Abstract and Keywords
Approximately 10–20% of students experience a mental health problem during their school-age years. The Every Student Succeeds Act (ESSA) assumes school-based mental health providers will serve these students in schools. The DSM-5 made five significant changes from previous editions. Enabling students with mental disorders to be eligible for school-based services requires familiarity with the assessment requirements of the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act. School counseling can be provided using a multitiered system of supports ranging from universal prevention to intensive intervention. The best way to serve students is to collaborate with teachers, parents, community providers, and even school administrators. Finally, students’ progress toward general education goals should be monitored regularly so that they can graduate on time, become employed, and be engaged citizens.
Keywords: DSM-5, Every Student Succeeds Act (ESSA), Individuals with Disabilities Education Act (IDEA), multitiered systems of support (MTSS), research domain criteria (RDoC), progress monitoring, school-based mental health providers, Section 504, specialized instructional support personnel (SISP), wrap-around planning
This book is premised on the idea that schools have become the default mental health providers for children and adolescents (Atkins, Hoagwood, Kutash, & Seidman, 2010). The broad audience for this book is school-based mental health providers. The Every Student Succeeds Act (ESSA) defines this group as follows:
The term “school-based mental health services provider” includes a State-licensed or State-certified school counselor, school psychologist, school social worker, or other State licensed or certified mental health professional qualified under State law to provide mental health services to children and adolescents. (Section 4102(6), emphasis added)
It therefore includes school-employed mental health practitioners as well as school-contracted mental health practitioners. This book’s narrow audience is school social workers and clinical social workers working primarily in schools. It is written from a social work perspective for social workers. This book is not aimed at mental health practitioners who are primarily community-based, but they may find it helpful when collaborating with a public school. Some examples from my own career in schools may be helpful. While working in the borough of Brooklyn, New York, I was employed to work in a community-in-schools program which had a contract to provide mental health services to students in grades 6–8 who were labeled with a severe emotional disturbance. I knew all of the special education teachers, the (p.2) special education coordinator, and the other mental health professionals in the building. Since my primary caseload and my office were in the school, I was a school-based mental health services provider. After I left that agency, I worked for a child guidance center in the borough of Queens, New York. One day per week, I did mental health consultation at Hillcrest High School, which had 5,000 students and one part-time school social worker. I knew only a few students, the school secretary, school principal, and most of the mental health providers in the building. Since my primary caseload and my office were in the community, I was really a community-based mental health services provider using a clinical, not a systems model. After moving to Chicago, I worked in three suburban school districts as a school-employed social worker. For the first time, I knew all of the students in my school, all of the teachers, and all of the staff. My role was thoroughly integrated into the life of the school. Since my primary caseload and my office were in a school, I was once again a school-based mental health services provider. The term “school-based mental health services provider” is not, however, synonymous with the new term for related services personnel, now called specialized instructional support personnel (SISP). The ESSA defines that group later in the statute as follows:
The term “specialized instructional support personnel” means—
(i) school counselors, school social workers, and school psychologists; and
(ii) other qualified professional personnel, such as school nurses, speech language pathologists, and school librarians, involved in providing assessment, diagnosis, counseling, educational, therapeutic, and other necessary services (including related services as that term is defined in section 602 of the Individuals with Disabilities Education Act) as part of a comprehensive program to meet student needs. (Section 8002(47)(A), emphasis added)
It may help to visually illustrate this complicated relationship using a Venn diagram (Figure 1.1). The advantage I experienced as a school-based mental health provider and as a member of the SISP team was perspective—I knew the rhythms and harmonies of the school and could see systemic issues that needed to be addressed when the beat was disrupted or the music was discordant.
This chapter summarizes the need for mental health services in schools, recent changes in the field of mental health diagnosis, and the process of making students eligible for services. It then addresses school-based mental health assessment and levels of available service. It also addresses how to collaborate with others in the school environment who are instrumental in helping youth improve their mental health. It ends with a comparison of evidence-based practice standards under No Child Left Behind Act (NCLBA) and the ESSA.
Prevalence of Youth Mental Health Problems
The prevalence of mental disorders among youth depends, in part, on who you ask and how you ask. According to the latest US government statistics, in 2013, slightly more than 5% of children were reported by their parents as having “serious difficulties with emotions, concentration, behavior, or being able to get along with other people” (Federal Interagency Forum on Child and Family Statistics, 2015, p. 61). That may be an optimistic assessment. Of youth aged 12–17, 11% report having had a major depressive episode in the past year. Despite this discrepancy, there is some good news. Parents reported that increased use of special education resources for emotional and behavioral difficulties has gone up from 5.4% in 2001 to 10% in 2013. Likewise, parental contact with a mental health professional (including clinical social workers) went up from 15% in 2001 to 20.1% in 2013. Still, only 38.1% of youth with a major depressive episode received treatment.
(p.4) A recent report from US Centers for Disease Control and Prevention (CDC) revealed that 7.5% of American children are on mental health medications (Howie, Pastor, & Lukacs, 2014). The authors note that “over the past 2 decades, the use of medication to treat mental health problems has increased substantially among all school-aged children and in most subgroups of children” (p. 5). Some authors place the prevalence rate for mental disorders for children in the United States as high as 20% (Younger, 2017), while others believe that such numbers are inflated by mis- and overdiagnosis (Merten, Cwik, Margraf, & Schneider, 2017). Probably the best estimate is that 10% of students have a diagnosable mental disorder, but that only 2% are served by schools and even fewer are served by community agencies (Eber, Malloy, Rose, & Flamini, 2014).
Estimates of prevalence rates for mental health problems among children and adolescents are always a little murky (Holbrook, Bitsko, Danielson, & Visser, 2016). Some of the problems are systemic. When the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) (American Psychiatric Association [APA], 2013) lowered its clinical thresholds on a number of disorders, more children were diagnosed with a mental disorder than previously (Mikolajewski, Scheeringa, & Weems, 2017). As implied earlier, data sources and survey techniques make a difference. Using estimates based on insurance claims omits those families who do not have insurance or live in underserved areas. How one phrases the question changes the answer. For example, the Individuals with Disabilities Education Act (IDEA) dropped the term “serious” from emotional disturbance in the 1997 revision to make more children eligible for special education services. Words matter.
Major Changes to the DSM-5
The DSM has been around for more than 65 years. The first edition (1952) mentioned 94 mental disorders, and the second edition (1968) nearly doubled this number to 182. The third edition (1980) jumped to 265 disorders, and the DSM-IV had 340 mental disorders (Pomeroy & Parrish, 2012). While the new DSM-5 is not expected to increase the number of disorders, it is important to note that some disorders have been combined and others have been split. As mentioned earlier, the changes to the DSM-5 have real-life consequences for children and adolescents. While the APA mentioned nine “enhancements” in its introduction to the new manual, this chapter will address the five most important ones for social workers.
The first major change is the dropping of the multiaxial system. DSM-5 combines the first three axes into one list that contains all mental disorders (p.5) (including personality disorders and intellectual disability) as well as other medical diagnoses (APA, 2013). Axes IV and V have simply disappeared. This probably follows psychiatrists’ tendency to ignore Axes IV anyway, but this poses a problem for many social workers (Probst, 2014). Axis IV was the only opportunity to discuss psychosocial or environmental factors that caused or contributed to a mental disorder. The new edition does make a slight change in wording to its definition of a mental disorder:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (APA, 2013, p. 20, emphasis added)
The APA (2013) was aware of many of these criticisms so it suggested a potential solution. It recommends that clinicians use “a selected set of the ICD-CM V codes and the new Z codes contained in ICD-10-CM” (p. 16). Walsh (2016) has explored how this might work. He notes that four of the Axis IV categories were already represented in the V codes (e.g., academic problem or parent–child problem) and that the number of Z codes has grown from 23 to 118. Some of the categories of Z codes of most interest to social workers engaged with children and adolescents include problems related to family upbringing, child abuse and neglect, educational problems, housing and economic problems, and problems related to the social environment.
The one exception to relegating environmental issues to the Z codes is a new chapter on trauma- and stressor-related disorders in the DSM-5. This chapter includes reactive attachment disorder (newly defined), disinhibited social engagement disorder (new), posttraumatic stress disorder, acute stress disorder, and adjustment disorders. It is within this last diagnostic category that the DSM-5 allows that “individuals from disadvantaged life circumstances experience a high rate of stressors and may be at increased risk for adjustment disorders” (APA, 2013, p. 288).
(p.6) Axis V was the only place to identify strengths (functioning) of the individual being diagnosed. Without these two axes, the DSM reverts back to a biologically driven, deficit-based model of mental illness. The Society for Humanistic Psychology (Division 32 of the American Psychological Association) wrote an online open letter about similar concerns and garnered more than 15,000 individual signatures and the official support more than 50 professional associations, but not that of the National Association of Social Workers. Here is an excerpt from the petition:
In light of the growing empirical evidence that neurobiology does not fully account for the emergence of mental distress, as well as new longitudinal studies revealing long-term hazards of standard neurobiological (psychotropic) treatment, we believe that these changes pose substantial risks to patients/clients, practitioners, and the mental health professions in general. (Society for Humanistic Psychology, 2011)
The new DSM-5 has replaced the strengths-based global assessment of functioning (GAF) measure with the deficit-based World Health Organization (WHO)’s Disability Assessment Schedule (WHODAS, version 2.0). While this aligns with the International Classification of Functioning, Disability and Health system, it completely eliminates any strengths-based focus in the DSM-5.
The second major change was to harmonize the DSM-5 with the International Classification of Disease (ICD) system, specifically ICD-11. One of the consequences of this decision was to eliminate the DSM-IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence. All of the disorders listed therein have been redistributed into other clusters, reflective of a new lifespan approach to mental disorders. For example, attention deficit hyperactivity disorder (ADHD) is now placed with the neurodevelopmental disorders, such as autism spectrum disorder and specific learning disorder. It is significant that this change moves it away from disruptive behavior disorders, which are discussed in a different chapter (Sethi, 2015; Sharma, 2014). After the neurodevelopmental disorders, the DSM-5 is organized by internalizing disorders and externalizing disorders. This reorganization not only makes the diagnoses for children and adolescents more difficult to locate, it also subtly suggests that these disorders will continue into adulthood. Perhaps this is due to the fact that two-thirds of children with a mental disorder do not get the help they need, and the one-third that do (p.7) receive help get it through their local school—most likely from a school social worker (Raines, 2008). The assumption, however, that mental disorders are lifelong is a pessimistic prognosis about the possibility for improvement.
The third major change is the elimination of the “not otherwise specified” (NOS) categories. This is accomplished in three ways. First, this reduction is accomplished by combining diagnoses. For example, the new autism spectrum disorder (ASD) now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. This change was highly controversial for people who were diagnosed with high functioning autism because they did not wish to be lumped together with people who were lower functioning (Linton, Krcek, Sensui, & Spillers, 2014; McLaughlin & Rafferty, 2014). Likewise, specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Second, this reduction is accomplished by creating new diagnoses. For example, the DSM-5 now includes hoarding disorder, excoriation (skin-picking) disorder, disruptive mood dysregulation disorder, and disinhibited social engagement disorder. The increase in child-related disorders, however, has some professionals worried. The Society for Humanistic Psychology (2011) states that it is “gravely concerned about the introduction of disorder categories that risk misuse in particularly vulnerable populations” and explicitly mentions disruptive mood dysregulation disorder for children as a case in point. The final method for reducing NOS diagnoses is to replace them with two options: other specified disorder and unspecified disorder. The first allows a practitioner to specify the reason that the criteria for a disorder are not met; the second allows a practitioner the option to forgo any specificity.
The fourth major change is the addition of dimensional aspects to diagnostic categories. At this point, some history is in order. Some of us have been practicing long enough to remember the DSM-III (1980). That edition of the DSM was predicated on the belief that each mental disorder
would ultimately be validated by its separation from other disorders, common clinical course, genetic aggregation in families, and further differentiation by future laboratory tests—which would now include anatomical and functional imaging, molecular genetics, pathophysiological variations, and neuropsychological testing. (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 645)
(p.8) Thus, the goal of the DSM-III was to initiate a scientific taxonomy that would be validated by current medical procedures. The primary goal of the new DSM-5 is not much different. The committee aimed “to produce diagnostic criteria and disorder categories that keep pace with advances in neuroscience” (Regier, Narrow, Kuhl, & Kupfer, 2011, p. 21).
Thus, the dimensional approach was a response to the overly optimistic wish that every patient would fit neatly into a clear diagnostic category. In the DSM-III, this led to what Regier (2007) calls a “Chinese-menu approach” where the presence of a disorder would be founded on meeting a certain number of criteria (e.g., 5 out of 8) from a longer list of symptoms. The DSM-III also introduced a hierarchical system that precluded the diagnosis of a lower level disorder if the same client met the criteria for a higher level disorder. Thus, it viewed clients through a reductive lens to preclude the possibility of comorbid disorders.
This problem was partially corrected in DSM-IIIR and DSM-IV, but each diagnosis was compartmentalized in such a way that any patient was likely to be labeled with several distinct disorders. Clinicians can now add dimensions or aspects to diagnoses such as ADHD, major depression, or schizophrenia. The dimensional approach is an attempt to avoid the reductionism of a single diagnosis for a complex problem as well as to avoid the problems of multiple diagnoses. As the DSM-5 concedes,
[i]ndeed, the once plausible goal of identifying homogenous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity with disorders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like more common human ills, mental disorders are heterogeneous at many levels, ranging from genetic risk factors to symptoms. (APA, 2013, p. 12)
For example, the following dimensions may now be added to widely divergent diagnoses: symptom severity, duration (acute or chronic), symptoms outside of the primary diagnosis (e.g., “anxious distress,” catatonia, or suicidality), sleeping or eating habits, cognitive factors, substance use, psychosis, relationship history, and degree of insight.
The fifth major change is diminution of the bereavement exclusion. First, although the DSM-5 explicitly rejects the idea that bereavement typically lasts (p.9) only 2 months (as in DSM-IV), it now allows the diagnosis of major depression after only 2 weeks. Second, the DSM sees bereavement as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual. Third, it argues that bereavement-related major depression is most likely to occur in individuals with past personal and family histories of depression. Finally, it argues that bereavement-related depression responds to the same psychosocial and medication treatments as depression.
Social work professor Joanne Cacciatore (2012) objects, however, that bereavement does not need to be cured. She works with parents who have lost a child—certainly the most heart-wrenching pain any parent can imagine (Hone, 2017). What can any professional do to heal their hurt? Many people simply cannot tolerate being present while another grieves—they want to say or do the right thing, and psychiatrists are no different, but what is intolerable is turning normal sorrow into a psychiatric disorder (Horwitz & Wakefield, 2007; Paris, 2013). Robbins (2014) calls this change “the medicalization of normal or distressing life experiences” (p. 203). The medical establishment, however, views death as the enemy and pain as bad. Anyone who needs to embrace death as part of life must be viewed as sick or mentally ill. The real problem is the medical profession’s dis-ease with death and pain, and this discomfort demands quick fixes in the form of medication, evidently a solution that psychiatry is only too happy to fulfill.
The APA must have felt the sting of this criticism because it responded in two ways. First, it repeated its differentiation of major depressive episode from grief three times throughout the manual (pp. 126, 134, 161). The table shows a brief side-by-side comparison of the two conditions:
(p.10) Second, it moved persistent complex bereavement disorder to chapter three, “Conditions for Further Study.” That chapter is focused on issues for which future research is needed and not for clinical use at this time. Social workers wanting to know more about possible future diagnostic categories may want to familiarize themselves with this chapter, but are advised against using any of those categories at this time.
Child and Adolescent Diagnostic Changes
Most social workers are ambivalent about giving psychiatric diagnoses to clients. Many clinicians only give a diagnosis to receive financial reimbursement for services rendered (Lacasse, 2014; Probst, 2013; Robbins, 2014). This puts many social workers into an ethical dilemma: on one hand, they want to obtain needed services for their clients; on the other hand, they wish to preserve the dignity of their clients by avoiding the stigma of a mental disorder (Phillips, 2013; Probst, 2013). Thus, social workers should carefully consider whether or not to utilize some of the more debatable changes and diagnostic categories.
ADHD: (1) The cross-situational requirement has been strengthened to “several” symptoms in each setting, (2) the onset criterion has been changed to “several inattentive or hyperactive impulsive symptoms were present prior to age 12 [versus age 7],” (3) subtypes have been replaced with presentation specifiers, (4) the threshold of symptoms has been lowered from six to five for older adolescents, and (5) a comorbid diagnosis with ASD is now allowed. A conservative approach to diagnosis would maintain the age of onset at prior to 7 years and consider other diagnoses (e.g., trauma-related disorders) for attentional problems occurring later (Frances, 2013).
ASD: Combines eight previous disorders into one category (McBride, 2015). Instead of three main criteria being used, the new edition combines these into two: (A) persistent deficits in social communication or social interaction and (B) restricted, repetitive patterns of behavior, interests, or activities. The 2016 update clarifies that criterion A must apply to all of the following three subcriteria. The text clarifies that individuals previously diagnosed with Asperger’s disorder, autistic disorder, and pervasive developmental disorder (NOS) should be included so that students should not lose their eligibility for services.
Communication Disorders: Includes language disorder (which combines expressive and mixed receptive-expressive language disorders), speech (p.11) sound disorder (a new name for phonological disorder), and childhood-onset fluency disorder (a new name for stuttering). Social (pragmatic) communication disorder (often found in Asperger’s disorder) has also been added. This may allow students diagnosed with ASD to also receive speech and language services.
Intellectual Disability: Replaces the term “mental retardation” in alignment with the American Association on Intellectual and Developmental Disabilities and the US Department of Education. It also aligns with Rosa’s Law (P.L. 111-256). Most importantly, the DSM-5 criteria move away from relying exclusively on IQ scores and toward using additional measures of adaptive functioning. DSM-IV criteria had required an IQ score of 70 as the cutoff for diagnosis. The new criteria only recommend IQ testing and use of “deficits in adaptive functioning” as the primary means to determine if the individual has failed to meet standards for personal independence and social responsibility (Raines, 2009).
Separation Anxiety Disorder: This is now classified as an anxiety disorder. The wording of the criteria has been modified to represent the expression of separation anxiety symptoms in adulthood. The diagnostic criteria no longer specify that age at onset must be before 18 years.
Selective Mutism: This is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious. It also rules out English language learners from this diagnosis.
Reactive Attachment Disorder: The DSM-IV reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited. In DSM-5, these subtypes are distinct disorders: reactive attachment disorder and disinhibited social engagement disorder. Reactive attachment disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed attachments to caregiving adults.
Gender Dysphoria: The DSM-IV’s gender identity disorder has been replaced by the new term “gender dysphoria.” It has separate criteria for children and adolescents. Being transgender, by itself, is insufficient reason to diagnose a student. It must be accompanied by significant distress or impairment in social, occupational, or other areas of functioning. It is also not clear why a posttransition specifier would ever be needed because one would hope that after a sex-change operation was performed, the person would no longer be dysphoric about his or her gender.
(p.12) Clinical social workers are by far the largest constituency of mental health professionals, comprising more than 100,000 potential users of the DSM-5 (Bureau of Labor Statistics, 2013; Manderscheid & Berry, 2006). By contrast there are only 33,000 psychiatrists. According to John Oldham (2011), President of the American Psychiatric Association, however, only one social worker was present out of the 160 professionals who served on 13 different DSM-5 committees, while there were 97 psychiatrists. This means that social work representation was 0.6% while psychiatric representation was 60%! Yet Oldham makes the amazing claim that there was sufficient variety “to achieve a diversity of opinion” (p. 2). If the APA was organizing a multiracial gathering, we would call this tokenism.
One final caution: the DSM-5 was published with many errors in the original manual (including coding errors). Users should download the most recent updates (i.e., APA, 2016) from https://www.psychiatry.org/psychiatrists/practice/dsm to ensure that they are working with the most up-to-date version. This is the reason that Raines (2014) recommended that social workers download the app rather than purchase the book.
Some social workers have observed that the National Institute for Mental Health (NIMH) has stopped using the DSM-5 to fund mental health research (Probst, 2014). While many might find reason to celebrate the end of the APA’s hegemony in the field of mental diagnosis, social workers should be aware that the NIMH’s Research Domain Criteria (RDoC) has issues of its own (Box 1.1). (p.13) (p.14)
Eligibility for School-Based Treatment
Raines (2013) described four phases in the development of American schools, starting with “grammar” schools in late eighteenth and early nineteenth centuries, the establishment of “common” schools during the Industrial Revolution, “compulsory” education that accompanied child labor laws, and, finally, “inclusive” education that embraced children with special needs in the late twentieth century. Eligibility for students with disabilities is found in two major federal statutes: the IDEA and Section 504 of the Rehabilitation Act.
Individuals with Disabilities Education Act
Most children with severe and persistent mental disorders should be covered under the 2004 IDEA. Education of children with an “emotional disturbance” was part of the Education of All Handicapped Children’s Act of 1975 (P.L. 94-142) and was reauthorized as the IDEA in 1990, 1997, and 2004. As mentioned earlier, the requirement was that the disability had to be “severe,” but the definition never changed. An important requirement was that an emotional disturbance had to negatively affect school performance:
A condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance:
(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.
(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. (34 C.F.R. Section 300.8(c)(4)(i), emphasis added)
As defined by IDEA, emotional disturbance includes schizophrenia but does not apply to children who are “socially maladjusted,” unless it is determined that they also have an emotional disturbance. Clearly, this definition does not mesh well with the APA’s (2013) definition of a mental disorder presented earlier, which does not require an adverse effect on educational performance (Tobin & House, 2016), but it is apparent from characteristic (B) that IDEA means to include both internalizing and externalizing disorders.
The term has never been defined in the legislation nor in the federal regulations. Some experts have tried to differentiate between the two categories based on volition—those who were emotionally disturbed were viewed as driven by their own emotional problems while those who were socially maladjusted were viewed as deliberately choosing to engage in acts of delinquency. This distinction is untenable for three reasons. One is that both interpersonal theory and communication theory see all behavior as communicative. Secondly, these theories form the basis for completing functional behavioral assessments by which schools are mandated to determine the purpose of a child’s misbehavior regardless of diagnosis. Third, a trauma-informed approach views acting out as a natural reaction to adverse childhood experiences that are beyond the student’s control. (SSWAA, 2017)
A fourth objection might be added. The APA (2013) is specifically agnostic about whether there are volitional aspects of having a mental disorder:
A diagnosis does not carry any necessary implications regarding the etiology or causes of the individual’s mental disorder or the individual’s degree of control over behaviors that may be associated with the disorder. . . . Even when diminished control over one’s behavior is a feature of the disorder, having the diagnosis in itself does not demonstrate that a particular individual is (or was) unable to control his or her behavior at a particular time. (p. 25)
Section 504 of the Rehabilitation Act
Although not as commonly used for mental disorders as emotional disturbance for IDEA, Section 504 of the Rehabilitation Act of 1973 provides eligibility for a broader range of students than does IDEA. It was amended by the Americans with Disabilities Act Amendments Act of 2008 (ADA Amendments Act), effective January 1, 2009. Unlike IDEA, it does not come with any federal funds attached, so schools always prefer to use IDEA when they have a choice. Section 504 covers anyone who has a physical or mental impairment that substantially limits one or more major life activities. Major life activities include “walking, seeing, hearing, speaking, breathing, learning, working, caring for oneself, and performing manual tasks” (34 C.F.R. Section (p.17) 104.3(j)(2)(ii), emphasis added). Thus, Section 504 is more inclusive than IDEA in its scope and can be used to provide services to students with severe and/or persistent mental disorders even if they do not adversely affect school performance (Figure 1.2).
Impairment is defined as follows:
Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive; digestive; genito-urinary; hemic and lymphatic; skin; and endocrine; or any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. (US Department of Education, 2015, emphasis added)
One of the important changes made to Section 504 when it was amended in 2009 is that most “transitory” impairments are no longer covered. “Transitory” is defined as lasting less than 6 months. Thus, adjustment disorders probably can no longer be covered under Section 504. It is still possible, however, that students with adjustment disorders can still be covered under the multitiered systems of support (MTSS) discussed later.
Some students, however, can be covered for temporary disabilities so long as these disabilities are deemed “substantial.” This determination is made on a case-by-case basis, taking into consideration both the extent to which the (p.18) disability actually limits a major life activity and the duration (or expected duration) of the impairment. This may be especially useful for debilitating short-term disorders, such as brief psychotic disorder, major depressive disorder, separation anxiety disorder, and acute stress disorder.
Tobin and House (2016) raise the question about who is qualified to diagnose a student with a mental disorder. Generally, a mental health professional working in a school should have three qualifications: (1) a graduate degree with specific training in the ethics and skills of psychiatric assessment and diagnosis, (2) experience with regular clinical supervision by another mental health professional in the same discipline, and (3) clinical credentials (usually requiring a clinical examination) provided by a state or national board. Those school-based providers lacking these three qualifications should seek to obtain them to provide the most comprehensive services to youth with emotional disturbances.
Tobin and House (2016) warn, however, that some states mandate that only a physician or medical provider can diagnose for certain educational categories, such as Other Health Impaired, which is defined as follows:
Having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that—(a) is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis [a kidney disorder], rheumatic fever, sickle cell anemia, and Tourette syndrome; and (b) adversely affects a child’s educational performance. (34 C.F.R. Section 300.8(c)(9), emphasis added)
Thus, school social workers would be best advised to consult their state education agencies to determine whether such limitations exist in their respective states.
Mental Health Assessment
Under IDEA, assessment has both procedural and content requirements. The US Department of Education (2007) outlines 10 steps to meet the due process requirements. Additional comments are [bracketed]:
Step 1. Child is identified as possibly needing special education and related services. Referrals are typically made by an education professional or a parent.
Step 2. Child is evaluated. This assessment must evaluate all of the areas related to the child’s suspected disability. [A comprehensive evaluation should be multimodal and multi-informant.]
Step 3. Eligibility is decided. The multidisciplinary professionals and the parents form the Individualized Education Program (IEP) team and collaborate to make this determination. A hearing may be requested if there is no agreement.
Step 4. Child is found eligible for services. Within 30 calendar days after a child is determined eligible, the IEP team must meet to write an IEP for the child.
Step 5. IEP meeting is scheduled. School personnel must:
• contact the participants, including the parents;
• notify parents early enough to make sure they have an opportunity to attend;
• schedule the meeting at a time and place agreeable to parents and the school;
• tell the parents the purpose, time, and location of the meeting;
• tell the parents who will be attending; and
• tell the parents that they may invite people to the meeting who have knowledge or special expertise about the child.
Step 6. IEP meeting is held and the IEP is written with annual measurable goals. Before the school system can provide special education and related services [e.g., social work services] to the child for the first time, the parents must give consent.
Step 7. Services are provided. Parents are given a copy of the IEP. The child’s teachers and service providers [e.g., social workers] have access to the IEP and know their specific responsibilities for carrying out the IEP. This includes the accommodations, modifications, and supports.
Step 8. Progress is measured and reported to parents. Parents are regularly [usually quarterly] informed of their child’s progress and whether that progress is enough for the child to achieve the goals by the end of the year.
Step 9. IEP is reviewed. The child’s IEP is reviewed by the IEP team at least once a year, or more often if the parents request a review.
Step 10. Child is reevaluated. At least every 3 years the child must be reevaluated. This evaluation is often called a “triennial.”
(p.20) The US Department of Education (2007) also specifies the content requirements of each IEP. There are also 10 required components.
1. Present level of performance. The IEP must state how the child is currently doing in school [strengths and weaknesses]. This information usually comes from classroom tests and assignments, individual tests given to decide eligibility for services, and observations made by parents, teachers, or related service providers.
2. Annual measurable goals. These are goals that the child can reasonably accomplish in a year. The goals are broken down into short-term objectives or benchmarks. Goals may be academic, physical, social, behavioral needs [especially those that impede the learning of self or others], or other educational needs [e.g., limited English proficiency].
3. Special education and related services. The IEP must list the special education and related services [e.g., counseling or therapy] to be provided to the child. This includes supplementary aids that the child needs. It also includes accommodations [adaptations to meet standards] or modifications [changes that reduce standards].
4. Least restrictive environment. The IEP must explain the extent (if any) to which the child will not participate with nondisabled children in the regular class and other school activities.
5. Participation in state- and district-wide tests. Most states and districts give achievement tests to children in certain grades or age groups. The IEP must state what accommodations [e.g., extra time] in the administration of these tests the child will need.
6. Dates and places. The IEP must state when services will begin, how frequently they will be provided, where they will be provided, and how long they will last.
7. Transition planning. Beginning when the child is age 14, the IEP must address (within the relevant parts of the IEP) the transition services he or she needs to take to reach his or her post-high school goals.
8. Transition services. Beginning when the child is age 16, the IEP must state what transition services are needed to help the child prepare for leaving school.
9. Age of majority. Beginning at least 1 year before the child reaches the age of majority [usually 18], the IEP must include a statement that the student has been told of any rights that will transfer to him or her at the age of majority.
Social Developmental Study
If the referring problem is about social, emotional, or behavioral issues, then a social developmental study should be performed by a social worker. First, as mentioned in Step 2 earlier, this assessment should be multimodal, based on interviews, rating scales, and direct observation in the classroom. Second, this assessment should also be multi-informant, based on information from the teacher(s), parent(s), and child. Third, the assessment should inquire about the student’s performance in multiple settings: home, school, and community. Finally, it must include statements about the child’s strengths as well as weaknesses (Gleason, 2007; Nickerson & Fishman, 2013; Raines, 2008).
The social developmental study should begin with a parental interview with questions about prenatal development, early developmental milestones, family characteristics, child characteristics, and the school environment (Raines, 2003). Self-rating scales should include the 10-item ACEs questionnaire (https://acestoohigh.com/got-your-ace-score/). This is especially important due to our increased understanding of how epigenetics affects mental health (Box 1.2). Two excellent broad multi-informant strengths-based measures are the Behavioral and Emotional Rating Scale, 2nd edition (BERS-2; Epstein, 2004) and the Social Skills Improvement System (SSIS; Gresham & Elliott, 2008). Social workers can also use the Devereux Student Strengths Assessment (DESSA; LeBuffe, Shapiro, & Naglieri, 2009). Direct observation of the student within the classroom milieu should compare the referred student to an index peer (Massat & Sanders, 2009) and may use a standardized measure, such as the Behavioral Assessment System for Children (BASC) student observation system (Lett & Kamphaus, 1997).
Functional Behavioral Assessment
Under the IDEA, functional behavioral assessments (FBAs) focus on the purpose or communicative function of a student’s misbehavior. FBAs utilize a person-in-environment framework that relies on direct observation of students within the milieu in which the behavior occurs (Filter & Alvarez, 2011; McIntosh, Brown, & Borgmeier, 2008; Raines, 2002a). This assessment process involves obtaining information about the antecedent environmental conditions that precede the problem behavior and the reinforcing consequences that follow the behavior (What Works Clearinghouse, 2016). (p.22) (p.23) According to IDEA, FBAs must be considered whenever a student’s behavior interferes with learning by self or others. FBAs must be conducted whenever the disciplinary action of a student results in a significant change to his or her educational placement (Zirkel, 2011). A recent meta-analysis of FBAs found that they were more effective when conducted in natural classroom environments rather than pull-out settings (Bruni, Drevon, & Hixson, 2017).
Section 504 Assessments
The US Department of Education (2015) suggests that some kind of testing is needed. It also specifies that tests are carefully selected to match the needs of the student:
Tests used for this purpose must be selected and administered so as best to ensure that the test results accurately reflect the (p.24) student’s aptitude or achievement or other factor being measured rather than reflect the student’s disability, except where those are the factors being measured. Section 504 also requires that tests and other evaluation materials include those tailored to evaluate the specific areas of educational need and not merely those designed to provide a single intelligence quotient. The tests and other evaluation materials must be validated for the specific purpose for which they are used and appropriately administered by trained personnel.
This federal guidance has three implications. First, it requires that school social workers are knowledgeable about a broad range of assessment measures. An excellent resource that school districts may want to purchase is Corcoran and Fischer’s (2013), Measures for Clinical Practice, Volume 1, which has dozens of rapid assessment instruments for children and adolescents. Accordingly, chapter authors in this book have been asked to identify relevant rapid assessment instruments related to the suspected diagnosis of the student. Second, social workers should be mindful to only use tests with established reliability and validity. For example, Ross Greene’s (2014) popular book, The Explosive Child, has an assessment tool, but he admits that it has never been subjected to third-party testing. Finally, any test needs to be administered by a qualified professional. Most MSW-level practitioners will meet the requirements of a Level-B user. Pearson test publishers (Pearson Clinical Psychology, 2017) describe this as follows:
A master’s degree in psychology, education, occupational therapy, social work, counseling, or in a field closely related to the intended use of the assessment, and formal training in the ethical administration, scoring, and interpretation of clinical assessments OR
Formal, supervised mental health, speech/language, occupational therapy, social work, counseling, and/or educational training specific to assessing children, or in infant and child development, and formal training in the ethical administration, scoring, and interpretation of clinical assessments.
Many test publishers will require users to complete a qualification form prior to ordering a test. Ethically, if it has been several years since the social worker completed training in testing and measurement, recertification should be sought via a refresher course from a professional association.
(p.25) The US Department of Education (2015) also recommends that the assessment use multiple informants, “Section 504 regulatory provision at 34 C.F.R. 104.35(c) requires that school districts draw from a variety of sources in the evaluation process so that the possibility of error is minimized.” At the very least, it seems prudent that these sources include teacher(s), parent(s), and the student.
One of the 2009 changes to the law relaxes the requirement that the multidisciplinary committee consider any “mitigating measures” that might reduce the possibility that the student had an impairment that substantially limited that student in a major life activity. The amendments provide a nonexhaustive list of mitigating measures:
The mitigating measures are as follows: medication; medical supplies, equipment or appliances; low-vision devices (which do not include ordinary eyeglasses or contact lenses); prosthetics (including limbs and devices); hearing aids and cochlear implants or other implantable hearing devices; mobility devices; oxygen therapy equipment and supplies; use of assistive technology; reasonable accommodations or auxiliary aids or services; and learned behavioral or adaptive neurological modifications.
Since the only exceptions to mitigating measures appear to be eyeglasses or contact lenses, then it is reasonable to conclude that psychotropic drugs would fall under medication and that psychotherapy provided outside of school would fall under auxiliary services.
Mental Health Intervention
Recently, Kaplan, Tarvydas, and Gladding (2014) reported on a consensus definition of counseling endorsed by 29 professional counseling associations, “Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (p. 366). The American School Counseling Association (ASCA) rejected this definition because it was not distinctive enough to separate counseling from the other mental health professions. In IDEA, however, “counseling services means services provided by qualified social workers, psychologists, guidance counselors, or other qualified personnel” (34 C.F.R., (p.26) Section 300.34(2)). Clearly, counseling is not just performed by school counselors.
While many SISP and perhaps most school-based mental health services providers may think that they are providing psychotherapy rather than counseling, the US Code of Federal Regulations never defines psychotherapy. Ironically, it does define psychotherapy notes:
Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. (45 C.F.R., Section 164.501(2)(vi)(F), emphasis added)
Since it has become increasing common for many school-based mental health services providers to bill Medicaid for their services, many have wondered how the Family Educational Rights and Privacy Act (FERPA) is related to the Health Insurance Portability and Accountability Act (HIPAA). Fortunately, the US Department of Health and Human Services and the Department of Education (2008) issued joint guidance around this issue at https://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa-guidance.pdf. Since the entire 13-page document is easily available online, it will not be reproduced here. The joint guidance does clarify that:
Where a school does employ a health care provider [e.g., clinical social worker] that conducts one or more covered transactions electronically, such as electronically transmitting health care claims to a health plan for payment [e.g., Medicaid], the school is a HIPAA covered entity and must comply with the HIPAA Transactions and Code Sets and Identifier Rules with respect to such transactions. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health information only in student health records that are “education records” under FERPA and, thus, not “protected health information” under HIPAA. Because (p.27) student health information in education records is protected by FERPA, the HIPAA Privacy Rule excludes such information from its coverage. (pp. 3–4, emphasis added)
Finally, it is important to discuss how school social work services should be designated on the IEP. Many practitioners have simply put “social work” on an IEP as if that sufficed for what services should be rendered. Raines and Dibble (2017) point out that the IDEA regulations (US Department of Education, Office of Special Education and Rehabilitative Services, 2006) provide guidance about how this should be done:
The definition of social work services in schools includes examples of the types of social work services that may be provided. It is not a prescriptive or exhaustive list. The child’s IEP team [including parents] is responsible for determining whether a child needs social work services and what specific social work services are needed in order for the child to receive FAPE [free appropriate public education]. (p. 46575, emphasis added)
There are two implications of this guidance. First, the school social workers do not get to choose their own caseload—it is defined by the IEP team. Second, “social work” is an insufficient description of the services provided. There are two reasons for this. It is not uncommon for one social worker to assist in the writing of an IEP and another social worker to provide the actual services, so clear communication is called for. It is also important that all educational professionals be accountable for their actions. Imagine if a teacher simply listed “education” on an IEP—it would be deemed irresponsible. School social workers must be held to the same standards as our colleagues in other professions. Accordingly, the editor has asked each of the chapter authors to reflect on the specific kinds of interventions that are appropriate for children with specific mental health problems.
Multitiered Systems of Support
MTSS is essentially a public health approach to public schools (Box 1.3). With the advent of the new IDEA of 2004, schools were allowed to use a student’s response to intervention as one indicator (among others) that a child might have a learning disability (see Chapter 9). From a public health perspective, schools were expected to meet the needs of 80% of their students through universal prevention programs (Tier 1), 10–15% of the students would need additional targeted/selective support (Tier 2), and 1–5% would (p.28) (p.29) need additional intensive/indicated support (Tier 3) (Batsche et al., 2006). See Figure 1.3.
Tier 1: Universal Services. While most school social workers are employed to work in Tiers 2 and 3, the policy landscape changed with the ESSA (P.L. 114-95) signed by President Obama in December 2015. First, school social workers are not just “related services” providers and relegated to special education. Under Title I, they are “school-based mental health services providers” who are now recognized as SISP who have responsibilities for general education as well. Second, like other school-based mental health providers (school counselors and school psychologists), they have an obligation to contribute to the school-wide program plan that should include “counseling, school-based mental health programs, specialized instructional support services, mentoring services, and other strategies to improve students’ skills outside the academic subject areas” (Section 1008(b)(7)(A)(iii)(I), emphasis added).
(p.30) Also mentioned under Title I are prevention programs for students who are neglected, delinquent, or at-risk. Universal health promotion programs under this part address drug prevention and violence prevention.
Third, under Title II, school-based mental health services providers should also be involved with in-service training of school personnel to educate their colleagues about specific topics:
1. the techniques and supports needed to help educators understand when and how to refer students affected by trauma, and children with, or at risk of, mental illness;
2. the use of referral mechanisms that effectively link such children to appropriate treatment and intervention services in the school and in the community, where appropriate;
3. forming partnerships between school-based mental health programs and public or private mental health organizations; and
4. addressing issues related to school conditions for student learning, such as safety [suicide and violence prevention], peer interaction [bullying], drug and alcohol abuse, and chronic absenteeism [parent engagement]. (Section 2103(b)(3)(I))
Fourth, under Title IV, 21st Century Schools, school districts are authorized to provide evidence-based programs and activities that include:
(i) school-based mental health services, including early identification of mental health symptoms, drug use, and violence, and appropriate referrals to direct individual or group counseling services, which may be provided by school-based mental health services providers; and
(ii) school-based mental health services partnership programs that are conducted in partnership with a public or private mental health entity or health care entity; and provide comprehensive school-based mental health services and supports and staff development for school and community personnel working in the school that are based on trauma-informed practices that are evidence-based . . . coordinated (where appropriate) with early intervening services provided under the Individuals with Disabilities Education Act (20 USC. 1400 et seq.); and provided by qualified mental and behavioral health professionals who are certified or licensed by the State involved and practicing within their area of expertise. (Section 4108 (5)(B))
Thus, the ESSA provides legislative support for school social workers to collaborate with their school- and community-based colleagues to create Tier 1 mental health prevention programs on a macro level (Teasley & Richard, 2017). Interestingly, a meta-analysis found that mental health prevention programs were more effective when delivered by school employees rather than by contracted outside service providers (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). It might be surmised that in-service training equips classroom educators to use teachable moments to cue, shape, and reward appropriate behavior in a way that external providers cannot. Thompson and Cox (2017) identify three steps for a school-wide approach: (1) screening, assessment, and ongoing performance monitoring that provides a contextualized assessment of student risk factors; (2) identifying universal concerns using both aggregated (whole school) and disaggregated (by gender, racial-ethnic, or age) data to inform a school-wide program plan; and (3) implementing a continuum of evidence-based programs at the universal level (e.g., positive behavior interventions and supports [PBIS], social-emotional learning, the Good Behavior Game (aka Pax), etc.).
Tier 2: Targeted/selective Services. Under the IDEA, early intervening services are activities for students in kindergarten through grade 12 who have not been identified as needing special education services but who do need supplemental or academic support. This is where students diagnosed with adjustment disorders might receive services. These services are not to be confused (p.32) with early intervention services that are provided to children younger than age 3 who have been identified as needing special education.
Many schools now use universal screening instruments as gatekeeping mechanisms into Tier 2. Patel and Runge (2011) examined 23 brief screening instruments and identified three screens with high reliability and validity scores. These include the BASC-3 Behavioral and Emotional Screening System (BASC-3 BESS; Kamphaus & Reynolds, 2015), Social Emotional Assets and Resilience Scales—Short Form (SEARS; Merrell, 2011), and the Social Skills Improvement System Performance Screening Guide (Elliott & Gresham, 2008).
It is important that social workers understand the purpose of early intervening services. In the Individuals with Disability Educational Improvement Act (IDEA-2004) (P.L. 108-446), school districts are required to use 15% of their special education funding whenever there is significant disproportionality of racial/ethnic minorities or English learners in special education (US Department of Education, Office of Special Education and Rehabilitative Services, 2005). Thus, providing Tier 2 services is intended to provide more support to disadvantaged or oppressed groups.
This legal mandate authorizes two types of interventions:
• Professional development (which may be provided by entities other than LEAs) for teachers and other school staff to enable such personnel to deliver scientifically based academic instruction and behavioral interventions, including scientifically based literacy instruction, and, where appropriate, instruction on the use of adaptive and instructional software; and
• Providing educational and behavioral evaluations, services, and supports, including scientifically based literacy instruction.
There are four reflections that can be offered about Tier 2 interventions. First, once again, this provision gives school social workers a leadership opportunity to create in-service trainings for school personnel. Second, school social workers may want to coordinate the provision of behavioral supports for Check-In, Check-Out (CICO) programs, such as the Behavior Education Program (Crone, Horner, & Hawken, 2004) rather than providing these services directly (Lindsey & White, 2009; Wolfe et al., 2016). Third, social workers should consider using small groups as an efficient way of delivering early intervening services. Finally, (p.33) short-term interventions lasting no more than one quarter (10 weeks) should be considered.
A simple teacher-led intervention that social workers can easily train teachers to use is Instructional Choice. The method started in inclusive classrooms to help teachers differentiate their explicit teaching methods from their implicit teaching methods and to find a middle ground. Explicit teaching is defined as direct instruction of knowledge or skills in a clear manner that promotes student competency. Implicit teaching is defined as indirect instruction within an appropriate context that facilitates student learning (Mercer, Lane, Jordan, Allsopp, & Eisele, 1996). More of a strategy than a program, Instructional Choice trains teachers to give challenging students limited choices about academic activities. It occurs when “the student is provided with two or more options, is allowed to independently select an option, and is provided with the selected option . . . within naturally occurring classroom events” (Jolivette, Stichter, & McCormick, 2002, p. 28). Students can be give three types of choices within the classroom. First, they may have a choice of tasks (which task to do first). Second, they may make a choice within tasks (e.g., which materials to use, where to work, or with whom to work). Finally, they may be given options of reinforcers (running an errand, iPad time, or telling a joke). In a systematic review, Royer, Lane, Cantwell, and Messenger (2017) found that simply providing more choices to students reduced student behavior problems, increased academic engagement, and resulted in faster task completion.
Small groups should be used carefully. Studies have indicated that segregating antisocial youth into separate groups can have an iatrogenic effect. Specifically, “group interventions may escalate or maintain, rather than reduce, youth behavior problem” (Lochman, Dishion, Powell, Boxmeyer, Qu, & Sallee, 2015, p. 728). Nonetheless, there is evidence that group interventions are effective and efficient ways to assist students with internalizing disorders, such as anxiety (Kelly, Raines, Stone, & Frey, 2010), depression (Clarke, 2010; Kelly et al., 2010), and eating disorders (Heinicke, Paxton, McLean, & Wertheim, 2007). Third, small groups have been effective in improving social skills (Franzwa, Triandis, Truitt, & Dupper, 2013; Kelly et al., 2010). They also help in ameliorating academic problems, such as poor reading skills (Fien, Smith, Smolkowski, Baker, Nelson, & Chaparro, 2015; Kruse, Spencer, Olszewski, & Goldstein, 2015).
Lyon et al. (2015) have developed a brief, four-session intervention that uses quick identification of “top” problems, introduction to a (p.34) problem-solving approach, and inclusion of regular progress monitoring. In their most recent study, they addressed the feasibility of clinician delivery within a school context, acceptability of the protocol for students, and goodness-of-fit with common student problems. Results indicated that the treatment regimen was too short for two-thirds of the students and that service linkage to community resources was beneficial. Nonetheless, a short-term intervention may help with client engagement and triage of mental health services.
A recent meta-analysis of Tier 2 interventions examined early intervening services within a multitiered system of support framework (Bruhn, Lane, & Hirsch, 2014). First, they found that CICO was generally effective in reducing problem behaviors although its effectiveness was reduced for severe behavior problems. Second, they found that use of the Social Skills Improvement System (SSIS; Gresham & Elliott, 2008) that connected assessment to targeted social skills intervention was successful. Finally, they determined that Tier 2 interventions were effective at improving academic engagement and reading skills.
Thus, school-based mental health professionals can provide primary prevention, secondary prevention, or mental health treatment through a wide variety of means within schools. Schools, however, are not mental health agencies. Professionals working in schools need to know how to meet eligibility requirements, how to conduct thorough assessments, and how to choose the appropriate level of intervention to help youth.
Collaboration with Others
Working in a host setting is like swimming in a fishbowl. There are countless others who can observe who is being seen, where they’re being seen, and how often they’re being seen. There are plusses and minuses to this situation. On one hand, the school-based mental health provider is often well-known in a school, and adults who have concerns about a youth can easily obtain consultations or make referrals. On the other hand, there is a distinct lack of privacy for student-clients. School-based offices may have built-in windows or be located in busy areas of the building. Overall, students do benefit from the creation of a supportive collaboration between mental health providers, teachers, and parents (Feinstein, Fielding, Udvari-Solner, & Joshi, 2009). In the next section, four types of collaborative relationships are addressed.
As mentioned earlier, teachers are an important source of information about how a student is functioning in the classroom. No assessment should neglect to get information from a student’s teacher(s). Many teachers will expect the exchange of information to be reciprocal, but sharing this information would violate ethical guidelines from all of the school-based professional associations, so it is important to do some brief education about the nature of mental health services. Usually some brief introductory statement like the following will help. “As you may know, Jose has been referred for an evaluation. While I am not at liberty to disclose the details for the referral, you are an important professional in his life who can help with the accurate assessment and remediation of any problems that Jose might have. I would like to (a) ask you a few questions to get an idea of how he is functioning in your class, (b) schedule an opportunity to observe him in your class, and/or (c) request that you complete a quick questionnaire about him. Do you have any questions before we proceed?”
Such a statement keeps the discussion student-focused. It also puts the ethical issues up front while recognizing that teachers are also fellow professionals who are important contributors to both the assessment and the treatment process.
Since a student’s general education teacher is also part of the IEP team, it is also important for school-based mental health professionals to separately determine what information is collected and what information is reported. For example, in gathering information from a teacher, the school social worker may learn that the teacher actively dislikes the student and wants him or her removed from the class. Accordingly, the social developmental study report may allude to repeated student–teacher conflicts and might raise the question about whether a change in classroom milieu might be beneficial.
It also helps to distinguish between sharing what a student discloses and what a mental health provider recommends. A student might share that she gets frustrated with her homework and gives up because her immigrant single parent dropped out of school after eighth grade and there is no one at home to help. A corresponding professional suggestion for teachers might be the development of a homework plan that is reviewed before the end of class so that students have an opportunity to clarify expectations before they go home (Hampshire, Butera, & Hourcade, 2014; Warger, 2001). While (p.36) this accommodation might be initially targeted at only one student, many students could benefit from the change.
Finally, the school-based mental health professional may notice patterns that a community-based provider cannot. For example, using the number of office disciplinary referrals (ODRs) to identify students for Tier 2 services has come under scrutiny for a glaring lack of reliability and validity (Bezdek, 2011; Hyde, 2014). As Martella and colleagues (2010) reported,
ODRs cannot be assumed to be representative of the level of disruptive classroom behavior, at least as recorded by teachers. It is possible that each teacher had different tolerance levels and each school building had different definitions as to what behaviors constituted an office discipline referral. Repeated off-task behavior (i.e., noncompliance to teacher instructions) to some teachers may result in an ODR whereas other teachers might attempt to address the behavior in class. (p. 31)
In other words, ODRs may tell us more about the teachers making the referrals than they do about the students being referred. They may be indicative of a need for in-service training or mentoring of teachers in classroom management. Helping teachers become more effective at dealing with mental health and behavioral issues in the classroom may be a far more efficient use of a school social worker’s time. Thus, chapter author(s) have been asked to reflect on how to work with teachers to help students with each disorder covered in the book.
Parents of children with mental health problems have a variety of needs. These needs include emotional support, specialized parenting skills, and more self-care. They also dislike coercive methods of behavior management by schools.
First, parents of children with mental health problems need support. Upon learning of a child’s mental illness, many parents go through a grieving process (Richardson, Cobham, McDermott, & Murray, 2013). Unlike loss by death, this grieving process is ambiguous because the child has not disappeared (Patrick-Ott & Ladd, 2010; Penzo & Harvey, 2008; Young, Bailey, & Rycroft, 2004). When the disorder is relatively rare, parents experience greater loneliness because there are few people in their social network who understand what they’re going through (Andershed, Ewertzon, & Johansson, 2017; Stein, (p.37) Aguirre, & Hunt, 2013). Not surprisingly, a child’s mental illness can also be hard on a marriage or domestic partnership (Abbott, 2013), although the evidence is mixed about whether a child’s mental disability is more likely to lead to parental divorce (Freedman, Kalb, Zablotsky, & Stuart, 2012; Hartley et al., 2010).
Second, parents of children with a mental illness also need parenting skills. Children with disabilities are at increased risk for child maltreatment and neglect, and this is especially true for children with intellectual disability, mental/behavioral problems, and conduct disorders (Maclean, Sims, Bower, Leonard, Stanley, & O’Donnell, 2017). This is a complex and reciprocal relationship because young children with a disability are at a higher risk for abuse and neglect, and young children who are mistreated are at a higher risk for developing a disability (Corr & Santos, 2017).
Third, parents of children with a disability need more self-care. Luijkx, Putten, and Vlaskamp (2017) compared parents of children with severe or multiple disabilities with parents of normally developing children. They found that the parents of both groups had similar use of both contracted (work or educational) time and necessary (personal hygiene, eating, and sleeping) time, but significant difference in committed (time for domestic work and supervision of children) time, leaving very little free time for self-care.
Finally, parents strongly disapprove of aversive/coercive methods by others to manage their children’s behavior (Westling, Trader, Smith, & Marshall, 2010; Zirkel & Lyons, 2011). Aversive/coercive methods include corporal punishment, restraint, and seclusion. Unfortunately, research shows that these methods are still quite common in public schools, especially those that serve lower socioeconomic class families (Barnard-Brak, Xiao, & Liu, 2014). They are also disproportionally meted out to students who are male, black, or have disabilities (Gershoff & Font, 2016). Ironically, there is federal legislation that prohibits and regulates the use of restraints in mental health facilities in the Children’s Health Act of 2000 (P.L. 106-310).
Based on these research findings, a comprehensive assessment should include an investigation into parental quality of life, especially when doing an evaluation for early intervention services for young children. Penzo and Harvey (2008) put this well, “Too often in clinical programs where children are the ‘clients,’ professionals do not attend to the needs of the parents. Social workers may ‘engage’ parents as partners in helping their children but the parents are not recognized for their own needs as well” (p. 335). Possible family assessment scales include the 32-item Child and Family Quality of (p.38) Life measure (Markowitz, Reyes, Embacher, Speer, Roizen, & Frazier, 2016), the 18-item Family Support Scale (Dunst, Jenkins, & Trivette, 1984), or the 36-item the Parent Stress Index—Short Form (Abidin, 1990).
A number of interventions have been proposed to help parents care for their children with mental disorders. Ryan and O’Connor (2017) experimented with a single-session clinic to facilitate faster access to services. Tellegen and Sanders (2013) conducted a meta-analysis of the Stepping Stones Triple P-Positive Parenting Program (SSTP; Sanders, Mazzucchelli, & Studman, 2004) and found significant positive effects for parenting styles, parenting satisfaction, parent efficacy, parental adjustment, and the parental relationship. Stattin, Enebrink, Özdemir, and Giannotta (2015) did a national study in Sweden and found that parent behavioral training programs, such as Comet (Kling, Forster, Sundell, & Melin, 2010), Cope (Cunningham, 2005), and Incredible Years (Webster-Stratton, Reid, & Hammond, 2001), worked well. Butler and Titus (2015) examined ways that parent training programs could be adapted for racial/ethnic minority parents, including recent immigrants. Overall, they identified five different types of adaptations:
(a) peripheral strategies that modify the observable properties of intervention materials; (b) linguistic strategies that alter language used in intervention materials to make them comprehensible; (c) constituent-involving strategies that utilize the cultural knowledge and experience of members of the minority group; (d) sociocultural strategies in which a minority group(s) cultural values, beliefs, and behaviors are recognized, reinforced, and built upon; and (e) evidential strategies that use “evidence” for a specific group or experiences from individuals with similar backgrounds to increase the perceived relevance of information. (p. 312, emphasis in the original)
Strunk (2010) conducted a systematic review of respite services for parents of children with disabilities. She found six primary effects across all of the studies:
(1) Family characteristics that appear to influence the use of respite include the level of family stress, access to informal support networks, family size, and marital status; (2) Respite care is associated with significant reductions in parental stress; (3) Implementing any form of more structured intervention appears to have a positive impact over no support or the receipt (p.39) of standard services; (4) Respite is an important contribution that offers short breaks to families who care for children with multiple disabilities; (5) Respite care appears to result in reductions in psychological distress in parents of children with developmental disabilities; and (6) Respite care may be considered an intervention for child abuse, especially for those children suffering from challenging behaviors. (pp. 618, 627)
Thus, IEP teams should use wrap-around services to ensure that families of children with mental disorders have the option of utilizing respite care as needed. There is strong evidence that school-based wrap-around programs are effective (Eber et al., 2014). Since children under age 5 are at far greater risk of child maltreatment (Corr & Santos, 2017), respite care is especially important if one is completing an Individualized Family Service Plan (IFSP) under Part C of IDEA. An IFSP should include family training, parent counseling, home visits, and service coordination services. Another option is the use of parent peer support services (Olin, Hemmelgarn, Madenwald, & Hoagwood, 2016), where parents are matched with parent peer specialists, usually parents of children with disabilities themselves, who provide emotional support, coaching, mentoring, and consultation. Certification for this new profession is available nationally through the Federation of Families for Children’s Mental Health, as well as in several states (e.g., Illinois, New York, Tennessee). Since parents are integral to children’s prognosis and recovery (Sabatino, 2001), chapter author(s) have been asked to reflect on how to assist parents with each disorder covered in the book.
Finally, social work organizations should actively advocate for the restriction and regulation of the use of corporal punishment, physical restraint, and seclusion of children with disabilities as other professional groups have already done (Association for Behavior Analysis International, 2010; Association of Professional Behavior Analysts, 2009). The overrepresentation of corporal punishment by gender, race, or ability is in violation of at least three federal statutes: Title I of the Education Amendments of 1972, Title VI of the Civil Rights Act of 1964, and Section 504 of the Rehabilitation Act of 1973 (Gershoff & Font, 2016). Last, it makes no sense to have separate standards for schools and children’s mental health facilities.
Administrative concerns regarding students with mental health issues revolve around two main issues: school discipline and the inclusion of students with (p.40) disabilities in general education. When it comes to student discipline, three issues are pertinent. These problems include school bullying, disproportional discipline practices, and zero-tolerance policies (Englehart, 2014).
First, children with disabilities are at much greater risk for being victims of school bullying (Yell, Katsiyannis, Rose, & Houchins, 2016). In fact, it has been such a problem that the US Department of Education’s Office for Civil Rights (2014) published a third Dear Colleague letter about it admonishing administrators “to address and prevent disability discrimination in our schools” (p. 1). That letter clarified that school-based harassment is in “violation under Section 504 and Title II when: (1) a student is bullied based on a disability; (2) the bullying is sufficiently serious to create a hostile environment; (3) school officials know or should know about the bullying; and (4) the school does not respond appropriately” (p. 4, emphasis added). While it may be true that some students with disabilities (e.g., those with conduct disorders) may be perpetrators of bullying (Farmer, Wike, Alexander, Rodkin, & Mehtaji, 2015), this does not excuse schools from addressing the issue systemically. Since bullying seems to reach its peak in early adolescence, that is an ideal time to institute a school-wide prevention program. Sullivan, Sutherland, Farrell, Taylor, and Doyle (2017) compared the individual skill-building model of Second Step and the school-wide approach of the Olweus Bullying Prevention Program separately and combined. They found that students with disabilities did better in the combined condition than they did with just one program alone.
Second, the problem of exclusionary discipline (i.e., expulsions and suspensions) remains a problem in spite of evidence that they are ineffective or inequitable methods for improving student conduct (American Academy of Pediatrics, 2003) or academic achievement (Christani, Revetti, Young, & Larwin, 2015). Students with disabilities are one of the demographic groups facing disproportional school exclusion (O’Conner, Porowski, & Passa, 2014; Sullivan & Bal, 2013; Vincent, Sprague, & Tobin, 2012). Burke and Nishioka (2014) found that this was true even when controlling for the type of infraction (e.g., verbal or physical aggression vs. insubordination). Moreover, studies have shown that, within students with disabilities, those with emotional disturbances are most at risk (Achilles, McLaughlin, & Croninger, 2007; Bowman-Perrott, Benz, Hsu, Kwok, Eisterhold, & Zhang, 2013). In fact, Sullivan, Van Norman, and Klingbeil (2014) found that students with emotional disturbances were nearly three times more likely to receive two or more out-of-school suspensions than any other disability group.
(p.41) Third, zero-tolerance policies began with the 1994 Gun-Free Schools Act and have fed the school-to-prison pipeline ever since (McCarter, 2017; Mongan & Walker, 2012). Despite evidence that such policies are ineffective in reducing disciplinary problems (González, 2012; Teske, Huff, & Graves, 2012), more than 90% of US public schools have endorsed them (Skiba, Horner, Chung, Rausch, May, & Tobin, 2011). A more effective approach to school discipline has been the adoption of school-wide positive behavior interventions and supports (SWPBIS). George, George, Kern, and Fogt (2013) reported on the implementation of SWPBIS in an alternative education school serving students with severe emotional disturbances or ASD, aged 6–21. Instituting the “high five” approach reported by Taylor-Green and Kartub (2000), they found that the rate of physical restraints declined from a high of 121 over a 4-week period to zero by the end of the school year.
The inclusion of students with disabilities in general education has remained a problem even though IDEA requires that students with disabilities be placed in the least restrictive environment to the maximum extent possible. Morningstar, Kurth, and Johnson (2017) report that students with significant disabilities (including ASD, intellectual disability, multiple disabilities, and deaf-blindness) were those most likely to be excluded. This situation persists in spite of evidence that inclusion of students with disabilities into general education improves their education outcomes (Kleinert et al., 2015).
There are several ways that school-based mental health providers can address these student issues. First, social workers can assist school administrators in the monitoring of bullying incidents to identify patterns of victimization. Based on these patterns, they can help schools develop and implement prevention strategies that target both the whole school and individual classrooms. Second, social workers can make sure that schools are following federal laws that provide due process protections to students with disabilities who are facing disciplinary action. As Raines and Dibble (2017) explain, school social workers should be involved in manifestation determinations. A manifestation determination assesses whether the student’s misbehavior is a symptom of an identified or “previously unidentified” disability (US Dept. of Education, 2003, p. 1, emphasis added). These evaluations are required by IDEA (a) if a student with a disability receives an out-of-school suspension for more than 10 days (consecutively or cumulatively), or (b) if the student is sent to an interim alternative education setting for drug or weapon possession or for causing serious bodily harm. Knoster (p.42) (2000) and Katsiyannis and Maag (2001) suggest five questions for the team to consider:
1. Does the student have the needed skills to use an appropriate behavior?
2. Can the student engage in appropriate problem-solving?
3. Does the student tend to distort social realities?
4. Does the student have control over his or her behavior?
5. Was the behavior a manifestation of a disability?
Third, school social workers should take a leadership role in the initiation and implementation of SWPBIS programs. Ideally, they should use the RE-AIM framework (Box 1.3) to ensure that the program was integrated throughout the school and sustainable over time. Another way for social workers to help is by establishing restorative justice programs in schools. While the evidence is inconclusive about whether these programs reduce disproportionality, they are effective at keeping students in school (Anyon et al., 2016).
Finally, social workers serving on IEP teams should ensure that parents know their child’s educational rights, including the right to an education in the least restrictive environment (McCloskey, 2016). Zirkel and Hetrick (2017) found that process violations of parent participation were the most common reasons for lawsuits against school districts, a situation most school administrators would like to avoid. Yell, Katsiyannis, Ennis, Losinski, and Christle (2016) also warn about content violations, stating:
The IEP team must clearly delineate the frequency, duration, and location of the services. The nature and amount of services listed in a student’s IEP should be specific enough that the parents have a clear understanding of the services that will be provided by a school district. (p. 36, emphasis added)
Cheatham, Hart, Malian, and McDonald (2012) make it clear that the least restrictive environment should be the expected norm, stating that “this presumption may be set aside by the team (which includes the parents) only after intensive supports, supplementary aides and services have been provided in the general education classroom without success” (p. 53, emphasis added).
One last important part of the content of the IEP is to indicate whether the student is to receive accommodations or modifications to the general education standards. Many parents and even some professionals get these terms confused. As Raines (2002b) clarifies, accommodations are changes in (p.43) the format, presentation, setting, timing, or response that enable students with disabilities to meet the same standards as students without disabilities, but modifications are changes to the substance of a task that lower the general education standard. Parents should know what they’re agreeing to before signing an IEP. Since school administrators are key to ensuring that students with disabilities maintain their civil rights, the editor has asked each chapter author to consider how these very important people can assist with each of the disorders discussed.
Community-Based Service Providers
School-based wrap-around planning has been around for more than 20 years (Eber & Nelson, 1997). “Wrap-around” is not a program or a service; it has been defined by Suter and Bruns (2009) as “a team-based, collaborative process for developing and implementing individualized care plans for youth with SEBD [serious emotional and behavioral disorders] and their families” (p. 337). Bruns, Walker, and the National Wrap-around Initiative Advisory Group (2008) identify 10 philosophical values and principles behind wrap-around planning:
1. Family voice and choice: Family and student perspectives are intentionally elicited and prioritized during all phases of the wrap-around process.
2. Team-based: The team consists of individuals agreed upon by the family and committed to the family through informal, formal, and community support and service relationships.
3. Natural supports: The team actively encourages the full participation of team members drawn from family members’ networks of interpersonal and community relationships.
4. Collaboration: Team members work cooperatively and share responsibility for developing, implementing, monitoring, and evaluating a single wrap-around plan.
5. Community-based: Service and support strategies take place in the most inclusive, most responsive, most accessible, and least restrictive settings possible.
6. Culturally competent: The wrap-around process builds on the values, preferences, beliefs, culture, and identity of the student and family and their community.
7. Individualized: To achieve the plan’s goals, the team develops and implements a customized set of strategies, supports, and services.
9. Unconditional: A wrap-around team does not give up on, blame, or reject students or their families.
10. Outcome-based: Goals and strategies are tied to measurable indicators of success, set dates for progress monitoring, and make revisions as needed.
In a meta-analysis, wrap-around planning has proved effective across four domains of youth outcomes, including more stable living situations, improved mental health, better school functioning, and reduced juvenile justice involvement (Eber, Hyde, & Suter, 2011; Suter & Bruns, 2009). For those coordinating students’ mental health, a wide variety of community-based providers might be involved, including child psychiatrists, parent peer support specialists, pediatric neurologists, nutritionists, probation officers, psychotherapists, and rehabilitation counselors. Accordingly, the editor has asked each chapter author to delineate the kinds of community-based support needed for each of the disorders addressed.
In terms of MTSS or SWPBIS, Eber, Lindsey and White (2010) see wrap-around as an essential element of Tier 3 support. The Illinois State Board of Education (2012) provides eight practical assessment tools in English and Spanish for school-based wrap-around teams to use: (a) Referral Disposition Tool; (b) Educational Assessment Tool; (c) Home, School, Community Tool; (d) Family Satisfaction Tool; (e) Parent Survey Tool; (f) Wrap-around Integrity Tool; and (g) Youth Satisfaction Tool (available at: http://www.istac.net/resources/illinois-pbis-network-resources/PBIS-Evaluation/simeo-ii-tools/simeo-ii-tools---renew). Finally, Eber Malloy, Rose, and Flamini (2014) describe the RENEW wrap-around model for transition-age youth (aged 14–18) that focuses on Rehabilitation for Empowerment, Natural supports, Education, and Work meant to improve school completion, employability, and postsecondary education/training.
IDEA requires that the content of the IEP include how progress will be measured. The IEP team reviews progress on the student’s measurable annual goals every year. This does not mean, however, that a review cannot occur before this; parents or any other IEP team member can request a review of the IEP at any time. Furthermore, parents must receive periodic reports “on (p.45) the progress the child is making toward meeting the annual goals (such as through the use of quarterly or other periodic reports, concurrent with the issuance of report cards) will be provided” (34 C.F.R. 300.320(a)(3)). These progress reports may or may not be coordinated with quarterly report cards, although this practice is common in many states.
Evidence-Based Practice Standards
A little-heralded change between NCLBA (P.L. 107-110) and the ESSA was a major revision in evidence-based practice standards. Both sets of standards are provided here.
The NCLBA of 2001 called for rigorous “scientifically-based practice”:
(a) means research that involves the application of rigorous, systematic, and objective procedures to obtain reliable and valid knowledge relevant to education activities and programs and
(b) includes research that
(1) Employs systematic, empirical methods that draw on observation or experiment;
(2) Involves rigorous data analyses that are adequate to test the stated hypothesis and justify the general conclusions drawn;
(3) Relies on measurements or observational methods that provide reliable and valid data across evaluators and observers, across multiple measurements and observations, and across studies by the same or different evaluators;
(4) Is evaluated using experimental [randomized controlled trials] or quasi-experimental designs in which individuals, entities, programs, or activities are assigned to different conditions and with appropriate controls to evaluate the effects of the condition of interest, with a preference for random assignment experiments, or other designs to the extent that those designs contain within-condition or across-condition controls;
(5) Ensures that experimental studies are presented in sufficient detail and clarity to allow for replication or, at a minimum, offer the opportunity to build systematically on their findings; and
(6) Has been accepted by a peer-reviewed journal or approved by a panel of independent experts through a comparably rigorous, objective, and scientific review. (Raines, 2008, pp. 6–7)
The term “evidence-based,” when used with respect to a State, local educational agency, or school activity, means an activity, strategy, or intervention that—
(i) demonstrates a statistically significant effect on improving student outcomes or other relevant outcomes based on—
(I) strong evidence from at least 1 well-designed and well-implemented experimental study [randomized controlled trial];
(II) moderate evidence from at least 1 well-designed and well-implemented quasi-experimental study; or
(III) promising evidence from at least 1 well-designed and well-implemented correlational study with statistical controls for selection bias; or
(ii)(I) demonstrates a rationale based on high quality research findings or positive evaluation that such activity, strategy, or intervention is likely to improve student outcomes or other relevant outcomes; and
(II) includes ongoing efforts to examine the effects of such activity, strategy, or intervention. (p. 290, emphasis added)
It is possible that state education agencies and local school districts struggled to meet the very rigorous standards of NCLBA and lobbied their members of Congress to lower the standards to make them more feasible in real-world settings. Thus, readers should consider the level of the evidence presented in the subsequent chapters of this book before adopting or adapting the evidence to fit the needs of students in their schools.
Students with mental disorders require services in public schools. Whether those services are met through IDEA or Section 504 matters less than the fact that services are provided. The DSM-5 remains an imperfect tool for assessment and diagnosis of children and adolescents. Therefore, school-based mental health providers should use it judiciously and cautiously to assist students in getting the help they need. School social workers, psychologists, and counselors are part of the solution to removing barriers to learning that inhibit students from academic success. If children receive the social-emotional supports they need, then they are more likely to finish school, become employed, and be engaged citizens.
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