- Email: [email protected]
Training Programs in School Consultation
SCHOOL CONSULTATION /INTERVENTION
1056--4993/01 $15.00
+
.00
TRAINING PROGRAMS IN SCHOOL CONSULTATION Irving H. Berkovitz, MD, and Esther Sinclair, PhD
A RATIONALE FOR TRAINING PROGRAMS
A major initiative to foster mental health in schools was recently implemented by the Department of Health and Human Services. 8 Its mission is to improve outcomes for youth by enhancing policies, programs, and practices relevant to mental health in schools. Much research has shown that school-based mental health consultation is successful in bridging the gap between need and utilization in terms of increased access to services and beneficial outcomes. 4• 10• 11 Psychiatrists are in a unique position to make a contribution to children's mental health through a close working relationship with schools. 5-s As a result, training programs designed to improve how schools enhance healthy development and technical assistance centers that maintain the requisite infrastructure to promote mental health have been established. 1• 2 Training for school consultation is provided in many child psychiatry fellowships as well as in community psychiatry training programs and community mental health centers. Most commonly, such training occurs during the child and adolescent psychiatry residency. Some programs divide the course content between year 1 and year 2; other programs present the material only in the second year of training. This article presents several models for training programs in school consultation with varying emphasis on time commitment, supervision, and systems analysis.
The authors are from the Department of Psychiatry and Behavioral Sciences, UCLA School of Medicine (IHB, ES), and the Educational Consultation and Advocacy Program, UCLA Neuropsychiatric Institute (ES), Los Angeles, California
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 • JANUARY 2001
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CLASSROOM OBSERVATION AND ELECTIVE CONSULTATION
Observation of the classroom milieu within the school system may constitute the principal training activity during the first 6 months of the training program module. The resident spends 3 to 4 hours per week in a variety of educational programs ranging from infant, toddler, and preschool Head Start programs to kindergarten- grade 5 elementary school programs and finally grades 6- 8 middle school programs. These 6 months of observation provide residents with a background for general clinical work. The residents observe students in the school setting and learn the parameters of school behaviors of "normal" children. The residents become familiar with the structure of various school settings and the range of available services within the school infrastructure to support children. They begin to identify expectations for children of various ages in the cognitive, academic, and social/ emotional domains of function and learn how schools influence children both positively and negatively. In general, the observation format is informal, and the resident may pursue a variety of interests that include having conversations with teachers, principals, and school psychologists about issues concerning their students. School faculty may discuss individual children or may seek information regarding more generic issues such as working with children with attention deficit hyperactivity disorder (ADHD). As the resident gains more experience in various school settings, he or she becomes more knowledgeable about selective interventions and may take on more of a leadership role with school staff and parents. Talking with parents and students about school concerns and learning how to advise parents about obtaining the best values from their children's schools are beneficial. The emphasis is not on direct service provision but rather observation and awareness of how school settings deal with high-risk children and how prereferral teams work at the systems level. During the second year of residency, the residents have a block of time during which they may elect to return to school settings, to work with groups of teachers, or to engage in consultations by evaluating individual students. Ideally, this second year goes beyond the awareness level of learning, and the resident regularly visits the same school setting. This schedule of visitation allows for more intense problem solving and crises intervention. PUBLIC SCHOOL VISITS WITH ASSOCIATED DIDACTIC SCHOOL CONSULTATION COURSE
During the second year of the child and adolescent psychiatry training, school visits are more formal; an educational specialist/ school mental health consultant accompanies each resident on every visit, and there is a schedule to observe specific classes and programs. The resident
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visits the same local public elementary school approximately six times, spending 2 hours per week at the site. This visitation schedule includes time in various classrooms representative of all age levels. The presence of the school consultation faculty member ensures that critical observation elements are not missed relating to child/ child interactions and teacher I child interactions. Frequently, teachers and administrators ask for input regarding the classroom milieu, and this allows the resident to observe how school consultation is accomplished. Throughout the visitation period, the resident learns to understand the functions of various school personnel and how they affect student outcomes. They learn of new developments in school educational practices and mental health interventions. The accompanying faculty member describes various educational programs and points out similarities and differences among them. Indeed, the entire structure of the school day, the ways students are grouped for skill development in the major subject areas, and the types of teaching styles and learning strategies are an additional focus of each school observation date. Prior to visiting the classrooms, the essential elements of observation are presented in didactic form with emphasis on program evaluation, quality and training of staff, organization and administration, opportunities for parent involvement, and student evaluation. Refer to the boxed material on the following page for the component elements of classroom observation. Overall, the resident is encouraged to interact with as many members of the school staff as possible and to bring back observations for group discussion and supervision. The residents may eat lunch with the children and visit special education classrooms. The classroom observation lecture is one of six seminars that provide orientation to the school milieu and practices. Although all six lectures are within the area of education, the various presentations are interdisciplinary, with emphasis on how a child psychiatrist provides school consultation, the role and impact of special education on school populations, how child assessment data are translated into viable school interventions, and the structure of school systems and available options to at-risk children. A bibliography is assigned and distributed for each lecture. The faculty who conduct the lecture series include a child psychiatrist with extensive school consultation experience and two educational psychologists with research interests in advocacy and special education. The child psychiatrist pays special emphasis to the problem of entry into the school system, the need to maintain sanction in the school, and analysis of the ecology of the school organization as well as its social role and its relationship to the community and to other agencies. The educational psychologists focus on special education law and the fact that more than 90% of school-aged children are served in the general education program. The residents learn how children with special needs are dealt with and supported within the general education program. Various alternative school programs such as magnet schools, charter schools, and private schools are contrasted to public school education programs.
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Classroom Observation Components Program Evaluation • Curriculum • Class size/age groupings • Teaching/instructional methods • Educational philosophy • Discipline Quality and Training of Staff • Total number and ratio to students • Length of employment • Teacher specialists • Availability of counselor/psychologist Organization and Administration • Size of school/grade levels • Age of school • Function of administrators • School finance/booster clubs • Availability of after-school care Opportunities for Parent Involvement • School-based management • Time/influence/money • Parent meetings/PTNservice leagues • After-school special interest clubs Student Evaluation • Progress and promotion • System of grading • Parent/teacher conferences • Homework rules • Student absences
Dysfunctional aspects of the school are studied, particularly as these impinge on the needs of the students. Residents learn how to advocate on behalf of children by consulting with teachers and attending child study conferences and individual education plan (IEP) meetings. Special emphasis is given to the pitfalls in consultation, differences between the consultant-consultee relationship and the therapist-patient relationship, and the role of consultation toward the goal of primary prevention of mental illness in children. DIDACTIC SEMINAR CONSULTATION WITH SPECIAL EDUCATION AND GROUP SUPERVISION
Didactic seminars on school consultation are provided to the child and adolescent psychiatry residents during their second year of training. Each resident is assigned as a consultant for the school year to one or two
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schools that contain special day classrooms for children with emotional disturbance. The resident spends half-a-day per week at the school consulting with students and school personnel. This type of consultation is much more specific in terms of the targeted population. The entire focus is on a particular special education program and requisite behavioral and psychiatric interventions to support the attainment of educational goals and objectives within the parameters of a specific program. Group supervision occurs 1 hour per week with a child psychiatrist and educational specialist. The weekly experiences of the residents during their school visits constitute the core discussion of the seminars. The group supervision process seems to work more effectively than individual supervision, as the residents learn from sharing their experiences with their colleagues. It is useful for school social workers and/ or psychologists to attend at least one supervision seminar per month. This facilitated collaborative discussion and intervention on behalf of specific children as the seminar format became an individual case conference. In addition, the residents are tested on a written clinical vignette in a manner similar to the Child Board Examination on School Consultation.
ORIENTATION AND CONSULTATION TO DAY TREATMENT AND SUPERVISION
This program provides psychiatric consultation to a network of 24 school-based day-treatment programs for children ages 3-21 years old with emotional disturbance. Psychiatric consultation is offered through a cooperative agreement with a private, nonprofit, psychoeducational day-treatment program. Consultation is provided to six elementary schools (including prekindergarten and preschool programs), eight middle schools, five high schools, and two vocational training programs. In addition, consultation is provided to special education programs for children with hearing impairments and programs for gifted children with emotional disturbance. The latter group represents an underidentified population of students who benefit from psychiatric consultation but are often "missed" because academic achievement levels are not significantly discrepant with chronologic grade placement, although discrepant from mental age or ability expectations. Five second-year child and adolescent psychiatric residents and an attending child psychiatrist provide the psychiatric consultation to these various schools. Each resident and supervisor consults with one school weekly and usually covers an average of three to five schools during the school year. The frequency of consultation visits is determined by the needs of each school and the population being served. The consultants spend 4 hours at the assigned schools per visit. Both child-centered and staff-centered modes of consultation are used.
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In approximately 50% of the schools, the residents provide staffcentered consultation as well as a diagnostic medication management program for the children. At the other schools, a more restricted consultative model is practiced, although child diagnostic evaluations and parent and family-oriented consultations may be provided. Medication monitoring is typically not offered in these schools, and teachers have numerous questions surrounding behavioral and cognitive expectations of children on psychiatric medications. Before the onset of the school visit practicum, an orientation to school consultation is conducted by the attending child psychiatrists. Research papers are discussed that provide information on theoretic aspects of school consultation, techniques of school consultation, intervention models, the history of special education, and finally the role of the psychiatrist in the schools. Once consultation has started, the residents meet with the attending child psychiatrist for an hour of supervision each week. Supervision and the practicum last throughout the 9month academic school year. CONSULTATION IN A PUBLICLY FINANCED INNERCITY SCHOOL PROGRAM
Increasing numbers of expanded school mental health programs have been developed in diverse communities in response to increasing recognition of limitations of community mental health centers and other private practitioners in meeting the mental health needs of children and youth. Child and adolescent psychiatry residents serve multiple functions in this school mental health program, which is entirely funded by city departments of mental health and mental retardation. The consultation is structured through a renewable contract with a private universityaffiliated hospital. The program currently serves four elementary schools in a large urban area where the population demographics include single-parent households, low socioeconomic status, and a majority of ethnic minority children of color. A variety of services are contractually available to this population, including individual, group, and family mental health therapies; physical health care; educational parents' groups; literacy training; and guidance for teachers on case management issues. The goals of the program for the residents are both education and consultation. Beyond a service delivery systems model, they become familiar with the range of stressors, issues, and problems that confront low-income, urban elementary school children and how school systems are prepared or unprepared to address these difficulties. The residents are assigned to one of the schools for 2 hours per week to observe the operation of the school, speak with the child's teacher, and observe other students in the class. With time and experience, their level of sophistication in dealing with teachers is apparent. Mental health consultation may be provided in several ways. Resi-
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dents may act as consultants to the on-site clinical staff on issues of evaluation, therapy, and medication. This includes data-gathering functions, such as classroom observation, that serve clinical and research purposes. Classroom observations include resource programs for children with learning disabilities and designated instructional services such as counseling, speech therapy, and adapted physical education. Residents consult with teachers and other school personnel on such issues as appropriate referrals for mental health intervention, the school's role in clinical management of the on-site cases, and working with parents to provide inclusion and advocacy. The residents also teach school personnel about developmental issues, behavior management in the home, and specialized evaluations or referrals. Typically, teachers find the technical assistance around child development issues valuable since they only have taken one course on child development as part of their teaching certification program. Discussion of home-based behavior management helps foster the collaborative spirit between home and school and parents and teachers. The residents also serve as consultants to parents through lectures, workshops, or individual consultations as deemed appropriate by on-site staff.
SYSTEM CONSULTATION PROGRAM
This program consists of approximately six lectures and three or four site visits to schools. After the introductory lectures that are usually provided during the summer months when school is not in session, the child and adolescent psychiatry residents observe and participate in a number of specific school consultations. No generalized classroom observation is involved within this program. It is the accompanying child psychiatrist who performs and is responsible for the consultation that may emphasize training, technical assistance, and education. The resident is provided with the opportunity to observe, provide input, and review the content and process issues of the consultations that may include assessment, evaluation, development of pilot programs, and establishment and expansion of the prevention focus of the school level infrastructure. All consultation visits occur in a suburban school system with 15 elementary schools, two junior high schools, and two high schools. The specific problems presented for consultation are based on the clinical need of the student population at the time of the rotation. Given the size of the school system, the consultation requests may include issues related to staff welfare, training, and morale; individual children's education programs; programmatic issues for children within the general education curriculum; and troubleshooting for children in special education programs.
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COMMUNITY CONSULTATION PROGRAM
The emphasis in this training program is more broad-based than school consultation alone. An overview of service integration systems, policy implications, and effectiveness of service integration efforts are presented. Senior residents in general psychiatry and residents in child and adolescent psychiatry attend a 10-week course on community consultation. This course emphasizes consultation concepts as they relate to a number of areas of consultation work: consultation to schools, organizations, business and industry, hospital teams, and forensics. Concurrently, the child psychiatry residents begin yearlong consultation experiences to assigned schools, which can be in elem entary, middle, and senior high schools. The overall goal of the various rotations is to provide an opportunity for trainees to apply consultation concepts with a systems orientation. For example, the child psychiatry resident consults only to the division of special services and is available to psychology and social work staff from the school district. A supervisor is assigned to each trainee. Group discussions augment the community consultation placement. The school trainees are encouraged, along w ith other trainees rotating in consultation placements, to bring experiences and questions to the community consultation course or group discussion. In that setting, similarities and differences among the various consultation experiences are discussed. This school consultation-training program attempts to integrate supervised individual experiences with more didactic material that emphasizes generic consultation concepts and allows for group discussions. The course work, readings, large group discussions, consultation rotations, and individual supervision complement each other and allow for an interdisciplinary presentation of consultation. A MULTIFACETED PROGRAM COMBINING EDUCATION, MENTAL HEALTH, AND THE JUVENILE JUSTICE SYSTEM
Residents spend half a day per week for 9 months observing general and special education classrooms at all levels in a supervised experience in a metropolitan school. The educational objectives and goals are to understand the public educational process, which includes awareness of the system's flexibility and constraints as it tries to accommodate the academic, physical, emotional, and vocational needs of students as well as understanding the hierarchy of roles, responsibilities, and provision of services of various school personnel. To foster mutual understanding between educators and psychiatrists, opportunities are provided for the resident to establish rapport with special education and general education personnel. The resident learns about intervention assistance teams, sometimes called child study
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or prereferral teams, and the need for interagency cooperation and communication among representatives from education, mental health, substance abuse, and the juvenile justice system. Central to this purpose is familiarity with the referral and eligibility identification process of children with disabilities under the Individuals with Disabilities Education Act (formerly called PL 94-142). In developing consulting skills, the residents participate in IEP meetings, provide psychiatric case evaluations, and suggest recommendations for the management of specific special needs. An alternative site for consultation is a therapeutic preschool for children, aged 3-6, with emotional disturbance and behavioral disorders. The residents observe the therapeutic milieu, which includes structured and semistructured education and play activities, small group instruction, social skills training, and conflict resolution techniques to deal with anger and frustration. They participate in team meetings and observe the interdisciplinary team members in their roles with children and families. Residents may take an active role in the clinical management of a small number of children in the preschool program under the direct supervision of a child psychiatrist. This may include classroom observations, individual play therapy, staff consultation, parent education, family therapy, parents' group, or medication management. A third site where the residents have the opportunity to participate is in a clinic devoted to children with behavior and/ or learning disorders. The child psychiatrist is a key member of the interdisciplinary evaluation team, and residents perform child evaluations under supervision by a child psychiatrist. Comprehensive evaluation includes case management in which residents contact teachers, referring physicians, and other community professionals as well as provide parent education and individual psychotherapy. In this paradigm, each resident functions as co-leader with a child psychiatrist in a group for 4 to 6 months and gradually assumes the role of primary leader. Residents spend 5 months on child and adolescent psychiatry inpatient units, working closely with the teaching staff in developing appropriate treatment planning for children and adolescents, with attention to both psychiatric and education needs. Frequently, the educational placement prior to the inpatient hospitalization is no longer appropriate or efficacious. Residents observe certified special education teachers working in the inpatient classrooms and participate in the liaison and advocacy work with the child or adolescent's school. The didactics that support the practicum include modules on infancy and early childhood, latency, adolescence, and consultation and liaison. Readings are assigned each week, and a bibliography of current literature relevant to the scheduled lectures is prepared by each speaker and distributed to the residents. SUMMARY
The need to train psychiatrists in school consultation is important to approach mental health and psychosocial concerns from the broad
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perspective of addressing barriers to learning and promoting healthy development. There is a major national impetus to improve academic achievement and literacy, which can be amplified by addressing the social, emotional, and mental health needs of children and youth. Training in school consultation allows the psychiatrist to better understand a critical institution in each child's life and also provides technical assistance and training to school personnel, which facilitates networking between programs and individuals involved in or interested in school mental health. Each of the described programs approaches consultation from a specific focus that varies in time commitment, placement options, and frequency and order of didactic presentations. There is no conclusive available evidence as to which program is most effective, since such evaluation depends on the overall goals of the consultation program itself. References 1. Adelman HS, Taylor M: Reframing mental health in schools and expanding school reform. Educational Psychologist 33:135-152, 1998 2. Adelman HS, Taylor M, Weist S, et al: Mental health in schools: A federal initiative. Children's Services: Social Polit Research and Practice 2:95-115, 1999 3. American Psychiatric Association: Psychiatric Consultation in Schools. Washington, DC, American Psychiatric Association, 1993, pp 73-80 4. Amibruster P, Gerstein H, Fallon T: Bridging the gap between service need and service utilization: A school-based mental health program. Community Mental Health J 33:199- 211, 1997 5. Berkovitz IH, Sinclair E: Teaching child psychiatrists about intervention in school systems. Journal of Psychiatric Education 8:240-245, 1984 6. Berlin IN: Psychiatry and the school. In Kaplan HI, Freedom AM, Sadow BJ (eds): Comprehensive Textbook of Psychiatry, ed 3. Baltimore, William & Wilkins, 1980, pp 2693-2706 7. Caplan G: The Theory and Practice of Mental Health Consultation. New York, Basic Books, 1977 8. Department of Health and Human Services: Initiative for Mental Health In Schools. Report from the Summit on Maternal and Child Health Bureau. Washington, DC, Office of Public Health Service, 1998 9. Edelsohn GA, Williams VC: Child psychiatry consultation to a public high school: A developmental perspective. Journal of Child and Adolescent Psychotherapy 2:105109, 1985 10. Han Y, Rosenthal B, Weist MD: The Development of School Based Mental Health Services in Baltimore. Baltimore, Center for School Mental Health Assistance, 1998 11. Kister EB, Brown RS: Do school-based health centers improve adolescents' access to health care, health status, and risk-taking behavior? J Adolesc Health 18:335- 343, 1996
Address reprint requests to Esther Sinclair, PhD UCLA Neuropsychiatric Hospital 300 Medical Plaza, Room 1253 Los Angeles, CA 90095- 6967 e-mail: [email protected]
1056--4993/01 $15.00
+
.00
TRAINING PROGRAMS IN SCHOOL CONSULTATION Irving H. Berkovitz, MD, and Esther Sinclair, PhD
A RATIONALE FOR TRAINING PROGRAMS
A major initiative to foster mental health in schools was recently implemented by the Department of Health and Human Services. 8 Its mission is to improve outcomes for youth by enhancing policies, programs, and practices relevant to mental health in schools. Much research has shown that school-based mental health consultation is successful in bridging the gap between need and utilization in terms of increased access to services and beneficial outcomes. 4• 10• 11 Psychiatrists are in a unique position to make a contribution to children's mental health through a close working relationship with schools. 5-s As a result, training programs designed to improve how schools enhance healthy development and technical assistance centers that maintain the requisite infrastructure to promote mental health have been established. 1• 2 Training for school consultation is provided in many child psychiatry fellowships as well as in community psychiatry training programs and community mental health centers. Most commonly, such training occurs during the child and adolescent psychiatry residency. Some programs divide the course content between year 1 and year 2; other programs present the material only in the second year of training. This article presents several models for training programs in school consultation with varying emphasis on time commitment, supervision, and systems analysis.
The authors are from the Department of Psychiatry and Behavioral Sciences, UCLA School of Medicine (IHB, ES), and the Educational Consultation and Advocacy Program, UCLA Neuropsychiatric Institute (ES), Los Angeles, California
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 • JANUARY 2001
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CLASSROOM OBSERVATION AND ELECTIVE CONSULTATION
Observation of the classroom milieu within the school system may constitute the principal training activity during the first 6 months of the training program module. The resident spends 3 to 4 hours per week in a variety of educational programs ranging from infant, toddler, and preschool Head Start programs to kindergarten- grade 5 elementary school programs and finally grades 6- 8 middle school programs. These 6 months of observation provide residents with a background for general clinical work. The residents observe students in the school setting and learn the parameters of school behaviors of "normal" children. The residents become familiar with the structure of various school settings and the range of available services within the school infrastructure to support children. They begin to identify expectations for children of various ages in the cognitive, academic, and social/ emotional domains of function and learn how schools influence children both positively and negatively. In general, the observation format is informal, and the resident may pursue a variety of interests that include having conversations with teachers, principals, and school psychologists about issues concerning their students. School faculty may discuss individual children or may seek information regarding more generic issues such as working with children with attention deficit hyperactivity disorder (ADHD). As the resident gains more experience in various school settings, he or she becomes more knowledgeable about selective interventions and may take on more of a leadership role with school staff and parents. Talking with parents and students about school concerns and learning how to advise parents about obtaining the best values from their children's schools are beneficial. The emphasis is not on direct service provision but rather observation and awareness of how school settings deal with high-risk children and how prereferral teams work at the systems level. During the second year of residency, the residents have a block of time during which they may elect to return to school settings, to work with groups of teachers, or to engage in consultations by evaluating individual students. Ideally, this second year goes beyond the awareness level of learning, and the resident regularly visits the same school setting. This schedule of visitation allows for more intense problem solving and crises intervention. PUBLIC SCHOOL VISITS WITH ASSOCIATED DIDACTIC SCHOOL CONSULTATION COURSE
During the second year of the child and adolescent psychiatry training, school visits are more formal; an educational specialist/ school mental health consultant accompanies each resident on every visit, and there is a schedule to observe specific classes and programs. The resident
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visits the same local public elementary school approximately six times, spending 2 hours per week at the site. This visitation schedule includes time in various classrooms representative of all age levels. The presence of the school consultation faculty member ensures that critical observation elements are not missed relating to child/ child interactions and teacher I child interactions. Frequently, teachers and administrators ask for input regarding the classroom milieu, and this allows the resident to observe how school consultation is accomplished. Throughout the visitation period, the resident learns to understand the functions of various school personnel and how they affect student outcomes. They learn of new developments in school educational practices and mental health interventions. The accompanying faculty member describes various educational programs and points out similarities and differences among them. Indeed, the entire structure of the school day, the ways students are grouped for skill development in the major subject areas, and the types of teaching styles and learning strategies are an additional focus of each school observation date. Prior to visiting the classrooms, the essential elements of observation are presented in didactic form with emphasis on program evaluation, quality and training of staff, organization and administration, opportunities for parent involvement, and student evaluation. Refer to the boxed material on the following page for the component elements of classroom observation. Overall, the resident is encouraged to interact with as many members of the school staff as possible and to bring back observations for group discussion and supervision. The residents may eat lunch with the children and visit special education classrooms. The classroom observation lecture is one of six seminars that provide orientation to the school milieu and practices. Although all six lectures are within the area of education, the various presentations are interdisciplinary, with emphasis on how a child psychiatrist provides school consultation, the role and impact of special education on school populations, how child assessment data are translated into viable school interventions, and the structure of school systems and available options to at-risk children. A bibliography is assigned and distributed for each lecture. The faculty who conduct the lecture series include a child psychiatrist with extensive school consultation experience and two educational psychologists with research interests in advocacy and special education. The child psychiatrist pays special emphasis to the problem of entry into the school system, the need to maintain sanction in the school, and analysis of the ecology of the school organization as well as its social role and its relationship to the community and to other agencies. The educational psychologists focus on special education law and the fact that more than 90% of school-aged children are served in the general education program. The residents learn how children with special needs are dealt with and supported within the general education program. Various alternative school programs such as magnet schools, charter schools, and private schools are contrasted to public school education programs.
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Classroom Observation Components Program Evaluation • Curriculum • Class size/age groupings • Teaching/instructional methods • Educational philosophy • Discipline Quality and Training of Staff • Total number and ratio to students • Length of employment • Teacher specialists • Availability of counselor/psychologist Organization and Administration • Size of school/grade levels • Age of school • Function of administrators • School finance/booster clubs • Availability of after-school care Opportunities for Parent Involvement • School-based management • Time/influence/money • Parent meetings/PTNservice leagues • After-school special interest clubs Student Evaluation • Progress and promotion • System of grading • Parent/teacher conferences • Homework rules • Student absences
Dysfunctional aspects of the school are studied, particularly as these impinge on the needs of the students. Residents learn how to advocate on behalf of children by consulting with teachers and attending child study conferences and individual education plan (IEP) meetings. Special emphasis is given to the pitfalls in consultation, differences between the consultant-consultee relationship and the therapist-patient relationship, and the role of consultation toward the goal of primary prevention of mental illness in children. DIDACTIC SEMINAR CONSULTATION WITH SPECIAL EDUCATION AND GROUP SUPERVISION
Didactic seminars on school consultation are provided to the child and adolescent psychiatry residents during their second year of training. Each resident is assigned as a consultant for the school year to one or two
TRAINING PROGRAMS IN SCHOOL CONSULTATION
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schools that contain special day classrooms for children with emotional disturbance. The resident spends half-a-day per week at the school consulting with students and school personnel. This type of consultation is much more specific in terms of the targeted population. The entire focus is on a particular special education program and requisite behavioral and psychiatric interventions to support the attainment of educational goals and objectives within the parameters of a specific program. Group supervision occurs 1 hour per week with a child psychiatrist and educational specialist. The weekly experiences of the residents during their school visits constitute the core discussion of the seminars. The group supervision process seems to work more effectively than individual supervision, as the residents learn from sharing their experiences with their colleagues. It is useful for school social workers and/ or psychologists to attend at least one supervision seminar per month. This facilitated collaborative discussion and intervention on behalf of specific children as the seminar format became an individual case conference. In addition, the residents are tested on a written clinical vignette in a manner similar to the Child Board Examination on School Consultation.
ORIENTATION AND CONSULTATION TO DAY TREATMENT AND SUPERVISION
This program provides psychiatric consultation to a network of 24 school-based day-treatment programs for children ages 3-21 years old with emotional disturbance. Psychiatric consultation is offered through a cooperative agreement with a private, nonprofit, psychoeducational day-treatment program. Consultation is provided to six elementary schools (including prekindergarten and preschool programs), eight middle schools, five high schools, and two vocational training programs. In addition, consultation is provided to special education programs for children with hearing impairments and programs for gifted children with emotional disturbance. The latter group represents an underidentified population of students who benefit from psychiatric consultation but are often "missed" because academic achievement levels are not significantly discrepant with chronologic grade placement, although discrepant from mental age or ability expectations. Five second-year child and adolescent psychiatric residents and an attending child psychiatrist provide the psychiatric consultation to these various schools. Each resident and supervisor consults with one school weekly and usually covers an average of three to five schools during the school year. The frequency of consultation visits is determined by the needs of each school and the population being served. The consultants spend 4 hours at the assigned schools per visit. Both child-centered and staff-centered modes of consultation are used.
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In approximately 50% of the schools, the residents provide staffcentered consultation as well as a diagnostic medication management program for the children. At the other schools, a more restricted consultative model is practiced, although child diagnostic evaluations and parent and family-oriented consultations may be provided. Medication monitoring is typically not offered in these schools, and teachers have numerous questions surrounding behavioral and cognitive expectations of children on psychiatric medications. Before the onset of the school visit practicum, an orientation to school consultation is conducted by the attending child psychiatrists. Research papers are discussed that provide information on theoretic aspects of school consultation, techniques of school consultation, intervention models, the history of special education, and finally the role of the psychiatrist in the schools. Once consultation has started, the residents meet with the attending child psychiatrist for an hour of supervision each week. Supervision and the practicum last throughout the 9month academic school year. CONSULTATION IN A PUBLICLY FINANCED INNERCITY SCHOOL PROGRAM
Increasing numbers of expanded school mental health programs have been developed in diverse communities in response to increasing recognition of limitations of community mental health centers and other private practitioners in meeting the mental health needs of children and youth. Child and adolescent psychiatry residents serve multiple functions in this school mental health program, which is entirely funded by city departments of mental health and mental retardation. The consultation is structured through a renewable contract with a private universityaffiliated hospital. The program currently serves four elementary schools in a large urban area where the population demographics include single-parent households, low socioeconomic status, and a majority of ethnic minority children of color. A variety of services are contractually available to this population, including individual, group, and family mental health therapies; physical health care; educational parents' groups; literacy training; and guidance for teachers on case management issues. The goals of the program for the residents are both education and consultation. Beyond a service delivery systems model, they become familiar with the range of stressors, issues, and problems that confront low-income, urban elementary school children and how school systems are prepared or unprepared to address these difficulties. The residents are assigned to one of the schools for 2 hours per week to observe the operation of the school, speak with the child's teacher, and observe other students in the class. With time and experience, their level of sophistication in dealing with teachers is apparent. Mental health consultation may be provided in several ways. Resi-
TRAINING PROGRAMS IN SCHOOL CONSULTATION
89
dents may act as consultants to the on-site clinical staff on issues of evaluation, therapy, and medication. This includes data-gathering functions, such as classroom observation, that serve clinical and research purposes. Classroom observations include resource programs for children with learning disabilities and designated instructional services such as counseling, speech therapy, and adapted physical education. Residents consult with teachers and other school personnel on such issues as appropriate referrals for mental health intervention, the school's role in clinical management of the on-site cases, and working with parents to provide inclusion and advocacy. The residents also teach school personnel about developmental issues, behavior management in the home, and specialized evaluations or referrals. Typically, teachers find the technical assistance around child development issues valuable since they only have taken one course on child development as part of their teaching certification program. Discussion of home-based behavior management helps foster the collaborative spirit between home and school and parents and teachers. The residents also serve as consultants to parents through lectures, workshops, or individual consultations as deemed appropriate by on-site staff.
SYSTEM CONSULTATION PROGRAM
This program consists of approximately six lectures and three or four site visits to schools. After the introductory lectures that are usually provided during the summer months when school is not in session, the child and adolescent psychiatry residents observe and participate in a number of specific school consultations. No generalized classroom observation is involved within this program. It is the accompanying child psychiatrist who performs and is responsible for the consultation that may emphasize training, technical assistance, and education. The resident is provided with the opportunity to observe, provide input, and review the content and process issues of the consultations that may include assessment, evaluation, development of pilot programs, and establishment and expansion of the prevention focus of the school level infrastructure. All consultation visits occur in a suburban school system with 15 elementary schools, two junior high schools, and two high schools. The specific problems presented for consultation are based on the clinical need of the student population at the time of the rotation. Given the size of the school system, the consultation requests may include issues related to staff welfare, training, and morale; individual children's education programs; programmatic issues for children within the general education curriculum; and troubleshooting for children in special education programs.
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COMMUNITY CONSULTATION PROGRAM
The emphasis in this training program is more broad-based than school consultation alone. An overview of service integration systems, policy implications, and effectiveness of service integration efforts are presented. Senior residents in general psychiatry and residents in child and adolescent psychiatry attend a 10-week course on community consultation. This course emphasizes consultation concepts as they relate to a number of areas of consultation work: consultation to schools, organizations, business and industry, hospital teams, and forensics. Concurrently, the child psychiatry residents begin yearlong consultation experiences to assigned schools, which can be in elem entary, middle, and senior high schools. The overall goal of the various rotations is to provide an opportunity for trainees to apply consultation concepts with a systems orientation. For example, the child psychiatry resident consults only to the division of special services and is available to psychology and social work staff from the school district. A supervisor is assigned to each trainee. Group discussions augment the community consultation placement. The school trainees are encouraged, along w ith other trainees rotating in consultation placements, to bring experiences and questions to the community consultation course or group discussion. In that setting, similarities and differences among the various consultation experiences are discussed. This school consultation-training program attempts to integrate supervised individual experiences with more didactic material that emphasizes generic consultation concepts and allows for group discussions. The course work, readings, large group discussions, consultation rotations, and individual supervision complement each other and allow for an interdisciplinary presentation of consultation. A MULTIFACETED PROGRAM COMBINING EDUCATION, MENTAL HEALTH, AND THE JUVENILE JUSTICE SYSTEM
Residents spend half a day per week for 9 months observing general and special education classrooms at all levels in a supervised experience in a metropolitan school. The educational objectives and goals are to understand the public educational process, which includes awareness of the system's flexibility and constraints as it tries to accommodate the academic, physical, emotional, and vocational needs of students as well as understanding the hierarchy of roles, responsibilities, and provision of services of various school personnel. To foster mutual understanding between educators and psychiatrists, opportunities are provided for the resident to establish rapport with special education and general education personnel. The resident learns about intervention assistance teams, sometimes called child study
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or prereferral teams, and the need for interagency cooperation and communication among representatives from education, mental health, substance abuse, and the juvenile justice system. Central to this purpose is familiarity with the referral and eligibility identification process of children with disabilities under the Individuals with Disabilities Education Act (formerly called PL 94-142). In developing consulting skills, the residents participate in IEP meetings, provide psychiatric case evaluations, and suggest recommendations for the management of specific special needs. An alternative site for consultation is a therapeutic preschool for children, aged 3-6, with emotional disturbance and behavioral disorders. The residents observe the therapeutic milieu, which includes structured and semistructured education and play activities, small group instruction, social skills training, and conflict resolution techniques to deal with anger and frustration. They participate in team meetings and observe the interdisciplinary team members in their roles with children and families. Residents may take an active role in the clinical management of a small number of children in the preschool program under the direct supervision of a child psychiatrist. This may include classroom observations, individual play therapy, staff consultation, parent education, family therapy, parents' group, or medication management. A third site where the residents have the opportunity to participate is in a clinic devoted to children with behavior and/ or learning disorders. The child psychiatrist is a key member of the interdisciplinary evaluation team, and residents perform child evaluations under supervision by a child psychiatrist. Comprehensive evaluation includes case management in which residents contact teachers, referring physicians, and other community professionals as well as provide parent education and individual psychotherapy. In this paradigm, each resident functions as co-leader with a child psychiatrist in a group for 4 to 6 months and gradually assumes the role of primary leader. Residents spend 5 months on child and adolescent psychiatry inpatient units, working closely with the teaching staff in developing appropriate treatment planning for children and adolescents, with attention to both psychiatric and education needs. Frequently, the educational placement prior to the inpatient hospitalization is no longer appropriate or efficacious. Residents observe certified special education teachers working in the inpatient classrooms and participate in the liaison and advocacy work with the child or adolescent's school. The didactics that support the practicum include modules on infancy and early childhood, latency, adolescence, and consultation and liaison. Readings are assigned each week, and a bibliography of current literature relevant to the scheduled lectures is prepared by each speaker and distributed to the residents. SUMMARY
The need to train psychiatrists in school consultation is important to approach mental health and psychosocial concerns from the broad
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perspective of addressing barriers to learning and promoting healthy development. There is a major national impetus to improve academic achievement and literacy, which can be amplified by addressing the social, emotional, and mental health needs of children and youth. Training in school consultation allows the psychiatrist to better understand a critical institution in each child's life and also provides technical assistance and training to school personnel, which facilitates networking between programs and individuals involved in or interested in school mental health. Each of the described programs approaches consultation from a specific focus that varies in time commitment, placement options, and frequency and order of didactic presentations. There is no conclusive available evidence as to which program is most effective, since such evaluation depends on the overall goals of the consultation program itself. References 1. Adelman HS, Taylor M: Reframing mental health in schools and expanding school reform. Educational Psychologist 33:135-152, 1998 2. Adelman HS, Taylor M, Weist S, et al: Mental health in schools: A federal initiative. Children's Services: Social Polit Research and Practice 2:95-115, 1999 3. American Psychiatric Association: Psychiatric Consultation in Schools. Washington, DC, American Psychiatric Association, 1993, pp 73-80 4. Amibruster P, Gerstein H, Fallon T: Bridging the gap between service need and service utilization: A school-based mental health program. Community Mental Health J 33:199- 211, 1997 5. Berkovitz IH, Sinclair E: Teaching child psychiatrists about intervention in school systems. Journal of Psychiatric Education 8:240-245, 1984 6. Berlin IN: Psychiatry and the school. In Kaplan HI, Freedom AM, Sadow BJ (eds): Comprehensive Textbook of Psychiatry, ed 3. Baltimore, William & Wilkins, 1980, pp 2693-2706 7. Caplan G: The Theory and Practice of Mental Health Consultation. New York, Basic Books, 1977 8. Department of Health and Human Services: Initiative for Mental Health In Schools. Report from the Summit on Maternal and Child Health Bureau. Washington, DC, Office of Public Health Service, 1998 9. Edelsohn GA, Williams VC: Child psychiatry consultation to a public high school: A developmental perspective. Journal of Child and Adolescent Psychotherapy 2:105109, 1985 10. Han Y, Rosenthal B, Weist MD: The Development of School Based Mental Health Services in Baltimore. Baltimore, Center for School Mental Health Assistance, 1998 11. Kister EB, Brown RS: Do school-based health centers improve adolescents' access to health care, health status, and risk-taking behavior? J Adolesc Health 18:335- 343, 1996
Address reprint requests to Esther Sinclair, PhD UCLA Neuropsychiatric Hospital 300 Medical Plaza, Room 1253 Los Angeles, CA 90095- 6967 e-mail: [email protected]