Download Behavioral Supports for Students: Addressing Mental Health Needs

Behavioral Supports
for Students:
Addressing Mental Health Needs
Leah Benazzi & Robin Fernstrom
Behavior Consultants/School Psychologists
Beaverton School District
[email protected]
[email protected]
Agenda
 Common mental health diagnoses in the schools
 Mental health diagnoses and special education eligibility
 Understanding mental health issues as representative of Lagging
Skills
 Behavior Support at three levels
 Preventative Interventions
 Skill Building Interventions
 Response Interventions
 Potential role of school nurses at each level of intervention
Common mental health diagnoses in the
schools
 ADHD (SPED classification: Other Health Impairment)
 Autism Spectrum Disorder (SPED classification: Autism Spectrum Disorder)
 Anxiety Disorders (SPED classification: Emotional Disturbance)
 Conduct Disorder (SPED classification: Emotional Disturbance if it manifests in
conjunction with an Emotional Disturbance)
 Depression (SPED classification: Emotional Disturbance)
 Bipolar Disorder (SPED classification: Emotional Disturbance)
 Eating Disorders (SPED classification: Emotional Disturbance if related
emotional issues impact education performance)
 Self-Harm/Mutilation (SPED classification: Emotional Disturbance if related
emotional issues impact education performance)
Some students may be served via a 504 plan or may be in the general education population.
ADHD
 Inattentive Type, Hyperactive Type, or Combined Type
 Symptoms include (but are not limited to):
 Daydreaming
 Fidgeting or being in near constant motion
 Lack of organization and lack of work completion
 Difficulty with sustained attention
 Excessive talking
 Impulsivity
 Frequently trouble waiting for one’s turn.
 Six of nine total DSM-V characteristics must be endorsed (with additional
criteria) for individuals younger than age 12, five of nine for those over age
12.
Autism Spectrum Disorder
 A developmental disability significantly affecting verbal and nonverbal
communication and social interaction.
 Other characteristics that may be associated with autism are engagement
in repetitive activities, stereotypic movements, resistance to environmental
change or change in daily routines, and unusual responses to sensory
experiences.
 Essential features are typically, but not necessarily, manifested before age
three.
 In Oregon Schools, core characteristics include impairments in:
 • Communication
 • Social Interaction
 • Patterns of behaviors, interests, and/or activities that are restricted, repetitive,
or stereotypic
 • Unusual responses to sensory experiences
Anxiety Disorders
 Primary characteristic is worry – a fear that future events will have
negative outcomes
 Separation Anxiety Disorder
 Generalized Anxiety Disorder
 Posttraumatic Stress Disorder
 Social Phobia
 May present as: inattention, perfectionism, forgetful behavior,
withdrawal and reluctance to participate, and truancy.
Conduct Disorder (CD)/Oppositional
Defiant Disorder (ODD)
 CD: a repetitive and persistent pattern of behavior in which the rights of
others or age-appropriate societal norms or rules are violated. At least 3 of
15 criteria in the past 12 months from any of the categories below, with at
least one criterion present in the past 6 months:
 Aggression to people and animals
 Destruction of property
 Deceitfulness or theft
 Serious violations of rules
 The disturbance in behavior causes clinically significant impairment in
social, academic, or occupational functioning.
 ODD is differentiated from CD based on the defiance of rules and
argumentative verbal interactions involved in ODD; CD involves more
deliberate aggression, destruction, deceit, and serious rule violations.
Major Depressive Disorder
 Five of the following symptoms almost every day for at least two weeks.
Number one or two must be endorsed.
 1. Depressed mood most of the day, almost every day, indicated by
student report or by the report of others
2. Markedly diminished interest or pleasure in all or almost all activities most
of the day nearly every day.
3. Significant weight loss when not dieting, or weight gain.
4. Inability to sleep or oversleeping nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may
be delusional) nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every
day.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or specific plan for
committing suicide.
 There must be clinically significant impairment in an important area of
functioning.
 There are also exclusionary criteria related to substance use, schizophrenia,
mania, and other psychotic disorders.
Bipolar Disorder
 A mental health condition that is characterized by periods of both mania and
depression; the criteria for bipolar requires at least one depressive episode and
one manic episode.
 Mania must have at least three of the following symptoms: inflated self-esteem,
little need for sleep, pressure of speech (talking constantly), flight of ideas, easily
distracted, excess pursuit of goal-directed activities or psychomotor agitation
(pacing, hand wringing, etc.), excess pursuit of pleasure with a high risk of
danger
 Depression: must have at least four of the following symptoms: Changes in
appetite or weight, sleep, or psychomotor activity, decreased energy, feelings
of worthlessness or guilt, trouble thinking, concentrating, or making decisions,
thoughts of death or suicidal plans or attempts
 Bipolar I disorder involves one or more manic episodes or mixed (mania and
depression) episodes while Bipolar II disorder has one or more severe major
depressive episodes with at least one hypomanic (less severe mania) episode.
 Cyclothymia is characterized by fluctuating low-level depression along with
periods of hypomania.
 Rapid-Cycling Bipolar Disorder is a severe form of bipolar disorder, occurring
when a person has at least four episodes of major depression, mania,
hypomania, or mixed states within a year.
Eating Disorders
 Binge Eating Disorder: Recurring episodes of eating significantly more food
in a short period of time than most people would eat under similar
circumstances, with episodes marked by feelings of lack of control.
Someone with binge eating disorder may eat too quickly, even when he or
she is not hungry. The person may have feelings of guilt, embarrassment, or
disgust and may binge eat alone to hide the behavior.
 Anorexia Nervosa: Primarily affects adolescent girls and young women.
Characterized by distorted body image and excessive dieting that leads to
severe weight loss with a pathological fear of becoming fat.
 Bulimia Nervosa: Frequent episodes of binge eating followed by
inappropriate behaviors such as self-induced vomiting to avoid weight
gain.
Self Harm /Self Mutilation
 Repetitive Self-Mutilation Syndrome (RSM)
 Behaviors include cutting, scratching, burning, head banging, preventing
wounds from healing, picking, poking, and hair pulling.
 Generally considered an impulse disorder (the same category as
substance abuse, eating disorders, etc.).
 Incidents occur episodically (not every day) and there is some gratification
achieved contributing to its repetitive nature.
 The brain releases endorphins following self-injury. Individuals report feeling
relief, release, calm, and satisfaction.
 This is a maladaptive coping mechanism for strong emotions or feelings of
anxiety and sadness.
 Occurs with Depression, PTSD (there is a correlation with sexual and physical
abuse), and other mental health disorders.
Understanding mental health issues as
representative of Lagging Skills
 Students may have various mental health diagnoses and it is essential for
school-based specialists to have basic knowledge about a student’s mental
health, however…
 Regardless of their diagnoses, it is useful for school-based personnel to view a
student’s emotional, behavioral, and mental health profile as indicative of
lagging skills in one or more areas:
 Executive Functioning
 Language Processing
 Emotional Regulation
 Cognitive Processing
 Social Skills
 Educational settings require students to have skills in these five areas to
experience educational and social success.
 Conceptualizing student needs in terms of Lagging Skills helps us get specific
about student supports without becoming bogged down in mental health lingo
and diagnoses.
Behavior support at three levels
 Preventative Interventions –
 How can the environment be altered to reduce the student’s exposure
to proven triggers?
 Skill-Building Interventions
 What instruction can the student receive to help develop new skills and
behavior – particularly in areas of lagging skills?
 Response Interventions
 How can the environment be altered to reduce or remove aversive
stimuli and pair desired behavior with reinforcement?
Preventative Interventions
 Sample Interventions
 Break tasks into smaller units.
 Reduce or avoid unexpected
situations.
 Provide a quiet space with few
distractions
 Allow for proactively scheduled and
known breaks (may include
movement, drawing, journaling,
reading etc.)
 Change format of communication
with the student (for example, allow
written instead of oral presentation
for a student with anxiety).
 Pair a student with a trusted peer.
 Provide organizational support via a
planner or schedule.
 Potential Role of School Nurse
 Act as known supportive/trusted
person that students can visit when
feeling overwhelmed (before acting
in a maladaptive manner).
 Provide information to staff about
warning signs for various mental
illnesses to increase their ability to
act proactively to support their
students.
 Provide fact sheets with the side
effects of commonly used
medications to improve staff
awareness and ability to share
useful information with doctors.
Skill-Building Interventions
 Sample Interventions
 Potential Role of School Nurse
 Modify broad mental health
information (for example cognitive
behavioral therapy goal areas) to
observable/measurable counseling
goal for a student’s IEP.
 Communicate with doctors and
mental health professionals
regarding how skill-building,
counseling, and therapy goals may
inform school-based supports.
 Provide the student with
opportunities to participate in
supportive general education
activities such as Friendship Groups.
 Teach wellness, nutrition, stress
management, and
mood/emotional awareness.
 Teach the student how and where
they may access emotional
supports at school. For example,
develop a protocol for various
recurring mental health-related
events.
 Teach students (if appropriate) and
staff about health management
protocols.
Response Interventions
 Sample Interventions
 Reinforcement /incentive systems
for younger students
 Increased freedom,
independence, or privileges for
older students
 Design safety plans as needed
following a risky event.
 Potential Role of School Nurse
 Membership on Crisis Team (or
similar) with school psychologist,
counselor, and social worker to
respond to observed mental
health issues
 Provide general information and
resources to students about
various disorders and where they
may obtain help and support.
Resources
 American Psychiatric Association. (2013). Diagnostic and statistical manual
of mental disorders: DSM-5. Washington, D.C: American Psychiatric
Association.
 Beaverton School District Special Education Handbook
 livesinthebalance.org (in addition to Ross Greene’s books and conferences
on Collaborative Problem Solving)
 nasponline.org
 pbis.org (in addition to various Functional Behavioral Assessment texts by
Rob Horner and others)