student anxiety and depression...anxiety and depression are common cumulative lifetime prevalence of...

Student Anxiety and Depression

Mona Potter, MD and Abigail Stark, M.S.

Lincoln Sudbury, March 11, 2019

Anxiety and Depression are Costly

Students and Families• Social, emotional, and identity

development

• Academic/school performance

• Secondary psychiatric problems and substance abuse

• Physical symptoms

• Family functioning

• Life satisfaction (e.g., marriage, employment)

Schools

• Classroom management

• School avoidance

• Teacher burnout – loss of confidence and “empathy fatigue”

• Financial and resource burden

They can lead to problems with…

Anxiety and Depression are Common

Cumulative Lifetime Prevalence of Childhood Psychiatric Disorders

J Am Acad Child Adolesc Psychiatry. 2010 Oct; 49(10): 980–989. n=10,123

Anxiety

• Anxiety is the most common childhood psychiatric disorder

• Almost 1/3 of youth will struggle with anxiety by age 18

Anxiety and Depression are Common

Past Year Prevalence Of Major Depressive Episode Among US Adolescents (2016)

Data Courtesy of SAMHSA

• Depression often presents with irritability, physical symptoms, and/or withdrawal in younger children

• Past year prevalence of depression in adolescents was 12.8% in 2016

Teenagers See Anxiety and Depression as a Major Problem

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Anxiety andDepression

Bullying Drug Addiction DrinkingAlcohol

Poverty TeenPregnancy

Gangs

The percentage of teens who perceive each of the following as a major problem among peers

Source: Pew Research Center Feb 2019 Report

Many Students Are Not Getting Help

Child Mind Institute 2015 Children’s Mental Health Report childmind.org/report

Who DOES NOT get treatment…

“How do I know if this is typical stress or something more?”

High AnxietyNo Anxiety

Biology and Environment Impact Depression and Anxiety

Biology and Environment Impact Depression and Anxiety

Temperament

NATURE

Biology and Environment Impact Depression and Anxiety

Temperament

NATURE NURTURE

Depressed Pediatric Brain Anxious Pediatric Brain

Fear sensitivity

McClure et. al, 2007

Attention bias to threat

Britton et al, 2012

Altered connections

Roy et. al, 2013

Miller et. al, 2015

Altered activation

Reduced Hippocampal volume

Chan et. Al, 2010

Anxious Brain: Fear Circuitry

The Young Brain is a Malleable Brain

Myelination

The Young Brain is a Malleable Brain

What brains are we building?

System of Support: Let’s Work Together

• Communication and collaboration across systems for early, integrated interventions using common language

• Understand what the child brings to the table, both strengths and deficits, and respond accordingly

• Be mindful of what environment we are fostering

pediatrician Family and community

school

Psychiatrist/Therapist

Treatment of Adolescents with Depression Study (TADS)

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CBT fluoxetine CBT +fluoxetine

placebo

Response Rate (%)

36-week (with one year follow-up), Randomized Control Trial (RCT) of 439 children ages 12-17 diagnosed with Major Depressive Disorder (MDD)

•Treatment groups:•Cognitive Behavioral Therapy (CBT) alone•Fluoxetine alone: 10-40mg/day•CBT + fluoxetine•Placebo

•Response Rate:•CBT alone: 43% •Fluoxetine alone: 61% •CBT + fluoxetine: 71% •Placebo: 35%

March et al., JAMA (2004), NIMH funded

Child/Adolescent Anxiety Multimodal Study (CAMS)

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CBT alone sertralinealone

CBT +sertraline

placebo

Response Rate (%)

12-week, randomized, controlled trial (RCT) of 488 children ages 7-17 (mean 11.8) diagnosed with separation anxiety disorder, generalized anxiety disorder, or social phobia.

•Treatment groups :•CBT alone: 14 sessions of CBT •Sertraline alone: up to 200mg/day, average dose 140mg/day•CBT + sertraline•Placebo

•Response Rate:•CBT alone: 60% •Sertraline alone: 55% •CBT + sertraline: 81% •Placebo: 24%

Walkup et al, 2008, NIMH funded

What Can We Do

Similar skills both within school and family systems

Mindful Awareness of Thoughts, Behaviors, and

Feelings

Validation: Connect before you redirect

• Gradual exposure to situations that create uncomfortable emotions• Acting Opposite to emotion urges• Challenging unhelpful thoughts

• Using coping skills when emotions are intense

Across systems,we can model targeting thoughts,

feelings and behaviors…

Making Emotions Understandable:The 3-Component Model

What you DO

What you THINK

What you FEEL

Environment

Environment

Foundational Skill: Mindfulness

“Mindfulness means paying attention on purpose, in the present moment, and non-judgmentally.” ~Jon Kabat-Zinn, PhD

Yurgelon-Todd 2006

Adolescent brain Adult brain

Foundational Skill: Validation

Why Validate?

• Shows we are listening and want to understand.

• We are nonjudgmental.

• We care about the relationship

• Helps regulate emotions

• Helps move towards problem solving

• Make eye contact.

• Look for a word that

describes the feeling, or say,

“I really want to understand

what you’re feeling.”

• Reflect the feeling back

without judgment.

• Start a sentence with: “It

sounds like you feel...” or “It

makes sense that you’re

feeling…”

• Stick the landing!

How to Validate

Addressing Behaviors Associated with Anxiety and

DepressionWhat

you DO

Exposure to

Emotions: Protect vs.

Push?

The Role of Avoidance

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The Role of Avoidance

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AVOIDANCE

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The Role of Avoidance

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AVOIDANCE

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The Role of Avoidance

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The Role of Avoidance

So what can you do about it?

Face your stressors

instead of avoiding them!

Approaching Stressful Situations

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XAPPROACH

APPROACH

APPROACH

APPROACH

Exposure Hierarchies

Opposite Action

• Taking opposite action to emotion

• Identify the action urge

• Choose an action opposite to the action urge

• Do it ALL THE WAY

Addressing Thoughts Associated with Anxiety and Depression

What you THINK

Connecting Thoughts and Feelings

• Catch an increase in uncomfortable feelings

• Check whether thoughts are helpful and true

• Identify a more helpful version of that thought

Catch, Check, and Change

Is it helpful?Is it true?

If not, develop a more helpful and true version of that thought.

Emotion Thought Is it helpful?Is it true?

What’s a more helpful thought?

Catch, Check, and Change

Addressing Emotions Associated with Anxiety and Depression

What you FEEL

Self-Soothe with the Six Senses:

• Sight

• Hearing

• Touch

• Taste

• Smell

• Movement

Build a Self Soothe Kit!

Not just for kids!...

Thank you!

Mona Potter, MD: mppotter@mcLean.harvard.edu

Abi Stark:amstark@mgh.harvard.edu