MindMatters Module 4.2 – Youth Mental Health Difficulties

Julia Zemiro:
Hello, I’m still Julia. Welcome to the MindMatters panel. It’s all well and good to talk about positive mental health and wellbeing, but the reality is that many young people suffer from a range of mental health difficulties. 

Here to talk about the kinds of difficulties that are particularly common among young people are: Young and Well Cooperative Research Centre Managing Director, Dr Michael Carr-Gregg; Brain and Mind Research Institute Executive Director and Professor of Psychiatry, Professor Ian Hickie; National Centre of Excellence of Youth Mental Health senior research fellow, Dr Alexandra Parker; school psychologist Sarah Inness, and teacher Martin De Clercq.

But first, once again, let’s find out what’s on the minds of the staff at Eagleton High.

Eagleton High Clip:

PHILLIP
One of the challenges in talking about mental health is how to deal with labels like anxiety, depression, ADHD... Labels are great because they’re simple and they give you the heads-up on what you’re dealing with, but sometimes they can be too simple and if you’ve got a label, there’s always a risk you’ll be stigmatized or excluded.

Which is why I have made up these badges, each with their own mental health disorder, and we just randomly handed them among the students. Now, everyone has a label!

The Two Graces have got dissociative disorder and Casey’s got agoraphobia... and Caitlin’s got a whole stack of badges. 

CAITLIN
Well, Mr Schmuttermaier gives them away as prizes in HPE and, I got Tourette’s!

PHILLIP
Oh... well done...
C-Train here is one of our star athletes. Off to regionals this year?

CAITLIN
Yeah, I’m trying to win narcissism!

PHILLIP
Ah, that’s my girl.

CAITLIN
Thank you. 

PHILLIP
Kids just love ‘em.

Julia Zemiro:
Too late Caitlin. Narcissism’s mine – all mine. Now look these are great – aren’t they? They’re like those little awareness ribbons but a lot more fun. The downside is that people keep asking about them and you don’t get anything done. Labels and diagnoses, you have to be so careful, what do they actually mean?

Ian Hickie:
Well we use the language. If we say physical health, well what’s that, we go diabetes, asthma, cancer, you go oh, that’s serious I know that. It gives you a way of talking about things, specifying what’s going on, actually that helps to de-stigmatise things, make them ordinary. The more everyone’s got a label the better, we can all talk about the physical health problems we’ve all had. Once we start to use specifics, we get out of the sort of airy fairy and the mystery to helping.

Julia Zemiro:
Who uses these terms a lot? Is it good that it’s become a good language to use, or?

Ian Hickie:
We’ve needed the language. We haven’t had a common shared language, whereas the rest of physical health, we pretty much some common shared language. If I’ve got a headache, you go I’ve got a headache, if I’ve got a migraine – it sounds a bit worse, if I’ve got a brain tumour that’s a lot worse, you know. So we’ve got a language and we’ve got a gradation within that language – and in the mental health world, that’s where we’re headed.

All of these things are not so simple as a simple physical diagnosis, but they do give us a way of communicating, so suddenly things that couldn’t be communicated, that couldn’t be discussed, couldn’t really be described, can be talked about and the severity and the level of those problems and the likelihood that you might require really serious help versus something you can sort out yourself.

Julia Zemiro:
So, we’re hearing a lot more now about being able to label something, but how prevalent is it? How prevalent are youth mental health disorders? Are they becoming more common?

Ian Hickie:
Well we know a lot now. We’ve tracked, we’ve looked at these things for a very long time; in fact some of the best work in the world has come out of Victoria, tracking teenagers over long periods of time. So we know about, half of teenagers will have a significant problem, while they’re a teenager and have come back as an adult, half of them will have gone away – we know through the evidence –  but actually half of them will have gone on to actually have adult problems.

So this is a critical period of the onset of problems that can persist and be serious, so we need to have a realistic awareness, that’s got to do with brain development, social development, there are reasons why we understand this happens. So as we move from not knowing what to call it, or what to do about it, we now have better evidence about what it is, at what levels we should start to intervene, or try to react because we don’t want long term problems or short term problems to arise. You know so, we’re headed down the track that we’ve seen in every other health area, be that asthma, be that diabetes, be that heart disease. Earlier recognition of problems, better intervention at the right level to try and prevent long term difficulties.

Michael Carr-Gregg:
The other part is of course that many of these things can co-occur. So it’s not at all unusual for me to see a young person with depression who also has some anxiety. Also to see a person with an anxiety disorder with a little bit of depression. So nothing’s clear cut, necessarily. What we do have, as Ian said, is a language, and we actually have to operate off a thing called DSM-5. I’m not sure if you’re familiar with this, but it’s sort of like a taxonomy so that when I say to Ian, look I think I’ve got this patient and they have a major depressive illness, then he knows what to look for and so it enables us to communicate as professionals.

Julia Zemiro:
What does it mean for schools to have a label? Does it make it easier? Is it stigmatising people?

Ian Hickie:
The key issue is, not just the diagnosis, but what problem, so if we say the kid’s got an autism spectrum problem, a complicated thing, but that means they’re gonna struggle in certain kind of social interactions. They’re not gonna be able to initiate certain interactions. A kid’s got a certain kind of anxiety disorder, so they’re avoidant of certain social situations they can’t do. Clearly the communication, not just the label, it’s what’s the problem and what would be really helpful in the school and home to respond in appropriate ways. Now I think that’s the level of communication we’re trying to get to is – what is the implication, for this individual, and what sort of behaviours, that you otherwise might misinterpret?  Well that’s a bloody difficult kid, or that’s a kid who doesn’t talk, or that’s a kid who won’t come to class. You know it’s the difference between saying, well hang on a second, the kid is not just a bad kid, or a kid who’s not trying or whatever else. The kid’s got a difficulty that we need to help facilitate, you know, to take what is known in a professional sense and make it real and active and helpful back in the school environment.

Martin De Clercq:
Again, it comes to educating the students, about the mental illness and that reduces the stigma too, especially the common ones, about what is going on physically and just the basics. But I know we’ve got a life skills class and we discuss mental illness there and, to get the students to identify common physical illnesses and then sort of the common mental illnesses and to get them to see that correlation between the two.

Julia Zemiro:
To help us put these labels and diagnoses into some kind of real world scenario, we’ve put together a hypothetical example for you. 

A student volunteered to talk at assembly about his recent experience while travelling for a sporting competition. His presentation was very well received. A couple of months later the school received a note from his psychologist, explaining that he would not be able to do his oral presentation, in class, because of anxiety. This is a major part of his assessment. So here’s a confident and capable student, who’s struggling with some mental health difficulties that are preventing him from reaching his full potential. What allowances, or tolerances, do you make for a student, to help them get there?

Michael Carr-Gregg:
Well I think the first thing is you actually have to have a good communication with the clinician to find out the nature and extent of the problem. That’s the first thing. And if you can get schools working with psychologists and psychiatrists, you can actually get advice from them about the nature and extent of those allowances. So for example, if somebody is on a lot of medication, then that’s one scenario. If this is a relatively recent thing, ah, they’re actually in active treatment, then perhaps actually enabling them to avoid this isn’t necessarily the right thing to do.

Ian Hickie:
So in a lot of the physical health areas, we see the obvious issue between the onset of a problem, the need to plan out the recovery from that before the person will be able to resume what we expect in these things. I think the confusion here is often we dunno, what’s really gonna happen, what’s the next step, what’s the useful thing to do?

So we actually already see in educational institutions, a great deal of allowance for these sorts of issues. And we see a lot of people putting in forms about “I should get allowance”. But not a lot of good communication, about what needs to be done, at what point, what will really help. So that anxiety one is a great one, do you further support avoidance or do you actually help the person to learn to speak in class, again etcetera. And then monitoring whether that’s working.

Julia Zemiro:
That sounds like a lot of work – is that a teacher constantly talking with the parent talking with the child…

Ian Hickie:
You know, if you’ve busted your leg and you’re in a cast, it’s not that complicated to communicate between the parents, the teachers and the health professionals about what needs to be done.

Julia Zemiro:
Well, you’re saying, because it’s a broken leg, they’re going ‘oh this is easy to talk about’?

Ian Hickie:
Well no. No, but it’s known, everyone knows in common. Everyone can see. Everyone goes, well ok look, there’s a time for recovery. If you bust a leg as an adolescent, you are not going to be back on the football field in two weeks. So we’ve got to sort it out in terms of all the people involved. Involved in the person themselves, how they’re gonna deal with it, what’s the reasonable time expectation, what are the straightforward, kind of, particularly psychological treatments that really do work for a lot of these common problems?  How do you get them, how do you reinforce them?

See everyone is on the same page of expected rates of recovery likelihood. And then if it gets complicated, sometimes things get complicated. You know, something happens, you thought they’d be okay in six weeks but actually it’s more complicated, so what we’ve not had is very open communication. It’s all a bit mysterious, all a bit mental illness, “he’s gone a bit off”, you know, maybe next year he’ll come good, maybe he wouldn’t, maybe we shouldn’t talk a about it – so you know, that’s been the problem, a lack of frank communication. With the physical health problems, kids for physical health difficulties in schools we’ve got enormous ways to make sure they get included, that they don’t get left out, we’ve still got a way to go on the mental health issues.

Julia Zemiro:
Back to that case that we had before, what could you do, what would be some things that you would do in class if that presented itself? What options can you give that child?

Sarah Inness:
Well at our school I guess we would offer an alternative way to have the assessment. So you can do the oral one-on-one with the teacher, you can record it and have the teacher look at that later on, there’s so many ways to do that these days with our technology. And to be flexible, I think that’s the key message I would give um people who might be watching this is being flexible and open minded, um there’s so much scope, creativity and asking the student what works.

And they can get a sense from what would work best for them and give us feedback along the way.

Julia Zemiro:
To get that result?

Sarah Inness:
Yeah.

Martin De Clercq:
Having the staff that understand, and are not going “Well that’s a cop out, why can’t they be doing the same as everyone else?” and getting them to understand that. Including the student in that process has always been really important. 

Informing staff about their mental illness, I always include the student in the writing of the email – who to inform – and that they would sit there with me and write it, so they’re aware of what information is going out and they feel part of that process.

Julia Zemiro:
They’re included.

Dr Alex Parker:
With this particular example, I think the challenge around anxiety, social anxiety is that avoidance behaviour. And when that gets reinforced, that sense of relief can be very reinforcing from avoiding doing something that feels really challenging and scary. That tapping in and checking in as Michael said and as Ian said – with the clinician to see what’s part of the treatment plan as well. Are we at the phase we we’re thinking about trying to help the young person push themselves a little bit to stay engaged and to stay working at it and to face those challenges and to learn ways of managing the distress in those situations.

Ian Hickie:
Part of the growing up thing is the experience of challenges. Overcoming certain fears, learning new skills, talking in public, talking to girls, that’s more scary than talking in public, you know – absolutely terrifying.

Julia Zemiro:
We’re terrifying, and pretty as well!

Ian Hickie:
You know all sorts of stuff – you’re still making me blush – all sorts of stuff to be done that’s very challenging. You know so this issue of dealing with, in a sense, longer term hidden problems, these things when something happens out of the blue and someone goes ‘that kid’s changed’, that’s kind of easy in one world. A lot of the stuff’s in the background, never actually had the opportunity to learn the skill, put it into practice and then actually experience great pleasure out of success. That might be an academic challenge, a social challenge, you know, for a lot of these problems, having the opportunity to practise and learn, you know, at a key developmental stage. We need to make that happen to prevent further problems.

Martin De Clercq:
I mean, that’s the responsibility of schools, they need to be proactive, not reactive to those things. They need to provide safe and secure environments for students to be able to take those safe risks.

Dr Alex Parker:
I think there’s lots of opportunities and I think that’s the important thing is that the teachers need to be familiar with what they’re recommending as well – to know how to use it. Um, but particularly things that are about mood monitoring or mindfulness-based activities or simple breathing exercises or knowing how to direct students to have look at YouTube clips for example. 

That might be looking at progressive muscle relaxation or things like that that they can try out at home. And then just sort of check in, because that’s the important thing as well, make a recommendation but then follow it up and like all exercises, all of these need to be done regularly to have benefit, so you have to commit to this sort of thing too, so that’s a hard thing as well. So I talk to a lot of the young people I work with about putting reminders in their phone about when to do some mindfulness or when to do their relaxation exercises, throughout the day so they just get those little calendar appointments popping up – to remember.

Julia Zemiro:
Should schools encourage students and parents to disclose a diagnosis?

Sarah Inness:
I think it’s setting up a nice place for them to do that. I don’t know if we should be encouraging putting people under pressure to disclose but making it a place where they know who to talk to about that. Ultimately I would love to have an open conversation and for everyone to understand, but I think we’ve already identified that they’re some students who still don’t feel comfortable or some parents who don’t feel comfortable with those open disclosures.

Martin De Clercq:
And it can be as much as an email to the student’s teacher, saying “please be aware that this student is going through some difficult times, at this point, and that they will or may be leaving class to go to health care or to…“ and that’s all the teacher needs to know. They’re not gossips, they don’t want to pry into all the rest of the information.

Ian Hickie:
I think disclosure is important. Not only yes or no. But if you don’t disclose enough, you can’t really expect the student to do enough, or others to do enough. Or the environment to do enough. So I think there’s an issue about disclosure about what, so that we’re all clear about what everyone’s trying to help with.

Michael Carr-Gregg:
I think the great fear amongst many parents is that you’re gonna have a scenario where a kid acts out in class and a teacher says “well we can see who hasn’t taken their medication today” and while that might be apocryphal I’m quite sure that it has happened and that of course really undermines the likelihood that any parent is gonna let you guys know that their kid’s unwell. Because there is still a very strong stigma around mental health.

Julia Zemiro:
Would they disclose to a peer group before they would disclose to a teacher?

Sarah Inness:
Absolutely, yeah. I think research shows that consistently, that young people are more likely to disclose to their friends before they will disclose anywhere else. So we’ll frequently have someone coming through my door or Mart’s door and say “I’m really worried about so and so, they disclosed suicidal thoughts last night on Facebook, and I don’t know what to do – and they don’t know that I’m here, I don’t want them to know I’m here.” 
It becomes very complicated, but, we can work through that.

Michael Carr-Gregg:
We’ve got an app for that. It’s called the Check-In app by beyondblue and it’s absolutely fantastic, because it gives those young people the information on how to approach those conversations.

Julia Zemiro:
If you’re concerned about a student, what can you do?

Dr Alex Parker:
I think that, first of all, just as we were saying, about monitoring or being aware of any changes that might have happened. So if teachers are aware of changes in behaviour, has there been any difference in the way they’ve been acting in class, or with their peers, becoming isolated or withdrawn, and then thinking about maybe consulting with colleagues to see whether others have noticed those patterns as well, and then doing that gentle checking in, as a first step, with the young person. Just asking them if there is something there, and being prepared to listen first, before then thinking about what next? 
Most schools though, do have that option where they’ve got the support from the guidance counsellor, or welfare coordinator, or someone in that role, so you know you’ve got that back up, but be prepared to have that conversation first and to see in their own words, let them tell you what’s been happening.

Julia Zemiro:
To wrap this up, Professor Ian Hickie, what is the one message you want school staff to take away from this?

Ian Hickie:
They’re the ones that matter. This is a funny thing to say, we don’t really care what’s in your head. We care you go to school. And you interact with people and you succeed. So schools can tell us, whether that is actually happening. They monitor whether people are declining and that and they’re critical in terms of people getting back to that. Not to become psychologists, not to become social workers, not to become the counsellors, but they are the real measure, in the functional world of whether our young people are succeeding. So they are the heart of what we’re all trying to achieve.