, bingeing and purging, fatigue, insomnia, dizziness or fainting, bluish discoloration of the fingers, hair that thins, breaks or falls out, soft, downy hair covering the body, dry or yellowish skin, intolerance of cold.

Bulimia Nervosa (Bulimia)-The common symptoms may include: ninge eating, forceful vomiting, long-term fear of gaining weight, preoccupation with weight and body, a strong negative self-image, overuse of laxatives or diuretics, use of supplements or herbs for weight loss, excessive exercises, stained teeth (from stomach acid), calluses on the back of the hands, withdrawal from normal social activities.

Avoidant/Restrictive Food Intake Disorder (ARFID)- ARFID symptoms vary widely and can evolve with the developmental context of the individual. Common symptoms may include avoidant sensory triggers, restrictive eating habits and fear-based eating experiences. These symptoms may also present as a lack of interest in food, a fear-based food restriction, and /or limiting food intake.

Binge-Eating Disorder- A disorder involving frequent consumption of large amounts of food and uncontrollable eating. Behavioral and emotional signs and symptoms of binge-eating disorder include: eating unusually large amounts of food in a specific amount of time, such as over a two-hour period, feeling that your eating behavior is out of control, eating even when you're full or not hungry, eating rapidly during binge episodes, eating until you're uncomfortably full, frequently eating alone or in secret, feeling depressed, disgusted, ashamed, guilty or upset about your eating, frequently dieting, possibly without weight loss

Rumination Disorder- A feeding and eating disorder in which a person -- usually an infant or young child -- brings back up and re-chews partially digested food that has already been swallowed. In most cases, the re-chewed food is then swallowed again; but occasionally, the person will spit it out. Symptoms of rumination disorder include: repeated regurgitation of food, repeated re-chewing of food, weight loss, bad breath and tooth decay, repeated stomachaches and indigestion, raw and chapped lips.

Pica- A disorder characterized by a tendency to eat substances that provide no nutritive value such as soil, chalk, hair, paper, etc. Symptoms may include: persistent eating of non-food items such as clay, wool, lead, wood etc; at an age when it is considered to be developmentally inappropriate, craving for materials that have no nutritive value, however, some people enjoy the textures and flavors of some of these items.

Other symptoms may appear as a consequence of what is being eaten: abdomen pain, nausea, vomiting, bloating, fatigue, poor nutrition, food poisoning.

What schools can do

For more information, see Bulimia Guide. School Strategies for Assisting Students with Eating Disorder. https://bulimiaguide.org/school-strategies-for-assisting-students-with-eds/

• Classroom education as part of the comprehensive health education curriculum should contain opportunities for learning and discussion about societal attitudes and media messages regarding weight and appearance.
• Because of the danger from eating disorders to physical health, it is important to share concerns with school health professionals including any mental health providers, who should consult with the student and parent for a referral to the student’s primary health care provider.
• Eating disorders are complex conditions that can arise from a variety of potential causes. Once started, however, they can create a self-perpetuating cycle of physical and emotional destructions. All eating disorders require professional help.
• The National Eating Disorder Association provides toolkits and more detailed information. The Toolkits available were created specifically for school personnel that include teachers, coaches, and administrators. Please go to http://nationaleatingdisorders.org/ for more information or to access those Toolkits.

Somatic Complaints

What are they?

These complaints are known to occur among children and adolescents and are caused by a combination of organic and psychological factors. Persistent or frequently recurring symptoms such as headache, stomachache, nausea, diarrhea, and palpitation are often difficult to diagnose. Some children may be predisposed to psychosomatic illness because of specific physiological and psychological vulnerabilities. It is common for an individual to experience somatic symptoms in a stressful situation.

Somatic illnesses result when an individual experience a patterned persistent exaggeration of somatic complaints. Most adults recognize that a headache is a result of being stressed and take steps to reduce or withdraw from the stress. Others, especially children, may not recognize the connection between the symptom (headache) and the cause (worry about the big test tomorrow). The headaches may persist because the student does not recognize and or seek help for an underlying problem -- in this case, fear of tests or in more serious situations the fear of parental reactions or abuse/neglect.

Why should we know about them?

Somatic symptoms in youth with anxiety disorders may be associated with greater psychopathology. Relative to anxiety-disordered children without somatic complaints, children with anxiety disorders and somatic complaints have more severe anxiety and poorer global functioning. They perform less well academically and are more likely to refuse school. Also, anxiety-disordered youth with somatic symptoms are more likely than their counterparts without somatic symptoms to have comorbid externalizing disorders and depressive symptoms. Finally, among anxiety-disordered adolescents, somatic symptoms are negatively associated with perceived competence across multiple domains.

What does it look like?

In primary disorders, a physiological problem (such as diabetes or asthma) is already present. The psychosomatic element is the aggravation of already existing symptoms. Thus, a child with diabetes may develop recurrent bouts of metabolic imbalance triggered by emotions. A child with asthma may have severe attacks at times of extreme emotional stress. In both cases, there is a physiological illness present.

In secondary disorders, no preexisting medical problem can be found. Thus, the child with headaches due to test anxiety may undergo a battery of tests that produce no physiological evidence to explain the headaches. It should be noted, however, that it is likely that headaches and other physical symptoms are as real and painful as are those of someone with a medical diagnosis.

Following is a list of some of the most seen psychosomatic complaints in children:

• Asthma - Bronchial asthma is typically caused by allergic reactions, but in some cases emotions and stress can trigger an attack.
• Stomach Problems - Emotions have a marked effect on the gastrointestinal system. When a child is upset, the appetite may diminish, or nausea and cramping may occur. Vomiting may be induced by anxiety provoking experiences. A large proportion of complaints such as upset stomach, heartburn, stomachache and diarrhea can be caused by reactions to emotional stress.
• Headaches - Simple headaches (not migraine) may be the result of tension or stress. They can also result from hunger or lack of sleep, which is why a thorough assessment/interview is needed. Migraine headaches are uncommon in children under age 12, but they may begin during adolescence and must be monitored by a health care provider.
• Urinary Incontinence (Enuresis) - Enuresis is common in childhood. When there are no abnormalities found in the physical examination it is likely that enuresis is caused by emotional factors. It may be a sign of anxiousness or insecurity. Unexpressed anger may manifest itself in this way, particularly in cases of abuse and neglect. Even without treatment, most children outgrow their enuresis by puberty or early adolescence.
• Encopresis - Encopresis may be defined as fecal holding with constipation and fecal soiling. The constipation results in overflow incontinence. Children are often unaware of their accidents and unable to control them. While the origin of encopresis is frequently physical, some factors which can lead to withholding behavior resulting in constipation and/or leaking of stool include the school environment, the school bus environment, the busy routine of the school day, lack of privacy in school bathrooms as well as abuse and neglect.
• Cardiovascular Symptoms - Anxious children may experience a prolonged rapid heart rate (tachycardia). The child may describe it as a “pounding heart” or “racing pulse” and may fear that a heart attack is impending. This fear of heart attack increases the anxiety that aggravates the tachycardia which can set up a vicious cycle.
• Psychosomatic Skin Disorders - Most cases of skin rash (urticaria) are due to disease or allergic reactions; other cases may be caused by emotional stress. Urticaria due to emotional stress usually occurs on the neck, face, and arms; although, it may appear over the entire body. It is more common in girls than boys and occurs more frequently in adolescents than younger children.
• Diabetes - The emotional state of a diabetic child may have a marked effect on the course of the illness. Deviations from the prescribed medication or diet may result in serious medical emergencies.

What schools can do

Determine whether an ailment is a physical disorder or caused by emotional factors. If treated early, many psychosomatic complaints will not become chronic problems. It is important for school personnel to pay close attention to illnesses in children. Children who have frequently recurring episodes of the same symptoms should be referred to a primary care provider or mental health provider.

Post-Traumatic Stress Disorder (PTSD)

What is it?

Post-traumatic stress disorder (PTSD) is an individual’s response to a traumatic event that exceeds one’s coping resources. All the following information is for PTSD in children over the age of six. PTSD is described in the DSM-5 as caused by the “exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

• Directly experiencing the traumatic event(s).
• Witnessing, in person, the event(s) as it occurred to others.
• Learning that the traumatic event(s) occurred to a close family member or friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s). "

Examples of these events could include sexual abuse or violence, physical abuse, disasters such as fires, hurricanes or floods, violent crimes, or motor vehicle accidents. PTSD may also occur after witnessing violence such as domestic violence, community violence, or war. It is important to note that nearly all individuals, especially children, will display some type of distress or behavioral changes immediately following a traumatic event. However, children are incredibly resilient, and many will return to their prior level of functioning. It is when the symptoms last longer than one month or when the symptoms cause significant impairment in functioning that a PTSD diagnosis is warranted. Risk factors for having an increased chance of symptoms of PTSD are: exposure to multiple traumas, history of anxiety problems, or having experienced familial adversity according to the APA.

Why should we know about it?

Post-traumatic stress disorder affects about 6.8 percent of people across a lifetime, with a prevalence of about 5 percent among adolescents, and a prevalence of 1.5 percent for symptoms with severe impairment (i.e. unable to function at home, school, or socially). According to the American Psychological Association (APA) as many as two thirds of adolescents’ report experiencing a traumatic event by age 16. Ignoring the impact of a devastating event or of traumatic situations that are on-going may result in the unreleased energy from the flight, fight freeze response to remain trapped. It may make one hyper-aroused or numb or alternate between the two extremes.

What does it look like?

According to the American Academy of Child and Adolescent Psychiatry (AACAP), children who experience repeated trauma may experience dissociation, or an emotional numbing that helps to block the pain and trauma. They may also become depressed, withdrawn, and detached from their feelings. In many adolescents, symptoms of a trauma may present themselves as somatic complaints such as a headache or a chronic stomachache.

• Avoidance/Numbness - This type of response is essentially the mind and body shutting down due to the intensity of their symptoms. For parents trying to get their child help, this can be frustrating because they may struggle with recalling details of the traumatic event. They may also refuse to share their emotions or just claim that they don’t care. The apathy can also extend to other areas of their life and parents may notice a drop in grades along with reduced social activity. The following are some further examples of avoidance symptoms.
  • Emotional Numbness- Emotional numbness may seem like a vague symptom, but it is identifiable and concerning. It can best be described as a dulling of the emotional senses. The person isn’t unfeeling, but will react softer, or less than before, may have a harder time expressing joy or sadness, and will be harder to reach.
  • Hypervigilance- Hypervigilance is another subconscious form of avoidance, in the form of elevated perception and reactivity. A person with hypervigilance will experience anxiety very quickly, as their fight-or-flight sense remains active and overstimulated. It can be incredibly tiring and can affect a person’s sleep.
  • Antisocial Behavior- Antisocial behavior can be especially noticeable in teens with PTSD. A teen with PTSD may intentionally avoid their friends, will greatly reduce the amount of time they spend around others, will go out less, and will generally push others away, either indirectly or confrontationally.
  • Avoiding Certain Places- While many symptoms of PTSD can occur without triggers, triggers do exist, and can exacerbate symptoms – even years later. These include certain smells, faces, places, and even sounds. A person with PTSD may intentionally or subconsciously avoid these things, taking longer routes to work or school, cutting out activities or places from their lives, and so on.
• Hypersensitivity- Exposure to things that remind the adolescent of the traumatic event can intensify these feelings. For example, a teen who was physically assaulted at a local park may feel the same emotional response as they drive by the playground as they experienced on the initial day of the trauma. The following are some further examples of the hypersensitive symptoms.
  • Heightened Startle Response- This can be anything from reacting excessively to a tap on the shoulder, to flinching when being called by name. Certain actions, from sudden movement to something related to the trauma, may result in more of a startle response.
  • Sleeplessness- The stress of an overly active stress response can take its toll both physically and psychologically but can also disrupt sleep and rest. This causes a dangerous cycle where a person’s mood and mental state continues to deteriorate under less and less sleep, while their symptoms make it harder and harder to fall asleep and get an adequate amount of rest.
  • Random Irritation- Another form of increased agitation is increased aggression, both towards others and towards oneself. While this may be a difficult symptom to quantify, random and completely unwarranted bouts of aggressive behavior and irritability can be a clear sign that something’s wrong.

Additionally, one may also revert to earlier behaviors such as thumb sucking or having separation anxiety. In addition, children may experience what is called “time skew,” in which the adolescent may mis-sequence the events of the trauma or not remember exact details. They may also have “omen formation” which is a belief that there were warning signs preceding the trauma.

What schools can do

Intervening with traumatized youth on school campuses is a much needed role for the school mental health consultant. Whether a trauma occurs on the school campus, in the surrounding community, or to individual students and families, teachers and administrators may be uncertain how to best support the affected students. A key role that a mental health professional can play is giving school staff the tools in which to support and refer students who may be suffering with PTSD and other trauma-related mental health conditions. School-based clinicians can and should be aligned with the educational mission of schools. By providing early intervention services to students who have PTSD symptoms, clinicians can not only help in improving the social-emotional well-being of students, but also their academic performance in the classroom.

School-based services may be particularly important for underserved ethnic minority youth who traditionally are less likely to receive such services. For example, a randomized study comparing two efficacious treatments for youth with posttraumatic stress symptoms in post-Katrina New Orleans found that 91% of the youth completed the school-based intervention compared to only 15% who completed the clinic-based intervention.

The following list of programs have all been proven to support students who are experiencing PTSD.

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
• Multimodality Trauma Treatment (MMTT)
• University of California Trauma Grief Component Therapy for Adolescents (TGCT-A)

If the trauma is a widespread trauma that may affect multiple students, bringing in a crisis team or additional mental health resources may be warranted. Having a plan in place for crisis response is required by New Mexico Administrative Code 6.12.6.8: “a plan addressing the behavioral health needs of all students in the educational process by focusing on students’ social and emotional wellbeing” with school safety plans at each school building. School safety plans are addressed in Chapter 11. Psychological First Aid (PFA) is also a resource for school mental health personnel as it details how to help the adolescents with less severe symptoms and gives information on how to refer out the adolescents with more severe symptoms. Psychological first aid was created by the National Child Traumatic Stress Network and the National Center for PTSD.

Listen, Protect, Connect (LPC) is a form of PFA strategies focusing on children, parents, families and community members. LPC uses parents, teachers, primary care and “neighbor-to-neighbor” providers to give basic psychological support.

Trauma Informed Schools

Trauma is not a new concept. However, until recently, it has largely been viewed to be applicable to only a select group of individuals, under extraordinary circumstances – for example, survivors of catastrophic events. There have been some notable exceptions, but for the most part, trauma has not been recognized as a part of the daily, regular, experience of many individuals, including children and adolescents. Nor has the profound linkage between trauma and child development and the disruption of physical and emotional health been fully recognized.

Research has shown that today’s school communities have the potential to face many more crisis situations than ever before. In addition, the nature and severity of the types of crisis and trauma that can develop today were almost nonexistent 30 years ago. Examples include; hostage taking, sniper attacks, adolescent suicide, high teenage rates of motor vehicle-related deaths, bomb scares, war, natural disasters, and terrorist activities. Along with the crisis situations mentioned above, children are often victims/witnesses to domestic violence, experience child abuse and neglect which may include physical, emotional, or sexual abuse, experience family substance abuse issues and the loss of family members due to homicide, suicide or drug overdose or are part of the immigrant community. Trauma can happen to anyone, regardless of gender, age, socioeconomic status, or ethnicity.

Traumatic response results from exposure to drastic and tragic change in an individual’s environment which has become common and familiar to them. Trauma response can also result from exposure to long term conditions that continually break down an individual’s ability to cope day to day, such as poverty or neglect and abuse.

Many of the children who will arrive at school with behavioral health or substance abuse problems have experienced one or more traumas in their lives. Therefore, it is very important that school health personnel, educators, and administrators are aware of how trauma impacts the lives of their students, their behavior, their ability to form meaningful relationships and their ability to learn.

Implementing a trauma-informed system within the school setting can be challenging but can have a major impact on the school environment and has been shown to decrease many of the disruptive behavioral issues a school community deals with on a regular basis. By integrating trauma sensitivity into school policies and teaching strategies, school climates and academic achievement can greatly improve, especially in districts serving fiscally depressed communities.

The National Child Traumatic Stress Network (NCTSN) serves as a valuable resource for developing and disseminating evidence-based intervention, trauma-informed services, and public and professional education by combining knowledge of child development, expertise in the full range of child traumatic experiences, and attention to cultural perspectives. NCTSN offers specific information on how trauma impacts children of varying ages, important information for teachers, administrators, and parents.

Becoming trauma-informed should be an essential component of the overall mission of the education system. A trauma-informed school recognizes that trauma affects staff, students, families, communities, and systems. Thus organizational support, partnerships, and capacity-building are essential.

Essential Elements of a Trauma-Informed School System:

• Identifying and assessing traumatic stress.
• Addressing and treating traumatic stress.
• Teaching trauma education and awareness.
• Having partnerships with students and families.
• Creating a trauma-informed learning environment (social/emotional skills and wellness).
• Being culturally responsive.
• Integrating emergency management & crisis response.
• Understanding and addressing staff self-care and secondary traumatic stress.
• Evaluating and revising school discipline policies and practices.
• Collaborating across systems and establishing community partnerships.

Suicidal Ideation

Symptoms/Warning Signs for Suicide and Corresponding Actions

When you hear, or see any one of these behaviors:

• Someone threatening to hurt or kill themselves.
• Someone looking for ways to kill themselves: seeking access to pills, weapons, or other means.
• Someone talking or writing about death, dying, or suicide, when these actions are out of the ordinary for the person.

OR:

If you witness, hear, or see anyone exhibiting one or more of these behaviors:

• Hopelessness—expresses no reason for living, no sense of purpose in life,
• Rage, anger, seeking revenge,
• Recklessness or risky behavior, seemingly without thinking,
• Expressions of feeling trapped—like there’s no way out,
• Increased alcohol or drug use,
• Withdrawal from friends, family, or society,
• Anxiety, agitation, inability to sleep, or constant sleep,
• Dramatic mood changes,
• No reason for living, no sense of purpose in life.

Seek immediate help from a mental health provider, 9-1-1 or the local emergency provider:

• New Mexico Crisis and Access Line 1-855-662-7474
• National Suicide Prevention Lifeline at 1-800-273-TALK (8255)
• 988

Suicide attempts can be considered a symptom of depression. A suicide death is a devastating event for everyone, including the school. Therefore, it is worthwhile for educators to learn more about suicide specifically. There is some evidence that a suicide death of one student may lead to suicide attempts and/or completions by other students in the same school because of a “contagion” or copycat effect.

According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Preventing Suicide: A Toolkit for High Schools guidebook, “risk factors for suicide refer to personal or environmental characteristics that are associated with suicide. The environment includes the social and cultural environment as well as the physical environment. People affected by one or more of these risk factors may have a greater probability of suicidal behavior. Some risk factors cannot be changed—such as a previous suicide attempt—but they can be used to help identify someone who may be vulnerable to suicide.”

The Model School District Policy on Suicide Prevention gives educators and school administrators a comprehensive way to implement suicide prevention policies in their local community.

SAMHSA notes that there is no “agreed-upon” list regarding risk factors of youth suicide. However, SAMHSA does provide a list of risk factors identified by the most recent research:

Behavioral Health Issues/Disorders- Depressive disorders, substance abuse or dependence (alcohol and other drugs), conduct/disruptive behavior disorders, other disorders (e.g., anxiety disorders, personality disorders), previous suicide attempts, self-injury (without intent to die), genetic/biological vulnerability (mainly abnormalities in serotonin functioning, which can lead to some of the behavioral health problems listed above). It is important to note that the presence of multiple behavioral health disorders (especially the combination of mood and disruptive behavior problems or substance use) increases suicide risk.

Personal Characteristics- Hopelessness, low self-esteem, loneliness, social alienation and isolation, lack of belonging, low stress and frustration tolerance, impulsivity, risk taking, recklessness, poor problem-solving or coping skills, perception of self as very underweight or very overweight, capacity to self-injure, perception of being a burden (e.g., to family and friends).

Adverse/Stressful Life Circumstances- Interpersonal difficulties or losses (e.g., breaking up with a girlfriend or boyfriend), disciplinary or legal problems, bullying, either as victim or perpetrator, school or work problems (e.g., actual, or perceived difficulties in school or work, not attending school or work, not going to college), physical, sexual, and/or psychological abuse, chronic physical illness or disability, exposure to suicide of peer.

Risky Behaviors- Alcohol or drug use, delinquency, aggressive/violent behavior, risky sexual behavior.

Family Characteristics- Family history of suicide or suicidal behavior, parental mental health problems, parental divorce, death of parent or other relative, problems in parent-child relationship (e.g., feelings of detachment from parents, inability to talk with family members, interpersonal conflicts, family financial problems, family violence or abuse, parenting style either under protective or overprotective and highly critical).

Environmental Factors- Negative social and emotional environment at school, including negative attitudes, beliefs, feelings, and interactions of staff and students, lack of acceptance of differences, expression and acts of hostility, lack of respect and fair treatment, lack of respect for the cultures of all students, limitations in school physical environment, including lack of safety and security, weapons on campus, poorly lit areas conducive to bullying and violence, limited access to mental health care, access to lethal means, particularly in the home, exposure to other suicides, leading to suicide contagion, exposure to stigma and discrimination against students based on sexual orientation; gender identity; race and ethnicity; disability; or physical characteristics, such as being overweight.

Suicide Response Plan

Collaboration and coordination between the school district, its various schools, the School Based Health Center (if applicable), community agencies, and regional hospitals are critical and essential for a youth suicide response plan to be effective. Considering access to care issues for the plan means identifying both primary care and behavioral health care service providers, in close proximity, if these services are not provided by the school district staff or contract staff.

What schools can do

Indicators for Assessing Suicide Risk

Under no circumstance should an untrained person attempt to assess the severity of the suicide risk of an individual student; all assessments of ideation, attempts, or other risk factors must be left to the appropriate professionals. In the assessment risk tables provided below the user should keep in mind that crisis responder refers to a medical or mental health provider trained in suicide prevention; school personnel refers any student that they believe may be at risk for suicide to designated faculty crisis responder (usually school nurse or social worker).

No individual teacher or other school professional should feel responsible for or decide alone how to proceed with a potentially suicidal student. Every school professional should learn how to notice signs of mental distress and how to respond to a student’s request for help. In addition, every school system and every school should have a crisis protocol (policy & procedures), a crisis team, and have knowledge of community resources that are available to appropriately handle students who exhibit suicidal behavior and any other crisis situations.

Every school should have a crisis protocol (See Chapter 8), a crisis team, and community resources available to deal with suicidal students and other crisis situations.

• Implement a primary suicide prevention program, teaching staff, parents and children to be aware of the seriousness of suicidal comments and how to ask for help promptly if they have such thoughts or know of someone else who is having such thoughts.
• Avoid displaying shock, judgment, or disapproval if someone discloses suicidal thoughts.
• Show any identified individual true concern that his/her disclosure is taken seriously.
• Tell the individual that suicidal intent or thoughts cannot be kept confidential and that it is necessary to seek help from others. Remind the individual that this is because he/she is cared for and that needed help is being accessed.
• If someone has talked about suicide, discuss it with a school psychologist, counselor, school nurse, principal, or other designated person so that potential risk assessment can occur immediately.
• Do not leave a suicidal individual alone. Take him/her along to get help or call/send someone else for help.
  • Prepare yourself! Once a suicide crisis presents it becomes the priority and other tasks should be delegated or set aside to maintain student safety.
  • Include the following in a crisis response manual:
    • A checklist of procedures to follow in the event of a crisis including responses to clear-cut or suspected suicidal thoughts or intent.
    • A list of crisis intervention team members with updated telephone numbers.
    • A list of community resources that includes addresses and telephone numbers, such as Department of Social Services, the local mental health agency, Suicide Hotline, AIDS Hotline, National Runaway Switchboard, police and fire departments, and local or regional addiction and psychiatric resource

General Guidelines for Assessing Suicide Risk

• National Institutes of Mental Health (NIMH)
• American Academy of Pediatrics (AAP)
• Substance Abuse and Mental Health Services Administration (SAMHSA)
• National Suicide Prevention Lifeline (NSPL)

Suicide Crisis Response

When intervening with a student who has been determined to be at risk for suicide, the following guidelines are intended for use by a mental health clinician on the school staff or attached to a School Based Health Center (SBHC).

Best Practice/Recommended Intervention

When intervention in an individual suicidal crisis is indicated, the clinician should follow these guidelines.

• Immediately intervene one-on-one to address directly and empathetically the student’s self-report of stressors.
• Provide positive reinforcement to the student for seeking assistance and/or accepting assistance.
• Continue to assess the lethality of the suicide risk and assess the concreteness of plan and means of implementation of the plan.
• Inform and educate student of the need to develop a collaborative safety plan based on student’s strengths, resources, and coping skills.
• Move to the safety planning process, using the information learned during the initial intervention to create an individualized safety plan.
• Do not hesitate to seek additional consultation services during or after the crisis.

Safety Plan for Low and Moderate Risk Levels

• The safety plan should follow administrative procedures regarding communication and protocols established for an individual in suicide crisis. It should include the way the parent/guardian will be notified, unless the clinician determines this would increase danger to the student. The student should be informed of the need for the clinician to act on identified information and to follow school district protocol, and the clinician should assist the student in understanding this process. If the clinician determines the suicide risk is low and referral to emergency services is not indicated, he/she should begin the next intervention with the anticipation of parent/guardian arrival.
• In collaboration with the student both informal (family, friends, clergy, etc.) and formal (doctor, other treatment providers, 24-hour crisis lines, nearest emergency room, etc.) resources should be identified as safety contacts should the risk for suicide persist or increase. Contact information for these supports should be provided to the student.
• The student should be helped to identify coping resources and personal strengths.
• The safety plan should include removing potentially lethal means of pursuing suicide and plans for formal follow up (e.g. next appointment with clinician or another provider). Lack of willingness to adhere to a safety plan would place the student at a higher risk level.
• The safety plan should be formalized into a written document ensuring 24-hour, 7-day week supervision until follow up assessment occurs.
• The safety plan should be reviewed with parent/guardian and contact information verified. Obtaining signatures from parent/guardian and student as well as clinician indicates agreement and formalizes the plan.
• If parent/guardian is unavailable or refuses to participate the clinician should attempt to verbally review the plan with an adult designated by the parent/guardian. If this proves unsuccessful, child protective services channels should be initiated.

Safety Plan for High to Severe Risk Levels

• The safety plan should follow administrative procedures regarding communication and protocols established for an individual in suicide crisis. It should include the way the parent/guardian will be notified, unless the clinician determines this would increase danger to the student. The student should be informed of the need for the clinician to act on identified information and to follow school district protocol, and the clinician should assist the student in understanding this process.
• If the clinician has determined that the student needs immediate medical or psychiatric evaluation and/or hospitalization, steps to facilitate this process should be outlined in formal agreements with acute crisis service providers for referral services.
• Transportation arrangements for the student should be guided by the school district’s established and approved policies covering emergency transportation.
• A qualified adult should be identified to accompany the student to a safe environment or until care is transferred to another caregiver that is another professional or a parent/guardian.

Documentation of Intervention Events

Crisis intervention should always be documented; such documentation should include (but is not limited to):

• Risk assessment information
• Clinician’s decision-making process
• Student’s response to intervention
• Communication with school, parents and other providers, etc.
• Record of any consultation received
• Instructions given to student and caregivers of student
• Plans for follow up
• Communication with School Health Officer (See NMDOH Adverse Event Form for Schools)
• A copy of the safety plan in its entirety should be kept in the student’s chart along with all other documentation.

Non-Suicidal Self-Injury (NSSI)

Non-suicidal self-injury (NSSI) can also be known as self-mutilation, self-harm, or self-abuse, but it is most known as cutting. NSSI is any deliberate, non-suicidal behavior or physical harm that a person self-inflicts on their body and is primarily aimed at relieving emotional distress. NSSI is a maladaptive coping mechanism used to deal with extreme stress or painful emotions. There are many different reasons for NSSI, some reasons might be to avoid feeling numb, lonely, to stay alive, or sometimes clusters of cutting behaviors form in social groups. The behavior of NSSI may be an expression of a more serious mental illness such as borderline personality disorder or dissociative disorder.

What does it look like?

If cutting behaviors are present, the injury could be anywhere on the arms, wrists, hands, stomach, legs or in between the toes. It is not uncommon for someone to cover up their wounds by wearing long sleeved shirts or jackets when it is not appropriate for the weather. However, others might display their wounds openly. If any NSSI behaviors are observed, regardless of the severity, knowledge of the behavior requires staff to step into action by following up with the proper intervention and care to prevent further self-injury or potential wound infection due to the self-injurious behavior.

Is It a Suicide Attempt?

Non-suicidal self-injury is not always an attempt to suicide. When youth self-injure or cut themselves, they are expressing their inner pain which might be keeping them from suicide. Nevertheless, there is an increased risk for suicidal behavior for those who self-injure. It is recommended as best practice to assess and make the necessary referrals for suicide risk assessment when youth self-injure or cut themselves.

What schools can do

It is important to incorporate best practice into your school policy and procedures when implementing NSSI interventions. Whether individual schools or entire school districts, it is recommended to identify and fully implement a crisis team. The crisis team should receive comprehensive training on how to address and manage NSSI behavior on campus and develop student safety procedures.

Schools can appropriately manage NSSI behavior by providing annual and routine mock training to every staff member of the school. This training should include:

• Policy and procedures on NSSI.
• Identification and response to NSSI.
• Referral and follow-up to NSSI.
• Required/not required notification process (parents, staff members, CYFD, etc.).
• Linkages and coordination with community mental health resources.

If any signs of NSSI are visible on a student, staff should:

• Approach the student in a calm and caring matter-remember it could be easy to be shocked or in disbelief, and staff should keep their emotions under control.
• Never leave the student alone.
• Listen and be available to the student.
• Inform the student that you are required to report this.
• Emphasize to the student that they are not in trouble nor will they be punished.
• Ensure a safe transfer of the student to a school counselor, social worker, and/or nurse.
• Notify a school administrator.

Substance Use/Abuse

What is it?

Substance abuse refers to a set of related conditions associated with the consumption of mind- and behavior-altering substances that have negative behavioral and health outcomes. Social attitudes and political and legal responses to the consumption of alcohol and illicit drugs make substance abuse one of the most complex public health issues. In addition to the considerable health implications, substance abuse has been a flashpoint in the criminal justice system and a major focal point in discussions about social values: people argue over whether substance abuse is a disease with genetic and biological foundations or a matter of personal choice. Substance or alcohol use by an adolescent should be considered abuse because the adolescent cannot legally obtain or use the substance (unless taking as prescribed by a physician). Prescription drug abuse occurs when the adolescent is either taking the substance in excess of the prescription, using another person’s prescription or using the prescription for a reason other than prescribed; for example, an adolescent sharing their Ritalin prescription with other students.

Why should we know about it?

Teenagers in New Mexico are 37.04% more likely to have used drugs in the last month than the average American teen. 19,000 (or 11.42%) of 12- to 17-year-olds report using drugs in the last month. Among them, 84.21% report using marijuana in the last month. 18.63% of all 12- to 17-year-olds report using marijuana in the last year.

What does it look like?

Physical symptoms include watery eyes, redness, puffiness of eyes, impaired memory, cognition and vision, behavioral changes, lack of attention, disturbed sleep routine, and/or depression. If an adolescent starts behaving differently for no apparent reason—such as acting withdrawn, frequently tired or depressed, or hostile—it could be a sign he or she is developing a drug-related problem. Parents and others may overlook such signs, believing them to be a normal part of puberty. Other signs include a change in peer group, carelessness with grooming, decline in academic performance, missing classes or skipping school, loss of interest in favorite activities, changes in eating or sleeping habits, and/or deteriorating relationships with family members and friends.

What schools can do

Teachers and other school personnel may suspect a student of being on a substance and send them to the school health personnel per the school district policy. However, it is not the role of the school health personnel to confirm or disprove that a student is under the influence of a substance. Each school district should have a policy in place for referring students out to an independent testing location for such tests. Counseling for substance abuse should also be referred out as only a Licensed Alcohol and Drug Abuse Counselor (LADAC) can provide the service.

Divorce

It is estimated that about half of all children in the United States will spend part of their lives in a single-parent family. Given this statistic, it is likely that every school will have at least some students of divorced or divorcing families in every class. Indeed, it is not uncommon for a high proportion of students in a classroom to have divorced parents.

The divorce process is a time during which all family members must learn to achieve a new balance. It is a time of loss, growth, and change. Children may experience a wide range of emotions: anger, grief, guilt, and sadness following a divorce. Separation or divorce may be experienced as a relief for some, particularly if there has been constant conflict or abuse. Predictably, it is a time of stress. Divorce can affect children from the same family in very different ways; it is important not to presume to know how any given child will react to the situation.

There is considerable variability in how children cope with divorce and separation. In addition to causing varying degrees of disruption and stress for the entire family, divorce may also result in a change in financial status. This may necessitate relocation and/or restricted ability to participate in school programs. Students may experience behavioral or academic performance problems in school and an overall dip in self-esteem or a sense of helplessness and lack of control over life situations. There may be continuing tensions between parents over arrangements for any children. Parental work patterns may change, and children may have less contact with one or both parents.

Signs of stress after a divorce

All the following behaviors may be indicative of normal reactions to divorce if they are not extremely severe, protracted, or numerous. If these symptoms persist or become increasingly severe, then the student may need additional help from a mental health professional.

• Inability to concentrate.
• Either a drop in or perfectionist obsession with school performance and grades, often to the extreme.
• Crying for no apparent or immediate reason.
• Displays of anger or being sullen, acting out or rebelliousness.
• Loss of enthusiasm, sense of humor or joy.
• Regression to outgrown self-comforting behaviors such as thumb sucking.
• Development of tics or nervous behaviors such as nail biting or hair pulling.
• Withdrawal or isolation of self.
• Loss of memory or inability to follow directions.
• An intense need to please.
• Pervasive sadness.
• Rejection of one parent.

What schools can do

The school represents a safe environment for any child of divorcing parents. Educators can help by being supportive of all students, being alert to signs of failure to cope and by having a plan to help students having trouble. Schools should set the tone that both parents are important partners in the family-school relationship. Educators can respond in the following ways to try to help students cope:

• Offer teachers consultation on various reactions children may have to divorce.
• Keep in touch with parents about the student’s school experience.
• If the parents or student self-disclose, explain that during divorce, children may feel strong emotions that sometimes make it hard to pay attention in school or do school work as usual. Encourage the student to talk to a trusted adult about his/her feelings. Continue to monitor the student and offer support.
• Encourage participation in family counseling and/or a divorce support group if available. This is an optimal opportunity for prevention.
• When there is concern in any way about the severity of a child’s reaction, lack of signs of recovery (recovery may take months) or any other aspects of behavior contact the parents/guardians for referral of the child to a mental health professional immediately.
• Encourage participation in a divorce support group if appropriate and available.
• Arrange for all parents/guardians to receive information from the school and for all parents to attend conferences and other school events.
• Do not presume that there are two biological parents in the home. Sensitivity to children living in single parent families, with guardians, or in households with other relations or responsible adults is key to validating a child’s sense of well-being.
• If appropriate, become familiar with the child’s schedule for seeing parents. The change in routine may be confusing for the child and it may help the child to know that someone is aware of the changes.
• Never take sides or bad mouth a parent.

General resources for divorce:

• Children of Divorce Intervention Program (CODIP)
• Rainbows for Children
• Students and Divorce: A Guide for School Counselors
• Helping Children Adjust to Divorce: A Guide for Teachers

Grief and Loss

What is it?

Sometimes students and school personnel are forced to deal with the death of a classmate or staff member. In addition, the death of a pet may be a traumatic event or a best friend moving away. Children whose parents divorce, who are in foster care or who have been adopted at older ages can experience multiple losses.

Why should we know about it?

It is important to recognize that grief is a normal and necessary reaction to any type of loss. Students who are grieving need to be given as much time and opportunity as they need to grieve. It is crucial that school staff DO NOT try to fix, deny, or overlook student’s grief.

Children’s grief behavior may differ from that of adults; they may or may not openly mourn. There are two types of grief that children may experience – normal grief (also called uncomplicated bereavement) and childhood traumatic grief. In both normal and traumatic grief, some of the emotions that children and adolescents experience are denial, anger, acting out, withdrawal, guilt, and depression.

Other reactions to both normal and traumatic grief may include temporary physical complaints, they may regress returning to behaviors they had previously outgrown, like bed wetting, thumb sucking or clinging to parents. Both groups may have sleep problems, loss of appetite, and decreased interest in family and friends.

Children who develop childhood traumatic grief reactions experience the cause of that death as horrifying or terrifying, whether the death was unexpected or due to natural causes. Even if the manner of death is not objectively sudden, shocking, or frightening to others, children who perceive the death this way may develop childhood traumatic grief.

For some children and adolescents, responses to traumatic events can have a profound effect on the way they see themselves and their world. They may experience important and long-lasting changes in their ability to trust others, their sense of personal safety, their effectiveness in navigating life challenges and their belief that there is justice or fairness in life.

It is important to keep in mind that many children who encounter a shocking or horrific death of another person will recover naturally and not develop ongoing difficulties, while other children may experience such difficulties. Every child is different in their reactions to traumatic loss.

Childhood Traumatic Grief (Information below) is summarized from the “In Depth General Information Guide to Childhood Traumatic Grief for School Personnel” available at this link: https://www.nctsn.org/sites/default/files/resources/childhood_traumatic_grief_materials_educators.pdf.

What does it look like?

For more information, see the National Child Traumatic Stress Network: https://www.nctsn.org./

Although everyone grieves differently when a family member, loved one, or close friend dies, there are some common grief experiences for children and teenagers:

• Feeling different from other kids or teenagers- Often, this feeling of alienation just comes over the child. He or she may not even associate it with the death or the grief, but just feels different. Other times a child or teenager is very clear that the death was a turning point that separated her from friends, peers, or family members. She may say that no one understands how she feels, or that people don’t know how to talk to her anymore. While some kids grow closer to surviving family members after the death, other children and teens feel alone with what they’re going through.
• A rollercoaster of emotions- Numbness, anger, fear, confusion, sadness, loneliness, happiness, fatigue, agitation, resentment, manic excitement, guilt, disappointment, worry, and so on. The feelings can come in quick succession, and be unpredictable, adding to the instability the child may already be feeling. The child may feel like a different person than he was before the death. Parents and caregivers often comment, “I don’t know him anymore. He’s not the same person he used to be.”
• Adjusting to secondary losses- Besides the death itself, there are usually other changes in a child’s life caused by the death, some of which will feel like losses. Family dynamics among surviving family members may shift—sometimes quite dramatically. In many cases the family feels unstable to the child. If the surviving parent(s) or caregivers are grieving, the child may feel that she has temporarily lost those people, too, or at least that they’ve changed. Routines and schedules, so important to children, are often disrupted. Family finances may change. The child’s identity and self-esteem undergo a significant shift when a key person is suddenly missing from her life. These are just a few examples of secondary losses.
• Anger, irritability, lashing out and getting in trouble- Many grieving children and teens have sudden bursts of anger or a “short fuse.” Parents, caregivers, and teachers may be startled by the child or teen lashing out, defying adults or becoming sullen and withdrawn. Some kids start to have trouble at school or start to get in trouble at school or at home as a reaction to the death and to the death-related changes in their lives.

• Trying to be perfect- Many grieving children and teens try to suppress their grief or hide it from other family members. They may also try to be “perfect” (get straight A’s, overachieve), both to feel in control and to compensate for the pain and turmoil the family is experiencing. Kids with this pattern of response are typically emotional caretakers for their parents or for other grieving family members. Often these behaviors are subconscious, but sometimes the child is aware of doing these things.

• Can’t think straight, preoccupied- Periods of not being able to pay attention, focus or complete tasks often go on for a long time after the death, and may come in waves, just as grief does. This can affect grades and relationships with teachers and adults.

• Shock and delayed reaction, or grief intensifying as time goes on- Most children and teenagers look back on the time right after the death and say that they were in shock, and that it really hit them several months later. Many times, grieving children and teenagers are hitting the deepest part of their grief right when other people are expecting them to be “getting over it” or “moving on.”

• Guilt and regrets- Some kids have regret and guilt about any times when they were mad at the person who died or having argued with the person. Also, they may blame themselves for the death in ways that seem to make no logical sense to others, or feel that if only they had done something different, they might have prevented it.

• Processing grief through play, art, sports, tears and other non-verbal ways- Children often have a hard time putting their feelings about the death into words. If they do not say much about their grief, they may be able to process it through play, art, sports, or other physical activity, crying, or though nurturing and reassurance (being held by a person they love or snuggling with pets or stuffed animals). While this is normal, it can be challenging for parents and caregivers who wish their children would talk about it to let them know how their grief process is going.

• Crying and not crying- Some children cry a lot, and others very little or not at all. It’s all normal. Children often need to be told that it’s okay to cry. On the other hand, judging a child for not crying or pressuring him to cry is not helpful. Some children are very upset but may have a hard time expressing through tears.

• Cyclical grieving- Many children and teenagers are still strongly affected by the death many, many years later. Their grief may come up unexpectedly sometimes and take them by surprise. Some people say that grief is a life-long process for them.

Other Common Manifestations of Grief

• Re-grieving at life milestones
• Re-grieving at new developmental stages
• Physical symptoms like headaches, chest pains, stomachaches, dizziness, etc.
• Fear that other people will die and they will be left alone, sometimes manifesting as clinging to parents and caregivers or anxious behavior
• Anxiety and worry, sometimes panic attacks
• Nightmares
• Changes in eating and sleeping patterns; not wanting to sleep alone
• Regressing to younger behaviors
• Having unanswered questions if they were not told the whole story of the death
• If very young, unable to comprehend the finality of death
• Mixed feelings about the death, including relief, sometimes causing guilt
• Questioning beliefs
• Lower self-esteem; identity loss
• Social changes: isolating and/or not wanting to be alone
• Keeping pictures or special things that remind them of the person
• Transformation

How schools can help

• National Education Association (NEA)
• Good Grief Schools
• National Association of School Psychologists (NASP)

Child Abuse and Neglect

Child abuse and neglect are serious public health problems and adverse childhood experiences (ACEs). They can have long-term impacts on health, opportunity, and wellbeing. This issue includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child. There are four common types of abuse and neglect:

• Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
• Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities. Please see CDC’s Preventing Child Sexual Abuse webpage for more information.
• Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.
• Neglect is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

Indicators of Abuse and Neglect

Physical Indicators

Physical Abuse- When physical abuse occurs, the signs are often visually evident but may go unnoticed and/or be considered normal for an active child. Here are some signs that may trigger suspected abuse for a health care provider.

• Bruises in various stages of healing
  • on the face, lips, mouth, torso, back, buttocks, or thighs
  • forming a pattern/imprint reflecting the shape of the article that was used to inflict the mark on the body
  • on different skin surfaces of the body inconsistent with the history of the injury
  • regularly appearing bruises after absence, weekend, or vacation
• Burns for which the child has no explanation
  • classic cigar or cigarette burns on the soles, palms, back or buttocks
  • sock-like or glove-like intentional immersion burns on the extremities that may be doughnut shaped on buttocks or genitalia and spare creases of the body
  • intentional burns leaving a characteristic imprint pattern on the skin surface such as curling iron, electric burner, iron, or heated objects
  • infected burns as result of delay in seeking treatment
• Deformities with accompanying swelling/pain suspicious of fractures/dislocations
  • commonly of extremities, skull, nose, or facial structure
  • multiple fractures in various stages of healing revealed on medical evaluation
• Lacerations, abrasions, injuries, or hair loss/bald patches on a child with no reasonable or consistent explanation offered
  • seen most often on the child’s face, eyes, internal and external oral area, genitalia, buttocks, and anus
• Injuries in various stages of healing
  • circumferential ligature marks may be the result of “rope burns” around the ankles, wrists, and neck
• Hair loss usually in patches and potentially the result of forceful pulling

Sexual Abuse - Indicators of sexual abuse are more likely to be subtle and behavioral in nature; however, physical indicators of sexual abuse may include the following signs.

• New onset of difficulty walking or sitting
• Bloody, stained, or inappropriately soiled underwear (leaves and dirt inside underwear but not present on outer clothing)
• Swelling, bruising, lacerations, or bleeding in genital or anal area
• Pregnancy
• Pain or bleeding on urination
• Vaginal/penile discharge and/or odor
• Sexually transmitted infections (STIs)
• Poor sphincter tone (poor bowel or bladder control).

Neglect and Emotional Abuse - The effects on children of neglect and emotional abuse are long term and are more likely to manifest by chronic physical and mental ill health. The health care provider may observe any or all the following neglect and emotional abuse signs and symptoms.

• Unattended physical problems and unmet medical needs of the child
• Underweight child or small stature for age with no known medical diagnosis to explain condition (failure to thrive)
• Normal intelligence but showing deficiencies in areas of intellectual and motor development
• Inappropriate care consistent with hunger, poor hygiene, and unsuitable clothes for climate

Behavioral Indicators

Behavioral indicators of abuse are nonspecific; the child who is experiencing sexual abuse may demonstrate the same behavior as a child who is experiencing emotional abuse. For example, sexual or emotional abuse of a five-year-old child may result in a behavior change such as “wetting his/her pants”. The observer should keep in mind that a sudden change in behavior is more concerning than observation of a behavior which has always been present in that child. The observer should be aware that many factors can influence a child’s behavior. Family difficulties such as domestic violence, drug addiction, parental loss will also result in behavioral changes in a child. Behavior indicators seen in children who may be abused or neglected might include emotional changes, school problems, inappropriate sexual behavior, signs of neglect.

Emotional Changes

• Withdrawal, depression, or expression of suicidal thoughts (e.g., I want to die, I should just go away, I feel like killing myself)
• Child demonstrates anger by violent or self-abuse acts
• Child demonstrates unreasonable fearful reactions to normal circumstances (e.g., a child who is afraid to be alone in a room)
• Younger child demonstrates new clingy or irritable behavior (e.g., always wants to sit in the teacher’s lap or cries, becomes angry, lashes out with little provocation).

School Problems

• New onset of poor concentration or decreased attention span
• Consistently demonstrates fatigue or listlessness (e.g., falling asleep in class)
• Delinquent or anti-social behaviors (e.g., stealing, violence or threatened violence towards classmates)
• Truancy or frequent absences from class
• Dramatic change in academic achievement
• Unwillingness to change for or participate in physical education class
• Poor peer relationships/friendless (e.g., a child no one wants to play with)
• Demonstration of low self-esteem by behavior or statements
• Demonstration of regressive behavior (e.g., a 6-year-old who now sucks her thumb, refuses to eat unless fed, and talks “baby talk”)
• Demonstration of fear of a specific person or situation or new onset of withdrawal (e.g. a child who previously went gladly with a caretaker now resists vigorously)
• Extension of stay at school with early arrival and late departure (e.g. abuse occurs at home and child is fearful to return).

Inappropriate Sexual Behavior

• Inappropriate displays or seeking of “affection” (e.g., attempts French kissing with teacher, sexually provocative dress or manner for developmental level)
• Demonstration of sophisticated, precocious knowledge of sex acts by engaging others in sexual acts (e.g. attempts oral sex on other children or inserts objects in another child’s anus or vagina)
• Inappropriate compulsive masturbation to the exclusion of other enjoyable activities
• Masturbation in a manner that could cause injury (e.g. inserts objects in vagina or anus).

Evidence of Neglect

• Begging for or stealing food at school
• Lack of appropriate supervision outside of school
• Child is alone for extended periods of time inappropriate to developmental level
• Child makes statements indicating no caretaker in the home
• Untreated medical condition (e.g. untreated seizures, asthma, ADD, ADHD, or diabetes).

What schools can do

When a child discloses indicators discussed in the following pages, it does not prove conclusively that a child is abused or neglected. He/she may tell a story that seems difficult to believe, but the story should be taken seriously, and the child’s concerns explored. Any verbal statement from a child that he/she has been sexually or physically assaulted in any way constitutes suspicion of abuse and must be reported.

The New Mexico Children's Code (32A-4-1 NMSA through 32A-4-34 NMSA) sometimes cited as the Abuse and Neglect Act, states that physicians, law enforcement officers, nurses, school personnel and others acting in official capacities who SUSPECT abuse must report it immediately to the local offices of the Children, Youth, and Family Department (CYFD), Social Services Division in their respective communities or appropriate tribal social services offices. All certified school personnel, including school nurses, are required to complete training in the detection and reporting of child abuse and neglect during the person's first year of employment by a school district in New Mexico (NMSA § 22-10A-32).

The presence of more than one indicator combined with other information warrants further assessment by CYFD. School employees do not need to substantiate abuse before reporting it to CYFD. They only need to SUSPECT it. In New Mexico, the CYFD or appropriate tribal social service office investigates all reports of suspected child abuse or neglect.

Reporting

Report suspected child abuse or neglect by calling #SAFE (#7233) from a cell phone or 1- 855-333-SAFE. Child Protective Services (CPS) strives to enhance the safety, permanency, and well-being of children and families in New Mexico. Reports are more likely to result in appropriate action and/or investigation if the following information is available at the time the report is being made:

• Name of child, parent and legal guardian, address where child resides
• Age, sex, SS# of child
• Family composition, language spoken in home
• Location of the child at time of reporting
• Location where suspected abuse occurred
• Name and address of person alleged to be responsible for abuse/neglect
• Nature and extent of suspected abuse or neglect
• Names of other professionals in contact with child
• Past history of child/family
• Child’s affect
• Any disability the victim may have
• History of domestic violence, substance abuse/mental illness, or criminal activity

Follow-up on Reporting

Collaboration between the schools and social services is strongly encouraged to maintain reliability and continuity of care. The school nurse can establish a working relationship with the local social service agency by contact and follow up with the assigned social worker/case manager. Consideration should be given to regular meetings with school nurses, other school staff and social services staff to establish and maintain an ongoing rapport.

Human and Sex Trafficking Awareness

Human trafficking is the trade of humans for the purpose of forced labor, sexual slavery, or commercial sexual exploitation for the trafficker or others. Human trafficking can occur within a country or trans-nationally. Human trafficking is a crime against the person because of the violation of the victim's rights of movement through coercion and because of their commercial exploitation. Human trafficking is the trade in people, especially women and children, and does not necessarily involve the movement of the person from one place to another. According to the National Human Trafficking Resource Center, human trafficking is a form of modern-day slavery in which traffickers use force, fraud, or coercion to control victims for engaging in commercial sex acts or labor services against his/her will. Sex trafficking has been found in a wide variety of venues within the sex industry, including residential brothels, escort services, fake massage businesses, strip clubs, and street prostitution. Labor trafficking has been found in diverse labor settings including domestic work, small businesses, large farms, and factories.

Signs a child may be involved in human trafficking/sex trafficking may be considered normal or familiar adolescent behavior. Here are some signs that may trigger suspected human/sex trafficking for a health care provider.

Behavioral Indicators of a child sex trafficking victim:

• Inability to attend school on a regular basis and/or unexplained absences
• Frequently running away from home
• References made to frequent travel to other cities
• Bruises or other signs of physical trauma, withdrawn behavior, depression, anxiety, or fear
• Lack of control over a personal schedule and/or identification or travel documents
• Hunger, malnourishment, or inappropriate dress (based on weather conditions or surroundings)
• Signs of drug addiction
• Coached or rehearsed responses to questions
• Sudden change in attire, behavior, relationships, or material possessions (e.g., expensive items)
• Uncharacteristic promiscuity and/or references to sexual situations or terminology beyond age-specific norms
• A “boyfriend” or “girlfriend” who is noticeably older and/or controlling
• Attempt to conceal scars, tattoos, or bruises
• Sudden change in attention to personal hygiene
• Tattoos (a form of branding) displaying the name or moniker of a trafficker, such as “daddy”
• Hyperarousal or symptoms of anger, panic, phobia, irritability, hyperactivity, frequent crying, temper tantrums, regressive behavior, and/or clinging behavior
• Hypoarousal or symptoms of daydreaming, inability to bond with others, inattention, forgetfulness, and/or shyness.

Behavioral indicators for labor trafficking victim:

• Being unpaid, paid very little, or paid only through tips
• Being employed but not having a school-authorized work permit
• Being employed and having a work permit but clearly working outside the permitted hours for students
• Owing a large debt and being unable to pay it off
• Not being allowed breaks at work or being subjected to excessively long work hours
• Being overly concerned with pleasing an employer and/or deferring personal or educational decisions to a boss
• Not being in control of his or her own money
• Living with an employer or having an employer listed as a student’s caregiver
• Desire to quit a job but not being allowed to do so

What schools can do

To build healthy learning environments, school personnel must be knowledgeable about the signs and symptoms of child trafficking, ways to support disclosure, and the steps to take if there is a strong suspicion of trafficking. If a school staff member notices a student who shows signs of potential trafficking, the first rule is to always pay attention. Learn about the school’s policies and protocols. If the school does not have clear policies and protocols, talk to the principal about instituting them. Share this information with school staff, administrators, school boards, and members of the community.

Schools have several responsibilities regarding child trafficking. To be effective, they should:

• increase staff awareness and educate staff on the nature of trafficking and on which youth are most vulnerable to it,
• increase parent and student awareness of the risks and realities of trafficking, and
• develop district or schoolwide policies and protocols for identifying and supporting trafficking victims.

More information can be found:

• National Center on Safe & Supportive Learning Environments (NCSSLE)
• US Department of Education (USDE)
• American School Health Association (ASHA)

Psychotropic Medication: Use with Children and Adolescents

A psychotropic describes any drug that affects behavior, mood, thoughts, or perception. It’s an umbrella term for a lot of different drugs, including prescription drugs and commonly misused drugs. They work by adjusting levels of brain chemicals, or neurotransmitters, like dopamine, gamma aminobutyric acid (GABA), norepinephrine, and serotonin. There are five major classes of legal psychotropic medications: anti-anxiety agents, antidepressants, antipsychotics, mood stabilizers, and stimulants. Some can cause very serious side effects and have special monitoring requirements by healthcare providers.

Ensuring Quality Care

School nurses play an integral role in promoting quality student care. When a student requires a psychopharmacological intervention, school nurses may refer to an appropriately licensed provider who can prescribe psychotropic medication. Though psychotropic medication is sometimes prescribed without behavioral health support services, it is recommended that the student be offered behavioral health resource information. If the student refuses counseling, it is important to know that the prescribing provider is responsible for monitoring the student’s medication reactions per guidance set forth by the American Academy of Child and Adolescent Psychiatry (AACAP).

School nurses can also promote integrated and coordinated services for students who are prescribed psychotropic medication. Integrated care can best be achieved through close coordination among the prescribing provider, the student’s Primary Care Physician, the treating Behavioral Health Provider, and school health and behavioral health resources.

Also, it is important to know that several policies and state statutes guide provider prescribing practices for psychotropic medications. Among these are the guidance set forth by the Food and Drug Administration (FDA) and American Academy of Child and Adolescent Psychiatry (AACAP). Providers must also adhere to New Mexico Statutory Authority (NMSA) regarding consent for psychotropic medications, as follows:

• In accordance with NMSA § 32A-6A-14, for students age 13 and younger, the informed consent of a student’s legal custodian is required before providing treatment, including psychotropic medication. Custodial written consent must be included in student’s medical record.
• In accordance with NMSA § 32A-6A-15, for students age 14 and older, psychotropic medications may be prescribed with the informed consent of the student. When psychotropic medications are prescribed, the provider must notify the child's legal custodian of medications the student is taking and possible side effects or medication interactions. Student written consent and custodial notification must be documented in the student’s medical record.

Finally, because of complex drug interactions and effects of certain medications on children and adolescents, it is highly recommended that providers consult with a child and adolescent psychiatrist for assistance with evaluation and medical management under the following circumstances:

• Student presents with complex behavioral health needs or the co-occurrence of medical and behavioral health conditions.
• Greater than three psychotropic medications are being prescribed
• Two or more antipsychotic medications are being prescribed.
• Prescribing psychotropic medication to children 5 years of age or younger.

More information can be found here: Psychotropic Medications: Benefits, Side Effects, Alternatives & More

Social Contagion

Social contagion is the manner of behavior that can spread among members of a group after finding out their peer has engaged in that same behavior. This can be problematic for school staff when those behaviors are negatives ones, such as cutting or suicide attempt. Suicide contagion happens when individuals with high-risk factors (those things that predispose them to depression, anxiety, or poor decision-making) and low protective factors (those things that combat depression, anxiety, or poor decision-making) are affected by the news of a suicide. Whether it is a celebrity, a member of the community, or otherwise, this death has a profound impact on them. They may identify with the loss, they may obsess about the loss, or they may compare themselves to the deceased. Death becomes a more viable option.

Social media is a perfect venue for the spread of self- injurious behavior among social groups. School staff should encourage parent(s) or guardian(s) to monitor their children’s social media accounts and encourage them to talk with their children when self-injurious behaviors are mentioned or displayed, as well as immediately informing a responsible adult to help others stay safe.

To prevent social contagion in schools, school staff must:

• Reduce communication around self-injury by advising students not to explicitly talk with other students.
• Do not convene a school-wide assembly on the topic.
• Do not discuss with the students how or why the youth hurt themselves.
• Do not conduct a group setting intervention.
• Assist in the management of scars and wounds of those students who self-injure. Visible scars, wounds, and cuts should be discouraged.

What schools can do

Best practices indicate that school staff should:

• Educate students about the signs of distress in themselves and others.
• Teach the use of positive coping skills and provide access to mental health resources.
• Keep conversations regarding self-injury amongst those who “need to know” and in a private setting.
• Focus on preventing imitative behaviors.
• Provide ongoing monitoring of students by all staff and parents.
• When self-injury is identified, provide immediate and appropriate services and referrals for the student.

Primary Editors: Jim Farmer, SMHAs, Secondary Editor: Crista Pierce, SW SHA