How you can save a child and family years of suffering and wasted potential

Is there anything more disruptive to a learning environment-and your ability to provide children with a quality education-than a student whose behavior or emotions are out of control? What percentage of your teaching career have you had to devote to managing such students? How much time and attention have you re-allocated to these kids from others who are willing and able to learn? When students with serious, chronic mental health or behavioral problems go through school untreated, everyone suffers: classmates, the affected children and their families, the school community, and you. Although many of the conditions leading to classroom disruption are treatable, the path from your recognition of problems to actual treatment is confusing and filled with barriers. The following information will help clarify your options for facilitating treatment and improve the likelihood of successful outcomes.


Behavioral Feedback: A Teacher's Right



Although psychiatric evaluation is not in your job description, the amount of time you spend observing children qualifies you as an expert in distinguishing age-appropriate behavior from that which is clearly inappropriate, disruptive, or impairing to a child's learning and development. Therefore, teachers are as qualified as any mental health professional to give feedback to parents about their child's behavior, including incidences in which the child's behavior is problematic. Some parents or other professionals may question your credibility when you discuss student behavior problems in detail, but you are almost always the most credible and objective source of this information.

Furthermore, the first signs of child mental health conditions are often exhibited in the classroom. The stress of academic work, peer relations, and school structure can trigger behaviors and symptoms not evident prior to school enrollment. Without teacher feedback, how can parents learn of these developments? Restricting teacher feedback can result in years of failure, underachievement, and even damage before parents understand the need and process for getting help.

Hammer The Objective Facts

Once teachers believe in their right to give parents behavioral feedback, most are good at it. Since you are trained to inform parents about academic progress, you can use that same framework for behavior. For example, if you report, "Dana's reading fluency is 75 words per minute, but the expectation at this grade level is 100 words per minute," you can also report, "Dana can stay in her seat and pay attention to a task for five minutes, but the expectation for her age and grade level is thirty minutes." Feel free to use the following examples of objective behavioral feedback, stated in the context of grade-level expectations:

When you ask Susan a direct question, she struggles to give a response, and either remains silent or changes the subject without answering. By __ grade, most students do respond to direct questions. She is going to need this skill.

Many __-graders talk in class, but most will stop talking after I warn them once or twice, and almost all will stop when threatened with a consequence or loss of privilege. Rebecca continues to talk in class regardless of my warnings and threats. This interferes with her learning, and is also disruptive to other students.

Jerome is one of the three brightest students in the class. In my experience, it is unusual for such an intelligent student to struggle so mightily with ___ (the subject in question, e.g. reading). The amount of frustration he experiences, and the extent to which he avoids this subject, are also unusual given his abilities.

By __ grade, the vast majority of students who complete their homework turn it in, and they are expected to do so at this point. Diana always finishes her homework, and usually does a good job, but almost never turns it in. What do you suppose is getting in the way of this?

Howard has a tremendous amount of energy, which at times gets him in trouble and keeps him from paying attention, completing work, and learning. I've taught many children in my career, and he has one of the highest energy levels of any child I've taught at this age.

Chris clearly has the intelligence and the ability to complete the work, but she is not producing any work in class. By __ grade, students are expected to produce _____. I have tried various techniques to motivate her, but she is still not producing work anywhere near to expectation. I do not know what is interfering with her motivation and task completion, but if it does not improve, she will fall behind academically.

For good reasons, some teachers feel the need to "sugar-coat" information about students' behavior when speaking with parents. Parents who are defensive or have unrealistic views of their children can influence teachers to tread lightly when discussing their kids. In other cases, teachers who are holding in a lot of frustration about a child may fear opening a floodgate of criticism and negativity if they start speaking frankly, and try to focus solely on the child's strengths. When you struggle with difficult parents or a high frustration level, the following techniques can help you communicate the essential information:

1. Before meeting with parents, manage your feelings about this child. When a student disrupts a learning environment, a teacher is entitled to some negative feelings about that child. In such cases, privately venting feelings with a trusted colleague or friend can help maintain objectivity and prevent carrying frustrations into parent meetings. Putting the child in perspective further promotes emotional neutrality. For example, some children, such as those with Attention-Deficit Hyperactivity Disorder (ADHD), have severely limited impulse control resulting from a neurological condition. Framing these deficits as disabilities that need accommodation and treatment-rather than as personality defects-can help de-personalize the child's behavior.

2. Consult with administrators, mental health staff, or special education staff about how you are going to present the information, and if appropriate, invite them to parent conferences. This will help organize your thoughts and increase your comfort level. Involving these professionals is the first step toward building a supportive "school team" for this child.

3. Start all conversations with a focus on the child's strengths and any positive feelings you have about him to set the tone for the discussion. If you have difficulty identifying strengths, you can always try reframing problem behaviors in a positive light. For example, if a child acts defiantly in your classroom, you might say, "Maurice is a strong willed kid, and I find him unique in how confident he is to speak his mind." This technique helps to build an alliance with the parents around a common goal of helping their child succeed. Once this rapport is established, you are better positioned to discuss the down side of this behavior. For more information about reframing problem behaviors, see Appendix A.

4. Present the least controversial facts first. For example, if a student often gets distracted, leaves his seat, and engages in inappropriate touching of classmates, start with the distractibility problem and assess the parents' sensitivity level and receptiveness to feedback before mentioning the other issues.

5. Maintaining an emotionally neutral tone is critical when providing feedback about delicate behavior problems. If teachers come across as frustrated, overwhelmed, critical, or judgmental-no matter how slightly-parents will only pay attention to those factors and dismiss the information. However, if you convey support and a problem-solving approach, they will hear you better.

6. If parents become defensive, it is okay to stop and check in with them. For example, you might ask, "How do feel hearing me say these things about your daughter? Do you feel like I'm being critical or trying to single out your son?" You can also make validating comments, such as, "I know it's uncomfortable hearing someone say something negative about your kid. No one wants to hear these things, so I wouldn't blame you if you felt angry or offended."

7. Follow-up this check-in and validation with an emphasis on collaboration and clear communication. For example, you might say, "My goal is to work with you to help your daughter be successful. In my experience, the best way to do that is to give you the most accurate description of her behavior here at school. When this involves talking about problem behaviors, it's understandably unpleasant, but it leads to us working together to find solutions to these problems so they don't keep her from learning." This message-that the child's behavior, attention, and/or emotional states are interfering with her educational development-is the key point to communicate to parents. Yet, it is difficult for them to hear and accept, and may require frequent repetition over time before it is received.

8. Once you have determined that parents are reasonably receptive to feedback, you can connect problem behaviors to potential consequences, and express concerns about these. To extend the previous example regarding on-task behavior, you could say, "Dana can stay in her seat and pay attention to a task for five minutes, but the expectation for her age and grade level is thirty minutes. This has been a consistent pattern for her. If it continues, I'm concerned that it will badly interfere with her ability to learn and produce work, and could make her dislike school and strive to avoid it." Many teachers present objective behavioral information, but hesitate to review potential consequences or express concerns. If your professional judgment tells you that a child's behavior will impact future learning and social development, then the parents deserve to hear that opinion-and your concern-so they can take preventive action.

9. Repeat objective information as often as necessary to help parents see the patterns, understand how the behaviors impair their child, and become motivated to intervene. Pointing out that behaviors have not changed over time (especially if interventions have been attempted in class) further strengthens the case for higher-level interventions and treatment. Charting problem behavior patterns over time-including sending home daily report cards documenting specific problems-can also help discourage the "watch and wait" approach that most parents naturally want to take.

At this point, you have laid the foundation for referring a child for assessment. However, your referral strategy depends on your school or district referral policy, as well as the ability and willingness of parents to accept suggestions.



Overcoming Policy Barriers


Some schools and school districts set policies forbidding teachers from directly suggesting mental health assessment to parents. Without debating these policies at length, consider the following:

• Many teachers, both in public and private schools, regularly refer students for assessments
• Such policies, despite their rationale, engender a feeling of powerlessness among teachers, and question a teacher's right to provide behavioral feedback to parents (which, previously argued, is appropriate and justified)
• Many schools and districts restrict teacher mental health referrals, but place no restraints on a teacher's right to suggest physical health checkups

Teachers need not feel powerless or unqualified to suggest counseling assessments, and can always find a way to accomplish this. One way to avoid bureaucratic barriers is to always consult with your Administrator/ Principal and any available school mental health staff prior to making any specific recommendations to parents. With a consensus of all these parties that an assessment is warranted, a referral takes the form of a school team recommendation, and gains credibility with parents. It also prevents parents from singling out the teacher if they disagree with the recommendation. 

Policies that give sole referral authority to school mental health professionals also confuse and delay the referral process. For instance, if a School Psychologist visits a school once monthly and has a backlog of evaluations, then teachers will feel like their hands are tied-they need that person to assess the student, but the help is not readily available.  However, most policies do not state that a School Psychologist must assess a child; rather, they specify that only these professionals have the authority to make a referral for a counseling assessment, which any qualified professional can conduct. Thus, if a policy demands that School Psychologists govern all referrals, then the teacher/ school team can request one's presence specifically for that purpose: to meet briefly with the school team and the parents and suggest that they have their child assessed, based on the cumulative information that the teacher has provided. Such a practice gives families more options for assessment resources, but more importantly saves months of waiting time (which also deters parents from insisting on a school-provided assessment, as opposed to a private or community-based one).


"Counseling Assessment" Defined

This paper suggests that teachers use the term "Counseling Assessment" because it avoids stigmatizing language such as "mental health" and "psychiatric" which tend to confuse parents and increase their resistance to the recommendation. The counseling assessment entails a complete psychosocial evaluation, in which the child's presenting behavioral and emotional problems, history, family dynamics, cultural background, and environment are all considered. The methods of this process include in-person interviews of the child and family, consultation with teachers, and use of questionnaires to gather additional information to arrive at a preliminary diagnosis. Once the initial assessment is complete, then a treatment plan is discussed with the parents to address the problems. Treatment plans for school-related problems should always involve feedback from the teacher/ school to track the child's response to treatment. The counseling assessment does not initially involve formal psychological testing; however, if this is indicated, the professional conducting the assessment can recommend it. 

Here, many schools send students off-course: rather than suggesting a counseling assessment, a school follows the formal process of having children tested through the School Psychologist/ IEP, which most often changes the focus to the child's academic abilities without addressing underlying mental health issues. In such cases, the school ultimately intervenes with special education programs, which do not fully address the mental health conditions of the child.  If a counseling assessment precedes psychological testing and the IEP, the professional who assesses the child may implement a treatment plan that stabilizes the underlying behavioral/ emotional issues and allows the child to learn up to potential without special education.

Thus, using the counseling assessment as a standard step PRIOR to the IEP/ special education evaluation can save critical school time and resources, help children access necessary resources sooner, and prevent inappropriate special education placements that stigmatize and damage the self-esteem of these students.


Presenting Information to Parents

If you have been presenting objective behavioral information to parents, highlighting grade-level expectations that are not being met, and expressing concern about how their child's behavior is impairing the learning process, then you most likely have some indicators of how accepting parents will be to the idea of a counseling assessment.

When Parents Ask, "What can we do?"

This is the most favorable circumstance for making a referral, since parents are inviting a suggestion. If you are bound by policy and must make the suggestion with the school team or School Psychologist, then you must buy time and say, "Let me get back to you when I have more information," and arrange a meeting with the necessary participants as soon as possible, while the parents are actively interested. If you have consulted with your Administrator in advance and have the school's endorsement to make a referral, you can respond as follows: 

SUGGESTION 1:

"Have you ever considered a counseling assessment for ____ by a qualified professional?"

Once you pose this question, be prepared for the following responses (and how to counter them):

Response 1: What's that?

Counter: (Explain the process using the previously described information) 

Response 2: Yes, we have considered it.

Counter: What made you decide not to pursue it? 

Response 3: Yes, we already had him assessed.

Counter: You did? What was the outcome? 

Response 4: Yes (or no), but we don't want that.

Counter: Okay, I respect your decision, but I'm curious, what are your concerns about it?

These questions may give you information about parents' beliefs or values that impede the referral process, which you might be able to resolve through educating them and presenting a realistic perspective of the assessment process. In addition, if you learn that the child is already in treatment, you can use this discussion as an opportunity to get involved in the feedback process with the treating professional. 

If parents have fears or concerns about mental health assessment, then urging them to attend will not be helpful; in these instances, parents rarely follow through with referrals. However, if you listen to their concerns about the referral process, validate their feelings, emphasize the voluntary nature of treatment, and remind them of the risks their child faces if the behaviors do not change, then you have planted seeds for future consideration. 

Example
It sounds like you had a bad experience with a counselor in the past. I don't blame you for feeling reluctant to go through that again. I imagine most people would not want to give that a second chance. No one is saying you have to do anything. It's completely your decision to have ___ assessed or not. I'm just concerned that his education will continue to suffer if we can't help him change some of these behaviors, and so far what we have tried has not helped him enough. Have you ever imagined how things would be if that counselor had acted more professionally and given you clear, helpful information and suggestions?

When You Want to Make a Referral, But The Parents Have Not Specifically Requested It

This is a less secure position for teachers. You have provided the objective behavioral feedback, but the parents have not taken any action (to your knowledge) or asked you for suggestions. Under these circumstances, it is wise for the school to make the referral as a team. To enhance the parents' receptivity to the recommendations, the person who has the best relationship with them should discuss the counseling assessment. This person can then begin with Suggestion 1 on the previous page, and follow the responses and counter-responses as described.

When Parents do not Appear Receptive

At times, despite all of your sensitive feedback, parents still seem unwilling or unable to accept suggestions, making you hesitant to recommend any service for their child. Suggesting an assessment when parents clearly are not receptive will not bring the child any closer to treatment. Giving unwanted referrals may also cause strain between teachers and families.

Instead, teachers can ask parents questions that suggest the need for a counseling assessment, without directly stating such a recommendation. These leading questions plant seeds for parents to consider assessment in the future, and may even prompt them to ask, "What can we do?"

• What do you think about all of her problems that I have presented to you?
• Have you noticed problems with his behavior/ attention/ emotions outside of school?
• What do you think will happen to her if these behaviors don't change?
• Do you get the feeling that there might be something more to these behaviors/ symptoms?
• Considering how long these problems have endured, despite our efforts, what do you think it will take to help your child?
• Can you think of anyone that might be able to give you more expert feedback about his behavior?

If these questions do not lead resistant parents to consider assessment, another strategy is to wait for a critical moment to directly suggest one. Students with untreated mental health conditions get in fights, commit serious offenses, fail subjects, and get suspended. When these occur, even parents in deep denial cannot completely ignore the seriousness of their child's problems. Immediately following such incidents, teachers have a brief window in which parents may be more open to suggestion.

When Parents Accept the Referral

Do not assume that parents' resistance and denial have disappeared simply because they took your suggestion. Many families you refer for assessment will never call the number (s) you give, and of those that do call, the majority of those will not follow through with the assessment. Thus, it is critical that you...

• reinforce their decision to have their child assessed
• offer to assist the family with contacting the professional or clinic, and offer your support to them throughout the process
• follow up with the parents and ask if they contacted the referral, scheduled an assessment, etc.
• be alert to barriers, such as accessibility of services, cost issues, or communication problems with the referral
• provide encouragement to parents if they appear discouraged, and help them explore options (e.g. using different resources) if they encounter problems
• offer to provide updated behavioral feedback both to them and the professional
• help parents develop the expectation of improvement of behaviors/ symptoms over time, rather than quick fixes

To Whom Do You Refer?

Schools generally need a diverse referral base to meet the counseling assessment needs of students. Although some families will have resources through their insurance plans or the financial resources to pay privately, others will need low-cost providers, including county-operated or county-contracted clinics that offer sliding scale fees and accept Medi-Cal. Ideally, schools (and even individual teachers) will develop relationships with a core group of professionals or clinics that provide assessments and services on a regular basis. Such a relationship not only enhances the communication process, but also increases the comfort level of the teacher and school team when making a referral, since they are familiar with the professional (s) and their level of competence. 

Any qualified mental health professional can conduct a counseling assessment. Clinical Social Workers, Psychologists, Marriage and Family Therapists, Psychiatrists, and Pediatricians-either licensed or practicing under the supervision of a licensed professional-can all potentially assess child mental health issues, make a diagnosis, and develop a treatment plan. To select clinicians to include in a referral base, schools should consider the following criteria:

• training/ expertise with child mental health disorders
• experience working with children
• professionalism and reliability
• ability to engage resistant families
• willingness to communicate with teachers/ schools
• ability to track and re-assess problems over time
• language and cultural competency
• cost
• location

For more information about talking to parents or developing mental health resources, feel free to contact Jason Sackett directly.