Working with Students with Intensive Mental Health Intervention Needs

Purpose

The purpose of this module is to discern the difference between Tier 2 and Tier 3 needs and to explore some of the traditional mental health approaches as well as alternative school placement for children experiencing persistent psychiatric disabilities.

Retrieved from: TOT 2: Working with Students with Intensive Mental Health Intervention Needs (2019)

What’s the difference between Tier 2 and Tier 3?

You demonstrated a clear understanding of Tier 2 interventions in your previous course. You identified that Tier 2 interventions are for students at-risk for behavioral and mental health issues. You designed and developed group interventions since small groups are the primary Tier 2 approach.

In theory, only about 15% of the students in any given school would require the second level of support, or Tier 2 services. Even fewer students should need Tier 3 supports. It is estimated that 5% of students will require additional support beyond small group interventions. Tier 3 is only for those few students who need more intensive support in addition to the school-wide supports. Students receiving Tier 3 services have usually been identified or diagnosed with emotion, behavioral, and/or psychiatric disorders. It is important for OT Practitioners to have an understanding of symptoms associated with psychiatric disorders, as many Tier 3 interventions address symptom reduction as a way to support increased participation and engagement in school and life activities.

Watling and Nielsen review the psychiatric disorders identified in children in Chapter 5 of the Occupational Therapy in Mental Health Advanced Practice book by Scheinholtz. You will find the chapter in the Readings and Resources folder. Familiarize yourself with this chapter before you continue through the TOT 3 course.

Note that the diagnosis of Bipolar is no longer used for children. The DSM 5 now classifies children who show signs of affective disorders as having something called Disruptive Mood Dysregulation Disorder (DMDD). View this 2-minute video on why this change was made then read through the information regarding this new disorder here: https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorder-dmdd/disruptive-mood-dysregulation-disorder.shtml

Tier 2 and Tier 3 Supports can also be differentiated according to intensity and frequency of support. Tier 3 interventions are provided much more frequently, perhaps daily. Also, Tier 3 services are usually provided at a greater intensity and may be delivered one-on-one.

For additional information and a review of key concepts, please look over Tier 3: Intensive Supports Guide: https://ecsd-fl.schoolloop.com/file/1346930923545/1341557484889/1685804588073933351.pdf

Retrieved from: TOT 2: Working with Students with Intensive Mental Health Intervention Needs (2019)

Children requiring Tier 3 services in schools typically:

Are identified with emotional, behavior, or psychiatric disorder
Have some of the poorest outcomes of all disability groups
Face school-based services that are seriously inadequate
Are often segregated in restrictive settings and are at risk of getting even fewer related services
Are missed as 9-14% of students who would likely benefit from supportive services do not receive them because their behavior is not unacceptable enough to warrant the severely emotionally disturbed (SED) special education category and/or their academic performance is not significantly impaired
Have outcomes that are even more limited because students live in poverty and/or belong to racial minority groups (Macklem, 2011; Sokol, 2009)

Identifying children who may need/benefit from Tier 3 mental health supports can be difficult especially as it is easy to overlook children who may hide their distress. It is important to look for students who present with emotions that are not consistent or typical for the given context or situation. Look for students who exhibit anger, angry outbursts, or extreme emotions in situations that would not typically be as upsetting to most other individuals. Inappropriate behavior or reactions may suggest underlying mental health concerns. Be aware of students who exhibit emotions more intensely and for longer periods then would be considered typical, compared to their peers. Another issue to consider is difficulty switching one’s attention away from an event, person, and situation when he or she cannot deal with the fact that the event/situation/or interaction with the person has occurred. (Macklem, 2011).

Retrieved from: TOT 2: Working with Students with Intensive Mental Health Intervention Needs (2019)

General Discussion Post:

A powerful example of kids with Tier 3 needs is this video of a Therapeutic Day School in the City of Chicago. This video was filmed a number of years ago and is an example of a severely underfunded program within a part of the city that is rife with violence. The school was closed down (essentially) in 2015. All the students were transferred back to their neighborhood schools or to privately run therapeutic day schools. Here is an article if you are interested. http://www.chicagoreporter.com/montefiore-now-a-school-without-students-but-says-cps-it-is-not-closed/

This is the first of a multi-part series. For our purposes I would like you to simply observe some of the tier 3 behaviors in kids who are not likely receiving the mental health support they need. The students in this school have been exposed to a number of things most kids never see. It is also important to note that most of the mental health services on the south side of Chicago were closed due to budget issues and lack of funding for social services in the early 2000s and very little has happened to bring them back – a few have reopenned. BEWARE of the language. It is rough.

https://www.youtube.com/watch?v=n-B_kmAebbQ&list=PLw613M86o5o6Aj8MXuh9GK5ZooRpLMGBp

It is important to understand that this isn’t a typical therapeutic day school. Despite the challenges the staff appear to be dedicated to the students although some are clearly undertrained. The first episode is nearly 30 minutes. You don’t need to watch the whole thing but watch at least 10 minutes, maybe skip around a little, to get a sense for the behaviors. There is a scene in the gym that is worth watching as it shows how these are still just kids. Be aware that it is easy to see these kids as just bad kids. Keep in mind they are kids who have seen and experienced too much. They also have serious learning challenges, mental health diagnosis and sensory issues and PTSD. Watch the level of alertness, the constant attention to the environment, the fear and the anger (so often anger is the result of fear). Think about what we have talked about earlier in the TOT courses. What is the purpose behind their behavior???

Once you have watched the video post your thoughts about the video in the discussion titled TOT3 Week 2: Tier 3 Behaviors. Speculate on some of the reasons behind some of the behavior you saw in the video. What insight could OT bring to a setting like this? What sorts of interventions do you think would be important to incorporate in this school setting?

After watching the video on the therapeutic day school, I was astonished by the behaviors that some of the children expressed towards not only their peers, but to the teachers and staff as well. Working in a school like that has got to be so challenging and frustrating. It seemed like every time they made an inch of progress, the next day would come and the kids were pushed back a mile. This never-ending battle appeared to cause strain on the students, and it prevents them from learning in school. I think most the behavior is due to the children’s home environments and their inability to feel safe at home, at school, and in the community. I think the behaviors are a defense mechanism to protect themselves from others sensing their fear. The community that they are being raised in is dangerous and full of violence for unprovoked reasons. I would assume most of the children are being raised in single family homes, have parents that are absent due to addiction, or have parents that have a low level of education and are unable to provide proper guidance through their own behaviors. From my experience babysitting young children, one of the most important things I have learned is that children like structure and rules. Children who do not receive that structure usually act out and seek attention from their parents in different way, typically by behaving poorly. As an OT, I think structure, guidance, and accountability provide a strong foundation for not only school, but the foundational skills learned can be used in their home lives as well and throughout their community. A school like the one in the video should have more structure, more responsibility for the students to contribute, and more understanding of the behavior by taking a more psychological approach and explaining why the behavior was wrong versus punishing the child for a behavior they may think is normal. I think an intervention that models proper behaviors, as well as responsibility is something that should be implemented into a school like this one. For example, having expectations to come into the school and put their things in a specific spot, come into the room, and have weekly roles. By instilling some guidance from the OT perspective and bringing some meaning into the children’s lives, the behavior may carry over to their life outside of school.

It is worth stopping to talk about Therapeutic Day Schools as this is a potential employment option for people who like mental health and school practice. Read Bazyk Chapter 10: Occupational Therapy for Children with Severe Emotional Disturbance in Alternative Education Settings.

Although Barnes, Vogel and Beck (authors of the chapter) state that few OT’s work in this setting, this is the school setting I worked in for a number of years. It was nothing like Montefiore. I really enjoyed working at this school. I felt like we made a huge difference in the lives of the kids and parents. Doing therapy while kids are engaging in a typical daily occupation fits well with the recovery model and with the evidence to support the role of occupation in recovery. The goal of the therapeutic day school is to return the kids to their home school with the skills to function successfully. Our school had an average length of stay of three academic years.

Therapeutic day schools have some drawbacks. They are focused on primarily two things, academics and counseling, and often lack access to extra-curricular that are really important for social and emotional development. There is often a PE or sport program but few schools offer things like clubs, access to learning an instrument, art education, music performance, playacting, or courses like home economics, woodworking, mechanics, or other trade based programs. In my school I introduced the recorders to my kids and participated in field trips, explored volunteer options, helped with the Christmas concert and typically looked for any opportunity to infuse some of these extra school experiences into the program, along with my IEP goals. I wasn’t alone as the teachers and counselors also saw the value of engaging the kids in experiences beyond the usual academics and counseling. We also developed a school wide sensory and trauma informed care program which changed the atmosphere of the school dramatically.

Retrieved from: TOT 2: Working with Students with Intensive Mental Health Intervention Needs (2019)

Anxiety disorders are the most common psychiatric disabiilty of school-aged students. Social anxiety and other anxiety disorders may lead to depression and externalizing behaviors. The COPING CAT program, developed at Temple University, addresses anxiety and is based on cognitive behavioral treatment (CBT) strategies. It is the most widely researched and used program for anxiety disorder and received the highest evidence-based rating on SAMHSA’s National Registry of Evidence-Based Programs and Practice. If you’re interested, review the article included on COPING CAT (Beidas et al., 2010). Consider how OT Practitioners may be able to support COPING CAT and how engagement in occupation may support the main principles of the program. Consider how OT Practitioners can use CBT strategies to complement occupation-based and occupation-focused approaches. For more information about CBT, check out this link https://www.youtube.com/watch?v=bUOaHsxe8OQ (if link is not active, cut and paste into your browser). Feel free to find and review a few more resources on CBT.

Retrieved from: TOT 2: Working with Students with Intensive Mental Health Intervention Needs (2019)

TOT Scholars

You recently participated in a standardized teacher experience. Please take some time and review your video. Then, answer the following two prompts in a word document and send as an attachment to Lisa at lmahaf@midwestern.edu:

1. Provide a brief summary of the video contents and how it demonstrates your ability to support and/or provide information that can inform mental health interventions and strategies to optimize present and future occupational engagement in school. (200-250 words recommended)

2. Describe the insights you have gained and reflect on how the analysis experience will likely inform your future practice in school settings and efforts to expand the role of OT practitioners to provide school-based mental health services. (400-500 words recommended)

After sending this to Lisa save one in your portfolio. It can serve as a good outline for Self-Analysis of Video Recording which can be used to address several different criteria for AOTA Board and Specialty Certifications.

TOT Simulation Encounter Reflection

During my simulation the teacher and I discussed many different topics involving Annie and her transfer into the new school she will be attending in the fall. The two of us discussed potential behavior issues, what the teacher’s concerns are for Annie, and what potential accommodations can be made to make her day a little bit easier. I advised the teacher on some of the group therapy mental health programs I have learned about throughout the TOT modules. I used to the Par Fore program as an example that might be beneficial for the students in this PSD classroom. It works on behavior by having to follow rules, as well as social skills because most sports require teamwork and communication skills. I suggested other sports that might be more accessible at the school to avoid any forms of transportation to a golf course. The teacher seemed on board with the suggestion and eager to include the rest of her class in the program opportunity. Once instilled within this classroom, a program like this could potentially continue to help the PSD programs in the future, as well as help the students that participate take some of the learned behaviors and communications skills to the next phase of their lives.

One thing I learned about myself, which I mentioned in the feedback, is that I like to talk, so I don’t think I did a great job making the teacher feel like it was her classroom. I think I came almost too over prepared because I wasn’t sure how much information the actress had prior to my arrival. In the future, I would sit back and maybe take more of a listen role. I did, however, feel like I did a good job answering her questions (which she had a lot of). I felt like she asked me a bunch of questions which also played into why it appeared like I did most of the talking. I think this experience allowed me to gain some insight on when I should be a listener and not so overbearing. Throughout the entire time I was in the room, the teacher appeared interested and intrigued to hear what I had to say and how my suggestions could help not only Annie, but the rest of her class as well. She asked great questions and I felt like I was prepared to answer all of them, other than the ones about Annie that we both did not know about her. As the actress pointed out as well, I thought my ability to turn Annie’s situation into a case of strengths was also an important thing to note because she has been through a lot and many times behaviors are a reflection of how a child is treated or ignored. I think my point to make sure Annie had a line of defense prior to being judged based on past behaviors was a good thing to include within this session. She is in a new environment with all new people, so having the freedom to start over is something that should be considered. Overall, I think I did okay. I wouldn’t say it was my best performance, but I do think I was prepared and seemed well-educated on the topics we talked about.

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