Improving Children's Mental Health    
  July 2014
In This Issue
Supporting Young Children's Mental Health
Yale Child Study Center
Shooters and Risk Management
Maslow's Hierarchy


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Wow! Editor
Carolyn Lieberg
Editorial Assistants
Melanie Holland
Ingrid Padgett


Dear Educators,   


Schools play an essential role in preparing our children to become knowledgeable, responsible, caring adults. More and more cities, including Boston, for example, are emphasizing the importance of tending to children's mental health. 


Research shows that when students' mental health needs are properly addressed, the possibility of school success increases. High quality, effective school mental health promotion has been linked to increases in academic achievement and competence, decreases in incidence of problem behaviors, improvements in the relationships that surround each child, and substantive, positive changes in school and classroom climates.


In this edition of Wow! we highlight resources designed to enhance mental health promotion, prevention, treatment, and referrals within school environments. You will hear from Naomi Marshall, an elementary educator, on Early Intervention, as well as Suzan Mullane, a CEI Research Associate, on Proactive Risk Management techniques. Our CEI Intern provides additional perspectives and tools with (1) The Child and Traumatic Stress Intervention Mode, and (2) Maslow's Hierarchy of Needs.



Early Intervention Key to Supporting Young Children's Mental Health
by Naomi B. Marshall

Schools are in a key position to identify mental health problems early and to provide links to appropriate services. However, in the most progressive approaches, schools work in tandem with parents. Parents and guardians are no longer expected to assume a secondary role of simply following the professionals' recommendation. Instead, they are viewed as the experts on their children.


Recent  data from the National Center for Children in Poverty at Columbia University indicate that between 9 and 14 percent of children under age 6 experience emotional and behavioral problems that negatively impact their functioning, development, and school-readiness (Cooper, Masi, &Vick, 2009). The National Institutes of Mental Health (NIMH) report that one-half of the mental health disorders in the U.S. appear by age 14, suggesting that early intervention may be critical to getting needed help to children. Many educators may be aware of the relationship between substance abuse, significant weight loss, or anger and mental health concerns. However, educators have focused less on the signs for younger children. A fact sheet produced by NIMH urges caution prior to identifying a possible mental health concern, recommending closer examination if parents observe:

  • Problems across a variety of settings (home, school, or with peers)
  • Changes in appetite or sleep
  • Social withdrawal, or fearful behavior toward things your child normally is not afraid of
  • Returning to behaviors more common in younger children, such as bed-wetting, for a long time
  • Signs of being upset, such as sadness or tearfulness
  • Signs of self-destructive behavior, such as head-banging, or a tendency to get hurt often
  • Repeated thoughts of death
According to the Mayo Clinic, common mental health disorders in children include anxiety, ADHD, mood or eating disorders, autism, and schizophrenia. In considering the implications for schools, it is noteworthy that the prevalence of mental health problems is markedly higher for children in families facing economic hardship and other stressful circumstances, such as maternal depression (Feder, et al., 2009).




Bright Futures, a national health care promotion and disease prevention initiative that uses a developmentally-based approach to address children's health care needs in the context of family and community, has developed a Pediatric Symptom Checklist (PSC). Designed for children ages 4 to 16, the PSC can facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible. On the Checklist, parents or guardians have the ability to assess 35 of their children's behaviors as never, sometimes, and often. Here are some examples from the Symptom Checklist:

  1. Complains of aches and pains
  2. Spends more time alone than with peers
  3. Acts as if driven by a motor
  4. Is irritable, angry
  5. Fights with other children
  6. Visits with the doctor with doctor finding nothing wrong
  7. Does not show feelings
  8. Acts younger than children his or her age
  9. Refuses to share
  10. Worries a lot

Bright Futures has also developed a companion scale: the PSC-Y for self-assessment by youth ages 11 and older.


Traditionally, educators have considered the need for counseling, special education interventions, or other social skills supports for youth displaying many of the above behaviors. In light of the serious mental health issues that many adults exhibit, it may be time to learn more about when a "behavioral" or "social skills" issue may be a possible precursor to mental illness. If some of the above symptoms are not readily resolved, persist over time, or intensify, that could signify more significant problems where in addition to counseling and classroom interventions, psychotherapy or medication may be warranted.



Cooper, J.L., Masi, R., & Vick, J. (2009).  Social-emotional development in early childhood: What every policymaker should know. New York: National Center for Children in Poverty. Columbia University. 


Feder, A., Alonso, A., Tang, M., Liriano, W., Warner, V.,  Pilowsky, D., et al, (2009). Children of low-income depressed mothers: Psychiatric disorders and social adjustment. Depress Anxiety, 26, 513-20. doi: 10.1002/da.20522.


Naomi B. Marshall is an Elementary Educator, Administrator, and Adjunct Instructor in Early Childhood Care and Education at Savannah Technical College, Savannah, Georgia   


Yale Child Study Center Aids with Trauma and Pre-Trauma Reactions
By Melanie Holland, CEI Intern

The Yale Child Study Center works to improve the mental health of children and families using a multi-disciplinary approach that includes child psychiatry, pediatrics, neurobiology, psychology, nursing, and social work. The Center manages the Childhood Violent Trauma Clinic, which offers a wide range of treatments and interventions for children and adolescents, including the Child and Family Traumatic Stress Intervention (CFTSI) model. CFTSI is an early intervention and secondary prevention model that aims to reduce traumatic stress reactions and posttraumatic stress disorder (PTSD) in children ages 7-18 along with their parent/guardian.


CFTSI is recommended for children after they have experienced potentially traumatic events (PTEs), for example: community violence, rape, assault, physical abuse, and motor vehicle accidents. The model is designed to enhance communication about the impact of the PTE, and it also gives parents the necessary tools to help their children move forward. Children are most frequently referred to the program by law enforcement agencies, pediatric emergency rooms, mental health providers, schools, and child protective services.


The goals of CFTSI are to:

  • Improve screening and identification of children impacted by traumatic stress
  • Reduce traumatic stress symptoms
  • Increase communication between the caregiver and the child about the child's traumatic stress reactions
  • Provide skills to help master trauma reactions
  • Assess the child's need for longer-term treatment
  • Reduce concrete external stressors (e.g. housing issues, systems negotiation, safety planning, etc.)

The CFTSI model occurs in four sessions that each address comprehensive evaluation, treatment recommendations, and the recovery process. In the first session, the treatment providers meet with the parent/guardian to explain the process and its intervention, as well as to give the caretakers questionnaires to assess their perceptions about the PTE. The second session includes the provider, child, and parent/guardian. The child is given similar questionnaires, and then the group works together to provide the child and parent/guardian with behavioral skill modules to help them develop at-home techniques (i.e., sleep disturbance, intrusive thoughts, techniques to manage stress symptoms). In the third session, participants reflect on the effectiveness of the behavioral skill modules and the child's changing perspective on the PTE. As part of the final session, the treatment provider focuses on developing a plan for future check-ins or more extensive treatments.


Initial findings about CFTSI have shown it to be very effective in diminishing and addressing the effects of PTEs. Berkowitz, Stover, and Marans (2010) found that:

  1. Youth in the Child and Family Traumatic Stress Intervention (CFTSI) group had significantly lower posttraumatic and anxiety scores than comparison groups of youth.
  2. The CFTSI group was significantly less likely to have PTSD at follow-up, reducing the odds of PTSD by 65 percent.

The Childhood Violent Trauma Clinic also provides treatment for children with posttraumatic stress disorder following traumatic events, and for children with other disorders and functional difficulties that result from chronic traumatization.


For more information on the CFTSI, go here. 



Berkowitz, S. J., Smith Stover, C. & Marans, S.R. (2011). The child and family traumatic stress intervention: Secondary prevention for youth at risk of developing PTSD.The Journal of Child Psychology and Psychiatry, 56, 676-85.  


School Shooters and Risk Management -- A Proactive Approach
by Suzan Mullane, M.S. Ed, CEI Research Assoc.

Eric Harris was "the type of kid who, when he was in front of adults, he'd tell you what you wanted to hear," reflected Columbine principal  Frank DeAngelis.

"It was a wake-up call for me after the tragedy," DeAngelis says. "I was thinking all's well at Columbine, but some kids didn't feel welcome. I had to make an effort to connect with those kids. It's difficult as an administrator to figure out what they're thinking. There are kids who get lost out there in a school of our size."

The thoughts in the mind of a potential school shooter can be elusive. Sociopathic and psychotic behavior can be confusing, even for clinicians. But what are the warning signs? How should principals mitigate potential violence?


Best Practice #1: Disseminate Information before an Incident. Principals can help ensure that their staff know of important warning signs. However, identification can be tough. Sociopaths, for instance (a label used for adults but increasingly used to describe some high school shooters), occur in only 1% of the population, according to Robert Hare, professor emeritus of psychology at the University of British Columbia and author of Without Conscience: The Disturbing World of the Psychopaths Among Us. Hare states that psychopaths are not delusional but manipulating and calculating; they lack remorse, empathy, and a conscience. In contrast, psychoses is where reality is severely distorted--either experiencing delusions or hallucinations.


Some students, on the other hand, may "simply" be in crisis mode, with no discernible pathology--imploding before exploding. Student trauma that leads to violence has many faces. Here are a few warning signs offered by Harvard professor, Katherine S. Newman, author of Rampage: The Social Roots of School Shootings, in an interview with NBC News after Jeff Weise killed nine people in Red Lake, Minnesota, in 2004:

  • Script like behavior and dialogue that may follow a violent video game
  • Outcast or stigma of a social "loser," which leads to social isolation
  • Drawings that follow animated violence that depict an "anti-hero"
  • Rejection by peers the individual would like to be friends with, painful social situations combined with rural isolation
  • Comments, stories, or drawings of a violent nature, frequently done to gain attention-a passion to go out in a blaze of glory
  • Family history of suicide
Other signs of trauma that could signal suicide ideation include: dramatic changes in behavior such as depression, self-mutilation, risky behavior and rage, sexual identification gender issues, change in grades, personal hygiene, friends, cruelty to animals/peers and finally no sense of purpose. For a detailed analysis to differentiate between warning and risk factors, click here.

Best Practice #2: Risk Assessment. For students who have made a verbal or threatening statement online, or have written a poem/paper that shows suicide or homicidal ideation, conduct an immediate risk assessment regardless of the student's race, socio-economic class, or great family reputation. A paper trail is essential. At times, educators can become too lax in a quest to not stigmatize kids; consequently, crucial history is lost as students age or transition.  


Best Practice #3: Have a Protocol. Many school districts have step-by-step protocols to intercede in risk management. Usually a trained counselor or social worker conducts ideation questionnaires and in-takes; elementary schools may not have qualified personnel. A local school psychologist or the National Suicide Prevention Hotline to find age-appropriate services in local areas could be helpful (1-800-273-TALK). Legitimate threats to self or others may require a report to Child Protective Services, depending on the state.


The Secret Service in conjunction with the Department of Education (DOE) has a free detailed questionnaire with questions such as whether:

  • An individual has an attack plan
  • Friends have been alerted and "warned away"
  • The individual has access to weapons
  • Information suggests despair or desperation
  • The individual is having difficulty reacting to a stressful event
  • Those who know the student are concerned that he/she might take action?


Images of school shootings can keep principals awake at night. But proactive approaches to mitigate potential tragedy can be comforting for all stakeholders.

School-wide SEL anti-bullying programs like Operation Respect or CEI's own Heart Centered Education are proactive approaches.


Prevention Strategies. Perhaps one of the most effective prevention strategies is the relationships we build with our students and their families as they successfully engage in their education. Differentiated instruction that reflects students' interests is a powerful school climate mind-set builder. Celebrating students' success within the community is a powerful self-esteem builder, even with surrogate parents.


Mr. DeAngelis retired this year. But his "wake-up" call to become a "guardian" since that tragic day will remain in the hearts and minds of many of his students long after graduation. Connecting with kids by popping into class in costume, giving fist bumps in the cafeteria, and walking the halls to find disconnected kids in order to establish relationships are just a few hallmarks of Frank's legacy.



     Principal Frank DeAngelis in a selfie with this spring's graduating class.  


Suzan Mullane has worked with at-risk children and teens for decades,
including as a school counselor and as a volunteer with Americorps. She
has assisted with in-takes for adults and youth who suffered from
suicidal thoughts or homicidal ideation in clinical settings.

For more information checkout a digital storytelling memory of Columbine. 
Looking to Maslow's Hierarchy for Mental Health Goals
by Melanie Holland


Abraham Maslow's Hierarchy of Needs provides a clear and straightforward example for why many of our nation's students are not meeting educational standards. Maslow posited his hierarchy on the basis of two groupings: deficiency needs and growth needs. 


Although we, as educators, are well-aware of Maslow's structure, it is very rarely thought about in connection with our schools or students. Maslow proposed the Hierarchy of Needs in 1943, in his paper, "A Theory of Human Motivation," in the Psychological Review. After 70 years in print and use, Maslow's Hierarchy continues to be relevant in psychology, but it also is worth attention by educators and policy makers as they consider how to best support students in the face of school safety concerns.   

Within the deficiency needs, each lower need must be met before moving up to a higher level need. Once each of the deficiency needs has been satisfied, individuals can move forward to growth needs.


Level 1: Physiological--the need for air, water, nourishment, health, and rest

            What they need: Individuals at this stage seek coping information in order to meet their basic needs. Information that isn't directly connected to meeting these needs is left unattended.


Level 2: Safety and Security--the need for finding safe circumstances, stability, and protection

            What they need: Individuals seek out structure, order and limits. They seek out helping information that helps show them how they can be safe and secure. This is also when individuals develop fears and anxiety.


Level 3: Love and Belonging--the need for others to love and provide a sense of belonging

            What they need: Individuals look for enlightening information to help them determine their sense of belonging, frequently in books, social media, or music.


Level 4: Esteem--the need for feelings of self-worth, attention, recognition, and appreciation

            What they need: Individuals seek empowering information that shows them how to develop their egos. They want respect from others, as well as at a higher level, the need to respect one's self.


Level 5: Self-Actualization--the need to understand, the aesthetic needs, self-actualization, and transcendence

            What they need: Many researchers break the Self-Actualization level into four individual needs, as listed above. Individuals in any layer of the Self-Actualization stage look for intellectual information that develops their relationship with their universe. They want to connect to something beyond themselves.


Maslow anticipated that only 1 in 100 people reach the transcendence level, but that by the time they are adults, everyone should move out of their deficient needs. Unfortunately, moving out of deficient needs proves difficult for many children, especially those living in urban settings. If children are still dealing with deficiency needs, the issues can negatively impact a child's performance and behavior in school. Many children attend school tired and hungry, and that lack of energy makes it harder for students to participate actively in the classroom.


Once we begin to consider the second level of Maslow's Hierarchy--safety and security--it is clear that there are issues with our current school system that could be preventing students from reaching their full potential. Many children live in unstable home environments that may prevent them from having a sense of security or trust in adult figures or their peers. But, looking past at-home security, schools themselves are no longer the safe havens they appeared to be.


In light of the high number of school shootings in the last two school years, fear is becoming more widespread. Parents, teachers, school leaders, and students are more worried than ever about how to remain safe while in schools. One teacher in Iowa has even created a safety device teachers can buy that will forcibly keep their classroom doors shut in case of a school shooter. Students--even elementary-aged--are aware of the increased stress and emphasis on protecting schools from shooters. In such an environment, it can be difficult for students to feel safe and secure enough to attempt the self-actualization stage, especially if students are already struggling with other levels of the deficiency needs.


Now more than ever, it is important to create compassionate school environments that will allow students to regain the level of security and safety they previously held. Without a sense of security, it is increasingly difficult for students to feel a sense of belonging or pride in their school and in their education.


Keeping Our Children Safe  

Questions about how to appropriately and effectively address mental health issues in our schools are increasing as society is recognizing that young disenfranchised adults are acting out with horrendous consequences-- and that is only the "high drama" that is making concerns more visible. The answers are not simple and a multifaceted approach is needed. Parents, schools, and mental health professionals need to team together. CEI believes that helping to reduce stress in schools is one of the critical factors. Our new pamphlet on Heart Beaming is our modest start to helping elementary school educators with easy tools to make their classrooms more compassionate. I have been personally practicing heart beaming for the past year; I urge you to try it and to try some of our simple 3-7 minute exercises with your students. As always we welcome your feedback.



Christine Mason
Executive Director, Center for Educational Improvement
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