Healthy Minds With Dr. Jeffrey Borenstein

- [Dr.

Borenstein] Welcome to "Healthy Minds."

I'm Dr.

Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

Today on "Healthy Minds:" - Close to 15% of youth identify clinical level symptomatology of depression within the last year.

This is a epidemic kind of level endorsement of depressive symptoms, and that's just depression.

That doesn't necessarily include anxiety, which often overlaps with depression, as well as the substance use disorders, the early addictions, and symptoms of what are referred to as severe persistent mental illnesses.

- [Dr.

Borenstein] That's today on "Healthy Minds".

This program is brought to you in part by: The American Psychiatric Association Foundation, The John & Polly Sparks Foundation, and the WoodNext Foundation.

(bright radiant music) Welcome to Healthy Minds.

I'm Dr.

Jeff Borenstein.

How can schools enhance the mental health of students?

Today I speak with leading expert Dr.

John Constantino about screening in the schools for mental health problems, as well as developing curriculum which can enhance a student's ability to be resilient.

John, thank you for joining us today.

- Pleasure.

Great to be with you, Jeff.

- I want to jump right in and speak with you about an important topic, which is screening for mental health issues in the schools.

Let's start by telling us what is the current status of that right now?

- Well, it's very mixed nationally.

The tendency for schools to implement screening of youth for active mental health conditions is in many ways a function of the enthusiasm or the support of the local community, the school boards and so forth.

And so we still have a lot of work to do to make it something that families and the public feel is an important enough thing to do in school, to make sure that it's really happening and identifying kids who could really use help.

What we know is that when screened, children will identify treatable conditions that are often at a clinical level that no one knew about and that were really otherwise not identifiable except through their own account in being screened.

When youth are identified, they can often be treated very successfully and very early in the course of a mental health condition.

And what we know from principals around the country, there was a recent study that asked school principals around the country just to survey them about screening, most of them were not systematically screening for mental health conditions in their schools.

- We know that early identification and if needed, treatment makes a big difference in the life of the child.

And also significant percentages of children at some point will have symptoms of psychiatric condition, anxiety, depression, and others.

I'd like you to speak about the scope of this, how often children may develop those kind of symptoms.

- Well, for the more common conditions like depression and anxiety, the statistics are relatively staggering.

So there was a recent SAMHSA study of a large nationally representative cohort of youth and adolescents that looked at the one year prevalence for depression.

If you go back to the year prior to and up including the moment that the youth were screened in this particular study, close to 15% of youth identify clinical level symptomatology of depression within the last year.

I mean, this is a epidemic kind of level endorsement of depressive symptoms, and that's just depression.

That doesn't necessarily include anxiety, which often overlaps with depression, but it can also often be separate and is somewhat more common than depression, as well as the substance use disorders, the early addictions, and symptoms of what are referred to as severe persistent mental illnesses.

- So I'd like you to tell us a little bit about the screening process.

How does it work?

- Typically what will happen nowadays is that everyone will take advantage of the students' smartphones.

Now, there are issues and positive ones with getting smartphones out of schools during the school day.

But one way or another, whether through workstations or laptops or smartphones or other kinds of electronic devices, typically now there are methods for whole school populations to be screened with the push of a button so that the screening tools are pushed out to the students and the students respond to those privately in a way that they feel comfortable endorsing whatever that they're experiencing to endorse symptomatology of a mental health condition.

These are ascertained using standardized ratings that can identify when is this a typical fluctuation of mood or behavior in adolescence, or is this far enough outside of the typical range that it deserves clinical attention?

- And when the child adolescent is filling out these questionnaires, are they accurate?

What's the experience with the level of accuracy of the information that the student provides?

- You know, for disruptive behaviors or things that students might not necessarily want to own up to, the accounts of the people around the student are more useful.

And so screening by teachers' accounts of what they're observing on the playground or what they're observing in the classroom can be very valuable because those direct observations of disruptive behaviors or things where kids are getting into clashes with other youth are obviously very important and amenable to support and treatment and behavioral kind of revision to course correct those kinds of issues for kids.

But what's really valuable about screening for the students themselves are the things that they actually are the best informants.

In other words, for anxiety-related states, depressive-related states and early addictions, students are really the best, most accurate informants.

They will let you know things that aren't necessarily apparent or they haven't necessarily divulged to their loved ones or caregivers.

And yet if you just ask them, they will let you know and again, these ratings are calibrated to what is the range of typicality for youth and then what really is outside the range and deserves evaluation and potential clinical attention.

- Now a question many people would ask, I would ask it as a parent, is the issue of privacy with this, and does this go on what we refer to as the permanent record for the child?

How is that managed in order to provide that privacy?

- There are mechanisms within schools that afford the same kind of privacy as health information, you know, it's protected by federal law.

And I don't think privacy is really the biggest concern.

One of the things that has been advanced relatively recently has been the ability to move information from a screening directly to caregivers through password protected electronic kinds of mechanisms that would allow families to get the information that they need about a screen positive and then for parents to make their best decision about what they want for their child given a positive screen.

And most families will take the next step and say, well, get this evaluated, or let's understand, or let's bring this to our primary care physician that this screening occurred.

One of the things that people tend to worry about, any kind of evaluation of behavior of children or the diagnosis, potential diagnosis of children with a mental health condition is that it's stigmatizing.

And what I try to help parents and school personnel and communities understand is honestly, there's nothing more stigmatizing to a child than the behavior itself.

If they are withdrawn, if they are acting out, if they are in a clinical state that is affecting their ability to interact with their peers and not getting help with those things, that's way more stigmatizing than a caregiver or an adult or a school saying let's try to adjust things and support this child to make their best adaptation.

- I think that's a very important point and it really normalizes the issues of depression, anxiety, other mental health concerns.

Growing up, they gave an eye test in school and a hearing test in school and it normalized maybe needing glasses or having other things addressed.

This takes a problem that's even more prevalent and makes it more normal, more reasonable to talk about, more comfortable to talk about.

I'd like you to speak a little bit about that.

- One of the things that I remember all the way back to my training is that you needed your fifth tetanus shot to even walk in the door in kindergarten and be screened for that.

But as an adolescent, to enter high school, you don't need to be screened for an active psychosis or an early drug addiction or something like that.

That just doesn't make sense to me.

The issue of health, and mental health is health, making sure that we're doing everything we can to support youth, especially in the context of what I think is pretty widely recognized now as a youth mental health crisis.

If we're going to address it, we have to know who is suffering and how we can get to the kids that really need our help.

- So when they do the screening and let's say a child tests positive, what's the next step?

- So the next step is to afford the children's caregivers with what the scope of opportunity is to address that.

And again, the first thing is not to have a reflux that it has to be treated on the spot, but to make a next step in more completely evaluating.

What is the cause of that screen positive?

In all schools in which screening is conducted, there are opportunities for the students to have at least a first level evaluation by a school counselor.

Now, a parent may or may not want that to happen as a result of a positive screen.

They may prefer to go straight to that child's pediatrician, or they may want to go straight to a mental health professional in the community that they have access to through this child's medical insurance.

All of those are options.

And some schools also have embedded health and mental health services within the schools.

So there's a lot of options and parents have a lot of autonomy and freedom of how they handle the first step in a positive screen, including talking with their children and indicating that they are there to support them and that if the screen positive was a surprise or something that is really important for them to talk about in their own relationship with their child and their child's status in their family, it can be a great relief to a child for what they endorse, to be validated by the people that love and care about them most and that they may have for whatever reason, and there's lots of reasons, been reluctant to share with their primary caregivers.

- I want to shift gears a little bit and speak about the skills that schools potentially can teach children in terms of resilience.

I know this is an area that you've been looking at.

Tell us about that.

- Yes, so there are many preventive and supportive interventions for youth that can get out in front of these conditions or at the earliest stages that the schools can be major agents of strengthening children.

So one of the things that I think has been very well validated over the past 10 to 15 years in child mental health has been the opportunity to deliver to children the same kinds of skills that are acquired in the psychotherapies that are usually delivered after the fact of a clinical condition.

In other words, therapies like cognitive behavioral therapy or dialectical behavioral therapy are associated with skill sets that are learned within the course of those therapies for coping mechanisms and emotion regulation and the revision of perspectives about what do you conclude from an experience that gives you an emotional kind of activation?

How do you really think about that and break that down and respond and so forth?

So these kind of therapies are designed to deliver to a patient with a condition, a way of mastering the things that make those conditions clinical in nature and affect the child's or use adaptive functioning.

But there's no reason why those skills can't be engendered on the front end.

And so delivering those kinds of learnings can be done and there are now manualized ways for them to be taught in groups or to be delivered within groups of children who are not clinically affected, but they are normalized and they are life skills and they are rendered to youth in a way that now has been syndicated and is in a sense off the shelf that can be delivered within schools.

Unfortunately, the uptake has not been that great.

And I think despite the fact that these skills are associated with very significant reductions in the occurrence of clinical level symptoms in mood and anxiety disorders, we have a long way to go to leverage these tools that we actually have.

And this is not to say that it's solely the school's responsibility because schools have to do a lot of things.

They have to individualize their approaches to children, they've gotta teach and they've got all of the academic tasks, but it's important for the public to know and for parents to know and the schools to know that these skills can be taught on the front end to build resilience in youth.

So there are many ways in which manualized kinds of interventions that schools can implement that have literally been studied in school populations that show effects on prevention of adverse life events and crises that require literally emergency room visits or other kinds of really adverse outcomes of use.

So it's a very promising time for what's possible.

And then many of our colleagues around the country are starting to think about how to enable schools by making the presence of not only these kinds of resiliency-building interventions, but also personnel, people that can be there to help support youth in the playing field of where they're spending their life.

- We don't have to wait for somebody to develop a depression or anxiety to help them.

Athletes do it all the time.

Professional sports teams, college sport teams have coaching and training for resilience for the athletes because they're under stressors.

Why not do that for all of our kids?

- Yeah.

And if you think about what are they learning in school?

What are the things that are gonna power them through their adult lives?

One can make the case that of course, math makes the world go round.

And of course, reading and writing and all the things that they have to be able to do.

But in this era where things that are really very much affecting the entire life of a child as they grow into adulthood, long-term consequences of things like addictions or chronic depression or the correlates of those that affect the ability to successfully sustain work in the workforce and to avoid the legal system in their lives and in how they conduct their lives, these are just as important life lessons.

And it's not to say that again, that it's the school's overt responsibility that they should wholesale go out outside the guardrail and that our schools should be the places where the social and emotional development of children is as high a priority as math and reading.

But maybe it should be.

And I think we have to wrestle with that as a nation and think about what the stakes are of if those things aren't prioritized enough, particularly for the more vulnerable and fragile kids.

Because many kids learn these aspects of life and development and adaptation outside of school.

There's no question.

Their families, their friendships, their faith communities, their life outside of the classroom in school.

But when it's not happening or it's not working and we're watching kids sink, then if schools are able to be an agent of partnering with families and partnering with the community, I think we have to take a very hard look, especially for the most vulnerable of our youth and leverage the platform of school.

The fact that they're there for 30 or 40 hours a week, that that's what's going on.

And the fact is is that we already do that and have already agreed to do that as a matter of federal law for youth with some of the most disabling conditions.

And so when a child has a disability, whether it's a severe mental health condition or a developmental disability, it's a matter of federal law that education has to be individualized to them.

And that aspect of individualized education almost invariably includes elements of behavioral support and the inclusion of their social and emotional development as a high priority of how their education proceeds.

So we're already doing that for a subset of our youth and I think we have to think about how we do that for ones that aren't quite in that particular level of disability.

- John, those are really important points.

I want you to share with us, 'cause you've told me about in a particular school how they have the go-to person for the student and every student identifies that person.

Tell us about that.

- Yeah, well, we're very proud of that in Georgia.

So this is a district in Hall County where the leaders of that school district and the superintendent and his team have decided that it is so important that children never be in a situation, all the way through high school, that there is not somebody that they feel that they can go to if they get into a pinch or are feeling desperate or are needing to reach out to an adult that they can trust for help, particularly for these kinds of moments or experiences of desperation or marginalization or really not knowing what to do.

And so literally every kid in that school district, they have ID badges that they use and wear in school and on the back of every badge of every child is the name of their go-to person that they have identified and that that person knows that they're that child's go-to person and it's specified.

And that simple rubric, that simple structure speaks volumes to the kids, the families, the teachers that this is a place of accountability.

That this is a place where there's always a door to go to go.

There's no closed doors when you're in a place where you don't know what to do.

And it's interesting because oftentimes when we think of some of the most catastrophic things that happen in schools or that people worry about, school-related violence and so forth, it is very common if you go through the process of understanding, like essentially doing a root cause analysis of why did this adverse event happen?

Whether it's one of the more common, kind of common but serious school disruptive events all the way up to the most catastrophic of school violence-related kind of events, it almost always resolves to a mental state of a student in which they were under the impression that there was no other choice to solve a problem that they could not solve other than to do what they did.

If you're in that kind of a situation, before you act or before you assume that there is no other path than to do something that could be damaging to yourself or to somebody else, that first you go to your go-to person or that there's always a way.

And this is a standard that we use clinically in safety plans for patients who are experiencing suicidal thoughts and symptoms.

That there's an identified go-to member of your village that everybody agrees that that's part of the safety plan.

That that's what's gonna happen if you get to a place where you just don't feel safe anymore.

And that's what we do in the emergency rooms and in the clinical realm.

But school isn't a clinical realm.

But the idea to make that available to the kids in a supportive posture, not to pathologize what's going on, just to make sure that they have a go-to person to me I think is really a great structure, a great idea, and I hope it spreads.

- You know, we all need a go-to person.

You and I need a go-to person and certainly adolescents, children need a go-to person.

And encouraging that and having that a part of the culture is just so impactful.

- Yep.

- John, I want to thank you so much for the work that you do, for joining us today to share this important information.

Thank you.

- It was a pleasure to be with you today.

- It's so important that we don't allow any child or adolescent to fall through the cracks.

If there is a mental health condition, we need to identify it early and help that child as soon as possible to get treatment and support.

Remember, with help, there is hope.

(bright radiant music) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by: The American Psychiatric Association Foundation, The John & Polly Sparks Foundation and the WoodNext Foundation.

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