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Mental Health 2018-19

 

Kristin Moore, Psy.D.
Clinical Psychologist

Kristin received her doctorate degree in clinical psychology from John F. Kennedy University. Her specialty is in the area of child and adolescent psychology, and she has provided mental health and psychodiagnostic assessment services to children, adolescents, and their families in California community mental health clinics and hospitals for over a decade. Her interests include trauma, mood disorders, and bilingual and projective assessment.

 

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  • new!What to do about out of control behavior for a general education student with mental health needs?

Question:

Hello,

I am a Resource Specialist, who has volunteered to help in an elementary classroom with tier one and two supports. In particular, there is a student who has been officially diagnosed as having ADHD, Mood Disorder, and Anxiety. His parent has indicated that doctors feel certain it is Bipolar Disorder, but that he is too young for that diagnosis.

The student, the teacher, and the classroom assistant are all struggling. An SST has been held, and a follow-up SST is in the making. However, I was asked to assist because of several reasons:

  1. Frustration on the teacher’s and aide’s part; not knowing what to do, or feeling like she’s unable to do what’s being asked
  2. Student is getting kicked out of class multiple times a day, 4 to 5 days a week
  3. Student engages in yelling, screaming, running away, physical aggression, not following directions, task avoidance, etc.

We are in the process of taking observable and measurable ABC data, but I am wondering if you have any go-to solutions/strategies that we can implement with a student like this, with these known diagnoses.

Thanks!


Answer:

This is an excellent question that cannot be answered without first considering the problem this student’s behavior is causing. In order to proceed to work on his mental health issues, you will need to address his behavior.

Behavior Interventions:

When considering how to intervene with this student from the perspective of addressing the significant behavior reported above, there are several first step strategies and ideas to keep in mind:

Identify the problem
While there is some consideration that should be taken regarding student specific diagnoses, the external symptoms that manifest as maladaptive behavior are what teachers and school staff can focus on, rather than the labels that may be attached to them. The most important question for the team to consider is what is the cause, or function of the disruptive behavior. Given that this child has a complex mental health profile, it is likely that at least some of the behavior is driven by internal emotional factors. This kind of behavior requires a combined approach that addresses both the external behavior and the internal emotional distress. Therefore, keep in mind that behavior intervention will help with decreasing disruptive behavior, but it is only one piece of the intervention approach for this child.

The Goal: Create a plan
This student may require intensive intervention to address his complex behavior and mental health needs. It sounds like your team has started this process by collecting ABC data. From that point, it may be appropriate to:

  • Involve a professional who has expertise in data analysis and determine the function of the behavior.
  • Create a Behavior Intervention Plan that outlines how the student will learn a more appropriate replacement behavior, rather than engage in the maladaptive behavior, that meets the same functional need.
  • Create a dense positive reinforcement system that will allow immediate and highly attainable access to desired activities/items several times per day for appropriate behavior.
  • Determine what triggers the behavior (antecedents) and determine if any preventative strategies can be put in place to decrease the likelihood that the behavior will occur. This is particularly important given that the student will likely be learning new coping tools within a therapeutic setting…and that takes time.

Implement Tier One (and Two) Positive Behavior AND Social Emotional Supports

It will take time for the higher level interventions described above to come together, especially at this time of year. In the meantime, it is important that the team focus on ensuring that supports are being provided for behavior and social emotional wellness at the Tier 1 and 2 levels. Sometimes it is easy to overlook the “basic” strategies because the behavior is so severe. However, the consistent implementation of these supports can often be highly effective. Several “highlights” from each tier of support, as well as some robust lower tier resources, are listed below.

Universal and targeted Positive Behavior Supports

  • Ensure that the learning environment has 3-5 positively worded rules that are explicitly defined and referenced throughout the day
    • Consider: Be Safe, Be Responsible, Be Respectful
  • Provide direct behavior feedback when the student is following the rules. Catch them being good!
  • Provide more positive verbal reinforcement – the more the student struggles the more positive feedback they need. Aim for 5 positive interactions for every 1 redirection
  • Align work and academic demands with the student’s personal areas of interest. Provide instruction at the student’s level
  • Use simple first/then statements when you want the student to engage in non-desired tasks or activities (i.e., First do 5 minutes of math, then you can have computer time)

Universal and targeted Social Emotional Supports

  • Create a safe and supportive learning environment (see resources for environmental checklist of strategies)
  • Address fundamental needs prior to placing a demand – this may include ensuring that students are not hungry, have adequate sleep, and are physically well enough to learn
  • Spend time creating a trusting relationship with all students (but especially the difficult students). This is a primary support that must be in place for students struggling with social/emotional difficulties to learn
  • Create physical and emotional safety in the classroom
    • Tell students “it is my job to keep you safe.”
    • Ask students “how will you know you’re safe in my classroom?”
  • Keep the perspective that the big picture isn’t about the work – it’s about helping students be more successful
  • Provide daily instruction in Social Emotional Learning, using evidence-based curriculum

Resources

Mental Health:
Once this student’s behavior is under control, you will need to start addressing some of his underlying emotional struggles. Because I am missing significant details about the manifestation of his ADHD, anxiety, and mood disorder, I have just listed a couple of key considerations under each reported diagnosis.

ADHD
This student likely has significant difficulties with inattention, impulsivity, hyperactivity, or any combination thereof. Additionally, students with ADHD often struggle with executive functioning and self-monitoring.

  • Add a rating scale to all assignments. This student will benefit from the practice of rating how hard he perceives a task/request to be, and then afterwards rating how hard the assignment actually was. This helps a learner with ADHD understand how their aversion to the task can often be worse than the reality of the task itself. Rating is generally done on a scale of 1 to 5.
  • Use a visual timer so the student has a better understanding of the time quoted, and can visually see how long certain tasks will take.

Anxiety
This student likely experiences frequent worry, fear, and distress. He may suffer from somatic symptoms including headaches, stomachaches, or fidget on a regular basis. Additionally he might feel a significant need for control and demonstrate rigidity when faced with changes in routines and transitions.

  • Provide more structure and consistency in the classroom setting. The student should have a visual schedule, and the ability to check off tasks as they are completed.
  • Identify the stressors that are causing anxiety and utilize Cognitive Behavioral Therapy (CBT) interventions such as teaching relaxation strategies, or providing fidgets or sound-cancelling headphones and other supports that could decrease his distress.

Mood Disorder/Bipolar Disorder
This student probably struggles with emotional regulation. He likely has intense reactions to various people, tasks, and situations. A student with emotional dysregulation will need help expressing their thoughts and feelings in a more prosocial manner.

  • Consider incorporating therapeutic supports that teach emotion identification and coping skills for dealing with “big feelings.”
  • Use role playing and create a “tool kit” of skills and options the student can use in various situations where they tend to struggle.

On a side note: considering this student’s profile, I wonder about the possibility of trauma, given the strong overlap between trauma symptoms and the three disorders outlined above. This might be something to keep in mind.

Good luck!

Kristin N. Moore, Psy.D.
Clinical Psychologist

Tara Zomouse, M.Ed., BCBA, NCED
Behavior Analyst/Education Specialist


  • ID, Anxiety, Behavior

Question:

Hello,

I am writing to ask about students with intellectual disabilities who display signs of anxiety related to traumatic experiences, as well as oppositional behavior, at school. These students are being referred for ERMHS services on a consistent basis in our district. Can you provide us with information on the efficacy of counseling services for these students?


Answer:

This is a great question. Generally speaking, one’s ability to benefit from traditional counseling services depends on a number of factors including cognitive capacity, awareness, motivation, and insight. Traditional therapeutic services or “talk therapy” may be beneficial for some individuals with intellectual deficits, but it might not always be the best option when the student lacks the ability to reflect on emotional struggles at a deeper level. Even in such cases, however, there are a number of behavioral and coping strategies that can be taught to help decrease internalized distress and oppositionality. It is important to note that individuals with intellectual disabilities often experience anxiety due to their struggle to make sense of the world around them; anxiety disorders are highly comorbid with intellectual deficits. Similarly, oppositional defiant behavior can occur for various reasons. It could be viewed as a way to communicate a preference or an aversion, a way to take back control, or a means to escape, avoid, or seek attention. It’s helpful to try to identify what is driving the anxiety or oppositional behavior before starting intervention services.

Depending on a student’s cognitive capacity, strategies will vary in complexity, and may require additional modifications. For example, therapeutic services may include more visuals and concrete interventions. There may be a need for increased structure and repetition, with decreased emphasis on abstract and intangible concepts. Adding a behavior system with rewards might also be beneficial. These interventions work towards shaping and modeling preferred behavior. The most critical aspect will be to make sure that the therapeutic interventions are appropriate for the student’s level of functioning. It is important to meet each student at their level, and tailor interventions to their particular needs. Like their typically developing peers, students with intellectual disabilities experience anxiety and trauma. Their ability to express and make sense of it, however, may require alterations to traditional interventions.

Thank you for your question,

Kristin
  • Social Emotional Learning (SEL)

Question:

Hello, I am working to increase mental health awareness in my classroom. Could you provide some recommendations about where I can start?


Answer:

This is a great question. In February of 2018, State Superintendent of Public Instruction, Tom Torlakson, announced that the California Department of Education had released new guiding principles for teaching social and emotional skills in order to ensure students have the necessary capacity to support their future development. I will outline the five guiding principles with summarized descriptions below.

  1. Adopt Whole Child Development as the Goal of Education
  • Systems change: Embed and promote Social Emotional Learning (SEL) across education (i.e. mission statements, school policy, instructional practices).
  • Diverse and inclusive leadership: System change is most effective when driven by bringing people together with diverse backgrounds.
  • Social and emotional skills development: Students and adults have the opportunity to practice, demonstrate, and reinforce social and emotional skills.
  • Student-centered discipline policies and practices: Discipline policies are aligned with prompting social and emotional growth.
  • Climate and culture: SEL and school climate are interrelated and reciprocal.
  1. Commit to Equity
  • Address the opportunity gap: Opportunities to build SEL must be offered to all students.
  • Ensure representation: When the workforce is representative of and connected to the student body, academic, social, and emotional outcomes improve for students.
  • Student and adult-led: SEL efforts are most effective when schools are participatory and engage diverse voices.
  • Healing-informed: Educational experiences must seek to counteract the institutional and structural biases and related trauma that often drive inequitable outcomes.
  1. Build Capacity
  • Positive relationship and belonging: To cultivate resilience to adversity and build the foundation for social emotional growth.
  • Student and adult competencies: Identify specific, research-based social emotional competencies to address (e.g. self-awareness, self-management, relationship skills, etc.).
  • Developmental standards: To bring intentionality to practice, identify SEL teaching and learning standards.
  • Pre-service training and ongoing professional learning: Professional learning should address student social emotional development.
  1. Partner with Families and Communities
  • Family engagement: Provide families with options for meaningful contributions.
  • Expand learning: Establish shared goals across all youth serving settings.
  • Early learning: Consider the inclusion of early learning and care programs as SEL systems are developed.
  • Community partnerships: Address basic needs of students through partnerships with community-based organizations and other local stakeholders.
  1. Learn and Improve
  • Implementation plans and progress monitoring: Adopt policies and practices that highlight places where additional resources or supports are most necessary.
  • Measurement: Social Emotional skill development should be tracked and outcomes should be reported and studied.

While the above guidelines are aspirational, the intention is that schools will continue to adopt policies that are directly linked to social emotional development and child wellbeing. I recommend starting with ways you can implement these guidelines into your classroom milieu. This will be an important first step working towards creating a positive, mental-health informed environment.

I am also including the link to California’s SEL Guiding Principles

https://www.cde.ca.gov/eo/in/documents/selguidingprincipleswb.pdf

Sincerely,

Kristin Moore, Psy.D.
  • Social-Emotional Learning

Question:

Good Afternoon,

I am a 4th grade teacher and I am wondering if you could provide some information about the new social emotional learning guidelines.


Answer:

In February of 2018, the California Department of Education (CDE) released guidelines related to Social-Emotional Learning or SEL. SEL has been defined as the process by which children learn how to acknowledge and express their emotions in a healthy manner. SEL promotes empathy, friendship, and overall wellbeing, which together allow students to problem solve and interact in their environments in a more attuned and positive manner. The guidelines were created by a planning team in the fall of 2016. The planning team consisted of 35 educators and was part of the Collaborating States Initiative. After several meetings, the following five guidelines were identified:

1. Adopt Whole Child Development as the Goal of Education
2. Commit to Equity
3. Build Capacity
4. Partner with Families and Communities
5. Learn and Improve

After each guideline, additional information and examples are provided to help schools consider ways to implement them. It should be noted that overall the guidelines are general in how they are written. The intention is to afford schools significant latitude to decide what interventions and approaches will work best for their districts.

See the links below for more detailed information regarding the CDE SEL guidelines. Additionally, I recommend looking at the Collaborative for Academic, Social, and Emotional Learning (CASEL) website, which outlines specific competencies in social emotional learning and provides several tools to help promote SEL in educational settings.

RESOURCES:
California Department of Education SEL Guidelines:

https://www.cde.ca.gov/nr/ne/yr18/yr18rel15.asp

CASEL: Collaborative for Academic, Social, and Emotional Learning:

https://casel.org/


  • Supports for youth over summer break

Question:

I am a single parent with a full time job. I am worried about the upcoming summer vacation, and how my 8-year-old son will do with his grandmother. Last summer was awful, and I am concerned that his behavior will be too much for my mother this year. Do you have any recommendations?


Answer:

Summer vacation can sometimes be a difficult time for children. It is important to recognize how much structure and routine is built into a typical school day. Children know exactly where they are supposed to be, when they are supposed to be there, and what is expected of them.  Rules and limits are clear, and children have constant access to peers and supportive adults throughout the day.

When it’s time for summer break, the predictable routine of the school term is interrupted. Children’s waking and sleeping hours can vary, and days often lack consistency or routine. For some children, the absence of structure and organization can be overwhelming and anxiety producing. These feelings may cause children to test limits by engaging in more challenging behaviors to assess new boundaries and see where rules will be imposed. In essence, these children are “asking” for more containment and structure, because limits ultimately lead to a sense of safety and stability. When children know what to expect, their levels of fear or anxiety naturally decrease.

It will be important for your family to create a summer routine that incorporates more structure and predictability, especially as it complements your lifestyle and your child’s interests. There are several day and overnight camps offered to families during the summer months. Some of these camps cost money while others are free. There are also a variety of programs offered at public places like libraries and parks. It is a good idea to start looking at options now, as space can be limited. I also recommend speaking with your child’s teacher; sometimes schools have a list of opportunities and activities available for children during the summer vacation.


  • Trauma, PTSD

Question:

I was reading a student’s evaluation and saw that the psychologist diagnosed her with Complex Trauma. Could you please clarify the difference between Complex Trauma and Posttraumatic Stress Disorder?


Answer:

Posttraumatic Stress Disorder (PTSD) is a diagnosis listed in the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5). An individual has to exhibit specific symptoms in order to receive a diagnosis of PTSD. I have summarized the diagnostic criteria below:

A. Exposure to actual or threatened death, serious injury, or violence.

B. The presence of intrusion symptoms associated with the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s).

F. The symptoms last for more than a month.

G. The symptoms cause clinically significant distress and impairment in functioning.

In 1980, the diagnosis of PTSD was added to the DSM-III in order to provide appropriate services for soldiers returning from the Vietnam War. It was reported that many were experiencing negative mental health symptoms, including anxiety, nightmares, restricted range of affect, difficulty sleeping, and the tendency to want to avoid any stimuli that would provoke reminders of the combat experience. Since that time, the diagnostic criteria has changed very little.

An individual who has experienced trauma does not necessarily meet criteria for a diagnosis of PTSD. For example, a child may live in a neighborhood that is unsafe--bearing witness to several assaults and robberies. We can say that the child has experienced trauma, but unless he/she/they present with intrusive memories, emotional dysregulation, marked avoidance, and the other symptoms listed above, it would not be appropriate to diagnose that individual with PTSD. This example highlights a significant distinction; experiencing a traumatic event(s) in and of itself does not necessarily equate to a diagnosis of PTSD.

A relatively new and developing sphere in trauma research explores the concept of Complex Trauma. Complex Trauma, also known as Developmental Trauma Disorder (DTD), or Complex Posttraumatic Stress Disorder (C-PTSD), produces negative mental health symptoms as a result of having to endure repeated traumas of an interpersonal nature. Individuals who demonstrate symptoms consistent with C-PTSD often times do not meet criteria for PTSD, but struggle with specific, negative mental health sequelae. Examples of situations that could lead to the development of C-PTSD include a child experiencing repeated abuse with no ability to escape, sex/trafficking, or exposure to chronic domestic violence. 

Currently, C-PTSD is not a recognized disorder in the DSM-5; however, many professionals use the label in order to communicate a specific cluster of symptoms, as C-PTSD can be a more accurate way of describing an individual’s clinical presentation. While there is not one unifying definition of C-PTSD, the following elements are generally considered when characterizing it:

A. Emotional regulation (i.e. affect dysregulation, sadness, anger, suicidal thoughts)

B. Attention/Consciousness regulation (i.e. inattentive, dissociative, forgetting)

C. Self-Perception (i.e. guilt, shame, ineffectiveness, minimizing)

D. Relations with others (i.e. interpersonal discord, distrust, withdrawal)

E. One’s system of meanings (i.e. helplessness, despair, misattributions)

An individual who is described as having C-PTSD has likely experienced repeated trauma to the point that profound changes have occurred in how he/she/they view themselves, others, and the world. And given the fact that complex trauma/C-PTSD is not in the DSM-5, it would be important to ask the professional making the clinical distinction for additional information regarding that individual’s symptoms and behaviors across various settings.

In sum, you can experience trauma without meeting criteria for PTSD or receiving a label of C-PTSD. PTSD is recognized as a diagnosable disorder in the DSM-5, where C-PTSD is not. C-PTSD is used to describe a specific cluster of symptoms that tend to be displayed after an individual has experienced repeated trauma of an interpersonal nature.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
U.S. Department of Veteran Affairs. (2016, February). PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp


  • Who to Help a Student Who is Showing Signs of Depression

Question:

Hello, I am a fifth grade teacher and I have a question about a student who I suspect is depressed. This is a child who, at the beginning of the school year appeared much happier, and was talking and engaging with his peers. Now, he is more withdrawn, he doesn’t participate unless I call on him directly, and he appears to be in a bad mood most of the day. Do you have any recommendations about how to best help this student?


Answer:

Hello,

Thank you for sending in this great question.

First, I would like to highlight that it is normal for children and adolescents to go through periods where they experience increased feelings of moodiness or sadness. Children are highly susceptible to their surrounding environments, and there may be extenuating circumstances that are negatively impacting this student, such as family discord, peer struggles, or academic difficulties. It is concerning, however, that you mention this student has been behaving differently for the past few months. The fact that his withdrawn presentation is persisting, and represents a marked change from his affect at the beginning of the school year, warrants support.

When children are struggling to cope with stress, it can be difficult for them to know how to articulate their feelings. Depending on the child, the emotional turmoil could be internalized, externalized, or a combination of both. It will be important for this student to feel that he has a safe and caring place to share his thoughts and feelings without judgment or fear of consequences. I usually encourage teachers to start by asking the child if everything is okay, or to offer support. Sometimes kids don’t like being called on in class if they are having trouble keeping up, or if they are being bullied by others. If a teacher becomes aware of such issues, they will be better equipped to support the student in working towards a resolution.

There are also moments when students share that they are struggling with issues in their personal lives, or simply acknowledge that something is bothering them, without providing details. In these moments it may be most helpful to offer continued support, but also help the student identify someone with whom they feel more comfortable talking. This could be a favorite teacher, a sports coach, or an office support staff member. We want to encourage students to seek an adult who can help provide emotional support and aid in problem solving. Other resources may include school psychologists or trained mental health professionals who work on campus.

Finally, sometimes after checking in with a student, it is recommended that caregivers be contacted. Often this serves to increase communication between school and home, and lets the child know that there is a broad support system available to him/her. Strengthening the contact between school and the student’s caregivers also decreases the risk of the child “slipping through the cracks,” which could lead to further deterioration of the student’s mental health functioning. Children need to feel safe, respected, and cared for. Providing an empathetic, non-judgmental space is the first step in identifying how best to support the student’s current needs. I’m glad that you were able to notice these symptoms in your student, and I hope that you will have a chance to meet to talk with him soon.

Sincerely,
Kristin Moore, Psy.D.