Emotional and Behavioural Disorders

EPSE 317

AUNTIE LIZZIE’S STORY TIME:

This is Gwendolyn:

Kicking Horse Elementary School

• A small K-7 school in Golden • A geographically large school district with

a dispersed student population• Gwen is now in grade 6. She’s been at

Kicking Horse since kindergarten.• Gwen’s marks have been mostly Bs. • She doesn’t care for sports or assemblies.• The district office is in Golden; and most

district resource staff work out of Golden.

Gwen’s family

• Dad: Charles, works as a mechanic for the railway.

• Mom: Irma, is a part-time librarian.• Grandma: Eunice, is retired from the

post office.• Orval: Gwen’s big brother. He’s in

grade 10 at Golden High School. • The collie: Flora—keeps the small farm

they all live on running in good order.

Gwen’s friends

• Sally is Gwen’s “best friend.” They’ve been “best friends” since kindergarten.

• They hang with a nice group of girls and spend lots of time in one another’s homes.

• Gwen has always been invited to parties and sleep-overs.

A little more about Gwen

• She loves animals and has wanted to be a veterinarian as long as she can remember.

• She likes spending time with her Grandma. They bake together, and take care of the chickens.

• She and Orval have always gotten along well.

Things Changed This Last Summer:

• Loss of appetite• Stayed home; just sat• Lost her temper with Orval and her

grandmother• Tearful• Her folks thought it might be the

onset of puberty

School is Different This Year(It’s mid-October)

• No attempt to complete homework– Discussions with parents doesn’t help– Gwen says “it doesn’t matter.”

• Isolates herself from classmates• Refuses to take part in physical

education and to attend assemblies• Sits in principal’s office, staring at

the floor, and twiddling her hair

Last Week it Got Scary:

• Sally invited her to a birthday “sleep-over”• Gwen went, at her Mom’s insistence. (Irma

thought it might cheer her up.)• At 1 am, Sally’s Mom phoned—Gwen was

missing.• At 1:30 Gwen showed up at her own home,

having walked 3 kms along back roads to get home—she said she’d just got fed up with the other kids.

• She also kicked Flora, who barked when she arrived.

What’s going on?

• What should we be asking?

• http://www.youtube.com/watch?v=pAvm4BJwhso&feature=related

In BC

• Gwen and many other students with similar problems will fall into a category called “Behavioural needs and mental illness.”

• It is presented in two levels: – Severe (which requires inter-agency

involvement)– Moderate (can be addressed at school

level exclusively)

Prevalence

• In 2006, 27% of children identified as special needs within the Province were within the Behavioural needs and mental illness category. (Categories H and R)

• This incidence was almost doubled among First Nations students.

Definitions

• Moderate Behaviour Support– Aggression and/or hyperactivity– Behaviours relating to social problems such as

delinquency, substance abuse, child abuse or neglect

• Mental Illness– Diagnosis by “a qualified mental health clinician”

• Internalised states such as depression, anxiety, or stress-related disorders

• Thought disorders or neurological or physiological conditions.

• Frequency or severity must have a disruptive effect on “classroom learning environment, social relations or personal adjustment.”

• Conditions must be present over an extended period, in more than one setting and with more than one person

• Have not responded to support through classroom management or school discipline

Intensive Behaviour Intervention (IBI) or Serious Mental Illness

• IBI– Antisocial, extremely disruptive behaviour in

most environments– Consistent/persistent over time

• Serious mental illness– Serious mental health conditions diagnosed by

qualified MH clinician (psychologist, psychiatrist, or physician with appropriate training

– Profound withdrawal– Seriously “at risk” in classroom without

extensive support

IBI or Serious Mental Illness, Continued

• Must be known both to school and district personnel and other community service providers

• Must present a serious risk to the student or to others and/or significantly interfere with academic progress of the student or others.

• Beyond the normal capacity of the school to educate

Reduction in class size or placement in an alternate program or learning environment is not by itself a sufficient service to meet criteria.

Identification and Assessment

• Behaviour– School-based team, behaviour experts,

district psychologists– Rule out other causes, such as

intellectual disability, illness, side-effects of medication

– Analyse functional behaviours

• Mental health—collaboration with medical or MH professionals

Functional Behaviour Analysis

• Assumes behaviour has a function for student

• Ethically, although behaviour can be changed, function should be recognised and alternate means of meeting function provided.

• See http://cecp.air.org/fba/default.asp

Primary Prevention:School-/Classroom-Wide Systems forAll Students,Staff, & Settings

Secondary Prevention:Specialized GroupSystems for Students with At-Risk Behavior

Tertiary Prevention:Specialized IndividualizedSystems for Students with High-Risk Behavior

~80% of Students

~15%

~5%

CONTINUUM OFSCHOOL-WIDE INSTRUCTIONAL & POSITIVE BEHAVIORSUPPORT

ALL

SOME

FEW

From Sugai, 2006

Mental Health: Internalising

• Depression• Anxiety

Depression

• As many as 5% of all children and adolescents may experience a major depressive episode.

• Symptoms differ from those of adults but are disabling.

Depression in Young Children

• Sadness• Distance (“far-away look”)• Anger and aggression• Timidity, fearfulness• Moodiness, irritability• Physical complaints—stomach ache,

headaches, nausea, sleep troubles

Older Children and Adolescents

• Sad mood• Irritability• Moodiness• Isolation• Apathy—loss of interest in previously

favoured activities• Anger• Low frustration threshold• Deterioration of schoolwork• Physical complaints

Triggers

• Biological basis for depression• But can be triggered by changes in

child’s circumstances—– Loss– Move– Parent separation– New baby – Etc.

Diagnosis

• Physician, psychologist, psychiatrist• Depression inventories• Observation

Treatment

• Therapy– With young children and children with

language limitations, play therapy– Older children, Cognitive Behaviour

Therapy– Possibly EMDR

• Medication (controversial but sometimes helpful)– SSRIs (selective serotonin reuptake

inhibitors)

Anxiety Disorders

• Generalised anxiety disorder: chronic, excessive anxiety about multiple areas of their lives

• Separation anxiety: fear of separation from home or caregivers

• Specific phobias• Social phobias: anxiety in social or performance

settings• Panic disorder: unexpected, brief episodes of intense

anxiety with no apparent cause• Obsessive-compulsive disorder: repetitive acts to

alleviate anxiety• Post-traumatic stress disorder: anxiety symptoms after

exposure to a traumatic event

Diagnosis

• By psychiatrist, psychologist or MD

• Treatment– Therapy– Medication (SSRIs again)

How to support depression and anxiety in school

• Collaborate with healthcare professionals

• Acknowledge existence of condition• Adjust academic and social demands

to meet student’s capacity.• Recognise sources of irritable and

acting-out behaviour and minimise consequences.

Back to Gwen:

• Let’s assume a diagnosis of clinical depression and develop an IEP

• Diagnostic information• Goals?• Collaboration and scheduling

Monitor for medication

• Side effects of SSRIs• Nausea, weight gain, dry mouth, sleep

disturbance• Antidepressants increase the risk of suicidal

thinking and behavior (suicidality) in children, adolescents and young adults (up to age 24) with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. (US FDA, 2004)

• Exercise can be good• Don’t tell a person to snap out of it, or

cheer up. Most people with depression feel guilty already.

• Light can be good.• Friends can be good, but crowds can

be difficult• Reassurance for anxiety can be a

trigger

Adaptations to program?

• Reduce work load• Minimise physical education but

encourage exercise.• Time frame?• Grade 7 exams.

Serious mental illness

• Should not be treated as an academic issue any more than any other medical condition.

• Child may need hospitalisation• Psychosis, childhood schizophrenia,

severe depression and bipolar disorder, anorexia and bulemia

Behaviour

• Should be reduced by pro-active individualised instruction and behavioural planning.

• Look for function of behaviour• Do NOT attempt to suppress behaviour

without addressing function—– It’s unethical– And it won’t work (or it will have side

effects)

Some common reactive behavioural strategies

• Reinforcement schedules• Time-out for undesirable behaviour

– Very tricky to make effective– Controversial– Potentially dangerous– Initially was meant as a form of

extinction but has become a punishment

• Extinction

Suspension, expulsion and medical exclusion

• Suspension—– Can be used for any age of child– Principal can suspend for any length of

time but duration must be specified

• Expulsion– For student 16 or over

• Medical exclusion

Medical exclusion (AKA Section 91)

• Administrator or Board can exclude a student if he or she is regarded as having health issues that put the student or classmates at risk.

• This is usually used for behaviour rather than measles.

• Student cannot return to school until deemed fit to do so by the district medical officer.

• Board must offer instructional program to student during the term of the exclusion.

Intervention for unacceptable or dangerous behaviour

• No matter what age and size, two staff should be involved in any physical intervention– Safer for all concerned– Legal issues less likely to ensue – Doesn’t turn into personal wrestling match

• Don’t intervene physically unless there is physical risk to a person (furniture isn’t worth it)

• Look for nonviolent crisis intervention programs• Model calm. Speak slowly, breathe slowly, relax

shoulders. Learn to do these things before you need them.

• Develop behaviour plans that everyone can agree to. No one should be able to use “linebacker behaviour modification” even if they are built like a gorilla.

• “He behaves for me” is a worse than useless assertion. Behavioural learning should be generalisable like all learning.