1. Emotional and Behavioural Disorders EPSE 317

2. AUNTIE LIZZIE’S STORY TIME: This is Gwendolyn:

3. 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.

4. 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.

5. 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.

6. 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.

7. 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

8. 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

9. 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.

10. What’s going on? What should we be asking?

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

12. 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)

13. 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.

14. 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.

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. Tertiary Prevention: Specialized Individualized Systems for Students with High-Risk Behavior CONTINUUM OF SCHOOL-WIDE INSTRUCTIONAL & POSITIVE BEHAVIOR SUPPORT FEW ~5% Secondary Prevention: Specialized Group Systems for Students with At-Risk Behavior ~15% SOME Primary Prevention: School-/Classroom- Wide Systems for All Students, Staff, & Settings 23 ALL ~80% of Students From Sugai, 2006

22. Mental Health: Internalising Depression Anxiety

23. 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.

24. Depression in Young Children Sadness Distance (“far-away look”) Anger and aggression Timidity, fearfulness Moodiness, irritability Physical complaints—stomach ache, headaches, nausea, sleep troubles

25. 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

26. Triggers Biological basis for depression But can be triggered by changes in child’s circumstances— Loss Move Parent separation New baby Etc.

27. Diagnosis Physician, psychologist, psychiatrist Depression inventories Observation

28. 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)

29. 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

30. Diagnosis By psychiatrist, psychologist or MD Treatment Therapy Medication (SSRIs again)

31. 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.

32. Back to Gwen: Let’s assume a diagnosis of clinical depression and develop an IEP Diagnostic information Goals? Collaboration and scheduling

33. 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)

34. 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

35. Adaptations to program? Reduce work load Minimise physical education but encourage exercise. Time frame? Grade 7 exams.

36. 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

37. 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)

38. 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

39. 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

40. 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.

41. 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.

42. 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.