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Embd Chilliwack Embd Chilliwack Presentation Transcript

  • 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
  • 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
  • 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.