A Guide to Psychiatric Services in Schools

Understanding Roles, Treatment, and Collaboration

Shawna S. Brent

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135197629
• Edition: 1
• Topic: Education
• Subtopic: Education Theory & Practice

In order to provide comprehensive care to students with a wide variety of social and emotional challenges, close collaboration between psychiatrists and school-based mental health professionals is vital. This book provides practical information about psychiatric diagnoses and medications, as well as effective ways to communicate with physicians, to ensure that the needs of all students and their families are met. Brent reviews the process and content of a psychiatric evaluation, the general principles of psychopharmacology, and the various classes of medications. Subsequent chapters then focus on different psychiatric diagnoses and treatment options. Characteristics, evaluation, and treatment methods are discussed for mood, anxiety, psychotic, pervasive developmental, and externalizing behavior disorders with case examples provided throughout for illustration. A brief overview of mental health crises, including suicidal statements, physical aggression, and self-harm behaviors, and how these can best be handled in the educational setting is also provided. School-based mental health professionals will find this book to be a clear, concise, and practical guide to facilitating strong communication and collaboration amongst themselves, educators, and physicians.

One

Introduction to Psychiatry in Schools

CLINICAL CASE: ERIN

Erin was a 7-year-old Caucasian female who was referred for a psychiatric evaluation by her school district over 1 year ago. (The original psychiatric evaluation, which was modified to protect Erin’s privacy, is included on the accompanying CD: 2.1.) At the time of the evaluation, she was living with her mother, father, and sister. She was a second-grade student who had moved into the referring school district 2 months before the evaluation. The sources of information for this evaluation included a clinical interview with Erin and her parents. Erin was seen individually. Her parents were seen together. In addition, five school personnel were present, including the director of special education, building principal, guidance counselor, classroom teacher, and learning support teacher. Early education records and a previous psychiatric evaluation were reviewed before the clinical interview.

Erin’s strengths were described as her intelligence, her ability to learn things quickly when she hears them, and her supportive family. She enjoyed playing outside and riding her bike.

For much of Erin’s life, she has presented with challenging behaviors. At the age of 2, it became clear that Erin had significant difficulty with transitions. Her parents recounted the story that when she was 3 years old, she spent three hours, twice a week, with a babysitter. When her mother would drop her off in the kitchen, Erin would refuse to leave that room until her mother returned to take her home. Erin had always presented as extremely strong willed. Many other examples of her having prolonged tantrums with transitions were also provided. Her parents described that it had always been very difficult to have Erin engage in a task that she did not want to do. When her parents attempted to have her stop doing a pleasurable activity, the resulting tantrum could last as long as 30 minutes. Trying to have her complete a chore or simple task became so challenging because of her refusal that her parents had stopped asking her to do tasks. Tantrums would occur equally between the home and in public places. Her degree of tantrums and refusal had resulted in the family being unable to eat in restaurants or go to stores.

Over the past several years, Erin had also begun to display significant physical aggression. She became very physically aggressive to her sister and her mother. This had resulted in her giving bruises, scratches, and bites to these family members. Erin had been significantly physically assaultive at school, to the point of bruising adults and scratching them as well. These episodes of extreme anger tended to be triggered by very minor and typically unpredicted events. The extent of the anger outburst and aggression was nearly always out of proportion to the trigger. Although the outbursts were often unpredictable, it was identified that any attempt to enforce structure or rules would cause Erin to react aggressively. A second identified trigger was related to Erin’s perception of perfection. If something did not meet Erin’s perceived standards of symmetry or perfection, Erin would become aggressive. For example, Erin wanted a ponytail placed on her Barbie doll on the morning of the evaluation. She did not perceive that her mother had done it perfectly, which resulted in a 1-hour tantrum and scratches to her mother’s forearm. It was also noted that during these times of extreme anger, she would revert to talking in baby talk and “gibberish.” She became frustrated if people did not respond to her. She also would talk faster than her normal rate and talk excessively.

Over the past 6 to 8 months, Erin had been frequently making comments about wanting to die. She made numerous statements such as “I want to go to heaven, it is easier” or “I do not want to live.” She made several specific statements about what she would do to end her own life, including starving herself, slicing her throat, or hitting her head against a metal post. She also requested that her parents do something to kill her. These statements were, at times, made during episodes of anger, but at other times they seemed to occur more spontaneously, when she was unprovoked.

Despite the above-identified difficulties, Erin’s parents and school personnel describe that there were many times when she was very compliant, sweet, and developmentally appropriate. During these times, which could last for as long as a day but never as long as 2 days in a row, Erin would be cooperative, compliant, and appropriately engaged. However at least once a day, Erin would have some type of “rage outburst” as described above.

Past mental health treatment was significant for a one-time evaluation completed 6 months previously, which diagnosed Erin with an adjustment disorder. This evaluation was pursued by her former school district, although the report did not clarify why the evaluation was being pursued. The behaviors described were similar to those described above but were less frequent and severe. There were no significant medical problems. There was no history of head injury or seizures.

There were no reported difficulties with Erin’s mother’s pregnancy. Erin had a broken collarbone upon delivery. It took a week for this to be recognized and may have contributed to difficulty with early breast-feeding and Erin’s being very irritable and tearful during her first week of life. Motor milestones were all reached on time or early. Erin began walking at 9 months of age. At a young age, she began climbing to high places. Language milestones were delayed, and she did not begin speaking in sentences until 3 years of age. The family had moved three times in Erin’s life, with the most recent move being 2 months before this evaluation. One additional stressor that was identified for Erin was her sister’s birth when she was 2 years of age.

Educationally, Erin was a second-grade student within a local school. A review of records from her previous school suggested that there was some instructional support team (IST) involvement for learning concerns but not a high level of behavioral problems at school. IST is a team of educators who provide informal support for a targeted concern in an effort to avoid more intensive interventions in the future. Academically, there seemed to be appropriate progress being made.

At the start of her present school, Erin was seen as a shy and reluctant child. Within a few weeks, Erin began to present with significant aggression and defiance in that setting. It had reached a point where Erin frequently needed to be taken out of the room because of her aggression. The reason for the removal was primarily for the safety of others. She had engaged in a number of high-level risk-taking behaviors that could potentially harm others within the classroom. It was interesting that when she was removed from the classroom, she directed her physical aggression toward herself. For example, numerous times she had attempted to kick out glass from building windows. She had also kicked at concrete walls while not wearing shoes. She had been very physically aggressive to staff. On one occasion, during a restraint, she urinated in what was thought to be a particularly willful way on a teacher. The frequency and patterns of her escalation were difficult to predict. At times academic demands were thought to be a trigger; at others the episodes of physical aggression seemed unprovoked. On at least two occasions, Erin had to leave school early because of concerns about her safety. In addition, at times when her aggression escalated at school, Erin made statements about wanting to harm herself.

Within the school setting, Erin was described as being somewhat isolated from peers. She did not like to interact in groups and would not work on group assignments. In addition, she seemed more isolated on the playground and preferred solitary activities. However, Erin also seemed to have the social skills to interact and a desire to interact, but her negative, defiant, and disruptive behaviors seemed to impair these interactions.

Academically, it is perceived that Erin was capable of doing the work. She had demonstrated advanced artwork and academic work product at times. When she was compliant and engaged with work, she was noted to be highly perfectionistic and would become frustrated if her work was not perfect. However, at other times during classwork assignments, she would scribble on papers to the point where they ripped. She would refuse to do work.

There was report of an extended family member with an autism spectrum disorder. There was no other mental health history known.

Erin presented willingly to her individual portion of the interview. She was casually and stylishly dressed and demonstrated good grooming and hygiene. Her hair was neatly combed and arranged. She was able to separate from her parents without difficulty. She also was able to stop a fun activity that she had been engaged in with her teacher, and she readily participated in her portion of the evaluation. She maintained good eye contact throughout the interview. There were no tics or abnormal behaviors noted. She was moderately fidgety throughout the interview but remained in the same general area within the room. Erin seemed to engage with me quickly with charming mannerisms.

Her speech was of normal rate, tone, and volume. She described her mood as “OK now.” Her affect was slightly superficial but generally full range and appropriate. Her thought form was clear and organized. There were no psychotic symptoms elicited. Erin was able to talk about her wishes to die and seemed to have some understanding about the permanency of death. She denied having current ideas or thoughts about wanting to die. She did admit at times to having a high degree of frustration, but she had a difficult time articulating emotions or events that precipitated these.

Erin was able to talk about worries and her desire to have all things perfect. Despite my asking numerous questions, no specific obsessions were identified. Erin was able to discuss her frustration about her difficulty making friends and interacting with others.

My initial diagnostic impressions included mood disorder, not otherwise specified; anxiety disorder, not otherwise specified; and oppositional defiant disorder. I was particularly concerned about whether her explosive pattern of mood dyscontrol was an early presentation of bipolar disorder. In addition, because of her need for order and symmetry and her high level of perfectionism, at times I was also considering if her specific anxiety symptoms were caused by obsessive-compulsive disorder. Because of the high level of potentially harmful behaviors, the unpredictability of her explosiveness, and the need for better diagnostic clarification, she was referred to a partial hospitalization program.

Erin participated for 2 weeks at the partial hospitalization program and was successfully discharged with a diagnosis of mood disorder, not otherwise specified and impulse control disorder. I was not involved in her treatment during her stay, but by report clonidine was prescribed to reduce her impulsivity. She was reported to have learned better ways of expressing her anger and frustration. Her mood was described as more stable and predictable, although she remained easily frustrated and periodically angered. Educational recommendations that were forthcoming from the partial hospitalization program suggested an educational placement in a full-time emotional support classroom. Her local district did not have a full-time emotional support classroom in its district, so she was referred to this type of classroom in a center program.

I was one of the psychiatric consultants at the school to which Erin was referred, and for the remainder of her second-grade year and the beginning of her third-grade year, I remained peripherally involved in her care. In my consultative role with the center, I did not meet with Erin or her parents, but I was available for staff consultation. Within that setting Erin was placed in a first- through third-grade classroom with six other students. The teacher was a special education teacher. A social worker was assigned part-time to the classroom, which included 30 minutes a week of individual therapy for Erin. A behavioral-level system existed within the classroom where positive behaviors were reinforced. At times of excessive behavioral disruption, students were removed from the classroom to a single room where staff was available to help the students deescalate.

Erin continued to display aggressive and oppositional behaviors in the classroom. Her level of aggression put herself and others at risk, as she would throw heavy items at staff and began to strongly bang her head on objects. By the fall of her third grade year, Erin spent more time in a time-out room isolated from her peers than she was able to spend in a classroom doing work. The behavioral outbursts became increasingly unpredictable again. She was noted to cry easily and excessively. She continued to have times of talking in what was described as “gibberish.”

During this time, a psychiatrist affiliated with the partial hospitalization program Erin had previously attended managed her medications. Because of her increased mood shifts, the clonidine was changed to Risperdal. During this time, it was becoming clearer that her mood episodes were consistent with mania. It was hoped that Risperdal would stabilize her moods and reduce her aggression. Also during this time Erin received mental health treatment with a team of wraparound providers. Wraparound support is a mental health service where a child can receive individual supports where ever that child is. For example, a therapeutic support staff can provide prompt behavioral redirection in a classroom, on the playground, in the home, or in the community. A behavioral specialist consultant can provide behavioral planning and support to the parents and teachers. A therapeutic support staff was assigned to work with her during the school day. It was hoped that a person with mental health training would be able to prevent some of Erin’s anger and frustrations so she could remain within the classroom setting. A mobile therapist was assigned to work with Erin at home, and this person also began to address the conflict at home between Erin and her sister.

Three months into her third grade academic year, it became clear to Erin’s home school district, the treatment team at the center, her wraparound agency, and her parents, that she was not making educational or therapeutic progress. Her moods remained labile and unpredictable. She needed to control her environment, and any change was met with significant aggression and oppositionality. She was also becoming increasingly aggressive to her sister, and her parents were having more concerns about her sister’s safety at home. A decision was made to have her transitioned to a school-based partial treatment center where she would receive more intensive educational and therapeutic support.

For continuity of care, Erin was transitioned to a program where I was the treating psychiatrist. In this program, Erin was one of eight students with a special education teacher, educational aide, classroom therapist, and classroom mental health aide. A psychiatrist was involved for classroom consultation and medication management. In addition, the family participated in monthly meetings with the psychiatrist and therapist.

This setting allowed some very important information to be added to her clinical history. Erin’s mother likely had unrecognized and untreated postpartum depression for the first 6 months of Erin’s life. Erin had pronounced irritability during her infancy. She was likely experiencing significant pain while trying to feed because of the unrecognized broken collarbone. From a temperamental perspective, she was difficult to soothe and cried often and easily. Her mother’s depression in combination with Erin’s irritability made the attachment and bonding more tenuous. Her attachment to her mother was likely insecure. The described difficulty with transitions began to make more sense in the context of an insecure attachment with her mother. Her father was able to soothe Erin more easily, and she seemed to form a strong connection with him.

Erin also had a very difficult time adjusting to her sister’s birth when she was 2 years old. The adjustment was complicated by her mother’s identified postpartum depression and her father’s decreasing availability due to his increased work demands. She returned to her very irritable disposition, which was more apparent because of her sister’s easy temperament.

In addition, it was learned that there was a family history of anxiety disorders in numerous extended family members. Not all of these individuals had received formal diagnoses or treatment, but the core struggles were present in several aunts and uncles. These included separation anxiety disorder, generalized anxiety disorder, and specific phobia. There was also a positive family history for mood disorders, specifically postpartum depression in mothers. In addition, several maternal family members likely experienced major depression. Several extended family members were treated with SSRI (selective serotonin reuptake inhibitor) medications successfully.

Erin’s aggression was targeted primarily toward her mother and sister. This had been conceptualized as a disrupted psychological connection. Specifically, she had a less secure attachment with her mother, and anger at her sister for “replacing” her. There was an increased genetic likelihood for mood disorders and anxiety disorders, as learned by the family history.

Differences in her parents’ style of parenting had also begun to emerge. Erin viewed her father as her primary playmate. He was easygoing and played often with her. Although this was positive, she struggled to comply with parenting requests that he made. Because of her reluctance to cooperate, his solution was to place fewer demands on her to avoid the anger explosions. Her mother was more emotionally distant and often became the primary disciplinarian. This role acted to further distance Erin from her mother, and her mother became the primary target of her anger.

Within this educational setting, Erin had begun to make educational progress. For the first month, she completed very little academic work and would spend long portions of time each day drawing detailed mazes. This activity seemed to be a way to engage the classroom adults and allowed her to remain in a room with other students. As she began to adjust to the classroom participation, in-group activities were encouraged. She initially resisted interacting with peers, preferring the adults, but with gradual and titrated support from staff, she was able to begin to integrate with a few peers. However, she continued to prefer adult attention.

Erin had been able to successfully make use of the adjoining therapy room. Although it took several weeks, she was now able to ask to leave the classroom when frustrated and go to the therapy room where she could have brief breaks of play or other therapeutic interventions. She would frequently make use of a mini trampoline to help her deescalate from her anger.

Behavioral interventions were not the focus of this program, but there was some use of a token economy and achieving points for positive behavior. Erin had been able to use the positive reinforcement in a way that had helped her begin t...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Series Editors’ Foreword
• Preface
• 1. Introduction to Psychiatry in Schools
• 2. Psychiatric Evaluation and Formulation
• 3. Psychiatric Roles
• 4. Psychopharmacology
• 5. Disruptive Behavior Disorders
• 6. Mood Disorders
• 7. Anxiety Disorders
• 8. Psychotic Disorders
• 9. Eating Disorders
• 10. Pervasive Developmental Disorders
• 11. Treating Target Symptoms
• 12. Medicating Children
• 13. Mental Health Crises
• References
• Index
• CD Contents