Professional Documents
Culture Documents
Children with Major Depression
Neglected in CNMI Public Schools
(Draft)
Richard Nigh
September 1, 2009
Saipan, CNMI
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Introduction
This is a draft. Some of the data herein is not the most recent, but it is the most
recent I was able to find at this time. I expect to continue to modify this research as I
find new data. However, I believe that it does reflect fairly what the true situation is in
public schools in the US and in the CNMI regarding children suffering from major
depression and mental illnesses.
Although it was meant to be specifically about major depression, the reader will
find that due to the very low instance of diagnosis of children with major depression,
numbers and percentages are given in a more general form; for example, regarding
mental illnesses or “emotional disturbances.”
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Children with Major Depression Neglected in CNMI Public Schools
Major depression is an extremely serious illness that changes one’s personality: it
takes away selfconfidence and the ability to think clearly. If severe, it can lead to
violence and suicide. To emphasize the personality change, I offer the following
quotation by Roger, who suffers from major depression and spoke with me about a visit
from a close friend who he had not seen for several years:
I hoped that maybe, just maybe, he would be able to see some good qualities in
me. But I didn't think to ask. I think it would be nice to hear from someone what
my good qualities are. If I have any. Maybe that would show me that I am still
me and that I don't really look different or act so different than before. Because I
don't know how I act. Really, I feel like I don’t act. I just am. Numb. Tired. I
can’t think well. I am not the same person I used to be.
Later, Roger described how he regretted not meeting his friend more during the
friend’s time in the area but that he “just couldn’t.” He tired easily and had to stay at
home at least half of the time. About the time that he did spend with the friend, he said
this:
I would say that about a third of the time, I didn’t think about myself much. I
didn’t think about the effort I had to put into the conversation. So my mood and
stress levels got better at those times. At other times though, I could feel my
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mood and stress levels getting worse. Maybe a 7 or 8. Sometimes, they got really
high. I don’t know how people will react to what I say. I have to try hard to look
normal. It’s like being on drugs. You know, like trying to maintain. I wanted to
excuse myself, even to the point of leaving my friend and going home. Well, I
actually did leave him in a restaurant a few times. Just for a few minutes. I had to
get outside for awhile. (July 2009.)
Although this quotation is that of an adult, children also suffer from this illness.
It can be difficult to identify a child suffering from major depression. Although
younger children often have similar symptoms and responses to those of this man, they
may try to hide these feelings rather than to verbalize them. They also naturally have
much more energy than adults. “The depressed child may not show significant
behavioral disturbance.” (NAMI, Fact Sheet #2). Older children (14 and older) may
also have these symptoms, but they more often react actively with irritability, anger and
bitterness toward their parents or teachers. In severe cases, they may run away from
home or commit suicide. A teenager with major depression might easily say, “I never
asked to be born.” (NMHIC, Major Depression in Children)
Whether younger children or older, the number of cases of students with major
depression is astounding, estimated by many sources as 5%. The US Department of
Health and Human Services estimates more conservatively that major depression is the
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most common form of mental illness and that, at any one time, 4.3% of children
between the ages of 1217 suffer from it (Pratt and Brody p.1). Data from the Center for
Disease Control published in 2008 shows that the number of cases of students identified
as having emotional disturbances has fallen rapidly since 2004. At its peak in 2004,
only 0.66% of children of school age were being treated for “emotional disturbances,” a
category which includes mental illnesses and, of course, major depression (Appendix
1). This corresponds to the year that IDEA (the Individuals with Disabilities Education
Act) first came into law. This also corresponds inversely to a growing population of
children in schools, according to data collected by the US Census Bureau. (US Census
Bureau, Current Population Survey, 2007).
These children nearly always end up without being identified and without
intervention. One would expect the number of identifications and evaluations of mental
illnesses, particularly major depression because it is so common, to rise with a rising
student population; however, they have actually decreased.
The purpose of this study is to explore whether this lack of identification occurs
in CNMI schools, and if so, what are the reasons that it does? Could it be, as I
mentioned, problems with the national legislation itself? What other factors would
explain this problem? At the lowest level of the system, how much do teachers know
about major depression and mental illness in general, and where did they learn about it?
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Statistics from the Public School System (PSS) and interviews with specialists of public
schools will be used to understand the local side of this issue. As noted in the
introduction, it may appear many times that this report is about emotional disturbances
or about mental illness in general rather than major depression in specific. This is due
to the wording in the IDEA legislation which constrains the discussion to the broad
category of emotional disturbances. It will only be near the end of this report that
specific statistics about major depression in the CNMI can come out.
As the research progresses, it will become apparent that there is little knowledge
moving among the specialists and teachers involved in the process of identification to
assessment, meaning that people at all levels are working with limited knowledge. The
collection of available data from various sources and the evaluation of that data will
prove to be justification for this report.
Prior to discussing the local issues, this study will review the literature to show
the significance of this problem by discussing the following topics:
1. Major depression in children
2. Major Depression in the Individuals with Disabilities Act (IDEA)
3. Comments opposed to various IDEA regulations
4. Some IDEA responses
5. The number of children with major depression identified and treated in the
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U.S.
Definitions
Identification is used to mean the discovery of a student who, through observation
by a teacher or specialist, may have a problem of some kind. Identification does not
mean diagnosis, only a suspicion that a child is at risk in some way.
Assessment and evaluation refer to the testing of a child through observation,
discussion, testing or other means to determine the problem a child may have. When a
specialist assesses or evaluates a child, the specialist may only suspect a problem.
When a professional assesses or evaluates a child, the assessment itself is not the
diagnosis but the gathering of evidence by which the diagnosis is made.
Diagnosis refers to a professional psychiatrist’s, psychologist’s or medical
doctor’s designation of a child’s illness or disability.
Please note that the words defined above are not related only to emotional
disturbances, mental illnesses or major depression. They refer to a perceived problem
of some type.
Major Depression in Children
Major depression is the most common name for this illness, but it is called by a
number of other names, among them, major depressive disorder, unipolar disorder,
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unipolar depression, unipolar major depression and clinical depression. It is classified
as a mental illness, and its definition is given in very similar terms by most sources. The
American Psychiatric Association (APA) defines it like this:
Major depression is a clinical syndrome of at least five symptoms that cluster
together, last for at least 2 weeks, and cause impairment in functioning. Mood
symptoms include depressed, sad or irritable mood, loss of interest in usual
activities, inability to experience pleasure, feelings of guilt or worthlessness, and
thoughts of death or suicide. Cognitive symptoms include inability to concentrate
and difficulty making decisions. Physical symptoms include fatigue, lack of
energy, feeling either restless or slowed down, and changes in sleep, appetite, and
activity levels (APA, Diagnostic and Statistical Manual p.412).
According to the National Center for Health Statistics, major depression can be
classified as mild, moderate, moderately severe and severe. The severity of functional
impairment rises as the severity of the illness increases. Even major depression which
is mild causes some functional impairment (Pratt and Brody p.1).
Besides the symptoms mentioned above, people suffering from major depression
may experience many other symptoms. Although a diagnosis can be made according to
the “cluster” of five basic symptoms necessary to evaluate a person with major
depression, any of a number of other symptoms, which are not necessary for diagnosis,
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may go along with those. These other symptoms may be caused by the depression itself
or by medication. Because there are so many symptoms that can occur along with
major depression, teachers and other school personnel could think a child has either a
learning disability or a behavior problem. If the former, the child may at least get some
treatment.
The danger is that in either case, the child may go untreated for the cause of her
problems. If she is evaluated with a learning disability, she will receive treatment for
the observable symptom. If treated as a discipline problem, the child has a good chance
of becoming more severely depressed. In either case, only the symptoms as defined by
school personnel are treated. If the symptoms become extreme enough, the child may
run away from home or commit suicide.
The symptoms in Appendix 2 are all symptoms that have been brought out in
group therapy sessions I have attended and in interviews. In my own case, I can attest
to having experienced nearly all of these symptoms but never all at once. Some
symptoms may suddenly appear and then, after several weeks or months, be replaced by
another set of symptoms or a mix of some of the old symptoms and some new. Some of
the symptoms which have continued unabated and have most seriously affected my life
are a moderate to severe loss of memory, inability to read fiction or to follow the plot of
a movie, difficulty socializing with others, and a difficulty distinguishing between
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dream and reality. The APA’s list of symptoms do, of course, persist; but these others
have also continued almost uninterruptedly for the past two years. All the other
symptoms in Appendix 2 come and go.
Among children, major depression shows itself in various forms which include
the symptoms as defined by the APA. Most usually, according to NIMH (National
Institute for Mental Health), children will have the symptoms described by the
American Psychiatric Association, but sufferers are more difficult to identify than
adults with the same problem. Younger children may, as a consequence, “pretend to be
sick, refuse to go to school, cling to a parent, or worry that the parent may die.” Older
children “may sulk, get into trouble at school, be negative, grouchy, and feel
misunderstood” (NIMH, Depression in Children). The characteristics of aggression
and irritability given by NIMH regarding older children contrast with the more
observable lack of selfconfidence and decrease in activity shown by both younger
children and adults.
SAMHSA (Substance Abuse and Mental Health Services Administration) gives a
slightly different view of the adolescent sufferer. It points out the aggressive
characteristics of older children but also the other characteristics which are
symptomatic of all these children: the sadness, hopelessness, boredom, lack of self
confidence, crying, poor school performance, and the aches and pains that don’t get
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better (SAMHSA, Major Depression in Children, 2003). There are given symptoms
which define major depression. The response to the depression, no matter what
symptoms the child may develop, may vary. However, when there is depression with or
without further symptoms, school performance is bound to suffer.
Major depression is the fourth most common of all illnesses causing a
significant burden of disease. According to the World Health Organization, “Unipolar
depression makes a large contribution to the burden of disease, being at third place
worldwide and eighth place in lowincome countries, but at first place in middle and
highincome countries” (WHO, Burden of Disease, Part 4, p. 5). DALY (Disability
Adjusted Life Year) is a term introduced by WHO to measure the amount of time that
people live with disabilities.
IDEA and Major Depression
IDEA (The Individuals with Disabilities Education Act 2004) as it was revised in
2006 places all mental illnesses into one category, “emotional disturbances”
(Department of Education, IDEA 2006). CFR Section 300(8)(4)(i) defines emotional
disturbances as follows:
Emotional disturbance means a condition exhibiting one or more of the
following characteristics over a long period of time and to a marked degree that
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adversely affects a child’s educational performance:
(A) An inability to learn that cannot be explained by intellectual, sensory, or
health problems.
(B) An inability to build or maintain satisfactory interpersonal relationships
with peers and teachers.
(C) Inappropriate types of behavior or feelings under normal circumstances.
(D) A general pervasive mood of unhappiness or depression.
(E) A tendency to develop physical symptoms or fears associated with
personal or school problems.
(ii) Emotional disturbance includes schizophrenia. The term does not apply
to children who are socially maladjusted, unless it is determined that they have an
emotional disturbance under paragraph (c)(4)(i) of this section. (IDEA, p.46756)
The term, “emotional disturbance” is a term that was created by legislation. This
category is not medical terminology in any sense. According to its five criteria,
students with mental illnesses are not the only group categorized. Emotional
disturbances would include behavior problems of many types, the causes of which may
be conflicts in the family, abuse, neglect, changes of environment, bullying or any
number of other factors.
This term is unique to U.S. legislation and continues in the 2006 revision of
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IDEA. IDEA does not discuss specific mental illnesses. The term “mental illness” is
mentioned three times in the entire 397 page document, and all of those references are
in one paragraph. The term “schizophrenia” is used once, as quoted above, to show that
it is an emotional disturbance. The term “depression” is also used once, but it is used to
indicate an emotion not an illness. “Bipolar” is used twice in the comments section.
None of the following words are ever used in the Act: major depression, unipolar,
clinical, mentally ill, obsessive, ptsd, borderline, dysthymia, anorexia, and bulimia.
This was not a complete search for every type of mental illness, but the result does infer
that other mental illnesses are also not mentioned in the Act. Major depression is the
most prevalent but only one of a subset of illnesses within the category. It would be
interesting to know if this lack of attention to mental disorders is due to a purposeful
decision to give the least priority possible to mental illnesses.
Comments Opposed to IDEA Regulations
The National Alliance on Mental Illness (NAMI) is one of the largest private,
nonprofit organizations to disseminate information about and to actively lobby for the
rights of people with mental illnesses. In its 2002 Policy Platform, it pointed out the
problem with the wording of section 300.8.(c)(4)(i) authorizing the category of
emotional disturbances. “NAMI supports the existing eligibility criteria despite the fact
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that the language included in the definition for ‘emotional disturbance’ does not
adequately reflect the scientific advances and our current understanding of earlyonset
mental illnesses” (NAMI, Position, 2002).
In August 2006, NAMI submitted comments which were called for by the
Department of Education on the proposed IDEA 2006 regulations. Helpful to the
present study is NAMI’s comment that the term “socially maladjusted” be eliminated.
According to NAMI, this term is not defined anywhere in the regulation, “nor is there
research to support a definition for this term.” It appears that the term “socially
maladjusted” is another unique term that was created by legislation with no support or
backing from any research or organization. NAMI was not the only organization or
individual to point this out.
It points out as well in this section that “children with mental illnesses…
unfortunately continue to have the lowest academic achievement and highest dropout
and failure rates of any disability group” (NAMI, Comments, p.3).
Within a separate comment rationale, it pointed out that “students with mental
illnesses…may manifest behaviors or symptoms of their illnesses that are not
substantially similar” (Comments, p.8). Although this was not a separate comment
meant to change the legislation, it fairly sums up the need for early identification, early
intervention for children with mental illnesses, and trained teachers who can observe
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and recognize to some degree mental illnesses in their students.
IDEA Responses
The call for comments for IDEA 2006 ended on September 6, 2006. The
Department of Education responded to a number of comments at the beginning of the
revised IDEA legislation. Comments to both terms, “socially maladjusted” and
“emotional disturbance” were responded to.
Regarding “socially maladjusted,” the Department of Education noted that many
comments were given asking for either a definition of the term or the elimination of the
term completely. Many, like NAMI, pointed out that “there is no valid or reliable
instruments or methods to identify children who are, or are not, ‘socially maladjusted.’”
Comments also stated that children who might otherwise be given treatment through
special education were excluded because of this misunderstood phrase. (p.46459)
With regard to “emotional disturbance,” commenters stated that this is a
misunderstood category that is improperly used. Also, “the definition of emotional
disturbance is vague and offers few objective criteria to differentiate an emotional
disability from an ordinary development.”
The Department of Education’s discussion of these two terms was basically the
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same.
1. “Historically, it has been very difficult for the field to come to consensus on
the definition which has remained (in the case of emotional disturbances)
unchanged since 1977.”
2. “The comments received… expressed a wide range of opinions and no
consensus on the definition was reached.”
3. “Given… the fact that Congress did not make any changes that required
changing the definition, the Department recommended that the definition…
remain unchanged” ( Individuals with Disabilities Education Act,
S300.8(c)(3))
Comments were also made to suggest that general education teachers receive
training about emotional disturbances and special education. The Department
responsed to this by stating, “Personnel training needs vary across States and it would
be inappropriate for the regulations to require training on specific topics” (IDEA,
S300.18).
The Number of Children Identified and Treated
It is difficult to assess with any reliability how many children with major
depression are identified and treated in the U.S. Statistics regarding children with
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mental illnesses are treated in the broad category of emotional disturbances.
Nevertheless, it can be seen according to the statistics in Appendix 1 and related Chart
1 that only a small percentage of students are evaluated for emotional disturbances, of
which major depression is a part. According to the most recent available statistics, there
were 440,020 cases of evaluations of emotional disturbances in 2007. This was nearly
the same as the number in 1995, which amounted to 439,164. From 1995 to 2004, when
IDEA 2004 was enacted, identification of children with emotional disturbances rose
each year. The years 1992 to 1994 are shown, but the ages of children included in the
statistics changed in 1995. From 2004 until 2007, the number identified decreased by
nearly 10%.
As written earlier, it is estimated that somewhere between 4.3% and 5% of
students suffer from major depression. There is, of course, a variance in the severity of
symptoms; however, in 2004, only 0.66% of the student population was evaluated with
an emotional disturbance, and in 2007, that decreased to only 0.59%. Both percentages
are far short of even the 4.3% of students who are estimated to suffer from major
depression, and these low percentages cover a broad range of mental illnesses including
schizophrenia, ptsd, bipolar, anorexia and others.
Discussion
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Major depression is a serious illness which disrupts the lives of millions of adults
and children. A conservative estimate is that 4.3% of children have this illness, and the
World Health Organization statistics show that for people aged 1544 years, it was the
leading cause of DALYs lost worldwide. Considering the lack of confidence and lack
of memory that major depression commonly brings with it, there is little doubt that
children’s grades at school suffer greatly.
Consider Roger’s description of his feelings and thoughts. He didn’t know who
he was anymore. Was he the same person he had always been before he developed
major depression? This is a telling point of the illness. Like Roger, sufferers lose their
identities, and socializing becomes an extremely uncomfortable experience. Those with
severe depression feel they are hollow and their lives have no meaning.
Diagnosis and early intervention can be difficult given the variety of symptoms
that may emerge. The young girl in the back of the class who looks lost and rarely
speaks may have major depression. The rude teen boy who is often angry, misses many
days of school and acts up in classes may also be suffering from major depression. On
the other hand, another boy of the same age may be polite, somewhat quiet but with a
few friends, absent from school occasionally, and be unable to concentrate on lessons.
Any of these may be misdiagnosed as having learning disabilities or “social
maladjustment” unless diagnosed by a psychiatrist or psychologist.
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The Individuals with Disabilities Act should support these children through early
identification and appropriate treatment. On the contrary, this legislation makes it
difficult for schools, counselors and teachers to understand the law’s intent. All mental
illnesses are grouped into a single category, “emotional disturbance,” which could
include anything from mental illnesses to severe behavioral problems. Notwithstanding
the many commenters who oppose this category and call for clear definitions of the
illnesses covered, IDEA appears to be bogged down in bureaucracy. Its answers show
little respect for research, emerging research and best practices but focus rather on a
lack of consensus among the commenters and the inability of Congress to make any
changes to the legislation. One may wonder how much time Congress put into the
question of whether these definitions and categories are appropriate. Furthermore,
there are no requirements in IDEA for actions to be taken by schools.
The effect of the vague, unique wording used in IDEA coupled with its
recommendation not to require teacher training came at the beginning of a 10%
reduction in evaluation and treatment of children with “emotional disturbances” in the
U.S. during the three years from 2004. In 2007, only .59% of students were evaluated
as having an “emotional disturbance.” The trend is for fewer instances diagnosed each
year, and one might easily suspect that this downturn in the number of children treated
began the year that IDEA was first implemented.
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Further research in this study will attempt to find if the same problems exist in the
CNMI. The research will explore statistics of special education, including instances of
assessments of emotional disturbances, mental illnesses and major depression.
Specialists will be interviewed to discover any hindrances which might place
identification of sufferers as a low priority. Any specialist should know the actions
taken at their own schools toward identifying instances of the illness and the amount of
training having been given to counselors and teachers. It ultimately falls on the
teachers’ shoulders to suspect and intervene for children with major depression, and
their knowledge or lack of knowledge determines the success of early identification and
evaluation.
Research Beginnings: Survey
Research began in a class of teachers and counselors studying for their M.Ed
degrees. The number of respondents was admittedly limited with only 18, but the
answers received brought up questions I may have otherwise overlooked. Table 1
shows the results of the questions from the survey which could be answered either yes
or no. Tables 2 and 3 provide the written answers to four survey questions.
In Table 1, the results of eight yes and no questions are charted. The answers are
categorized according to school level (primary, junior high, high school) and
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counselors. The purpose of the questions was to ascertain whether respondents had
been trained about mental illnesses and major depression. The disadvantage of this
survey was that further questions could not be asked as all answers were anonymous.
Here are some results from answers given by the 15 teachers:
a. Two (13%) had received training about mental illnesses.
b. One who had been trained had also received information about major
depression.
c. Only primary school teachers had been trained.
d. Three teachers (20%) indicated some confidence that they would suspect a
child of having major depression.
e. Six (40%) answered that they had suspected major depression at some time,
notwithstanding the fact that only one teacher had been trained about major
depression.
f. Four (27%) had intervened at some time for a child with major depression.
Here are the answers from counselors:
a. All had received training at PSS.
b. One had received training at another location as well and had studied alone.
c. All had suspected and had intervened.
Tables 2 and 3 give the written answers to four specific questions. The purpose of
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the questions was to find out how much respondents knew about major depression.
Of the group that had received training (Table 2,) two of the three respondents
who answered the questions knew some of the basic symptoms of major depression.
Two knew that major depression is differentiated from normal depression by the length
of time symptoms persist.
In Table 3, almost all respondents answered “I don’t know” to questions 2 and 3
(symptoms and length of time.) Answers to the other questions varied widely. For
question one, one teacher thought that major depression is synonymous with mental
retardation. Another stated, “Someone in the mental institute.” Most respondents
included sadness or unsociability in their answers. One of the 13 gave an answer that
may show some understanding. “There’s no definite description of a depressed
person!”
No one was able to answer number 4 correctly, the answer being that it is the
length of time symptoms continue that differentiates normal from major depression.
The answers by those who had been trained were more often correct. It may be
inferred from this data that there has been some kind of training about mental illnesses
at PSS at some time in the past and that counselors, who answered the questions more
accurately than the other respondents, may receive compulsory training. Later
interviews should provide information about whether there is required training for at
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least some personnel and if that training originates at the PSS central level or the school
level. It should also be easy to find if there is regular training and when the training is
held.
Since training did improve these teachers’ and counselors’ understanding of major
depression, it might be thought that training would also increase the chance for
identification of sufferers. It would be interesting to know if the percentage of students
identified with “emotional disturbances” in the CNMI follows the national trend.
Interviews and Data Collection
Unfortunately, the statistics that I was able to obtain are not all up to date. Most
employees at the PSS Central Office were on vacation while I was doing research and
would not return until the first day of school. The Administrative Office personnel were
able to give the student population as “about 10,000.” The exact number was
confidential as it had not yet been published for 2008. I would have to obtain
permission in order to get the newest figures. That would be after the person in charge
returned from vacation. The newest available Annual Report of PSS that I was able to
acquire was from 2006, and this gives the student population as 11,718, which I will use
in this report. Even up until the 27th of August, with only a few days left to the
beginning of the school year, no one remaining at the Special Education Department
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was able to provide any information except for that in Appendix Three: SPED Student
Data (April 2009,) and they held up no hope that the person in charge would be back to
work by September 4th, by which time I had hoped to finish initial data collection.
I was able to interview three CCST (Contacts for the Children’s Services Team.)
The contacts are the special education specialists at each school, and the team is the
sum of these contacts. Everyone I interviewed was worried, some extremely, that they
might be identified in the report. I also interviewed an educational psychologist and a
director in the special education department.
It looked that I would not be able to complete data collection on time and chances
looked slim that the PSS even had statistics on the reasons that children were identified
as ED. However, on Thursday, August 27th, I was able to get in contact with one of the
educational. Then, on Friday, August 28, I received a call from a director of special
education at PSS. She would be in the office for two hours that morning.
First Data
From Appendix 3, SPED Student Data (April 2009,) it can be noted that there
was a total of 830 students in special education at that time. Of those, the smallest three
of the 13 categories were blindness (1 instance,) traumatic brain injury (3 instances,)
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and emotional disturbances (8 instances.) Using the 2006 student population figure, the
following percentages can be calculated for emotional disturbances:
Total student population: 11,718
Students with ED: 8 0.068% of total student population
0.96% of total SPED population
Sources: PSS Annual Report 2006, and PSS Dept. of Special Education (Appendix 3).
The percentage of students identified with ED compared to the total student
population in the CNMI is about onetenth the percentage reported in U.S. national
statistics for 2004 (0.66%) and about 11.5% of those reported in 2007 (0.59%.) While
the national percentages were surprisingly low, the averages in the CNMI were
disturbingly so. The number of children identified with ED is less than 1% of the total
number of SPED students.
As students identified with ED may be mentally ill or merely have temporary
behavior problems, this gave no indication of how many of these were mentally ill or
had major depression.
Interviews: CCST
In order to discover the reasons for the lack of identification of students with ED,
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I interviewed several specialists. Three of the interviewees were the special education
specialists at their respective schools where they are referred to as CCST (Contact for
Children’s Services Team.) The team itself is referred to as CST and is comprised of
the CCST from each of the schools in PSS. Their role in the process is to be the first
contact point for teachers who suspect that a student has a disability. These three were
Amanda, Bob and Carolyn.
Before any child is referred to the principal and then later to one of the three
educational psychologists, the contact and the teacher work together to collect data. All
three contacts explained the basic procedure for identifying and intervening for a child
with a disability.
a. The teacher acknowledges that a particular student has a problem, and the
teacher needs support in order to verify officially that a problem does exist.
b. The teacher meets with the contact. The two discuss the child in question and
discuss interventions that may be beneficial to the child.
c. The teacher uses the interventions in the class, keeps detailed records of the
results of that intervention, writes daily observations about the child, and may
meet with the child’s parents.
d. If the child’s comprehension, grades or behavior improve, then no further
action is necessary. If there is no improvement, the contact then meets the
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parents, often going to the child’s home, to discuss the teacher’s observations.
This process is more complicated than it appears due to both legal constraints
and cultural constraints. The contacts described these in slightly different ways.
Amanda and Bob were both Chamorro and discussed the cultural stigma attached to
mental illness in the CNMI. Parents do not want their child to be identified with any
kind of mental illness. Legally, according to the policy of PSS, the teachers and
contacts are not allowed to use any terms which would show that even a guess was
being made. They are not allowed to use the term mentally ill, nor are they allowed to
use the names of any specific mental illnesses. When in consultation, the teacher and
contact may discuss only the observations made by the teacher and the data collected
regarding interventions and grades. Amanda, in particular, was very concerned about
using these terms and made the point strictly and repeatedly that they were not allowed
to make any diagnosis. That is only up to a professional. Both said that they had used
the term emotionally disturbed at some time but rarely and only with good cause.
Once the identification of a child with a disability is done, the contact meets with
the parents and then, with their consent, can have the child evaluated by a professional.
Parental consent is difficult to obtain, and Bob reported that one teacher, when meeting
with parents, emphasizes the point that should the child be placed into the SPED
program, the family would receive an extra $550 per month from Medicare. This can
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sometimes counter the stigma that parents might feel. In Bob’s opinion, this money
would most likely be used for poker. For both Amanda and Bob, if they cannot obtain
parental consent, they take the case to an educational psychologist, whose hands are
also tied.
Carolyn is a EuropeanAmerican, a part of a small minority of 1.8% of the
population in the CNMI. Due to her different cultural background, Carolyn is less
concerned about the legal and cultural constraints. The main difference between her
and the others is that she prefers to talk more frankly with the teachers she meets.
Although they are not allowed to discuss the child in terms of any specific category or
illness, Carolyn would much rather hear teachers’ candid remarks about the children. If
the teacher thinks a mental illness is involved, she wants to know. Carolyn knows that
teachers are mostly untrained in emotional disturbances, but she believes that talking
frankly in private can produce better chances for providing the best interventions and
the best way to proceed thereafter. At the very least, it may provide some starting point
for further discussion.
Carolyn was not surprised to hear the APA estimate of 4.3% of children having
major depression, nor was she surprised at the extremely low percentage of children for
whom intervention has been taken in the U.S. She gave the opinion that the percentage
of interventions and identifications in the CNMI was probably lower, a prediction that
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turned out to be true. Amanda stated that she had never seen a child identified as ED.
Regarding training, all said that there are annual training days for counselors and
for CCST on development days. Some of the counselors have degrees in psychology,
but the other counselors and the CCST know only basic information about emotional
disturbances and mental illnesses. They know little information about specific
illnesses, and they all agreed that teachers throughout the PSS probably leave many
children with disabilities unidentified.
Interview: The Educational Psychologist
The educational psychologist, Charles, is a trained psychologist with degrees in
Psychology. He is one of three educational psychologists in the CNMI. He said that
according to the Department of Education, there should be one educational psychologist
(called school psychologist in the U.S.) for every 1,000 students. In the CNMI, the ratio
is 1:3,906. Charlie’s responsibilities include one high school and one junior high school
in Saipan. He is also responsible for Rota and the private schools in Saipan. He is
highly qualified for his position, he has had many years of experience here, and he is
very knowledgeable of ED, mental illness and the numerous types of mental illnesses
including major depression. Charlie is in contact with all the psychologists,
psychiatrists and mental health support groups in the CNMI, and he refers students to
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these contacts for treatment when possible.
Charlie states that in the CNMI, “little gets done except in extreme situations.”
He pointed to the recent news of a father who punished his daughter by locking her into
a refrigerator and biting her buttocks. This man was arrested and incarcerated for his
action. However, in the CNMI, there is a great amount of sexual abuse, psychological
abuse, physical abuse and neglect in families. These actions, or lack of action, are
mostly ignored. A part of the reason for this, he said, is the refusal of the legislature to
deal with the Juvenile Justice Law that was submitted to it nearly two years ago. There
has been very little debate about this proposed law that would “give teeth to the CGC
(Community Guidance Center), psychologists and doctors to have children or parents
arrested for abuse, drug use, and neglect.”
According to Charlie, all of the instances of ED and many other categories of
disabilities that he has investigated are caused somehow by bad home environments,
particularly neglect and abuse. One part of Charlie’s job is to visit the homes of children
identified with ED, where he usually is met only by the mother. Charlie often begins by
saying that the woman’s son or daughter is bright but is having trouble studying at
school and cannot concentrate. He would like to know the reason for the child’s
problem. As Charlie tells it, the mother often replies that there is nothing wrong, but
after being asked several times looks down and describes a common dilemma. The
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father spends all the money on poker and alcohol. He may sexually or physically abuse
the children. The mother works two or three jobs to allow him to keep his habit, but she
does not want to complain because she is afraid of her husband or is hoping to get a
green card and does not want to destroy her chances to get it. Therefore, she lets the
abuse or neglect continue. In other cases, the mother may be afraid of further physical
violence or abuse against the children.
No matter what the reasons for the child’s lack of ability to learn or study, when
Charlie must go to a home to meet the parents, he is usually faced with a “horrible
situation.” This extends not only to the cases of ED but to any special education related
disability. Learning disabilities are not, of course, exclusively the product of bad
environments; but the parents who take good care of their children have probably, by
this time, already had their children diagnosed either at CGC, by a professional
psychologist, or by a medical doctor.
Charlie assesses children, usually at a classroom at school, and he has the right to
diagnose specific learning disabilities. Parents must give permission for him to make
the assessment, and this reduces the number of assessments made. After assessment, he
decides whether to refer a child to a professional for treatment. Even if parents give
permission for Charlie to evaluate their child, they still must not only give permission
for the child to be assessed or treated by a professional but must also take the child to
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the clinic themselves. Charlie has no legal right to take the child even if permission has
been granted. Few children make it this far through the process.
One of the major reasons that parents refuse to have their children assessed is, as
contacts of the CST pointed out, the stigma involved in having children in the special
education program. Having children categorized as ED is even worse, and no local
family wants their child stigmatized by being called mentally ill. Some parents may
meet teachers or with both teachers and specialists, but they will not permit an actual
diagnosis to be made.
According to Charlie, training is held for counselors and contacts of the CST, who
are required to attend this training one day per year. The number of attendees is limited,
with counselors and contacts given priority; regular classroom teachers rarely attend.
For most contacts, this is the only study about ED or mental illnesses that they have
ever received. Some counselors are in the same position. Although there are
counselors who have degrees in counseling and are highly qualified, there are also those
who are in their positions because they have a family member in high office. Charlie
guessed that the two teachers in the survey who had received training were school
contacts. He was not surprised that the contacts and one of the counselors did not know
much about major depression, and he put his opinion about the training into a question.
“How can you teach a class on ED, which contains behavior problems, mental illness,
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what have you, in a one day development class? “ He went on to say that it is
impossible to give more than a few basic facts about specific mental illnesses.
The Child Services Team members, partly for the reason just given, do not work
with ED. Furthermore, they do not work with it because although the category includes
behavior problems, they and other teachers tend to see the behavior problems as
something that can be solved through effective classroom management or by sending
the student to “the office.”
We discussed parents, legislation, contact teachers and other teachers, but what
about the children themselves? When I asked about the children, we finally came to the
point where we could discuss individual illnesses. Charlie has seen children who have
mental illnesses and knows that he doesn’t see nearly as many as there actually are. As
just noted, teachers rarely identify ED, and parents do not notify the school of any
suspicions they may have because they do not want to live with the stigma of having a
child with a mental illness. More education is necessary to make people realize that
mental illnesses are not uncommon and that they are not all incurable.
Children with major depression often run afoul of the law. They often abuse
drugs and alcohol. It is common for children to sniff glue, paint, gasoline or anything
else that will get them high. Charlie knows of children who, he believes, would not
have committed suicide had the parents allowed diagnosis and treatment. Suicide is
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common in the CNMI, and is usually done by either hanging or cutting.
Finally, he told me about a few ED cases he had been involved with. One 12year
old girl was failing but not due to depression. She was a behavior problem in class.
She smoked, used alcohol, and was prostituting herself. The real cause of her problem
was negligence by the parents, who paid no attention to her at all. Another child, who
Charlie was able to get classified as ED, had very similar problems, including physical
abuse. Again, this child did not have major depression.
A serious case he encountered was of a girl who was being sexually abused at
home, although the mother denied it and did nothing about it. This elementary school
girl was very smart, but in Charlie’s words, “was just awful.” She was manipulative and
was uncontrollable when she wanted to be. This girl may have been suffering from
depression along with other problems.
In almost every case of ED that he has seen and in every case for which he was
able to get a child diagnosed, the cause has come from home. Major depression, he
admitted, was rarely identified, but its results can be devastating, such as drug abuse,
suicide, disrespect for any authority, and physical violence, even including murder.
The Eight PSS Cases of ED
Donna, a director of the special education program at the PSS central office,
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called me one morning and said she would be in the office for two hours. I rushed to
the office, where Donna took out the files of the eight ED cases and read to me
information she thought I could use and that she could give without compromising the
children or families. Since so much of what I had learned had been considered
extremely confidential, including the student population of the CNMI for 2008, this was
quite a surprise. The discussion about each child increased as Donna became
increasingly interested in the cases, and I was able to get a better idea of how many
instances of major depression had been diagnosed. These are the eight cases of children
assessed as having ED in the CNMI.
1. A 9yearold girl had behavior problems but did not respond to intervention in the
classroom. She sat in the back of the class, got up and walked around as she pleased,
was aggressive to the point of throwing things, and was always argumentative. She was
given a behavior selfassessment report to complete for the contact teacher but did not
complete more than about half of it. The parents allowed her to see the educational
psychologist, who placed the girl into the ED category. There was no diagnosis for any
mental illness, including major depression.
2. An 11yearold was failing in school. She rarely participated in classes and only
when asked, and she had poor attendance. The child was softspoken, used only short
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answers to communicate, and always covered her mouth when she spoke. She never
talked about having any difficulty and was cooperative when asked to do something.
The girl lived with her grandfather, mother and siblings. Her father was serving
time in prison. During a visit to the home, the contact teacher found that the
grandfather drank heavily but was nicer when he drank than when sober. When sober,
he was angry and irritable toward family members.
The girl was diagnosed as having a specific learning disability (SLD) and was
classified into the ED category. No mention was made of major depression.
3. According to the special education contact teacher, this 10yearold boy had
learning and behavior problems at both school and home, problems which had become
more severe over the past few years. He had been identified and assessed at 4years
old, but at that time only his relationship with parents was affected. Now, his
relationship with peers was negatively affected. He was argumentative with his parents
and had become argumentative with his classmates as well. At school, he could not
think clearly and had academic problems. He could be either aggressive or distracted.
The boy had regular checkups at CGC where he was found to have problems with
sleep. Although he said that he slept at night, he often slept at his desk at school. He
was put on a reward system that seemed to help, and he was put into a sports program.
He received no medication. No mention was made of major depression or any other
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illness.
4. An 11yearold girl was diagnosed as having ADHD and was put on medication.
She was retained for one year previous to the diagnosis. She is presently not taking
medication.
Her present teacher describes her as cooperative and compliant. Her most recent
interview with the educational psychologist shows her to be alert and to have had no
distress during testing. She was attentive but gave up easily with difficult tasks.
At school, she is cooperative but quiet, and the teacher describes her as having no
behavior problems, no ADHD, and a level of activity that seems comparable to other
girls her age. The educational psychologist, on the other hand, has made a very
different assessment:
The girl believes she is getting worse..
She believes she is dumb.
She believes that nothing goes right for her.
She is sad all the time.
“Things bother her.”
She has a problem with selfhatred.
Because of low selfesteem, her academic performance is worsening.
When asked what would change things so that things would go right, she
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had no answer.
Diagnosis: Major depression.
5. A 12yearold 6th grade girl has significant behavior problems. She loses her
temper easily and throws things. She is particularly aggressive when disciplined.
Sometimes she says she is a dog and will only bark. At other times, she always has to
have the last word and argues about everything.
Her parents took her to CGC for treatment but stopped after taking her twice. The
counselor suspects ADHD and some unknown environmental cause.
6. A 9yearold boy works well when given individual attention. Otherwise, he
ignores rules. He touches his classmates and school staff inappropriately, and he has
threatened to cut off the head of another student.
He was given journal writing as an assignment to help him get his problems out
into the open. He will not sit until the teacher forces him to. After he does sit, he
writes for only a few minutes, gets up and leaves the room. During Reading lessons, he
can read for about five minutes and then wants to play with blocks.
During his evaluation, he was guarded. He was alert, and his concentration
appeared to be normal. When faced with a difficult task, he gave up. He was found to
like to get rewards and will work for them.
He is negative when talking about his life. He says his parents are not proud of
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him. He gets bad grades; so he thinks the teacher doesn’t like him. He can’t stop
himself from making mistakes; things go wrong even when he tries hard. He can’t
think during tests and just gives up. Life is getting worse and worse. He is always in
trouble. No one understands.
The boy was placed in the ED category. He was not diagnosed as having major
depression.
7. This 7yearold girl was assessed when she was 6yearsold. Her mother is
concerned about her daughter for a few reasons. There is a history of mental illness in
the family. The girl stares off into space for extended periods of time. She can be
talkative, but at other times she is incoherent. For example, when asked where she was
born, she might answer, “My dad’s work.” Were you born here in Saipan? “No, at the
beach.” The answers are not totally unrelated to the questions, but they are not in touch
with reality.
She has few if any friends and during recess sometimes stands and plays with the
doorknob. She fidgets in class and moves around. When taking the assessment test,
she was more interested in the testing room rather than the test.
She talks about hearing voices, but she will not answer questions about them.
Her teacher brought the girl to the attention of her school’s contact teacher
because the girl stared into space, answered incoherently and was not social.
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Her family was asked to seek the help of a psychiatrist, but they have not done so.
The girl was placed into the category of ED but was not diagnosed as having major
depression.
8. This boy is 10yearsold. He had his first assessment at the age of four at CGC.
He was found to have speech problems, and he did not respond when called by his
name. He could play with toys for about four minutes. He liked blocks but not action
figures. He was active, ran under the table, and pretended to be a dog. He responded to
physical restraint by his mother.
At that time, he was given a behavior plan which included receiving rewards for
good work. Also, the teacher encourages him when the lessons appear difficult and it
appears that he might give up.
At eight, he was improving. Before the plan, he was failing, but at eight his
scores were low to average, and he could read although his comprehension was low.
He still has problems such as difficulties in waiting, sharing and taking turns. He also
has temper tantrums. A new plan has been made which includes receiving a happy face
when he is good and a sad face when he is bad. When he begins to feel angry or when
he is becoming frustrated, he may put his head down on the desk. He has no absence
problem.
These eight cases are the only ED cases at the present time. Out of the eight, one
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was diagnosed as having major depression, and that case does have many of the
symptoms related to major depression. Two others also appeared to be candidates for
major depression, but neither of them were diagnosed with any specific illness. The 11
yearold girl (2.) had low selfesteem, was failing in school, and was quiet, all
symptoms typical of major depression. The 9yearold boy (6.) also displayed some of
the main features of major depression. He was negative about life and had very low
selfesteem, thinking that his parents were not proud of him and that his teacher didn’t
like him. He thought of himself as making many mistakes. Life was getting worse, and
no one understood him. It is quite possible that these two have either major depression
alone or in combination with another illness.
Conclusions
There will necessarily be some guesswork involved when discussing the statistics
in the CNMI. The student population is approximately 11,718. As everywhere, the
estimate of 4.3% to 5% of the population suffering from major depression can probably
be used in the CNMI as well. For the purposes of this paper, it will have to be. There
can be no estimate made unless one believes that the number of cases identified gives a
good approximation of the true percentage of cases.
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Statistics:
Using these figures, of the 11,718 students at 4.3%, there should be approximately
500 cases of major depression in the CNMI. Instead, there were 830 students in the
SPED program (7.1% of the total) and eight ED students. The students evaluated as ED
make up 0.068% of the total student population and about 1% of all SPED students.
Of the eight ED students, only one was diagnosed as having major depression.
That is, of the total student population, .0085% were diagnosed with major depression,
and of all SPED students, the percentage was 0.12%.
If, as I wrote above, this is indicative of the overall percentage of cases of major
depression in the CNMI, then the CNMI has probably the lowest incidence of major
depression in the world. More likely, the CNMI school system is failing to identify
children with major depression by neglecting them.
Regarding age groups, the children having ED fall in the range of 7 to 12years
old, the average being about 10, which places them in the range of first to sixth grades.
This means that all children evaluated as ED were of elementary school age. There
were no students in either junior high school or high school evaluated as ED.
In contrast, in 1995 the US Department of Education wrote that the age
representing the highest percentage of students with ED was 15 (61,168 students.) The
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top six ages for numbers of students identified as ED in the U.S. were ages 11 to 16.
(Dept. of Ed.; Office of SPED Programs, August 28, 2009.)
Age and Gender of Students Evaluated as ED in the CNMI.
7 1 girl
9 2 1 boy, 1 girl
10 2 2 boys
11 2 2 girls
12 1 girl
Factors related to identification
There may be several factors involved in the CNMI’s identification of only
elementary school students.
1. The amount of time that teachers spend with students. Elementary school
teachers see their children all day long, whereas junior high and high school teachers
teach several classes comprised of different students each day. The older children are
less likely to be observed. This may be a factor in the identification of elementary
children in the CNMI, but it does not differ from other places in the U.S.
2. The lack of teacher training in the CNMI. PSS specialists (counselors and
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CCST) receive one day of training each year, while regular teachers receive no training
about ED, mental illness or specific mental illness. Contrary to what some teachers
think, major depression is not mental retardation, nor is there any evidence to think that
sufferers of major depression are curled up in fetal positions or institutionalized.
3. The difficulty of identifying older children with major depression (and other
mental illnesses) is due to the more active response to the illness by older students.
Major depression may be mistaken for behavior problems.
4. Similarly, older children who are sufferers of major depression often self
medicate by using drugs, alcohol, cigarettes, glue, and other substances. However, they
are not the only students who use these substances. If caught they may be punished for
the substance abuse, but the cause will go undiscovered.
5. Parents do not permit their children to be assessed or diagnosed because they
are afraid of the social stigma attached to having a child with a mental illness. Even if a
teacher identifies a student, that student may receive no intervention unless the parents
agree. Furthermore, if a child is assessed and referred to a professional, the parents
must take the child to the clinic themselves. The school is not allowed by law to do so.
6. The Individuals with Disabilities Act as it was revised in 2004 makes ED
appear unimportant. The Department of Education, the author of the Act, refuses to
admit that it is using words that have no medical foundation. It refuses to validate those
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words by defining them more clearly. It has made the emotional disturbance category
so broad that it can include a multitude of behaviors. And it does not require teachers to
be trained.
In order to continue to receive federal funding, the PSS does what it is required to
do and, therefore, ED is not a high priority.
Summary: Neglect
The CNMI’s public school system is neglecting childen with major depression.
Although there were eight cases of emotional disturbance, only one of the children
assessed was diagnosed with major depression. Two others, which had symptoms of
major depression did not receive diagnoses at all. The national average for children
with major depression is said to be between 4.3% and 5%. Nevertheless, PSS has been
able to diagnose only 0.068% of the total student population as having the illness.
At this point it may be fruitless to discuss major depression alone. All mental
illnesses are being neglected, and the broader category of emotional disturbances is
being neglected as well. The discussion may as well turn to mental illnesses in general.
Two main factors cause this neglect. One of the main factors is the IDEA
legislation itself which makes identification of children with mental illnesses difficult.
The legislation requires no training for teachers, counselors or anyone else in what it
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calls emotional disturbances, which is a catch all for behavioral problems.
Because there are no requirements, PSS does not place any priority on the
training and identification of emotional disturbances. It does give training, but that
training is far too little to give its specialists the knowledge they need to understand
these illnesses. It also gives no training to teachers themselves, the ones who have the
responsibility of identifying disabilities of all kinds. PSS, by necessity, places priority
on those things that satisfy requirements which will guarantee the inflow of federal
funds.
The neglect permeates the system from the IDEA legislation to the school system
and on down to the CCST and regular classroom teachers. Because of the complete
lack of training for teachers and the little training the CCST receive, teachers and
specialists at the school level do not have the information they need to identify mental
illnesses. The best they can hope to do is to identify problems, and those problems
may, but rarely, turn out to be diagnosed as mental illnesses.
There is a secrecy within the system that can be thought of as very strict
considering the fact that one must obtain permission to get the latest student population
report, and that the most recent report available is from 20052006. Teachers speak
guardedly. Two of the three contact teachers I spoke with would not even tell me yes or
no if they had ever heard of a student being identified as having a mental illness at their
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schools. The other said frankly that, no, she had never heard of any such
identifications.
This is not just an issue of confidentiality, as the “secrets” affect no one’s privacy.
Teachers and teacher contacts are not to blame for this. They are not permitted to use
the term mental illness, nor are they allowed to say the names of any specific mental
illnesses. They cannot offer an opinion of what they think may be wrong with a child,
even in private.
If a child is sad all the time and occasionally cries, if he can not concentrate on
lessons or do simple addition in his head, and if he writes about his worthlessness and
wanting to die, the teacher may not say, “We had better have the educational
psychologist look at him. I think this boy may have major depression that needs to be
treated immediately.”
Teachers are neglected. Their hands are tied by not being informed through
training. Without knowledge, the best they can do is to identify problem behavior.
Rarely do these identifications turn out to be mental illnesses. Teachers in junior high
schools and high schools appear to be at a disadvantage because they daily see children
acting up and probably see much bad behavior as normal. By neglecting to train these
teachers, students with mental illnesses are neglected.
Finally, there is the neglect by parents. They are worried about stigma. They are
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concerned about the green card. They may allow their children to be abused or may be
the abusers themselves. Or they may even neglect their children completely. Educating
parents is a key, but PSS, which is in the best position to do so, neglects to bring up the
issue.
Who is to blame for the neglect? Is it the Department of Education through its
IDEA legislation that is bound up in bureaucracy? Is it PSS because it neglects
emotional disturbances in favor of other projects that will ensure the continued inflow
of money from the federal government? Or is it the teachers and teacher contacts
because they don’t inform themselves? Perhaps it is parents, uninformed about mental
illnesses and worried about being stigmatized.
The answer is probably something like this: “All are to blame, but some are more
to blame than others.” I did get the impression that the educational psychologists, at
least, do know what they are doing but have no choice but to get help for children in any
way they can, even if that means not diagnosing a child as having a mental illness.
In conclusion, there needs to be a stop to the neglect, and this research suggests
some solutions that can be taken on the islands. Stop the secrecy. Open up the flow of
information. Bring the problem out into the open and educate everyone from those who
work at PSS central all the way to the parents and community. On a national level, the
Department of Education needs to be responsive to commenters’ opinions and be
Nigh, 49
willing to support communities through various means, including training and project
funding.
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Appendix 1: Related Statistics
Number of Evaluated
Children ED cases
Notes on Appendix 1 Statistics:
2007: 440,202 cases of emotional disturbance in schools (lowest number since 1995)
2004: 484,567 cases of emotional disturbance in schools (the peak)
1995: 439,164 cases of emotional disturbance in schools. Percent rose until 2004.
From 1995 to 2007, the number of school children increased by approximately 8%, but
the instances of evaluation of emotional disturbances was approximately the same.
From 2004 to 2007, the population of school age children increased by approximately
1%, but the instances of emotional disturbances fell by 44,365 cases, a reduction of
approximately 9%.
Information on student population retrieved from
ChildStats.gov: Federal Interagency Forum on Child and Family Statistics.
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http://www.childstats.gov/americaschildren/tables/pop1.asp
Source: US Census Bureau, Current Population Reports (Series P25, No. 311)
Information about SPED and ED populations retrieved from Individuals with
Disabilities Education Act (IDEA) Data
https://www.ideadata.org/TABLES31ST/AR_13.htm
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Appendix 2: Further symptoms caused by major depression or medication
• difficulty understanding what is said
• loss of memory; mild to severe
• inability or difficulty performing skills that could previously be performed; e.g.,
cannot calculate mathematical problems in one's head, cannot memorize and
recite, or cannot remember new vocabulary
• cannot read and comprehend works of fiction
• inability or difficulty socializing with others
• a feeling of nearly complete withdrawal into oneself
• insomnia, sleep deprivation often due to nightmares, but inability to stay awake
during the daytime
• vivid dreams similar to hallucinations, or dreams which are later thought to have
been real events
• inability to articulate
• headaches
• somnambulism
• irritability or a feeling of wanting to escape from public and noisy places
• heart palpitations
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• twitches
• forgetting/losing things
• difficulty concentrating
• increased use of drugs or alcohol
• extreme difficulty getting out of the house
• fear that one will not recover
• in the extreme, fear of death or death itself from either stressrelated illness or
suicide
• strong desire to sleep; unable to stay away from bed or couch
• unable to perform very easy tasks; e.g., answering telephone, writing email,
doing simple household chores like washing dishes
• lack of selfconfidence
• inability to do multitasking
• loss of appetite or binge eating
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TABLE 1: Survey Results
Teacher and Counselor Training at PSS
2. 3.
1. Level PSS Other 4. Self 5. M.Dep. 6. Suspect 7. Suspected 8. Intervened
primary 1
primary 1
primary 1 1
primary 1 1 1
primary 1
primary
primary
primary
primary 1
SUBTOTAL
9 2 0 0 1 2 3 1
junior high
junior high 1 1 1
junior high 1 1
SUBTOTAL
3 0 0 0 0 0 2 2
high school
high school 1 1 1
high school
SUBTOTAL
3 0 0 0 0 1 1 1
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TEACHER
15 2 0 0 1 3 6 4
counselor 1 1 1 1 1
counselor 1 1 1
counselor 1 1 1 1 1 1
1
COUNSLR
3 3 1 1 2 2 3 3
TOTAL 18 5 1 1 3 5 9 7
Questions:
2. PSS Was the respondent trained about mental illnesses by PSS?
3. Other Was the respondent trained about mental illnesses somewhere else?
4. Self Did the respondent study mental illness by own initiative?
5 M. Dep. If trained, did the training include information about major depression?
6.Suspect Would the respondent suspect a student to have major depression?
7. Suspected Has the respondent ever suspected a student to have major depression?
8. Intervene Has the respondent ever intervened on behalf of a suspected student?
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Table 2: Survey Results
Teacher Training at PSS: Level of understanding based on training time
Teachers are divided into groups depending on whether they have received training on
mental illnesses and/or major depression. Written responses to each question are shown
for each group. Respondents were requested to write "I don't know," when they did not
know the answer.
Group 1: Respondents who had received training.
(P) Primary; (C) Counselor
Note: Of the five respondents who had been trained, two answered they don't know for
all questions. One was a primary school teacher and the other a counselor. These have
been omitted.
Question 1: What is your first reaction when you hear the word "major depression?"
What kind of person do you envision?
Answers: (P) My first reaction would be, "This person needs help!" I envision the
person to be withdrawn, agitated, and basically cannot function properly!
(C) Sad, reclusive
(C) prolonged feelings of sadness and hopelessness that affect a person's
outlook, mood, personality, effectivity, and relationships
Question 2: What are the symptoms of major depression.
Answers: (P) I have no idea!
(C) Major noticeable changes in regular activities and character.
(C) Feeling sad, hopeless, continuous feeling despite changing
circumstances.
Nigh, 60
Question 3: How long must these symptoms persist in order to be considered major
depression?
Answers: (P) I don't know.
(C) More than a week.
(C) I don't know.
Question 4: What is the difference between major depression and normal depression?
Answers: (P) I have no idea!
(C) One goes away after a few days or after the event has passed. The other
continues.
(C) Length of symptoms.
Nigh, 61
Table 3: Survey Results
Teacher Training at PSS: Level of understanding based on training time
Teachers are divided into groups depending on whether they have received training on
mental illnesses and/or major depression. Written responses to each question are shown
for each group. Respondents were requested to write "I don't know," when they did not
know the answer.
Group 1: Respondents who had not received training.
(P) Primary; (J) Junior High; (H) High School
Note: Of the 13 respondents who had not received training, all answered at least one
question. There were no counselors in this group.
Question 1: What is your first reaction when you hear the word "major
depression?"
What kind of person do you envision?
Answers: (P) Stress. I envision sick people. Mental retardation.
(P) It can be a "regular Joe." There's no definite description of a
depressed person!
(P) Curled up in the fetal position in bed, unable to carry on normal
life and responsibilities.
(P) Someone in dire need of a listener
(P) I don't know.
(P) A person who is sad and a loner
(J) 1st reaction on word depression is sad.
An image of a depressed person is a person who is helpless, isolated.
(J) Somebody who is dealing with issues that they feel that they can't
face. Someone who doesn't want to socialize like how they used to
be.
(J) When I hear "major depression", my first reaction was to think
about the weather. I envision someone who is sad, looks down when
they walk in public, has slumped shoulders, doesn't smile often.
Nigh, 62
(H) Someone in the mental institute.
(H) Isolated. Withdrawn.
(H) Who is depressed? I envision any regular looking person.
Question 2:What are the symptoms of major depression.
Answers: (P) I don't know.
(P) I don't know.
(P) I don't know.
(P) I don't know.
(P) Withdrawal.
(P) Headache. Tired.
(J) a. withdrawn
b. lack of appetite
c. shame
(J) I don't know.
(J) I don't know.
(H) I don't know.
(H) I don't know.
(H) I don't know.
Question 3: How long must these symptoms persist in order to be considered major
depression?
Answers: (P) I don't know.
(P) I don't know.
(P) I don't know.
(P) I don't know.
(P) I don't know.
(P) I don't know.
Nigh, 63
(J) I don't know.
(J) I don't know
(J) I don't know.
(H) I don't know.
(H) I don't know.
(H) I don't know.
Question 4:What is the difference between major depression and normal depression?
Answers: (P) I don't know.
(P) Greater difference in attitude. Affects social and school life.
(P) Major is a quick change or a change that continues to get worse
and worse. Normal lasts a short amount of time or allows the person
to continue normal activities but with sadness.
(P) Not sure.
(P) I don't know,
(P) Major: needs immediate intervention such as counseling by
psychologist.
Normal: talk to peers/parents and find out what they can do to help.
(J) The difference is selfesteem and ability to seek help.
(J) I don't know.
(J) Great question. Maybe my answers to C, D and E should be "No."
(H) I don't know.
(H) Major is more clinical. Normal medication.
(H) I don't know.
Nigh, 64
Chart 1: Number of Cases of ED per year in the U.S.
Nigh, 65
References
NAMI, National Alliance on Mental Illness, "Fact Sheet on Depression in Children and
Adolescents", September 2003
.<http://nami.org/content/microsites138/nami_fort_wayne_indiana/home128/resource_
manual_for_educators/depression_facts.pdf>
U.S. Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration (SAMHSA), National Mental Health Information Center
(NMHIC), "Major Depression in Children and Adolescents," April 2003
<http://mentalhealth.samhsa.gov/publications/allpubs/ca0011/default.asp>
Pratt, Laura A, Ph.D, and Brody, Dera J., M.P.H., US Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Health
Statistics, “NCHS Data Brief, No. 7, September 2008,”
<http://www.cdc.gov/nchs/data/databriefs/db07.htm>
U.S. Census Bureau, "Current Population Survey, October 2007, internet release file
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American Psychiatric Association, “Diagnostic and statistical manual of mental
disorders”, 4th ed., American Psychiatric Association: Washington, DC., 2000., pg. 412.
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Health, “Depression in Children and Adolescents”, 2006
http://www.nimh.nih.gov/health/topics/depression/depressioninchildrenand
adolescents.shtml
US Dept. of Health and Human Services, Substance Abuse and mental Health Services
& Administration, SAMHSA’s National Mental Health Information Center, “Major
Depression in Children and Adolescence.,” April 2003
http://mentalhealth.samhsa.gov/publications/allpubs/ca0011/default.asp
World Health Organization (WHO), GBD Report, “Burden of Disease DALYs”, 2004
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http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part4.
Nigh, 66
Department of Education, IDEA, 34 CFR Parts 300 and 301, Part II, Assistance to
States for the Education of Children With Disabilities and Preschool Grants for
Children With Disabilities: Final Rule, August 14, 2006
National Alliance on Mental Illness (NAMI), “NAMI's Position (summarized from the
NAMI Policy Platform)”, June 2002
http://www.nami.org/Content/ContentGroups/Policy/WhereWeStand/Individuals_with_
Disabilities_Act_(IDEA)WHERE_WE_STAND.htm
National Alliance on Mental Illness (NAMI), “NAMI Comments on the Proposed
IDEA Regulations”, August 2006
http://nami.org/Template.cfm?Section=eNews_Archive&template=/contentmanagement
/contentdisplay.cfm&ContentID=28787&title=NAMI%20Strongly%20Urges%20Famili
es%20to%20Submit%20Comments%20on%20Proposed%20IDEA%20Regulations
Commonwealth of the Northern Mariana Islands, Public School System, “Annual
Report 20052006”.