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Adolescent Mental Health:
Anxiety, Depression, and
Stress: Coping Skills for Teens
David W. Holdefer
MCPS School Psychologist
Mental Health
 There is a straw that breaks the camel’s
back.
 Sometimes the “camel’s back” is another
name for our internal mental health. Our
predisposition to coping or falling apart.
Our ability to be resilient. Resilience is
highly related to self-esteem, self-image,
and self concept. In the school setting,
academic success and resilience are highly
correlated to cognitive and emotional
intelligence, but…
COPING SKILLS
 What are the major stressors facing
adolescents?
 What are positive coping skills adolescents
use to alleviate stress? (How about the
negative coping strategies?)
 How do some teenagers manage their time,
advanced classes, and friendships?
 Instructional match? How can parents help
students to have reasonable expectations?
How might anxiety,
depression, and stress
affect a teen’s
academic
performance?
Research suggests that anxiety
and depression inhibits:
Attention
Memory
Language skills
Social skills
Mental processes
Depression interferes with
academic achievement
Anxiety Quote:
 “ No sharp-witted judge knows how to
interrogate, to examine the accused, as
anxiety does, which never lets him escape,
neither by diversion nor by noise, neither at
work nor at play, neither by day nor by
night.”
Soren Kiekegaard
The Stats:
 40 million Americans suffer the gnawing
unease of anxiety in its many forms; more
people seek treatment for anxiety than for
back pain.
 Anxiety is one of the most common
experiences of children and adults with the
primary characteristic of “worry”.
 It is estimated that as many as 10% of all
teens experience significant anxiety
problems.
Anxiety Symptoms:
 Concentration and Attention Problems
 Memory Problems
 Problem-Solving Difficulties
 Fear and Worry
 Restlessness and Fidgeting
 Irritability
 Withdrawal
 Perfectionism
Anxiety as an Impairment
 Anxiety disorders can impair social,
personal, and academic functioning. The
frequency of anxiety disorders ranges from
about 3% up to 20% of children and
adolescents. With a 10% frequency rate, a
high school class of 30 students could have
as many as three students with an anxiety
disorder and perhaps two of them would be
girls who appear quiet and hard working.
Emotional Symptoms
 The primary symptoms of depression are a
sad mood and/or loss of interest in life.
Activities that were once pleasurable lose
their appeal. Patients may also be haunted
by a sense of guilt or worthlessness, lack of
hope, and recurring thoughts of death or
suicide.
 Anxiety is a feeling of apprehension and
fear characterized by physical symptoms.
Depression Symptoms: Physical
 Depression is sometimes linked to physical
symptoms. These include:
 Fatigue and decreased energy
 Insomnia, especially early-morning waking
 Excessive sleep
 Persistent aches or pains, headaches,
cramps, or digestive problems that do not
ease even with treatment.
Anxiety Symptoms:
 The main symptom of anxiety is a constant
and exaggerated sense of tension and stress.
A student may not be able to pinpoint a
reason why he/she feels tense. Or the teen
may worry too much about ordinary
matters, such as grades, relationships, or
his/her health. All this worrying can
interfere with sleep and the ability to think
straight. The teen may also feel irritable due
to poor sleep or the illness itself.
Physical Symptoms of Anxiety
 Body problems usually come along with the
excess worry. They can include:
 Muscle tension or pain
 Headaches
 Nausea or diarrhea
 Trembling or twitching
Self-Care for Anxiety
 Teens can support their treatment of anxiety
symptoms by making a few simple changes
in habits. 1) Avoid caffeine, street drugs,
and even some cold medicines, which can
boost anxiety symptoms. 2) Try to get
enough rest/sleep and eat healthy foods. 3)
Try relaxation techniques, such as yoga or
meditation. 4) And be sure to exercise;
there's evidence that moderate physical
activity can have a calming effect.
Depression can make other
health problems feel worse,
particularly chronic pain.
Key brain chemicals
influence both mood and
pain. Treating depression has
been shown to improve coexisting illnesses.
Depression Symptom: Appetite
 Changes in appetite or weight are another
hallmark of depression. Some students
develop increased appetite, while others
lose their appetite altogether. Depressed
teens may experience serious weight loss or
weight gain. Some medications can also
contribute to weight gain.
Impact on Daily Life
 Without treatment, the physical and
emotional turmoil brought on by depression
can derail grades in school, hobbies, and
relationships. Depressed students often find
it difficult to concentrate and make
decisions. They turn away from previously
enjoyable activities, including friends. In
severe cases, depression can become lifethreatening.
Suicide Warning Signs
 Suicide Warning Signs
 People who are depressed are more likely to
attempt suicide. Warning signs include
talking about death or suicide, threatening
to hurt people, or engaging in aggressive or
risky behavior. Anyone who appears
suicidal should be taken very seriously. Do
not hesitate to call one of the suicide
hotlines: 800-SUICIDE (800-784-2433)
and 800-273-TALK (800-273-8255).
Causes of Depression
 Doctors aren't sure what causes depression,
but a prominent theory is altered brain
structure and chemical function. Chemicals
called neurotransmitters become
unbalanced. What pushes these chemicals
off course? One possibility is the stress of a
traumatic event, such as losing a loved one
or loss of a relationship. Endogenous
combine with exogenous…internal
predispositions (biochemical/genetic with
stress).
Seasonal Depression
 If your teen’s mood matches the season –
sunny in the summer, gloomy in the winter
– he/she may have a form of depression
called seasonal affective disorder (SAD).
The onset of SAD usually occurs in the late
fall and early winter, as the daylight hours
grow shorter. Experts say SAD affects up to
3% of the U.S. population, or about 9
million people, mainly in the northern part
of the country.
Depression in Children
 Depression clouds the days of one in every
20 American kids. It interferes with the
ability to play, make friends, and complete
schoolwork. Symptoms are similar to
depression in adults, but some children may
appear angry or engage in risky behavior,
called "acting out." Depression can be
difficult to diagnose in children and both
depression and anxiety are often
misdiagnosed as ADHD in students of all
ages.
Talk Therapy for
Anxiety and Depression
 Studies suggest different types of talk
therapy can fight mild to moderate
depression. Cognitive Behavioral Therapy
aims to change thoughts and behaviors that
contribute to depression. Interpersonal
therapy identifies how your relationships
impact your mood. Some patients find a few
months of therapy are all they need, while
others continue long term.
Exercise for Depression
 Research suggests exercise is a potent
weapon against mild to moderate
depression. Physical activity releases
endorphins that can help boost mood.
Regular exercise is also linked to higher
self-esteem, better sleep, less stress, and
more energy. Any type of moderate activity,
from swimming to housework, can help.
Choose something your teen enjoys and let
them aim for 20 to 30 minutes four or five
times a week.
The Role of Social Support
 Loneliness goes hand-in-hand with
depression, students need to develop a
positive social support network as an
important part of treatment, similar to group
counseling. This may include joining a
support group, finding online support, or
making a genuine effort to see friends and
family more often. It is important to connect
with people on a regular basis.
Did You Know…?
 8.5% of teens aged 12 to 17 (1 in 12)
experience depression in any given year.
 Suicide is the 3rd leading cause of death
among individuals ages 15-24 years old. In
2011, an average of 11.5 individuals in this
age group completed suicide each day.
 7.5% of Maryland youth attempted suicide in
2007. For every completed suicide, there are
approximately 100-200 attempts.
 As many as 200,000 individuals will be
affected by the loss of a loved one or
acquaintance to suicide.
Red Flags of Mental Health
Deep Sadness and/or Hopelessness
 Long-lasting irritability, anger and/or rage
 Depression can be anger turned inward
Dramatic Changes in Appearance,
Personality, and/or Behavior
 Withdrawal from friends, family and/or activities
 Major changes in sleeping or eating habits, such as
unexpected gain or loss of weight
 Marked change in levels of energy, motivation and/or
concentration
Risky Behavior (promiscuity, substance
abuse)
Red Flags of Mental Health
Increased Physical Complaints like
Headaches or Stomachaches
Thoughts and/or Talk of Death
 Giving away of prized possessions
Morbid fascination revealed through artwork,
poetry, etc.
Drops in Academic Performance
Frequent absences from school
Increased frequency of incompletes or bad
grades
Ensuring Students’ Well-Being
and Safety
One out of every 53 high school
students report having made a
suicide attempt serious enough that
it required treatment by a doctor or
nurse
– Centers for Disease Control, 2010
Prevention
 It is estimated that four of five suicide
victims demonstrated identifiable warning
signs before completing suicide. School
personnel and parents need to be
knowledgeable about warning signs of
youth suicide and potential triggers.
Warning Signs for Suicide
 Someone threatening to hurt or kill
themselves
 Someone looking for ways to kill
themselves; seeking access to pills,
weapons, or other means
 Someone talking or writing about death,
dying, or suicide, when these actions are out
of the ordinary for the person
U. S. Dept. of Health and Human Services, 2012
Social-Emotional Learning
 Emotional intelligence/resilience relates to
our ability to cope with stress and anguish,
pain and failure. Teenagers fall in love and
break-ups can be emotionally devastating.
 Low grades can eliminate the opportunity to
play on a high school sports team. Low
skills can cause students who have played a
recreational sport their entire life to be cut
from a team.
Bullying
 Unfortunately there are students who bully
and students who are bullied and now we
have cyber-bullying where feelings get hurt
and students fear coming to school.
 Many parents take their anxious or
depressed teen to a private psychologist for
a comprehensive evaluation and we often
see the diagnosis: ADHD? Let’s look a
little further into this diagnosis:
ADHD Look-Alikes
 There are many psychological and medical
problems that look like ADHD, so children who
present signs of ADHD need to be carefully
evaluated. Look-alike ADHD children may meet
the DSM-IV diagnostic criteria, but have a
completely different primary problem.
 Anxiety Disorders often go undetected, but they
occur in 5-10% of school children.
 Among children with ADHD, the rate of anxiety is
3 to 6 times greater (co-occuring).
 One of main characteristics of an anxiety disorder
is “inattention”.
Most of the Time Other
Disorders Accompany ADHD
 A person with ADHD is six times more
likely to have another psychiatric or
learning disorder than most other people.
ADHD usually overlaps with other
disorders.
 Difficulties with learning, emotional
regulation, executive functioning, social
functioning, or behavior.
 ADHD has extraordinarily high rates of comorbidity with all psychiatric disorders.
A List of Common Look-Alikes
 Depression
 Stress-induced
 Tourette’s Syndrome
Anxiety
 Biologically Based
Anxiety
 Child Abuse or
Neglect
 Bipolar Disorder
 Medical Conditions:
Chronic Fatigue,
Thyroid dysfunction,
etc.
Disorders
 Speech and Language
Impairments
 Sensory Integration
Disorders
 Auditory Processing
Disorders
 Other Affective Mood
Disorders
 Autism Spectrum
Multimodal Treatment Study (MTA Cooperative
Group 1999) Children Ages 7 to 9 with ADHD:
70% were found to have at least one other
psychiatric disorder:
 Oppositional Defiant Disorder 40%
 Anxiety Disorder 34%
 Conduct Disorder 14 %
 Tic Disorder 11 %
 Affective Disorder (depression) 4%
 Mania (or hypomania) 2%
 Learning Disorders: Reading, Math, and
Written Expression
Additional Research Findings in Older
Children and Adults
 Ages 9 to 16:
– Depressive Symptoms 48%
Adults:
Combined Type Inattentive
 Substance Abuse
69%
43%
 Major Depression
63%
63%
 Oppositional Defiant 40%
16%
 Anxiety Disorders
35%
23%
 Conduct Disorders
30%
20%
 Social Phobia
24%
31%
Study of Adults with ADHD:
Rachel Milstein and others (1997)
 Combined Type
– Substance Abuse 69%
– Major Depression 63%
– Oppositional Disorder
40%
– Anxiety Disorders 35%
– Conduct Disorders
30%
– Social Phobia 24%
 Inattentive Type
– Substance Abuse 43%
– Major Depression 63%
– Oppositional Disorder
16%
– Anxiety Disorders 23%
– Conduct Disorders
20%
– Social Phobia 31%
ADHD Subtypes
 Internalizing
 Inattentive Type:
– Anxiety
– Affective Mood
Disorders
– Depression
– Somatic
Complaints
– Child Abuse
– Sleep Disorder
 Externalizing
 HyperactiveImpulsive Type:
– Conduct Disorder
– Disruptive
Behavior Disorder
– Mania
– Aggression
– Oppositional
Defiant Disorder
ADHD and Depressive Disorders
 Children and adults referred for ADHD
demonstrate a higher-than-chance incidence
of depression and individuals referred for
depression have elevated rates of ADHD.
 Because the presence of an underlying or
co-occurring mood disorder may complicate
the treatment of ADHD, the mood disorder
must be properly diagnosed and treated.
Depression in Youth
 Irritability, social withdrawal, school
dysfunction, negativity, and somatic
disorders.
 Approximately 30% of 237 youth with
ADHD assessed could also be diagnosed
with major depression (Beiderman).
 After four years, the rate was more than
40% compared with approximately 5% of
the control group.
ADHD and Depression
 Youth with co-occurring disorders have
high rates of a variety of mental health
problems, including bipolar disorder and
anxiety disorder.
 Seventy percent of children referred for
severe or mild depression had co-occurring
ADHD. When classified by age, rates of
ADHD were 84% in children up to seven,
66% in children 8-12 and 39% in children
ages 13 to 18.
Treatment Options
 Options that are most effective for ADHD
(e.g. stimulants) do not significantly
improve depression, and treatments for
mood disorders are generally not helpful for
ADHD.
 When a co-occurring mood disorder exists,
stimulants are less effective.
Mental Health Treatment
 Appropriate levels of service need to be
authorized:
–
–
–
–
–
Medication needs to be monitored
Intensive personal and family therapy
Environmental interventions
Special education services
Hospitalization and/or residential treatment
may be needed at some point in time
ADHD and Substance Abuse
 ADHD, with or without co-occurrence, is a
risk factor for substance abuse among
adolescents and adults.
 When an individual presents with both
substance abuse and ADHD, clinicians
should first stabilize and treat the substance
abuse. They should then treat the
depression and then the ADHD.
ADHD and Substance Abuse
 Successful treatment of ADHD in either childhood
or adolescence appears to offer some protection
against later-life substance abuse.
 In a four year study of ADHD and non-ADHD
families, Biederman observed that patients whose
ADHD was not treated had much higher rates of
later substance abuse than either the treated
ADHD patients or the controls.
 Untreated ADHD is also associated with higher
rates of alcoholism use at 15 year follow-up.
The Key
 ADHD is frequently associated with
coexisting psychiatric disorders such as
depression and anxiety
 The key to positive outcome is the correct
and early diagnosis of all co-occurring
disorders, followed by robust treatment.
 Comprehensive multidisciplinary evaluation
and proper diagnosis
 Effective efficacious therapy
– Ongoing monitoring
Points to Remember
 Children with pure ADHD do not manifest mood
disturbances, thus the presence of such instability
is clear evidence of a co-occurring disorder.
 Although co-occurrence complicates treatment it
does not preclude successful intervention.
 The key to a positive outcome is the correct and
early diagnosis of all co-occurring disorders,
followed by a robust regimen built around the
most efficacious therapies.
Coping with Anxiety, Depression
and Stress
 Coping implies a camel with a ton of straws
on his back or a juggler juggling a dozen
balls in the air.
 Counseling/Therapy, medication, activities,
friendships, social activities are ways to
take the straws off the camel’s back or take
a few apples out of the juggle.
 Reduce the stress, don’t worry about college
Thank You!
David W. Holdefer
MCPS School Psychologist
Student Services Office
Rockville High School
2100 Baltimore Road
Rockville, Maryland 20851
301-738-5733
[email protected]