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Mental Health Archive 2010

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Margaret L. Stivers, Ph.D.
Clinical Psychologist

Margaret is a clinical and social psychologist trained at the University of Kansas and the University of Miami. She has taught psychology at four major universities and directed mental health, residential, and nonpublic school programs for children and adolescents. Her experience includes 30 years of consultation and collaboration with educational programs throughout the country, including schools in urban and rural areas and on Indian reservation.

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  • Appropriate replacement behaviors for a child with Reactive Attachment Disorder.

Question:

We have a fifth grader with reactive attachment disorder.  We are finding him eligible for special education.  Much of the literature around RADs focusing on modifying the environment and the behaviors of adults in order to encourage an attachment between the parent/guardian and child.  We know that much of the behavior exhibited by the student (lying, stealing, manipulating) is his attempt to control his environment when he does not feel safe.  We are wondering about appropriate replacement behaviors for a child with RADs.  Insight oriented therapy is not usually encouraged, since this allows an opportunity for the student to manipulate and triangulate; much of the work is done with parents and the child.  We were thinking about focusing on the development of relaxation and stress reduction techniques as the replacement for the stealing, lying, etc.  Do you have any suggestions?

Susan Roberts
Program Specialist


Answer:

Dear Susan,

First, I want to commend you and your district for recognizing this student’s disability and exploring ways to support more positive behavior rather than simply seeing him as a problem student who uses “bad” behavior to make your lives difficult. As you point out, most methods used to treat attachment disorders focus on establishing and strengthening the bond between the child and primary caregiver. The school program plays a supportive role. Even the best individualized program of school supports is extremely unlikely, by itself, to produce full recovery in a student with a severe attachment disorder. However, many factors in the school environment can be carefully arranged to encourage, promote, and set the occasion for more positive behaviors. Conversely, school factors can exacerbate current problems and even inspire the development of new, often more creative and sophisticated, problem behaviors.

Reactive attachment disorder ( RAD) is a relatively recent diagnosis and is still unfamiliar to many people, even those who work with children. There is still some controversy about the diagnosis and a lack of consensus about the nature and definitions of attachment disorder(s). This lack of clarity may be a reason that evidence on the components of effective treatment is sparse. Still, students with attachment disorders can be some of the most difficult students encountered by school staff and it is important to recognize what can be done to make the job easier.

Here are some suggestions, some discussion of potential methods, and some things to consider when developing plans for students with attachment disorders to help them develop more adaptive behaviors at school:

Positive behavior support plans (BSPs)

Because of the lack evidence-based practices focused on treating attachment disorders, you made a good decision in turning to broader approaches, such as behavior analysis, that have proven effective with a wide range of behaviors, regardless of the students’ diagnoses. While behavior support plans (BSPs) are effective for addressing a variety of behaviors, this method may be difficult to apply to behaviors such as lying and stealing in students with RAD. BSPs are most likely to be effective when there is strong, observational evidence that the student’s behaviors are triggered and maintained by specific antecedents and consequences in the school environment. If you have data indicating such a relationship, it should be the basis for your plan. If you and the staff have not yet gathered data, you are encouraged to do so. It will be useful to determine whether the target behaviors are more likely to occur under some circumstances than others and to identify any ways in which particular features of the school environment or staff behaviors may increase the probability of those behaviors. This information can be incorporated into your student’s plan with or without a BSP.

The difficulties in developing a BSP for your student center on identifying the function of the target behaviors and finding a functionally equivalent alternative. You used your understanding of the underlying dynamics of attachment disorders to develop a reasonable hypothesis about the likely functions (gaining control over his environment, feeling safe) of your student’s behaviors (telling lies, stealing, manipulation). These functions are complex and suggest that behaviors are not primarily under the control of environmental factors and are more often triggered and maintained by internal emotional states (anxiety, helplessness), possibly bolstered by patterns of thinking (e.g. “I can’t trust anyone to take care of me, so I better take everything I can”). Many experts in the behavioral field consider functions such as “control over his environment” not to be appropriate functions to designate in designing a BSP because a student may not be given this level of control over his environment and the people in it and it is difficult to imagine an appropriate, desirable replacement behavior which serves this function.

Even if a BSP is not used for the RAD-related behaviors such as lying, stealing, and manipulating, it is likely to be a very useful method to decrease other problems by increasing targeted positive behaviors. Increasing the time your student spends engaging in positive, pro-social behaviors will benefit everybody. However, the positive behaviors may not serve as functionally equivalent alternatives to lying and stealing, so do not necessarily count on seeing immediate, dramatic decreases in those behaviors.

Overall approach

Your awareness of the general functions, or underlying needs, being met through your student’s behaviors is very useful, whether or not this knowledge is used to create a formal behavior plan. Responding to your student’s needs for increased feelings of safety and decreased anxiety or helplessness is very likely to help him develop a broader and stronger repertoire of adaptive behaviors, which will, most likely, result in an eventual decrease in problematic behaviors. Select strategies and environmental modifications to help your student feel safe and provide him with appropriate opportunities to make choices. In using communication strategies to help student feel safe, it is useful to adopt a neutral, matter-of-fact tone. Keep in mind that reassuring words are fine, once you have won the student’s trust, but that student at first may be mistrustful about positive statements. Consistent behavior and reliable actions to follow up on spoken words are more far persuasive. Avoid anything that may be interpreted as lying to the student about anything important (even by omission). Take pains to avoid any appearance of hypocrisy or selective enforcement or interpretation of school or classroom rules. Consider interventions designed to contribute to an increased sense of group membership, or belonging, investment in being a contributing member of the classroom or school community, and increased experiences of success and sense of responsibility for that success.

Staff education

With parental permission, ensure that all school staff members or adult volunteers who may have contact with this student know something about his background and understand the basic dynamics of attachment disorders. This should help them be more understanding, less likely to convey blame and better able to refrain from taking child’s behavior personally. This minimizes the likelihood of their unwittingly escalating the student’s behavior. In response to an earlier letter, I provided an overview of RAD which can be found in the ask-a-specialist mental health section by clicking “previous.”

Unified staff

Some students with attachment disorders (and yours sounds like one of these) use their observational knowledge of others’ strengths and weaknesses, likes and dislikes to “play on” their feelings and manipulate them. They often go to different adults for different things and “triangulate” or play them off against one another. They may misrepresent each adult’s actions and words when they talk to other adults, especially if they perceive this as a useful way to elicit sympathy, strengthen alliances, or “divide and conquer.” Remember that these are actually young and vulnerable children who probably perceive life as others perceive war; they may feel as though they are alone, struggling for survival, with no one they can trust or count on.

The kind of control children gain from manipulation and divisive behavior is not beneficial for the student and certainly not good for staff. To limit manipulation, agree on clear, specific rules, limits and consequences. I hardly ever advocate inflexibility, but in this situation, I strongly suggest that staff members adhere rigidly to agreed-upon procedures. This means that, within reason, there will be no leeway for adults to use individual judgment in responding to the student’s behavior. Have a script to avoid giving in to the student’s appeal to have “one more chance,” to be given a reward he “almost” earned and “deserves” because he “tried really hard,” or to avoid a specified consequence “just this once, because I already feel so awful.”

Therapy

I generally agree that for the student with RAD, individual insight-oriented therapy is often not helpful and can even be harmful, especially if the therapist is not experienced and skilled in working with children who have attachment disorders. However, therapy can provide a safe and consistent environment with non-contingent acceptance (of the child, not of everything he says or does) and s ome therapeutic techniques may be useful. Because children with attachment disorders have high anxiety, including constant vigilance and never feeling safe, I like your idea of teaching relaxation and stress reduction techniques. Even though these relaxation techniques and strategies for coping with anxiety are unlikely to serve as functional equivalents for lying and stealing, the skills will benefit your student. In the hands of a skilled, experienced therapist, some additional cognitive-behavioral techniques may be appropriate as well. This may help the student identify and examine some of his underlying assumptions about his life and the people in it (e.g. “It doesn’t matter what I do – they’re all out to get me”).

With the right environment and social supports, the problematic thoughts, emotions, and behaviors associated with RAD can improve considerably. We recently saw a girl at the center who was adopted after she spent her first 6 years in multiple homes, experienced lengthy periods of neglect, was exposed to drugs and violence, and was a victim of physical and sexual abuse. At age 10, she continues to struggle with many challenges, but has formed a secure attachment with her adoptive mother and is making rapid progress. Her behavior has been a major problem in some school environments, but few problems have been reported in her current, highly supportive school program.

There is hope, but as far as I know, there is no quick fix; it is a gradual, long-term process that requires patience and time. You understand the disorder, have some very good ideas, and appear to be on the right path. I wish you success!

Marji


  • How can we bring her out of this desperation? (Part 3)

Question:

I have a student who was doing well in her studies till 12th grade. She was a competitive child who was many times (though she may have not realized it) insecure about her relationships with others, sometimes making her act dominating and aggressive. Unfortunately, she fell apart in 12th grade when she failed to get admission to any college. She was not able to take the trauma and tried to commit suicide twice.

My question is how can we bring her out of this desperation? Her suicide attempts occurred despite several talks with a psychologist, parents, friends and others, a change in her surroundings, and other attempts to give support.

Isn't so much pressure – by parents, peers, society -- too much for children to handle?


Answer:

You pose two important questions in your letter, each worthy of discussion, and this is the third of a three-part response. My previous entry focused on student stress – is it really a problem? This issue will address:

How can we help provide support, reduce stress, and help them cope?

Parents:

Realize that your junior high or high school student is likely to feel more anxiety and put more pressure on himself to do well in school than you realize. While occasional stress, especially at mild-to-moderate levels, can enhance learning and performance, more intense or chronic stress can impair concentration and memory and become increasingly counter-productive. If your student is already stressed, any additional pressure you add could quite possibly do more harm than good.

Beware of unwittingly adding stress. Think carefully about what you say and how it might be interpreted, or incorporated, into your child’s worldview. This can be a minefield because it is easy to trigger or feed into their fears. For instance, motivational conversations or “pep talks” about the benefits of going to one of the “best” colleges might be taken to imply that going to a less selective college is a life-ruining tragedy. Even “setting an example” by sharing information about obstacles you overcame and accomplishments you made should be carefully worded so your child does not feel you are just raising the bar. Even words meant to be supportive and convey encouragement can have unexpected impact. For instance, “I know you can get an A in that class” may elicit the thought “If you know I can, how awful and disappointing a kid does it make me if I don’t manage to get an A?” A message such as, “I know you can be the very best in your class” might raise the question in your child’s mind “What happens if I’m not really as good as you think I am? How will you feel about me when you find out?”

School staff:

Consider making a significant reduction in assigned homework. This is not a recommendation to lower your standards. It is a challenge to clarify your goals by identifying the critical knowledge and skills that are essential for your students to acquire. Assign work that is necessary for learning/ practicing these knowledge areas and skills. Avoid busy work such as memorization of details or excessive practice of already-mastered skills. Non-essential homework and testing do not increase course rigor or raise standards. These practices are more likely to transform a potentially enjoyable learning experience into a an endurance test.

When at all possible, make available overall support (not related to specific course content), such as school-based help with study skills, organization, time management, and possibly, social-emotional coping skills. Among bright adolescents, there are dramatic differences in the extents to which they have developed these skills. Significant lags in these areas can sabotage academic careers, even among extremely promising students with creative and original ideas to offer.

Parents and school staff:

Validate students’ feelings.

When students complain or appear anxious, irritable, or stressed, you can help by listening and acknowledging their feelings. Well-meaning comments such as “These are the best years of your lives” can easily be interpreted as ways of denying or minimizing the stress with which the students is struggling to cope. This not only inhibits rapport and communication, but may also increase the student’s distress. Students will not only worry, and worry about how much they are worrying, but might also end up feeling guilty about feeling stressed and worried.

Maintain your perspective in order to help students maintain theirs.

Remember that high school students are individuals moving through an important stage of personal development. Encourage students to explore areas of interest and pursue activities (at least one each) that they enjoy, whether or not they are “stars” or the activities carry prestige. The whole purpose of the high school years is not to “be the best” or get into the most competitive, college. Emphasize this in talks with students. For instance, if a student asks for advice about a choice of classes, ask what the student enjoys and finds interesting. Do not simply point out which class you think will look better on a college application.

Consistently acknowledge and point out to students that there are many kinds of success and that it is not necessary to go to a famous school in order to achieve any of them. Remember that many people have attended community or state colleges, or no college at all, and led remarkably productive, fulfilling lives. Quite a few people have gone to prestigious universities, but have not been happy or successful, in their own and others’ eyes. And some individuals have made mistakes or experienced failure and disappointment early in life, yet gone on to make major contributions to society. One of my favorite things about our country is that our life and career paths are unusually flexible. We encounter new opportunities and potential turning points throughout our lives. No one’s fate is determined by a letter received during twelfth grade.

Resources

MassGeneral Hospital for Children
http://www.massgeneral.org/children/adolescenthealth

American Academy of Pediatrics, 2007 report on the importance of unstructured time during childhood and adolescence
http://www.aap.org/pressroom/play-public.htm

American Psychological Association (APA), 2009 survey on parents’ perceptions of their children’s stress
http://www.apa.org/news/press/releases/2009/11/stress.aspx

American College Health Administration/ National College Health Assessment
http://www.acha-ncha.org/reports_ACHA-NCHAoriginal.html

National Survey of College Counseling Directors
http://www.education.pitt.edu/survey/nsccd/archive/2009/monograph.pdf


  • How can we bring her out of this desperation? (Part 2)

Question:

I have a student who was doing well in her studies till 12th grade. She was a competitive child who was many times (though she may have not realized it) insecure about her relationships with others, sometimes making her act dominating and aggressive. Unfortunately, she fell apart in 12th grade when she failed to get admission to any college. She was not able to take the trauma and tried to commit suicide twice.

My question is how can we bring her out of this desperation? Her suicide attempts occurred despite several talks with a psychologist, parents, friends and others, a change in her surroundings, and other attempts to give support.

Isn't so much pressure – by parents, peers, society -- too much for children to handle?


Answer:

You pose two important questions in your letter, each worthy of discussion, and this is the second of a three-part response. My previous entry focused on ways to support the young woman who attempted suicide after she did not get into college.

Student stress is emerging as a “hot” topic. Most frequently and strongly expressed concerns focus on the pressures faced by competitive junior high and high school students who are anxious about college admissions. The story of the young woman described in your letter certainly suggests that these pressures have the potential for negative, even possibly tragic, consequences.

It was my good fortune to have an opportunity to hear first-hand accounts and observations of the impact of pressure on students. I interviewed two guest “experts” on high school life, Sean Simpson and Marie Brashears. Both are juniors at public high schools in California. They reported that they experience almost-constant pressure coming from multiple sources. Although both Sean and Marie are resilient students with strong social support, they feel that they would definitely benefit from having fewer pressures. They are quite concerned about the toll of stress on some of their classmates and friends, who may not all be equally equipped to cope. I am grateful to them for speaking about their own experiences and sharing their observations and insights about the impact of stress on their friends and classmates.

Is student stress really a problem?

Although the question is complex, there is substantial support for concern. Several credible groups and individuals who are in a position to observe the impact of stress on today’s students are giving similar messages. The American Academy of Pediatrics (AAP) recently issued a report warning that students’ lives have become overly prescribed and programmed, depriving them of the unstructured time needed for exploration and personal development. The Academy also pointed out that years of cumulative stress can increase students’ risk of current and future mental health problems. The report noted that “colleges are seeing a generation of students who appear to be manifesting increased signs of depression, anxiety, perfectionism, and stress.”

A survey by the American College Health Administration showed a 56% increase in the proportion of college students diagnosed with depression over a recent six-year time-span. Information gathered annually through the National Survey of Counseling Center Directors indicates that in 1988, only 58% of college counseling center directors reported seeing students with serious mental health problems, but that last year 93% reported seeing serious problems. Over 40% of the students who sought help were considered to have such serious problems that they could not expected to continue at school without intensive mental health support. Another 7-8% of the students seeking help were considered too seriously impaired to remain in school. In short, almost half of the students seen at college counseling centers last year were struggling with problems considered sufficiently serious to jeopardize their abilities to function in college.

Why might students be entering college with more emotional problems?

What is going on in these students’ lives that can possibly account for the apparently record-breaking number of serious problems? There are many individual factors as well as a wide range of possible common causes. Some widely shared experiences seem likely to be major contributors to student anxiety. For instance, many students repeatedly receive the message, directly and indirectly, that they “absolutely must” get into a highly desirable (usually highly selective) college “OR ELSE.” Although they try hard not to let their imaginations run too wild about that “OR ELSE,” it is almost impossible not to dwell on it.

Pressures from parents, teachers, and other sources become internalized as self-pressures and are mutually reinforced and perpetuated through peer groups. Students become conditioned to think of everything they do in terms of how well they are positioning themselves, relative to others, to look desirable to college admissions committees. They become used to feeling competitive most of the time about most things they do and monitor every shift, no matter how small, in their standing relative to that of their peers. They become hyper-aware of own performance and that of their classmates, while continually conscious that everyone else is watching them just as closely.

Once established anxiety cycles are often self-perpetuating because anxiety tends to feed on itself. For instance, a student may tell herself, “I’m way too tired to keep going, but if I push myself to study just ten more minutes, it might mean getting one more point on the test, which might make the difference between an A- and B+ in the class, which might end up making a difference about whether I get into….” Of course, the guilt and fear are almost impossible to alleviate; after ten more minutes of studying, the same reasoning still applies to the next ten minutes, and then to the next ten. Further, the same dilemma is constantly recurring in multiple classes. Positive motivation, such as intellectual curiosity, the pleasure of learning, or interest in a particular subject, recedes as everyday behavior is increasingly driven by fear and guilt.

How good are we at recognizing adolescents in distress?

Teachers, parents, and adults who work with youth know that many young people experience anxiety about whether they can cope with the real and/or perceived expectations and pressures they face. Ironically, some evidence suggests that while we are well aware that there is a big problem “out there,” we still tend to underestimate the severity of anxiety experienced by young people.

Over many years of working as a psychologist, I have consistently noticed that many perceptive and caring adults considerably underestimate the distress experienced by the children and adolescents. This may be the reason that results of a national survey just released by the American Psychological Association (APA) caught my attention. The survey compared self-report data on anxiety provided by teens (13-17) and tweens (8-12) to parental estimates of their sons’ and daughters’ anxieties. While only 2-5% of parents rated their children’s stress as extreme (8-10 points on a 10-point scale), 14% of tweens and 28% of teens reported that their anxiety falls in this range. Parents also estimated fewer worries, or sources of stress, than were reported by their offspring. Far more children and adolescents reported intense anxiety about doing well in school and worries about family finances than estimated by parents. Relative to parental estimates, children and adolescents also reported far more physical symptoms of stress, such as headaches and difficulty sleeping.

This survey focused on parents’ perceptions rather than those of school personnel. The results of this study how easily adults may underestimate distress in a younger generation, especially teenagers. There are many possible reasons for our underestimations of their distress. Many teenagers are more likely to discuss problems with one another than with adults. They may perceive that being identified by adults as “having a problem” can lead to more problems (lots of questions, greater scrutiny, increased monitoring). Some students may not confide in anybody because they feel on the verge of “falling apart” and fear that talking about it might “open the floodgates.” Others may feel ashamed and hide their distress, thinking “everyone else seems to be coping and doing fine, so I’d better look fine too.” Many young adults are motivated to “look good” to others and have honed their skills in appearing to be the way they believe others expect them to be. Not only are young adults adept at maintaining the appearances they wish to present, but, as adults, we may unknowingly participate in preserving our illusions. As adults who care about youth, we would certainly prefer to think that they are struggling or suffering less than they may actually be. We may also think that we are better than we actually are at minimizing the pressures we put on them and at protecting them from “adult” levels of worry.

How can we help provide support, reduce stress, and help them cope?

To be answered in next month’s edition.

Resources

MassGeneral Hospital for Children
http://www.massgeneral.org/children/adolescenthealth

American Academy of Pediatrics, 2007 report on the importance of unstructured time during childhood and adolescence
http://www.aap.org/pressroom/play-public.htm

American Psychological Association (APA), 2009 survey on parents’ perceptions of their children’s stress
http://www.apa.org/news/press/releases/2009/11/stress.aspx

American College Health Administration/ National College Health Assessment
http://www.acha-ncha.org/reports_ACHA-NCHAoriginal.html

National Survey of College Counseling Directors
http://www.education.pitt.edu/survey/nsccd/archive/2009/monograph.pdf