CHAPTER 17: Helping Students With Mental and Emotional Disorders

1. CHAPTER 17:Helping Students With Mental and Emotional Disorders Transforming The School Counseling Profession Fourth Edition Bradley T. Erford

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 20 has a serious mental or emotional illness. Of children ages 9-17 years who have a serious emotional illness, only 20% receive mental health services. Children are presenting with mental health concerns at younger ages.

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. Leaders in the counseling field argue that the role of school counselors is still evolving, while others believe that new delivery systems for providing school-based mental health services are required (Bemak, Murphy, & Kaffenberger, 2005)

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. 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.

9. Current & Future Trends in the Way Services Are Provided The U.S. Dept. of Ed. and the U. S. Dept. of Health and Human Services (2008) are encouraging preventive care. Schools are a logical place to implement programs to both prevent and ameliorate mental health problems in students and their families. In many schools, this responsibility is shared between the professional school counselor and outside agencies, or contracted out completely.

10. 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.

11. 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.

12. What Professional School Counselors Need To Know About Mental & Emotional Disorders (cont.) The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 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. With the parent’s permission, they may be asked to provide input from the school, including observations, behavioral checklists, and samples of schoolwork.

13. Mental Disorders In Infants, Children, & Adolescents 1. Intellectual Development Disorder 2. Learning, Motor, and Communication Disorders 3. Autism Spectrum Disorders 4. Attention-deficit Hyperactivity Disorder & 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

14. Intellectual Development Disorder- Diagnosis IDD, formerly known as mental retardation, has an impact on cognitive, emotional, and social development. IDD is diagnosed from results of individual intelligence tests, such as the WISC-IV and the SBIS-5 (IQ<70). To be diagnosed with IDD, 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. IDD is usually diagnosed in infancy or early childhood. About 1-2% of the population is diagnosed as IDD. Boys are 3 times more likely than girls to be diagnosed with IDD.

15. Intellectual Development Disorder- Degrees Borderline Intellectual Functioning- People with an IQ that is in the 71-84 range and are not diagnosed with IDD Four Degrees Of Intellectual Disability Mild IDD - The IQ score is in the range of 50-55 to 70. Moderate IDD - IQ score is in the range of 35-40 to 50-55. Severe IDD - IQ score is in the range of 20-25 to 35-40. Profound IDD - IQ score is below 20-25.

16. Intellectual Development Disorder- Causes Biological Causes 25-30% of people with IDD 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

17. Intellectual Development Disorder– 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

18. Intellectual Development Disorder- Prognosis Adults with a mild level of IDD often live independently and maintain a job with minimal supervision. People with moderate IDD may be able to live independently in group homes. Those with severe and profound IDD will probably reside in public and private institutions.

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

20. Specific Learning, Motor, & 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.

21. Learning Disorders 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.

22. Dyslexia (Reading Disorder) Dyslexia 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.

23. Dyscalculia (Mathematics Disorder) Approximately 1% to 6% of the population has a mathematics disorder Children with dyscalculia have difficulty with math problem-solving, calculations, or both.

24. Dysgraphia (Disorder of Written Expression) This disorder is rarely found in isolation. In other words, another learning disability is often also present. Children with dysgraphia have difficulty with handwriting, spelling, grammar and/or the creation of prose. Care must be taken to differentiate these disorders from underachievement, poor teaching, lack of opportunity, and cultural factors

25. Communication Disorders Three Communication Disorders are identified in the DSM-5: 1. Language Disorder 2. Speech Disorder 3. Social Communication Disorder Also included: Unspecified Communication Disorder* * Unspecified is the diagnosis for disorders that belong in the category but don’t fully meet the diagnostic criteria for any specific disorder Language disorder is diagnosed when language skills are significantly below expectations based on nonverbal ability and interfere with academic progress and involves an inability to use developmentally appropriate speech sounds.

26. Specific Learning, Motor, & Communication Disorders Approximately 35-40% of boys with learning disorders 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 disorders.

27. Specific Learning, Motor, & 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.

28. Specific Learning, Motor, & 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

29. Specific Learning, Motor, & 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.

30. Autism Spectrum Disorders (ASD) ASD is diagnosed in approximately 1 in 88 people (CDC, 2012). Males with ASD outnumber females by 2.5:1. Four conditions were described in the DSM-IV-TR, in addition to PDD NOS, but these have all been shrunken onto a single spectrum in the DSM-5. Children with ASD are characterized by a flat affect, poor eye contact, language impairment, and minimal social speech. In addition, they do not seek social attention.

31. ASD & Prognosis For most, ASD will result in a lifetime impact. Early intervention, as well as technology and knowledge of effective treatment approaches have not yet advanced to allow these children to blend in seamlessly with their peer group. Those with mild ASD often succeed in becoming self-sufficient. Those with more severe ASD are likely to be placed into residential facilities as these disorders progress. EARLY INTERVENTION IS THE MOST IMPORTANT FACTOR FOR POSITIVE OUTCOME!

32. ASD & 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 ASD. Social skills and social communication training are beneficial for children with ASD.

33. ASD & 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 ASD are included in regular education classes.

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

35. Attention-Deficit/Hyperactivity Disorder (AD/HD) AD/HD is found in as many as 50% of children referred to counseling agencies. In 1995, public school systems spent more than $3 billion for services for children with AD/HD. AD/HD is divided into three types: Predominately Hyperactive-Impulsive Presentation Predominately Inattentive Presentation Combined Presentation (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

36. 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.

37. 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 nearly half 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.

38. 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.

39. 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.

40. Tic Disorders The DSM-5 identifies 4 Tic Disorders: Tourette’s Disorder Chronic Motor or Vocal Tic Disorder Provisional Tic Disorder Unspecified Tic Disorder Tics are defined as a recurrent, nonrhythmic series of movements and sounds (of a nonvoluntary nature) in one or several muscle groups. These symptoms are typically worse under stress, less noticeable when the child is distracted, and diminish entirely during sleep. More common in boys and an elevated incidence in children with other disorders such as AD/HD, Learning Disorders, Pervasive Developmental Disorder, Anxiety Disorders, and Obsessive-Compulsive Disorder.

41. Tic Disorders - Tourette’s Disorder Characterized by a combination of multiple motor tics and one or more vocal tics that have been present for at least one year. These tics commonly interfere with academic performance and social relationships. Tourette’s disorder is diagnosed in 4-5 children per 10,000 and tends to run in families.

42. Tic Disorders - Prognosis & Intervention Strategies Prognosis Habit-reversal techniques (behavioral interventions) showed a 90% reduction in tics as compared to medication that showed only a 50-60% reduction. Intervention Strategies Identification of any underlying stressors, cognitive-behavioral method for stress management, education of children and families about the disorder, advocacy with education professionals, and collaborative work with physicians if pharmacological interventions are necessary. Behavioral strategies (e.g. relaxation training). Social skills training. Pharmacological treatment for children who do not respond to behavioral interventions (e.g. Haloperidol).

43. Tic Disorders - Relevance To Professional School Counselors Professional school counselors can provide sources of referral and information to parents and teachers during the diagnostic period. Suggestions concerning classroom modifications to reduce stress, rewards for behavioral control, and adjustment of academic expectations can be facilitated by the professional school counselor. Social skills training can be implemented to help children deal with peer relationship problems.

44. Disruptive Behavior Disorders The DSM-5 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% for males and females.

45. 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

46. 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.

47. 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.

48. Disruptive Behavior Disorders - Prognosis Prognosis is best when there has been late onset of symptoms, early intervention, and long-term intervention. An important element of successful treatment is parents’ support and participation.

49. Disruptive Behavior Disorders – Intervention Strategies Four types of intervention strategies are suggested: Individual counseling Family interventions School-based interventions Community interventions Residential or day treatment programs are recommended when the child poses a danger to self or others. School-based interventions may include early education, classroom guidance units, classroom instruction, home visits, and regular meetings with parents.

50. Disruptive Behavior Disorders - Relevance to Professional School Counselors Of all the categories of mental disorders, professional school counselors will have the greatest need to be knowledgeable about AD/HD and Disruptive Behavior Disorders. School personnel and parents may look to the counselor for guidance. Frequently children are not diagnosed with Disruptive Behavior Disorders until they enter school; therefore, professional school counselors may need to work closely with parents to help them understand these disorders and make referrals.