Chapter Sixteen

1. Chapter Sixteen Helping Students With Mental and Emotional Disorders

2. Helping Students The professional school counselor’s primary responsibility is to help students learn. The No Child Left Behind Act of 2001 and school reform movement has increased the pressure to focus on academic achievement for all students. Environment and mental health issues affect an increasing number of children and are affecting student achievement, which makes it difficult for schools to provide an appropriate education for each child.

3. Prevalence of Mental Disorders and Mental Health Issues in Children and Adolescents One in five children and adolescents has a mild to moderate mental health issue; one in twenty has a serious mental or emotional illness. Of the children, ages 9-17, who have a serious emotional illness, only 20% receive mental health services. Children are presenting with mental health concerns at a younger age.

4. Prevalence of Mental Disorders and Mental Health Issues in Children and Adolescents (cont.) Suicide is the third leading cause of death for adolescents after accidents and homicide. It is estimated that 7% of adolescents who develop a Major Depressive Disorder will commit suicide and that 90% of teens who commit suicide have a mental disorder. High incidences of violent, aggressive and disruptive behavior is another reflection of children’s emotional difficulties.

5. Factors Contributing to a High Incidence of Emotional Disturbance Three factors are related to the prevalence of mental disorders and mental health issues affecting children and adolescents: Environmental factors (e.g., breakdown of the family, homelessness, poverty, violence in the community) are rising and are likely to result in an increase in mental health needs. Low-cost mental health services are limited. Special education legislation focusing attention on children’s special needs has increased.

6. Factors Contributing to a High Incidence of Emotional Disturbance (cont.) Children from ethnic and cultural minority groups are at risk for mental disorders and are overrepresented in special education programs. Children and adolescents of color have been unserved or underserved and have had their emotional difficulties overlooked or misdiagnosed. Estimates suggest that 48% of students with emotional problems drop out of school and that students with severe emotional problems miss more days of school than those in any other disability category. Lack of adequate community-based mental health resources puts pressure on schools to provide those services.

7. The Professional School Counselor’s Role The role of professional school counselors is in a period of transformation. The focus has shifted from emphasis on a personal growth model that promoted individual development in the 1950s and 1960s to a more recent focus on a comprehensive developmental model with emphasis on educational goals. There are arguments as to whether or not professional school counselors are doing enough to meet the complex needs of at-risk children. Dryfoos (1994) envisions full-service schools where community mental health resources combine forces with school and other agencies to provide adequate mental health services for students.

8. Barriers To Providing Mental Health Services In The Schools The ability of professional school counselors to meet the needs of students with mental health issues is limited by: Workload and non-counseling-related responsibilities Duties beyond those described by professional standards, such as lunch duty, bus duty, after-school functions, and administrative duties. Fragmentation and duplication of services and programs School- and community-based services and programs often have been developed in isolation, without consideration of existing services and programs.

9. Barriers To Providing Mental Health Services In The Schools Discrepancy between the professional school counselors’ need to understand mental disorders and their knowledge base Not all professional school counselors possess the knowledge, experience, and expertise needed to recognize the mental health needs of students.

10. Current & Future Trends In The Way Services Are Provided Some schools have increased their use of community and private resources by hiring psychiatrists and using outside consultants to treat students. A current service model includes professionals from different disciplines collaborating to promote mental health in children and adolescents (Flaherty et al., 1998).

11. Benefits Of The Direct Service Model Students who attend schools with fully implemented mental health programs are more academically successful and have a greater sense of belonging and safety. Comprehensive community-based services to children cut state hospital admissions and inpatient bed days by between 39 and 79 percent and reduced average days of detention by 40 percent. In order to maximize effectiveness, professional school counselors need to develop interdisciplinary and interagency relationships and practices.

12. What Professional School Counselors Need To Know About Mental & Emotional Disorders Professional school counselors must understand normal social, emotional, cognitive, and physical development. In addition, they should possess knowledge about mental disorders and mental health issues affecting youth. Professional school counselors need to be aware of the range of mental disorders in order to identify students experiencing emotional problems, interpret diagnostic information, and recommend school-based interventions.

13. What Professional School Counselors Need To Know About Mental & Emotional Disorders (cont.) The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) contains the criteria for diagnosing disorders. The professional school counselor generally is not expected or trained to make diagnoses. However, they will be expected to: Identify young people in need of mental health services. Consult with other school-based mental health professionals. Make referrals to outside community agency resources. Communicate mental health reports to school personnel and parents.

14. What Professional School Counselors Need To Know About Mental & Emotional Disorders (cont.) With the parent’s permission, they may be asked to provide input from the school, including observations, behavioral checklists, and samples of schoolwork.

15. Multiaxial System of Diagnosis The DSM-IV-TR uses a multiaxial approach to diagnosis to facilitate a comprehensive and systematic evaluation of a person. Axis I: Clinical Disorders (e.g., conduct disorders, eating disorders, anxiety disorders, mood disorders, etc.) Axis II: Mental Retardation and Personality Disorders Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems (e.g., occupational, family, or educational stressors) Axis V: Global Assessment of Functioning

16. Mental Disorders In Infants, Children, & Adolescents 1.Mental Retardation 2. Learning, Motor, and Communication Disorders 3. Pervasive Developmental Disorders 4. Attention-Deficit Disorders & Disruptive Behavior Disorders 5. Eating Disorders in Children & Adolescents 6. Tic Disorders 7. Elimination Disorders: Encopresis & Enuresis 8. Separation Anxiety Disorder 9. Selective Mutism 10. Reactive Attachment Disorder 11. Mood Disorders 12. Substance-Related Disorders 13. Psychotic Disorders 14. Obsessive-Compulsive Disorder 15. Posttraumatic Stress Disorder 16. Generalized Anxiety Disorder 17. Adjustment Disorders

17. Mental Retardation - Diagnosis Mental Retardation (MR) has an impact on cognitive, emotional, and social development. MR is diagnosed from results of individual intelligence tests, such as the WISC-IV (IQ<70) and the SBIS-5 (IQ<70). To be diagnosed as MR, onset must be prior to age 18 years, the student must possess sub-average intellectual functioning, and have impaired adaptive functioning in at least 2 of the following areas: Communication, social skills, self-care, home living, interpersonal skills, self-direction, leisure, functional academic skills, health, safety, or work. MR is usually diagnosed in infancy or early childhood. About 1-2% of the population is diagnosed as MR. Boys are 3 times more likely than girls to be diagnosed with MR.

18. Mental Retardation - Degrees Borderline Intellectual Functioning- People with an IQ that is in the 71-84 range and are not diagnosed with mental retardation. Four Degrees Of Mental Retardation Mild Retardation- The IQ score is in the range of 50-55 to 70. Moderate Retardation- IQ score is in the range of 35-40 to 50-55. Severe Retardation- IQ score is in the range of 20-25 to 35-40. Profound Retardation- IQ score is below 20-25.

19. Mental Retardation - Causes Biological Causes 25-30% of people with mental retardation have biological causes. Down’s Syndrome is a genetic type of mild or moderate retardation. Neurological Causes Neurological causes may be associated with more than 200 physical disorders, such as: Cerebral Palsy, Epilepsy, and Sensory Disorders. Environmental Causes

20. Mental Retardation – Intervention Strategies Early intervention is essential. Examples of interventions: Special education, home health care, language stimulation, and social skills training can have a positive impact. Family, group and individual counseling can be effective in promoting positive self-regard and improving social, academic, and occupational skills. Behavior modification

21. Mental Retardation - Prognosis Adults with a mild level of retardation often live independently and maintain a job with minimal supervision. People with moderate retardation may be able to live independently in group homes. Those with severe and profound retardation will probably reside in public and private institutions.

22. Mental Retardation - Relevance To Professional School Counselors Professional school counselors: Are involved in the identification of children with mild retardation. Help families understand and accept the diagnosis and make the transition to an appropriate school program. Provide social skills training. Educate other students about Mental Retardation to promote their understanding and tolerance.

23. Learning, Motor Skills, & Communication Disorders Children diagnosed with these disorders function significantly below normal expectations in a specific area, based on their age, cognitive abilities and education, as well as when their level of functioning is interfering with daily achievement.

24. Learning Disabilities Learning disabilities affect approximately 10% of the population, but are diagnosed in about 5% of students in U.S. public schools. Common Learning Disorders include: Reading Disorder (dyslexia) Mathematics Disorder (dyscalculia) Disorder of Written Expression (dysgraphia) These disorders are characterized by significant difficulties in academic functioning in a specific area.

25. Reading Disorder Reading Disorder is diagnosed in approximately 4% of the school-age population. Approximately 60-80% are boys. Children with this disorder have difficulty decoding unknown words, memorizing sight-word vocabulary lists, and comprehending written passages.

26. Mathematics Disorder Dyscalculia is a Mathematics Disorder in which children have difficulty with problem-solving, calculations, or both.

27. Disorder of Written Expression Dysgraphia is a disability of written expression. This disorder is rarely found in isolation. In other words, another learning disability is often also present. Children with this disorder have difficulty with handwriting, spelling, grammar and/or the creation of prose.

28. Communication Disorders Five Communication Disorders are identified in the DSM-IV-TR: 1. Expressive Language Disorder 2. Mixed Receptive-Expressive Language Disorder * Children who possess characteristics of disorders 1 & 2 display language skills that are significantly below expectations based on nonverbal ability and interfere with academic progress. 3. Phonological Disorder * Failure to use developmentally expected speech sounds that are appropriate for the individual’s age and dialect.

29. Communication Disorders (Cont’d) 4. Stuttering * Speech fluency interferes with the child’s ability to communicate or make good academic progress. 5. Communication Disorder - Not Otherwise Specified (NOS) * NOS is the diagnosis for disorders that belong in the category but don’t fully meet the diagnostic criteria for any specific disorder.

30. Learning, Motor Skills, & Communication Disorders Approximately 35-40% of boys with Learning Disabilities have at least one parent who had similar learning problems. Learning Disorders are associated with low socioeconomic status, poor self-esteem, depression, and perceptual deficiencies. Children with these disorders are often unhappy in school, have negative self-images and social difficulties, and show increased likelihood of dropping out of school. Depression, AD/HD and Disruptive Behavior Disorders will often coexist with learning disabilities.

31. Learning, Motor Skills, & Communication Disorders - Intervention Strategies Primary interventions occur at school. Children who demonstrate a significant discrepancy between intelligence and achievement may be eligible to receive special education services. An Individualized Education Plan (IEP) is developed. The IEP specifies areas of weakness, strategies for addressing deficit areas, behavioral goals, and criteria for determining whether goals were met. Motor or attention on-task behaviors are also included in the IEP. Interventions, counseling, individualized teaching strategies and accommodations, and social skills training are also aspects included in some IEP objectives.

32. Learning, Motor Skills, & Communication Disorders - Prognosis Learning Disorders (LD) continue to have an impact throughout adolescence and adulthood. If left undiagnosed and untreated, LD can lead to extreme frustration, loss of self-esteem, inadequate education, underemployment, and more serious mental disorders

33. Learning, Motor Skills, & Communication Disorders - Relevance to Professional School Counselors Professional school counselors: Serve on child study and special education committees tasked with screening and identifying children with LD. Are often the first to be aware of how learning problems are affecting the child’s performance in the classroom, home, and with peers. May be required by the IEP to provide individual or group counseling, help parents and children to understand and cope with the diagnosis, and implement accommodations. Act as a consultant or collaborator in dealing with coexisting issues, such as low self-esteem. Coordinate support groups for students with Communication Disorders.

34. Pervasive Developmental Disorders (PDD) PDD is diagnosed in approximately 10 to 20 cases per 10,000. Males outnumber females by 2.5:1. Four PDDs are described in the DSM-IV-TR, in addition to PDD NOS: Autistic Disorder Rett’s Disorder Childhood Disintegrative Disorder Asperger’s Disorder Children with PDD are characterized by a flat affect, poor eye contact, language impairment, and minimal social speech. In addition, they do not seek social attention.

35. Autistic Disorder Present in 2 - 20 of every 10,000 people. Causes significant deficits in socialization, communication, and behavior. Symptoms are evident by age three years. Mental retardation accompanies this diagnosis 75% of the time. Ability to communicate varies. Children with this disorder do not form close relationships with others and instead engage in repetitive interactions with inanimate objects.

36. Rett’s Disorder & Childhood Disintegrative Disorder Both disorders are: Less prevalent than Autistic Disorder. Characterized by normal development in early childhood (5 months-4 years for Rett’s and 2-10 yrs. for Childhood Disintegrative Disorder) followed by a steady deterioration. Rett’s Disorder Only diagnosed in females. Results in severe or profound retardation. Childhood Disintegrative Disorder Results in significant regression in at least 2 of the following areas: Language, social skills, elimination, play and motor skills.

37. Asperger’s Disorder Characterized by impaired social skills and repetitive or stereotypical behaviors, not characterized by the delayed language development and impairment in communication skills. Boys are diagnosed with this disorder five times more frequently than girls.

38. PDD & Prognosis Autistic Disorder - Some lead independent lives; however, 2/3 require care throughout their lives. Asperger’s Disorder- Have the best prognosis. Many succeed in becoming self-sufficient. Rett’s Disorder and Childhood Disintegrative Disorder- most likely these individuals will be placed in residential treatment facilities. **EARLY INTERVENTION IS AN IMPORTANT FACTOR FOR A POSITIVE OUTCOME**

39. PDD & Intervention Strategies Special education services may include: language and physical therapy, services of neurologists, medical specialists, and behavioral therapists. Smith (2001) suggested using Social Stories, a short story format to inform and advise the child about a situation. Therapeutic goals may include: development of social and communication skills, enhancing learning, and helping the family cope. Behavioral treatments have been found to be particularly effective in helping children with Autistic Disorders. Social skills and social communication training are beneficial for children with Autistic and Asperger’s Disorder.

40. PDD & Relevance To Professional School Counselors Professional school counselors may help siblings cope, as well as help parents access supportive resources (e.g. behavioral training programs). Professional school counselors may need to provide educators with resources as students with PDD are included in regular education classes.

41. Attention-Deficit Disorders & Disruptive Behavior Disorders These disorders have a high rate of comorbidity. Children with AD/HD or Conduct Disorder also often have Learning Disorders.

42. Attention-Deficit/Hyperactivity Disorder (AD/HD) AD/HD is found in as many as 50% of children referred for counseling. In 1995, public school systems spent more than 3 billion dollars for services for children with AD/HD. AD/HD is divided into three types: Predominately Hyperactive-Impulsive Type Predominately Inattentive Type Combined Type (both of the above simultaneously) To be diagnosed with AD/HD: Onset must be prior to age seven years Symptoms must occur in two or more settings Must interfere with social, academic, or occupational functioning. Symptoms need to be present for at least six months

43. Attention-Deficit/Hyperactivity Disorder (AD/HD) (cont.) Symptoms may include failure to give close attention to details, difficulty sustaining attention, poor follow-through on instructions, failure to finish work, difficulty organizing tasks, misplacement of things, distraction by extraneous stimuli, and forgetfulness. Diagnosis is made through medical, cognitive, and academic assessments, as well as through behavior rating scales and observations.

44. Attention-Deficit/Hyperactivity Disorder (AD/HD) - Prevalance Prevalence rates range from 3-7% of children. AD/HD is diagnosed in boys 2-9 times more frequently than girls. AD/HD is diagnosed in 44% of children receiving special education services. Girls with AD/HD had lower ratings on hyperactivity, inattention, impulsivity and externalizing problems and greater intellectual impairment and internalizing problems than boys; however more research is needed to clarify gender differences. High rates of diagnosis draw particular attention to the ways in which children are assessed. Diagnostic assessments remain controversial.

45. Attention-Deficit/Hyperactivity Disorder (AD/HD) - Prognosis The prognosis for treatment of AD/HD is good. Behavioral interventions have been found to reduce off-task and distractible behaviors. In addition, psychostimulant medications are used to help individuals with AD/HD stay on-task.

46. Attention-Deficit/Hyperactivity Disorder (AD/HD) Intervention Strategies Behavioral strategies and the use of stimulant medications are the most commonly used intervention strategies. Behavioral strategies include developing token economy systems. Common medications include Methylphenidate (Ritalin) and Dextroamphetamine (Dexadrine). Other medications include Adderall, methylphenidate (Concerta) and Strattera. The goal of intervention includes staying on task, completing work, and following directions. Social skills training programs, group therapy, and skill development are other intervention strategies.

47. Disruptive Behavior Disorders The DSM-IV-TR describes two additional Disruptive Behavior Disorders: Conduct Disorder Oppositional Defiant Disorder (ODD) Prevalence rates for Conduct Disorder include 6-16% of males under the age of 18 years and 2-9% of females. Prevalence rates for ODD are 2-16%.

48. Disruptive Behavior Disorders - Diagnosis Diagnosis requires the presence of repetitive and persistent violations of the basic rights of others or violations of major age-appropriate societal norms. Conduct Disorder can be diagnosed when the student displays: Aggression against people and animals Destruction of property Deceitfulness or theft Serious violations of rules

49. Disruptive Behavior Disorders - Conduct Disorder Conduct Disorder is divided into childhood-onset and adolescent-onset types. Adolescent-onset type is diagnosed when no symptoms are present before the age of 10 years. Many children with ODD qualify for the Conduct Disorder (CD) diagnosis during adolescence and, by the age of 18 years, CD sometimes has evolved into Antisocial Personality Disorder.

50. Disruptive Behavior Disorders - ODD ODD is characterized by a pattern of negativistic, hostile, and defiant behaviors lasting at least 6 months. Behavioral characteristics include losing one’s temper, arguing with adults, defying or refusing to comply with adults’ requests, deliberately annoying people, being angry and resentful, being easily annoyed by others, blaming others for one’s own negative behavior, and being vindictive. ODD is correlated with low socioeconomic status and growing up in an urban location. Symptoms usually first appear around the age of 8 years. ODD is more prevalent in childhood in boys than girls, but by puberty equal numbers are diagnosed.