Schools

Jeff Q. Bostic

Bradley Stein

Mary Schwab-Stone

Schools are among the most valuable sites for child psychiatrists to promote mental health. Almost all children attend schools, where many of their unique needs can be addressed daily by committed professional school staff. Symptoms of psychopathology usually manifest across home and school settings, yet the range of interventions is often much wider in schools where classrooms, school staff, and instructional/behavioral approaches to the child can be configured to optimize the fit between child and school.

As psychiatric hospitalization continues to give way to treatment efforts in more naturalistic settings, schools have become primary venues for management of mental health by child psychiatrists. At one end of the spectrum, the school psychiatrist provides direct treatment to students or staff. This direct treatment usually occurs on site at the school and may include face-to-face evaluations of students or staff, individual or group therapy, or medication management. This allows teachers and staff to access the child psychiatrist for specific mental health issues, and allows the child psychiatrist to factor in the school’s resources and philosophy in devising interventions. At the other end of the spectrum, the school consultant advises school staff, providing indirect services to students by assisting school personnel. The consultant may meet with administrators concerned about how best to respond to the death of a teacher, or to provide recommendations to help teachers work with students who have depression, attention deficit hyperactivity disorder, autism, or other special needs. Child psychiatrists often blend these roles, sometimes treating and advocating for a patient, and sometimes consulting to various school staff around complex problems (1).

Child psychiatrists will continue to become essential partners in schooling children, not just those children identified with psychopathology, but all children. The mental health consultant is often able to benefit many more children than would be possible through providing direct service on site at a school. Eight million children and youth are estimated to need mental health services in schools, yet less than one-fourth currently receive appropriate services (2,3). Proactive efforts to prevent and impede psychopathology will continue to supplant treatment only after full blown psychiatric disorders or crises are evidenced. Child psychiatrists will continue to provide input on specific emotional disabilities, and increasingly promote mental health for all students, providing input on programs and principles found effective for everything from combating depression to decreasing bullying, and by working directly with educators to adapt effective treatments to diverse school environments (4).

Emergence of School Mental Health Services

Mental health entwined with schools over the last half of the twentieth century following four significant social moments. First, after hundreds of thousands of refugee students were displaced at the end of World War II, Gerald Caplan used school-based interventions to assist teachers working with these students. Second, the civil rights movement in the 1960s brought about federal education rights legislation. No longer could schools require students with disabilities to fit into their existing programs. Systematic identification of students with emotional and behavioral disabilities began, accompanied by a need for clinical advice about assessing and treating these students in the least restrictive school settings. Third, increased social change in the late 1960s and wider recognition of problem behaviors among students, such as substance abuse, unprotected sexual intercourse, and more recently, bullying and school violence, caused schools to turn to mental health clinicians for advice. Fourth, the decrease in the 1990s in psychiatric hospitalizations and residential placements, coupled with the lack of access to mental health care among those most in need, resulted in proliferation of school-based mental health treatment, and delivery of psychiatric services within schools (5). Most recently the No Child Left Behind legislation has required intervention earlier for those students not progressing as expected. These events, and some important lessons learned from them, are provided in Table 7.2.1.

Models of Consultation

Multiple models of psychiatric consultation to schools have emerged, including the mental health model, the behavioral model, and the organizational model (6). These models are summarized in Table 7.2.2, as well as differences in their approach to the same problems. Regardless of the specific model, the child psychiatrist role appears broadening as collaborator, expert consultant, and partner in prevention, early intervention, and service delivery efforts (7).

Mental Health Consultation (MHC)

Mental health consultation (MHC)(8) stresses that the consultant’s goals are both to be helpful with the problem at hand and also to provide the consultee new knowledge and skills to handle similar problems in the future. This type of consultation is frequently indirect, as the consultant may hear about a troublesome student from a parent or staff, and make recommendations to these staff, sometimes without ever seeing the student. The consultant is usually paid by the school, and the consultee is free to follow (or not) the consultant’s recommendations.

Behavioral Consultation

Behavioral consultants attempt to change the behavior of teachers and students by focusing on: a) problem identification, b) problem analysis, c) plan implementation, and d) problem evaluation. During the problem identification stage, the consultant and teacher identify a specific problem to address.

Usually, a “problem” occurs when the student’s observed behavior is not what is desired and expected by the teacher or other school personnel. When a discrepancy exists between current and desired behavior, the consultant and teacher establish goals for the resolution of the problem, formulating the problem in behavioral terms. During problem analysis, the consultant and the school staff generate hypotheses about factors that influence the behavior and design a plan to solve the problem. During plan implementation, the consultant and school staff enact the plan and also collect data to measure how the problem behavior changes following implementation. During program evaluation, the consultant and school staff examine whether the goals have been attained, if new problems have arisen, and how the plan should be continued, modified, or phased out (9,10,11).

TABLE 7.2.1 MAJOR EVENTS IN PSYCHIATRIC CONSULTATION TO SCHOOLS

Social Event	Mental Health Impacts on Schools	Child Psychiatry Response	Lessons Learned
Aftermath of WWII	Displaced orphan students required emotional support to contend with school	Mental health providers worked with educators to manage displaced students	Life events require mindful planning to promote mental health and resiliency in children
Civil rights movement	Equality for all, including those with disabilities, required schools to accept and respond to diverse students	Child psychiatrists identified psychiatric disorders that schools considered as possible educational disabilities	Psychiatric disorders did not necessarily “fit” educational disability categories No consensual or empirical school interventions for identified disorders/disabilities existed
Social change and problem Behaviors	Problematic behaviors spilled into the classroom and interfered with schooling	Child psychiatrists provided input on lifestyle variables influencing quality of life	Little empirical evidence supported child psychiatry recommendations Efforts to identify the prevalence of substance abuse and other problem behaviors helped illuminate mental health issues
Decrease in psychiatric hospitalization	Students managed in nonschool environments returned to schools to receive an education appropriate for them, given complex needs	Child psychiatrists focused on discharge planning to provide outpatient treatment, including in school settings	Psychiatrists and educators partnered, by necessity, to address mental health issues impacting children in daily environments

TABLE 7.2.2 CONTEMPORARY MODELS OF SCHOOL CONSULTATION

	Consultation Model
Aspect of the Consultation	Mental Health Consultation	Behavioral Consultation	Organizational Consultation
Initial focus	Consultee’s understanding of problem	Problematic behaviors exhibited by students/staff	How school contributes to problem
How information is obtained from consultee	Listen to staff’s description of problem	Direct observation in classroom, counting frequency, length of specified behaviors	Review of school philosophy, curriculum, instructional philosophy, administrative procedures for problem class or group
Objective	Help consultee arrive at and implement new strategy/techniques	Help consultee measure problem behaviors, alter and shape student responses leading to problem behaviors	Help consultee refine organizational configuration and goals to diminish circumstances
Evaluation of model	Do students/staff identify and address specific issues? Do staff feel empowered/able to enact a solution?	Do specific problem behaviors diminish in frequency/intensity? What does “data collection” reveal?	Does this specific problem illuminate larger problems in policy impacting multiple students? Does the proposed solution benefit everyone?
Example case (17 year-old student who does not attend regularly the year after becoming a teen parent)	Consultee thinks back to when student attended, aware that family changes occurred, guides student to teen parent support services while adjusts schedule at school for student to attend later in day	Consultee keeps track of days/times missed, addresses directly with student, and they construct plan for student to be there on time by having others care for child on certain days; they measure success of plan, and revise as needed	Consultee identifies well intended but misattuned policies for attendance for current school population, and provide alternative schedule for students with children, course credit that can be completed at home, and course credit shifted to allow parenting study/work to count toward graduation

Behavioral consultation has advanced through the collaborative problemsolving model described by Greene and Ablon (12). This behavioral approach diverges from preexisting behavioral models by suggesting that students often lack a repertoire of other behaviors to employ when in complex situations, and so revert, almost inflexibly, to primitive or aggressive behaviors in such circumstances. Problem behaviors require adults (teachers or parents) to respond to the “message” attempted by the student’s behavior, rather than efforts to stop the behavior immediately or to ignore or tolerate it. Rather than conventional reinforcement when desirable behaviors spontaneously emerge, or punishment when misbehaviors occur, desirable behaviors have to be identified, agreed upon by the student and teacher, and practiced so that they become familiar parts of the student’s repertoire.

Organizational Consultation

Organizational consultation focuses on schools as systems and seeks to facilitate improvement in school functioning through the application of behavioral science concepts and the involvement of usually multiple system members (e.g., administrators and teachers) in the process of organizational change. Difficulties may emerge because of mismatches between the students and requirements of the educational system. Systemic problems such as communication breakdowns and ambiguity about responsibilities can cause anxiety and frustration among school staff, and impact student progress and behavior. Individual student problems may illuminate school system factors that contribute to the problem, and should be modified. For example, in one inner city charter school, a large number of students failed to graduate. During consultation it emerged that most students could not complete a swimming requirement, necessitating adjustment to this well intended, but misattuned, requirement. Models addressing low-achieving schools, such as the Comer School Development Program, precipitated school restructuring and change in school culture and climate, positively impacting student self-esteem, motivation, and achievement (13).

The Roles of School Staff within School Consultation

Most commonly, child psychiatrists interact with schools to coordinate treatment for their patients. Establishing an effective partnering relationship with school staff usually most benefits patients, particularly if the school sees the child differently or resists making accommodations for this student. Child psychiatrists often need to be aware of the staff options at a patient’s school so that helpful school staff can be accessed and empowered to address the patient’s needs.

Roles of School Personnel

As the demands on schools have intensified, staff roles have changed, such that consultants must have realistic expectations about who can perform specific interventions with students as recommendations are provided. The consultee may be anyone within the school hierarchy, and the consultant must address these needs while being mindful of how the consultation will impact everyone else within the system. The consultant must also consider who is in a position to implement recommendations when providing consultation.

Teachers remain the front-line staff most involved with students. Elementary teachers usually have approximately 25 students for 6 hours each day. By middle school, teachers usually teach in a specific content area, providing instruction to approximately 150 different students each day. Special education teachers are credentialed to provide alternative instruction to smaller groups of students with learning disabilities, including dyslexia, nonverbal learning disorders, or emotional disorders that interfere with learning. For students to receive instruction from special education teachers, they must have an individualized education plan (IEP). Aides often do not possess a 4-year college degree or teacher certification, but may work under a classroom teacher, or work with a specific student who has different teachers.

School psychologists either are employed by the school or have a contract with the school to test and help construct individualized educational plans (IEPs) for students to address their specific learning difficulties. They may also provide individual and group therapy to students. Guidance counselors sometimes provide psychotherapy to students, although their primary role is to assist students in college or vocational planning and class selection. School adjustment counselors and/or social workers have been added to school staffs in many locations, where their primary role is to provide psychosocial treatments to students, and sometimes their families.

School nurses address acute health care needs of students, and administer medications to students; however, school nurses sometimes travel between several schools each day so that complex or frequent medication regimens become difficult.

Occupational therapists work with students individually or in small groups to help students with basic activities of daily living, and alternative strategies for students who have sensory integration issues to help them learn to cope with various stimuli. Speech-language therapists meet with students who have communication and social skills difficulties individually and in small groups.

School administrators liaison between the school and the community. Principals manage all services (from teaching to custodial) within their school building, and report to the superintendent. The superintendent guides educational activities among all the schools within a school district, and reports to an elected school board in public schools, or an appointed board in private, parochial, or charter schools.

Establishing a Relationship with a School

Schools today face great demands to impart knowledge, to prepare students vocationally, to socialize children to interact with others effectively, and to protect their health and safety. These varied, often competing agendas impact every intervention proposed by the child psychiatrist, regardless of the child psychiatrist’s role “identified” by the school. Moreover, public, private, parochial, and charter schools not only vary widely in their priorities, but also in their
system hierarchy and their accountability to the community. Familiarity with each individual school, its priorities, and its staff is a prerequisite to any meaningful consultation.

Evaluating a School

When the child psychiatrist has the opportunity to visit a school, a framework for evaluating the school can help discern the fit between that school and a particular student, as well as better match interventions to the culture of that school. Table 7.2.3 provides a sample approach child psychiatrists can use when entering a school. Awareness of the general reaction the consultant has to the school and its staff helps clarify the likely fit between a school and an identified student. Depending on the needs of the student, the child psychiatrist may employ relevant questions from Appendix A.

The School Consultation Process

The goal of school consultation is to build alliances and to share information that helps the school staff recognize and resolve problems. This process can be broken down into three tasks: 1) allying with consultees; 2) aligning consultee objectives; and 3) mobilizing consultees to follow through with interventions (14). Allying with consultees requires the consultant to empathize with consultees and to decrease their possible resistance. In aligning consultees, the consultant reframes people’s comments, behaviors, or positions to establish unifying goals attractive to all participants. Mobilizing consultees to act requires the consultant to invest the participants in solving the problem and to empower consultees with the skills to be successful with the intervention. Consulting techniques helpful in accomplishing these tasks are described in Appendix B.

Special Education

Child psychiatrists often identify psychiatric disorders that require changes within the school setting for patients to benefit. The child psychiatrist is expected to identify specific disabilities (disorders) that impact a child’s performance in the classroom, and to clarify changes, such as additional time for test-taking for students with ADHD, or deviations from certain readings for patients with mood disorders or writing activities in patients with nonverbal learning disorder. Child psychiatrists may recommend services, such as social pragmatics instruction in patients with Asperger syndrome, and may comment on educational settings, although child psychiatrists should not recommend specific placements for their patients. Based on services needed, the child’s educational team is obligated to identify the most appropriate site for service delivery. Many options now exist for schools to educate students with psychiatric disorders, so the child psychiatrist must have some familiarity with the special education process, and the legal parameters surrounding educational planning for these students (15).

Special education refers to specialized instruction for students who cannot benefit from traditional classroom instruction. Eventually, all students will be appreciated as unique learners, as every child, wherever on the disability spectrum, deserves specialized instruction to optimize potential. Schools continue to become more sophisticated in addressing the needs of all their students, currently propelled by legal efforts to support education of each child in the United States. Legal protections have evolved beyond the equal protection clause of the 14th Amendment to the U.S. Constitution to provide every student with an appropriate education. Any child who is not progressing appropriately in school is entitled to an evaluation to determine if a disability is present, whether this disability interferes with school performance, and whether specialized teaching is needed. Anyone, including the student, the student’s family, school staff, or a clinician (such as a child psychiatrist) can request an evaluation for a student. This eligibility process is summarized in Appendix C and Table 7.2.4.

The American with Disabilities Act and Section 504 of the Rehabilitation Act of 1973

The Americans with Disabilities Act (ADA) prohibits the denial of educational services, programs, or activities to students with disabilities, and prohibits discrimination against all such students once enrolled. If parents suspect their child has a disability, they may request an evaluation to determine if a disability is present and interferes with educational progress. This is usually provided in writing to the school’s principal. A child with a suspected disability is usually referred to a child study team at the school to provide accommodations. Theoretically, accommodations refer to classroom changes that help the student meet requirements, without “lowering” academic standards.

Schools may generate an accommodation plan for such a student called a 504 Plan. These plans derive from Section 504 of the Rehabilitation Act (1973), which ensures that all disabled children receive a “free and appropriate public education” (FAPE) in the “least restrictive environment” (LRE). Both the ADA and Section 504 are managed by the Office for Civil Rights; the focus of both is to ensure that all students have an equal opportunity to benefit from the educational opportunities available to students in a given school. ADA is broader since Section 504 only pertains to school districts that receive federal funding. Section 504 services apply to any person who has a “physical or mental impairment which substantially limits a major life activity” so schools often attempt a 504 plan for students with disabilities minimally impacting educational progress. Students qualifying for a 504 plan may receive special accommodations to help them meet educational requirements, usually within regular school classrooms.

The Individual with Disabilities Education Act (IDEA)

For students with more severe psychiatric disorders, additional safeguards have been provided by Public Law 94–142 (1975), revised as the Individual with Disabilities Education Act (IDEA), and most recently reauthorized in 2004 (technically as the Individual with Disabilities Improvement Act). IDEA extended a free appropriate public education to students with disabilities, mandating specialized instruction and related services if necessary to meet these students’ unique needs. The IDEA defines “children with disabilities” to mean children with autism; deaf–blindness; deafness; emotional disturbance; hearing impairment; mental retardation; multiple disabilities; orthopedic impairment; other health impairment (ADHD historically has been included in this category); specific learning disability; speech or language impairment; traumatic brain injury; and visual impairment, including blindness. IDEA defines “emotionally disturbed” (previously called “serious emotional disturbance”) as a condition having one or more of the following over a long period of time, to a marked degree, and which adversely affect educational performance: An inability to learn that cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers

and teachers; inappropriate types of mood or behavior under normal circumstances; a general mood of unhappiness or depression; or a tendency to develop physical symptoms or fears associated with personal or school problems.

TABLE 7.2.3 FRAMEWORK FOR EVALUATING A SCHOOL

School Component	What to Observe	Potential Questions for Staff
School building	Safety/security: Does the building appear safe? Is the building comfortable (temperature, chairs beyond desks, lighting, noisy)? Does the building prize students (student art on the walls, recognition of student achievements, evidence of parent–teacher alliance)? Is this a place a child would want to be in?	How does one enter/exit the building? Where do students go if they are having a hard time? Where are students’ classwork or projects kept or displayed? What happens after school is over? Do students stay in the building before or after school?
Classrooms	What do classrooms look like? How big is the room? How many students are in this room, and how many adults? How many learning areas are there, and are they separated so children can be in a quiet place within the classroom? How stimulating (visual, auditory, tactile) is this classroom, and do the students appear over/understimulated?	What’s the average number of students in each classroom? How are teachers encouraged to set up their classroom? If a student is having a hard time in the classroom, where does he/she go? How did you (teacher) decide what to put up in your classroom?
School atmosphere	How is a stranger greeted? Does the school seem organized for students or for staff? Do most students appear engaged with instruction (students within classrooms, alert, attentive, answering/asking questions)? How do students and staff interact (smiling, directives, calm, tense)? Do children thrive here?	Whom should I meet when I enter the building? How do students move between classes/to lunch/recess? What do students do when they’ve finished classroom assignments? What do staff expect from students here? What do staff most worry about here regarding students?
School staff Administrators	Are administrators present/accessible? What kind of tone/impression does the administrator convey? Do staff appear comfortable around the administrator? Who does this administrator best serve (students, teachers, parents, other administrators)? What led to this administrator being selected for this building (student needs, up/down move for this administrator)?	What kind of interactions does the administrator have with students (discipline, earned reward time, common interests discussed in halls/lunch)? What is the administrator’s priority in this building? What do staff seek from the administrator (support, camaraderie, ideas, discipline, avoidance)?
Teachers	Do teachers want to be in this school (eager to be with students or staff)? Do teachers stay in this building? How do teachers engage students (time to work, demonstrate content, model enthusiasm, surprise students)? How often do teachers alter the instructional approach (every 10 minutes, something different [lecture, student reading, class discussion], or employ different modalities [visual, auditory, tactile] employed during instruction?	How many teachers left this building last year? Average over the last several (5) years? What is the student: teacher ratio? What’s the average length of time teachers have been in this district/building? How many teachers here have advanced (masters, doctoral) degrees? What kind of teachers do best in this school (independent, orderly, collaborative, creative)?
Special staff	Are other school staff present? How do teachers and other school staff interact (take student out, coteach, friendly/tense)? How do teachers describe other staff (particularly contributions of special educators)?	What kind of special educational staff work here? How often are they in this building (always, weekly)? What kind of other teachers are in the classroom (parent aides, “paraprofessional” aides)? Do they work with particular students, with everyone in the classroom….?
Support staff	Are support staff friendly? Do they appear open about discussing the school and students? Do support staff work well with other staff?	What kind of support staff are in this building? How long have most of them been here? How are support staff paired with other staff?

TABLE 7.2.4 SCHOOL SERVICE PLANS FOR STUDENTS WITH PSYCHIATRIC DISORDERS

Type of School Service Plan	District Service Plan	504 Plan	Individualized Educational Plan (IEP)
Purpose	To respond quickly to mild changes in the student’s life that impact learning; focus is on mild and/or brief circumstances that may impact learning	To ensure that all students have equal opportunity to learn, even if they have a disability; focus is student’s opportunities as compared to other students in that school	To remediate symptoms of a student’s disability; student’s unique needs are the focus
Criteria to receive this plan	Student has a symptom or disorder that impacts learning	Student has an impairment that limits a major life activity, but may not require specialized instruction	Student has a disability which interferes with educational progress, and which requires specialized instruction
Who develops this plan	Teacher and administrator, usually with parental input	Teacher, administrator (often the school’s designated 504 coordinator, school counselor and usually parent, student (if appropriate)	Educational team, including staff certified in special education; may include evaluations by school psychologist, social worker; parent may bring friends, advocates, own evaluators to be part of team
What is usually provided	Changes within classroom to enable student to perform better	Changes within classroom or school building to enable student to complete curriculum expectations	Changes within classroom setting(s) to provide student different instruction, and may substantially alter what is required of student
Example of what is provided	Student is allowed to sit closer to teacher during instruction; student is met by familiar staff to decrease anxiety	Student is allowed more time to complete tests; Student may be provided device to hear better	Student may leave regular language arts class and receive specialized reading program; student may be exempted from course requirements
Which staff deliver services	Usually regular education staff	Usually regular education staff	Staff with specialized training (special education teachers, speech therapists, occupational therapists)
Where the student receives services	Regular classroom	Regular classroom with regular peers “to the maximum extent appropriate”	Wide ranging, from regular education classrooms (inclusion) to pullout for special education classrooms, to offsite day school programs, to 24 hr/day residential schools
Review of the plan	As needed	Plan reviewed at least every year	At least every year plan is reviewed, and every 3 years the student is retested to see if still qualifies
Disciplinary actions	Usually not applicable	If “manifestation hearing” indicates student’s impairment or disability caused misbehavior, then student cannot be suspended/expelled; school is not required to provide free, appropriate education for suspended or expelled students	If “manifestation hearing” indicates student’s disability caused misbehavior, then student cannot be suspended/expelled; if student is suspended or expelled, school must still provide free, appropriate education
Appeal recourses	None provided	School may alter 504 plan immediately should circumstances indicate need; “notice” may be provided verbally; family may appeal to the Office for Civil Rights if perceive school is discriminating against child because of a disability	School must provide “prior written notice” before changes in educational plan or placement are made; family may appeal decisions or plan to local, then state, departments of education