Behavioral Supports for Students Addressing Mental Health Needs

Behavioral Supports for Students: Addressing Mental Health Needs Leah Benazzi & Robin Fernstrom Behavior Consultants/School Psychologists Beaverton School District leah_benazzi@beaverton. k 12. or. us robin_fernstrom@beaverton. k 12. or. us

Agenda Common mental health diagnoses in the schools Mental health diagnoses and special education eligibility Understanding mental health issues as representative of Lagging Skills Behavior Support at three levels Preventative Interventions Skill Building Interventions Response Interventions Potential role of school nurses at each level of intervention

Common mental health diagnoses in the schools ADHD (SPED classification: Other Health Impairment) Autism Spectrum Disorder (SPED classification: Autism Spectrum Disorder) Anxiety Disorders (SPED classification: Emotional Disturbance) Conduct Disorder (SPED classification: Emotional Disturbance if it manifests in conjunction with an Emotional Disturbance) Depression (SPED classification: Emotional Disturbance) Bipolar Disorder (SPED classification: Emotional Disturbance) Eating Disorders (SPED classification: Emotional Disturbance if related emotional issues impact education performance) Self-Harm/Mutilation (SPED classification: Emotional Disturbance if related emotional issues impact education performance) Some students may be served via a 504 plan or may be in the general education population.

ADHD Inattentive Type, Hyperactive Type, or Combined Type Symptoms include (but are not limited to): Daydreaming Fidgeting or being in near constant motion Lack of organization and lack of work completion Difficulty with sustained attention Excessive talking Impulsivity Frequently trouble waiting for one’s turn. Six of nine total DSM-V characteristics must be endorsed (with additional criteria) for individuals younger than age 12, five of nine for those over age 12.

Autism Spectrum Disorder A developmental disability significantly affecting verbal and nonverbal communication and social interaction. Other characteristics that may be associated with autism are engagement in repetitive activities, stereotypic movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. Essential features are typically, but not necessarily, manifested before age three. In Oregon Schools, core characteristics include impairments in: • Communication • Social Interaction • Patterns of behaviors, interests, and/or activities that are restricted, repetitive, or stereotypic • Unusual responses to sensory experiences

Anxiety Disorders Primary characteristic is worry – a fear that future events will have negative outcomes Separation Anxiety Disorder Generalized Anxiety Disorder Posttraumatic Stress Disorder Social Phobia May present as: inattention, perfectionism, forgetful behavior, withdrawal and reluctance to participate, and truancy.

Conduct Disorder (CD)/Oppositional Defiant Disorder (ODD) CD: a repetitive and persistent pattern of behavior in which the rights of others or age-appropriate societal norms or rules are violated. At least 3 of 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to people and animals Destruction of property Deceitfulness or theft Serious violations of rules The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. ODD is differentiated from CD based on the defiance of rules and argumentative verbal interactions involved in ODD; CD involves more deliberate aggression, destruction, deceit, and serious rule violations.

Major Depressive Disorder Five of the following symptoms almost every day for at least two weeks. Number one or two must be endorsed. 1. Depressed mood most of the day, almost every day, indicated by student report or by the report of others 2. Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day. 3. Significant weight loss when not dieting, or weight gain. 4. Inability to sleep or oversleeping nearly every day. 5. Psychomotor agitation or retardation nearly every day. 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day. 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide. There must be clinically significant impairment in an important area of functioning. There also exclusionary criteria related to substance use, schizophrenia, mania, and other psychotic disorders.

Bipolar Disorder A mental health condition that is characterized by periods of both mania and depression; the criteria for bipolar requires at least one depressive episode and one manic episode. Mania must have at least three of the following symptoms: inflated self-esteem, little need for sleep, pressure of speech (talking constantly), flight of ideas, easily distracted, excess pursuit of goal-directed activities or psychomotor agitation (pacing, hand wringing, etc. ), excess pursuit of pleasure with a high risk of danger Depression: must have at least four of the following symptoms: Changes in appetite or weight, sleep, or psychomotor activity, decreased energy, feelings of worthlessness or guilt, trouble thinking, concentrating, or making decisions, thoughts of death or suicidal plans or attempts Bipolar I disorder involves one or more manic episodes or mixed (mania and depression) episodes while Bipolar II disorder has one or more severe major depressive episodes with at least one hypomanic (less severe mania) episode. Cyclothymia is characterized by fluctuating low-level depression along with periods of hypomania. Rapid-Cycling Bipolar Disorder is a severe form of bipolar disorder, occurring when a person has at least four episodes of major depression, mania, hypomania, or mixed states within a year.

Eating Disorders Binge Eating Disorder: Recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with binge eating disorder may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. Anorexia Nervosa: Primarily affects adolescent girls and young women. Characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat. Bulimia Nervosa: Frequent episodes of binge eating followed by inappropriate behaviors such as self-induced vomiting to avoid weight gain.

Self Harm /Self Mutilation Repetitive Self-Mutilation Syndrome (RSM) Behaviors include cutting, scratching, burning, head banging, preventing wounds from healing, picking, poking, and hair pulling. Generally considered an impulse disorder (the same category as substance abuse, eating disorders, etc. ). Incidents occur episodically (not every day) and there is some gratification achieved contributing to its repetitive nature. The brain releases endorphins following self-injury. Individuals report feeling relief, release, calm, and satisfaction. This is a maladaptive coping mechanism for strong emotions or feelings of anxiety and sadness. Occurs with Depression, PTSD (there is a correlation with sexual and physical abuse), and other mental health disorders.

Understanding mental health issues as representative of Lagging Skills Students may have various mental health diagnoses and it is essential for school-based specialists to have basic knowledge about a student’s mental health, however… Regardless of their diagnoses, it is useful for school-based personnel to view a student’s emotional, behavioral, and mental health profile as indicative of lagging skills in one or more areas: Executive Functioning Language Processing Emotional Regulation Cognitive Processing Social Skills Educational settings require students to have skills in these five areas to experience educational and social success. Conceptualizing student needs in terms of Lagging Skills helps us get specific about student supports without becoming bogged down in mental health lingo and diagnoses.

Behavior support at three levels Preventative Interventions – How can the environment be altered to reduce the student’s exposure to proven triggers? Skill-Building Interventions What instruction can the student receive to help develop new skills and behavior – particularly in areas of lagging skills? Response Interventions How can the environment be altered to reduce or remove aversive stimuli and pair desired behavior with reinforcement?

Preventative Interventions Sample Interventions Break tasks into smaller units. Reduce or avoid unexpected situations. Provide a quiet space with few distractions Potential Role of School Nurse Act as known supportive/trusted person that students can visit when feeling overwhelmed (before acting in a maladaptive manner). Allow for proactively scheduled and known breaks (may include movement, drawing, journaling, reading etc. ) Provide information to staff about warning signs for various mental illnesses to increase their ability to act proactively to support their students. Change format of communication with the student (for example, allow written instead of oral presentation for a student with anxiety). Provide fact sheets with the side effects of commonly used medications to improve staff awareness and ability to share useful information with doctors. Pair a student with a trusted peer. Provide organizational support via a planner or schedule.

Skill-Building Interventions Sample Interventions Modify broad mental health information (for example cognitive behavioral therapy goal areas) to observable/measurable counseling goal for a student’s IEP. Provide the student with opportunities to participate in supportive general education activities such as Friendship Groups. Teach the student how and where they may access emotional supports at school. For example, develop a protocol for various recurring mental health-related events. Potential Role of School Nurse Communicate with doctors and mental health professionals regarding how skillbuilding, counseling, and therapy goals may inform school-based supports. Teach wellness, nutrition, stress management, and mood/emotional awareness. Teach students (if appropriate) and staff about health management protocols.

Response Interventions Sample Interventions Reinforcement /incentive systems for younger students Increased freedom, independence, or privileges for older students Design safety plans as needed following a risky event. Potential Role of School Nurse Membership on Crisis Team (or similar) with school psychologist, counselor, and social worker to respond to observed mental health issues Provide general information and resources to students about various disorders and where they may obtain help and support.

Resources American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D. C: American Psychiatric Association. Beaverton School District Special Education Handbook livesinthebalance. org (in addition to Ross Greene’s books and conferences on Collaborative Problem Solving) nasponline. org pbis. org (in addition to various Functional Behavioral Assessment texts by Rob Horner and others)