- Email: [email protected]
Consultation in the Classroom
SCHOOL CONSULTATION /INTERVENTION
1056--4993/01 $15.00
+
.00
CONSULTATION IN THE CLASSROOM H. A. P. Myers III, MD
Consultation by observing in the classroom and working closely with the school staff brings to children the great advantages of accurate diagnosis and educational progress. Furthermore, there are two advantages for a child and adolescent psychiatrist actually working within a school setting: direct observation and early detection. First, the difficulties the child is having can be observed directly, resulting in a much greater validity of diagnosis. In my practice, these classroom observations are always supplemented by playground observations. There, I can see the quality of socialization along with coordination and neurologic signs, if present-as seen in athletic skill or lack of same in ball play, on slides, and on gym rings. The hallways are also a place to observe activity such as aggressive interactions or avoidance. The second advantage is that when a child and adolescent psychiatrist is an in-house school employee, children with serious difficulties are seen earlier than they would be otherwise. Teachers' concerns for these children can be expressed more directly, and pertinent reports can be reviewed freely. Boise, Idaho, is the economically active home to the state capital, the newer high-tech companies, and the headquarters for Albertson's large grocery chain, as well as being the supply hub for the surrounding 250 miles. Boise Public Schools is a lively school district of 27,000 students of all socioeconomic levels and 1780 certified teachers teaching in 54 different buildings. Student teaching and learning are actively audited. For many decades, its students have been admitted to the best regional and national universities.
From the Boise Public Schools, Boise, Idaho
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 • JANUARY 2001
169
170
MYERS
DIAGNOSIS IN CLASSROOM, PLAYGROUND, AND FROM OTHER INFORMATION Diagnosis by Classroom, Playground, and Hallways Observation Gives Great Validity 1. Diagnostic criteria for disorders can be observed directly by
the clinician. During classroom observation, one sees the child's difficulties as they occur. Many of these observations rise to the level of diagnostic criteria in areas of sadness, anxiety, attention difficulties, interaction, and language as well as in dealing with autistic-like speech. Otherwise the clinician is more dependent on the less reliable test scores or reports of what someone else has observed. The playground allows the observer to view coordination and possible neurologic signs, and both hallway and playground observation show socialization qualities. The difficulties that the classroom teacher raised can then be discussed with the teacher, saying, "Was what you and I saw some of what you were concerned about?" And this helps assure the teacher that the clinician is observing her or his concerns. 2. Classroom and playground observation is a skill that the observing clinician must develop and is similar to those used for an interactive play diagnosis, conducting an interview, or watching a drama or group interaction. This skill can be learned and is a skill well worth developing. 3. Classroom, playground, and hallways observation, although valuable, do not stand alone. As I suggest in following sections, they must be combined with parental contact, consultation with other school professionals, and links to pediatric examination. Parents and School Add to These Above Observations
History from the Parents
The history-taking process, with parents, school staff, and helping agencies, moves along more validly and in-depth once the child and adolescent psychiatrist has actually observed much of the child's difficulties first hand. We physicians have been taught to start with a history. In clinic or office work most of us see the parents first, then the child. In my school consultation work I modify that by first obtaining the parents' permission to observe. After that, I ask for their input. These visits progress better than when taking the history first and then seeing the child. The parents are far more open and candid once they know I have observed what is going on with their child; they tend to withhold and deny less. The parents and I can then talk about my observations. After that they often will tell me any similar symptoms seen at home or
CONSULTATION IN THE CLASSROOM
171
in other members of the family. Observing the child before having the parent's detailed history makes the minimizing or denial of symptoms less likely. More Information Now from School-The Multidisciplinary Team
As in all of child and adolescent psychiatry, several different views need to be carefully combined to make a diagnosis. The m ultidisciplinary team (MDT) usually includes the school psychologist, the school nurse, the speech and language pathologist, the counselor, and a school administrator. After the observations and the first parent meeting, the MDT gathers to hear reports from its members. I also ask for a report from the physical education teacher about whether coordination is at age level and, if not, to describe the child's movements. Here I am screening for any possible neurologic signs. Previous central nervous system injury does, in my experience, have symptoms that can be confused with psychiatric difficulties. These meetings with the MDT greatly increase the depth of the overall picture. After the MDT meeting, teacher and support staff and I confer, and I may then interview the child or youth. I tend not to conduct interviews in earlier grades largely because I lose the ability to see the child in action in the class without his or her being too aware of me. On the other hand, if I interview the child, I receive his or her opinion and an idea of that child as an expressive person. If there is even a hint of physical problems, I suggest to parents that they get a pediatric consultation (history, physical, laboratory work, check for thyroid function, consideration for possible genetic defects, and diagnostic thoughts). As a pediatrician, I can perform some of these tests myself should the parents be unable to afford a pediatric consultation. In coordination with school staff, child/youth, and parents, I seek to arrive at a formulation, diagnostic impressions, recommendations, and plans. I follow up in 1 month to see how things are progressing. Because I am a fellow school employee, school staff can easily call me if there is a change. Case Examples
Attention Deficit Hyperactivity Disorder Variant
My most frequent referral is when the parents, invited to take their child to their primary physician with a check-off list from the school stating there is restlessness, lack of attention, not understanding instructions, and not completing work, receive the most likely diagnosis, Attention Deficit Hyperactivity Disorder (ADHD). However, the usual dose of medication not only does not help much but the child responds with
172
MYERS
increased upset and or somnolence. At this point I offer to consult with the primary physician. In the classroom I may see these symptoms but also some irritability, which is not common in usual ADHD. On the playground I may see some clumsiness, which the physical education teacher also reports. Then, when taking a history from the parents, I hear that the child has had perinatal distress, post-natal apnea attacks, and a closed head injury from going over the bicycle handle bars onto the surfaced road, or the child had in retrospect what probably was viral meningitis years before. With the irritability, clumsiness, and this positive new history my presumption is that this child has had a central nervous system insult that has resulted in all of the symptoms. Half the usual dose by weight of stimulant medication is all this child can take without side effects. Because even that amount provides some benefit to the child, it is worth continuing. Another case in which ADHD was first diagnosed was correctly rediagnosed as absence seizures. The teacher, alternatively, might have thought the child was daydreaming. Here again classroom observation pinpointed the difficulty. In these two examples and those that follow, the additional information gained during the consultation enabled better adaptation in the individual educational program and open the way for specific medical treatment. Intermittent Explosive Disorder
A frequent diagnosis is one in which the child becomes extremely unruly and fights a lot. I pick that up in the hallway and not in the supervised playground or classroom. There, the slightest irritations result in great anger, more than seems reasonable for the minimal provocation. In contrast to the first case, there is no history of a central nervous system insult. There is a family history of a similar temper, a normal electroencephalogram, and normal neurologic evaluation. With these findings, an Intermittent Explosive Disorder seemed a reasonable diagnosis. In one instance, staff reported that, in a parent conference, the mother of this boy seemed to bristle at parts of our report. Later, the mother acknowledged to me that she and her sister had difficulty controlling their tempers since childhood. Her son did much better on lithium. Pervasive Developmental Disorder
The signs of milder Pervasive Developmental Disorder (PDD) are seen readily on the playground (lack of socializing and little response to other children who may be inviting play). In the classroom I saw very different language, lack of facial response to affective events, being upset with change in schedule, and perhaps stereotyped, repetitive movements. These are usually not seen as readily in clinic or office visits. The recognition of PDD is important so that we can accommodate the instruction, as the thinking process is different in the autism spectrum.
CONSULTATION IN THE CLASSROOM
173
Anxiety Disorder
A third grader was not accomplishing work and seemed restless. The diagnosis of ADHD was entertained, but the medication made his behavior worse. The long history taking and conference with the parents revealed no history of CNS insults; however, the mother finally revealed that she had been diagnosed as having an anxiety disorder for which she was taking antianxiety medication, which helped her. I prescribed the same anti-anxiety medication, in a child's dose, and her son's symptoms in the classroom decreased and his attentiveness and grades increased. Depression, Compulsions, and Frank Signs of Psychosis. In other observations we can see behavior, schoolwork or lack of it, talking, and socializing that are significantly different from the age norm. These obervations bring up the possibility of an unusual formulation and diagnosis. Understandably, schools refer first the disruptive and the overtly dysfunctional students. The quiet, internalizing ones with equally severe difficulties need to be sought out by supplementing school psychiatric services. 1 Consultation Example
Devyn is in kindergarten and was referred to me after his classroom teacher had scheduled time with the MDT to ask for assistance regarding Devyn's hitting of other children. The hitting was far more than usual, ahd both teacher and adult staff assigned to the playground had tried to help him become more socialized. Devyn usually hit another child only if he believed he was not being observed by the adult staff. An MDT member contacted Devyn's mother seeking her input and asking for permission for MDT members to do more evaluation. Members of the MDT carefully observed, tested, and made suggestions about Devyn. These are usually helpful enough with most children seen by the MDT; I am called only if the overall situation is not getting better and if there is a reasonable possibility that the child has some psychiatric or pediatric difficulty. In Devyn's case his mother agreed some time ago to have him evaluated at a community mental health clinic, but that does not seem to have happened. His father was in jail. Scores on testing were low but not diagnostic. His mother has insulin-dependent diabetes, and Devyn was born by cesarean section at 8 months. During classroom observation, Devyn seemed restless and was not accomplishing the assigned work that the other child were completing. He easily got into difficulties with other children, even pushing back and forth. Although it seemed friendly, he hit them, sometimes from the back. On the continuous performance test, set at 1-second intervals with a simple index pattern, he scored below normal, pressing the report button both when the index pattern was there and when it was not. He missed reporting the index pattern one third of the time. Scores improved some but did not normalize when the test was repeated with the interval set at 2 seconds. At this point I met with his mother. She was reluctant to have her child on medication because she had heard of side effects and also because she considered herself a "naturalist," that is, avoiding medications. After some preliminary conversation with me, his mother seem ed to relax and become trusting. This
174
MYERS
has continued. I seek this in all parent conferences, as it helps the child. As a start I recommended a trial of stimulant medication. Fortunately, most of the difficulties cleared over the next 2 weeks. This is a good result for such a simple step. In a follow-up meeting with staff and Devyn's mother, she and the teacher agreed there were many things still to work out. I plan to stop by the class and also visit with mother every couple of months.
EMERGENCIES, DIRECT CARE, AND STAFF EDUCATION Emergencies
One in 5000 children per month presents with a severe acute psychiatric emergency. In these cases, the child is so upset that going home as usual at the end of the day is not safe for the child or youth. A child or youth may be so emotionally upset that he or she is unable to function. Acute psychosis, acute depression, suicidal impulses, or acute severe emotional decompensation are examples. Those threatening violence also often have severe psychiatric diffculties. After calling for police help, when there are threats the possibility of severe psychiatric difficulties should be kept in mind in the overall response. Each school does have a plan and specific staff designated to help with these emergencies. They call me only when needed. The parents are called. We may need to help them find some psychiatric help. While the child is still at school, we get as clear a clinical evaluation as possible, both diagnostically and as to level of seriousness. Experienced and willing mental health personnel in our community help guide the parents to immediate assistance in the community. We send a clinical record of what we found at school to the receiving clinician or hospital.
Direct Care and Prescribing for Those Children Without Insurance
In addition to classroom or playground consultations and emergencies, we provide medical care for children who do not or are not able to obtain health insurrance. Currently, in Boise Public Schools, I see 75 different children per year for diagnosis, prescribing, and on-going care. Two thirds of them have the need for continuing monthly prescriptions, including through the summer. This adds up to about 600 prescriptions per year. Those students needing care from me are limited to one third of our 54 school buildings. As in other cities, families of similar low financial level tend to be in the same neighborhoods. An additional one fifth of our students are very low income, but they have Medicaid and thus do not need my care. School-based health clinics are being considered for these students.
CONSULTATION IN THE CLASSROOM
175
Staff Education
Because my time is limited, I include brief medical education sessions as part of the regular meetings with the psychologists and nurses. I often add what is new in child and adolescent psychiatry in my consultation reports. Because medication information is readily available on the world wide web, and some medications recommended are not suggested for children or my use is not on the official list, I must explain to the staff that the research reports in child and adolescent psychiatric journals and in scientific meetings support my recommendation and that the Federal Drug Administration heretofore has not sought research involving children for them to release a medication. Uses of the mood-modulating medications (lithium, divalproex, etc.) and the newer antipsychotics are the ones most questioned. Thus, I quote research sources and explain the care with which we follow the child for whom we prescribe these.
Joint Problem Solving with Staff A Case Example. I had just finished seeing Jeremy, written my consultation note, and visited with staff. Even though he could not seem to settle down, was not getting his work done, was disturbing the class and class functioning, this situation, as often happens, did not rise to criteria for transfer to a special class. Thus, I began classroom observation about once a week. Then the teacher and I would discuss how he felt things were going. I made a few suggestions and told him some of the things I liked about what he was doing. Often, the teacher works out something that improves the situation. Jeremy was unhappy and understandably so. He was mean to friends, was clinically depressed, and occasionally beat on the classroom door shouting, "I hate you all." His mother essentially deserted him. Worse, she would call to arrange a visit and then not show up. When I conferred with Jeremy's father, he told us of a recent driving while intoxicated charge, of loss of a job, and of himself stopping his antidepressant medication and clinic visits. We will be recommending antidepressant medication for Jeremy. Jeremy regularly fixed his own meals, as his father was not available. My pep talks with his father yielded interest, but he seemed to have limited energy. In short, this was a difficult situation. One day when I arrived for an interview with him, Jeremy said he was willing to come but he would need to be finished before orchestra. Conferring later with his orchestra teacher, she told me with great appreciation that Jeremy was quite talented. For instance, even at age 11, he could know how the music sounded by looking at the score, and he could play each pitch exactly with his cello. Thus, we have added to our strategy, searching for community money and a willing high-level teacher so that Jeremy can come to realize the inner joy of substantial accomplishment in music. Father agreed to dextroamphetamine and a specific serotonin reuptake inhibitor for Jeremy. Three weeks later, when I was at his school seeing another student, Jeremy came up to me with a big smile and told me how happy he was to be finishing his school work. In my school work here, medications help about one third of the time. Here as with Devyn, we had a good result.
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DISCUSSION Advantages and Disadvantages of Classroom and Playground Observation
The advantages of direct observation, greater validity, early detection, and thus early intervention, already have been described. What I have covered in this article mainly applies to preschool through fourth grade. After second grade, testing and interviewing begin to give a higher yield. I do recommend classroom, playground, and hallway observation to community physicians (with proper arrangements) if the child they are seeing in their office is in serious condition and the diagnosis and formulation are not clear. Nevertheless, there are disadvantages. For both the in-house and the community child and adolescent psychiatrist, the greatest disadvantage is the extra time commitment of observing in the classroom (2 to 4 hours) plus the time driving to and from the school. Part of the time is waiting for a significant diagnostic behavior to occur in this natural environment. But nowhere else can these be as easily and clearly seen. Advantages and Disadvantages of Being Employed by the School District
The advantage to child, teacher, and school is the ready availability of a known clinician to see many quite ill children who would not otherwise be seen. The students and staff are best served when there is a long-term, close working relationship fostering trust, candor, and availability, making possible more and more assured teamwork as each one sees the students in need. With the availability of a child and adolescent psychiatrist, special education experts can plan and develop programs for the many students with special needs; having both special education and child and adolescent psychiatric components can give greater success. In addition, if a child regresses, the same clinician who saw him or her before is readily available. For the psychiatrist, it is a daily pleasure to be with a large number of happy children and competent teachers. One disadvantage of school district employment is that the pay amounts to two third of usual income. This may not be a serious loss because this work is often part time. Other work can be at more usual income. The potential conflict of school interest versus medical practice must be treated with caution. The amount of medication for a disruptive child needs to be what the child needs, not what makes for a quiet classroom. Another potential conflict of interest is deciding to whom to refer those needing diagnosis, care, and treatment. The in-house child and adolescent psychiatrist cannot refer to himself or herself or associates.
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ACKNOWLEDGMENTS I gratefully acknowledge the assistance of the students seen in consultation, the teachers, support staff, Dan Hollar, and administration of the Boise Public Schools in preparation of this article. Christine Pickford, PhD, Dorothy L.J. Olsen, EdD, and I together wrote the "Advantages and Disadvantages of Being Employed by the School District" section. Greg Myers, PhD, helped significantly with the overall final draft.
Reference 1. Myers HAP: The too quiet child. American Academy of Child and Adolescent Psychiatry News 30:125, 2000
Address reprint requests to H. A. P. Myers III, MD 1635 East Holly Lane Boise, ID 83712-8357
1056--4993/01 $15.00
+
.00
CONSULTATION IN THE CLASSROOM H. A. P. Myers III, MD
Consultation by observing in the classroom and working closely with the school staff brings to children the great advantages of accurate diagnosis and educational progress. Furthermore, there are two advantages for a child and adolescent psychiatrist actually working within a school setting: direct observation and early detection. First, the difficulties the child is having can be observed directly, resulting in a much greater validity of diagnosis. In my practice, these classroom observations are always supplemented by playground observations. There, I can see the quality of socialization along with coordination and neurologic signs, if present-as seen in athletic skill or lack of same in ball play, on slides, and on gym rings. The hallways are also a place to observe activity such as aggressive interactions or avoidance. The second advantage is that when a child and adolescent psychiatrist is an in-house school employee, children with serious difficulties are seen earlier than they would be otherwise. Teachers' concerns for these children can be expressed more directly, and pertinent reports can be reviewed freely. Boise, Idaho, is the economically active home to the state capital, the newer high-tech companies, and the headquarters for Albertson's large grocery chain, as well as being the supply hub for the surrounding 250 miles. Boise Public Schools is a lively school district of 27,000 students of all socioeconomic levels and 1780 certified teachers teaching in 54 different buildings. Student teaching and learning are actively audited. For many decades, its students have been admitted to the best regional and national universities.
From the Boise Public Schools, Boise, Idaho
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 • JANUARY 2001
169
170
MYERS
DIAGNOSIS IN CLASSROOM, PLAYGROUND, AND FROM OTHER INFORMATION Diagnosis by Classroom, Playground, and Hallways Observation Gives Great Validity 1. Diagnostic criteria for disorders can be observed directly by
the clinician. During classroom observation, one sees the child's difficulties as they occur. Many of these observations rise to the level of diagnostic criteria in areas of sadness, anxiety, attention difficulties, interaction, and language as well as in dealing with autistic-like speech. Otherwise the clinician is more dependent on the less reliable test scores or reports of what someone else has observed. The playground allows the observer to view coordination and possible neurologic signs, and both hallway and playground observation show socialization qualities. The difficulties that the classroom teacher raised can then be discussed with the teacher, saying, "Was what you and I saw some of what you were concerned about?" And this helps assure the teacher that the clinician is observing her or his concerns. 2. Classroom and playground observation is a skill that the observing clinician must develop and is similar to those used for an interactive play diagnosis, conducting an interview, or watching a drama or group interaction. This skill can be learned and is a skill well worth developing. 3. Classroom, playground, and hallways observation, although valuable, do not stand alone. As I suggest in following sections, they must be combined with parental contact, consultation with other school professionals, and links to pediatric examination. Parents and School Add to These Above Observations
History from the Parents
The history-taking process, with parents, school staff, and helping agencies, moves along more validly and in-depth once the child and adolescent psychiatrist has actually observed much of the child's difficulties first hand. We physicians have been taught to start with a history. In clinic or office work most of us see the parents first, then the child. In my school consultation work I modify that by first obtaining the parents' permission to observe. After that, I ask for their input. These visits progress better than when taking the history first and then seeing the child. The parents are far more open and candid once they know I have observed what is going on with their child; they tend to withhold and deny less. The parents and I can then talk about my observations. After that they often will tell me any similar symptoms seen at home or
CONSULTATION IN THE CLASSROOM
171
in other members of the family. Observing the child before having the parent's detailed history makes the minimizing or denial of symptoms less likely. More Information Now from School-The Multidisciplinary Team
As in all of child and adolescent psychiatry, several different views need to be carefully combined to make a diagnosis. The m ultidisciplinary team (MDT) usually includes the school psychologist, the school nurse, the speech and language pathologist, the counselor, and a school administrator. After the observations and the first parent meeting, the MDT gathers to hear reports from its members. I also ask for a report from the physical education teacher about whether coordination is at age level and, if not, to describe the child's movements. Here I am screening for any possible neurologic signs. Previous central nervous system injury does, in my experience, have symptoms that can be confused with psychiatric difficulties. These meetings with the MDT greatly increase the depth of the overall picture. After the MDT meeting, teacher and support staff and I confer, and I may then interview the child or youth. I tend not to conduct interviews in earlier grades largely because I lose the ability to see the child in action in the class without his or her being too aware of me. On the other hand, if I interview the child, I receive his or her opinion and an idea of that child as an expressive person. If there is even a hint of physical problems, I suggest to parents that they get a pediatric consultation (history, physical, laboratory work, check for thyroid function, consideration for possible genetic defects, and diagnostic thoughts). As a pediatrician, I can perform some of these tests myself should the parents be unable to afford a pediatric consultation. In coordination with school staff, child/youth, and parents, I seek to arrive at a formulation, diagnostic impressions, recommendations, and plans. I follow up in 1 month to see how things are progressing. Because I am a fellow school employee, school staff can easily call me if there is a change. Case Examples
Attention Deficit Hyperactivity Disorder Variant
My most frequent referral is when the parents, invited to take their child to their primary physician with a check-off list from the school stating there is restlessness, lack of attention, not understanding instructions, and not completing work, receive the most likely diagnosis, Attention Deficit Hyperactivity Disorder (ADHD). However, the usual dose of medication not only does not help much but the child responds with
172
MYERS
increased upset and or somnolence. At this point I offer to consult with the primary physician. In the classroom I may see these symptoms but also some irritability, which is not common in usual ADHD. On the playground I may see some clumsiness, which the physical education teacher also reports. Then, when taking a history from the parents, I hear that the child has had perinatal distress, post-natal apnea attacks, and a closed head injury from going over the bicycle handle bars onto the surfaced road, or the child had in retrospect what probably was viral meningitis years before. With the irritability, clumsiness, and this positive new history my presumption is that this child has had a central nervous system insult that has resulted in all of the symptoms. Half the usual dose by weight of stimulant medication is all this child can take without side effects. Because even that amount provides some benefit to the child, it is worth continuing. Another case in which ADHD was first diagnosed was correctly rediagnosed as absence seizures. The teacher, alternatively, might have thought the child was daydreaming. Here again classroom observation pinpointed the difficulty. In these two examples and those that follow, the additional information gained during the consultation enabled better adaptation in the individual educational program and open the way for specific medical treatment. Intermittent Explosive Disorder
A frequent diagnosis is one in which the child becomes extremely unruly and fights a lot. I pick that up in the hallway and not in the supervised playground or classroom. There, the slightest irritations result in great anger, more than seems reasonable for the minimal provocation. In contrast to the first case, there is no history of a central nervous system insult. There is a family history of a similar temper, a normal electroencephalogram, and normal neurologic evaluation. With these findings, an Intermittent Explosive Disorder seemed a reasonable diagnosis. In one instance, staff reported that, in a parent conference, the mother of this boy seemed to bristle at parts of our report. Later, the mother acknowledged to me that she and her sister had difficulty controlling their tempers since childhood. Her son did much better on lithium. Pervasive Developmental Disorder
The signs of milder Pervasive Developmental Disorder (PDD) are seen readily on the playground (lack of socializing and little response to other children who may be inviting play). In the classroom I saw very different language, lack of facial response to affective events, being upset with change in schedule, and perhaps stereotyped, repetitive movements. These are usually not seen as readily in clinic or office visits. The recognition of PDD is important so that we can accommodate the instruction, as the thinking process is different in the autism spectrum.
CONSULTATION IN THE CLASSROOM
173
Anxiety Disorder
A third grader was not accomplishing work and seemed restless. The diagnosis of ADHD was entertained, but the medication made his behavior worse. The long history taking and conference with the parents revealed no history of CNS insults; however, the mother finally revealed that she had been diagnosed as having an anxiety disorder for which she was taking antianxiety medication, which helped her. I prescribed the same anti-anxiety medication, in a child's dose, and her son's symptoms in the classroom decreased and his attentiveness and grades increased. Depression, Compulsions, and Frank Signs of Psychosis. In other observations we can see behavior, schoolwork or lack of it, talking, and socializing that are significantly different from the age norm. These obervations bring up the possibility of an unusual formulation and diagnosis. Understandably, schools refer first the disruptive and the overtly dysfunctional students. The quiet, internalizing ones with equally severe difficulties need to be sought out by supplementing school psychiatric services. 1 Consultation Example
Devyn is in kindergarten and was referred to me after his classroom teacher had scheduled time with the MDT to ask for assistance regarding Devyn's hitting of other children. The hitting was far more than usual, ahd both teacher and adult staff assigned to the playground had tried to help him become more socialized. Devyn usually hit another child only if he believed he was not being observed by the adult staff. An MDT member contacted Devyn's mother seeking her input and asking for permission for MDT members to do more evaluation. Members of the MDT carefully observed, tested, and made suggestions about Devyn. These are usually helpful enough with most children seen by the MDT; I am called only if the overall situation is not getting better and if there is a reasonable possibility that the child has some psychiatric or pediatric difficulty. In Devyn's case his mother agreed some time ago to have him evaluated at a community mental health clinic, but that does not seem to have happened. His father was in jail. Scores on testing were low but not diagnostic. His mother has insulin-dependent diabetes, and Devyn was born by cesarean section at 8 months. During classroom observation, Devyn seemed restless and was not accomplishing the assigned work that the other child were completing. He easily got into difficulties with other children, even pushing back and forth. Although it seemed friendly, he hit them, sometimes from the back. On the continuous performance test, set at 1-second intervals with a simple index pattern, he scored below normal, pressing the report button both when the index pattern was there and when it was not. He missed reporting the index pattern one third of the time. Scores improved some but did not normalize when the test was repeated with the interval set at 2 seconds. At this point I met with his mother. She was reluctant to have her child on medication because she had heard of side effects and also because she considered herself a "naturalist," that is, avoiding medications. After some preliminary conversation with me, his mother seem ed to relax and become trusting. This
174
MYERS
has continued. I seek this in all parent conferences, as it helps the child. As a start I recommended a trial of stimulant medication. Fortunately, most of the difficulties cleared over the next 2 weeks. This is a good result for such a simple step. In a follow-up meeting with staff and Devyn's mother, she and the teacher agreed there were many things still to work out. I plan to stop by the class and also visit with mother every couple of months.
EMERGENCIES, DIRECT CARE, AND STAFF EDUCATION Emergencies
One in 5000 children per month presents with a severe acute psychiatric emergency. In these cases, the child is so upset that going home as usual at the end of the day is not safe for the child or youth. A child or youth may be so emotionally upset that he or she is unable to function. Acute psychosis, acute depression, suicidal impulses, or acute severe emotional decompensation are examples. Those threatening violence also often have severe psychiatric diffculties. After calling for police help, when there are threats the possibility of severe psychiatric difficulties should be kept in mind in the overall response. Each school does have a plan and specific staff designated to help with these emergencies. They call me only when needed. The parents are called. We may need to help them find some psychiatric help. While the child is still at school, we get as clear a clinical evaluation as possible, both diagnostically and as to level of seriousness. Experienced and willing mental health personnel in our community help guide the parents to immediate assistance in the community. We send a clinical record of what we found at school to the receiving clinician or hospital.
Direct Care and Prescribing for Those Children Without Insurance
In addition to classroom or playground consultations and emergencies, we provide medical care for children who do not or are not able to obtain health insurrance. Currently, in Boise Public Schools, I see 75 different children per year for diagnosis, prescribing, and on-going care. Two thirds of them have the need for continuing monthly prescriptions, including through the summer. This adds up to about 600 prescriptions per year. Those students needing care from me are limited to one third of our 54 school buildings. As in other cities, families of similar low financial level tend to be in the same neighborhoods. An additional one fifth of our students are very low income, but they have Medicaid and thus do not need my care. School-based health clinics are being considered for these students.
CONSULTATION IN THE CLASSROOM
175
Staff Education
Because my time is limited, I include brief medical education sessions as part of the regular meetings with the psychologists and nurses. I often add what is new in child and adolescent psychiatry in my consultation reports. Because medication information is readily available on the world wide web, and some medications recommended are not suggested for children or my use is not on the official list, I must explain to the staff that the research reports in child and adolescent psychiatric journals and in scientific meetings support my recommendation and that the Federal Drug Administration heretofore has not sought research involving children for them to release a medication. Uses of the mood-modulating medications (lithium, divalproex, etc.) and the newer antipsychotics are the ones most questioned. Thus, I quote research sources and explain the care with which we follow the child for whom we prescribe these.
Joint Problem Solving with Staff A Case Example. I had just finished seeing Jeremy, written my consultation note, and visited with staff. Even though he could not seem to settle down, was not getting his work done, was disturbing the class and class functioning, this situation, as often happens, did not rise to criteria for transfer to a special class. Thus, I began classroom observation about once a week. Then the teacher and I would discuss how he felt things were going. I made a few suggestions and told him some of the things I liked about what he was doing. Often, the teacher works out something that improves the situation. Jeremy was unhappy and understandably so. He was mean to friends, was clinically depressed, and occasionally beat on the classroom door shouting, "I hate you all." His mother essentially deserted him. Worse, she would call to arrange a visit and then not show up. When I conferred with Jeremy's father, he told us of a recent driving while intoxicated charge, of loss of a job, and of himself stopping his antidepressant medication and clinic visits. We will be recommending antidepressant medication for Jeremy. Jeremy regularly fixed his own meals, as his father was not available. My pep talks with his father yielded interest, but he seemed to have limited energy. In short, this was a difficult situation. One day when I arrived for an interview with him, Jeremy said he was willing to come but he would need to be finished before orchestra. Conferring later with his orchestra teacher, she told me with great appreciation that Jeremy was quite talented. For instance, even at age 11, he could know how the music sounded by looking at the score, and he could play each pitch exactly with his cello. Thus, we have added to our strategy, searching for community money and a willing high-level teacher so that Jeremy can come to realize the inner joy of substantial accomplishment in music. Father agreed to dextroamphetamine and a specific serotonin reuptake inhibitor for Jeremy. Three weeks later, when I was at his school seeing another student, Jeremy came up to me with a big smile and told me how happy he was to be finishing his school work. In my school work here, medications help about one third of the time. Here as with Devyn, we had a good result.
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DISCUSSION Advantages and Disadvantages of Classroom and Playground Observation
The advantages of direct observation, greater validity, early detection, and thus early intervention, already have been described. What I have covered in this article mainly applies to preschool through fourth grade. After second grade, testing and interviewing begin to give a higher yield. I do recommend classroom, playground, and hallway observation to community physicians (with proper arrangements) if the child they are seeing in their office is in serious condition and the diagnosis and formulation are not clear. Nevertheless, there are disadvantages. For both the in-house and the community child and adolescent psychiatrist, the greatest disadvantage is the extra time commitment of observing in the classroom (2 to 4 hours) plus the time driving to and from the school. Part of the time is waiting for a significant diagnostic behavior to occur in this natural environment. But nowhere else can these be as easily and clearly seen. Advantages and Disadvantages of Being Employed by the School District
The advantage to child, teacher, and school is the ready availability of a known clinician to see many quite ill children who would not otherwise be seen. The students and staff are best served when there is a long-term, close working relationship fostering trust, candor, and availability, making possible more and more assured teamwork as each one sees the students in need. With the availability of a child and adolescent psychiatrist, special education experts can plan and develop programs for the many students with special needs; having both special education and child and adolescent psychiatric components can give greater success. In addition, if a child regresses, the same clinician who saw him or her before is readily available. For the psychiatrist, it is a daily pleasure to be with a large number of happy children and competent teachers. One disadvantage of school district employment is that the pay amounts to two third of usual income. This may not be a serious loss because this work is often part time. Other work can be at more usual income. The potential conflict of school interest versus medical practice must be treated with caution. The amount of medication for a disruptive child needs to be what the child needs, not what makes for a quiet classroom. Another potential conflict of interest is deciding to whom to refer those needing diagnosis, care, and treatment. The in-house child and adolescent psychiatrist cannot refer to himself or herself or associates.
CONSULTATION IN THE CLASSROOM
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ACKNOWLEDGMENTS I gratefully acknowledge the assistance of the students seen in consultation, the teachers, support staff, Dan Hollar, and administration of the Boise Public Schools in preparation of this article. Christine Pickford, PhD, Dorothy L.J. Olsen, EdD, and I together wrote the "Advantages and Disadvantages of Being Employed by the School District" section. Greg Myers, PhD, helped significantly with the overall final draft.
Reference 1. Myers HAP: The too quiet child. American Academy of Child and Adolescent Psychiatry News 30:125, 2000
Address reprint requests to H. A. P. Myers III, MD 1635 East Holly Lane Boise, ID 83712-8357