Mental health and kids
by Jody Demo-Hodgins, NAMI (National Alliance on Mental Health)-Ohio

To many people, it is unfathomable that 1 in 5 kids living in the U.S. shows signs or symptoms of a mental health disorder in a given year.  To most teachers, it is no surprise that in a classroom of 25 students, at least five are probably struggling with conditions that adults deal with — illnesses like depression, anxiety, and substance abuse. Sadly, most of those children — nearly 80% — who need mental health services do not receive them. With or without treatment, these children and youth attend school, and the problems they face are linked to difficulties found in schools: low achievement, chronic absence, disruptive behavior and school failure, and dropout.

The mere fact that an estimated 20% of children and youth struggle with a treatable health condition that impacts their school performance and overall functioning should mean that schools must play a role in identifying students with problems and helping them succeed. Nonetheless, it is a role that many schools are not equipped for.  Why? The reasons are many but are often tied to a lack of resources — both human and fiscal — to address the vast need. Those schools that attempt to do so are often overwhelmed with the needs and numbers of young people requiring help.

The average child spends six hours a day in school. This means that schools have a role in helping address mental health for all students. How can administrators, counselors, teachers and students work together to identify and support young people with a mental health condition in positive, proactive and effective ways? First, they need to know and understand the signs. Some are: 

  • excessive worrying or fear;
  • feeling excessively sad or low;
  • confused thinking or problems concentrating and learning;
  • extreme mood changes, including uncontrollable “highs” or feelings of euphoria;
  • prolonged or strong feelings of irritability or anger;
  • avoiding friends and social activities;
  • difficulties understanding or relating to other people;
  • changes in sleeping habits or feeling tired and low energy;
  • changes in eating habits such as increased hunger or lack of appetite;
  • abuse/use of substances like alcohol or drugs;
  • multiple physical ailments without obvious causes, such as headaches, stomach aches, vague and ongoing aches and pains;
  • thinking about suicide;
  • inability to carry out daily activities or handle daily problems and stress;
  • an intense fear of weight gain or concern with appearance.

Mental health conditions can also begin to develop in young children. Because they’re still learning how to identify and talk about thoughts and emotions, their most obvious symptoms are behavioral. Symptoms in children may include:

  • changes in school performance;
  • excessive worry or anxiety, for instance fighting to avoid bed or school;
  • hyperactive behavior;
  • frequent nightmares;
  • frequent disobedience or aggression;
  • frequent temper tantrums.

No one sign means that there is a problem. Examine the nature, intensity, severity and duration of a problem. Children can develop the same mental health conditions as adults, however, they sometimes express them differently. One example is that a child who is depressed might show more irritability than a depressed adult.

Mental health conditions in children and youth
You may wonder what are the most common mental health conditions that impact children. Children can experience a range of mental health conditions, including:

  • Anxiety disorders. Children who have anxiety disorders — such as obsessive-compulsive disorder, post-traumatic stress disorder, social phobia and generalized anxiety disorder — experience anxiety as a persistent problem that interferes with their daily activities. Some worry that it is a normal part of every child's experience, often changing from one developmental stage to the next. However, when worry or stress makes it hard for a child to function normally, an anxiety disorder should be considered.
  • Attention-deficit/hyperactivity disorder (ADHD). This condition typically includes symptoms in difficulty paying attention, hyperactivity and impulsive behavior. Some children with ADHD have symptoms in all of these categories, while others might have symptoms in only one.
  • Eating disorders. Eating disorders — such as anorexia nervosa, bulimia nervosa and binge-eating disorder — are serious, even life-threatening conditions. Children can become so preoccupied with food and weight that they focus on little else.
  • Mood disorders. Mood disorders — such as depression and bipolar disorder — can cause a child to feel persistent feelings of sadness or extreme mood swings much more severe than the normal mood swings common in many people.
  • Schizophrenia. This chronic mental illness causes a child to lose touch with reality (psychosis). Schizophrenia most often appears in the late teens through their 20s.

No matter what the issue is, we know that families and youth must be at the table and they must have input and be listened to as services are planned.  The earlier the identification the better.

Web-based information resources:

Please note that Ohio has an extensive system of NAMI Affiliates. Please check your local county to see if there is a NAMI near you. They frequently provide support groups for families and individuals as well as education programs like Family to Family and NAMI Basics. In addition to the websites above, there are several books that schools might consider having on site.  A few are:

  • “When My Worries Get Too Big! A Relaxation Book for Children Who live with Anxiety”
  • “Everyone”
  • "Can I catch It like a Cold? Coping With a Parent’s Depression”
  • “Mr. Worry: A Story about OCD”
  • “When Sophie gets Angry — Really, Really Angry”
  • “Purplicious” 

How can you be helpful to families?

  • Become familiar with mental health services in your area. Check with ADAMH/community mental health and recovery boards. The website www.oacbha.org has a map with each county board contact information.
  • Advise them to check with their insurance provider:  Large insurance carriers — including those providing Medicaid — have many different plans for their members. The only way you will know if a particular provider or center is covered is to ask about its unique plan. Many companies have lists of in-network providers on their website. If transportation is a barrier, and the child is on Medicaid, the provider is supposed to address this by arranging transportation.
  • Identify the child’s specific behavioral issues: Be specific about the problems you are seeing in the child.  Are they aggressive? Does he or she seem very sad and is this persistent? Has he or she been engaging in self-injurious behavior? Does the child seem very anxious? The more clarification provided, the better path to addressing the child’s need.
  • Suggest the family enlist the assistance of the child’s primary care physician. A referral for mental health services may be required, and the provider who knows the child best is the most likely choice. He or she can help identify the presenting issues.
  • Be persistent! Often, one call is not going to result in success. Make a plan and have a list of potential providers. Ohio is supposed to have parity for mental health as a condition. Sadly, it is often parity on paper but not in reality.

The impact of trauma, and the promise that lies in resilience
by Jody Demo-Hodgins, NAMI (National Alliance on Mental Health)-Ohio

We hear more and more about trauma now, and included in that information is often a reference to ACEs or adverse childhood experiences. An ACE score is a tally of different types of abuse, neglect, and other hallmarks of a difficult childhood. According to the Adverse Childhood Experiences (ACE) Study, the rougher the childhood, the higher the score is likely to be and the higher a person’s risk for later health problems.

When children are overloaded with stress hormones, they’re in flight, fright or freeze mode. They can’t learn in school. They often have difficulty trusting adults or developing healthy relationships with peers, that is they become loners. To relieve their anxiety, depression, guilt, shame and/or inability to focus, they turn to easily available biochemical solutions, such as nicotine, alcohol, marijuana or methamphetamine, or activities in which they can escape their problems, like high-risk sports, proliferation of sex partners and work/over-achievement. For example, nicotine reduces anger, increases focus and relieves depression. Alcohol relieves stress.

Research tells us that:

  • ACEs are common. Nearly two-thirds (64%) of adults have at least one.
  • ACEs cause adult onset of chronic disease, such as cancer and heart disease, as well as mental illness, violence and being a victim of violence.
  • ACEs don’t occur alone. If you have one, there’s an 87% chance that you have two or more.
  • The more ACEs you have, the greater the risk for chronic disease, mental illness, violence and being a victim of violence. People have an ACE score of 0 to 10. Each type of trauma counts as one, no matter how many times it occurs. You can think of an ACE score as a cholesterol score for childhood trauma. For example, people with an ACE score of 4 are twice as likely to be smokers and seven times more likely to be alcoholic. Having an ACE score of 4 increases the risk of emphysema or chronic bronchitis by nearly 400% and attempted suicide by 1200%. People with high ACE scores are more likely to be violent, have more marriages, have more broken bones, have more drug prescriptions, have more depression and have more autoimmune diseases. People with an ACE score of 6 or higher are at risk of their lifespan being shortened by 20 years.
  • ACEs are responsible for a big chunk of workplace absenteeism and for costs in health care, emergency response, mental health and criminal justice. So, the fifth finding from the ACE study is that childhood adversity contributes to most of our major chronic health, mental health, economic health and social health issues.
  • On a population level, it doesn’t matter which four ACEs a person has; the harmful consequences are the same. The brain cannot distinguish one type of toxic stress from another; it’s all toxic stress, with the same impact.

So, what is the ACE questionnaire? It is pretty simple and asks, While you were growing up, during your first 18 years of life:

  • Did a parent or other adult in your household often … 
    Swear at you, insult you, put you down or humiliate you? Or
    Act in a way that made you afraid that you might be physically hurt?
    Yes…….No        If yes, enter 1:    
  • Did a parent or other adult in the household often …
    Push, grab, slap, or throw something at you? Or
    Ever hit you so hard that you had marks or were injured?
    Yes….No        If yes, enter 1:    
  • Did an adult or person at least five years older than you ever …
    Touch or fondle you or have you touch their body in a sexual way? Or
    Try to or actually have oral, anal or vaginal sex with you?
    Yes…No        If yes, enter 1:    
  • Did you often feel that …
    No one in your family loved you or thought you were important or special? Or
    Your family didn’t look out for each other, feel close to each other, or support each other?
    Yes….No        If yes, enter 1:    
  • Did you often feel that…
    You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or
    Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
    Yes….No        If yes, enter 1:    
  • Were your parents ever separated or divorced?
    Yes….No        If yes, enter 1:    
  • Was your mother or stepmother …
    Often pushed, grabbed, slapped, or had something thrown at her?   Or
    Sometimes or often kicked, bitten, hit with a fist or hit with something hard?  Or
    Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
    Yes….No        If yes, enter 1:    
  • Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
    Yes….No        If yes, enter 1:    
  • Was a household member depressed or mentally ill or did a household member attempt suicide?
    Yes….No        If yes, enter 1:    
  • Did a household member go to prison?
    Yes….No        If yes, enter 1:    

Now, add up your yes answers. This is your ACE score. Remember that it isn't a crystal ball, it is really intended to serve as guidance. It tells you about one type of risk factor among many. It doesn't directly take into account your diet or genes or whether you smoke or drink excessively — to name just a few of the other major influences on health. There is now additional research on how to address young people with a high ACEs score by helping them increase protective factors as a means of growing their resilience. 

How best to find and help kids who are experiencing abuse and neglect right now? It is important to look for visible signs of stress to understand what might have happened to them and how best to intervene. Some kids have nightmares or recurring thoughts of a stressful event. Others may re-enact the trauma through play. Or, the child may seem distracted or withdrawn.

Sometimes, reactions to trauma are misdiagnosed as symptoms of attention deficit hyperactivity disorder, because kids dealing with adverse experiences may be impulsive — acting out with anger or other strong emotions. It is very common in those impacted by trauma to have difficulty in regulating emotions and behavior and is why a lot of trauma-impacted kids get in trouble with the classroom.

Three Types of ACEs:

ABUSE NEGLECT  HOUSEHOLD DYSFUNCTION
Physical Physical Mental illness
Emotional Emotional  Incarcerated relative
Sexual    Mother treated violently
    Divorce
    Substance abuse

Adversity is only one part of the calculation. Children may also have their own characteristics and experiences that protect them and help them develop resilience despite exposure to ACEs. Resilience is positive adaptation within the context of significant adversity. In the face of adversity, neither resilience nor disease is a certain outcome.  Resilience is the result of a set of interactions between a person’s adverse experiences and his or her protective factors. This interaction is what determines the developmental path toward health and well-being or toward illness and dysfunction. No child is magically resilient or invulnerable to ACEs, just as no individual child is automatically doomed in the face of ACEs. These protective factors can include a person’s own biological and developmental characteristics. But protective factors can also include characteristics of the family, community and systems that lessen the negative impacts of ACEs. Protective factors help explain how some people who have sustained a great deal of adversity as children have fared relatively well in adulthood.

The presence of protective factors, particularly safe, stable and nurturing relationships, can often soften the consequences of ACEs. Individuals, families and communities can all influence the development of many protective factors throughout a child’s life that can impact his or her development.

There are multiple pathways to resilience, and researchers continue to refine understanding about the ingredients and processes involved in supporting resilience. However, there is agreement about a variety of important individual, family and community conditions that support resilience. Here is a list of protective factors:

  • Close relationships with competent caregivers or other caring adults.
  • Parent resilience.
  • Caregiver knowledge and application of positive parenting skills.
  • Identifying and cultivating a sense of purpose (faith, culture identity).
  • Individual developmental competencies (problem-solving skills, self–regulation, agency).
  • Children’s social and emotional health.
  • Social connections.
  • Socioeconomic advantages and concrete support for parents and families.
  • Communities and social systems that support health and development and nurture human capital.

Protective factors help a child feel safe more quickly after experiencing the toxic stress of ACEs and help to neutralize the physical changes that naturally occur during and after trauma. If the child’s protective networks are in good working order, development is strong even in the face of severe adversity.

MindPeace

While at the 2018 CUBE Conference in Las Vegas, I had the opportunity to attend a presentation by several Cincinnati Public Schools (CPS) administrators and their mental health partner, MindPeace. One stat that caught the audience’s attention was the ability of CPS to provide extended mental health care services in all of their schools without the use of general operating funds. 

Through the assistance of MindPeace, CPS was able to develop a business model for on-site school mental health services. Most importantly to school leaders is the message that the capability for all school districts to incorporate the CPS model is there with the right partnerships.

To gain more information about MindPeace and what it is able to offer, I reached out to its executive director, Susan Shelton.

What is MindPeace, and what kind of work does the organization do?

MindPeace began as a project of the Junior League of Cincinnati (JLC) in 2002 to answer a significant need for an improved system of mental health care for children of the greater Cincinnati region. Hundreds of JLC volunteers devoted thousands of volunteer hours to develop a model for a seamless system of children's mental health and wellness care with the help of CPS, Cincinnati Children's Hospital Medical Center and many other community partners. In 2008, at the request of key community stakeholders and providers, JLC launched MindPeace as its own nonprofit, because no other mental health organization focused on systemic improvements to children's mental health access and quality.

The long-term mission of MindPeace is to create a seamless system of mental health care for children that meets specific characteristics of quality, provides a continuum of services, has system connections and is affordable. Our approach is one of collaboration and collective problem-solving. As system barriers to care are identified, MindPeace works with key partners to research and test new innovative solutions. An important focus is the improvement and expansion of school-based mental health services based on CPS' community learning center model. These school-based mental health partnerships are a pillar of the children’s mental health system infrastructure.

A CPS principal talked about the school-based mental health model for which MindPeace has been the catalyst.

“Gaining access to mental health services is not an easy path for many of our families,” the principal said. “Having a lead agency within the building has allowed the school to partner with parents to gain supports that will help students find success. The phobia of the ‘mental health’ label is diminished, since it becomes a part of school life."

What is your connection to CPS? 

CPS was the first school district to partner with MindPeace as the development of CPS community learning centers began. The belief that the community stakeholders drive the vision of community learning centers, and that those stakeholders choose the partnerships to meet the community’s need, was a tipping point for MindPeace. MindPeace is grounded in the values of community learning centers and leads the Network of School-Based Mental Health Partners that supports community learning centers. Seventeen mental health agencies belong to the network and agree with a sustainable, integrated school-based mental health model that supports students with any payer sources including Medicaid, private insurance and self-pay. Critical to the model is the foundation of Positive Behavioral Intervention Supports (PBIS) led by CPS. 

CPS is committed to providing a continuum of academic, social-emotional and behavioral supports to meet the needs of the whole child in each of its 63 school buildings and more than 36,000 students. The foundation of social-emotional and behavioral supports is PBIS. This is a framework that emphasizes proactive strategies for defining, teaching and supporting appropriate student behaviors to create positive school environments. Research indicates that effective implementation of PBIS in school settings will address 80-90% of a student population’s behavioral needs. School teams rely on data collection from universal supports, as well as indicators, such as chronic absenteeism, a sudden drop in grades, unexplained discipline problems and discipline referrals to identify students that may be in need of more intensive supports to enable school success.

Once viewed as being outside the scope of the school’s responsibility, student mental health and well-being is now recognized as a foundational piece to students’ academic success. National statistics indicate that approximately 20% of school-age children have, or will develop, a serious mental illness during their school years. The National Alliance on Mental Illness (NAMI) reports that half of all chronic mental illness begins by age 14. There is a growing recognition that the provision of mental health services at school is an integral and necessary component of academic readiness. 

Identification of students who may be in need of mental health services is a complex task, which is accomplished through analysis of multiple sources of data, a team approach to supporting the learning of every child and an open-door policy when it comes to referring a student for mental health services. As previously mentioned, school teams utilize academic and behavioral data from PBIS systems to identify students who may be in need of more intensive, individualized supports. Additionally, district staff and school-based mental health partners have provided training on recognizing indicators of mental health issues, and when a referral may be appropriate. Parents are able to refer their child for mental health services, and often, teachers or school support personnel, such as school psychologists, social workers and guidance counselors, make referrals for school-based mental health services. 

How do you support CPS?

MindPeace serves as the leader of the Network of School-Based Mental Health. We strive for real partnerships between community learning centers and mental health providers chosen by the school community. MindPeace facilitates new partnerships, provides technical assistance at school sites, collects and analyzes data and helps bring quality improvements to the community. MindPeace collaborates with CPS teams on initiatives including crisis response, suicide prevention and training about mental health as examples. 

Specifically, at the CPS site level, MindPeace partners with a community learning center to identify the mental health needs of students and their families and facilitates the process for selection of the lead school-based mental health partner. Once a partnership is established, MindPeace works collaboratively to ensure a healthy, sustainable, mutually-beneficial relationship that provides access to quality, affordable therapy and medication management services for students and to connect with and integrate evidence-based mental health prevention, intervention, and crisis support resources and programming. Examples of site-level integration of prevention and intervention resources includes trauma-informed care, calming spaces and transitions.

MindPeace is partnered with all CPS community learning centers, and in the 2017-2018 school year, 71% of students referred for services were connected to care. Typically, across our country, only 25-50% of children and adolescents who need mental health services are able to access those services. Over 3,200 CPS students chose to receive treatment in a community learning center setting. 
 
Does your organization support other districts?
MindPeace currently partners with 21 school districts in Hamilton, Warren and Butler counties.

You can contact with MindPeace at www.mindpeacecincinnait.com or by phone at (513) 803-0844.
 

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