Social-Emotional RTI: Building the Model

1. Social-Emotional RTI: Building the Model School & Common Childhood Disorders. What are some of the more common childhood psychiatric disorders that impact schools?

2. “Emotional Disturbance”: Federal Definition

3. “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, 21, 19-33.

4. “Emotional Disturbance”: Federal Definition “... the social maladjustment clause has received some criticism as well....Specifically, it states that students who are socially maladjusted should not be classified as ED; this part of the definition clearly contradicts Part B (“an inability to build or maintain satisfactory interpersonal relationships with peers or teachers”).” (Gresham et al., 2013) “By excluding students who are socially maladjusted, but including students who cannot build or maintain satisfactory interpersonal relationships, the definition simultaneously includes and excludes a subset of students, which is confusing.” (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, 21, 19-33.

6. Review of 4 Psychiatric Disorders • Attention-Deficit/Hyperactivity Disorder • Disruptive Mood Dysregulation Disorder • Oppositional Defiant Disorder • Generalized Anxiety Disorder

7. 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: • 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.

8. 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.

9. 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

10. 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.

11. 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.

12. 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.

13. 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, future-onset, 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 study. Journal of Clinical Psychiatry, 73, 1342-1350.

14. 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.

15. 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.

16. 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: • 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.

17. 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 North America, 32(3), 483-524. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018839/

18. 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.

19. 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

20. 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.

21. 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.

22. 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.

23. School Pathways to Student Mental-Health Support: A Source of Potential Confusion 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.

24. 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.

25. 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.