Transcript 2_Childhood_Disorder..

Response to Intervention
Social-Emotional RTI: Building the Model
School & Common Childhood
Disorders. What are some of the
more common childhood
psychiatric disorders that impact
schools?
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Response to Intervention
“Emotional Disturbance”: Federal Definition
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Response to Intervention
“Emotional Disturbance”: Federal Definition
“This definition has a number of inherent flaws. It
is contradictory, poorly specified, and redundant.
The limiting criteria are poorly and subjectively
defined, and in the case of the educational
impact criterion, redundant and unclear ...”
(Gresham et al., 2013)
Source: Gresham, F. M., Hunter, K. K., Corwin, E. P., & Fischer, A. J. (2013). Screening, assessment, treatment, and outcome evaluation
of behavioral difficulties in an RTI mode. Exceptionality,www.interventioncentral.org
21, 19-33.
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Response to Intervention
“Emotional Disturbance”: Federal Definition
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(Gresham
et al.,
2013)
Source: Gresham, F. M., Hunter, K. K., Corwin, E. P., & Fischer, A. J. (2013). Screening, assessment, treatment, and outcome evaluation
of behavioral difficulties in an RTI mode. Exceptionality,www.interventioncentral.org
21, 19-33.
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Response to Intervention
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Response to Intervention
Review of 4 Psychiatric Disorders
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•
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Attention-Deficit/Hyperactivity Disorder
Disruptive Mood Dysregulation Disorder
Oppositional Defiant Disorder
Generalized Anxiety Disorder
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Response to Intervention
Attention-Deficit/Hyperactivity Disorder: Essential Features
• The individual displays a level of inattention and/or hyperactivity-impulsivity that
interferes with functioning:
• Inattention. Six or more symptoms over the past six months to a marked degree
that impacts social/academic functioning:
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–
–
–
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–
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Fails to give close attention to details
Has difficulty sustaining attention in tasks or play
Seems not to pay attention when spoken to
Does not follow through on instructions or finish schoolwork
Has difficulty organizing tasks and activities
Avoids or dislikes tasks requiring sustained mental effort
Often loses things needed for tasks or activities
Is distracted by extraneous stimuli
Is often forgetful in daily activities (e.g., chores, errands)
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.7
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Response to Intervention
Attention-Deficit/Hyperactivity Disorder: Essential Features
• The individual displays a level of inattention and/or hyperactivity-impulsivity that
interferes with functioning:
• Hyperactivity/Impulsivity: Six or more symptoms over the past six months to a
marked degree that impacts social/academic functioning:
– Fidgets or taps hands or feet or squirms in seat
– Leaves seat when expected to remain seated
– Runs around or climbs in situations when the behavior is not
appropriate
– Is unable to play or take part in a leisure activity quietly
– Seems “on the go” “as if driven by a motor”
– Talks incessantly
– Blurts out an answer before a question has been fully asked
– Interrupts others
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.8
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Response to Intervention
Attention-Deficit/Hyperactivity Disorder: Prevalence
• It is estimated that perhaps 5% of children may meet criteria for
ADHD (APA, 2013).
• However, the percentage of children diagnosed with ADHD in
America has grown substantially over time:
– 2003: 7.8% ADHD
– 2007: 9.5% ADHD
– 2011: 11.0% ADHD
Sources: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC:
Author.
Centers for Disease Control and Prevention. (n.d.) ADHD:
Data & statistics. Retrieved from http://www.cdc.gov/ncbddd/adhd/data.html
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Response to Intervention
Disruptive Mood Dysregulation Disorder: Essential
Features
• [DMDD is one of the Depressive Disorders.]
• The individual experiences severe outbursts of temper with
underlying persistent angry or irritable mood.
• Temper outbursts occur 3 times or more per week, across at
least 2 settings—with severe symptoms in at least 1 setting.
• This pattern of outbursts and underlying anger has been evident
for at least 12 months.
• The condition can be diagnosed between ages 6 and 18-but
onset must be observed before age 10.
• DMDD cannot coexist with ODD, intermittent explosive disorder,
or bipolar disorder.
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Response to Intervention
Disruptive Mood Dysregulation Disorder: Prevalence
• The prevalence of DMDD is unknown.
• It is estimated that perhaps 2-5% of children and adolescents
may have the disorder (during a 6-month to 12-month
prevalence period) and that rates are likely to be higher among
pre-adolescents and boys (APA, 2013).
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Response to Intervention
Disruptive Mood Dysregulation Disorder: Issues
• DDMD replaces ‘Bipolar NOS’, a diagnosis used in DSM-IV to
classify children who met some, but not all, of the symptoms for
bipolar.
• During the use of ‘Bipolar NOS’, there was a 40-fold increase in
office visits between 1994 and 2003 (Hilt, 2012).
• Although bipolar is considered to be a life-long condition, both
the treatment and progression of ‘childhood bipolar’ were found
to differ from the adult version of the disorder.
• DDMD was designed as a diagnostic category in DSM 5 “to give
these children a diagnostic home and ensure they get the care
they need”. (APA, May, 2013).
Sources: Hilt, R. (2012). Childhood depression and bipolar disorders: What we know now. University of Washington/Seattle, WA: Author.
Retrieved from http://www.nami.org/contentmanagement/contentdisplay.cfm?contentfileid=167527
American Psychiatric Association. (May, 2013). Disruptive
mode dysregulation disorder: Finding a home in DSM. Washington, DC: Author.
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Response to Intervention
Disruptive Mood Dysregulation Disorder: Issues (Cont.)
• DMDD: Limited Diagnostic Utility? One recent study found
that, in a clinical sample, “DMDD could not be delimited from
oppositional defiant disorder and conduct disorder, had limited
diagnostic stability, and was not associated with current, futureonset, or parental history of mood or anxiety disorders. These
findings raise concerns about the diagnostic utility of DMDD in
clinical populations.” (Axelson et al., 2012; p. 1342).
Source: Axelson, D., Findling, R. L., Fristad, M. A., Kowatch, R. A., Youngstrom, E. A., Horwitz, S. M. , Arnold, L. E., Frazier, T. W., Ryan,
N., Demeter, C., Gill, M. K., Hauser-Harrington, J. C., Depew, J., Kennedy, S. M., Gron, B. A., Rowles, B. M.& Birmaher, B. (2012).
Examining the proposed Disruptive Mood Dysregulation Disorder diagnosis in children in the longitudinal assessment of manic symptoms
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Response to Intervention
Oppositional Defiant Disorder: Essential Features
• [ODD is one of the Disruptive, Impulse-Control, and Conduct Disorders.]
• The individual shows a pattern of oppositional behavior lasting at least 6
months that includes elevated levels of at least 4 of the following:
– Often loses temper
– Often argues with adults
– Often defies or refuses to comply with adults' requests or rules
– Often purposely annoys people
– Often blames others for his or her mistakes or misbehavior
– Is often touchy or easily annoyed by others
– Is often angry and resentful
– Is often spiteful or vindictive
• The individual displays these oppositional behaviors significantly more
frequently than typical age-peers.
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Response to Intervention
Oppositional Defiant Disorder: Prevalence
• “The prevalence of oppositional defiant disorder ranges
from 1% to 11%, with an average prevalence estimate of
around 3.3%.” (APA, 2013; p. 464).
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Response to Intervention
Generalized Anxiety Disorder: Essential Features
•
[GAD is one of the Anxiety Disorders.]
• The individual experiences excessive anxiety and worry about a variety of topics,
events, or activities over a period of at least 6 months. Worry occurs on the
majority of days. It is difficult for the individual to control the anxiety/worry.
• The worry is associated with at least 3 of these 6 symptoms:
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Restlessness.
Becoming fatigued easily
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
• The individual experiences 'clinically significant' distress/impairment in one or
more areas of functioning (e.g., at work, in social situations, at school).
• The worry or anxiety cannot be better explained by physical causes or another
psychiatric disorder.
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Response to Intervention
‘Normative’ Anxieties/Fears in Childhood & Adolescence
Stage/Age
Anxieties/Fears About…
Later Infancy:
6-8 months
• Strangers
Toddler:
12 months-2 years
• Separation from parents
• Thunder, animals
Early Childhood:
4-5 years
• Death, dead people, ghosts
Elementary:
5-7 years
• Germs, natural disasters, specific traumatic events
• School performance
Adolescence:
12-18 years
• Peer rejection
Source: Beesdo, K., Knappe, S. & Pine, D. S. (2009). Anxiety and anxiety disorders in children and adolescents: Developmental issues
and implications for DSM-V. Psychiatric Clinics of Northwww.interventioncentral.org
America, 32(3), 483-524. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018839/
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Response to Intervention
Generalized Anxiety Disorder: Prevalence
• The 12-month prevalence of GAD among adolescents is
estimated to be 0.9% while among adults the rate is 2.9%.
Source: American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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Response &
to Adolescence:
Intervention
Psychiatric Disorders of Childhood
Adjusted Comorbidity
Conduct
Disorder
Oppositional
Defiant
Disorder
Oppositional ADHD
Defiant
Disorder
Depressive
Disorders
Generalized
Anxiety
Disorder
Social
Phobia
11.5
--
--
--
--
--
ADHD
2.4
6.1
--
--
--
--
Depressive
Disorders
2.5
10.9
--
--
--
--
Generalized
Anxiety
Disorder
--
--
--
37.9
--
--
Social
Phobia
--
--
3.4
9.9
--
--
2.2
3.3
8.1
5.1
Separation
Anxiety
Disorders
Source: Copeland, W. E., Shanahan, L., Erkanli, A., Costello, E. J., & Angold, A. (2013). Indirect comorbidity in childhood and
adolescence. Frontiers in Psychiatry, 4(144), 1-8. doi:10.3389/fpsyt.2013.00144
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Response to Intervention
“
Problems are an unacceptable
discrepancy between what is expected
and what is observed…. A problem
solution is defined as one or more
changes to the instruction, curriculum,
or environment that function(s) to
reduce or eliminate a problem.
-Ted Christ
”
Source: Christ, T. (2008). Best practices in problem analysis. In A. Thomas & J. Grimes (Eds.), Best Practices in School Psychology V (pp.
159-176). Bethesda, MD: National Association of School
Psychologists.
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Response to Intervention
RTI: Identifying EBD Students Through
Intervention, Not ‘Psychometric Eligibility’
“RTI is based on the logic that if a student's behavioral
excesses and/or deficits continue at unacceptable
levels subsequent to an evidence-based intervention
implemented with integrity, then the student can and
should be eligible for ED [i.e., Special Education]
services.
RTI is based on the best practices of prereferral
intervention and gives school personnel the latitude to
function within an intervention framework rather than a
psychometric eligibility framework.”
Source: Gresham, F. M. (2005). Response to intervention: An alternative means of identifying students as emotionally disturbed. Education
and Treatment of Children, 28(4), 328-344.
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Response to Intervention
Factors Influencing the Decision to Classify as BD
(Gresham, 1992)
Four factors strongly influence the likelihood that a student
will be classified as Behaviorally Disordered:
• Severity: Frequency and intensity of the problem
behavior(s).
• Chronicity: Length of time that the problem
behavior(s) have been displayed.
• Generalization: Degree to which the student displays
the problem behavior(s) across settings or situations.
• Tolerance: Degree to which the student’s problem
behavior(s) are accepted in that student’s current
social setting.
Source: Gresham, F. M. (1992). Conceptualizing behavior disorders in terms of resistance to intervention. School Psychology
Review, 20, 23-37.
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Response to Intervention
School Pathways to Student Mental-Health
Support: A Source of Potential Confusion
1.
2.
3.
4.
A student with a diagnosis of ADHD and some oppositional
classroom behaviors could go down any of several pathways of
identification and support:
Emotionally Disturbed. The school may find that the student
meets criteria for ED and provides an IEP.
Other Health Impairment. The student’s ADHD diagnosis is
treated as a ‘medical condition’ and an IEP is granted.
Section 504. The attentional and/or behavioral symptoms of
ADHD may be identified as comprising a “major life impairment “
that requires a Section 504 plan.
No support. The student remains in general education with no
additional support.
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Response to Intervention
Schools & Psychiatric Disorders: Building Capacity
• Promote the expectation whenever possible that
students with behavioral or social-emotional
difficulties—even those with psychiatric diagnoses—
will go through the RTI problem-solving process as a
starting point.
RTI will demonstrate whether the student needs more
support than general education offers (“resistance to
intervention”) and will reveal what intervention
elements actually work.
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Response to Intervention
Activity: Psychiatric
Disorders & RTI
• Review the several ways
that a student with a
psychiatric diagnosis
might currently be
handled by your district
(e.g., Section 504,
Special Education, etc.).
• Discuss how an RTI
model might bring some
rationality and order to
this process.
Schools & Psychiatric Disorders:
Building Capacity
• Promote the expectation whenever
possible that students with behavioral or
social-emotional difficulties—even those
with psychiatric diagnoses—will go
through the RTI problem-solving process
as a starting point.
• RTI will demonstrate whether the student
needs more support than general
education offers (“resistance to
intervention”) and will reveal what
intervention elements actually work.
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