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School in a Psychiatric Hospital
School
In
a Psychiatric Hospital
Steven R. Forness, Ed.D. and Fmn/f H. Langdon , E d.D.
A number of emoti on all y di sturbed and mentally re tarded children ultimately require some fo r m of hospitalization . Wh ether they are ad m itted for long-term r esidential treatment or fo r short-term obse rvation and diagn osis, th eir lives are th ereb y a lte red , their patte r ns of living sometimes se r iously disrupted . So me continuity remains , however: ward ph ysicians and staff nu rses assume th e resp onsibility for parental ca re and supe rvision . If th ere is a hospital schoo l, thi s unit becomes the co u n te r part of th e public school wh ich these ch ild re n mo st likel y attended prior to admission . Ind eed , the familiar routine o f desks, cha lkboa rds, tea chers, and book s ma y brin g a ce rta in co m fo rt to wha t must seem for so me child re n an overwhelmin g e x pe r ie nce. Esp ecially for children with a jJrevio1lsl)' unsatisfying school experience, a good hospital school becomes an essential part of treatment. There are problem s, ho we ver , in operatin g a n e ffec tive school in a hospital setting. U nlike othe r special ed uca tio n sett ings in whi ch ed ucato rs ha ve relative a u to no m y, tea ch ers in a medical se tt ing se ld om ha ve primary program responsibility. U nlike man y spec ia l education settings in which teachers wor k in relativ e isolation and ar e expected to ass u me seve ra l helping rol es with chi ldre n, hospital tea chers work sid e by side with other profession als who undertake t he se functions often from different theoreti cal a p p ro aches. Unlike most special class sett ings in which normal child re n and regular classroo ms are part of the milieu, the hospital scho ol must prepare chi ld re n for the r eality o f normal peer relati onships and success in schoo l classrooms far removed from either. A schoo l staff operates, Dr . Forness is Associa te P rojessor of Psvchiatrv (in Residences, and Dr. Langdon is P rin cipal, Neu ropsvchiatrir I nstitute S chool, Unh.l(·rsil)' o] Ca lifo rn ia at Los , 1ngelt's. P repa ration of this pap er was support ed in par t In' U.S. Of fiCI' 0/ Education Gra nt No . OEG-O-72 3974 (603) and N IC H D Grant N o. HD O-l61 2 , M ental R etardation Cm ter, U CLA . Th e authors would like to acknoudrdge the va luable assista nce and com ment s 0I' NP I teachers a nd staff in preparin g the present manuscript. R ep ri nts IIW} be requested f rom Dr. Forn ess, UCLA Department 0/ Psvchia tr», 76 0 Westwood Pla za, Los Angeles, Calif 90024 .
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the re fo re , under ce rtain co ns trai n ts for whi ch th ey are se ldo m fo rmall y p repared . Med ical or psych iat ric sta ff a re likewise placed in a re lative ly unfam iliar role, workin g with classroom teach e rs a t close quarters on an almost hourly bas is. Interdisciplinary coo pe ra tio n always see ms to gene rate pro fessional iden tity cr ises, an d th ese proba bly become even more intensified in a ho sp ital sett ing. These issues are di scu ssed , parti cularly with re ference to the ac tu a l operation o f a n inpatient schoo l in a psychi at r ic hospital. TH E S C H O O L PR O GRAM
For ove r a decad e, the Neuropsychiatric Institute (NPI) Sch ool has been pa rt of the C hildre n's Division of th e UCLA Department of Psychi a try. Origin all y begun o n a modest sca le to provid e schooling for ch ild re n o n two psychi atric wards (Hewe tt, 1967), the schoo l was ex pa nd ed four yea rs ago to include pati en ts fr om th re e additio na l wa rds o f t he Depa rtment's newl y o pene d Me n ta l Retardati on Ce n ter. As in othe r un iversity medical ce n te rs, ch ild pat ients also serve as teach ing cases fo r th e De par t me n t's p sychiatric re sid e ncy p rogra m . Of th e five ch ild re n's war ds , two are fo r ad olescents: o ne whic h has a short-te r m inten sive treatm ent program fo r mildl y retarded adolesce nts and a no the r follow ing a rath er tradi tional psych oan alytic a p proach for di stu rb ed ado lesce nts. T here is a thi rd ward for retarded a nd a utistic child re n utilizing a behavior mod ificati on program , and a fourth for latency-age child re n with psychia tri c proble ms use s a so mew ha t eclectic a pproach . T he fifth ward is a pediat ric wa rd for d e velopmen tall y disabled ch ildre n with conco m itan t psychi a tric p robl ems. Eac h ward has a ra ted bed capacity o f 16- 20 pati ents. Mos t child ren o n th ese wards have had sig nifica n t schoo l lea rn in g o r behavio r p ro blems p rior to ad m issio n . T heir ave rage length of hospitali zation is abou t e igh t months a nd ra nges fro m two weeks to well over a yea r. Th e staff of the N PI School ap proaches th e problem o f providing schoo l for suc h a di verse ch ild populati on by placin g ch ildren in classroom s not on th e basis of p sychi atri c o r medical di agno ses, but on th e basis o f th eir level of re ad iness for class roo m fun ctionin g. Read iness is ass essed by p rio r schoo l ex perience a nd by eva lua tion o f the child's classr oom pe r formance duri ng his fir st few d ays o f hos pitalizatio n. Child ren are brough t upstair s to th e school by nursin g sta ff and a ttend up to three hOl I1'S of schoo l pe r d ay, two hou rs in the morn in g a nd o ne in th e after noon. With in the school, ch ild ren are ass igne d to presch ool , elementary, o r secondary le vels, wh ich a re briefl y d escri bed bel ow.
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S teve n R . Forn css-s- F ra. n k H . Lan gdon
T he preschool sta ff eva lua tes each ch ild as soo n as po ssible after ad m issio n to the ward . Hi s responses to se lected sa m p les of typi cal preschool or kindergarten situa tio ns a re syste ma tically observed a nd recorded (G ra ha m e t a l., 1971 ), a nd thi s baselin e observation is used to determine the ch ild 's level of fun ctioning and his su bseq ue n t school program. Emphasis is pla ced o n preparing ch ild re n for preschool and kind ergarten functionin g by co m bining small g ro u p or individu al in struction with vari ous tan gible reinforcers (food or tokens) and syste ma tic social rein forcement. Enrollment varies from 12 to 20 ch ild re n , aged 2 to 9 yea rs, who attend school in two classrooms separat ed by an observa tion room and subdivided into smaller work a reas. The program is ca rried out by a team of three teachin g ass ista n ts and three part- tim e teachers, who also share responsibility for training, research , policy decisions, and co m m u nica tio n with th e vario us hospital wards. In the preschool as well as other level s, stude n ts from the UC LA Scho o l of Education ma y se r ve as assistant teache rs for five o r six hours per week as part of special edu cati on practica. At the elem entary a nd high sch ool levels, eac h child is interviewed about hi s past school ex pe r ie nce a nd tested with standard ac hieve m e n t tests durin g th e fir st week of ad m issio n . At the elementary le vel, he ma y be placed in o ne of two classrooms: a preacademic elementary class in whi ch e m p has is is o n building skills, suc h as paying attention a nd followin g directions, co ns id e red req uisite to suc cessfu l class roo m learning , or a n academic elementary class in which e m p has is is o n tool skill subjects such as reading and math. The seconda ry lev el is co m posed of two classro o ms, one for English and so cial st u dies, a nd a second for math a nd science with adj oinin g science a nd photograph y laborat ory. Em p h asis is placed o n preparing adolescen ts to function in public junior or senior hi gh school settings, a nd an individual program o f studies is prepared to help each student keep pace with classm a tes in the school he attended prior to ad mission. A third classro om for retarded adolesce nts is also part o f th e secondary program a nd focuses on remedial academic skills a nd preparation for d ail y living. Since this cla ssroo m recei ves pupils primarily from a sho rt -te r m treatment ward, e m p hasis focu ses upon o ngo ing eva lua tio n to determine whi ch approaches will be effec tive in postdisch arge classroom placements. T he ge ne ral approach at eac h of these levels is to indi vidualize aca de m ic instruction usin g beh avioristi c approach es (che ckm ar ks, free time, anel soc ia l reinforcement) wh enever necessary fo r classroom management a nd moti vation . A no ther major incentive at
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the second ary level is to give th e studen t more co n t ro l ove r decisio n ma king regard ing hi s ow n classroom p rogress. Eac h classroom has a n e n ro llme n t of 8 to 14 ch ild re n wit h a teach er a nd , in so m e classes , a te achin g· assista nt. The school also has a sho p activiti es classroom un d er the d irection of a teacher who arra nges in di vidu al ized p roj ects for bo ys and girls fro m e le me n ta ry a nd seco nd a ry levels. H e re , the e mp ha sis rests upon high- inte rest projects whi ch pr ov ide o ppor t u nities for chi ldre n to ap p ly academic skills lea rn ed in the classroo m, to demo nstra te responsibil ity for pl annin g and co m p let ing tas ks, an d to d evelo p po te n tia l vocati onal skills a nd leisure tim e hobbies. There is also a h om e-living classroom, d esign ed as a four-room apa rt me nt, which teach ers ma y sche d u le for pe riod ic instruction in fa mi ly life ed uca tio n and home-living skills. T eachers I in th e scho ol att e nd weekl y ward me etings and are co ns id e red part o f the int erdi scipl inary trea tme n t tea m to ge ther with psych ia trist, nurse , socia l worker , psycho log ist , a nd rehabilitati on th era pist. Th e y also p rov id e week ly reports o n eac h ch ild 's schoo l progress for the me d ica l chart, with whic h war d staff a nd th erapists ca n compa re their o bserv at io ns of his progress in o the r ho spital setti ngs. As each ch ild 's da te of d isch a rge nears, hi s teacher noti fies th e schoo l p lace me n t coo r di nato r , a teach er wh o fu nct io ns as a resource a nd liaiso n pe r so n . Decisions a re m ad e rega rdin g a n a ppro pria te school place men t fo r the ch ild after h is d ischa rge , ta king in to account the available ed uc atio na l res ources in the ch ild 's ho me co m mu n ity. Place ment ma y ra nge fro m a r egu lar classroo m in p ublic schoo l to spec ial classes, or eve n private re side nti a l schools. Co ns idera ble effo rt is ex pended toward secu ring a p pro pria te ed uca tio nal pla cem ent, since th e right ma tch be tween a chi ld's level of read iness a nd the clas s in wh ich he is ultimatel y placed is cruc ia l to his su bseq ue n t scho o l success . A fina l report is prepared b y th e child's NPI teach e r , d etailing ed uc atio nal levels, progress, an d be havio ra l or ed ucatio na l ap p roaches likely to be succ ess f u l in th e school sett ing to wh ich the child is being referred. Two ad ditio na l teach ers provide spec ial ed uca tio n cons u lta tio n to a ra th er e xte nsive progra m of ou tpa tie n t evalua tio n fo r ch ild re n wit h psychi atric proble ms. O f se ve ral hundred ch ild ren who are see n a nn ua lly, th e cons u lting teach e r s see on ly those with relati vel y se r io us school problems. In th ese cases, a fte r e xamining previous school reco rds. eva luating th e ch ild's pe rfo rm a nce in a simu lated clas sroom se tting, a nd in so me cases visiting the ch ild's ho me 1 All teachers a re qu alified to teach in pu blic school s bu t need no t have special ed ucation ce rt ifica tio n.
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S tev en R . Forness-s-Fran k H . Langd on
school , consultin g te achers prepare written reports with specific recommendations for schoo l placement and ed uca tio na l intervention. School Philosophy. Although other members of th e interdisciplin ary team may ca rr y th e primary responsibility for direct treatment of the child 's social a nd emotional problems, the ho spital teachers are in volved in su ch treatment, consistent with their go al of preparin g the child for fun ctioning in a r eal classroom setting. Teachers set spec ific ed uca tio nal and behavioral goals for each child in their classroom based not only on th e teacher's initial ed ucational impressions, but on r elevant case material presented during th e child's admission staffing conference. While material on interpersonal relationships, past famil y pressures fo r sch ool achie vement, siblings' school performance, and pa st educational history ma y be co ns ide re d rel evant data, the ch ild' s observable beha vior in the classroom is consid ered th e primary datum upon which classroom approaches are based. At times, a child m ay be required to adjust to a cla ssroom regimen even wh en he m av not be so motivated . At other tim es, he ma y be given eve ry opportunity for succ ess and acco m p lish me n t at his level of fun ctionin g in ord er to overcome his feelin gs of failure and fru stration assoc iated with past scho o l ex pe r ie nce, eve n wh en this is clearly in compatible with traditional classr oom ex pecta tio ns . It is essential that ea ch child be provided su ch success so th at he will more readily view himself as a learner a nd experience the social a nd emotional gains th at this role provides. Behavioristic approa ches (Fo rn ess, 1970) are used , but are co nce ived merel y as a deli very system-techniques to achieve effecti ve and systematic progress compatible with the overall treatm ent goals arrived at by the illterdisciplina 1) ' team in which the teacher participates. To ach ie ve interdisciplinary treatment goals in day-to-day operation, however, a hospital school staff must address itself to certain sensitive issues inherent in working in a medical setting. I SS UES
School in a M edical Setting
Most special ed uca tio n classrooms for emotionally disturbed or mentall y retarded children are eithe r in public schoo l settings o r in private schoo ls. In those sett ings a ch ild's education is th e primary concern; and policy matters are decided by ed uca tors usuall y, but not nece ssaril y, in co ns u lta tio n with a nc illa ry personnel suc h as
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psychi atrists, psych ologists, pediat rician s, a nd social workers . Some specia l ed uca tio n p ro grams, ho wever, d o exi st in medi call y oriented settings in which schoo ling is of secondary import ance and policy is decided primarily by p h ysicians or arrived at jointly by mem bers of seve ra l pro fession s. I n th e latter situat ion, much o f wha t happens is no t under th e sch ool's co ntrol. Child ren may be admitted for re asons not nece ssari ly r elat ed to school ing or di sch a r ged be fore the teache r j u dges the m read y. Schoo l p ro gress, while co nsidered essential, is su bsu me d under p ro gress in ot he r areas wh ich ta ke priority. Ind ee d , th e go al o f pre paring a ch ild for pu blic school fu nctioning may even be viewe d by medi cal staff as in com patibl e with so u n d m ental health princip les , a view with which eve n hospital teache rs ma y be in clin ed to agree , give n the quality of life in so me pu blic school classrooms (j ack son, 196 8). It is also usu ally the case th at matte rs of bu dget, space alloca tio n, sch ed u ling, an d sta ffing fo r a h ospital schoo l are dec ided by ph ysician s, un d erstand abl y so since d epartm en tal m edical staff, parti cul a rl y in teaching hospitals, are ult im ately j udged o n qu al ity of medi cal or psych iatric care , and o n ly second aril y on anc illa ry servic es suc h as schoo l. A hospital schoo l seldom fu nct ions a u to no mo us ly. T he fa m iliar role of the teac her thus becomes obsc u re d in an inte rdis ciplina ry setting. Pro blems arise relative to his o r her part in treatme nt pr ograms a nd whether th is overlap s th at of othe r profession als. At va rio us points pu blic schoo l special ed uca tio n teach e rs are o r di narily ca lled u pon to assu me seve ral p rofession al ro les; fo r in stance , th at o f social worke r (dealing wit h parental feelin gs ab out th e child's lack of sch ool progre ss, su ggesting res ources fo r psych ological o r medical assistance , gat hering ma te ria l on deve lop me nta l hi sto ry); o r psych ologist (inte rpret ing resul ts of pr evio us tes ting, setti ng u p be havi or mo difi ca tion progra ms, eva luatin g pe rceptual-motor skills); nurse (ma king home visits, seeing th at th e ch ild tak es p rescri bed me di cation, ban daging cuts and bru ises); r eh abili tati on th erapi st (p lan n ing a nd su pe rvising rec rea tio na l activities, p ro vid ing activity for d evelo pm en t of fine a nd gross motor skills, d evel opin g basic vocation al skills); a nd psychiatrist (h elpin g the ch ild to co pe with frustra tion , assisti ng the chi ld to in terpret and exprf'ss e motiona l responses appro priate ly, developin g ap prop r iate socia l interaction). So me wou ld argue tha t teachers are not fo rmall y trained to ass u me all these rol es, or tha t schoo l d istricts ord ina r ily have a nc illary personnel (school psych ologists , cou nse lo rs, schoo l nu rses) to d eal wit h such ma tters. O ne has o nly to obse rve th e special classroom teac he r ove r th e co u rse of a typical
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S tev en R . F orness-s-Fra.n k H . Lan g don
da y or exa m ine the caseload o f a ncilla ry personnel in most scho ol districts to kn ow that tea chers are expected to do more th an just teach. In a hospital schoo l, however, the teacher may com e in direct confli ct with other professionals who not only are ex pected but a re supposedly better prepared to assume th ese roles . When working in a n interdisciplinary settin g, teach ers as well as othe r professiona ls must eithe r d elineate th eir rol es or a t least mak e care ful decisions as to when ove r la p is desir abl e. T eaching in a ho spital , there fore , presents a co n tin u ing problem in role defini tion . Compared with public school teach ers, who may hav e to fun ction in rel ative ign orance o f their pupils' backgrounds, the hospital teacher is not o nly inundated with case material o n eac h ch ild , but belabored with o pinio ns, su ggestion s, a nd eve n direct o rde rs on how th e ch ild sho uld be a p p roac hed . Sinc e o n ly a fr action of case material ma y prove di rectl y relevant to a ch ild's schoo ling, a nd since so me recommendation s ma v eve n co n flict with th e teach er's perception of acce p table clas srool~l m anagement, a h ospital sch ool staff is faced with continuing dilemmas. One must d ecide whi ch case history mat erial is relevan t for class roo m pro gress and , co nversel y, whi ch d at a o n clas sroom fun ctioning a re use ful fo r othe r members of th e interdisciplin ary team. One must d ecid e wh en to take th e initiati ve in plannin g classr oom beha vior mana gement programs and when to defer to th e d ecisions o f psychi atrists o r psych ologists. Schoo l sta ff must decide when schoo l h ours are sacrosan ct and when child ren need to be released from sch ool for more "important" acti vitie s su ch as psychothe rap y. Lastl y, teach ers must d ecid e wh ether o r not th e y sho u ld e nc roac h on d ecisionmaking in o the r tr eatment a reas suc h as th erap y or wa rd man agem ent. A ran ge of a ns we rs ex ists, d ependin g on th e schoo l sta ff 's perception of th eir rol e a nd th e importan ce of school in th e chi ld's life. At one ex tr e me , based on the premise th at physicians are not only more hi ghl y trained but also primarily responsibl e for tr eatment, teachers co uld look to th e ps ychiatrist to formul at e sch ool programs. At th e oth er, based o n th e premise that teachers a re su p posed ly ex pe r t in clas sroo m meth od s and material s, a n d th at schoo l o fte n becomes a cr itica l fac to r in th e ch ild 's lat e r adj us tme n t (Robins, 1966), tea chin g staff co uld sim p ly com e to view the rest o f the hospital as a dormitory for housing children wh en not in school. Educational philosoph y is often a determining factor, with psych od ynamicall y o r iented teachers tending to favor the former a p p roach, and the mo re militant behaviorists ad o p ting the latt er. Neithe r, howe ver, is clearl y acceptable. Based o n NPI School operati on , th ere are, in fact, two over lap-
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ping a reas of clas sroom functioning with whi ch teachers must d eal : acad emic learning and classroom behavior. Specificall y, the hospital tea ch er is qu alified to ass u me so le re spon sibilit y over acade mic tasks the ch ild shall undertake, books or materials used , and rat e of acceptable academic progress. With regard to cla ssroom social or motivational behavior, howe ver, th ere ma y be tim es when th e teach er mus t defer to overall treatm ent go als as co nceived b y th e primary phy sician or interdisciplinary treatment team . The setting is, after all, a medical one . The ho spital teacher has, however, a professional responsibilit y to make his or her views known, to la y o ut thoroughly the co nse q ue nces o f overall treatment goals in terms of the child' s subsequent school progress. If in his or her be st judgment suc h go a ls co n flict with acce p ta ble school progress, th e ph ysician or treatment team must be so ad vised . An ill-advised action, su ch as precipitous dis charge o f a ch ild before he is educationallv read y, should clearly be d eemed AEA (Aga ins t Educational Ad vice), just as the d esignation A MA (Ag ains t Medical Adv ice) is used to label precipitous ac tio ns from a medical o r psychi atric vie wpoint. Certain th eoretical approaches, such as behaviorism , whil e h a vin g had demonstrable impact o n special educati on , ma y cr ea te problems wh en u sed in a ho spital setting. Hi storicall y, behavi oristic approach es have not been warml y regarded in ps ychiatric hospitals, since th e y tend to run co u n te r to traditional p sychod yn amic conceptuali zati ons in both theory a nd technique. Suc h approaches do present , however, a valid a nd useful fram ework for specia l ed uca tio n te ach ers. H ewett ( 1968) , fo r e xa m p le, ha s outlined a hierarch v of ed uca tio nal goals based o n o bse rva ble behavior. Basi c cl aSSr~)()ll1 difficulties 'ar e conceiv ed o f in terms of a ch ild 's ability to a tte nd to tasks (atte n tio n problem ), to make ac tive responses to tasks (re spo nse problem ), a nd to make the m in o rderl y sequences, i.e ., to follow directions (order problem). Once those skills a re mastered , emph asis shifts to th e child's ability to fu nc tion independentl y o f th e teache r (exp lora to ry problem ), to fu nc tio n soc ially in the classroom (soc ia l problem) , a nd, finall y, to acq u ire acade m ic skills (mastery problem ). While H ewett's sp ecifi c terminology is se ld o m u sed in the N PI Scho o l, hi s co nce p ts hav e become a n integral pan o f program plannin g and co mp rise much of th e content of weekly reports to ward personnel on each child 's classroom fun ctioning. Simil arl y, ma terial on a child's case hi story, psycholo gical test results, progress in psychotherapy, re sponse to medication, a nd fun ction ing in o ther ho spital a reas ca n be p roductivel y integrated into th ese areas o f classroom functionin g. Focu s within the beh avioristic framework shifts from problems
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whic h th e teach er ca n not ad d ress directl y (e. g. , a nx iety neurosis) to observa ble beha vio r with whi ch the teach er is prepa red to d eal systemati cally. It provides a fra me o f refere nce fro m whi ch teachers can talk to each other a nd to oth er p rofessional s, just as psychoanalytic co nce pts co m p rise a fra me of re fe re nce fo r psychi atrists. It sho u ld be mad e clea r , ho weve r , th at beh avior modificatio n a nd psychod yn amic th erapies are not mu tu all y exclu sive . I n point o f fa ct , behavi o ristic a p p ro aches must be im p leme n ted withi n th e co nte xt o f d evelopm en tal a nd psych od ynamic co nsidera tio ns . O ve r the yea rs , N PI Schoo l staff ha ve th us fo un d th at beh avio r modificat ion is usefull y co nceived o n ly as a deliver y syste m . It provides tec hniques which can , once acceptable tr eatm ent goals a re d erived by th e inte rd isciplina ry team , effect systema tic a nd measurabl e cha nge tow ard th ose goa ls in a class roo m co ntex t. T h us , there a re times whe n be hav ior istic a pproaches are mo di fied to co n fo r m to other tr eatment modali ties. As a n ex ample , one ch ild in the prea cademic eleme nta r y classroom was elect ively mute a nd cra wled o n th e floor whe neve r he was in th e class ro o m . T o avoi d d eal in g di rectl y with thi s be ha vior not o nly r an co u n te r to th e goal o f p reparing a ch ild to fu nction in a classroom settin g, bu t also ignored a beh a vioristic tec h niq ue wh ich the schoo l sta ff had previou sly used with success in a n oste nsi bly sim ilar case (Krave tz an d Forness, 1971 ). Mat e rial presen ted by th e bo y's psychi a trist , however, indicated th a t hi s sym p to ms were part of a comple x beha vioral patte rn whi ch gav e th e boy co nsid e ra ble co m fort in times of stress, much o f wh ich seemed to be assoc iate d with th e classroom setting. Becau se o f th is, th e teacher pla nned lessons fo r th e bo y whi ch did not req uire a ver bal respon se, a nd he was allowed to cra wl fr om one classr o om a rea to a no the r until suc h time as his a n xie ty diminish ed. Suc h a n a p p roac h not o n ly d eparted fr om typ ical beh avioristic tech niq ues but also underscored th e rel evance o f p reviou s psychi a tric case history d ata in d e termining classroom practices. I n a sim ilar fashion , it sho uld be noted th a t th e hosp ital staff pro vid es clos e sup po r t fo r seve ra l of th e beh a vioristic a p p ro aches us ed in the sch oo l. For exa m ple , the p racti ce o f "time -o ut ," ex cludin g a child bri efl y from th e classr oo m for misb ehavior and re turning him to th e ward, is rein forced by th e nursin g staff who, o n th e recommenda tion o f th e schoo l sta ir , assign the ch ile! to so me fo r m of res tr ict io n for the duration a nd attempt to avoid pro vidin g uninte nded social reinforcem ent for his be ing sen t out o f th e classroo m (Fo rness e t al., 1971 ). It has also been N PI Schoo l policy th at schoo l hou rs a re regu-
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larl y sche d u led , a nd th at no oth er acuv u y, eve n psych otherap y, tak es precedence. T h is has p ro ved a useful approach whi ch co mmunicates to the ch ild the importance of schoo l. While there are ob viousl v em ergen cv sit ua tio ns o r occasio nal sched u ling co n flicts to wh ich tl{e policLy d o~s not a p ply, th e hosp ital sta ff has co ns iste n tly a tte m pt ed to su p po rt th e practice wh enever possible. Hospital su pport for a sch ool program, respect for a teach er's opinion , and relative ind epe ndence in plannin g school programs a re hard won. The y are d eserved onl y throu gh co n tin ued professional co m petence a nd r epeat ed d emonstrati on o f th e importan ce of schoo l in th e child 's postdischarge adjustment. Tra nsition to Postdischarge School S etti ngs
Alt hou gh most special ed uc a tio n teach ers view their task as on e o f preparing ch ild re n for regular cla ssroo m fun ction in g, such a task is rendered more d ifficult in a ho spital sch ool. It is virtua lly impossible in the relati vely she lte red e n viro n me n t of a hospital school to prepa re ever y ch ild co m p letely fo r pu blic schoo l fun ctioning. The problem is esse n tially o ne o f ge ne ra liza tio n, the ability to a p ply skill s learned in o ne situation to a varietv o f other situ ations. The fact th a t a ch ild learns a nd be hav es in a hospital school setting does not necessarily mean tha t he will d o eq ually well in th e ge ne r ally less su p po r tive a tmos p he r e o f a public schoo l. In so me cases, a child ma y be allowed, just prior to d ischar ge, to a tte nd a school o u tside the ho spi tal wh ile co n tin uing to live in the h ospital , or to live a t hom e whil e a tte nd ing th e N PI Schoo l. Such a techniqu e all o ws fo r mo re g rad ua l tran sition with a g rea te r cha nce fo r ge nerali zation to occur. While co m p le te ly effecti ve me th od s of ge nera liza tion a re seld om possibl e in hospital school se tt ings, it is essential to a rticu la te so me a p proach , howeve r limited . A ch ild 's tran sit ion to public school sh ould, in fact, become a primary consid e ration from th e very firs t d a y o f hospitali za tion . On e me th od mi ght be to co nsid e r th ree co m po ne n ts wh ich . as Hewett ( 1968) has poin ted o u t, are basic to eve ry teachi ng situatio n: task , se tt ing. and incentive . In th e NP I Sch ool, these components a re co nce ived as fun ctionall y rel ated co ntin ua in whi ch a ch ild moves fr om rathe r basic functi onin g le vels to le vels of fun ction in g required fo r regular classroom enrollmen t. Th e notion of a hierarch y o f incentives has been discu ssed el sewh e re (Forness, 197 3). As T able I illu strates, su ch a co n tin u u m mo ves fro m rath er primitive levels o f reinfo rcement to a level whe re th e chi ld e ngages in schoo lwo r k so le ly for th e satisfac tio n of ac q uir ing skill or co m pete nce (W h ite, 1959). T he setting a nd cu rrie-
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Steven R. Forness-s-Frank H . Lan gdon
ulu m co n tin ua move fr om th ose lev els o r d ina r ily used for ch ild re n with ver y lo w le vels o f fun ctioning to th o se le vel s o rd ina r ily required for fu nctio ning in a re gular clas sr oom. Obviously, not e very ch ild a tta ins th e hi ghest lev els be fore bein g di sch arged from the hospit al; a nd fe w, if a n y, a tta in th e hi ghest level sim u lta ne o us ly o n all three co n tin ua . A ch ild's le vel o n o ne con tinuum, moreover , ma y depend o n h is position on the o the r two . For example , a ch ild may fun ction in a large in stru ctional gro u p only with th e aid of checkmarks or tan gible reinforcement , ye t wo r k in a hi gh-interest remedial reader sim p ly for th e sa tisfaction it brings. One makes these decisions based on each indiv idual child. Thus one decides , bas ed on trea t me nt goals and rate of observabl e progress in the inpati ent classroom, tha t a ch ild sho u ld be moved to a hi gh er le vel o n one co nt in u u m o r dropped to lo wer levels on a no the r. In so me cases a teacher ma y ha ve to begin such a child at very low levels of fun ctionin g on a task, sett ing. or inc entive co ntinuum so th at he ca n expe r ience success as a learn e r. Once he has don e so a nd begins to ex p ress co m fo rt a t th ose level s eithe r verball y or be havi o ra lly, th e teacher ca n be gin to provid e e xperien ces for him a t hi gher level s. It sho u ld be not ed th at th ese co n tin ua , like th e hie rarch y of ed uca tio na l go als mention ed ea rlier, a re me rel y co nce p tualiza tio ns, co nve nie n t ways of di scussin g a ch ild's classro om progr ess. In a sense, children m a y be said to be referred to special edu cati on or admitted to psychiatric hospitals to the ex te nt th at th e y fail to ach ieve a n acceptabl e le vel o n on e or a not he r of th ese hi erarchies. Fo r both te ach ers a nd hosp ital sta ff, eac h co nti n u u m p resents a useful point o f reference for a ch ild 's readiness for postdischarge Ta ble I Co ntinua of Read iness for Classroom Fu nction ing J ncentiues
Setting)
Currirulum Tasks or ,\[aln i al.\
Self-compet ency
La rge group ins tr uctio n
Reg ular classroom tasks or tex tbooks
Tas k feedbac k Social a p pr ova l Contingent use of free lime Token s or checkmarks T an gible rewa rds Edi ble re wa rd s
Sup plementa ry cur ricu lu m mat er ials Smal l gr o n p inst r uctio n Re medial cu rriculu m mater ials O ne -to- o ne ins tructio n
I ndi vidu a lly tailored mate rials .
School in a P sychiatric Ho spital
57 3
schoo l pl acemen t and puts th e probl em o f ge ne ra lizatio n in d efinable perspective. Educational R esearch a nd T rain ing
Resp ect for a school staff and th e autonomy to run its own p wgram co me mainl y from a hospital school's abilit y to demonstrate its effectiven ess. This is parti cularl y tru e in a uni versity teachin g hospital. Just as a teaching hospital is a laboratory for dev elopment of new therapeutic techniques, th e hospital schoo l is a laboratory for edu cational re search a nd de velopment. All hospi tal tea chers, th erefore, are au to ma tica llv demon stration teachers who must often work in h ighl y visible 'se tt ings, i.e. , classrooms with o bse rvation windows, and who ma y co n tin ua lly be ca lled upon to d efend th eir pwgrams. It is es sential tha t th e effectiveness o f their various techniques a nd a p p roac hes be clearl y ev ide n t. Emphasis sho u ld th erefore be pl aced on applied research , preferabl y that d ealin g with problems generated b y actual classroom cases. A hospital populati on , with its co n tin ua l ad m issio ns a nd di sch arges a nd wid e ran ge of pa tients, ne gates th e use o f t radi tional experimental research desi gns . The hospital school staff ca n o fte n effecti vel y use a sin gle-subject d esign in whi ch basel ine d at a are taken o n a ch ild's pe rformance, and against which th e effect s of a p articular intervention can be m easured . Collaborativ e studies a re often po ssibl e , whereby measures of class roo m fu nc tio ning becom e a dependent va ria ble by whi ch the effec ts of tr ea t me n t in o the r areas o f the hospital are measured. The hospital school al so represe n ts a unique re search se tting ill whi ch sta ff, edu cation facul ty, and g rad ua te stude n ts ca n d evelop a nd refine inno vati ve ed uca tional methods on a sma ll but rel ativ ely well-controlled scale before appl yin g th em in public schoo l c1 as sro~m s . Trainin g o f ed uca tio n stu de n ts is a n essen tia l functi on o f a n in patient school. Just as medical students, re sidents, and interns become an int egral part o f ho spital operations, ed uca tio n practicum students be come cr uc ia l to a hospital schoo l pwgram. Exte ns ive individuali zati on of classroom pwgrams is seld om possibl e without addition al sta ff ass ista nce . Education stude n ts se rve as a re source for this purpose, whil e at th e sa me time recei ving e x per ie nce and supervision in a sett ing in whi ch innovative techniques an d particularl y challe ngi ng cases are co m mo n p lace . Supervision tim e needs to be systematicall y scheduled so that tea chers can devote su fficie n t time to st ude n ts and carefull y m onitor thei r progress with individu al ch ild re n. There are also ad di tio na l o bliga tions to public school teachers o r ed ucatio n st ude n ts wh o wish to visit and tour the school
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St even R. F omess-Frank H. Lan gdon
fac ility . Whil e int e rruptions occasi o ned by such visits ca n be tr yin g, th e di vid ends o f a co m m u nity teach er's increased familia rity with hospital schoo l pro gram s and, p erhaps, greater rec eptivi ty to ch ildren di scharged fro m ho spitals a re ultimatel y worth thi s di sruption . A ho spital teach e r fun ctions as a n in structor of trainees in o the r professi ons as th e y attempt to learn ab out tr eatment o f school learning a nd behavior problems. Each staff me e ting the teacher attends, each co n fe re nce with a chi ld's doctor, eac h re port wr itten for a medical cha rt represents a teac h ing o p po rtu nit y. While formal se mi na rs or gra nd rounds ma y be occas io ns fo r p resentin g did actic material a bo ut sp ecial ed uca tio n trends and techniques, th e primar y teachin g mod ali ty still remains case -o r iented problem so lving. A h ospital teach er sho u ld strive to place each resid en t's or tr ainee 's case in perspecti ve for him with reference to tr ends a nd issu es in public education which will apply when he leaves the hospital for privat e o r co m m u n ity practi ce . Since tec h niq ues and a pproach es are beginning to cha n ge as r apidl y in ed ucatio n as in othe r fields, th e hospital teach e r not o nly must be a good teacher but also must be familiar with th e re search literature in his or her own field . The goals o f teachin g ch ild re n, research in spec ial ed ucatio n, a nd pro fessio nal tra ining are, in a hospital school se tt ing, esse ntiall y dependent on one ano ther. T o provide go od tr ainin g ex perie nce fo r stu d e n ts req u ires tha t teachers kn ow effec tive a nd inno vative teac h ing me thod s. T o be able to se lect a p pro p r iate educati onal methods a nd tec h niq ues for a child's schoo l pro gram , a nd to d efend th eir use within the co n tex t o f interdisciplin ary treatment, require that teach e rs both kn ow a nd pa rt icipate in ed uca tio nal re search. CONCLU SION
There a re no give ns in hospital schoo l te aching. There a re, to th e best o f o u r kn owledge , no formal cu rricula specifica lly to pre pare teachers to functi on in a m edical or psy chiatric setting. T he a pproaches a nd procedu res d escribed ha ve been a r ri ved at o nly throu gh co ntin uo us ex perime n ta tio n a nd co ns ide rable str uggle ove r the yea rs an d most d ecid edl y do not represent a fin ished product. Yet, the importance of sch oo l in a child 's life, the problems it occasi on s, a nd its potential for making a d ifference make a n effe ctive inpatient schoo l program ind isp ensable to a psychi atric hospital.
School ill a Psychiatric Hospital
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R EFERENC ES FORNESS, S. R. (1970), Behav io ristic app ro ach to classroo m ma nage me nt and mo tivati o n , Psych01. s.«, 7 :35()....%3 . -' - (\ 973), The rein forc ement hierarchy. PS\'c!IOI. Sch., 10: 168-177. - - - ESVE LOT, K., &JA COBS, 1'\. ( 197 1), ciassr~om exclus ion in a chi ld ren 's ps ychi atr ic hospi tal. Ex cept. Child., 37 :4 63 -464 . GRA HA~ I , Y., KASS, W. , & FORNESS, S. (1971), Devel opm ent o f a be hav ior basel in e for ed uca tional in te r ve n tio n with a typical preschool childre n . Pr esent ed at Ca lifo rn ia Ed uca tio na l Res earch Associa tio n , San Diego . H EWETT, F. M. (19 67), Establi shing a sc hool in a psychi atric ho spital. M ent . Hyg.,
5 1:275-283. - - - (\ 9( 8), Th e Emotionallv Disturbed Child ill the Classroom. Bo ston : Allyn & Bacon. JACKSON, P. W. (1968), Life ill Cla ssrooms. New York : Holt, Rin ehart & Win ston . KRAV ETZ, R. J. & FORN ESS, S. R. (1971 ), Th e spec ial classroom as a desen sitization se tt ing . Exc ept. Child., 37 : :~89-39 1. ROBl:"s , 1.. ~ . (1966), Deviant Ch ildren GrowlI Up. Bal tim ore : W illiam s & Wilkin s. WHITE, R. W. (\ 959), Mot ivation reconsidered . Psychol. R eI'., 66:2 97-333 .
In
a Psychiatric Hospital
Steven R. Forness, Ed.D. and Fmn/f H. Langdon , E d.D.
A number of emoti on all y di sturbed and mentally re tarded children ultimately require some fo r m of hospitalization . Wh ether they are ad m itted for long-term r esidential treatment or fo r short-term obse rvation and diagn osis, th eir lives are th ereb y a lte red , their patte r ns of living sometimes se r iously disrupted . So me continuity remains , however: ward ph ysicians and staff nu rses assume th e resp onsibility for parental ca re and supe rvision . If th ere is a hospital schoo l, thi s unit becomes the co u n te r part of th e public school wh ich these ch ild re n mo st likel y attended prior to admission . Ind eed , the familiar routine o f desks, cha lkboa rds, tea chers, and book s ma y brin g a ce rta in co m fo rt to wha t must seem for so me child re n an overwhelmin g e x pe r ie nce. Esp ecially for children with a jJrevio1lsl)' unsatisfying school experience, a good hospital school becomes an essential part of treatment. There are problem s, ho we ver , in operatin g a n e ffec tive school in a hospital setting. U nlike othe r special ed uca tio n sett ings in whi ch ed ucato rs ha ve relative a u to no m y, tea ch ers in a medical se tt ing se ld om ha ve primary program responsibility. U nlike man y spec ia l education settings in which teachers wor k in relativ e isolation and ar e expected to ass u me seve ra l helping rol es with chi ldre n, hospital tea chers work sid e by side with other profession als who undertake t he se functions often from different theoreti cal a p p ro aches. Unlike most special class sett ings in which normal child re n and regular classroo ms are part of the milieu, the hospital scho ol must prepare chi ld re n for the r eality o f normal peer relati onships and success in schoo l classrooms far removed from either. A schoo l staff operates, Dr . Forness is Associa te P rojessor of Psvchiatrv (in Residences, and Dr. Langdon is P rin cipal, Neu ropsvchiatrir I nstitute S chool, Unh.l(·rsil)' o] Ca lifo rn ia at Los , 1ngelt's. P repa ration of this pap er was support ed in par t In' U.S. Of fiCI' 0/ Education Gra nt No . OEG-O-72 3974 (603) and N IC H D Grant N o. HD O-l61 2 , M ental R etardation Cm ter, U CLA . Th e authors would like to acknoudrdge the va luable assista nce and com ment s 0I' NP I teachers a nd staff in preparin g the present manuscript. R ep ri nts IIW} be requested f rom Dr. Forn ess, UCLA Department 0/ Psvchia tr», 76 0 Westwood Pla za, Los Angeles, Calif 90024 .
562
School in a Psschia tric H ospital
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the re fo re , under ce rtain co ns trai n ts for whi ch th ey are se ldo m fo rmall y p repared . Med ical or psych iat ric sta ff a re likewise placed in a re lative ly unfam iliar role, workin g with classroom teach e rs a t close quarters on an almost hourly bas is. Interdisciplinary coo pe ra tio n always see ms to gene rate pro fessional iden tity cr ises, an d th ese proba bly become even more intensified in a ho sp ital sett ing. These issues are di scu ssed , parti cularly with re ference to the ac tu a l operation o f a n inpatient schoo l in a psychi at r ic hospital. TH E S C H O O L PR O GRAM
For ove r a decad e, the Neuropsychiatric Institute (NPI) Sch ool has been pa rt of the C hildre n's Division of th e UCLA Department of Psychi a try. Origin all y begun o n a modest sca le to provid e schooling for ch ild re n o n two psychi atric wards (Hewe tt, 1967), the schoo l was ex pa nd ed four yea rs ago to include pati en ts fr om th re e additio na l wa rds o f t he Depa rtment's newl y o pene d Me n ta l Retardati on Ce n ter. As in othe r un iversity medical ce n te rs, ch ild pat ients also serve as teach ing cases fo r th e De par t me n t's p sychiatric re sid e ncy p rogra m . Of th e five ch ild re n's war ds , two are fo r ad olescents: o ne whic h has a short-te r m inten sive treatm ent program fo r mildl y retarded adolesce nts and a no the r follow ing a rath er tradi tional psych oan alytic a p proach for di stu rb ed ado lesce nts. T here is a thi rd ward for retarded a nd a utistic child re n utilizing a behavior mod ificati on program , and a fourth for latency-age child re n with psychia tri c proble ms use s a so mew ha t eclectic a pproach . T he fifth ward is a pediat ric wa rd for d e velopmen tall y disabled ch ildre n with conco m itan t psychi a tric p robl ems. Eac h ward has a ra ted bed capacity o f 16- 20 pati ents. Mos t child ren o n th ese wards have had sig nifica n t schoo l lea rn in g o r behavio r p ro blems p rior to ad m issio n . T heir ave rage length of hospitali zation is abou t e igh t months a nd ra nges fro m two weeks to well over a yea r. Th e staff of the N PI School ap proaches th e problem o f providing schoo l for suc h a di verse ch ild populati on by placin g ch ildren in classroom s not on th e basis of p sychi atri c o r medical di agno ses, but on th e basis o f th eir level of re ad iness for class roo m fun ctionin g. Read iness is ass essed by p rio r schoo l ex perience a nd by eva lua tion o f the child's classr oom pe r formance duri ng his fir st few d ays o f hos pitalizatio n. Child ren are brough t upstair s to th e school by nursin g sta ff and a ttend up to three hOl I1'S of schoo l pe r d ay, two hou rs in the morn in g a nd o ne in th e after noon. With in the school, ch ild ren are ass igne d to presch ool , elementary, o r secondary le vels, wh ich a re briefl y d escri bed bel ow.
564
S teve n R . Forn css-s- F ra. n k H . Lan gdon
T he preschool sta ff eva lua tes each ch ild as soo n as po ssible after ad m issio n to the ward . Hi s responses to se lected sa m p les of typi cal preschool or kindergarten situa tio ns a re syste ma tically observed a nd recorded (G ra ha m e t a l., 1971 ), a nd thi s baselin e observation is used to determine the ch ild 's level of fun ctioning and his su bseq ue n t school program. Emphasis is pla ced o n preparing ch ild re n for preschool and kind ergarten functionin g by co m bining small g ro u p or individu al in struction with vari ous tan gible reinforcers (food or tokens) and syste ma tic social rein forcement. Enrollment varies from 12 to 20 ch ild re n , aged 2 to 9 yea rs, who attend school in two classrooms separat ed by an observa tion room and subdivided into smaller work a reas. The program is ca rried out by a team of three teachin g ass ista n ts and three part- tim e teachers, who also share responsibility for training, research , policy decisions, and co m m u nica tio n with th e vario us hospital wards. In the preschool as well as other level s, stude n ts from the UC LA Scho o l of Education ma y se r ve as assistant teache rs for five o r six hours per week as part of special edu cati on practica. At the elem entary a nd high sch ool levels, eac h child is interviewed about hi s past school ex pe r ie nce a nd tested with standard ac hieve m e n t tests durin g th e fir st week of ad m issio n . At the elementary le vel, he ma y be placed in o ne of two classrooms: a preacademic elementary class in whi ch e m p has is is o n building skills, suc h as paying attention a nd followin g directions, co ns id e red req uisite to suc cessfu l class roo m learning , or a n academic elementary class in which e m p has is is o n tool skill subjects such as reading and math. The seconda ry lev el is co m posed of two classro o ms, one for English and so cial st u dies, a nd a second for math a nd science with adj oinin g science a nd photograph y laborat ory. Em p h asis is placed o n preparing adolescen ts to function in public junior or senior hi gh school settings, a nd an individual program o f studies is prepared to help each student keep pace with classm a tes in the school he attended prior to ad mission. A third classro om for retarded adolesce nts is also part o f th e secondary program a nd focuses on remedial academic skills a nd preparation for d ail y living. Since this cla ssroo m recei ves pupils primarily from a sho rt -te r m treatment ward, e m p hasis focu ses upon o ngo ing eva lua tio n to determine whi ch approaches will be effec tive in postdisch arge classroom placements. T he ge ne ral approach at eac h of these levels is to indi vidualize aca de m ic instruction usin g beh avioristi c approach es (che ckm ar ks, free time, anel soc ia l reinforcement) wh enever necessary fo r classroom management a nd moti vation . A no ther major incentive at
School ill a Psychiatric H ospital
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the second ary level is to give th e studen t more co n t ro l ove r decisio n ma king regard ing hi s ow n classroom p rogress. Eac h classroom has a n e n ro llme n t of 8 to 14 ch ild re n wit h a teach er a nd , in so m e classes , a te achin g· assista nt. The school also has a sho p activiti es classroom un d er the d irection of a teacher who arra nges in di vidu al ized p roj ects for bo ys and girls fro m e le me n ta ry a nd seco nd a ry levels. H e re , the e mp ha sis rests upon high- inte rest projects whi ch pr ov ide o ppor t u nities for chi ldre n to ap p ly academic skills lea rn ed in the classroo m, to demo nstra te responsibil ity for pl annin g and co m p let ing tas ks, an d to d evelo p po te n tia l vocati onal skills a nd leisure tim e hobbies. There is also a h om e-living classroom, d esign ed as a four-room apa rt me nt, which teach ers ma y sche d u le for pe riod ic instruction in fa mi ly life ed uca tio n and home-living skills. T eachers I in th e scho ol att e nd weekl y ward me etings and are co ns id e red part o f the int erdi scipl inary trea tme n t tea m to ge ther with psych ia trist, nurse , socia l worker , psycho log ist , a nd rehabilitati on th era pist. Th e y also p rov id e week ly reports o n eac h ch ild 's schoo l progress for the me d ica l chart, with whic h war d staff a nd th erapists ca n compa re their o bserv at io ns of his progress in o the r ho spital setti ngs. As each ch ild 's da te of d isch a rge nears, hi s teacher noti fies th e schoo l p lace me n t coo r di nato r , a teach er wh o fu nct io ns as a resource a nd liaiso n pe r so n . Decisions a re m ad e rega rdin g a n a ppro pria te school place men t fo r the ch ild after h is d ischa rge , ta king in to account the available ed uc atio na l res ources in the ch ild 's ho me co m mu n ity. Place ment ma y ra nge fro m a r egu lar classroo m in p ublic schoo l to spec ial classes, or eve n private re side nti a l schools. Co ns idera ble effo rt is ex pended toward secu ring a p pro pria te ed uca tio nal pla cem ent, since th e right ma tch be tween a chi ld's level of read iness a nd the clas s in wh ich he is ultimatel y placed is cruc ia l to his su bseq ue n t scho o l success . A fina l report is prepared b y th e child's NPI teach e r , d etailing ed uc atio nal levels, progress, an d be havio ra l or ed ucatio na l ap p roaches likely to be succ ess f u l in th e school sett ing to wh ich the child is being referred. Two ad ditio na l teach ers provide spec ial ed uca tio n cons u lta tio n to a ra th er e xte nsive progra m of ou tpa tie n t evalua tio n fo r ch ild re n wit h psychi atric proble ms. O f se ve ral hundred ch ild ren who are see n a nn ua lly, th e cons u lting teach e r s see on ly those with relati vel y se r io us school problems. In th ese cases, a fte r e xamining previous school reco rds. eva luating th e ch ild's pe rfo rm a nce in a simu lated clas sroom se tting, a nd in so me cases visiting the ch ild's ho me 1 All teachers a re qu alified to teach in pu blic school s bu t need no t have special ed ucation ce rt ifica tio n.
566
S tev en R . Forness-s-Fran k H . Langd on
school , consultin g te achers prepare written reports with specific recommendations for schoo l placement and ed uca tio na l intervention. School Philosophy. Although other members of th e interdisciplin ary team may ca rr y th e primary responsibility for direct treatment of the child 's social a nd emotional problems, the ho spital teachers are in volved in su ch treatment, consistent with their go al of preparin g the child for fun ctioning in a r eal classroom setting. Teachers set spec ific ed uca tio nal and behavioral goals for each child in their classroom based not only on th e teacher's initial ed ucational impressions, but on r elevant case material presented during th e child's admission staffing conference. While material on interpersonal relationships, past famil y pressures fo r sch ool achie vement, siblings' school performance, and pa st educational history ma y be co ns ide re d rel evant data, the ch ild' s observable beha vior in the classroom is consid ered th e primary datum upon which classroom approaches are based. At times, a child m ay be required to adjust to a cla ssroom regimen even wh en he m av not be so motivated . At other tim es, he ma y be given eve ry opportunity for succ ess and acco m p lish me n t at his level of fun ctionin g in ord er to overcome his feelin gs of failure and fru stration assoc iated with past scho o l ex pe r ie nce, eve n wh en this is clearly in compatible with traditional classr oom ex pecta tio ns . It is essential that ea ch child be provided su ch success so th at he will more readily view himself as a learner a nd experience the social a nd emotional gains th at this role provides. Behavioristic approa ches (Fo rn ess, 1970) are used , but are co nce ived merel y as a deli very system-techniques to achieve effecti ve and systematic progress compatible with the overall treatm ent goals arrived at by the illterdisciplina 1) ' team in which the teacher participates. To ach ie ve interdisciplinary treatment goals in day-to-day operation, however, a hospital school staff must address itself to certain sensitive issues inherent in working in a medical setting. I SS UES
School in a M edical Setting
Most special ed uca tio n classrooms for emotionally disturbed or mentall y retarded children are eithe r in public schoo l settings o r in private schoo ls. In those sett ings a ch ild's education is th e primary concern; and policy matters are decided by ed uca tors usuall y, but not nece ssaril y, in co ns u lta tio n with a nc illa ry personnel suc h as
School in a Psychiatric H ospital
567
psychi atrists, psych ologists, pediat rician s, a nd social workers . Some specia l ed uca tio n p ro grams, ho wever, d o exi st in medi call y oriented settings in which schoo ling is of secondary import ance and policy is decided primarily by p h ysicians or arrived at jointly by mem bers of seve ra l pro fession s. I n th e latter situat ion, much o f wha t happens is no t under th e sch ool's co ntrol. Child ren may be admitted for re asons not nece ssari ly r elat ed to school ing or di sch a r ged be fore the teache r j u dges the m read y. Schoo l p ro gress, while co nsidered essential, is su bsu me d under p ro gress in ot he r areas wh ich ta ke priority. Ind ee d , th e go al o f pre paring a ch ild for pu blic school fu nctioning may even be viewe d by medi cal staff as in com patibl e with so u n d m ental health princip les , a view with which eve n hospital teache rs ma y be in clin ed to agree , give n the quality of life in so me pu blic school classrooms (j ack son, 196 8). It is also usu ally the case th at matte rs of bu dget, space alloca tio n, sch ed u ling, an d sta ffing fo r a h ospital schoo l are dec ided by ph ysician s, un d erstand abl y so since d epartm en tal m edical staff, parti cul a rl y in teaching hospitals, are ult im ately j udged o n qu al ity of medi cal or psych iatric care , and o n ly second aril y on anc illa ry servic es suc h as schoo l. A hospital schoo l seldom fu nct ions a u to no mo us ly. T he fa m iliar role of the teac her thus becomes obsc u re d in an inte rdis ciplina ry setting. Pro blems arise relative to his o r her part in treatme nt pr ograms a nd whether th is overlap s th at of othe r profession als. At va rio us points pu blic schoo l special ed uca tio n teach e rs are o r di narily ca lled u pon to assu me seve ral p rofession al ro les; fo r in stance , th at o f social worke r (dealing wit h parental feelin gs ab out th e child's lack of sch ool progre ss, su ggesting res ources fo r psych ological o r medical assistance , gat hering ma te ria l on deve lop me nta l hi sto ry); o r psych ologist (inte rpret ing resul ts of pr evio us tes ting, setti ng u p be havi or mo difi ca tion progra ms, eva luatin g pe rceptual-motor skills); nurse (ma king home visits, seeing th at th e ch ild tak es p rescri bed me di cation, ban daging cuts and bru ises); r eh abili tati on th erapi st (p lan n ing a nd su pe rvising rec rea tio na l activities, p ro vid ing activity for d evelo pm en t of fine a nd gross motor skills, d evel opin g basic vocation al skills); a nd psychiatrist (h elpin g the ch ild to co pe with frustra tion , assisti ng the chi ld to in terpret and exprf'ss e motiona l responses appro priate ly, developin g ap prop r iate socia l interaction). So me wou ld argue tha t teachers are not fo rmall y trained to ass u me all these rol es, or tha t schoo l d istricts ord ina r ily have a nc illary personnel (school psych ologists , cou nse lo rs, schoo l nu rses) to d eal wit h such ma tters. O ne has o nly to obse rve th e special classroom teac he r ove r th e co u rse of a typical
568
S tev en R . F orness-s-Fra.n k H . Lan g don
da y or exa m ine the caseload o f a ncilla ry personnel in most scho ol districts to kn ow that tea chers are expected to do more th an just teach. In a hospital schoo l, however, the teacher may com e in direct confli ct with other professionals who not only are ex pected but a re supposedly better prepared to assume th ese roles . When working in a n interdisciplinary settin g, teach ers as well as othe r professiona ls must eithe r d elineate th eir rol es or a t least mak e care ful decisions as to when ove r la p is desir abl e. T eaching in a ho spital , there fore , presents a co n tin u ing problem in role defini tion . Compared with public school teach ers, who may hav e to fun ction in rel ative ign orance o f their pupils' backgrounds, the hospital teacher is not o nly inundated with case material o n eac h ch ild , but belabored with o pinio ns, su ggestion s, a nd eve n direct o rde rs on how th e ch ild sho uld be a p p roac hed . Sinc e o n ly a fr action of case material ma y prove di rectl y relevant to a ch ild's schoo ling, a nd since so me recommendation s ma v eve n co n flict with th e teach er's perception of acce p table clas srool~l m anagement, a h ospital sch ool staff is faced with continuing dilemmas. One must d ecide whi ch case history mat erial is relevan t for class roo m pro gress and , co nversel y, whi ch d at a o n clas sroom fun ctioning a re use ful fo r othe r members of th e interdisciplin ary team. One must d ecid e wh en to take th e initiati ve in plannin g classr oom beha vior mana gement programs and when to defer to th e d ecisions o f psychi atrists o r psych ologists. Schoo l sta ff must decide when schoo l h ours are sacrosan ct and when child ren need to be released from sch ool for more "important" acti vitie s su ch as psychothe rap y. Lastl y, teach ers must d ecid e wh ether o r not th e y sho u ld e nc roac h on d ecisionmaking in o the r tr eatment a reas suc h as th erap y or wa rd man agem ent. A ran ge of a ns we rs ex ists, d ependin g on th e schoo l sta ff 's perception of th eir rol e a nd th e importan ce of school in th e chi ld's life. At one ex tr e me , based on the premise th at physicians are not only more hi ghl y trained but also primarily responsibl e for tr eatment, teachers co uld look to th e ps ychiatrist to formul at e sch ool programs. At th e oth er, based o n th e premise that teachers a re su p posed ly ex pe r t in clas sroo m meth od s and material s, a n d th at schoo l o fte n becomes a cr itica l fac to r in th e ch ild 's lat e r adj us tme n t (Robins, 1966), tea chin g staff co uld sim p ly com e to view the rest o f the hospital as a dormitory for housing children wh en not in school. Educational philosoph y is often a determining factor, with psych od ynamicall y o r iented teachers tending to favor the former a p p roach, and the mo re militant behaviorists ad o p ting the latt er. Neithe r, howe ver, is clearl y acceptable. Based o n NPI School operati on , th ere are, in fact, two over lap-
School ill a Psvchiatri c H ospi tal
569
ping a reas of clas sroom functioning with whi ch teachers must d eal : acad emic learning and classroom behavior. Specificall y, the hospital tea ch er is qu alified to ass u me so le re spon sibilit y over acade mic tasks the ch ild shall undertake, books or materials used , and rat e of acceptable academic progress. With regard to cla ssroom social or motivational behavior, howe ver, th ere ma y be tim es when th e teach er mus t defer to overall treatm ent go als as co nceived b y th e primary phy sician or interdisciplinary treatment team . The setting is, after all, a medical one . The ho spital teacher has, however, a professional responsibilit y to make his or her views known, to la y o ut thoroughly the co nse q ue nces o f overall treatment goals in terms of the child' s subsequent school progress. If in his or her be st judgment suc h go a ls co n flict with acce p ta ble school progress, th e ph ysician or treatment team must be so ad vised . An ill-advised action, su ch as precipitous dis charge o f a ch ild before he is educationallv read y, should clearly be d eemed AEA (Aga ins t Educational Ad vice), just as the d esignation A MA (Ag ains t Medical Adv ice) is used to label precipitous ac tio ns from a medical o r psychi atric vie wpoint. Certain th eoretical approaches, such as behaviorism , whil e h a vin g had demonstrable impact o n special educati on , ma y cr ea te problems wh en u sed in a ho spital setting. Hi storicall y, behavi oristic approach es have not been warml y regarded in ps ychiatric hospitals, since th e y tend to run co u n te r to traditional p sychod yn amic conceptuali zati ons in both theory a nd technique. Suc h approaches do present , however, a valid a nd useful fram ework for specia l ed uca tio n te ach ers. H ewett ( 1968) , fo r e xa m p le, ha s outlined a hierarch v of ed uca tio nal goals based o n o bse rva ble behavior. Basi c cl aSSr~)()ll1 difficulties 'ar e conceiv ed o f in terms of a ch ild 's ability to a tte nd to tasks (atte n tio n problem ), to make ac tive responses to tasks (re spo nse problem ), a nd to make the m in o rderl y sequences, i.e ., to follow directions (order problem). Once those skills a re mastered , emph asis shifts to th e child's ability to fu nc tion independentl y o f th e teache r (exp lora to ry problem ), to fu nc tio n soc ially in the classroom (soc ia l problem) , a nd, finall y, to acq u ire acade m ic skills (mastery problem ). While H ewett's sp ecifi c terminology is se ld o m u sed in the N PI Scho o l, hi s co nce p ts hav e become a n integral pan o f program plannin g and co mp rise much of th e content of weekly reports to ward personnel on each child 's classroom fun ctioning. Simil arl y, ma terial on a child's case hi story, psycholo gical test results, progress in psychotherapy, re sponse to medication, a nd fun ction ing in o ther ho spital a reas ca n be p roductivel y integrated into th ese areas o f classroom functionin g. Focu s within the beh avioristic framework shifts from problems
570
St eue n R. F orness-s-Franh H . Lan gdon
whic h th e teach er ca n not ad d ress directl y (e. g. , a nx iety neurosis) to observa ble beha vio r with whi ch the teach er is prepa red to d eal systemati cally. It provides a fra me o f refere nce fro m whi ch teachers can talk to each other a nd to oth er p rofessional s, just as psychoanalytic co nce pts co m p rise a fra me of re fe re nce fo r psychi atrists. It sho u ld be mad e clea r , ho weve r , th at beh avior modificatio n a nd psychod yn amic th erapies are not mu tu all y exclu sive . I n point o f fa ct , behavi o ristic a p p ro aches must be im p leme n ted withi n th e co nte xt o f d evelopm en tal a nd psych od ynamic co nsidera tio ns . O ve r the yea rs , N PI Schoo l staff ha ve th us fo un d th at beh avio r modificat ion is usefull y co nceived o n ly as a deliver y syste m . It provides tec hniques which can , once acceptable tr eatm ent goals a re d erived by th e inte rd isciplina ry team , effect systema tic a nd measurabl e cha nge tow ard th ose goa ls in a class roo m co ntex t. T h us , there a re times whe n be hav ior istic a pproaches are mo di fied to co n fo r m to other tr eatment modali ties. As a n ex ample , one ch ild in the prea cademic eleme nta r y classroom was elect ively mute a nd cra wled o n th e floor whe neve r he was in th e class ro o m . T o avoi d d eal in g di rectl y with thi s be ha vior not o nly r an co u n te r to th e goal o f p reparing a ch ild to fu nction in a classroom settin g, bu t also ignored a beh a vioristic tec h niq ue wh ich the schoo l sta ff had previou sly used with success in a n oste nsi bly sim ilar case (Krave tz an d Forness, 1971 ). Mat e rial presen ted by th e bo y's psychi a trist , however, indicated th a t hi s sym p to ms were part of a comple x beha vioral patte rn whi ch gav e th e boy co nsid e ra ble co m fort in times of stress, much o f wh ich seemed to be assoc iate d with th e classroom setting. Becau se o f th is, th e teacher pla nned lessons fo r th e bo y whi ch did not req uire a ver bal respon se, a nd he was allowed to cra wl fr om one classr o om a rea to a no the r until suc h time as his a n xie ty diminish ed. Suc h a n a p p roac h not o n ly d eparted fr om typ ical beh avioristic tech niq ues but also underscored th e rel evance o f p reviou s psychi a tric case history d ata in d e termining classroom practices. I n a sim ilar fashion , it sho uld be noted th a t th e hosp ital staff pro vid es clos e sup po r t fo r seve ra l of th e beh a vioristic a p p ro aches us ed in the sch oo l. For exa m ple , the p racti ce o f "time -o ut ," ex cludin g a child bri efl y from th e classr oo m for misb ehavior and re turning him to th e ward, is rein forced by th e nursin g staff who, o n th e recommenda tion o f th e schoo l sta ir , assign the ch ile! to so me fo r m of res tr ict io n for the duration a nd attempt to avoid pro vidin g uninte nded social reinforcem ent for his be ing sen t out o f th e classroo m (Fo rness e t al., 1971 ). It has also been N PI Schoo l policy th at schoo l hou rs a re regu-
Sch ool in a Psychiatric H ospital
571
larl y sche d u led , a nd th at no oth er acuv u y, eve n psych otherap y, tak es precedence. T h is has p ro ved a useful approach whi ch co mmunicates to the ch ild the importance of schoo l. While there are ob viousl v em ergen cv sit ua tio ns o r occasio nal sched u ling co n flicts to wh ich tl{e policLy d o~s not a p ply, th e hosp ital sta ff has co ns iste n tly a tte m pt ed to su p po rt th e practice wh enever possible. Hospital su pport for a sch ool program, respect for a teach er's opinion , and relative ind epe ndence in plannin g school programs a re hard won. The y are d eserved onl y throu gh co n tin ued professional co m petence a nd r epeat ed d emonstrati on o f th e importan ce of schoo l in th e child 's postdischarge adjustment. Tra nsition to Postdischarge School S etti ngs
Alt hou gh most special ed uc a tio n teach ers view their task as on e o f preparing ch ild re n for regular cla ssroo m fun ction in g, such a task is rendered more d ifficult in a ho spital sch ool. It is virtua lly impossible in the relati vely she lte red e n viro n me n t of a hospital school to prepa re ever y ch ild co m p letely fo r pu blic schoo l fun ctioning. The problem is esse n tially o ne o f ge ne ra liza tio n, the ability to a p ply skill s learned in o ne situation to a varietv o f other situ ations. The fact th a t a ch ild learns a nd be hav es in a hospital school setting does not necessarily mean tha t he will d o eq ually well in th e ge ne r ally less su p po r tive a tmos p he r e o f a public schoo l. In so me cases, a child ma y be allowed, just prior to d ischar ge, to a tte nd a school o u tside the ho spi tal wh ile co n tin uing to live in the h ospital , or to live a t hom e whil e a tte nd ing th e N PI Schoo l. Such a techniqu e all o ws fo r mo re g rad ua l tran sition with a g rea te r cha nce fo r ge nerali zation to occur. While co m p le te ly effecti ve me th od s of ge nera liza tion a re seld om possibl e in hospital school se tt ings, it is essential to a rticu la te so me a p proach , howeve r limited . A ch ild 's tran sit ion to public school sh ould, in fact, become a primary consid e ration from th e very firs t d a y o f hospitali za tion . On e me th od mi ght be to co nsid e r th ree co m po ne n ts wh ich . as Hewett ( 1968) has poin ted o u t, are basic to eve ry teachi ng situatio n: task , se tt ing. and incentive . In th e NP I Sch ool, these components a re co nce ived as fun ctionall y rel ated co ntin ua in whi ch a ch ild moves fr om rathe r basic functi onin g le vels to le vels of fun ction in g required fo r regular classroom enrollmen t. Th e notion of a hierarch y o f incentives has been discu ssed el sewh e re (Forness, 197 3). As T able I illu strates, su ch a co n tin u u m mo ves fro m rath er primitive levels o f reinfo rcement to a level whe re th e chi ld e ngages in schoo lwo r k so le ly for th e satisfac tio n of ac q uir ing skill or co m pete nce (W h ite, 1959). T he setting a nd cu rrie-
572
Steven R. Forness-s-Frank H . Lan gdon
ulu m co n tin ua move fr om th ose lev els o r d ina r ily used for ch ild re n with ver y lo w le vels o f fun ctioning to th o se le vel s o rd ina r ily required for fu nctio ning in a re gular clas sr oom. Obviously, not e very ch ild a tta ins th e hi ghest lev els be fore bein g di sch arged from the hospit al; a nd fe w, if a n y, a tta in th e hi ghest level sim u lta ne o us ly o n all three co n tin ua . A ch ild's le vel o n o ne con tinuum, moreover , ma y depend o n h is position on the o the r two . For example , a ch ild may fun ction in a large in stru ctional gro u p only with th e aid of checkmarks or tan gible reinforcement , ye t wo r k in a hi gh-interest remedial reader sim p ly for th e sa tisfaction it brings. One makes these decisions based on each indiv idual child. Thus one decides , bas ed on trea t me nt goals and rate of observabl e progress in the inpati ent classroom, tha t a ch ild sho u ld be moved to a hi gh er le vel o n one co nt in u u m o r dropped to lo wer levels on a no the r. In so me cases a teacher ma y ha ve to begin such a child at very low levels of fun ctionin g on a task, sett ing. or inc entive co ntinuum so th at he ca n expe r ience success as a learn e r. Once he has don e so a nd begins to ex p ress co m fo rt a t th ose level s eithe r verball y or be havi o ra lly, th e teacher ca n be gin to provid e e xperien ces for him a t hi gher level s. It sho u ld be not ed th at th ese co n tin ua , like th e hie rarch y of ed uca tio na l go als mention ed ea rlier, a re me rel y co nce p tualiza tio ns, co nve nie n t ways of di scussin g a ch ild's classro om progr ess. In a sense, children m a y be said to be referred to special edu cati on or admitted to psychiatric hospitals to the ex te nt th at th e y fail to ach ieve a n acceptabl e le vel o n on e or a not he r of th ese hi erarchies. Fo r both te ach ers a nd hosp ital sta ff, eac h co nti n u u m p resents a useful point o f reference for a ch ild 's readiness for postdischarge Ta ble I Co ntinua of Read iness for Classroom Fu nction ing J ncentiues
Setting)
Currirulum Tasks or ,\[aln i al.\
Self-compet ency
La rge group ins tr uctio n
Reg ular classroom tasks or tex tbooks
Tas k feedbac k Social a p pr ova l Contingent use of free lime Token s or checkmarks T an gible rewa rds Edi ble re wa rd s
Sup plementa ry cur ricu lu m mat er ials Smal l gr o n p inst r uctio n Re medial cu rriculu m mater ials O ne -to- o ne ins tructio n
I ndi vidu a lly tailored mate rials .
School in a P sychiatric Ho spital
57 3
schoo l pl acemen t and puts th e probl em o f ge ne ra lizatio n in d efinable perspective. Educational R esearch a nd T rain ing
Resp ect for a school staff and th e autonomy to run its own p wgram co me mainl y from a hospital school's abilit y to demonstrate its effectiven ess. This is parti cularl y tru e in a uni versity teachin g hospital. Just as a teaching hospital is a laboratory for dev elopment of new therapeutic techniques, th e hospital schoo l is a laboratory for edu cational re search a nd de velopment. All hospi tal tea chers, th erefore, are au to ma tica llv demon stration teachers who must often work in h ighl y visible 'se tt ings, i.e. , classrooms with o bse rvation windows, and who ma y co n tin ua lly be ca lled upon to d efend th eir pwgrams. It is es sential tha t th e effectiveness o f their various techniques a nd a p p roac hes be clearl y ev ide n t. Emphasis sho u ld th erefore be pl aced on applied research , preferabl y that d ealin g with problems generated b y actual classroom cases. A hospital populati on , with its co n tin ua l ad m issio ns a nd di sch arges a nd wid e ran ge of pa tients, ne gates th e use o f t radi tional experimental research desi gns . The hospital school staff ca n o fte n effecti vel y use a sin gle-subject d esign in whi ch basel ine d at a are taken o n a ch ild's pe rformance, and against which th e effect s of a p articular intervention can be m easured . Collaborativ e studies a re often po ssibl e , whereby measures of class roo m fu nc tio ning becom e a dependent va ria ble by whi ch the effec ts of tr ea t me n t in o the r areas o f the hospital are measured. The hospital school al so represe n ts a unique re search se tting ill whi ch sta ff, edu cation facul ty, and g rad ua te stude n ts ca n d evelop a nd refine inno vati ve ed uca tional methods on a sma ll but rel ativ ely well-controlled scale before appl yin g th em in public schoo l c1 as sro~m s . Trainin g o f ed uca tio n stu de n ts is a n essen tia l functi on o f a n in patient school. Just as medical students, re sidents, and interns become an int egral part o f ho spital operations, ed uca tio n practicum students be come cr uc ia l to a hospital schoo l pwgram. Exte ns ive individuali zati on of classroom pwgrams is seld om possibl e without addition al sta ff ass ista nce . Education stude n ts se rve as a re source for this purpose, whil e at th e sa me time recei ving e x per ie nce and supervision in a sett ing in whi ch innovative techniques an d particularl y challe ngi ng cases are co m mo n p lace . Supervision tim e needs to be systematicall y scheduled so that tea chers can devote su fficie n t time to st ude n ts and carefull y m onitor thei r progress with individu al ch ild re n. There are also ad di tio na l o bliga tions to public school teachers o r ed ucatio n st ude n ts wh o wish to visit and tour the school
574
St even R. F omess-Frank H. Lan gdon
fac ility . Whil e int e rruptions occasi o ned by such visits ca n be tr yin g, th e di vid ends o f a co m m u nity teach er's increased familia rity with hospital schoo l pro gram s and, p erhaps, greater rec eptivi ty to ch ildren di scharged fro m ho spitals a re ultimatel y worth thi s di sruption . A ho spital teach e r fun ctions as a n in structor of trainees in o the r professi ons as th e y attempt to learn ab out tr eatment o f school learning a nd behavior problems. Each staff me e ting the teacher attends, each co n fe re nce with a chi ld's doctor, eac h re port wr itten for a medical cha rt represents a teac h ing o p po rtu nit y. While formal se mi na rs or gra nd rounds ma y be occas io ns fo r p resentin g did actic material a bo ut sp ecial ed uca tio n trends and techniques, th e primar y teachin g mod ali ty still remains case -o r iented problem so lving. A h ospital teach er sho u ld strive to place each resid en t's or tr ainee 's case in perspecti ve for him with reference to tr ends a nd issu es in public education which will apply when he leaves the hospital for privat e o r co m m u n ity practi ce . Since tec h niq ues and a pproach es are beginning to cha n ge as r apidl y in ed ucatio n as in othe r fields, th e hospital teach e r not o nly must be a good teacher but also must be familiar with th e re search literature in his or her own field . The goals o f teachin g ch ild re n, research in spec ial ed ucatio n, a nd pro fessio nal tra ining are, in a hospital school se tt ing, esse ntiall y dependent on one ano ther. T o provide go od tr ainin g ex perie nce fo r stu d e n ts req u ires tha t teachers kn ow effec tive a nd inno vative teac h ing me thod s. T o be able to se lect a p pro p r iate educati onal methods a nd tec h niq ues for a child's schoo l pro gram , a nd to d efend th eir use within the co n tex t o f interdisciplin ary treatment, require that teach e rs both kn ow a nd pa rt icipate in ed uca tio nal re search. CONCLU SION
There a re no give ns in hospital schoo l te aching. There a re, to th e best o f o u r kn owledge , no formal cu rricula specifica lly to pre pare teachers to functi on in a m edical or psy chiatric setting. T he a pproaches a nd procedu res d escribed ha ve been a r ri ved at o nly throu gh co ntin uo us ex perime n ta tio n a nd co ns ide rable str uggle ove r the yea rs an d most d ecid edl y do not represent a fin ished product. Yet, the importance of sch oo l in a child 's life, the problems it occasi on s, a nd its potential for making a d ifference make a n effe ctive inpatient schoo l program ind isp ensable to a psychi atric hospital.
School ill a Psychiatric Hospital
575
R EFERENC ES FORNESS, S. R. (1970), Behav io ristic app ro ach to classroo m ma nage me nt and mo tivati o n , Psych01. s.«, 7 :35()....%3 . -' - (\ 973), The rein forc ement hierarchy. PS\'c!IOI. Sch., 10: 168-177. - - - ESVE LOT, K., &JA COBS, 1'\. ( 197 1), ciassr~om exclus ion in a chi ld ren 's ps ychi atr ic hospi tal. Ex cept. Child., 37 :4 63 -464 . GRA HA~ I , Y., KASS, W. , & FORNESS, S. (1971), Devel opm ent o f a be hav ior basel in e for ed uca tional in te r ve n tio n with a typical preschool childre n . Pr esent ed at Ca lifo rn ia Ed uca tio na l Res earch Associa tio n , San Diego . H EWETT, F. M. (19 67), Establi shing a sc hool in a psychi atric ho spital. M ent . Hyg.,
5 1:275-283. - - - (\ 9( 8), Th e Emotionallv Disturbed Child ill the Classroom. Bo ston : Allyn & Bacon. JACKSON, P. W. (1968), Life ill Cla ssrooms. New York : Holt, Rin ehart & Win ston . KRAV ETZ, R. J. & FORN ESS, S. R. (1971 ), Th e spec ial classroom as a desen sitization se tt ing . Exc ept. Child., 37 : :~89-39 1. ROBl:"s , 1.. ~ . (1966), Deviant Ch ildren GrowlI Up. Bal tim ore : W illiam s & Wilkin s. WHITE, R. W. (\ 959), Mot ivation reconsidered . Psychol. R eI'., 66:2 97-333 .