For Teachers, Counselors, and School Personnel
There are many reasons why securing appropriate services for a child or family can be quite challenging. To name a few, some of the services needed are in short supply; school staff often get conflicting advice regarding what services are needed; many of the services provided lack an adequate research evidence base supporting the use of them; it can be quite difficult to know whether services being provided are adequate in scope and quality.
Generally school personnel want to know:
What is the problem? What is needed to restore academic function? Where can I refer the parent/guardian the needed services? How can I contribute to assessing whether services are appropriate? Here are some thoughts that may help you work your way through these questions.
To provide capable treatment, professionals must generally follow a step-wise process. Understanding the basics of this process may help you assess whether you getting your needs met. Steps are as follows:
1. Description of the concerns and data collection:
- The clinician should be collecting a thorough history, including an interview of parents/guardians and the child in question (at least one hour); observation of family interactions and communication style; review of all prior efforts to address the problem (typically including written medical records and prior evaluations, likely also including conversation with prior and current treaters); communication with school personnel about school-based social and academic function; communication with pediatrician about medical status and pediatrician’s knowledge about the child and family/guardian; possibly communication with natural supports (clergy, coaches, big brother/big sister, other family, etc.)
- You can help this by: explaining to parents/guardians the benefit to the child of there being communication between school personnel and the clinician; assuming consent is given, actively pursuing contact with the clinician, preferably with parent/guardian participation in the conversation; inquiring of the clinician of whether they would like you to use any measuring tool, and what observations you could be tracking that might help the treatment
2. Culling of data:
The clinician should be sorting through the information in order to make sure that all components that need attention are tended to. For example, if the child/family experienced a significant loss immediately before the development of symptoms, failure to integrate that fact into developing an understanding of the problem will likely lead to an inadequate treatment plan.
3. Develop a reasonable story (technically called formulation):
The clinician should pull together the information in way that establishes a reasonable theory/hypothesis about what the problem is. The clinician should be able to state the story in a way that is understandable to the parent/guardian, so you may give an opinion about the theory, and/or offer alternative theories, to be integrated into the plan for treatment. The reasonable story has to make sense, it has to fit with important elements of the history, and it has to lead logically to a diagnosis.
You can help this by: telling the clinician the best you’ve done so far at making sense of the problem; actively thinking about whether the story the clinician offers makes sense; speaking up about it if you have concerns.
4. Make a diagnosis:
Diagnoses are a way of summarizing or naming the problem. At best, there is existing research (also called the “evidence base”) that tells us something about how things will likely go if the problem remains untreated, and how to address the problem. When this is true, a correct diagnosis puts you in a position to know something with confidence about what the treatment plan should be. In the treatment of depression, for example, it is generally agreed that a combination of cognitive-behavioral therapy and medication is the treatment of choice. Regrettably, more often than not, the evidence-base is not sufficient to tell clinicians with certainty what is going to help. In the absence of sufficient evidence, clinicians serve children and families best by choosing treatment according to community standard or “best practices” according to diagnosis.
You can help this by: reading or otherwise informing yourself about the diagnosis; asking the clinician how this problem might present in the school setting
5. Develop a treatment plan: the plan for addressing the trouble must be based on the evidence, or if not available, on commonsense community standards. Sometimes treatment plans can demand quite a bit of time and work for multiple family members. If you are not resourced in a way that allows you to pursue all recommendations, the clinician should help you prioritize. The treatment plan should be comprehensive; typically it should include type(s) of therapy, whether medication is indicated; need for further consultations (for example, neurologic, genetic, developmental); lifestyle changes (diet, exercise, sleep, self-soothing practices). The clinician should tell you about the risks, benefits, and alternatives regarding each component of treatment. This last part is called “informed consent”
- You can help this by: being clear with the clinician and parent/guardian about what you can and cannot realistically do; asking questions if you do not understand; integrating the treatment plan into the academic day and making sure it coherently fits with educational planning (504, IEP
6. Assess progress and outcome:
- There should be well-defined criteria that are identified for assessing the effectiveness of the treatment. The more objective these markers are, the better to measure the treatment. While self-report is of value, a marker like “the child will feel better” is so vague that it would be of minimal help. More useful would be indicators that track frequency, severity, and duration of specific symptoms. For example, in the depressed child where he or she has been refusing to go to school and has stopped socializing, one might track frequency of school attendance and participation in social activities.
- You can help this by: asking the clinician and/or parent/guardian how you’ll all know that the child is recovering; participating in tracking the agreed-upon markers; making sure that any tracking/monitoring in school is being done with fidelity amongst all school staff, and that the data is getting to the parent/guardian and clinician in advance of appointments with the clinician.
- One further point: It can be quite difficult to know whether a child is in an effective treatment; most treatment takes time, there is almost always uncertainty about what will help, or how long it will take, and children often express reluctance about being in treatment. So a treatment that a child says he or she doesn’t like, that is taking awhile to have an effect, and where the clinician isn’t sure the treatment approach will be sufficient might still be the best treatment for a child! The best way to figure out whether a child and family are getting what they need is to support them asking questions of the clinician. The clinician is responsible for educating parents/guardians and school personnel about the treatment, and communicating in a way that allows you to make sense of the rationale for the treatment. If this kind of communication does not result in you being able to assess the quality of the care, it is reasonable to invite the parent/guardian to pursue a second opinion (if they are using insurance, they will cover a second opinion). The clinician providing a second opinion should speak openly and frankly with the current clinician as part of their assessment.