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School Materials for a Mental Health Friendly Classroom: Training Package

Eliminating Barriers for Learning: Social and Emotional Factors That Enhance Secondary Education

ACKNOWLEDGMENTS

This document was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Vanguard Communications, Inc. and the Gallup Organization, under contract number 280-99-0200, with SAMHSA, U.S. Department of Health and Human Services (DHHS). Paolo del Vecchio served as the Government Project Officer. Numerous peoeople contributed to the development of the document (see Appendix).

PUBLIC DOMAIN NOTICE

All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, DHHS.

ELECTRONIC ACCESS AND COPIES OF PUBLICATION

This publication may be accessed electronically through the following Internet World Wide Web connection: www.allmentalhealth.samhsa.gov. For additional free copies of this document please call SAMHSA's National Mental Health Information Center at 1-800-662-4357 or 1-800-228-0427 (TTD).

RECOMMENDED CITATION

Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Eliminating Barriers for Learning; Social and Emotional Factors that Enhance Secondary Education, SAMHSA Pub. No. P040478M. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2004.

ORIGINATING OFFICE

Associate Director of Consumer Affairs, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857

SAMHSA Publication No. P040478M 2004


CONTENTS

Introduction
Background

Eliminating Barriers for Learning is a packaged continuing education program for secondary school teachers and staff that focuses on mental health issues in the classroom. Its overall aim is to help eliminate barriers to learning by understanding and addressing mental health issues in the school environment. Developed by the Substance Abuse and Mental Health Services Administration, part of the U.S. Department of Health and Human Services, it offers information on adolescent social-emotional wellness and provides specific skill-based techniques for classroom use. It aims to—

Serious emotional disturbances affect 5-9 percent of American children and adolescents each year.1 That means, on average, that one or more students in every high school classroom could be affected.

Obviously, the impact of children's mental health on schools—teachers, classrooms, students, and staff—can be significant. However, the impact of school practices that promote mental health can also make a difference. This set of materials can help teachers and staff make a difference in the lives of their students and in the learning climate of their classrooms.

1 Farmer, E.M.Z., et al. The Epidemiology of Mental Health Programs and Service Use in Youth: Results From the Great Smoky Mountains Study. In M.H. Epstein et al. (eds.) Outcomes for Children and Youth With Behavioral and Emotional Disorders and Their Families. 2nd edit. (2003)


About the Training Package

This training manual consists of four modules which can be delivered together or at different times. Each one contains:

Because they are designed to stand alone, the modules contain some repetitions. For example, the definition of serious emotional disturbances is given twice. Trainers can tailor modules according to their own time tables. Like most forms of in service education and professional development training, Eliminating Barriers for Learning emphasizes knowledge and skill development.

Module I: Eliminating Barriers for Learning: The Foundation
This module describes the links between teen social-emotional development, mental health, and learning. It also addresses the impact of the stigma and discrimination that surround mental health issues and explores the teacher's role in helping students with mental health needs. It lays the foundation for, and is a prerequisite for, the three modules that follow.

Module II: Social-Emotional Development, Mental Health, and Learning
This module gives an overview of common mental health issues among adolescents and their potential effects on learning and behavior. It provides information on risk factors and protective factors for mental health and emotional problems, and signs indicating when teens may need help.

Module III: Making Help Accessible to Students and Families
This module provides practice in formulating a plan to help students with mental health needs. It encourages the creation of sustained school-home-community partnerships to meet the educational and developmental needs of these adolescents.

Module IV: Strategies To Promote a Positive Classroom Climate
This module addresses strategies to create an accepting classroom climate that promotes learning for all students, including those with mental health needs.


Delivering the Training

The training includes a variety of learning activities, including large group discussions, individual work with handouts, and small group brainstorming sessions.

Here are some key points to consider when planning the sessions:

Audience. The training is designed primarily for secondary school teachers. However, other school staff members who interact with students could benefit from the training as well.

Trainers. Trainers should know the school in which the training is given, especially the resources available for teens with mental health needs. The modules are designed for delivery by a member of the pupil services staff (a school psychologist, social worker, guidance counselor, or nurse, for example). Co-training with others such a as mental health professional (Module II) and a teacher (Module IV) is recommended.

Trainer preparation. Trainer preparation notes in each module provide background information on the topics presented, as well as detailed instructions for directing activities and facilitating discussions when needed. Trainers can prepare for the sessions by reading the trainer outline and notes with the slides and handouts alongside. Add notes about personal anecdotes or ideas for discussion in the margins.

Part of preparation is tailoring each module to the policies and practices of specific school buildings and districts. For example, a school's policy regarding teacher contact with parents can be woven into the development of an action plan (Module III). Or a State initiative on emotional and behavioral problems and schools can be discussed when introducing the links between mental health and learning (Module I).

A third preparatory step is to recruit guest trainers for help with specific areas. It is strongly recommended that an experienced teacher help deliver Module IV, which focuses on classroom strategies. Module II, which gives an overview of teen mental health issues, offers opportunities for a guest trainer who has first-hand experience with mental or emotional problems in adolescence.

Module III could be delivered with a school or community social worker.

A fourth step is to prepare participant materials. Each participant should have:

See the Trainer Preparation Checklist for more detailed instructions.

Length of training. The entire training package should take about 4 hours to deliver. However, each of the modules has been designed to stand alone, with the exception of Module I, which is a prerequisite for all or any of the following modules. This flexible format allows for training in specific areas or for ongoing training as time permits.

Training equipment. Equipment needed is an easel or chalkboard and a projector for overhead transparencies or PowerPoint slides.


Trainer Preparation Checklist

At least 4 weeks in advance of training:

At least 2 weeks in advance of training:

Two days before the training:



Module I: Eliminating Barriers for Learning: The Foundation
Overview for Trainers

Module I is designed around a vignette of a student who is having problems with social-emotional development. As the module progresses, you will use this vignette to explore:

Following participant introductions and orientation to the training, the module begins with a brief review of adolescent development. You can use the vignette, Caleb's Story, to draw participants into a discussion of how social and emotional development interacts with learning and achievement, inside and outside the classroom.

The module continues with a discussion of mental health and emotional problems and stigma, introducing basic definitions and concepts. Caleb's Story again serves as a framework for discussion as participants explore how stigma could be affecting his situation, creating a barrier to getting help.

The final exercise focuses on the teacher's role in helping a student with mental health needs, again using Caleb's Story as the framework for discussion.

Contents

Module I: Goal

The goal of Module I is to describe the links among social-emotional development, mental health, and learning.


Module I: Objectives

At the end of this module, participants will be able to:


Module I: Trainer's Outline

I-1 Introduction: Why Are We Here?
A. Participant and trainer introductions (icebreaker)

B. Show Slide I-A (What Would You Do About…) and ask:

Make the point: Mental and emotional problems among teens are common and need to be addressed, just like asthma and diabetes. But often, teachers are not as well prepared to deal with mental and emotional problems as they are with physical health problems.

C. Show Slide I-B (Why Focus on Mental Health Issues?). Make the points:

D. Show Slide I-C: The overall purpose of the training is to help eliminate barriers to learning by understanding and addressing mental health issues in the school environment.

E. Give overview of all four modules.

F. Introduce Module I.

I-2 Social-Emotional Development in Adolescence
A. On a flipchart or chalkboard write the three areas of development: physical, intellectual, and social/emotional/behavioral; refer to Handout I-A (Adolescent Development).

B. Clarify what is meant by social-emotional development (Trainer Note I-2).

C. Ask participants to read Caleb's Story (Handout I-B), and then to discuss Caleb's social-emotional development, using the description and milestones on the handout. Ask how Caleb displays:

I-3 Social-Emotional Factors Related to Academic and Nonacademic Success
A. Ask participants:

B. Use these answers to make the following points:

C. Transition to the following section by making the point:

I-4 Mental Health, Stigma, and Discrimination
A. Refer to Slide I-G (Serious Emotional Disturbances: Definition) and corresponding Handout I-C (Definitions: Serious Emotional Disturbances and Stigma); define serious emotional disturbances (SED) (Trainer Note I-4).

B. Make the following point:

C. Show Slide I-H (What Is Stigma?). Make the following point:

D. Show Slide I-I (Stigma, Discrimination, and Help-Seeking Behavior) and refer to Handout I-D (How Stigma and Discrimination Keep Teens and Families From Getting Help). Make the following points:

E. Refer back to Caleb's Story. Ask:

1 New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832: Rockville, MD: 2003.

I-5 The Teacher's Role
A. Refer to Caleb's Story again and ask participants how an educator might help Caleb. First make the following points:

B. As participants suggest other ways to help Caleb, try to group them under the teacher's roles shown in Slide I-J (The Teacher's Role).

C. Show Slide I-J and refer to corresponding Handout I-E; continue to brainstorm ways teachers could help Caleb in the various roles.

D. Ask participants if they perceive barriers in playing these roles.

I-6 Closing
A. Summarize major points of the module, referring to objectives.

B. Ask for comments and questions.

C. Ask participants to complete evaluation form.


Module I: Trainer Preparation Notes

I-1 Introduction: Why Are We Here?
Overview. This module begins with a discussion of the rationale and aims of the entire training package. It then goes on to describe the links among teen social-emotional development, mental health, and learning. It also addresses the impact of the stigma and discrimination that surround mental health issues and explores the teacher's role in helping students with mental health needs.

Background. Eliminating Barriers for Learning is part of a broad initiative that is working to reduce the stigma and discrimination surrounding mental illnesses. Developed by the Substance Abuse and Mental Health Services Administration, part of the U.S. Department of Health and Human Services, the Elimination of Barriers Initiative focuses on stigma and discrimination because these are serious barriers that keep people from getting the help and support they need to cope with mental and emotional problems.

Serious mental and emotional problems affect 5–9 percent of American children and adolescents each year. That means, on average, that one or more students in every high school classroom could be affected. The impact on schools can be significant. Children with these problems have the highest rate of school failure. Only about 42 percent of these students graduate from high school, compared with 57 percent of all students with disabilities.1

The benefits of addressing mental health issues include higher academic achievement, lower absenteeism, and fewer behavioral problems.2

The overall purpose of the training is to help eliminate barriers to learning by understanding and addressing mental health issues in the school environment.

Module I: This module describes the links among teen social-emotional development, mental health, and learning. It also addresses the impact of stigma and discrimination that surround mental health issues and explores the teacher's role in helping students with mental health needs.

Module II: This module gives an overview of mental health issues among adolescents and their potential effects on learning and behavior. It provides information on risk factors and protective factors for mental and emotional problems, and on signs indicating when teens may need help.

Module III: This module provides practice in formulating a plan to help students with mental health needs. It encourages the creation of sustained school-home-community partnerships to meet the educational and developmental needs of adolescents.

Module IV: This module addresses ways to create an accepting classroom climate that promotes learning for all students, including those with mental health needs.

I-2 Social-Emotional Development in Adolescence
Background. As teachers well know, adolescence is a time of rapid development, the second time since infancy that changes occur at an accelerated rate. The purpose of this section is to review and discuss one developmental area—social-emotional development—and how it impacts learning.

Expanded information about social-emotional development:

I-3 Social-Emotional Factors Related to Academic and Nonacademic Success
Notes on facilitating group discussion. Participants have observed youth in a variety of contexts: the classroom, hallways, cafeteria, sports, and assorted situations. It is through the process of observation that they begin to really see the effects of development across age ranges and between individuals. In the discussion of Caleb's Story, you will be asking participants to consider social-emotional development and its impact on performance in the classroom as well as success outside of it. Use their responses to illustrate the far-reaching impact of social-emotional development and mental health.

Examples of the relationship between social-emotional development and academic and nonacademic success. The following examples may reflect some participants' observations during this discussion. Keep in mind that the relationship between social-emotional development and success in and out of the classroom is not limited to the following; nor is the boundary between "academic" and "nonacademic" a rigid one.

I-4 Mental Health, Stigma, and Discrimination
NOTE: More details about specific disorders are in Module II. Here, the definition is supplied in order to introduce the concept of stigma surrounding mental health issues.

SED Definition and Information. Serious emotional disturbances (SEDs) are diagnosable disorders in children and adolescents that severely disrupt daily functioning in the home, school, or community.

"Serious emotional disturbance," not "mental illness," is the preferred term when referring to these disorders in children and adolescents.

In a given year, about 5–9 percent of children (up to 18 years of age) have a serious emotional disturbance.3 Unfortunately, as many as 25 percent of youth who may have a serious emotional disturbance do not receive mental health services of any kind.4

The 1999 report of the Comprehensive Community Mental Health Services for Children and Their Families Program of the Center for Mental Health Services reports that students with serious emotional disturbances showed significant difficulties in school: 14.1 percent of students had school attendance lower than 50 percent, and 43.3 percent of students were listed with below average or failing grades.

About Stigma. In these modules, stigma refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses. Stigma is not just a matter of using the wrong word or action. Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier. Fear of stigma and the resulting discrimination discourages individuals and their families from getting the help they need.

Stigma can cause discriminatory treatment toward youth and their families by their peers as well as by educators and community members. It also is dangerous because it can prevent people from seeking help and meeting their own needs. It does this by causing:

These are noted as WHAT, WHY, and WHERE on Slide I-I and Handout I-D. A more detailed explanation follows:

3 Farmer, E.M.Z. et al. The Epidemiology of Mental Health Programs and Service Use in Youth: Results From the Great Smoky Mountains Study. In M.H. Epstein et al. (eds.) Outcomes for Children and Youth With Behavioral and Emotional Disorders and Their Families. 2nd edit. (2003)

4 Hoagwood, K., & Johnson, J. (2003). School psychology: A public health framework I. From evidence-based practices to evidence-based policies, Journal of School Psychology, 41(I), 3-21.


Module I: Slides

Slide I-A: What Would You Do About...

Slide I-B: Why Focus on Mental Health Issues?

Slide I-C: Overall Purpose of Training

Slide I-D: Overview of Modules

Module I:  Eliminating Barriers for Learning: The Foundation

Module II: Social-Emotional Development, Mental Health, and Learning

Module III: Making Help Accessible to Students and Families

Module IV: Strategies To Promote a Positive Classroom Climate

Slide I-E: Goal
The goal of Module I is to describe the links among social-emotional development, mental health, and learning.

Slide I-F: Objectives

Slide I-G: Serious Emotional Disturbances: Definition
Diagnosable disorders in children and adolescents that severely disrupt their daily functioning in the home, school, or community. These disorders include:

Slide I-H: What Is Stigma?

Slide I-I: Stigma, Discrimination, and Help-Seeking Behavior

Slide I-J: The Teacher's Role


Module I: Handouts

Handout I-A: Adolescent Development

Area Description Milestones
Physical
  • Increase in height/weight
  • Hormonal changes
  • Maturation of brain/neural system
  • Secondary sex characteristics
  • Strength/dexterity
Intellectual
  • Reasoning
  • Abstract thinking
  • "Thinking about thinking"
  • Logic/consequences
  • Concepts/ideas
  • Metacognition
Social-Emotional
  • Formation of attitudes, beliefs, and values (identity development)
  • Recognition of consequences of decisions made
  • Awareness of one's own and others' behavior; formation of ideas of appropriateness
  • Self-direction
  • Sense of purpose
  • Autonomy
  • Conflict resolution
  • Self-esteem and self-efficacy

Handout I-B: Caleb's Story

Caleb was asked to leave Mrs. Parker's class for the third time this week. As he waited in the main office to see the assistant principal, Caleb started to think about what his mother might say. It was already the fifth week of the second marking period and nothing about Caleb's behavior had changed. He was talking in class, twirling his house keys, and Mrs. Parker, according to Caleb, had it in for him. How could he explain any of this to the assistant principal? To his mother? He just seemed to always stand out somehow.

Caleb thought about the years of getting into trouble at school. He had attention-deficit/hyperactivity disorder and had taken medicine from first grade to sixth grade. He switched medicines at different times and he remembered how many headaches and stomach aches went along with those medicines. Sometimes he fell asleep in class or he felt really jumpy or upset. In sixth grade, he stopped taking the medicine. It just didn't seem to keep him focused anymore. "So what!" Caleb mumbled to himself. No more headaches.

Yet Caleb remembered how bad sixth grade had been. He was in trouble every day. He recalled how he accidentally got stuck in his chair, falling in between the seat and the backrest. How on earth did he do that? The other students had laughed and the teacher was so mad! So many things had happened and his grades just kept going down.

The school said they couldn't help him, but Caleb told the other kids he got kicked out. Caleb's mother had told him that he didn't have to pretend he was a bad kid to get others to like him. He told her that being bad was better than being sick.

Middle school had felt like a big zoo with all the guys acting like gorillas. Caleb felt angry thinking about how many fights he had to avoid. He just seemed to annoy people for no reason. To top it off, his teachers just seemed to hate him. He lost his work or didn't write down the assignments. Detention was a weekly event. He ended up going to the guidance office to eat his lunch so he could avoid all the guys who made his life miserable. Once he took two pints of chocolate milk out of the cafeteria and put them in his backpack. That was a big mistake! When he walked down the hallway, one of the guys kicked his backpack. By the time Caleb made it to the guidance office the pints were crushed open and milk was on all of his schoolwork. The secretary yelled at him for making a mess and kicked him out of the office.

All anyone ever told Caleb was that he didn't try hard enough. They would tell him he was smart but an underachiever, whatever that meant. Caleb decided he was just lazy. It seemed like each time, he would decide to keep his mouth shut, and then he would forget. His teachers wrote that he was disruptive, talkative, and didn't follow the rules of the class.

Caleb was called into the assistant principal's office. The assistant principal told Caleb that detention just didn't seem to have any consequences, so he was given two days of in-school suspension because the number of incidences was escalating. Caleb thought about his failing grades. At least in suspension he could catch up on his work, he imagined. Wait until my mother sees my grades, Caleb worried to himself. I don't think I have above a 30 in math and I am failing English, too.

The bell rang. Caleb was going to be late for Earth Science and he'd forgotten to ask for a pass. Of course, the teacher probably wouldn't believe that he was at the office. Caleb decided he was in trouble anyway, so he might as well take his time. No one believed him, he decided. He thought maybe he should just do whatever he wanted. What was the point, anyway?


Handout I-C: Definitions: Serious Emotional Disturbances and Stigma

Serious emotional disturbances:
Diagnosable disorders in children and adolescents that severely disrupt their daily functioning in the home, school, or community. These disorders include depression, attention-deficit/hyperactivity disorder, anxiety disorders, conduct disorder, and eating disorders.

Source:
Glossary of Terms, Child and Adolescent Mental Health, Center for Mental Health Services; www.mentalhealth.samhsa.gov/publications/allpubs/CA-0005/default.asp

Stigma:
In these modules, stigma refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses. Stigma is not just a matter of using the wrong word or action. Stigma is about disrespect. It is the use of negative labels to identify a person living with mental illness. Stigma is a barrier. Fear of stigma, and the resulting discrimination, discourages individuals and their families from getting the help they need.

Sources:
Anti-Stigma: Do You Know the Facts? Child and Adolescent Mental Health, Center for Mental Health Services; www.mentalhealth.samhsa.gov/publications/allpubs/OEL99-0004/default.asp

New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.


Handout I-D: How Stigma and Discrimination Keep Teens and Families From Getting Help
Youth, parents, and educators all too often do not take steps toward seeking help because they do not know WHAT, WHY, or WHERE, as follows:

WHAT (Identification)

WHY (Referral)

WHERE (Treatment)

* "Crazy" is a stigmatizing term that reflects misunderstanding of mental illnesses and serious emotional disturbances. It should be avoided.


Handout I-E: The Teacher's Role
The teacher's role as a supportive adult is critical to a student with mental health and emotional problems. Specific functions within a supportive adult role include:


Module I Evaluation

Part I: Please answer the following questions by circling a number on the scales provided.

1) Was the content of this module relevant and applicable to your classroom/school?
Not at all relevant Somewhat relevant Extremely relevant
1 2 3 4 5 6 7

2) Was the information presented too simplistic or too involved?
Too simplistic Just right Too involved
1 2 3 4 5 6 7

3) Was the information new to you?
All previously known Some new information Mostly new information
1 2 3 4 5 6 7

4) Was the module well-organized?
Not well-organized Somewhat well-organizedVery well-organized
1 2 3 4 5 6 7

5) Was the module an appropriate length?
Too short Comfortable lengthToo long
1 2 3 4 5 6 7

6) Was there a sufficient variety of activities?
Not enough A good numberToo many
1 2 3 4 5 6 7

7) Were the materials (slides, handouts) clear and concise?
Not clear Somewhat clearVery clear
1 2 3 4 5 6 7

8) Were the materials helpful as supplements to the information presented?
Not helpful Somewhat helpful Very helpful
1 2 3 4 5 6 7

Part II: Please give us your comments:

I liked:
_____________________________________________
_____________________________________________

I didn't like:
_____________________________________________
_____________________________________________

I wish there had been more:
_____________________________________________
_____________________________________________

The most important thing I learned was:
_____________________________________________
_____________________________________________

Other comments:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________



Module II: Social-Emotional Development, Mental Health, and Learning
Overview for Trainers

This module gives a brief overview of mental health issues among teens and their potential effects in the classroom. It begins with a discussion of factors that can put teens at risk for, or protect them from, mental and emotional problems. It then looks at the continuum of problems, from wellness at one end to serious emotional disturbances at the other, and moves on to the various components of learning and behavior that can be affected by these problems. Next, slides describe the most common disorders among teens, while discussion centers on the ways that each one affects those components of learning and behavior. The final sections describe indicators that a teen may need help. An action plan for helping a student is briefly introduced. (This segment can be omitted if Module III is to follow immediately after.)

Note: Information on specific disorders is provided at three different levels. The slides provide a brief overview; the Trainer Preparation Notes give more background information; and the Appendix provides fact sheets for participants to take home for future reference.


Contents

Module II: Goal

The goal of Module II is to give an overview of mental health issues among adolescents and their potential effects on learning and behavior.


Module II: Objectives

At the end of this module, participants will be able to:


Module II: Trainer's Outline

II-1 Introduction
A. Remind participants that the overall purpose of the training is to help eliminate barriers to learning by understanding and addressing mental health issues in the school environment.

B. Show Slides II-A (Goal) and II-B (Objectives).

C. Give overview of the module, linking it to themes from Module I (Trainer Note II-1).

II-2 Risk and Protective Factors
A. Show Slide II-C (What Are Risk Factors?).

B. Refer to Caleb's Story from Module I (Handout I-B). Give participants time to re-read the vignette.

C. Ask participants what risks are present in Caleb's Story. Write responses on a flipchart and relate them to categories on the next slide.

D. Show Slide II-D (Risk and Protective Factors) and refer to corresponding Handout II-A (Risk and Protective Factors) (Trainer Note II-2).

E. Summarize areas of potential risk and protective factors that help to reduce the likelihood of negative developmental outcomes, making the following points:

II-3 The Adolescent Mental Health Continuum
A. Show Slide II-E (Mental Health: Definition).

B. Refer to Handout II-B (Adolescent Mental Health Continuum) (Trainer Note II-3).

C. Explain the continuum, making the following points:

II-4 The Impact of Mental Health Problems and Disorders on Learning and Social Functioning
A. Show Slide II-F (Serious Emotional Disturbances: Definition).

B. Refer to Handout II-C (Serious Emotional Disturbances).

C. Ask participants to consider how mental health and emotional problems may affect academic and nonacademic activities. Write participants' responses on a flipchart and relate them to the categories on the next slide and handout (Trainer Note II-4).

D. Show Slide II-G (Adolescents With Mental Health and Emotional Problems) and refer to Handout II-D (Problems Associated With Serious Emotional Disturbances).

E. Emphasize themes, contributions, and areas that are directly related to classroom learning.

F. On the easel or chalkboard, write the following components of learning affected by mental health and emotional problems:

II-5 Common Mental Health and Emotional Problems in Adolescence
A. Show Slides II-H–II-N to give a brief overview of the most common problems among teens. Refer participants to the appendix handouts for more detailed information (Trainer Note II-5).

II-6 Other Disorders

II-7 When Youth Need Additional Support
A. Show Slide II-O (Indicators of Need) and refer to Handout II-J (Indicators of Need).

B. Show Slide II-P (Action Plan).

C. Show Slide II-Q (Stages of an Action Plan) and summarize the components of a plan (Trainer Note II-7).

II-8 Closing
A. Summarize major points of the module, referring to objectives.


Module II: Trainer Preparation Notes

II-1 Introduction
Background. Module II gives a brief overview of the serious emotional disturbances most common among adolescents and their potential effects on learning and behavior. It begins with an overview of risk and protective factors, and goes on to describe specific disorders. The module concludes with a discussion of "indicators of need"—signs suggesting that a student may need additional support. A brief introduction to an action plan, to be devised when a student needs additional support, leads to the next module, in which participants practice creating an action plan. (This last section can be omitted if Module III is to follow immediately.)

Note on presentation: There are opportunities within this module to include youth speakers, family speakers, and other members of a two-member or three-member presentation team (e.g., mental health professionals, family members, school professionals). A guest speaker can discuss the impact of mental health problems on learning and other areas important to the school environment. Consider Section II-5 as especially adaptable for speakers with personal experience of mental health problems during adolescence.

II-2 Risk and Protective Factors
Background. The exact cause of mental disorders is not known, but most experts believe that a combination of factors—biological, psychological, socio-cultural—are involved.

While the same key events mark adolescencent development, youth develop at different rates. These differences sometimes are associated with their cultural, social, and economic groups, and/or their gender. Youth also differ in the degree to which they are insulated or protected from medical, environmental, and familial or personal events that could disrupt their developmental growth. When a group of factors have the potential to impede healthy development they are known as risk factors. Risk factors may be related to biology or environment (e.g., family, community).

Further information on risk and protective factors. Risk does not predict poor outcomes. It simply means that a number of conditions or situations can solidify a pathway that becomes increasingly difficult to shape toward positive results.

The areas of risk summarized on Slide II-D (Risk and Protective Factors) pertain to factors that are associated with delinquency, pregnancy, dropout, and crime. Some risk factors not mentioned include those related to individual differences, such as temperament and intelligence. Males appear more vulnerable to risk factors, as do children and youth with difficult, temperamental styles and lower IQs.

Protective factors include relationships, and opportunities to be involved and recognized for the skills and contributions made. Relationships with youth need to be genuine, authentic, and ongoing. Opportunities to be involved and contribute must match the youth's actual skill set. To fail at an opportunity due to insufficient skill sets the youth up for discouragement, frustration, and disillusionment.

The President's New Freedom Commission on Mental Health defines resilience as "the personal and community qualities that enable us to rebound from adversity, trauma, tragedy, threats, or other stresses—and to go on with life with a sense of mastery, competence, and hope."1 Resilient youth demonstrate favorable development despite exposure to a variety of risk factors. The promotion of mental health by building on strengths is a way to develop protective factors and bolster resilience for all youth.

1 New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. Final Report. (DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003) 5.

II-3 The Adolescent Mental Health Continuum
Background. The majority of youth experience overall wellness despite occasional difficulties. Mental health problems or disorders are a concern when difficulties disrupt developmental growth. Behaviors of youth occupy a range of what would be expected for them during their early, middle, and late stages of adolescent development. This range can be illustrated by a continuum, that depicts variation in behavior frequency (how often), duration (how long), and intensity (to what degree). Along this continuum, the American Academy of Pediatrics (1996) identifies various kinds of behaviors, including behaviors expected during adolescence; behaviors that are serious enough to disrupt day-to-day functioning, representing a mental health problem; and behaviors that would suggest a mental disorder is present.

Co-occurring substance use disorders can affect where youth fall along this continuum. In comparison to individuals with primary mental or substance use disorders, individuals with co-occurring disorders tend to be more symptomatic, have multiple health and social problems, and require more costly care, including hospitalization.

While secondary school teachers and staff are not expected to pinpoint where each student falls along the continuum, it is helpful to understand that problems of emotion and behavior are not merely absent or present, but are more differentiated by the frequency, duration, intensity, and impact to self and others.

About Handout II-B (Adolescent Mental Health Continuum). It is important to realize that the columns below the continuum line represent areas of functioning that have impact on life domains. These areas, more often than not, are not neatly clustered as shown in the columns and rows. Typically, some symptoms can show up at one level with other symptoms at a more intense level, and a completely different set of symptoms at an extreme level. That is, separate areas can be linked diagonally with each other. For example, a youth may show very appropriate social functioning but experience severe distress in biological patterns, as with an eating disorder.

II-4 The Impact of Mental Health Problems and Disorders on Learning and Social Functioning
Background. About 5–9 percent of children ages 9 to 17 have a serious emotional disturbance2.

Serious emotional disturbances (SEDs) are diagnosable mental disorders in children and adolescents that are severe enough to disrupt daily functioning in school and non-school settings. SED, rather than mental illness, is the preferred term for severe mental health problems among children and adolescents. SEDs include mood disorders, attention-deficit/hyperactivity disorder, anxiety disorders, conduct disorders, and eating disorders.

The term SED, or serious emotional disturbance, as used in this training, refers to a clinical diagnosis. It does not necessarily mean "qualifies for special education." Specific school/district policies regarding SEDs vary. In Module III, there will be an opportunity to address local policies regarding serious emotional disturbances.

Information about serious emotional disturbances' impact on academic activities. These disorders can affect important components of classroom behavior and learning, particularly attentiveness, concentration, and opportunities to rehearse and demonstrate new knowledge or skills. Self-appraisal, which is a set of attitudes and expectations about one's own ability and performance, is another important component of learning that can be affected by a serious emotional disturbance. Mastery of a skill, the prize of learning, is difficult to obtain when any or all the components of attention, concentration, self-appraisal, and rehearsal are affected by a serious emotional disturbance. Learning is a behavior, as are the social elements of conduct both inside and outside the classroom. While it might not be apparent how a disorder affects learning, the symptoms will show up in other ways, namely through behavioral conduct in the classroom and interactions with peers and adults.

Serious emotional disturbances also may affect classroom learning in more tangible ways, such as missed instruction time due to hospitalization or doctor's appointments.

2 Farmer, E.M.Z. et al. The Epidemiology of Mental Health Programs and Service use in Youth: Results From the Great Smoky Mountains Study. In M.H. Epstein et al. *(eds.) Outcomes for Children and Youth With Behavioral and Emotional Disorders and Their Families. 2nd edit. (2003)

II-5 Common Mental and Emotional Problems in Adolescence

In this section you will show Slides II-H–II-N, giving a very brief overview of the most common disorders among teens. The following bullets will give more background for the trainer. Much more complete information is available in the Appendix for participants' use after the training.

Discussion during this overview should center on the disorders' effects on learning and behavior. This information is included in the following handouts:

NOTE: There is no handout on the impact of disruptive behavior disorders; the impact on behavior is part of the description of the disorder.

You can refer to the list of potential effects you have written on the easel or chalkboard as you present this section. Consider asking participants to draw on their classroom experience to illustrate some of the effects. A guest speaker could also contribute to the presentation/discussion in this section.

• Mood Disorders

Mood disorders are persistent disturbances of mood that affect an individual's ability to conduct basic life tasks. Major depressive disorder, dysthymic disorder, and bipolar disorder are the most frequently diagnosed mood disorders in children and youth.

Information on the importance of treatment. Identification of a mood disorder and referral to treatment can be significant first steps in restoring a youth's functioning. Fortunately, the majority of those who receive treatment for depression are treated successfully. Treatment not only alleviates symptoms, it also prevents further complications. Youth with severe depression may experience profound withdrawal from social activities, feel intense isolation and loneliness, and become at high risk for suicide.

3 Kovacs, M., Kral, R., and Voti, L. (1994). Early onset psychopathology and the risk for teenage pregnancy among clinically referred girls. Journal of the American Academy of Child and Adolescent Psychiatry, 33: 106-113.

• Anxiety Disorders

Anxiety disorders are characterized by excessive fears, worries, and preoccupations that are a reaction to a perceived sign of danger. Anxiety itself is considered essential to adaptive functioning because it protects people from harm through a "flight or fight" biological response. An anxiety disorder, however, is a recurrent alarm that can tax the body excessively. Anxiety disorders include generalized anxiety disorder, separation anxiety disorder, panic disorder, phobias, obsessive-compulsive disorder, and post-traumatic stress disorder. If left untreated, anxiety disorders can have a significant and debilitating impact on an individual's life.

• Disruptive Behavior Disorders

Disruptive behavior disorders are a complicated group of behavioral and emotional problems that manifest as difficulty following rules and behaving in socially acceptable ways. The impact of the disruptive behavior is distressing to others and can interfere with establishing trusting and supportive relationships.

• Eating Disorders

Eating disorders refer to patterns of thoughts and behaviors about one's body, foods, and the intake of foods that lead to severe health, social, and school problems. Eating disorders negatively affect physical and psychological health, and if left untreated, can lead to damaging medical consequences, including death. Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

II-6 Other Disorders

Note on developmental disorders. Pervasive developmental disorders (PDD) are neurobiological disturbances that range from very mild to extremely severe. These impairments affect one or more areas of intellectual, language, motor, and social functioning. Pervasive developmental disorders are sometimes referred to as autistic spectrum disorders.

These disorders are not classified as serious emotional disturbances, although they can co-occur with these disorders.

Disorders that fall under the pervasive developmental disorder umbrella term include autistic disorder, childhood disintegrative disorder, and Asperger syndrome. These disorders are different from one another in the magnitude of delay or deviance from normal development.

More information on each of these disorders is available from the Web sites listed on the handouts, or from the National Institutes of Health (www.nih.gov) or the Substance Abuse and Mental Health Services Administration's National Mental Health Information Center (www.mentalhealth.samhsa.gov), which also offers an online mental health services locator.

II-7 When Youth Need Additional Support

Background. Indicators of a need for intervention include behaviors, thoughts, or feelings that limit the youth's ability to maintain positive relationships, cope with the demands of home and school life, and continue healthy development.

There is no clear dividing line between mental health, mental health problems, and serious emotional disturbances and thus no easy way to tell when a student needs additional support. The indicators shown on Slide II-O (Indicators of Need) are general guidelines. Some more specific signs that youth may need help are listed in Handout II-J (Indicators of Need). You can also refer to the Adolescent Mental Health Continuum (Handout II-B) during this discussion. Note that in both handouts there are numerous references to frequency (how often a sign occurs), duration (how long it lasts), and severity. These can be clues to when a teen may need help.

Information on stages of an action plan. Detailed information on an action plan is included below for the trainer's benefit. The information is included in Handout III-A of Module III, in which it is discussed in more detail. If you have elected not to use Module III in your trainings, provide participants with the handout at this point.

Stage I: Know your building and district policies, procedures, and resources. This sounds obvious, but schools do not have the time to advertise every support service available. Every district has procedures in place to work with students and staff. For example:

The key for staff is to learn how to access these professionals and other school resources.

Stage II: Voice your concern. This part is hardest. Tips for teachers and other staff:

Stage III: Follow up. It is important to stress that helping students isn't about shifting the problem to someone else. Following up reassures youth that you are someone who DOES care. Tips for teachers and other staff:

The action plan should be tailored to the needs of the student and his or her family and should include all the resources inside and outside the school that can meet his or her needs. Not all students will show an immediate beneficial response to intervention. Continue to provide support for the student within the classroom and provide feedback to the student at every hint of progress.

Researchers and educators have identified a number of specific intervention strategies and options. Functional behavior assessment and Positive Behavioral Interventions and Supports (PBIS) are among the practices that may be employed by teachers and schools. Find out your own school's policy for interventions, and see the Resource List, included as an appendix to this training, for more information.


Module II: Slides

Slide II-A: Goal

The goal of Module II is to give an overview of mental health issues among adolescents and their potential effects on learning and behavior.

Slide II-B: Objectives

Slide II-C: What Are Risk Factors?

Risk factors make it more likely that a teen will develop a disorder.

Protective factors make it less likely that a teen will develop a disorder.

Slide II-D: Risk and Protective Factors

Risk factors include:

Protective factors include:

Slide II-E: Mental Health: Definition

A state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. It is indispensable to personal well-being, family and interpersonal relationships, and contribution to community or society.

Slide II-F: Serious Emotional Disturbances: Definition

Diagnosable disorders in children and adolescents that severely disrupt their daily functioning in the home, school, or community.

Slide II-G: Adolescents With Mental Health and Emotional Problems Are More Likely To Experience:

Slide II-H: Mood Disorders

Slide II-I: Any threat of suicide should be treated seriously.

Slide II-J: Anxiety Disorders

Slide II-K: Attention-Deficit/Hyperactivity Disorder

Slide II-L: Disruptive Behavior Disorders

Slide II-M: Disruptive Behaviors and Other Disorders

Youth who show disruptive behaviors may have:

For example, a youth may have both ADHD and a learning disability

Slide II-N: Eating Disorders

Slide II-O: Indicators of Need

Indicators of need for intervention include behaviors, thoughts, or feelings that limit a youth's ability to:

Problem behavior may be an indicator of need.

Slide II-P: Action Plan

Slide II-Q: Stages of an Action Plan Include:


Module II: Handouts

Handout II-A: Risk and Protective Factors

Risk Factors
for mental health problems


Community
Drugs
Firearms
Crime
Media
Violence
Mobility
Poverty

Family
Family history of behavior
Family conflict
Family history of mental illness

School
Early antisocial behavior
Academic failure in late elementary school
Lack of commitment to school
Individual/peer alienation and rebelliousness
Friends who engage in a problem behavior
Early initiation of a problem behavior 		 
Protective Factors
against mental health problems

An adult, such as a community leader, church member, schoolteacher, or parent, who cares about the youth and his/her future

A genuine relationship with an adult who expresses clear and consistent rules and expectations about the youth's behavior, and discusses disappointments, poor decisions, and mistakes

Recognition for involvement, accomplishments, and worth as a person

Opportunities to be involved and to show skills that contribute

An adult who shows consistent dedication to the youth's overall health and development

Adapted from Hawkins, J. D., & R. F. Catalano. Communities that care: Action for drug abuse prevention. San Francisco: Jossey-Bass, 1992.


Handout II-B: Adolescent Mental Health Continuum

  Less Severe > >>> More Severe
Social Adjustment Adjusts to social situations Some ups and downs in adjustment to social situations Adjustment difficulties in social situations Severe impairment in social situations
Environment/ Coping Skills Adapts to environment At times shows difficulty coping with environment Ineffective or inconsistent coping with environment Restricted coping, dependency, or crisis
Emotional Responses Appropriate emotional responses Emotional Responses inconsistent Emotional responses are restricted, extreme, or inappropriate  Emotional responses are severely disproportiontate
Mood Control Controls mood  Some fluctuation in ability to control mood Mood swings, sad mood, or consistent irritability Mood seriously impairs day-to-day functioning
Thought Patterns Thoughts consistent with goals, intentions, beliefs Preoccupations, worries, or frustrations Intrusive thoughts or obsessions Bizarre or illogical thoughts
Biological Patterns* Regular biological patterns Minor disruptions to biological patterns Consistent disruptions of biological patterns Severe disruptions of biological patterns

*includes sleep cycles, eating patterns, etc.

About the Continuum:

Handout II-C: Serious Emotional Disturbances

Diagnosable disorders in children and adolescents that severely disrupt their daily functioning in the home, school, or community. These disorders include depression, attention-deficit/hyperactivity disorder, anxiety disorders, conduct disorder, and eating disorders.

The term SED, or serious emotional disturbance, as used in this training, refers to a clinical diagnosis by a mental health professional. It does not necessarily mean "qualifies for special education." Specific school/district policies regarding SEDs vary. In Module III, there will be an opportunity to address local policies regarding serious emotional disturbances.

Source:

Glossary of Terms, Child and Adolescent Mental Health, Center for Mental Health Services; www.mentalhealth.samhsa.gov/publications/allpubs/CA-0005/default.asp

Handout II-D: Problems Associated With Serious Emotional Disturbances

Adolescents with these problems are more likely to experience co-occurring social-emotional problems, face other health risks, and experience restricted opportunities. Each of these can manifest itself in the ways listed below.

Co-Occurring Social-Emotional Problems

Health Risks

Restricted Opportunities

Handout II-E: Signs of Depression

The following signs may be symtoms of depression in children and adolescents if they persist for over 2 weeks:

Handout II-F: Depressive Disorders: Effects on Learning and Behavior

Attention: Attention can be disrupted by discomfort and physical symptoms such as headaches or stomach aches.

Concentration: Concentration is difficult to maintain for extended periods of time and affected by fatigue or intrusive thoughts related to guilt, hopelessness, or suicide.

Self-appraisal/expectations: Lack of enjoyment, feelings of low self-worth, expectations of failure, sensitivity to feedback, and negative thoughts about the future impede motivation and effort.

Rehearsal: Deficits in attention, concentration, and motivation may make it difficult to retain and retrieve information for the purpose of rehearsal.

Mastery: Cognitive and emotional impairments may interfere with the mastery of material.

Behavior: Excessive absences; sleepiness or restlessness during class; slow responding or no participation; overall avoidance of social interaction or typical activities of peers; crying or expressions of excessive guilt and sadness.

Handout II-G: Risks for Suicide

Information on suicide prevention can be found at the Substance Abuse and Mental Health Services Administration's National Strategy for Suicide Prevention Web site: www.mentalhealth.samhsa.gov/suicideprevention

Schools are encouraged to develop a comprehensive plan for suicide prevention. A detailed description of such a plan can be found in Keith A. King, "Developing a Comprehensive School Suicide Prevention Program," Journal of School Health, April 2001, Vol 71, No. 4, pages 132-137.

Handout II-H: Anxiety and Attention-Deficit/Hyperactivity Disorder: Effects on Learning and Behavior

Anxiety Disorder

Attention: Attention can be disrupted by a sense of impending doom or the feeling that something is wrong.

Concentration: Concentration is difficult to maintain during moments of intense anxiety, or is affected by irritability, restlessness, or a feeling of being out of control.

Self-appraisal/expectations: Expectations of poor outcomes or a sense of inability to bring about good results.

Rehearsal: Disruptions in attention or worries about performance can interfere with effective rehearsal.

Mastery: It often is difficult to retrieve or demonstrate previously learned information when feeling acute anxiety.

Behavior: Freezing during exams; asking for help when unnecessary; talking about worries, "what if" statements, or exaggerated/irrational fears; being overly prepared for tasks or exams; seeming upset or frantic when worries escalate.

Attention-Deficit/Hyperactivity Disorder

Attention: Problems with attention are the hallmark of this disorder. Either the youth is overly attentive to insignificant details or completely inattentive. The youth often misses information due to daydreaming, overactivity, or attention to other aspects of the environment.

Concentration: Highly distractible or impulsive but concentration improves when task has full attention.

Self-appraisal/expectations: Often fails to use prior experiences to accurately predict abilities; may overestimate or underestimate the demands of tasks and skills required; prior negative social feedback can impact motivation and sense of competence.

Rehearsal: Lack of organization and attention often interferes with time on task; frustration can come from missing important information regarding the procedures involved; patience and persistence weakly linked to rehearsal.

Mastery: May show lopsided skills or have certain elements mastered but not other elements important to whole concepts; gaps in knowledge can lead to difficulty with building on previous learning.

Behavior: Excessively talkative during class; hard to redirect or has difficulty following verbal or written directions; impulsive social behavior; annoying others or poor acceptance by peers; disorganized with materials; forgetful and missing multiple assignments.

Handout II-I: Eating Disorders (Anorexia): Effects on Learning and Behavior

Attention: Targeted attention appropriate to task, note-taking, and other skills associated with high performance.

Concentration: May show very intense concentration and self-discipline.

Self-appraisal/expectations: Perfectionist; overly hard on or punitive toward oneself; may assign more work to self than necessary.

Rehearsal: High expectations for mastery and repeated rehearsal.

Mastery: Information typically mastered to high degree but seemingly not good enough.

Behavior: High expectations; may be involved in rigorous athletic or physical competition; ritualistic with food or avoidance of meals; underweight; voices concerns about body size, shape, or weight; discusses dieting or avoidance of food.

Handout II-J: Indicators of Need

Children and adolescents with mental health issues need to get help as soon as possible. A variety of signs may point to mental health disorders or serious emotional disturbances in children or adolescents. Pay attention if a child or adolescent you know has any of these warning signs persisting for longer than seems appropriate:

A child or adolescent is troubled by feeling:

A child or adolescent experiences big changes, such as:

A child or adolescent experiences:

A child or adolescent behaves in ways that cause problems, such as:

Source:

Child and Adolescent Mental Health, Center for Mental Health Services, http://www.mentalhealth.org/publications/allpubs/CA-0004/default.asp


Module II Evaluation

Part I: Please answer the following questions by circling a number on the scales provided.

1) Was the content of this module relevant and applicable to your classroom/school?
Not at all relevant Somewhat relevant Extremely relevant
1 2 3 4 5 6 7

2) Was the information presented too simplistic or too involved?
Too simplistic Just right Too involved
1 2 3 4 5 6 7

3) Was the information new to you?
All previously known Some new information Mostly new information
1 2 3 4 5 6 7

4) Was the module well-organized?
Not well-organized Somewhat well-organizedVery well-organized
1 2 3 4 5 6 7

5) Was the module an appropriate length?
Too short Comfortable lengthToo long
1 2 3 4 5 6 7

6) Was there a sufficient variety of activities?
Not enough A good numberToo many
1 2 3 4 5 6 7

7) Were the materials (slides, handouts) clear and concise?
Not clear Somewhat clearVery clear
1 2 3 4 5 6 7

8) Were the materials helpful as supplements to the information presented?
Not helpful Somewhat helpful Very helpful
1 2 3 4 5 6 7

Part II: Please give us your comments:

I liked:
_____________________________________________
_____________________________________________

I didn't like:
_____________________________________________
_____________________________________________

I wish there had been more:
_____________________________________________
_____________________________________________

The most important thing I learned was:
_____________________________________________
_____________________________________________

Other comments:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________


Appendix

What Is A Depressive Disorder?

A depressive disorder is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.

TYPES OF DEPRESSION

Depressive disorders come in different forms, just as is the case with other illnesses such as heart disease. This pamphlet briefly describes three of the most common types of depressive disorders. However, within these types there are variations in the number of symptoms, their severity, and persistence.

Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.

A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overtalkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state.

SYMPTOMS OF DEPRESSION AND MANIA

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

Depression

Mania

CAUSES OF DEPRESSION

Some types of depression run in families, suggesting that a biological vulnerability can be inherited. This seems to be the case with bipolar disorder. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder will have the illness. Apparently additional factors, possibly stresses at home, work, or school, are involved in its onset.

In some families, major depression also seems to occur generation after generation. However, it can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with changes in brain structures or brain function.

People who have low self-esteem, who consistently view themselves and the world with pessimism or who are readily overwhelmed by stress, are prone to depression. Whether this represents a psychological predisposition or an early form of the illness is not clear.

In recent years, researchers have shown that physical changes in the body can be accompanied by mental changes as well. Medical illnesses such as stroke, a heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depressive illness, making the sick person apathetic and unwilling to care for his or her physical needs, thus prolonging the recovery period. Also, a serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Later episodes of illness typically are precipitated by only mild stresses, or none at all.

Depression in Women

Women experience depression about twice as often as men.1 Many hormonal factors may contribute to the increased rate of depression in women—particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause. Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.

A recent NIMH study showed that in the case of severe premenstrual syndrome (PMS), women with a preexisting vulnerability to PMS experienced relief from mood and physical symptoms when their sex hormones were suppressed. Shortly after the hormones were re-introduced, they again developed symptoms of PMS. Women without a history of PMS reported no effects of the hormonal manipulation.6,7

Many women are also particularly vulnerable after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. While transient "blues" are common in new mothers, a full-blown depressive episode is not a normal occurrence and