Mocinic Snjezana and Feresin Catina (2012)

Occasional Papers in Education & Lifelong Learning: An International Journal Volume 6, Nos. 1—2, 2012, pp. 98—108

The importance of collaboration between teach-

ers and school psychologists in helping primary

schoolchildren to cope with mood disorders

SNJEZANA MOČINIĆ, University of Pula, Croatia CATINA FERESIN, University of Pula, Croatia/University of Padua, Italy Received 21 February 2012; received in revised form 23 June 2012; accepted 29 October 2012

ABSTRACT In recent years, a number of studies have reported the prevalence of mood disorders among primary schoolchildren. The research evidence is that the problems is underestimated when compared with the seriousness of mood disor-ders. Despite this evidence, symptoms of mood disorders among many children often go undiagnosed and untreated. Without any treatment, mood disorders can lead to severe psychiatric problems in later life for both adolescents and adults (Carretti et al., 2009; Muratori, 2008; Muratori and Apicella, 2008). The aim of this paper is two fold: first, to describe the principal symptoms of mood disorders in order to help primary schoolteachers to clearly recognise them; second, to un-derline the role of teachers who are, in the main, a valuable resource in early de-tention and prevention of mood disorders. In concluding this paper, we suggest a three-step prevention programme aimed at addressing the problems. This pro-gramme calls for close cooperation between teachers and clinicians; teachers are not expected to become school psychologists but, rather, to collaborate with clini-cians who are helping children to cope with mood disorders. Key words: mood disorders during childhood, close collaboration between teacher and school psychologist, three-step prevention programme

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Introduction In the last thirty years, there has been a renewed interest among researchers in depressive disorders among children. Although an observational study by Spitz (1946) has already documented the presence of depression during childhood in the mid 1940s, it was not until 1980 that authors of the Diagnostic and Statistical Manual of Mental Disorders III (American Psychiatric Association,1980) pointed out the need to systematically study mood disorders during childhood. Also, in the 1980s and 1990s, findings from various empirical studies confirmed the likelihood of clinical mood disorders during early period of human life (Birmaher et al. 1996a, 1996b; Keller et al., 1984; Kovacs et al., 1984a, 1984b, 1994). More re-cently, a number of studies have reported the prevalence of mood disorders among primary schoolchildren. The research evidence is that the problem is un-derestimated when compared with the seriousness of the illness. Despite this evi-dence, symptoms of mood disorders among many children often go undiagnosed and untreated. Without any treatment, mood disorders can lead to severe psychi-atric problems in later life particularly during adolescents and adulthood (Carollo et al., 2004). More specifically, research shows that untreated mood disorders increase the risk of suicide among the young people (Cheung et al., 2007); besides, mood disorders can interfere with the child’s normal developmental processes (Muratori, 2008; Muratori and Apicella, 2008). According to Shuchter et al. (1997), when adults suffer from depression, they do not lose the ability to recognise that the ‘odd mental phenomena’ they experi-ence are the product of a pathological condition, so they try to cope with their illness; initially by having a psychotherapy and, eventually, by taking some antide-pressants. On the contrary, children who suffer from depression may not have the coping ability as their adult counterparts; more often children ‘get lost’ in their depression. The fact is that children do not have sufficient life experience and ap-propriate cognitive skills to make a proper distinction between ill health and good health—therefore symptoms of depression [cause by mood disorders] are not of-ten obvious to children. However, children may show signs of depression in different ways: poor aca-demic performance, an increased irritability, a constant sadness, a low self-esteem, difficultly in social integration with friends, etc. Children suffering from mood disorders behave differently from their peers—they would not play with friends; they do not develop significant interpersonal skills with adults, and this can be a disadvantage, affecting the development of their personality. Moreover, in the context of a classroom (often very large class sizes in some contexts), these

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children would be generally quiet: they would not usually disturb the work of the teacher and they would not attract teacher’s attention (except for bi-polar chil-dren during manic or hypo-manic episodes). Against such background, it is im-perative, therefore, that the teacher is able to recognise the principal symptoms of depression in children. In order to detect depressive disorders early in children and to be able to provide effective help, it is important that teachers are up to date in their professional knowledge and that includes reading scientific papers and books about mood disorders (Lo Piccolo, 2005; Stark, 1995; Various Authors, 2001). The main purpose of this article is twofold: firstly, to describe the principal symptoms of mood disorders [in order] to help teachers of primary schools to clearly recognise them; secondly, to underline the role of teachers who are, in the main, a valuable resource in early detention and prevention of mood disorders. Teachers spend a considerable amount of time with children in the classroom and are in a unique position to give emotional support to children. At the end of this paper we shall suggest a three-step prevention programme to be held during the last two years of primary schools [designed] to fight mood dis-orders symptoms such as depression. This programme calls for a close cooperation between teachers and clinicians in identifying children who experience mood dis-orders. Of course, educators are not asked to become school psychologists, but are expected to collaborate with clinicians in order to help children to cope with mood disorders. Principal classifications of mood disorders among primary schoolchildren According to Caretti et al., (2009; pp. 43-44; pp. 190-193) and DSM IV-TR (American Psychiatric Association, 2000), there are basically two types of mood disorders: 1) depressive disorder and 2) bi-polar disorder (actually, there are more than two types of mood disorders which clinicians use to make different diagnosis among children, but the principal ones are those mentioned). Depressive disorder is divided into major depressive disorder and dysthymic disorder. The first is a severe condition characterised by one or more major de-pressive episodes lasting at least two weeks; the second is a mild disorder, but is more persistent; in fact children in the latter category are depressed for most of the times on most days and symptoms may continue for about one year (or several years among adults). Children affected by major depressive disorder sometimes show another mental disorder, such as conduct disorder, anxiety, phobias, atten-

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tion deficit hyperactivity disorder and oppositional defiant disorder—this phe-nomenon is called co-morbidity (Rietveld et al., 2002). Bi-polar disorder is classified into bi-polar I and bi-polar II. Bi-polar I disorder is considered the classic form of manic depression, with full manic episodes followed by major depressive episodes; bi-polar II involves again major depressive episodes followed by hypo-manic instead of full manic episodes (Kovacs et al, 1994; Kowatch et al., 2005). We do understand that recognising mood disorders among children is a complex task; however we claim that, after a correct training, pri-mary schoolteachers should be able to recognise the presence and duration of de-pressive and bi-polar disorders, observing the emotional, cognitive and physical symptoms of this illness [in children], as explained in the following paragraph. Main symptoms of mood disorders among primary schoolchildren Sadness /irritability

Sadness is one of the most significant emotional-cognitive symptom among de-pressed children (usually, bi-polar children often show more irritability than sad-ness). During major depressive episode, pupils perceive a deep sadness or cry without being able to understand the reason for why they are behaving this way. Teachers can observe this crucial symptom for a few weeks (at least two weeks according to the criteria of DSM IV-TR, 2000); and, if it disappears before two weeks, it is not connected with depression. Loss of pleasure (anhedonia)

Generally, children lose interest in things they loved very much in the past—which this is a normal behaviour. On the contrary, depressed or bi-polar children during depressive episodes show a clear emotional-cognitive symptom—they do not feel pleasure in anything; lose their normal desire to play with other children (in other words, they would stop participating in games activities). Teachers must observe if these children have also a decline in their academic performance as their illness might be affecting their ability to complete their homework or from main-taining regular school attendance. Difficulty in concentrating

Difficulty in concentrating is again an emotional-cognitive symptom. It is a simple task for a trained teacher to notice if children are not able to maintain concentra-


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tion. Children experiencing episodes of depression or suffering from bi-polar dis-order often have their minds preoccupied with their condition, a situation that often affect their ability to concentrate on classroom work. Negative self-evaluation-guilt / Grandiose notion of self

Negative self-evaluation is a cognitive symptom among children suffering for de-pression or bi-polar disorder during depressive episodes. Teachers are generally required to observe not only if negative self-evaluation affects school performance, but also if it influences the perception of pupil’s physical aspect and his/her social ability to interact with friends. Guilt is also a cognitive symptom: depressed chil-dren feel guilty more often compared to children who do not suffer from depres-sion. In this case, teachers are asked to notice whether these pupils blame them-selves for situations that they are not responsible for (for example, if they were separated from their parents). Bi-polar children, during manic or hypo-manic epi-sodes, often suffer from grandiose notion of self, showing an increased level of talking and feeling euphoric. Teachers should be able to observe clearly these cog-nitive and emotional symptoms, especially if these symptoms follow a period of negative self-evaluation. Recurrent thoughts of death, suicidal ideation and suicide attempts

Recurrent thoughts of death and the idea of committing suicide without a specific plan is a cognitive symptom among children suffering of depression or bi-polar disorder during depressive episodes. An actual suicide attempt or the ideation of a specific plan for committing suicide is a more frequent condition among adoles-cents (Cheung et al., 2007). According to Guetzloe (1991, p. 2-26), “Because mood disorders increase the risk of suicide, suicidal behaviour is a matter of seri-ous concern for parents, teachers, and clinicians.” Fatigue/hyperactivity

Teachers can easily observe if pupils are tired during lessons. Fatigue is a rare con-dition for healthy children, but it is a very common physical symptom among chil-dren suffering from depression or bi-polar disorder during depressive episodes. It can occur in a mild form without affecting a child’s learning behaviour, or can influence their daily activities, inhibiting their way of life. On the contrary, hyper-activity with an increased energy is a frequent symptom during manic and hypo-manic episodes in bi-polar children.

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Changes in appetite

A decrease in appetite may cause an unbalanced growth in a child’s body—s/he increases in height but no proportionate increase in weight; instead the child ex-periences possible physical disorders. Abnormal decrease in appetite is considered a physical symptom and is usually connected with depressive disorder or bi-polar disorder (during depressive episodes). An increase in appetite should not be con-fused with the normal growth process either. Such a situation is considered abnor-mal, if too much food intake causes the child to be overweight or when the thought of eating interferes with the child’s daily activities. Abnormal increase in appetite is again considered a physical symptom and is generally connected with bi-polar disorder during manic or hypo-manic episodes. Pain complaints without medical cause

Sometimes children refer to the teacher to feel headaches, stomach-aches or other kinds of pain. Complaints of pain are considered symptomatic when there is no objective reason for the pain. This physical symptom is usually connected with major depressive disorder and its severity is given by the intensity of pain and the frequency with which it occurs. Sleep disorders

This physical symptom is divided into insomnia, if child sleeps less hours than his/her minimum requirement. Hypersomnia occurs in a situation when a child sleeps longer hours than required—for example, if the child often have difficulty getting up in the morning. At the same time, insomnia is divided into initial insomnia and intermediate insomnia. The teacher may notice this symptom when pupil loses concentration and takes a nap on his/her desk. Among primary schoolchildren, nightmares during REM [Rapid Eyes Movements] sleep are very common and of-ten disturb the quality of sleep. Night terrors (restless leg, sleepwalking) are a common finding in children affected by bi-polar disorders and occur during deep sleep. Conclusion

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children to cope with mood disorders

Primary schools are generally not doing enough in early detention and identifica-tion of mood disorders in children (Cash and Cowan, 2006), a situation that might not be unconnected with lack of close working relationship between teachers and school psychologists in general and a wrong perception of the psychologists’ pro-fession in particular. According to Cash and Cowan (2006, p.24), “Unfortunately, many people, including some members of the profession, do not yet view school psychologists as providers of mental health services. Perhaps this is, in part, be-cause it is common to think of mental health service provision too narrowly as psychotherapy. Possibly it is a result of the failure to recognise prevention, assess-ment, and crisis intervention as mental health services.” We do suggest that a three-step precocious prevention programme to be imple-mented in primary schools is a possible way to tackle depression in children. Firstly, a programme on a large scale should be developed and applied during the last two years of primary schools, when the knowledge of mother tongue is comparable to adolescents and when the pupils can easily follow a written test. All children should be screened for possible mood disorders, just as they are screened for visual acuity or other health problems. Many valid and reliable tests can be used to collect data to identify children with likelihood to suffer from mood disor-ders using Child Behaviour Checklist and Children’s Depression Inventory (Achenbach, 1991; Gregory, 2004; Rivera et al., 2005). Australian clinicians have designed other two questionnaires for assessing mental health in primary schools. Accord-ing to Dix et al. (2008), the first instument is Goodman’s Strength and Difficulties

Questionnaire, which needs to be completed by each participating child’s parent/caregiver and teacher. The second instrument, is the Flinders SCS, which includes information about school, family and the child, “along with the outcome measures of student mental health.” Secondly, after the screening is completed, a diagnosis can be started by a trained clinician who can interpret the results of the previous mentioned tests. As Guetzloe (2003, p. 4) pointed out: “... A precise diagnosis of depression is a com-plex task, extremely difficult for even highly skilled physicians and other clini-cians. It requires a careful examination of physical, mental, emotional, environ-mental, and cultural factors related to the child”. Thirdly, at the end of the process, a treatment plan is traditionally coordinated by the school psychologist and the most frequently used therapies are cognitive behavioural therapy and interpersonal therapy which, help the depressed child to

change his/her distorted view of self, improving his/her social skills (Sherril and Kovacs, 2002). Only in severe cases of depression, medication, such as antidepres-

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sants, may be used (Bailly, 2006; Emislie et al., 1997; Wagner, 2005), although clinicians prefer to use mood stabilisers instead of antidepressants in the case of bi-polar disorder I, because some antidepressants can induce manic episodes (see Kowatch et al., 2005). Traditionally, teachers are not expected to diagnose depression in children; their role is to detect the symptoms of depression, to keep notes and make appro-priate referrals to the school psychologists. However, in the recent time, there has

been a suggestion for a close collaboration between teachers and clinicians (Vulić-

Prtorić, 2007, pp. 276-277). The school psychologists may ask teachers to col-laborate with them for example during the treatment—for instance, teachers could be asked to participate during the child’s therapy, giving the child a warm human touch and an emotional support. The school psychologists and teachers can provide a supportive environment not only during the therapy but also in the classroom: teachers can invite the school psychologists to join collective activities inside the classroom, helping depressed children to develop positive relationships with peers. It is understood that many children continue to attend school during the time they are being assessed for depression. This has further reinforced our assertion that children will benefit from a close collaboration between their teachers and the school psychologist. We believe that bringing together teachers and clinicians is good practice and an effective way to fight depression in early years or during childhood. Thus, a multidisciplinary team which meets regularly will be able to intervene and address a child’s mood disorders before the child becomes an ado-lescent. The three steps programme that we have suggested in the foregoing paragraphs might be very expensive from an economic point of view, but the cost of depres-sion for future adolescents, adults and society is even more expensive than organ-ising and applying this programme during the last two years of primary education. Correspondence Professor Snjezana Močinić Department of Educational Sciences University of Pula Juraj Dobrila Via Ivan Matetic Ronjgov 1, 52100, Pula, Croatia Email: [email protected] Tel.: 00385 52 377 544 Fax: 00385 52 377 550


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