Medical/Psychiatric Comorbidities Associated with Academic Failure

Transcription

1 Medical/Psychiatric Comorbidities Associated with Academic Failure Robin Steinberg Epstein M.D. Clinical Professor of Pediatrics Chief of Developmental Behavioral Pediatrics Center for Autism and Neurodevelopmental Disorders University of California, Irvine College of Medicine

2 Disclosure Neither I nor any member of my immediate family has a financial relationship or interest (currently or within the past 12 months) with any proprietary entity producing health care goods or services consumed by, or used on, patients related to the content of this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device.

3 Main points Neurodevelopmental diagnoses (including mental health) as well as psychosocial stressors are very common! They may present like a learning disability, when there is not one. They may make a learning concern worse. They may be worsened/triggered by the learning concern. (esp anxiety)

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5 For example Anxiety created by lack of ability Anxiety prevent production which looks like inability Or anxiety leads to avoidance or lack of practice leading to LD

6 Common mental health issues in children ADHD Ave 8.7% meet criteria, Around 4-5% diagnosed, 2-3% meds Anxiety- generalized, OCD, specific phobias, social, selective mutism % Depression- 3% of chidren, 8% of adolescents. Autism- 2% Substance Abuse- 12% of children live with at least 1 parent who has a substance abuse issue. Gifted child 1% above 135., 0.25% above 145

7 How Many Children Have Mental Health Concerns? About 15 million children in America have diagnosable emotional or behavioral health disorders Common examples: anxiety, depression, PTSD, eating disorders, substance abuse, and attention /conduct disorders Less than 25 percent of children in the US who need mental health services receive them Health Car US Surgeon s General Report

8 Mental Health Issues and Student Functioning Students with serious emotional disturbances showed significant difficulties in school: 14.1 % of students had school attendance lower than 50%, 43.3 % of students were listed with below average or failing grades.

9 Early SCHOOL Onset of Mental Health Issues (Spencer) 9

10 ADHD- underperforming, inconsistent performance due to poor attn and hyperactivity. 8.7% of the population 50% of ADHD also have a learning disability Studies show between 20-40% of people with (SLD-read)dyslexia has ADHD Most if not all who have ADHD have executive dysfunction. You need to be able to concentrate to read and to do multistep math problems. Working memory contributes to all subjects. This may contribute to why a child has an LD, or it may just look like they have an LD when they do not. Sometimes I treat ADHD and wait 3 months. If too far behind may need Sped to help catch up.

11 Executive Dysfunction (Often part of ADHD) The ability to plan, organize, execute. Leads to missing assignments, appearance of procrastination, messy backpack, poor calendaring.

12 Common Anxiety Disorders (10-15%) Generalized Anxiety Disorder Daily, multiple excessive and uncontrollable worries (health, school performance, future) May not ask for help, may get stuck, perfectionism. May be covering up a problem. Separation Anxiety Disorder Worry about separating from others, about harm to others or self May refuse school or be preoccupied by concerns Specific Phobia Excessive fear of specific object or situation Environmental: water, heights, animals Situational: flying, dentist, elevator Bodily phobia: blood, shots, vomit

13 Other anxiety disorders Agoraphobia/school refusal- made worse by learning challenges Social phobia- fear of interactions, talking, speaking in class. Selective mutism- Speaks only in certain environments (only at home, only on the playground). 0.6% of population. 40%+ have underlying lang/autism. OCD- compulsions driven by the fear that a consequence will occur. Can be mental compulsions. May interfere with completing writing assignments to the point of failure. Mental compulsions may result in inability to listen or act in school.

14 Child/Adolescent Anxiety Multimodal Study (CAMS), % responders to treatment 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CBT+SSRI CBT ONLY SSRI ONLY Placebo Walkup, et al. (2008)

15 CLASSROOM Strategies for Anxiety Do Acknowledge the fear: That must be scary to think about. Reflective listening: Sounds like you are not sure you can do well on the math test. Decide what you can do: I have my phone right here. If your mom is late, we ll call her. Do Not Discount the child s feelings: That will never happen. or There s nothing to worry about. II-S

16 The Anxious Child: Parenting Tips Encourage / reward independent behavior Don t overreact to physical symptoms Have the child teach coping / confidence Role play upcoming situations Consider a transition object Establish routines (AM, bedtime) Watch for negative media effects Consider bibliotherapy Don t over-talk about fears Consider drawings / stories / use of a journal Buchanan B. Yarnevich A

17 STEP 2. Everyday Stress: Self-Help Resources Websites: Anxiety and Depression Association Has free information, resources for parents and kids. Has ratings of apps (highest rated app: Breathe2relax) Books: Helping Your Anxious Child (Rapee 2008) You and Your Anxious Child (Albano 2013) Computer programs: BRAVE-Online (Spence 2008) Cool Teens (Cunningham 2006)

18 Cognitive Behavioral Therapy (CBT) School-based groups: FRIENDS (CBT for anxiety) Bounce Back (CBT for PTSD, Anxiety) Individual CBT for anxiety (Coping Cat, Kendall) Educate Child and Family about Anxiety Cognitive restructuring Recognizing negative/unrealistic thoughts and countering them Relaxation to manage somatic symptoms Gradual exposure to feared situation

19 SPED Eligibilities: Autistic-Like Disorder Co-occurring mental health disorders are: Highly prevalent in ASD Are more common in ASD than in the general population Between 69 and 79% of individuals with ASD experience at least one additional mental health condition during their lifetime (compared to rates of lifetime psychiatric disorder of approximately 40% in the general population) Autism is a language disorder. It is often accompanied by ADHD, anxiety, dyspraxia, sel mutism, dyslexia. Do not rule out comorbidity. (Croen et al., 2015; Lever and Geurts, 2016; Buck et al., 2014)

20 Mental Health Problems and ASD Anxiety disorders are seen in children with ASD with prevalence rates of 50% Between 28% and 53% of children with ASD meet criteria for ADHD Other conditions (depression, oppositional defiant disorder, psychosis) are more common in ASD than the general student population

21 Gifted Twice exceptional Can have ADHD, autism, anxiety,dyslexia, processing defecits, social issues, Tourettes, etc Extremely gifted-- commonly socially isolated, anxiety. May present as false ADHD, bored, defiant. May have an uneven learning profile. Easier to have internal inconsistency that is not recognized by school. Differentiated work.

22 Other medical comorbidities that impact learning Seizures Seizure meds- drowsy, personality/behavioral changes, cognitive dullness Allergies- mimic poor attn Allergy meds- drowsy Asthma meds/steroids- hyperactivity, mood lability, attention. Chronic medical conditions- IBD, cancer, postcancer, renal,migraines Vision impairment Hearing impairment Post treatment- cardiac and chemo= attn, learning, social??

23 Psychosocial contributions Food and housing insecurity Abuse- emotional, physical, sexual, parental substance Marital discord

24 Household Food Insecurity and Mental Disorders Both mental disorders and food insecurity are prevalent conditions among children and adolescents in the United States As the severity of household food insecurity increased so did the odds of youth having a mental disorder (P < 0.001) Students from very-low-food-secure households had higher odds of having a mental disorder with severe impairment [child OR: 2.55 (95% CI: 1.90, 3.43); adolescent OR: 3.44 (95% CI: 2.50, 4.75)]. J Nutr Oct;146(10): Epub 2016 Aug 31.

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26 Adverse Childhood Events Very common Hidden by time, shame, social taboos Strong predictors of later health risks and diseases Leading determinants of the health and social well-being of nation

27 Adverse Childhood Experiences are Common Of 17,000 Kaiser HMO Members San Diego: 2 out of 3 kids were exposed to 1 category of ACEs 1 in 4 exposed to 2 categories of ACEs 1 in 6 had FOUR or more adverse child experiences. 25% had at least 1 parent who abused substances 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood. Source: Adverse Childhood Experiences (ACE) Study. Information available at

28 ACES Questionnaire (Burke-Harris)

29 NOT Learning Problems Involve impairment in areas of hearing, Vision and motor function Dyspraxia/Apraxia Emotional disturbances Bullying

30 How Does Migration Affect Mental Health? Among immigrants, the prevalence of common mental health problems is initially lower than in the general population Over time, it increases to become similar to that in the general population Refugees who have had severe exposure to violence often have higher rates of trauma-related disorders, including post-traumatic stress disorder and chronic pain or other somatic syndromes Risk for mental health problems includes consideration of premigration exposures, stresses and uncertainty during migration, and postmigration resettlement experiences that influence adaptation and health CMAJ DOI: /cmaj

31 Look at the whole situation Neurodevelopmental diagnoses (including mental health) as well as psychosocial stressors are very common! They may present like a learning concern. They may make a learning concern worse. They may be worsened/triggered by the learning concern. (esp anxiety) Treat the whole child.