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Identifying Students With Mental Health Issues: A Guide for Classroom

Teachers

Article  in  Intervention in School and Clinic · September 2015

DOI: 10.1177/1053451215606706

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Current Topics in Review

Moira Konrad, Associate Editor
Intervention in School and Clinic 2016, Vol. 51(5) 318­–322
© Hammill Institute on Disabilities 2015
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DOI: 10.1177/1053451215606706
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Identifying Students With Mental Health Issues:

A Guide for Classroom Teachers

Robbie J. Marsh, MEd, BCBA1

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 without disabilities reported that their children experience
the United States. Currently, 20% of children experience serious emotional and behavioral difficulties. While special
severely debilitating mental health issues at some point education may provide mental health services for identified
within their lifetime (Merikangas, et al., 2010). Of children students, those not receiving special education services typ-
between the ages of 8 to 15, 13% have issues related to ically receive no intervention for these issues from the
mental health, the most common being attention-deficit/ school (Repie, 2005). Consequently, school personnel often
hyperactivity disorder (ADHD), followed by mood disorder have difficulty identifying students with mental health
and major depressive disorder (Centers for Disease Control issues prior to major incidents of problem behavior
and Prevention [CDC], 2013). As a result, schools are (Edmonds-Cady & Hock, 2008).
becoming major service providers of many basic mental The identification of behaviors associated with mental
health treatment services, including assessment, behavior health issues in the classroom is unfamiliar territory for
management, and specialized programs (Pastor & Reuben, most general education and special education teachers.
2009). Students who receive services under the Individuals Repie (2005) found that school psychologists, counselors,
with Disabilities Education Act (1997) related to mental general education teachers, and special education teachers
health typically fall under the eligibility category of emo- did not understand the mental health needs of the children
tional and behavioral disorder (EBD) or the other health in their school. Similarly, Anthony, Anthony, Morrel, and
impairment category. However, this does not account for all Acosta (2005) focused on teacher awareness of externaliz-
students that experience mental health issues. ing and internalizing behavioral issues, finding that the
Student mental health issues are characterized as a stu- teachers had difficulty identifying the internalizing behav-
dent experiencing difficulties regulating their mood, iors of students. These results are similar to the body of
thoughts, or behaviors (CDC, 2013). As the research con-
cerning the mental health needs of students identified as 1
University of Nevada, Las Vegas, USA
EBD evolves, few studies focus on the emotional and
Corresponding Author:
behavioral difficulties of other students who experience Robbie J. Marsh, University of Nevada, Las Vegas, 10824 Myrtle Grove
mental health issues while in school. In a survey conducted Ave., Las Vegas, NV 89166, USA.
by Pastor and Reuben (2009), parents of children with and Email: [email protected]

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Marsh 319

research related to the under identification of internalizing assigned seats, asking to use the restroom, using the pencil
behaviors, which typically do not interfere with the class- sharpener, remaining quiet during instruction), school cam-
room environment or challenge the teacher’s authority pus rules (e.g., walking in the halls, using a locker, truancy,
(Gresham & Kern, 2004). using appropriate language), and rules at home (e.g., run-
With the increasing recognition that mental health issues ning away, staying out late at night; Furlong et al., 2004).
are common in young people, educators may be required to The second manifestation of difficult temperament involves
act as the first line of prevention (Johnson, Eva, Johnson, & persistent argumentative behavior or tantrums related to
Walker, 2011; Wyn, Cahill, Holdsworth, Rowling, & Carson, perceived unreasonable demands by the child/youth (APA,
2000). This involves understanding externalizing versus 2013). Tantrums may involve screaming, crying, whining,
internalizing behaviors exhibited by students who may be arguing, throwing items, hiding under desks, hitting, kick-
struggling with mental health issues. Furthermore, preven- ing, biting, or spitting. As is the case with aggression,
tion includes the understanding of behaviors that may not behaviors related to difficult temperament have to occur
necessarily be problematic to classroom instruction, but ulti- consistently over a 6-month span (APA, 2013; Johnson
mately impact student outcomes in school and life beyond et al., 2011). The causes of a difficult temperament are
the boundaries of school. This column is an introduction for attributed to neurodevelopmental difficulties related to mal-
educators to a complex issue that is gaining momentum. nutrition or other health issues, witnessing parental argu-
ments, or poor interactions with parents at an early age
(APA, 2013; Kauffman & Landrum, 2013).
Externalizing Behaviors
Externalizing behavior refers to those behaviors directed
Behavior Impulsivity
outward toward the social environment (Furlong, Morrison,
& Jimerson, 2004). These behaviors usually present chal- Behavior impulsivity often is manifested as sudden aggres-
lenges in school (Furlong et al., 2004). Typically associated sive outbursts or inattention and disorganization (APA,
with these behaviors are conduct disorder, oppositional 2013). These outbursts may involve property destruction,
defiant disorder, and ADHD. Students who exhibit aggres- screaming, hitting, or kicking. Inattention is defined as trou-
sion, a difficult temperament, or behavior impulsivity may ble sustaining attention to tasks for prolonged periods of
be considered as showing externalizing behavior (Furlong time, difficulty providing details in describing events, and
et al., 2004). responding to discussions with off-topic statements (APA,
2013; Kauffman & Landrum, 2013). Disorganization is the
lack of ability to perform tasks requiring multiple steps
Aggression (APA, 2013). These behaviors are not predetermined and
Aggression often manifests itself as deliberate verbal threats result from issues or stresses a student is experiencing inter-
toward peers and school staff, physical actions (e.g., hitting, nally (APA, 2013; Kauffman & Landrum, 2013). As with
kicking, biting) that cause physical harm, and severely dam- aggression and difficult temperament, impulsive behaviors
aging the property of others (American Psychiatric must occur consistently over a 6-month span to be consid-
Association [APA], 2013). This does not mean that all stu- ered a problem (APA, 2013; Johnson et al., 2011). The
dents who are aggressive have externalizing behavior disor- cause of impulsive behavior may stem from early childhood
ders; however, displaying persistent aggressive acts over the trauma, hyperactivity, or stress (APA, 2013; Furlong et al.,
span of 6 months is not considered typical behavior (APA, 2004; Kauffman & Landrum, 2013).
2013; Johnson et al., 2011). The aggressive behavior may
stem from traumatic experiences, witnessing family mem-
Internalizing Behaviors
bers being verbally or physically aggressive, poor academic
skills, poor self-concept, and even a history of reinforcement Internalizing behavior refers to behaviors directed inward,
associated with aggressive or violent behaviors (Furlong toward the individual (Gresham & Kern, 2004). These
et al., 2004). In addition, these students often experience dif- behaviors often go unnoticed because of their subtle nature
ficulty in negotiating social situations and may lack higher- (Gresham & Kern, 2004). The two categories of internaliz-
order problem-solving skills (Furlong et al., 2004). ing behavior disorders are anxiety-related disorders and
mood disorders.
Difficult Temperament
Anxiety-Related Disorders
A difficult temperament typically is manifested in two dif-
ferent ways. The first form involves students engaging in Disorders characterized by the onset of fight or flight behav-
behavior that persistently defies established rules (APA, ioral and psychological responses to people or situations that
2013), that is, well-known classroom rules (e.g., sitting in are non-life-threatening are considered to be anxiety-related

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320 Intervention in School and Clinic 51(5)

Table 1.  Behavior Associated With Externalizing Behavior Disorders.

Externalizing Disorder Potential Classroom Behaviors

Attention-deficit/hyperactivity 1. Student constantly fidgets (tapping hands or feet, making noises) while sitting and regularly
disorder (ADHD) 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.

(APA, 2013; Gresham & Kern, 2004). Internally, these simultaneously are at a particularly high risk for developing
behaviors include increase in heart rate, respiratory rate, further mental health issues (Kauffman & Landrum, 2013).
and muscle tension (APA, 2013). Although understanding Anxiety, social withdrawal, and other internalizing behav-
the internal behaviors related to anxiety is important, iden- iors often occur in conjunction with externalizing behaviors
tifying a student based on these behaviors is very difficult (Kauffman & Landrum, 2013).
(Gresham & Kern, 2004). However, children and youth also
exhibit observable behavior related to anxiety. These
Identification and Awareness
include skipping class, truancy, or leaving class for long
periods of time (Kauffman & Landrum, 2013). 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
Mood Disorders promote self-regulation (Anthony et al., 2005; Polsgrove &
Mood disorders are characterized by disturbances in mood Smith, 2004). However, for students to receive support,
that affect overall functioning. These include sleeping pat- they first must be identified. In the classroom, teachers must
terns, eating patterns, and the ability to perform day-to-day be aware of common student behaviors that are indicators
tasks (APA, 2013; Gresham & Kern, 2004). Similar to stu- of possible mental health problems.
dents with anxiety-related disorders, students experiencing Externalizing behaviors may be more easily identified in
mood disorders exhibit a variety of internal behaviors such the classroom, as they are disruptive to the class environ-
as disruptive thinking, decreased energy, and suicidal ide- ment, as shown in Table 1.
ation that make them difficult to identify (Gresham & Kern, While the internal characteristics of a student struggling
2004; Kauffman & Landrum, 2013). These children/youth with an internalizing behavior disorder are difficult to
may exhibit observable behavior such as difficulty complet- observe, there are some common observable behaviors
ing school work, rapid increase or decrease in weight, com- associated with internalizing behavior disorders that may be
plaining of stomach pains, or becoming disinterested in noticed in the classroom, as shown in Table 2.
activities they previously enjoyed (APA, 2013; Gresham & There is a significant amount of overlap of behavior related
Kern, 2004). It is important to be aware of these behaviors to internalizing behavior disorders, as behaviors related to
as these students often are at an increased risk for suicide mood disorders are usually the initial indicators of other men-
(Gresham & Kern, 2004; Johnson et al., 2011). tal health issues (Johnson et al., 2011). Regardless of the men-
Educators must be aware that externalizing behaviors tal health issue a student may be experiencing, simply
may occur along with internalizing behaviors. Students identifying that a student may need assistance for a mental
who exhibit both internalizing and externalizing behaviors health issue is what is most important (Johnson et al., 2011).

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Marsh 321

Table 2.  Behavior Associated with Internalizing Behavior Disorders.

Internalizing Disorder Potential Classroom Behaviors

Anxiety-related 1. Student has a dramatic decrease in completion of schoolwork and homework.
disorders 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.

Conclusion internalizing and externalizing behaviors that may signal

that a student is struggling with a mental health issue.
Addressing student mental health issues is a complex, mul-
tidimensional problem. The current federal definition of Declaration of Conflicting Interests
emotional behavioral disorder describes students who may
be suffering from internalizing forms of EBD (Gresham & The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
Kern, 2004; Walker, Nishioka, Zeller, Severson, & Feil,
article.
2000). Despite the definition, more and more students are
being identified and receiving services for externalizing
Funding
forms of EBD (Anthony et al., 2005; Gresham & Kern,
2004; Johnson et al., 2011; Kauffman & Landrum, 2013). The author(s) received no financial support for the research,
Understanding the variety of behaviors related to mental authorship, and/or publication of this article.
health issues, both internalized and externalized, will result
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