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Helping Our Teens, Together Over the past seven years as the school psychologist at an ethnically diverse high school, I have observed that it is not uncommon for high school students (aged 14-18) to experience psychological, social, sexual, addictive, adjustment, and disability-based issues of such clinical significance as to warrant independent professional support. The professional psychologist can provide diagnostic clarification, therapeutic intervention, and even subsequent referrals when appropriate.
Parents intuitively recognize the significance of timely intervention at this important transitional age and are eager that their child be afforded the best help the community can offer. Many parents express intense devotion to do whatever is needed to get the support their teen needs. Their gratitude and joy is rewarding when suffering, anxiety or discord is assuaged. Focusing the high school camera’s field of view more tightly, we see that the high school student faces particular types of issues, many of which can be described as adaptive or existential in nature.
These include anxiety over grades and friendships, parental pressure and conflict, parental divorce, peer pressure, peer group conflicts, romantic problems, and existential issues regarding identity, sexuality, self worth, personal limitations, and meaning. Beyond the common adjustment challenges and troubling existential ones, there are the “biggies” which could even more likely develop into referrals. I will list the major ones I have observed, in order of frequency of occurrence.
Foremost are the Risk-taking Behaviors (elaboration to follow), then Conduct Disorder, Attention Deficit Hyperactivity Disorder (with or without hyperactivity), Oppositional Defiance Disorder, Depression, Bereavement, Autism Spectrum Disorder, Eating Disorders, Self Injury (Self-Mutilation or Cutting), Bipolar Disorder, Post Traumatic Stress Disorder, psychotic disorders (more frequently with premorbid or schizotypal personality features), and Traumatic Brain Disorder.
This list is by no means exhaustive, but represents the top baker’s dozen of psychological issues I’ve observed with high school adolescents. As for the most frequently occurring issue, “Risk-taking Behaviors,” I am referring to behaviors such as tobacco use, alcohol and other drug use, sexual behaviors, dietary and physical health-related behaviors, acts of violence (including gang violence, street “sport” fighting, and sexual assault), and suicide attempts.
Though sometimes not included in the national survey reports of adolescent risk taking behaviors, I also include gambling in this category, as it has been seen with increased frequency on our high school campuses and at the online gambling sites accessed by teens. There are excellent statistics available on adolescent risk-taking behaviors in America (1) and in San Diego (2). Who can help teens work their way out of at-risk behavioral difficulties and other significant problems and disorders? As Obama put it, “Together We Can. In most cases school teachers and staff turn to appropriate high school and district personnel and programs first. But school psychologists, counselors and nurses are also specifically trained to recognize when to refer out. Special Education IEP Teams are sensitive to this as well. (How referrals happen, and the criteria used for making them is addressed below). Many students find sufficient help from the substantial school and district support services that are available to them, while others require independent psychological or psychiatric expertise or treatment programs as well.
Parents and community members expect their school district to provide front line help for their children, and to refer to community mental health professionals when appropriate. Regarding school-based interventions, the goal is to provide help to the student in the “least restrictive environment” possible, per federal and state educational law. The school districts serve mental health needs of students in a number of ways, while maintaining their access to academic instruction. The following are a few of the ways that school personnel discover and address the psycho-social needs of high school youths.
In many cases, school teachers and staff are the first to notice troubling signs. The attendance clerk may notice excessive absences and alert the student’s assigned counselor, or the security officer may be called to break up yet another fight in which Tyler is involved. Discovery of need may occur when the vice principal hears of a student who committed a “zero-tolerance” offense, or it may happen when the school nurse notices marks of cutting or signs of depression. It may be the P. E. eacher overhears locker room conversation about a gang incident, the art teacher notices a persistent theme of blood, violence and death in a quiet antisocial student’s art work, or an English teacher reads a student’s paper telling of the recent loss of her parent or grandparent. Sometimes it is the student’s peers who are first to pick up on and report signs of trouble. The Yellow Ribbon Suicide Prevention Program and school anonymous crisis lines provide workable avenues for a student to report that his friend has been saying scary things about taking his life and ending it all.
Or it may be another student who talks her friend into showing the nurse or counselor the bruises on her arms and legs, and that she is staying with a friend because of threats by her alcoholic father. Occasionally a troubled teen will approach a counselor or the school psychologist directly and ask if they can talk about their difficulty sleeping and of incidents of panic with racing heartbeat and profuse sweating, and if they are “having a nervous breakdown or something. ” So what services does the school district offer these students?
First and foremost are the frontline professionals at the student’s school site. The ones most likely to address the psycho-social needs of the high school student are the school psychologist, counselor, nurse, and Life Skills Counselor. In our case, we also have a clinical psychologist who volunteers to see students at school for one or two mornings per week. In addition, bereavement counselors from San Diego Hospice hold small group and individual sessions on campus throughout the school year for students who have lost a loved one.
Together We Can. School counselors, nurses or psychologists may provide “intentional guidance groups” for anger management and impulse control, problem solving, social skills, etc. , and each school typically has its own Crisis Response Team. The school offers a number of other programs that provide substantial support for students in need. Worth mentioning first is the power of “ordinary” high school classes, programs and organizations. These should not be underestimated in their ability to psychologically benefit students.
Art classes, P. E. classes, athletic programs and music programs, not to speak of the many student organizations and clubs on campus, provide immeasurable mental health benefits through skill development, physical and emotional catharsis, diversion, recreation, personal expression, socialization, esteem building, and more. Specialty programs such as Technical, Art, Theater and Business provide students, many of whom are at-risk, with the opportunity to discover and express themselves and develop marketable skills.
Also programs such as ROP, work apprenticeships, and on-campus jobs provide not only job and career readiness, but social-emotional benefits through their emphasis on the need for punctuality, responsibility, and accountability. The School-to-Career program, the College, Career and Technical Education program, and the District’s Career Development Services especially help students whose technical, manual and practical aptitudes may exceed their academic ones. These students catch a vision of becoming someone important and doing something of interest to benefit the world.
I have seen many otherwise underachieving, directionless, depressed and self-deprecating students radically changed and energized by just such career involvement. But what direct mental health programs and services does the school district provide? The district’s Mental Health Resource Center (MHRC) provides mental health assessment and treatment at designated elementary, middle, and alternative high school sites, and it operates or oversees a number of programs including the ALBA (Alternative Learning for Behavior and Attitude) sites’ mental health services.
But perhaps the most comprehensive system of organized support for students with emotional and other disabilities is the district’s Special Education Program. Students with special needs each receive an Individualized Education Plan (IEP), a case manager and an IEP Team of multidisciplinary special education service providers who meet annually or more frequently as needed to identify IEP goals and assure that appropriate services, supports and placement are provided for the student to reach those goals.
One particularly relevant program, provided by the MHRC through Special Education, is the contractual arrangement that the District has with San Diego County Mental Health. Students with significant mental health needs are referred for professional mental health assessments and treatment for up to six months at a time. These services, made possible through Assembly Bill 2726, provide subcontracted outpatient services for the student and family, inpatient care when needed, or residential care.
Licensed Children’s Institutions (LCI) is also part of the Special Education Department and supports students who are placed in residential and day treatment programs within the district. Alternative schools such as Marcy School and New Dawn are available for high school students who would benefit from a program combining academic instruction with a full-day rehabilitation program that provides comprehensive treatment services. A Pregnant Minor Program is provided at Mark Twain and Garfield High Schools for teen-aged girls who are pregnant.
The School-Aged Parent and Infant Development (SAPID) program enables teen parents, both male and female, to complete their high school educations, to develop parenting skills and to explore vocational interests and job skills. Resources for Students with Autism (RSA) is a program that offers expert information on Autism and effective interventions for students with Autism Spectrum Disorders. The District also has behavior intervention specialists who provide behavioral analysis and behavior modification consultation.
So when do school personnel refer out to community based mental health providers? In most cases, under one of the following 3 conditions: 1) when a psychiatric diagnosis (as opposed to a determination of eligibility for special education services) is requested or deemed needful, 2) when psychological healing (as opposed to emotional/behavioral support for educational success) is the goal, or 3) when therapy (in contrast to educationally relevant behavior supports and counseling) is required or requested.
Parents of course may choose to refer their child to a community based mental health service provider directly, without consultation with or referral from school personnel. It should be noted that if a parent is curious to know if his or her child has a mental disorder of some kind, or even a learning disability, but has no interest in having an IEP and would refuse special education services if offered, the school psychologist would typically refer this assessment out.
As a general rule of thumb, school psychologists assess for special education eligibility, not for psychiatric or even learning disorders per se. When an assessment request is not directly related to the question of special education eligibility, it is typically referred out. Finally, how does a school psychologist or other school professional choose which professional to refer to in the community?
While most referrals are made to the mental health service providers that have contracted with the District through its Mental Health Resource Center (MHRC) and AB2726 plan, addition referrals are made by school psychologists, counselors and nurses on the basis of parent request, location, expertise and familiarity to the referring professional. It is in this last sense that a community-based psychologist would do well to place a timely phone call to his or her local high school and “network” with the school psychologist, head counselor and nurse.
Credentials, areas of specialty, and other pertinent information would be helpful. It not only takes a village to raise a child, but a village to aid and support him or her when the going gets rough. The median number of students per school psychologist in California is 2000. This is too many for a single school psychologist to handle alone. But by working together, school psychologists and community mental health professionals can do more than either can do alone in providing the supports that our teens need in one of the most important transitional periods of their lives, ages 14-18. The Youth Risk Behavior Surveillance, 2007, put out by the Department of Human Services Centers for Disease Control and Prevention at http://www. cdc. gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr. pdf. 2 http://apps. nccd. cdc. gov/yrbss/CompTableoneLoc. asp? X=1&Loc=SA&Year1=2005&Year2=2007 This article was published in the San Diego Psychological Association newsletter, San Diego Psychologist, Vol. 23 No 8 September 2008. The