module 4.3 when should i be concerned? · module 4.3 when should i be concerned? module overview 2...

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WHEN SHOULD I BE CONCERNED?

MODULE 4.3

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Module 4.3 When should I be concerned? Module overview 2

Table of contentsObjectives

Outcomes

Key messages

What is mental health?

The role of school staff

School staff members are in a good position to make observations

What are ‘normal’ adolescent moods, emotions and behaviours?

Young people’s capacity for coping

Things to notice

The variety of individual responses

Internalising versus externalising problems

Observational record keeping

What do I do when I notice things?

MindMatters action guidelines for responding to observations

Case study: Observing Max

The importance of acting early

Accessing mental health care

Diversity

References and key readings

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When should I be concerned?Objectives

• School staff can recognise mental health warning signs in students and know the process for facilitating support.

Outcomes• School staff will have a basic understanding of common signs and symptoms of

mental health problems.

• School staff will be able to recognise signs and symptoms of mental health problems.

• School staff will be able to facilitate support for students presenting with signs and symptoms of mental health problems.

Key messages• Adolescence is a time where many biological, psychological and social changes

are occurring.

• When thinking about mental health problems, it is important to consider a young person’s vulnerabilities, stressors and strengths.

• Major changes in the young person’s thinking, emotional state, physical state and behavior that disrupts the young person’s ability to study or work, complete day-to-day activities or continue usual personal relationships are indicators that action and follow up are required.

• Early support when difficulties are significant = early mental health care, and early mental health care = better outcomes.

• As teachers it is important to promote mental health and wellbeing and know the school’s processes and their role for facilitating access to mental health support.

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What is mental health?Having good mental health means being able to enjoy life. It means being able to handle challenges and relate to others in positive ways. It helps young people learn and achieve better results. Good mental health in childhood and adolescence sets up the basis for positive mental health and wellbeing throughout life.

Mental health problems are when young people experience disturbances in their thoughts, their feelings, their behavior, their ability to learn and their social relationships, as well as their physical health and wellbeing. Unlike some medical conditions that have a direct cause (for example, the ‘flu’ is caused by a virus), mental health difficulties and mental disorders are caused by multiple factors that interact in different ways depending on the individual, family and social circumstances. These factors are either risk factors, such as drug use, trauma, family disharmony and peer rejection; or protective factors, such as supportive parents or carers.

Mental illness does not discriminate. Whilst poverty, lack of information and exposure to adversity within a family may increase a person’s risk, anyone is at risk of mental health difficulties given the right combination of risk factors.

Module 1.3 What is mental health?For more information on protective and risk factors see Module 1.3: What is mental health?

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The role of school staffThe role of school staffThe role of school staffThe earlier a young person obtains support for emotional, behavioural or social difficulties, then the better the chance they have of overcoming those issues, and of reducing the chances of more serious mental health concerns.

For the majority of school staff, providing support does not require them to be a mental health professional or to find a solution to the problem themselves. School staff, being excellent observers of behavioural, emotional and cognitive changes in students, are often confronted by, and already dealing with, behaviours associated with mental health difficulties.

As school staff already notice things about their students, they are an important part of the early warning system that helps to spot potential mental health difficulties earlier so that appropriate support and action can be provided as soon as possible.

Staff can support students by providing a sympathetic and non-judgemental ear when students are troubled, making adjustments to school environment including renegotiating assignments or deadlines and helping them to access information and professional support when required. In general, staff can assist all students to develop their coping skills and to develop helpful ways of thinking about everyday challenges.

It’s important for school staff to get to know students and understand their personalities and interests.

Be aware that students may approach any staff member or teacher – not only their allocated ‘wellbeing’ teacher. All staff can be prepared to offer a caring and supportive response – this may simply mean listening sympathetically and helping them to access information and professional support.

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School staff members are in a good position to make observationsStaff members see students routinely and are often able to notice marked changes from the student’s usual emotions, thinking and behaviour.

Staff members are often able to observe when problems with student’s emotions, thinking and behaviour persist.

Staff members are able to identify changes to a student’s day-to-day functioning, for example, significant changes in their classroom participation, significant changes in their peer relationships and changes in their academic performance.

Staff who become aware of significant changes in a student’s behaviour should consider whether the changes may indicate a mental health problem and not assume the student is just being ‘difficult’.

Module 4.1 How schools help studentsFor more information on how schools and staff can help see Module 4.1: How schools help students

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What are ‘normal’ adolescent moods, emotions and behaviours?

Recognising concerning changes in student behaviours, thinking and emotions is something many teachers are intuitively quite good at – it’s also a skill that can be developed through practice. To consider what is ‘normal’ behaviour we first need to reflect on the changes occurring naturally in adolescents as part of development. These changes can be biological (physical and brain development) psychological (changes in thinking and emotions) or social (changes in relationships and roles).

For more information on these developmental changes see Module 2.1 Adolescent development.

Due to the numerous changes in adolescence, it is common to observe a wide range of behaviours in students including those listed below.

Increased sleep Adolescents require more sleep than adults. They also tend to stay up later in the night than adults. This is related to biological factors of brain development and hormonal changes.

Emotionally driven decision making Decisions are generally more emotionally driven due to the use of the emotional parts of the brain, for example smoking to feel included socially despite knowing the health risks.

Self-centeredness Adolescents have more difficulty understanding that others have thoughts, beliefs, desires and feelings that are different to their own.

Risk taking Adolescents may have a need for instant gratification along with poor self-control.

Individuation and experimentation Adolescents tend to experiment with behaviours that are different to those of the family and are more relevant to their peer group, for instance, dressing a certain way to belong to a particular subculture.

Clumsiness Adolescents may have reduced motor control due to changes in the brain.

All these behaviours are common and could be the result of adolescent development and not necessarily be signs or symptoms of mental health difficulties.

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Young people’s capacity for coping Young people’s capacity for coping with life’s challenges will vary depending on the individual. A person’s coping capacity can be thought of as a bucket the size of which is largely determined by the relative balance of risk and protective factors. Some students have a strong set of protective factors relative to a small number of risk factors and are thus able to cope better with life events or challenges such as transitioning into high school or managing peer relationship problems. Others have a smaller bucket or capacity to manage such challenges because of the relatively poor number of protective factors. The stage at which the bucket overflows can be thought of as the point at which mental health difficulties are being experienced by the student.

For instance, a student with a family history of anxiety and depression who has experienced the loss of a relative in an accident, and is also experimenting with drugs, is less able to manage a relationship breakup with their first intimate partner.

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Things to noticeStudent behaviour can be difficult to interpret. With so much going on, sorting out what is ‘normal’ adolescent behaviour and what is something more concerning can be challenging.

When looking at student behaviour through a mental health lens it’s important to remember that young people experiencing mental health difficulties will display different signs and symptoms across four key areas:

The table of signs and symptoms below can help determine when a student’s ‘bucket’ might have reached capacity and has begun to overflow.

EMOTIONS/ FEELINGS

COGNITION/ THINKING

PHYSICALBEHAVIOUR

Signs and symptomsEmotions/ Feelings

Prolonged periods of sadness

Prolonged periods of irritability

Anxiety or excessive worry

Loss of motivation

‘Flatness’ or apparent loss of enjoyment in things that used to be enjoyable

Excessive anger

Excessive fear

Cognition/ Thinking

Difficulty concentrating on tasks

Difficulty paying attention

Confusion

Hopeless thoughts, for example, “Nothing will ever get better”, “Nobody cares”.

Helpless thoughts for example, “I can’t do it”, “There’s no way I’ll be able to..”.

Suspicion

Unrealistic expectations on self that is causing distress

Anxious thoughts, for example, “Something bad will happen if…”.

Self-critical thoughts for example, “I’m not good enough.”

Behaviour

Social withdrawal or avoidance

Talking about, writing about or making artworks about death or suicide

Increased impulsivity or risk-taking

Increased alcohol or other drug use

Drop in academic functioning – handing in things late, handing in poorer work than usual

Absenteeism

Lots of fights with friends or family

Self-harm

Rigid behaviours, for example eating certain foods at fixed times and over-exercising

Uncharacteristic, odd or unusual behaviour

Physical

Tiredness and fatigue

Complaining of lots of headaches, stomach-aches

Loss of appetite or big increase in appetite

Sleeping lots, or difficulties getting to sleep and staying asleep

Restlessness or fidgeting

Significant weight loss or gain

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The variety of individual responsesDifferent people will display different signs and symptoms. For instance, two siblings may have the same vulnerabilities and experience the same stresses, but you may observe one sibling as withdrawn and sad, and the other as angry and irritable. Or you may have two students with a diagnosis of depression, and again one may be withdrawn while the other is vocal and easily angered.

Internalising versus externalising problemsIt’s important to remember that not all adolescents are good at expressing what they’re experiencing in words. It’s often their behaviour that provides hints that something is wrong. For this reason school staff may be more likely to notice students who act out or ‘externalise’ problems, for example by displaying aggressive and even hostile behaviour. On the other hand, students who internalise their difficulties may not come to adults’ attention.

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Observational record keepingIf staff start to notice any emotional, cognitive, behaviour or physical changes in a student, it’s a good idea to take note of the changes and keep a record. This is a helpful way to categorise observations and make sense of them. It provides a guide as to what other types of signs and symptoms to look out for when looking more closely at a student. It can also help sort out what is going on for students without making assumptions and help in identifying patterns which can lead to better conclusions over time.

Keeping a record of observations can make it easier to identify when it’s time to be concerned and take action. However, if staff have even the slightest concern or ‘gut feeling’ that something isn’t right, then they should always take action and seek advice.

Students’ expressions of concern about a peer should be taken seriously.

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What do I do when I notice things?If a school staff member notices changes in the way a student thinks, feels or behaves that cause concern then they should take action. The type of action required depends on the severity and frequency of the observations. The general rule is:

• the longer the worrying behavior persists

• the more risky or intense the worrying behavior is

• the more the behaviour interferes with the student’s functioning, and

• the more distress it causes the individual or others, then

• the greater the level of concern.

Always seek advice according to your school’s policies and procedures if you have noticed changes in a student that you are worried about. Your school may have a school welfare coordinator or wellbeing staff member whom you can speak to about your concerns.

Schools will have their own policies and procedures that clearly outline what action should be taken and at what point; however, the following traffic lights model can act as a general guide as to how to respond to different types of observations.

All school staff can support students by being aware of referral pathways to wellbeing in the school.

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MindMatters action guidelines for responding to observations

LEVEL 3 – ACT IMMEDIATELYAlert appropriate staff, seek immediate mental health or emergency support for alarming observations such as:

• risk to self, that is suicidal or self-harm ideas

• odd, bizarre or extreme behaviour, not making sense

• risk to others, for example making threats to harm someone they think is trying to get them.

LEVEL

3

LEVEL 2 – PROVIDE ASSISTANCEAdvise appropriate staff, support the student and refer for additional support:

• if you have noticed multiple changes such as not attending class, grades dropping, problems with friends, tearful

• if you have noticed that changes have occurred in multiple settings for example home, school or sports practice

• if the symptoms have been going on for a while and things aren’t improving

• if problems are occurring frequently

• if problems are causing difficulties in the person’s relationships, school work, usual activities.

LEVEL

2

LEVEL 1 – GATHER MORE INFORMATIONSpeak to student, parents or teachers. Continue to monitor and check in with others:

• if you have noticed minor changes that are out of character for the student, for example they are a little less talkative than usual, turning up late, appearing more tired.

LEVEL

1

Generally the more things you notice the more concerned you should be. But always act on the side of caution. If in any doubt, ask for some support.

It can be helpful for school staff to know state and territory legal requirements and guidelines regarding duty of care, confidentiality and emergency response so they can feel confident providing a response.

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Case study: Observing Max

Sally and Max have been in an intimate relationship for six months. This is the first close relationship Max has had. When Sally breaks up with Max, he is tearful and stays in bed for a few days. This may be quite normal for a first relationship, however if he becomes withdrawn, isn’t sleeping, isn’t eating, his grades are dropping, and he is missing days at school – and this continues or gets worse – then there is reason to be concerned.

Emotions/Feeling• Prolonged periods of

sadness• Upset

Cognition/Thinking• “I’m never going to get over my girlfriend”• “I’m a failure”• “My friends don’t even like me”

Behaviour• Withdrawn from friendship group• Drop in school grades• Conflict with peers

Physical • Not sleeping• Reduced appetite

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The importance of acting earlyThe earlier a young person obtains support for emotional, behavioural or social difficulties that they are unable to manage on their own, then the better chance they have of overcoming them. It is also less likely that they will have of future mental health difficulties.

If Max continues to decline without any support he’s likely to fall further behind with his school work and may drop out because he’s failing. He may end up losing friendships because his problems are causing difficulties with his friends. This may further impact Max’s confidence and self-esteem, as well as future prospects.

If, however, Max is offered some support early on to manage his problems, he’ll be more likely to be able to get ‘back on track’. He may be offered additional support with his school work and opportunities to sort things out with his friends. With counselling he may be able to work through managing his emotions related to his relationship breakup and develop some positive coping strategies to help him to deal with similar situations if they arise in the future.

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Accessing mental health careMental health care is tailored for individuals, and is always aimed at helping a young person stay ‘on-track’ with developmental tasks; and reducing the risk of developing a longstanding mental health problem or mental disorder.

Mental health care may include several components. Examples include:• counselling

• learning new skills (for example in managing strong emotions)

• learning thinking strategies (for example to reduce distress)

• provision of additional support to keep on track with what’s important (for example to stay in school and keep up with schoolwork; to maintain friendships), or

• if problems are severe, possibly medication to help manage symptoms.

All staff can support students who are having difficulties to remain engaged in their education.

WHO CANHELP?

MODULE 4.7

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BUILDING SUPPORT PATHWAYS

MODULE 4.8

C4 More informationFor more information on accessing mental health care see Module 4.7: Who can help? and Module 4.8: Building support pathways

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DiversityDifferent cultures have different ways of understanding individual mental health, mental health problems and mental illnesses.

Indigenous Australians’ social and emotional wellbeing is intimately related to collective wellbeing. For these reasons, the involvement of family, community organisations and elders in the school may be important strategies for promoting Indigenous young people’s wellbeing. In most Indigenous Australian communities, the term social, emotional and spiritual wellbeing is preferred to ‘mental health’ because of its more positive and holistic connotations.

In newly arrived or other immigrant communities, the idea of poor mental health might be very stigmatised and individuals may be reluctant to speak about mental ill health. Talking about ‘wellbeing’ generally can assist students, families and communities to feel safe to talk about the range of wellbeing issues that may arise. Where particular ethnic communities are involved in a school community, it may be useful to engage a community leader to help talk about that community’s understanding of mental ill health and to suggest safe ways to discuss mental health.

It’s important that cultural practices that are different from the dominant culture are not understood as signs or symptoms of mental ill health. For example, regular prayer, religious fasting, belief in ghosts or spirits are all experiences that are common in various cultures, although not common in Anglo-Australian culture.

Young people who have experienced discrimination, for example racist abuse, or exclusion from social events because they are same-sex attracted, may be more likely to experience mental health problems, and even mental disorders. Where school communities can address bullying, discrimination and exclusion, mental health problems may be less likely to occur.

MindMatters is a national mental health initiative for secondary schools developed by beyondblue with funding from the Australian Government Department of Health.

See more MindMatters resources at www.mindmatters.edu.au

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References and key readingsMcGorry, P., Goldstone, S. (2011). Is this normal? Assessing mental health in young people. Australian Family Physician, 40(3), 94- 97, retrieved from: http://www.racgp.org.au/download/documents/AFP/2011/March/201103mcgorry.pdf

Rickwood, D., Deane F.P., Wilson C.J. (2007). When and how do young people seek professional help for mental health problems? Med J Aust, 187(7), 35, retrieved from: https://www.mja.com.au/system/files/issues/187_07_011007/ric10279_fm.pdf

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