Excerpted from chapter 2 of The Educator's Guide to Medical Issues in the Classroom, edited by Frank M. Kline, Ph.D., Larry B. Silver, M.D., & Steven C. Russell, Ph.D.

Copyright © 2001 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

In general, the behavior of a child or adolescent with a neurologically based modulating disorder is chronic and pervasive. The brain has been with the individual all of his or her life; thus, the behavior pattern is chronic. In addition, the brain is always with the individual; thus, the behavior pattern is pervasive. Such behaviors differ from those that suggest that an individual is under stress. Stress-induced behaviors start at a certain time or occur only in certain situations. For example, the behaviors do not arise until after a child's parents separate, or they occur in school but not at home.

When a child or an adolescent experiences change, he or she often feels anxiety or sadness. For instance, many students feel anxiety when they graduate from elementary school and move on to middle school. They may also feel sad about leaving the safe and known world of elementary school. Such reactions are normal. When a child or adolescent experiences increased or prolonged stress, however, he or she will experience anxiety and/or depression. He or she may try to cope by

• Internalizing stress
• Externalizing stress
• Somatizing stress
• Using other approaches to cope with stress

It is important to realize that such behavior is a message, not a diagnosis. It demonstrates how an individual is handling the anxiety and/or depression caused by stress. It does not tell or explain what is causing the stress. It is essential to find out whether the stress is the result of family dysfunction, abuse, peer or community problems, academic difficulties, or any of many other possibilities. Only with this knowledge will a comprehensive intervention strategy be possible.

Internalizing Stress

Some children become very aware of their problems and feel anxiety, depression, or both. These feelings are seen in school and at home. The cause may be apparent, such as a recent divorce or death of a family member. For some children, however, the cause may need to be ascertained. Anxiety A student might focus his or her anxiety on school, showing a fear of going to school (i.e., school avoidance) or a fear of doing schoolwork. This anxiety might expand into a generalized anxiety disorder. For example, the child then might be afraid to ride the school bus. The student may become so upset when doing homework that he or she will not start or will become upset as soon as difficulty with the work is encountered. It is possible that the student will become fearful in the classroom. He or she may become unavailable for learning by either withdrawing from any potentially frustrating or uncertain situations by becoming upset and resisting work or by pulling back and becoming passive.

Nine-year old Bobby faced these issues. He was very intelligent; however, because no one identified his learning disabilities, he failed tests often and had to repeat second grade. When asked how he reacted in school when he could not do his work, Bobby replied, "When I was younger, I got mad. I used to scribble on my paper and be angry. School was no fun. Now, I get scared all of the time that the teacher will be mad with me or that I won't know how to do the work. I get so worried that I can't pay attention."

Depression

Some children experience stress by keeping their sadness inside and becoming depressed. The symptoms of depression in older children and adolescents may be similar to those in adults: sadness, crying, difficulty sleeping, or loss of appetite. Younger children might express their sadness by irritability and aggression. Some children or adolescents may become self-destructive, speak of "life not being worth living," or mention wanting to commit suicide.

Externalizing Stress

Some children and adolescents find it too hard to cope with the discomfort and pain of stress, as well as the resulting anxiety and depression. They decide not to handle the stress but, instead, to "get rid of it." They externalize the anxiety and depression. They get into fights at school and insist that the fights are due to someone else's behavior. "Don't blame me! He started it" is a common refrain.

By projecting all of the blame onto others, a child does not have to accept responsibility for his or her problems. Thus, a student who externalizes stress appears not to be anxious or depressed. Nonetheless, parents and teachers feel anxious and depressed about the child. It is often difficult to help these children because, as they accept no responsibility for their behaviors, they do not see a need for help.

Disruptive Behavior Problems

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), children and adolescents are diagnosed based on the extent of their externalizing behaviors. An individual who externalizes primarily within the family, by challenging rules and becoming oppositional and defiant, has an oppositional defiant disorder. If the behaviors expand beyond the family — leading to problems with other authority figures (e.g., teachers, principals, police officers) and resulting in challenging school and society rules, fighting, stealing, or breaking rules — then the individual has a conduct disorder. It is important to understand that a diagnosis of oppositional defiant disorder or conduct disorder describes how a student is coping with stress, but it does not identify the cause of the stress.

Somatizing Stress

A child or adolescent may focus his or her anxiety and depression onto bodily functions. A child might develop stomachaches, lower abdominal cramps, headaches, diarrhea, or frequent urination or bowel movements. These complaints might occur only on school-day mornings or just before a test. A child might need to leave class to go to the school nurse or home. As with any physical symptom, the discomfort is real. The pain goes away when the child is allowed to be in a situation that avoids the stress. For a child with an academic difficulty, staying home from school often relieves the stress, and the symptom goes away.

Seven-year old Katie said, "Sometimes I get into trouble because I forgot to do what the teacher said or I erase too much. The teacher yells at me, and I get scared. Then my stomach starts to hurt, and I have to go to the nurse." Similarly, 8-year-old Franklin woke up each school day with severe stomach cramps and vomiting. His mother kept him home from school and the pains usually disappeared by noon. A complete medical workup found Franklin perfectly healthy. He must have guessed why he was taken to a child psychiatrist. His first words were, "I know my stomach trouble is because I'm afraid of school. Only it really does hurt — no kidding!" Other children may explain their anxiety by focusing on their increasing awareness that something must be wrong with them. They hear parents or teachers talking about them. They may have been to several professionals for evaluations. They begin to express their worries through hypochondria: "My back hurts," "My head aches," "My knee feels funny." Sometimes this concern with a body part extends into a general concern with body image or body damage. At times, these complaints become a complete rationalization for failure, such as "I can't help it if I made a mistake. My arm hurts today."

Other Approaches for Coping with Stress

Some children or adolescents may express their stress in the way that they interact with others or influence their environment. Their behaviors reflect their problems.

The Class Clown

Some children cope with their stress by becoming the class clown. This behavior is often found in students with academic difficulties. "Clowning" serves several functions. It can be a way of controlling feelings of inadequacy by covering up feelings of worthlessness and depression. By playing the clown, a child seems to be saying, "They call me a clown, but that's only because I choose to be one. I really can turn it off if I want to, but it's too much fun this way." If the child "succeeds" in this behavior, he or she disrupts the lesson plan or is told to leave the group, thus avoiding the academic work and potential failure. Clowning behavior may also win a certain measure of peer acceptance. Suddenly the child everyone teased as being "dumb" becomes the class hero because of what he or she does. As a result, clowning behaviors are reinforced.

Handling Anger

One indirect style of expressing difficulty with feelings is passive aggression. The child's behavior is not actively aggressive, yet the child seems to make everyone angry with him or her. The student might dawdle in class, making the teacher angry. He or she might act in a way that angers others.

Other children might be passive dependent. Initially, a child prevents unpleasant feelings by staying out of the situations that cause such feelings. He or she avoids taking any initiative for anything and minimizes getting involved in activities. A child's passive-dependent behaviors often make people angry because the helplessness appears to be deliberate and contrived.

The Mind, The Brain, and Education

The classroom is the exciting laboratory in which the brain and mind interact in a positive way, resulting in growth and development. Anything that affects brain functioning might affect learning and behavior. In addition, anything that creates stress within a student might influence behavior and availability for learning. As the goal of teaching is to facilitate learning, anything that affects learning or a student's availability for learning will affect teaching. The teacher, then, may even become part of the breakdown in learning resulting from such difficulties. Yet the general classroom teacher is also the best person to recognize evidence of problems, to ensure that necessary evaluations are completed, to provide essential information in the diagnostic process, and to participate in the treatment plan.