- Email: [email protected]
High School Consultation
SCHOOL CONSULTATION /INTERVENTION
1056--4993/01 $15.00
+ .00
HIGH SCHOOL CONSULTATION Mary M. Kerr, EdD
Adolescents who feel closely connected to their schools are adolescents who are emotionally healthier and far less likely to engage in risky behavior than their counterparts who feel no sense of community in their school. Without question, it is the formation of friendship networks within the school along with a perception that teachers care, that teachers are fair, and that school is a place where one belongs that help to provide that sense of community. 27 Experts agree on the critical role of school in an adolescent's psychologic development. This article addresses two major goals for mental health consultation in the high school: • to promote students' safety and well-being in the context of their educational experiences; and • to reduce student's risk-taking behaviors, so that they can take full advantage of their school experiences. To illustrate the role of the consultant in meeting these goals, we consider four essential components of a caring high school. The skilled consultant can strengthen each of these four dimensions. We begin with an overview of these components, followed by a more detailed illustration of the consultant's role within each. The first component is developmental guidance or prevention. This step delineates how schools care for all students, consistent with their developmental needs. Classroom staff and administrators may provide these services with some assistance from support persons, including a consultant from within or outside the school. Second, we need to consider the needs of students who encounter trouble along their developmental paths: the "at-risk" population. This
From the University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
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component addresses a smaller, more focused group of students and their families. This component may also require special staffing. One might think of these as the "safety net" services and programs. The third component of a caring school is intervention. Students receiving interventions are not merely at risk; they are in need. Student assistance programs, support groups, individual counseling, and school mental health clinics are examples of an intervention tool. Crisis response or postvention, the fourth component, is the school's response to students in acute distress as a result of their own psychiatric issues, family discord, community events, or school tragedies. These students may be those whom the previous supports overlooked or simply failed. This component requires specialized skills, temporary changes in staff assignments, and a high degree of flexibility in procedures. During these crises, schools often reach out to the mental health community of psychiatrists and other mental health professionals. We begin with a look at the first component, those developmental needs of adolescents met through a caring school environment.
COMPONENT ONE: A CARING SCHOOL
Many studies of adolescents in schools concur in their findings that teenagers need to find a place in a valued group that provides a sense of belonging; to feel a sense of worth as a person; reliable and predictable relationships with other people, especially a few relatively close relationships or at least one; and to identify tasks that are generally recognized in the group as having adaptive value and thereby earn respect when a skill is acquired for coping with the tasks. 12 Other basic needs include safe places to gather (with adult supervision) and provision of experiences that allow teenagers to share their time and talents with their community and to have healthy, fun recreation.4 By their very structure, high schools often fail teenagers. These educational institutions are often large and impersonal. Some school personnel even declare that schools are places where "we teach content, not students." Exacerbated by a focus on academic outcomes, test scores, and athletic victories, today's high schools may thus endanger the very persons they set out to serve. Consider this teenager's e-mail following the Columbine High School violence: Yeah, I've had some fantasies bout taking out some of those jerks who run the school, have parties, get on teams, are adored by teachers, have all these friends. Sure, they hate me. Day by day, it's like they're taking pieces out of you, like a torture, one at a time. My school has 1500 kids. I could never make a sports team. I have never been to a party. I sit with my friends at our own corner of the cafeteria. If we tried to join the other kids, they'd throw up or leave. And by now, I'd rather die. Sometimes, I do feel a lot of real pure rage. (New Jersey, 1998.)
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How can high schools better meet their students' developmental needs? Teenagers Need Caring Relationships
The consulting child specialist can provide the high school staff with information on the normal developmental needs of adolescents, especially young adolescents whose needs are often the more difficult to meet, as they enter the large, challenging world of the senior high school. Caring Relationships Require Human-Scale Schools
Many educators are now searching for ways to provide a more human-scale environment. 9, 18' 30 A team of 25 to 30 teachers might be ideal. This implies a school of 325 to 420 pupils, itself a human-scale number."28 In its report, Breaking Ranks: Changing an American Institution, the National Association of Secondary School Principals urged its members to scale down high schools and implement systems of personal advocacy for all students. The relationship between the students and the advocate should ensure that no youngster experiences the sense of isolation that frequently engulfs teenagers during this critical period of their lives. We expect the advocate to meet regularly throughout the year on an individual basis with about 15 to 20 students. 21 The consulting mental health professional cannot always bring structural reform but can encourage schools to become more humanscale places. The shift from lecturer to listener does not come easily to many veteran educators. A consultant can help teachers reconnect with students by teaching them emphatic listening skills and suggesting activities to bring them and their students together during unstructured times. Goldberg10 has described how to set up advisory groups. /1
Teenagers Need High Expectations
Research studies on self-efficacy, resilience, and effective schools all confirm the importance of high expectations for students when those expectations are shared by an interested and caring adult. 2, 24, 26 Consultants can point out ways that schools can foster self-efficacy and resilience through caring relationships, high expectations, and opportunities to belong. 2 Examples of instructional practices that increase expectations are to display students' work, hold student-led parent conferences, and have students collect and reflect on their work thorough portfolio assessments. This kind of advice to school staff members can be enlightening, as it lessens the perceived gap between mental health practices and what
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happens in the classroom. Moreover, consultants can raise teachers' own self-efficacy about their role in preventing mental health problems. Some districts focus primarily or initially on specialized needs, that is, at-risk programs, crisis responding, safety and security, special education, and alternative education; however, consultants can urge school district personnel to focus on prevention for several reasons. Often, specialized needs result from basic ordinary needs going unmet. A student with a strong relationship with a component caring adult20 is far less likely to disrupt class than his or her alienated peer. Students with behavioral problems often report how their actions were in response to the frustration of "nobody listening." A second example is special education services. Often, students are referred for special education and related services because they are not succeeding in the general education setting. Consultants can suggest and implement inservice programs, including coaching, and supervision to improve general educators' behavioral assessment and intervention skills. Most teachers have had little or no coursework in working with behaviorally challenging students. Some schools seem to be in "chronic crisis" because they overlook the essential work of providing good educational experiences in the context of caring relationships. The consultant can help schools caught in this cycle to refocus on prevention and developmental guidance supports. For example, when ninth-grade teachers are not fully aware of normal developmental behaviors in young adolescents, they may well imagine that they have a classroom full of emerging juvenile delinquents and attempt to suspend them or possibly refer individual students to special education or mental health services. The consultant can provide staff development (or encourage principals to offer it) that addresses these inappropriate referrals. COMPONENT TWO: SERVICES FOR STUDENTS AT RISK
Consultants can help educators recognize the warning signs for psychiatric problems. As the earlier e-mail illustrated, many teenagers feel and are often, in reality, left out of the community of their high schools. Many drop out altogether. Several factors contribute to the problem. Detachment from Parents
As adolescents spend less and less time with their parents, cliques increasingly fill the emotional vacuum, and the high school game of acceptance or rejection is being played for even higher emotional stakes." 1 Adolescents come into daily contact with information that either endorses or creates interest in high-risk behaviors, including high-risk 11
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sex, substance use, and violence. The onset of puberty is earlier, which heightens the biologic press for sexual activity. Lacking a sense of belonging at school, adolescents seek to fit in with their peers. Their activities often can include substance use, aggression, and sex. Noonan23 points out that these factors are exacerbated by educators' lack of awareness of the mental and emotional illnesses that emerge at high rates in adolescence, for example, depression, suicidality, anxiety, eating disorders, and intense aggressive impulses.
Tighter School Sanctions
Already alienated from their schools, teens in trouble may be further marginalized by an educational system that suspends, rejects, or expels them. Second chances do not exist in many districts intent on enforcing a "zero tolerance" policy for alcohol and other drug use, threats of violence, and weapons violations. Contributing to these factors is the inability of many classroom teachers to identify or respond to students at risk for serious medical and psychiatric problems. The consultant can introduce the following protocol for engaging at-risk students to share their thoughts and feelings (see boxed area).
Steps in Assisting a Student at Risk
• Have a conversation with the student in private. • Let the student know that you are concerned and want to help. • If the student hesitates, gently offer an example of the worrisome behavior. • Resist the urge to explain the symptom and/or offer advice. • Be a good listener so the student feels comfortable talking. Pay attention to how much you are actually listening versus counseling. Do not badger! If the student does not want to talk, try another option. • Be patient! Students with problems are not always articulate. It may take a little while for them to explain how they feel. Do not interrupt. Show the student that you are interested by looking at him or her and nodding your head. • Avoid judgments. This is no time to evaluate the student's perceptions. • Next, name some action that you can take with the student. If you cannot immediately think of a plan, at least show your acceptance and willingness to help. • Close the conversation with reassurance (even if you cannot genuinely show acceptance of the student's views). Some students need information to help them view their situations more hopefully. If this is the case, offer it. • Follow up on your commitment. Even if you have promised only to talk again, be sure you do. If you offered specific help, get it quickly. Know how to help. Your work obligates you to know child and adolescent
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referral procedures, to understand the mental health services in your community, to know warning signs, and so forth. • Know how to handle confidentiality. Do not promise total confidentiality to a student; you may not be able to keep your word. Do not promise confidentiality, for example, in the case of suicidal or homicidal threats. 16 Adapted from Kerr MM, Nelson CM: Strategies for Managing Behavior Problems in the Classroom, ed 3. Columbus, OH, Merrill, 1998, pp 325-326; with permission.
This interaction described in the box is more easily and effectively achieved in schools that have successfully implemented advisory groups, small homerooms, and other ways of connecting with their students. We have found it most effective to teach all instructional staff these steps, because many distressed students seek out adults they trust and see every day, for examples, favorite teachers, club sponsors, coaches, and counselors. COMPONENT THREE: INTERVENTION
The consultant can offer administrators, counselors, psychologists, and social workers advice on how to identify and refer adolescents with psychiatric disorders such as eating disorders, depression, anxiety disorders, and chemical dependency. Consultation is especially important for students with internalizing disorders that may otherwise go unnoticed. One tool that may help teachers recognize students at risk is the Teacher Interview for Psychiatric Symptoms (TIPS), 17 a structured telephone interview designed for mental health professionals to use in questioning educators about patients' psychiatric symptoms. The TIPS, patterned after the K-SADS, includes examples of symptoms as teachers might observe them in a school setting. To review the information that educators need, refer to the boxed outline we have used to identify and refer students with deliberate self-harm.
Adolescents with Deliberate Self-Harm: What Educators Need to Know
Summary of statistics on suicide Risk factors for adolescent suicide Symptoms of depression Symptoms of bipolar disorder Risk factors for recurrence of depression Assessment of suicidal risk in adolescents (The SAD ADOLESCENT Assessment) • Sex • Age
• Depression
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• • • • • • • • • •
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Availability of firearms or/other methods Discord in family or parental psychopathology Organized plan/intent/preparation Lack of social supports/peer conflicts Earlier suicide ideation/attempts Substance abuse/dependence Cognitive distortions/hopelessness Exposure to others' suicidality Not agreeable to "no suicide" contract Temper/aggression/recent homicidally
The consultant can also introduce the following protocol : Response to a Young Person at Risk for Suicide
• Remain calm and patient; do not panic or become agitated. • Let the young person know that • help is available, • talking about suicidal feelings is okay, • there is hope, • that depressed people do benefit from treatment. • Never leave a suicidal young person alone or send him or her home on a school bus or pubic transportation without having made a plan with his/ her parents. • Make whatever referral is necessary in collaboration with parents. A young person at risk requires evaluation by a mental health professional. • Know whom to contact in your school or organization. • Be aware of the referral resources in your community. How To Complete A "No Suicide" Contract • Adolescent agrees not to hurt him/herself. • Adolescent, parents, and counselor rehearse strategies to cope with suicidal thoughts should similar precipitants recur. • Adolescent will tell parents or counselor if he or she is having suicidal thoughts. • Adolescent will present him/herself at emergency room if there is no one available to help. • Adolescent will structure his/her activities in a way that will reduce suicidal potential. The Referral Process • • • • • • • • •
Involuntary hospitalization procedure Call your county mental health office for process Each county has own procedures Call police if risk of violence to self/others Health insurance issues Psychiatric outpatient services Local agency or provider networks Emergency room (medical or psychiatric) Voluntary hospitalization procedures
Other Support Resources • Primary care physician • Parent's employee assistance program • School counselor
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• Spiritual/religious counselor • Bereavement counselor Follow-up Action Plan Maintain regular communication with family • • • • •
Check on status of referral/s Maintain regular collaboration with mental health provider Provide alternative referrals as needed Periodically reevaluate suicidality/suicidal risk Reaffirm "No Suicide Contract" as needed.11
From Greaves MM: Level I Training, Services for Teens at Risk (STAR-Center). Pittsburgh, PA, Western Psychiatric Institute & Clinic, 1999; with permission.
COMPONENT FOUR: CRISIS RESPONDING AND POSTVENTION
The kinds of crises that affect schools are numerous. Many are those of unintentional harm, for example, sports injuries, automobile accidents, weather-related disasters, and contagious diseases. Districts across the country currently are paying more attention to students who threaten violence. School administrators, wanting to know whether certain students will become violent, often refer them for psychiatric assessments. Consultants can help schools develop their own initial threat assessment procedures to avoid inappropriate referrals to already crowded emergency rooms and inpatient services. Table 1 includes some risk factors that can alert school personnel to the potential for possible aggression or violence. We recommend that schools have a
Table 1. RISK FACTORS FOR POTENTIAL AGGRESSION OR VIOLENCE
Characteristically resorts to name calling, cursing, or abusive language. Habitually makes violent threats when angry. Has previously brought a weapon to school. Has a background of serious disciplinary problems at school and in the community. Has a background of drug, alcohol, or other substance abuse or dependency. Is on the fringe of his/her peer group with few or no close friends. Is preoccupied with weapons, explosives, or other incendiary devices. Has previously been truant, suspended, or expelled from school. Displays cruelty to animals. Has little or no supervision and support from parents or a caring adult. Has witnessed or been a victim of abuse or neglect in the home. Has been bullied and/ or bullies or intimidates peers or younger children. Tends to blame others for difficulties and problems s/he causes her/himself. Consistently prefers TV shows, movies, or music expressing violent themes and acts. Prefers reading materials dealing with violent themes, rituals, and abuse. Reflects anger, frustration, and the dark side of life in school essays or writing projects. Is involved with a gang or an antisocial group on the fringe of peer acceptance. Is often depressed and/or has significant mood swings. Has threatened or attempted suicide. From National School Safety Center: Checklist of Characteristics of Youth Who Have Caused School-Associated Violent Deaths. Westlake Village, CA [On-line]. Accessed 1998; with permission.
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threat assessment team that involves educators who know the student well as well as representatives from school administration, mental health, and law enforcement. Good advance planning can reduce significantly the negative impact of a tragedy on youth and those who work with them. School districts, with consultants, can prepare for tragedies by developing postvention policies and procedures that may be activated on short notice. The three goals of most postventions are (1) to return the school to its normal routines, (2) to support those who are grieving the loss of a classmate, teacher, or colleague, and (3) to identify and assist those at risk for unhealthy behaviors and reactions. Postvention in high schools is especially important, as students usually develop close relationships with their peers. It is natural, therefore, for the school family to come together to support one another when a tragedy befalls one of its members. No single model is adequate for every school or community, but we do follow certain basic guidelines in supporting schools through a tragedy. Each postvention plan should include the following: 15 l. School board policy authorizing postvention activities. 2. Interagency agreements to ensure that resources are available in the event of a tragedy. 3. Communications plans • Internal communications plan for faculty, administration, district administrators, school board members, and crisis team members, for example, "on-call" arrangements, phone/fax/ pager contact lists, telephone tree, with updates twice a year. • External communications plan, including how to reach qualified professionals for consultation, how to respond to media requests, and how to keep parents and guardians informed. 4. Deployment of key personnel by name and area of responsibility during the postvention period. These personnel may include • Postvention coordinator • Postvention team • School pupil services staff or student assistance teams • Community mental health professionals • Monitors and escorts for students • Clerical support persons • Security staff • Group facilitators • Central office contact persons • School board liaison 5. Refresher training for district employees assigned to crisis response. 6. Ongoing recruitment and training for new crisis responders. 7. Strategies for debriefing the crisis responders, evaluating the postvention, and discussing how to prevent another such tragedy. 8. Annual review of postventions and revisions to the plan.* *From Kerr MM, Brent DA, McKain BW: Postvention Standards Guidelines: A Guide for a School's Response in the Aftermath of a Sudden Death, ed 3. Pittsburgh, PA, Services for Teens at Risk, STAR-Center Publications, 1997; with permission.
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SUMMARY
High schools painstakingly plan their academic standards, curricula, instructional approaches, technology, and facilities. Also essential to the vision is a systematic plan for developmental guidance, prevention, at-risk services, intervention, crisis responding, and postvention. The consultant, working in partnership with a caring school staff, can promote safety and well-being and reduce risk-taking behaviors so that adolescents can get the most benefit from school experiences. Several protocols have been described that may guide a consultant in helping school personnel.
References 1. Adler J: The truth about high school. Newsweek, May 10, 1999:56-57 2. Benard B: Fostering resilience in children. Champaign, IL, Children's Research Center. [On-line]. Available at: http://ericps.crc.uiuc.edu/eece/pubs/digests/1995/benard95.html. Accessed 1995. 3. Benard B, Marshall K: A framework for practice: Tapping innate resilience [On-line]. Available at: www.coled.umn.edu/ CARElwww /ResearchPractice/v5nl /benard.htm 4. Blum RW: Lost children or lost parents of Rockdale County? WGBH/FRONTLINE. [On-line]. Available at: http:/ /www.pbs.org/wgbh/pages/frontline/shows/georgia/ isola ted/blum.html. Accessed 1999. 5. Boyd B: Scottish schools: An ethos of achievement. Phi Delta Kappan November: 252-253, 1997 6. Carnegie Council on Adolescent Development: Turning Points, Preparing American Youth for the 21st Century. Washington, DC, 1989. For more information, call 202265-9080. 7. Crisis Management Manual. Butler, PA, Butler Area School District, 1995 8. Early Warning, Timely Response: Guide to Safe Schools. Juvenile Justice Clearinghouse. Rockville, MD. [On-line] . Available at: http:/www.ed.gov I offices/OSER/OSEP I earlywrn.html. Accessed 1998. 9. Fowler WJ Jr: What do we know about school size? What should we know? Presented at the 73rd Annual Meeting of the American Educational Research Association, San Francisco, April 22, 1992 10. Goldberg MF: How to design an advisory system for a secondary school. Alexandria, VA, Association for Supervision and Curriculum Development, 1998 11. Greaves MM: Level I Training, Services for Teens at Risk (STAR-Center). Pittsburgh, Western Psychiatric Institute & Clinic, 1999 12. Hamburg DA: A Development Strategy to Prevent Lifelong Damage. Annual Report Carnegie Corporation of America, Minneapolis, MN, Watt/Peterson, Inc, 1995, p 12 13. Harris J: Developmental Neuropsychiatry. New York, NY, Oxford Press, 1995 14. Johnson WD: What makes cooperative groups work? Teaching Times Pittsburgh, University of Pittsburgh Center for Instructional Development and Distance Education, 1999 15. Kerr MM, Brent DA, McKain BW: Postvention Standards Guidelines: A Guide for a School's Response in the Aftermath of a Sudden Death, ed 3. Pittsburgh, PA, Services for Teens at Risk, STAR-Center Publications, 1997 16. Kerr MM, Nelson CM: Strategies for Managing Behavior Problems in the Classroom. Columbus, OH, Merrill, 1998, pp 325- 326 17. Kerr MM, Schaeffer AL: Teacher interview for psychiatric symptoms (TIPS), 1987 Available from Mary Margaret Kerr, Ed.D. at 3811 O'Hara Street, Pittsburgh, PA 15213. 18. Kohn A: Constant frustration and occasional violence: The legacy of American high
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19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
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schools. American School Board Journal [On-line]. Available at: http:/ /www.asbj.com/ 199909/0999coverstory.html. Accessed 1999. MacBeath J, Boyd B, Rand J, et al: Schools Speak for Themselves. London, National Union of Teachers, 1996 Masten AS: Resilience in children at-risk. Research Practice, 5. [On-line]. Available at: http: I I carei.coled.umn.edu/ResearchPractice/v6nl/masten.htm. Accessed 1997. National Association of Secondary School Principals: Breaking Ranks: Changing an American Institution. Reston, VA, National Association of Secondary School Principals, 1996 National School Safety Center: Checklist of Characteristics of Youth Who Have Caused School-Associated Violent Deaths. Westlake Village, CA [On-line]. Available at: http:/ I www.nsscl.org/ reporter I checklist.htm. Accessed 1998. Noonan C: Brief interventions foster student resiliency. The Education Digest, April 1999, pp 36-38 Pajares F: Current directions in self-efficacy research: Self-efficacy lecture [On-line]. Available at: http:/ /userwww.service.emory.edu/-mpajares/ efftalk.html. Accessed 1998. Resnick MD: Adrift in America. WGBH/FRONTLINE. [On-line]. Available at: www.pbs.org/wgbh/pages/ frontline/ shows/ georgia/isolated/resni ck.html. Accessed 1999. Resnick MD, Bearman PS, Blum RW, et al: Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. JAMA [On-line]. Available at: www.ama-assn.org. Accessed 1997. Riley R: The American high school in the 21st century [On-line]. Available at: www.ed.gov/Speeches/09-1999 /990915.html. Accessed 1999. Sizer TR: Horace's Hope: What Works for the American High School. New York, Houghton-Mifflin, 1996 Sizer TR: Michael Alone: Anonymity is the Curse of the American Comprehensive High School. American School Board [On-line]. Available at: http:/ /www.asbj.com/ 199909/0999coverstory.html. Accessed 1999. Student Crisis Assistance Manual. Nonpublic Department of the Colonial Intermediate Unit 20 [On-line]. Available at: http:/ /iu20.npss.org/crisismanual. Accessed 1998.
Address reprint requests to Mary M. Kerr, EdD 3811 O'Hara Street Western Psychiatric Institute Pittsburgh, PA 15213
1056--4993/01 $15.00
+ .00
HIGH SCHOOL CONSULTATION Mary M. Kerr, EdD
Adolescents who feel closely connected to their schools are adolescents who are emotionally healthier and far less likely to engage in risky behavior than their counterparts who feel no sense of community in their school. Without question, it is the formation of friendship networks within the school along with a perception that teachers care, that teachers are fair, and that school is a place where one belongs that help to provide that sense of community. 27 Experts agree on the critical role of school in an adolescent's psychologic development. This article addresses two major goals for mental health consultation in the high school: • to promote students' safety and well-being in the context of their educational experiences; and • to reduce student's risk-taking behaviors, so that they can take full advantage of their school experiences. To illustrate the role of the consultant in meeting these goals, we consider four essential components of a caring high school. The skilled consultant can strengthen each of these four dimensions. We begin with an overview of these components, followed by a more detailed illustration of the consultant's role within each. The first component is developmental guidance or prevention. This step delineates how schools care for all students, consistent with their developmental needs. Classroom staff and administrators may provide these services with some assistance from support persons, including a consultant from within or outside the school. Second, we need to consider the needs of students who encounter trouble along their developmental paths: the "at-risk" population. This
From the University of Pittsburgh Medical School, Pittsburgh, Pennsylvania
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 •JANUARY 2001
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component addresses a smaller, more focused group of students and their families. This component may also require special staffing. One might think of these as the "safety net" services and programs. The third component of a caring school is intervention. Students receiving interventions are not merely at risk; they are in need. Student assistance programs, support groups, individual counseling, and school mental health clinics are examples of an intervention tool. Crisis response or postvention, the fourth component, is the school's response to students in acute distress as a result of their own psychiatric issues, family discord, community events, or school tragedies. These students may be those whom the previous supports overlooked or simply failed. This component requires specialized skills, temporary changes in staff assignments, and a high degree of flexibility in procedures. During these crises, schools often reach out to the mental health community of psychiatrists and other mental health professionals. We begin with a look at the first component, those developmental needs of adolescents met through a caring school environment.
COMPONENT ONE: A CARING SCHOOL
Many studies of adolescents in schools concur in their findings that teenagers need to find a place in a valued group that provides a sense of belonging; to feel a sense of worth as a person; reliable and predictable relationships with other people, especially a few relatively close relationships or at least one; and to identify tasks that are generally recognized in the group as having adaptive value and thereby earn respect when a skill is acquired for coping with the tasks. 12 Other basic needs include safe places to gather (with adult supervision) and provision of experiences that allow teenagers to share their time and talents with their community and to have healthy, fun recreation.4 By their very structure, high schools often fail teenagers. These educational institutions are often large and impersonal. Some school personnel even declare that schools are places where "we teach content, not students." Exacerbated by a focus on academic outcomes, test scores, and athletic victories, today's high schools may thus endanger the very persons they set out to serve. Consider this teenager's e-mail following the Columbine High School violence: Yeah, I've had some fantasies bout taking out some of those jerks who run the school, have parties, get on teams, are adored by teachers, have all these friends. Sure, they hate me. Day by day, it's like they're taking pieces out of you, like a torture, one at a time. My school has 1500 kids. I could never make a sports team. I have never been to a party. I sit with my friends at our own corner of the cafeteria. If we tried to join the other kids, they'd throw up or leave. And by now, I'd rather die. Sometimes, I do feel a lot of real pure rage. (New Jersey, 1998.)
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How can high schools better meet their students' developmental needs? Teenagers Need Caring Relationships
The consulting child specialist can provide the high school staff with information on the normal developmental needs of adolescents, especially young adolescents whose needs are often the more difficult to meet, as they enter the large, challenging world of the senior high school. Caring Relationships Require Human-Scale Schools
Many educators are now searching for ways to provide a more human-scale environment. 9, 18' 30 A team of 25 to 30 teachers might be ideal. This implies a school of 325 to 420 pupils, itself a human-scale number."28 In its report, Breaking Ranks: Changing an American Institution, the National Association of Secondary School Principals urged its members to scale down high schools and implement systems of personal advocacy for all students. The relationship between the students and the advocate should ensure that no youngster experiences the sense of isolation that frequently engulfs teenagers during this critical period of their lives. We expect the advocate to meet regularly throughout the year on an individual basis with about 15 to 20 students. 21 The consulting mental health professional cannot always bring structural reform but can encourage schools to become more humanscale places. The shift from lecturer to listener does not come easily to many veteran educators. A consultant can help teachers reconnect with students by teaching them emphatic listening skills and suggesting activities to bring them and their students together during unstructured times. Goldberg10 has described how to set up advisory groups. /1
Teenagers Need High Expectations
Research studies on self-efficacy, resilience, and effective schools all confirm the importance of high expectations for students when those expectations are shared by an interested and caring adult. 2, 24, 26 Consultants can point out ways that schools can foster self-efficacy and resilience through caring relationships, high expectations, and opportunities to belong. 2 Examples of instructional practices that increase expectations are to display students' work, hold student-led parent conferences, and have students collect and reflect on their work thorough portfolio assessments. This kind of advice to school staff members can be enlightening, as it lessens the perceived gap between mental health practices and what
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happens in the classroom. Moreover, consultants can raise teachers' own self-efficacy about their role in preventing mental health problems. Some districts focus primarily or initially on specialized needs, that is, at-risk programs, crisis responding, safety and security, special education, and alternative education; however, consultants can urge school district personnel to focus on prevention for several reasons. Often, specialized needs result from basic ordinary needs going unmet. A student with a strong relationship with a component caring adult20 is far less likely to disrupt class than his or her alienated peer. Students with behavioral problems often report how their actions were in response to the frustration of "nobody listening." A second example is special education services. Often, students are referred for special education and related services because they are not succeeding in the general education setting. Consultants can suggest and implement inservice programs, including coaching, and supervision to improve general educators' behavioral assessment and intervention skills. Most teachers have had little or no coursework in working with behaviorally challenging students. Some schools seem to be in "chronic crisis" because they overlook the essential work of providing good educational experiences in the context of caring relationships. The consultant can help schools caught in this cycle to refocus on prevention and developmental guidance supports. For example, when ninth-grade teachers are not fully aware of normal developmental behaviors in young adolescents, they may well imagine that they have a classroom full of emerging juvenile delinquents and attempt to suspend them or possibly refer individual students to special education or mental health services. The consultant can provide staff development (or encourage principals to offer it) that addresses these inappropriate referrals. COMPONENT TWO: SERVICES FOR STUDENTS AT RISK
Consultants can help educators recognize the warning signs for psychiatric problems. As the earlier e-mail illustrated, many teenagers feel and are often, in reality, left out of the community of their high schools. Many drop out altogether. Several factors contribute to the problem. Detachment from Parents
As adolescents spend less and less time with their parents, cliques increasingly fill the emotional vacuum, and the high school game of acceptance or rejection is being played for even higher emotional stakes." 1 Adolescents come into daily contact with information that either endorses or creates interest in high-risk behaviors, including high-risk 11
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sex, substance use, and violence. The onset of puberty is earlier, which heightens the biologic press for sexual activity. Lacking a sense of belonging at school, adolescents seek to fit in with their peers. Their activities often can include substance use, aggression, and sex. Noonan23 points out that these factors are exacerbated by educators' lack of awareness of the mental and emotional illnesses that emerge at high rates in adolescence, for example, depression, suicidality, anxiety, eating disorders, and intense aggressive impulses.
Tighter School Sanctions
Already alienated from their schools, teens in trouble may be further marginalized by an educational system that suspends, rejects, or expels them. Second chances do not exist in many districts intent on enforcing a "zero tolerance" policy for alcohol and other drug use, threats of violence, and weapons violations. Contributing to these factors is the inability of many classroom teachers to identify or respond to students at risk for serious medical and psychiatric problems. The consultant can introduce the following protocol for engaging at-risk students to share their thoughts and feelings (see boxed area).
Steps in Assisting a Student at Risk
• Have a conversation with the student in private. • Let the student know that you are concerned and want to help. • If the student hesitates, gently offer an example of the worrisome behavior. • Resist the urge to explain the symptom and/or offer advice. • Be a good listener so the student feels comfortable talking. Pay attention to how much you are actually listening versus counseling. Do not badger! If the student does not want to talk, try another option. • Be patient! Students with problems are not always articulate. It may take a little while for them to explain how they feel. Do not interrupt. Show the student that you are interested by looking at him or her and nodding your head. • Avoid judgments. This is no time to evaluate the student's perceptions. • Next, name some action that you can take with the student. If you cannot immediately think of a plan, at least show your acceptance and willingness to help. • Close the conversation with reassurance (even if you cannot genuinely show acceptance of the student's views). Some students need information to help them view their situations more hopefully. If this is the case, offer it. • Follow up on your commitment. Even if you have promised only to talk again, be sure you do. If you offered specific help, get it quickly. Know how to help. Your work obligates you to know child and adolescent
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referral procedures, to understand the mental health services in your community, to know warning signs, and so forth. • Know how to handle confidentiality. Do not promise total confidentiality to a student; you may not be able to keep your word. Do not promise confidentiality, for example, in the case of suicidal or homicidal threats. 16 Adapted from Kerr MM, Nelson CM: Strategies for Managing Behavior Problems in the Classroom, ed 3. Columbus, OH, Merrill, 1998, pp 325-326; with permission.
This interaction described in the box is more easily and effectively achieved in schools that have successfully implemented advisory groups, small homerooms, and other ways of connecting with their students. We have found it most effective to teach all instructional staff these steps, because many distressed students seek out adults they trust and see every day, for examples, favorite teachers, club sponsors, coaches, and counselors. COMPONENT THREE: INTERVENTION
The consultant can offer administrators, counselors, psychologists, and social workers advice on how to identify and refer adolescents with psychiatric disorders such as eating disorders, depression, anxiety disorders, and chemical dependency. Consultation is especially important for students with internalizing disorders that may otherwise go unnoticed. One tool that may help teachers recognize students at risk is the Teacher Interview for Psychiatric Symptoms (TIPS), 17 a structured telephone interview designed for mental health professionals to use in questioning educators about patients' psychiatric symptoms. The TIPS, patterned after the K-SADS, includes examples of symptoms as teachers might observe them in a school setting. To review the information that educators need, refer to the boxed outline we have used to identify and refer students with deliberate self-harm.
Adolescents with Deliberate Self-Harm: What Educators Need to Know
Summary of statistics on suicide Risk factors for adolescent suicide Symptoms of depression Symptoms of bipolar disorder Risk factors for recurrence of depression Assessment of suicidal risk in adolescents (The SAD ADOLESCENT Assessment) • Sex • Age
• Depression
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• • • • • • • • • •
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Availability of firearms or/other methods Discord in family or parental psychopathology Organized plan/intent/preparation Lack of social supports/peer conflicts Earlier suicide ideation/attempts Substance abuse/dependence Cognitive distortions/hopelessness Exposure to others' suicidality Not agreeable to "no suicide" contract Temper/aggression/recent homicidally
The consultant can also introduce the following protocol : Response to a Young Person at Risk for Suicide
• Remain calm and patient; do not panic or become agitated. • Let the young person know that • help is available, • talking about suicidal feelings is okay, • there is hope, • that depressed people do benefit from treatment. • Never leave a suicidal young person alone or send him or her home on a school bus or pubic transportation without having made a plan with his/ her parents. • Make whatever referral is necessary in collaboration with parents. A young person at risk requires evaluation by a mental health professional. • Know whom to contact in your school or organization. • Be aware of the referral resources in your community. How To Complete A "No Suicide" Contract • Adolescent agrees not to hurt him/herself. • Adolescent, parents, and counselor rehearse strategies to cope with suicidal thoughts should similar precipitants recur. • Adolescent will tell parents or counselor if he or she is having suicidal thoughts. • Adolescent will present him/herself at emergency room if there is no one available to help. • Adolescent will structure his/her activities in a way that will reduce suicidal potential. The Referral Process • • • • • • • • •
Involuntary hospitalization procedure Call your county mental health office for process Each county has own procedures Call police if risk of violence to self/others Health insurance issues Psychiatric outpatient services Local agency or provider networks Emergency room (medical or psychiatric) Voluntary hospitalization procedures
Other Support Resources • Primary care physician • Parent's employee assistance program • School counselor
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• Spiritual/religious counselor • Bereavement counselor Follow-up Action Plan Maintain regular communication with family • • • • •
Check on status of referral/s Maintain regular collaboration with mental health provider Provide alternative referrals as needed Periodically reevaluate suicidality/suicidal risk Reaffirm "No Suicide Contract" as needed.11
From Greaves MM: Level I Training, Services for Teens at Risk (STAR-Center). Pittsburgh, PA, Western Psychiatric Institute & Clinic, 1999; with permission.
COMPONENT FOUR: CRISIS RESPONDING AND POSTVENTION
The kinds of crises that affect schools are numerous. Many are those of unintentional harm, for example, sports injuries, automobile accidents, weather-related disasters, and contagious diseases. Districts across the country currently are paying more attention to students who threaten violence. School administrators, wanting to know whether certain students will become violent, often refer them for psychiatric assessments. Consultants can help schools develop their own initial threat assessment procedures to avoid inappropriate referrals to already crowded emergency rooms and inpatient services. Table 1 includes some risk factors that can alert school personnel to the potential for possible aggression or violence. We recommend that schools have a
Table 1. RISK FACTORS FOR POTENTIAL AGGRESSION OR VIOLENCE
Characteristically resorts to name calling, cursing, or abusive language. Habitually makes violent threats when angry. Has previously brought a weapon to school. Has a background of serious disciplinary problems at school and in the community. Has a background of drug, alcohol, or other substance abuse or dependency. Is on the fringe of his/her peer group with few or no close friends. Is preoccupied with weapons, explosives, or other incendiary devices. Has previously been truant, suspended, or expelled from school. Displays cruelty to animals. Has little or no supervision and support from parents or a caring adult. Has witnessed or been a victim of abuse or neglect in the home. Has been bullied and/ or bullies or intimidates peers or younger children. Tends to blame others for difficulties and problems s/he causes her/himself. Consistently prefers TV shows, movies, or music expressing violent themes and acts. Prefers reading materials dealing with violent themes, rituals, and abuse. Reflects anger, frustration, and the dark side of life in school essays or writing projects. Is involved with a gang or an antisocial group on the fringe of peer acceptance. Is often depressed and/or has significant mood swings. Has threatened or attempted suicide. From National School Safety Center: Checklist of Characteristics of Youth Who Have Caused School-Associated Violent Deaths. Westlake Village, CA [On-line]. Accessed 1998; with permission.
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threat assessment team that involves educators who know the student well as well as representatives from school administration, mental health, and law enforcement. Good advance planning can reduce significantly the negative impact of a tragedy on youth and those who work with them. School districts, with consultants, can prepare for tragedies by developing postvention policies and procedures that may be activated on short notice. The three goals of most postventions are (1) to return the school to its normal routines, (2) to support those who are grieving the loss of a classmate, teacher, or colleague, and (3) to identify and assist those at risk for unhealthy behaviors and reactions. Postvention in high schools is especially important, as students usually develop close relationships with their peers. It is natural, therefore, for the school family to come together to support one another when a tragedy befalls one of its members. No single model is adequate for every school or community, but we do follow certain basic guidelines in supporting schools through a tragedy. Each postvention plan should include the following: 15 l. School board policy authorizing postvention activities. 2. Interagency agreements to ensure that resources are available in the event of a tragedy. 3. Communications plans • Internal communications plan for faculty, administration, district administrators, school board members, and crisis team members, for example, "on-call" arrangements, phone/fax/ pager contact lists, telephone tree, with updates twice a year. • External communications plan, including how to reach qualified professionals for consultation, how to respond to media requests, and how to keep parents and guardians informed. 4. Deployment of key personnel by name and area of responsibility during the postvention period. These personnel may include • Postvention coordinator • Postvention team • School pupil services staff or student assistance teams • Community mental health professionals • Monitors and escorts for students • Clerical support persons • Security staff • Group facilitators • Central office contact persons • School board liaison 5. Refresher training for district employees assigned to crisis response. 6. Ongoing recruitment and training for new crisis responders. 7. Strategies for debriefing the crisis responders, evaluating the postvention, and discussing how to prevent another such tragedy. 8. Annual review of postventions and revisions to the plan.* *From Kerr MM, Brent DA, McKain BW: Postvention Standards Guidelines: A Guide for a School's Response in the Aftermath of a Sudden Death, ed 3. Pittsburgh, PA, Services for Teens at Risk, STAR-Center Publications, 1997; with permission.
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SUMMARY
High schools painstakingly plan their academic standards, curricula, instructional approaches, technology, and facilities. Also essential to the vision is a systematic plan for developmental guidance, prevention, at-risk services, intervention, crisis responding, and postvention. The consultant, working in partnership with a caring school staff, can promote safety and well-being and reduce risk-taking behaviors so that adolescents can get the most benefit from school experiences. Several protocols have been described that may guide a consultant in helping school personnel.
References 1. Adler J: The truth about high school. Newsweek, May 10, 1999:56-57 2. Benard B: Fostering resilience in children. Champaign, IL, Children's Research Center. [On-line]. Available at: http://ericps.crc.uiuc.edu/eece/pubs/digests/1995/benard95.html. Accessed 1995. 3. Benard B, Marshall K: A framework for practice: Tapping innate resilience [On-line]. Available at: www.coled.umn.edu/ CARElwww /ResearchPractice/v5nl /benard.htm 4. Blum RW: Lost children or lost parents of Rockdale County? WGBH/FRONTLINE. [On-line]. Available at: http:/ /www.pbs.org/wgbh/pages/frontline/shows/georgia/ isola ted/blum.html. Accessed 1999. 5. Boyd B: Scottish schools: An ethos of achievement. Phi Delta Kappan November: 252-253, 1997 6. Carnegie Council on Adolescent Development: Turning Points, Preparing American Youth for the 21st Century. Washington, DC, 1989. For more information, call 202265-9080. 7. Crisis Management Manual. Butler, PA, Butler Area School District, 1995 8. Early Warning, Timely Response: Guide to Safe Schools. Juvenile Justice Clearinghouse. Rockville, MD. [On-line] . Available at: http:/www.ed.gov I offices/OSER/OSEP I earlywrn.html. Accessed 1998. 9. Fowler WJ Jr: What do we know about school size? What should we know? Presented at the 73rd Annual Meeting of the American Educational Research Association, San Francisco, April 22, 1992 10. Goldberg MF: How to design an advisory system for a secondary school. Alexandria, VA, Association for Supervision and Curriculum Development, 1998 11. Greaves MM: Level I Training, Services for Teens at Risk (STAR-Center). Pittsburgh, Western Psychiatric Institute & Clinic, 1999 12. Hamburg DA: A Development Strategy to Prevent Lifelong Damage. Annual Report Carnegie Corporation of America, Minneapolis, MN, Watt/Peterson, Inc, 1995, p 12 13. Harris J: Developmental Neuropsychiatry. New York, NY, Oxford Press, 1995 14. Johnson WD: What makes cooperative groups work? Teaching Times Pittsburgh, University of Pittsburgh Center for Instructional Development and Distance Education, 1999 15. Kerr MM, Brent DA, McKain BW: Postvention Standards Guidelines: A Guide for a School's Response in the Aftermath of a Sudden Death, ed 3. Pittsburgh, PA, Services for Teens at Risk, STAR-Center Publications, 1997 16. Kerr MM, Nelson CM: Strategies for Managing Behavior Problems in the Classroom. Columbus, OH, Merrill, 1998, pp 325- 326 17. Kerr MM, Schaeffer AL: Teacher interview for psychiatric symptoms (TIPS), 1987 Available from Mary Margaret Kerr, Ed.D. at 3811 O'Hara Street, Pittsburgh, PA 15213. 18. Kohn A: Constant frustration and occasional violence: The legacy of American high
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schools. American School Board Journal [On-line]. Available at: http:/ /www.asbj.com/ 199909/0999coverstory.html. Accessed 1999. MacBeath J, Boyd B, Rand J, et al: Schools Speak for Themselves. London, National Union of Teachers, 1996 Masten AS: Resilience in children at-risk. Research Practice, 5. [On-line]. Available at: http: I I carei.coled.umn.edu/ResearchPractice/v6nl/masten.htm. Accessed 1997. National Association of Secondary School Principals: Breaking Ranks: Changing an American Institution. Reston, VA, National Association of Secondary School Principals, 1996 National School Safety Center: Checklist of Characteristics of Youth Who Have Caused School-Associated Violent Deaths. Westlake Village, CA [On-line]. Available at: http:/ I www.nsscl.org/ reporter I checklist.htm. Accessed 1998. Noonan C: Brief interventions foster student resiliency. The Education Digest, April 1999, pp 36-38 Pajares F: Current directions in self-efficacy research: Self-efficacy lecture [On-line]. Available at: http:/ /userwww.service.emory.edu/-mpajares/ efftalk.html. Accessed 1998. Resnick MD: Adrift in America. WGBH/FRONTLINE. [On-line]. Available at: www.pbs.org/wgbh/pages/ frontline/ shows/ georgia/isolated/resni ck.html. Accessed 1999. Resnick MD, Bearman PS, Blum RW, et al: Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. JAMA [On-line]. Available at: www.ama-assn.org. Accessed 1997. Riley R: The American high school in the 21st century [On-line]. Available at: www.ed.gov/Speeches/09-1999 /990915.html. Accessed 1999. Sizer TR: Horace's Hope: What Works for the American High School. New York, Houghton-Mifflin, 1996 Sizer TR: Michael Alone: Anonymity is the Curse of the American Comprehensive High School. American School Board [On-line]. Available at: http:/ /www.asbj.com/ 199909/0999coverstory.html. Accessed 1999. Student Crisis Assistance Manual. Nonpublic Department of the Colonial Intermediate Unit 20 [On-line]. Available at: http:/ /iu20.npss.org/crisismanual. Accessed 1998.
Address reprint requests to Mary M. Kerr, EdD 3811 O'Hara Street Western Psychiatric Institute Pittsburgh, PA 15213