Identifying Students With Mental Health Issues

Abstract

Child and adolescent mental health is a growing concern in schools. Students suffering from mental health conditions struggle in the school environment if their needs are not being met. Teachers play an important role in the identification of these students. This article highlights the distinctions between externalizing and internalizing behaviors related to mental health conditions and provides teachers with an introductory guide to assist them in identifying students with mental health issues.

Keywords

emotional and behavioral disorders behavior issues depression suicide identification

Child and adolescent mental health is a growing concern in the United States. Currently, 20% of children experience severely debilitating mental health issues at some point within their lifetime (Merikangas, et al., 2010). Of children between the ages of 8 to 15, 13% have issues related to mental health, the most common being attention-deficit/hyperactivity disorder (ADHD), followed by mood disorder and major depressive disorder (Centers for Disease Control and Prevention [CDC], 2013). As a result, schools are becoming major service providers of many basic mental health treatment services, including assessment, behavior management, and specialized programs (Pastor & Reuben, 2009). Students who receive services under the Individuals with Disabilities Education Act (1997) related to mental health typically fall under the eligibility category of emotional and behavioral disorder (EBD) or the other health impairment category. However, this does not account for all students that experience mental health issues.

Student mental health issues are characterized as a student experiencing difficulties regulating their mood, thoughts, or behaviors (CDC, 2013). As the research concerning the mental health needs of students identified as EBD evolves, few studies focus on the emotional and behavioral difficulties of other students who experience mental health issues while in school. In a survey conducted by Pastor and Reuben (2009), parents of children with and without disabilities reported that their children experience serious emotional and behavioral difficulties. While special education may provide mental health services for identified students, those not receiving special education services typically receive no intervention for these issues from the school (Repie, 2005). Consequently, school personnel often have difficulty identifying students with mental health issues prior to major incidents of problem behavior (Edmonds-Cady & Hock, 2008).

The identification of behaviors associated with mental health issues in the classroom is unfamiliar territory for most general education and special education teachers. Repie (2005) found that school psychologists, counselors, general education teachers, and special education teachers did not understand the mental health needs of the children in their school. Similarly, Anthony, Anthony, Morrel, and Acosta (2005) focused on teacher awareness of externalizing and internalizing behavioral issues, finding that the teachers had difficulty identifying the internalizing behaviors of students. These results are similar to the body of research related to the under identification of internalizing behaviors, which typically do not interfere with the classroom environment or challenge the teacher’s authority (Gresham & Kern, 2004).

With the increasing recognition that mental health issues are common in young people, educators may be required to act as the first line of prevention (Johnson, Eva, Johnson, & Walker, 2011; Wyn, Cahill, Holdsworth, Rowling, & Carson, 2000). This involves understanding externalizing versus internalizing behaviors exhibited by students who may be struggling with mental health issues. Furthermore, prevention includes the understanding of behaviors that may not necessarily be problematic to classroom instruction, but ultimately impact student outcomes in school and life beyond the boundaries of school. This column is an introduction for educators to a complex issue that is gaining momentum.

Externalizing Behaviors

Externalizing behavior refers to those behaviors directed outward toward the social environment (Furlong, Morrison, & Jimerson, 2004). These behaviors usually present challenges in school (Furlong et al., 2004). Typically associated with these behaviors are conduct disorder, oppositional defiant disorder, and ADHD. Students who exhibit aggression, a difficult temperament, or behavior impulsivity may be considered as showing externalizing behavior (Furlong et al., 2004).

Aggression

Aggression often manifests itself as deliberate verbal threats toward peers and school staff, physical actions (e.g., hitting, kicking, biting) that cause physical harm, and severely damaging the property of others (American Psychiatric Association [APA], 2013). This does not mean that all students who are aggressive have externalizing behavior disorders; however, displaying persistent aggressive acts over the span of 6 months is not considered typical behavior (APA, 2013; Johnson et al., 2011). The aggressive behavior may stem from traumatic experiences, witnessing family members being verbally or physically aggressive, poor academic skills, poor self-concept, and even a history of reinforcement associated with aggressive or violent behaviors (Furlong et al., 2004). In addition, these students often experience difficulty in negotiating social situations and may lack higher-order problem-solving skills (Furlong et al., 2004).

Difficult Temperament

A difficult temperament typically is manifested in two different ways. The first form involves students engaging in behavior that persistently defies established rules (APA, 2013), that is, well-known classroom rules (e.g., sitting in assigned seats, asking to use the restroom, using the pencil sharpener, remaining quiet during instruction), school campus rules (e.g., walking in the halls, using a locker, truancy, using appropriate language), and rules at home (e.g., running away, staying out late at night; Furlong et al., 2004). The second manifestation of difficult temperament involves persistent argumentative behavior or tantrums related to perceived unreasonable demands by the child/youth (APA, 2013). Tantrums may involve screaming, crying, whining, arguing, throwing items, hiding under desks, hitting, kicking, biting, or spitting. As is the case with aggression, behaviors related to difficult temperament have to occur consistently over a 6-month span (APA, 2013; Johnson et al., 2011). The causes of a difficult temperament are attributed to neurodevelopmental difficulties related to malnutrition or other health issues, witnessing parental arguments, or poor interactions with parents at an early age (APA, 2013; Kauffman & Landrum, 2013).

Behavior Impulsivity

Behavior impulsivity often is manifested as sudden aggressive outbursts or inattention and disorganization (APA, 2013). These outbursts may involve property destruction, screaming, hitting, or kicking. Inattention is defined as trouble sustaining attention to tasks for prolonged periods of time, difficulty providing details in describing events, and responding to discussions with off-topic statements (APA, 2013; Kauffman & Landrum, 2013). Disorganization is the lack of ability to perform tasks requiring multiple steps (APA, 2013). These behaviors are not predetermined and result from issues or stresses a student is experiencing internally (APA, 2013; Kauffman & Landrum, 2013). As with aggression and difficult temperament, impulsive behaviors must occur consistently over a 6-month span to be considered a problem (APA, 2013; Johnson et al., 2011). The cause of impulsive behavior may stem from early childhood trauma, hyperactivity, or stress (APA, 2013; Furlong et al., 2004; Kauffman & Landrum, 2013).

Internalizing Behaviors

Internalizing behavior refers to behaviors directed inward, toward the individual (Gresham & Kern, 2004). These behaviors often go unnoticed because of their subtle nature (Gresham & Kern, 2004). The two categories of internalizing behavior disorders are anxiety-related disorders and mood disorders.

Anxiety-Related Disorders

Disorders characterized by the onset of fight or flight behavioral and psychological responses to people or situations that are non-life-threatening are considered to be anxiety-related (APA, 2013; Gresham & Kern, 2004). Internally, these behaviors include increase in heart rate, respiratory rate, and muscle tension (APA, 2013). Although understanding the internal behaviors related to anxiety is important, identifying a student based on these behaviors is very difficult (Gresham & Kern, 2004). However, children and youth also exhibit observable behavior related to anxiety. These include skipping class, truancy, or leaving class for long periods of time (Kauffman & Landrum, 2013).

Mood Disorders

Mood disorders are characterized by disturbances in mood that affect overall functioning. These include sleeping patterns, eating patterns, and the ability to perform day-to-day tasks (APA, 2013; Gresham & Kern, 2004). Similar to students with anxiety-related disorders, students experiencing mood disorders exhibit a variety of internal behaviors such as disruptive thinking, decreased energy, and suicidal ideation that make them difficult to identify (Gresham & Kern, 2004; Kauffman & Landrum, 2013). These children/youth may exhibit observable behavior such as difficulty completing school work, rapid increase or decrease in weight, complaining of stomach pains, or becoming disinterested in activities they previously enjoyed (APA, 2013; Gresham & Kern, 2004). It is important to be aware of these behaviors as these students often are at an increased risk for suicide (Gresham & Kern, 2004; Johnson et al., 2011).

Educators must be aware that externalizing behaviors may occur along with internalizing behaviors. Students who exhibit both internalizing and externalizing behaviors simultaneously are at a particularly high risk for developing further mental health issues (Kauffman & Landrum, 2013). Anxiety, social withdrawal, and other internalizing behaviors often occur in conjunction with externalizing behaviors (Kauffman & Landrum, 2013).

Identification and Awareness

Research supports interventions at the classroom level to prevent social and emotional problems in children and youth as well as to modify negative thought patterns and promote self-regulation (Anthony et al., 2005; Polsgrove & Smith, 2004). However, for students to receive support, they first must be identified. In the classroom, teachers must be aware of common student behaviors that are indicators of possible mental health problems.

Externalizing behaviors may be more easily identified in the classroom, as they are disruptive to the class environment, as shown in Table 1.

Table 1.

Behavior Associated With Externalizing Behavior Disorders.

Externalizing Disorder	Potential Classroom Behaviors
Attention-deficit/hyperactivity disorder (ADHD)	1. Student constantly fidgets (tapping hands or feet, making noises) while sitting and regularly gets out of seat.
	2. Student struggles to work on a single task for prolonged periods of time and struggles to maintain statements on topic during class discussions.
	3. Student’s materials are disorganized and student regularly forgets or loses assignments.
	4. Student often misses details in assignments and instructions from staff.
Conduct disorder	1. Student bullies, threatens, and verbally or physically attacks (e.g., shouting, swearing hitting, kicking, spitting, throwing items,) other students and staff.
	2. Student destroys property of other students and staff (e.g., books, pencils, and computers).
	3. Student leaves class, avoids going to class, or is truant from school regularly.
	4. Student regularly steals items from students and staff.
Oppositional defiant disorder	1. Student becomes annoyed easily and verbally attacks (e.g., shouting, swearing, protesting) students and staff when annoyed.
	2. Student often argues with teachers, school staff, or any perceived authority figures when demands are placed on him or her.
	3. Student refuses to follow any directives from teacher, school staff, or other perceived authority figures.
	4. Student regularly attempts to bother other students (e.g., making noises, name calling, poking, throwing pencils or papers) while they’re trying to listen or work in class.

While the internal characteristics of a student struggling with an internalizing behavior disorder are difficult to observe, there are some common observable behaviors associated with internalizing behavior disorders that may be noticed in the classroom, as shown in Table 2.

Table 2.

Behavior Associated with Internalizing Behavior Disorders.

Internalizing Disorder	Potential Classroom Behaviors
Anxiety-related disorders	1. Student has a dramatic decrease in completion of schoolwork and homework.
	2. Student is irritated easily by staff and peers, which may result in yelling or fighting with staff and peers.
	3. Student is persistently tired and complains of tiredness or falls asleep in class.
	4. Student regularly refers to himself or herself in a negative view (e.g., “I’m a bad kid,” “everyone hates me,” “no one trusts me, I’ll just mess everything up”).
Mood Disorders	1. Student suddenly quits current school activities (e.g., student government, school sports, or school clubs) in which he or she was once heavily involved.
	2. Student has trouble completing schoolwork and consistently starts work over or has trouble beginning work.
	3. Student displays dramatic weight loss or gain in a short amount of time.
	4. Student is persistently tired and complains of tiredness or falls asleep in class.
	5. Student’s ability to copy notes, write during assignments, or complete class assignments has dramatically diminished.
	6. Student displays a sudden change in attitude and becomes excessively talkative and enthusiastic about completing schoolwork for 2–3 school days.
	7. Student becomes disorganized, loses schoolwork, and struggles to remain on topic during class discussions.

There is a significant amount of overlap of behavior related to internalizing behavior disorders, as behaviors related to mood disorders are usually the initial indicators of other mental health issues (Johnson et al., 2011). Regardless of the mental health issue a student may be experiencing, simply identifying that a student may need assistance for a mental health issue is what is most important (Johnson et al., 2011).

Conclusion

Addressing student mental health issues is a complex, multidimensional problem. The current federal definition of emotional behavioral disorder describes students who may be suffering from internalizing forms of EBD (Gresham & Kern, 2004; Walker, Nishioka, Zeller, Severson, & Feil, 2000). Despite the definition, more and more students are being identified and receiving services for externalizing forms of EBD (Anthony et al., 2005; Gresham & Kern, 2004; Johnson et al., 2011; Kauffman & Landrum, 2013). Understanding the variety of behaviors related to mental health issues, both internalized and externalized, will result in better outcomes for students (Anthony et al., 2005; Johnson et al., 2011).

Teacher awareness concerning behaviors associated with mental health disorders is essential as they are in the unique position of observing student behavior on a daily basis (Johnson et al., 2011). The first step is awareness, and the second step is bringing the concerns to the attention of the appropriate school staff who can provide assistance (Johnson et al., 2011). Educators need to revisit and reaffirm their commitment to doing what is best for students; this includes students with EBD as well as students with other mental health issues.

Currently, there is no comprehensive report outlining the extent of services available for students with mental health issues in schools (Committee on School Health, 2004). This is unfortunate in that school districts are quickly becoming basic mental health service providers for the children and youth who reside within their care (Pastor & Reuben, 2009). Because educators are the first line of support for most students, it is imperative for them to become familiar with the internalizing and externalizing behaviors that may signal that a student is struggling with a mental health issue.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Anthony

B. J.

Anthony

L. G.

Morrel

T. M.

Acosta

(2005). Evidence for social and behavior problems in low-income, urban preschoolers: Effects of site, classroom, and teacher. Journal of Youth and Adolescence, 34, 31–39.

Centers for Disease Control and Prevention. (2013). National Health and Nutrition Examination Survey: Analytic guidelines, 1999–2010. Washington, DC: Author.

Committee on School Health. (2004). School-based mental health services. Pediatrics, 113, 1839–1845.

Edmonds-Cady

Hock

(2008). Children in crisis: Special education status and other stressors in the lives of children removed from school by expulsion. School Social Work Journal, 32, 72–86.

Furlong

M. J.

Morrison

G. M.

Jimerson

S. R.

(2004). Externalizing behaviors of aggression and violence and the school context. In Rutherford

R. B.

Quinn

M. M.

Mathur

S. R.

(Eds.), Handbook of research in emotional and behavioral disorders (pp. 243–261). New York, NY: Guilford.

Gresham

F. M.

Kern

(2004). Internalizing behavior problems in children and adolescents. In Rutherford

R. B.

Quinn

M. M.

Mathur

S. R.

(Eds.), Handbook of research in emotional and behavioral disorders (pp. 262–281). New York, NY: Guilford.

Individuals with Disabilities Education Act of 1990, 20 U.S.C. §1400 et seq. (1990) (amended 1997).

Johnson

Eva

A. L.

Johnson

Walker

(2011). Don’t turn away: Empowering teachers to support students’ mental health. Clearing House, 84, 9–14.

10.

Kauffman

J. M.

Landrum

T. L.

(2013). Characteristics of emotional and behavioral disorders of children and youth (10th ed.). Upper Saddle River, NJ: Pearson.

11.

Merikangas

K. R.

Burstein

Swanson

S. A.

Avenevoli

Cui

. . . Swendsen

(2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the national comorbidity study-adolescent supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 49, 980–989.

12.

Pastor

P. N.

Reuben

C. A.

(2009). Emotional behavioral difficulties and mental health service contacts of students in special education for non-mental health problems. Journal of School Health, 79, 82–89.

13.

Polsgrove

Smith

S. W.

(2004). Informed practice in teaching self-control to children with emotional and behavioral disorders. In Rutherford

R. B.

Quinn

M. M.

Mathur

S. R.

(Eds.), Handbook of research in emotional and behavioral disorders (pp. 399–425). New York, NY: Guilford.

14.

Repie

M. S.

(2005). A school mental health issue survey from the perspective of regular and special education teachers, school counselors, and school psychologists. Education and Treatment of Children, 28, 279–298.

15.

Walker

H. M.

Nishioka

V. M.

Zeller

Severson

H. H.

Feil

E. G.

(2000). Causal factors and potential solutions for the persistent underidentification of students having emotional or behavioral disorders in the context of schooling. Assessment for Effective Intervention, 26, 29–39.

16.

Wyn

Cahill

Holdsworth

Rowling

Carson

(2000). Mind matters: A whole-school approach promoting mental health and wellbeing. Australian and New Zealand Journal of Psychiatry, 34, 594–601.