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Mental Health Archive 2012

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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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  • Prader-Willi Syndrome and Aggressive Behavior

Question:

Hello,

I’m wondering about the onset of aggressive behavior with a 6 year old SDC kindergarten student. This student has average to low average cognitive ability. He has had significant speech and language therapy to address expressive and receptive language deficits. He’s made good progress in this area; receptive language is stronger however there is a latency of response. He kicks, hits, slaps, and pulls hair when instructed by adults. The behavior serves work avoidance and attention seeking motives. Extensive behavior support planning is in effect with use of visual strategies, social stories, break time, structured choices. He continues to engage in the target behaviors about once a week.

In your experience, how common is this scenario for students with Prader-Willi Syndrome? If so, what is the typical age of onset? What positive behavior support interventions have you found most effective, or is the biological component of this a significant, mitigating factor? When he’s not aggressive, he is loving and quite charming.

Thank you,
Krista Arrington
School psychologist,
Quail Run Elementary School

Answer:

Dear Krista,

Since your question has both medical and mental health components, our pediatrician and clinical psychologist have collaborated to provide a response. Although there can be wide variation in the number and severity of symptoms that students with Prader-Willi Syndrome (PWS) display and these can change over time, the features your student has demonstrated are certainly consistent with patterns seen in children with PWS.

About Prader-Willi Syndrome

Prader-Willi (pronounced “prah-dur VIL-ee”) Syndrome is a congenital disorder caused by an absence of some genetic material from the long arm of the 15th chromosome (deletion15q 11-13). The several deleted genes happen to be involved with coding for the proteins that are necessary in order for the hypothalamus to develop and function normally. Through both neural and endocrine mechanisms, the hypothalamus plays a central role in maintaining homeostasis through various feedback mechanisms, typically involving the release of hormones which exert either inhibitory or excitatory effects. Abnormalities involving the hypothalamus may compromise the body’s ability to self-regulate such functions as appetite, thirst, sleep, body temperature, heart rate, blood pressure, and emotional responses.

PWS is estimated to occur in 1 of every 12-15,000 births, and the symptoms present in two distinct stages. At birth and throughout the first year of life, infants characteristically have reduced muscle tone, weak sucking reflex, and slow weight gain. They often have dysconjugate gaze (crossed eyes), excessive fatigue, impairment in their ability to respond appropriately to environmental stimuli, and difficulty transitioning between sleep and wakefulness. These aspects predominate through the first year of life, and then are superseded by the symptoms which characterize the second stage of PWS.

The second stage of PWS evolves throughout early childhood (anywhere from 1-8 years of age). Insatiable food cravings and the associated weight gain become the primary features of this stage. The malfunctioning hypothalamus continues to signal these children that they are starving, regardless of how many calories they consume. Due to decreased muscle mass, they do not efficiently metabolize the calories they take in, and so their weight gain trajectory accelerates. Food craving becomes paramount, and any delay in their achieving gratification may be met with an explosive behavioral outburst. With your student, if his insatiable appetite has just begun to emerge, then it may account in part for some of his recent displays of aggressive behavior.

PWS is considered to be a spectrum disorder, so that not every symptom will be displayed by any single child, and each symptom may vary from mild to severe. Mild to moderate cognitive impairment is typically seen, as are learning disabilities. Speech onset is often delayed until two years of age, and poor articulation may persist throughout childhood.

The typical cognitive profile for children with PWS involves relative strengths in visual organization and perception, so they often do relatively well with reading and vocabulary. Spoken language is characteristically at a lower level than their comprehension. They experience significantly greater difficulty with auditory information processing, sequential processing, arithmetic, writing skills, both auditory and visual short term memory, and auditory attention span. Although some improvements in these areas may be seen over time, significant deficits will typically persist throughout childhood.

Compulsive behaviors and increased anxiety are manifested frequently by children with PWS. They characteristically display extreme stubbornness, temper tantrums, obsessions and compulsions (e.g. repetitive behaviors designed to reduce the anxiety caused by recurring intrusive thoughts). Psychotic symptoms and depression are seen much less frequently, affecting about 5-10 % of young adults with PWS.

Children with PWS seem to spend the majority of their time riding a behavioral and emotional roller-coaster, as they attempt to get their needs met. They always seem to be dealing with states of under-stimulation or over-stimulation, but rarely are able to achieve any sense of balance or harmony.

Although children with PWS often display a higher than normal pain threshold, their capacity for tolerating frustration may be very low. Consequently, it would be helpful to remain vigilant for early signs of frustration, as the behavioral outburst may occur in a very short period of time following the onset of frustration. It would also be helpful to consider whether any of the behavioral outbursts were associated with adults acting in a way which precluded your student from getting a basic need fulfilled.

Behavioral Implications

The pattern of behavior you describe in your letter is certainly consistent with the behavioral pattern often observed in students with PWS. It sounds as though you and your colleagues are doing a very good job identifying your student’s needs and providing appropriate supports and services. Children with PWS characteristically present challenging behaviors which are easily triggered and unusually persistent. Try not to become overly discouraged by the fact that, despite all your efforts, your student continues to engage in problematic behaviors. It is quite likely that he is in the process of moving from stage 1 to stage 2 of the syndrome. If so, his behaviors, and the functions underlying those behaviors, can be “moving targets.”

Many of the most common behavioral difficulties associated with PWS revolve around food. Because those with PWS may eat to the point of gastronomic distress and still feel as though they are “starving,” they tend to engage in extreme behaviors to obtain desired food items, including manipulation, lying, and stealing food items.

However, dysregulated appetite is just one of many types of neurologically-based dysregulation experienced by children with PWS. While food-oriented behavioral difficulties are nearly universal, there is a wide range of individual variation in the severity and types of dysregulation experienced and behavior manifested by children with this syndrome.

Children with PWS frequently engage in reactive and volatile behaviors due, at least in part, to brain differences which compromise their ability to modulate sensations and emotions in response to both external and internal stimuli. Hypothalamic dysregulation is a prominent feature of Prader-Willi and impaired functioning of the hypothalamus disrupts the internal “thermostat” that helps modulate sensations and feelings in order to produce a comfortable state of equilibrium. Children with PWS rarely experience anything in moderation, but rather they tend to experience extreme states of stimulation and emotion in response to events or changes in their environment. Children with PWS can be extremely sensitive to stimuli around them and highly reactive to even minor changes in settings and routines. They can rarely maintain a restful state or experience any sustained sense of well-being, as such states depend upon the ability to maintain balance and stability.

These extreme states are often reflected in their behavior. Students with PWS are typically exceedingly reactive, irritable, excitable, and easily “set off” (with very low thresholds), and many of them display frequent and intense meltdowns. Their behaviors probably represent their attempts, usually unsuccessful, to achieve some degree of sensory and emotional equilibrium. Since these children have very limited capacity to adapt and can be obsessive, they may rigidly insist on doing things the same way every time.

Children with PWS are likely to perceive themselves to have very limited control over their own experience and to feel “at the mercy” of unpredictable elements in the environment and their own potent physical and emotional reactions to those elements. They crave predictability and often have a strong drive to try to control their environment, which includes the people with whom they interact. Their behaviors often interfere with successful adaptation to the school setting and limit their availability for learning. Although there is a strong biological component to his behaviors, environmental interventions can often reduce their intensity.

School Recommendations

It is important to periodically remind everyone who works with the student that children with PWS are often highly impulsive and reactive, and their behaviors are most often spontaneous rather than being planned or deliberate attempts to disrupt or do harm. Following behavioral outbursts, the student may feel remorse and have the desire, but not the ability, to explain their actions or repair any damage caused by their behavior.

Recognize that behavioral outbursts are generally triggered by:

1) some stimulus in the student’s environment which is perceived to be unpleasant,

2) the student’s failure to get his way, receive the desired attention, or obtain the desired response from others. It may help to view the student as having to select from a limited array of marginally effective options in order to help him get his way or be able to exert control over his own life.

Dealing with behaviors triggered by something in the student’s environment

  • Children with PWS can be extraordinarily sensitive to changes in their environment or routine that seem insignificant to others. They may react stongly to minor variations in their usual environment (e.g. a change in room temperature, a meal served somewhat earlier or later than usual, food prepared or presented slightly differently, altering the usual route taken to go somewhere, unfamiliar people/change in staff, etc.) Any change, even positive ones, may prompt impulsive/negative/explosive reactions.
  • Due to their heightened sensitivity to change, they typically crave predictability. Since they often display inflexibility, they are highly dependent on predictable routines, settings, and people. They possess a limited ability to adjust to changes from what they are accustomed to or events which deviate even minutely from their anticipated course.

Some recommended strategies:

  • Try to minimize the amount of change the student must respond to at any one time.
  • Establish consistent expectations for all adults who work with the student.
  • Encourage adults to respond to the student in a consistent manner in order to get consistent responses and improvments in behavior.
  • Provide a highly structured learning environment tailored to the student’s cognitive level, as this is the setting most likely to elicit an optimal response.
  • Clearly delineate the expected behavior, establish regular routines, and frequently enforce limits with respect to acceptable behavior.
  • Use a neutral, matter-of-fact voice and manner when interacting with the student, because voice tone and gestures which convey excessive emotion may be misinterpreted or precipitate an over-reaction.
  • Be firm, but, when possible, avoid words (e.g. “No” or “Don’t”) or gestures that may be interpreted as authoritarian or hostile and trigger a power struggle. Being overly sympathetic may prompt the child to infer that their plight is hopeless. Balancing the need to enforce limits consistently against the desire to avoid arguments may require the “Wisdom of Solomon.”
  • When a regular schedule must be altered, warn the student and try to help him prepare for the change. When possible, avoid placing him under pressure, especially time pressure.
  • Keep in mind his heightened sensitivity, in that when you talk to other people around him and not to him, he may feel slighted. Conversely, talking at length with him may make him feel singled-out or overwhelmed.
  • Staff should present a “united front” whenever possible, as open dissension among school staff or others who work closely with the child on a frequent basis may throw the child with PWS “off kilter” or precipitate a “meltdown.”

When dealing with behaviors triggered primarily to get something:
Keep in mind:

  • Use extreme caution in order to avert a power struggle. Students with PWS have a high need for some sense of personal control, and exert a great deal of effort to control everything they can about their environment, including the people in the environment. They often experience a constantly shifting set of needs and cravings along with a limited sense of personal control over their lives.
  • Avoid words, looks, or gestures, which might be perceived as confrontational; and instead try to redirect the student by suggesting an alternate activity or behavior.
  • Provide some choices, but limit the universe of choices to prevent overwhelming the student with too many options.
  • Do not overestimate the student’s ability to meet demands. Even for students with PWS who possess higher intellectual ability, social and emotional immaturity often prevents them from exhibiting their cognitive abilities.
  • Realize that the student is likely to have particular difficulty applying his abilitities and skills to solving problems or accomplishing desired goals in daily life. It would be unrealistic to expect that a child who functions well during brief tasks in controlled settings could function equally well with more complex tasks in less structured environments.
  • Similarly, recognize that a student with PWS who shows some promising language abilities for a brief period under highly controlled conditions (testing), may not be able to demonstrate those same skills in social settings, due in part to being unusually susceptible to interference.
  • Be cognizant that children with PWS have difficulty processing environmental stimuli, and their struggle to manage multiple inputs may deplete their finite supply of mental energy.
  • Break messages into very small chunks given slowly and sequentially to allow the student to absorb what is being said.
  • Accept that students with PWS have a high need for some sense of personal control.
  • Don’t assume that your messages are encoded, processed and understood or that the student’s needs have been effectively communicated.
  • Realize that the student may converse reasonably well on topics that are familiar, as they will have had a chance to rehearse specific vocabulary and organize their response. When the topic is unfamiliar and linguistically more complex and demanding, the student may become anxious and irritable. He may lack effective ways to organize, link and store novel information.

General recommendations for behavior management:

  • All adults who are working with a child who has PWS need to agree upon and use consistent preventive and reactive practices and common instructional and intervention language across all environments.
    • Prepare student at a time when he is available
    • Use “if… then”…approach.
    • Tell student the specific words or phrases adults will use to prompt him.
    • Guide him toward a venting area and/or ‘heavy bag’ (big punching bag) at the first sign that he is becoming overwhelmed.
  • Use fairly concrete teaching materials that are both interesting and at an age-appropriate level.
  • Adjust activities to the student’s attention span, and very gradually increase the duration of his active learning periods.
  • Model or demonstrate all desired behaviors. Use “think out loud” strategies to rehearse problem solving processes.
  • Help identify the student’s “islands of competence,” and use the student’s particular interests to tailor his learning program.

Potential for Medical Intervention

Although there is currently no cure for PWS, medical intervention can sometimes be helpful. Hormone therapy may help lessen some of the more obvious features of growth hormone deficiency and hypogonadism, and thereby reduce some of the social and emotional stressors with which each child must cope. If obstructive sleep apnea is diagnosed, then continuous positive airway pressure may help normalize oxygen saturation levels through the sleep cycle and thereby improve brain functioning, increase the capacity for learning, and decrease agitation during waking hours.

This is clearly a challenging situation for you and your school. It is also quite frustrating for the student and his family. Hopefully, with cooperation between all parties, a near-optimal set of strategies can be identified and implemented. We wish you well in your continued efforts on behalf of this child and his family.

John L. Digges, MD, PhD, MPH, FAAP
Behavioral Pediatrician

Marji Stivers, PhD
Clinical Psychologist


  • Bullying and Students with Special Needs

Dear Ask A Specialist Readers,

Did you know that children with disabilities are at an increased risk of being bullied?  Any number of factors:  physical vulnerability, social skill challenges, or intolerant environments, may increase the risk. Research suggests that some children with disabilities may even bully others as well.

On April 3, 2012 the U.S. Education Secretary, Arne Duncan, and Health and Human Services (HHS) Secretary, Kathleen Sebelius, unveiled the revitalized Stop Bullying website: www.stopbullying.gov.

The Stop Bullying Website:

“The site encourages children, parents, educators, and communities to take action to stop and prevent bullying, and provides a map with detailed information on state laws and policies, interactive webisodes and videos for young people, practical strategies for schools and communities to ensure safe environments, and suggestions on how parents can talk about this sensitive subject with their children. The site also explores the dangers of cyberbullying and steps youngsters and parents can take to fight it.”

Special Resources to Help Children with Disabilities:

This website also provides special resources to help children with disabilities who are bullied or who bully others. The website illustrates how IEPs or Section 504 plans can be useful in designing specialized approaches for preventing and responding to bullying.  Additionally, the website discusses how civil rights laws protect students with disabilities against harassment. That is, when bullying is directed at a child because of his or her disability and it creates a hostile environment at school, bullying behavior may cross the line and become “disability harassment.”  Under Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990, the school must address the harassment.

Act Now!

We know that bullying can negatively impact a student’s ability to learn and threaten their physical and emotional safety at school. We know, too, that the best way to address bullying is to stop it before it starts. The Stop Bullying website and the other websites listed in the Resources provide a number of actions school staff can take to make schools safer and prevent bullying.

We here at Ask A Specialist encourage you to do your part to help all students be safe at school.

Submitted by Ann England, Assistant Director, Diagnostic Center, Northern California on behalf of all the Ask A Specialist Contributors

RESOURCES:

  • Positive Behavioral Interventions and Supports
  • I have a student with significant behavior problems and she has to be physically restrain her so she won’t hurt me or herself. We don’t have a diagnosis and we don’t know where to go from here?

Question:

Sheyenna is displaying violent outbursts at school where she is hitting and attacking school personal. She curses, throws things, scratches, and destroys property. Usually when she is so out of control, I have to physically restrain her so she won’t hurt me, herself. Along with that she has severe anxiety attacks that seem to trigger the violent behavior. Her IQ (according to the school) is only 59 and although she is supposed to be in 4th grade, she is only doing 1-2 grade work. Sheyenna has a multitude of behaviors and symptoms but after years of counseling and even a stay at Loma Linda for 9 days, we do not have a solid diagnosis of what we are dealing with. Where do I go from here??


Answer:

Thank you for writing. The situation you describe is complicated, so two of us, Dru Saren, who writes about behavior for Ask-a-Specialist, and Marji Stivers, who writes about mental health, have written a joint response to your question.

First, a discussion of the behavioral issues raised in your letter:

Your description of Sheyenna’s behavior might be one of “severe” behavior, as it is defined by the Education Code. That would mean that a behavior support plan is called for, ASAP! However, people use language in their own way, and your “throwing things, scratching, and destroying property” may or may not be mine, when it comes to severity. Cursing itself would never rise to the level of a restraint. Throwing things, only if they were heavy or dangerous and well aimed. Destroying property would have to be property of worth and danger, such as a computer, not a book. And scratching? Well if it’s herself, does she draw blood and truly seem to be hurting herself? If it’s staff, why can’t they withdraw?

Restraint, as I’m sure you know, is a serious undertaking. It crosses the lines of student: staff conventions and therefore affects all individuals profoundly. For some students, it has an addictive quality; once restrained, they appear to seek it over and over again. That is one reason why your question of diagnosis is so important, because restraint for some mental health diagnoses is contraindicated (although not all students with challenging behavior have a mental health diagnosis). Staff can also suffer from the emotions engendered.

I’m not positive that Sheyenna has an IEP, though I would guess so since you know her assessed level of cognition. If not, the first step would be an assessment to see if she qualifies for special education and under what handicapping services. The resulting IEP should address any curricular issues that might be contributing to the behavior. For example, if the outbursts seem to be triggered by academic demands, then accommodations, adaptations, and modifications should be included. That is not to imply that her behavior problem can be solved by accommodations, but they need to be in place and could possibly mitigate the problem. The IEP and a Behavior Support Plan would also delineate the steps to take to both avoid an outburst, prevent its escalating, and what to do if it can’t be avoided.

Have you followed the steps to avoid a restraint?

  • Nonverbal directions to stop
  • Restating expectations
  • Verbal directions to stop
  • Redirection
  • Providing choices
  • Setting limits and consequences
  • Allowing the student to verbally vent
  • Isolating the individual and/or removing others
  • Calling for assistance so other staff are present

When reading that you restrain Sheyenna, I am hoping you have a written policy in place? Is an incident report (“Behavioral Emergency”) filed? Who participates in restraining Sheyenna and are these people properly and adequately trained? Are the parents notified within one school day? If she does not have a formal behavior plan, the administrator must schedule an IEP meeting within 2 days to review the emergency report, determine the necessity of a functional analysis assessment (FAA) and determine if an interim behavior plan is necessary.

The legal requirements for the use of restraint are:

  • Used as a last resort in an emergency when the student or others might be in imminent physical danger
  • Restraint may only last as long as it is needed to resolve the danger
  • Use the least amount of physical force possible
  • Only trained and qualified educational personnel may perform restraints
  • Parents should be included indecision about performing restraint
  • Restraints should be performed pursuant to the provisions in the behavior plan, 504 plan or IEP.

Some helpful behavioral resources are:
Johnson, S. Preventing physical restraints in schools: a guide for parents, educators and professionals www.edlawrc.com

http://www.pent.ca.gov/beh/rst/restraint08_DK.pdf

Next, a discussion of the mental health concerns suggested in your letter:

You mention in your letter that Sheyenna has “severe anxiety attacks” that seem to trigger her violent behavior. Anxiety is often associated with aggression. When someone feels threatened, fear and anxiety cause chemicals to be released in the body to prepare for a “fight or flight” reaction. Heart rate and breathing speed up, the field of awareness is narrowed to focus on the perceived threat, and higher-order thinking is switched off. (This is why students cannot learn well when they are experiencing severe anxiety.) The chemical changes triggered by threat prepare the body to run away faster or fight with maximal strength, which explains why children can exert extraordinary strength when they panic.

When a student’s violent behavior (fight) is triggered by anxiety, you want to put in place a system to support the student in leaving the situation (flight) instead, although not by running away. If you have not already done so, provide Sheyenna with a safe place to calm down and prompt her to go there as soon as you see signs that she is becoming agitated. A quiet, secluded corner with picture books and/or headphones for music may help her block out the anxiety-provoking stimuli, re-focus, and restore her equilibrium. At times when Sheyenna is calm, teach her emotional coping strategies, such as progressive muscle relaxation and slow, even breathing through counting. Have her practice often so these behaviors become well-rehearsed and automatic. Some regular practice in the “quiet space” may foster an association that will help her apply the skills in this location when she is distressed.

There are many reasons to avoid the use of restraint, whenever possible, with all children. It is particularly important in working with children whose challenging behaviors may be anxiety-based. The challenging behaviors are likely to worsen and mental health problems are likely to intensify when restraint is used.

  • Physical restraint can elicit panic, causing more chemicals to be released in the child’s body to prepare her for fight or flight. This chemical cascade will decrease rational thought and increase the child’s immediate physical energy and strength. These effects are likely to increase the intensity and duration of an anxiety-based outburst of aggression.
  • The adults involved in restraining a child are more likely to be perceived as threatening by that child. Because they are associated with the restraint process, they may elicit panic more easily during future interactions with the child.
  • Conversely, being held may help the child feel safer and lead to an increase in future acting out in order to be held, feel socially connected, or feel reassured that a strong adult is in charge. In this case, it is important to find a better way to reassure or connect with the child.
  • While childhood anxiety may have many causes, it sometimes results from traumatic stress associated with a child’s history of physical or sexual abuse by adults, in or outside the home. If this is the case (and abuse can be very hard to determine, and therefore very hard to completely rule out), then physical restraint by an adult is likely to re-traumatize the child each time it occurs and increase the severity of her emotional disorder.

I hope that the school psychologist is involved in development of the treatment plan and that Sheyenna has access to competent, thorough mental health assessment and treatment. Treating professionals should be involved in the planning of her school program.

Thank you very much for writing and good luck.

Dru and Marji


  • My son receives county mental health services under AB3632 and I heard it will be ending at the end of the school year. What if my son still needs counseling to cope with school and keep up with his class?

Question:

My fifth grader has been having trouble in school since second grade. Last year he was diagnosed with an anxiety disorder and finally got an IEP. He has been getting counseling once a week to help him learn ways of coping with his anxiety and increase his self-confidence. His mother and I feel that the counseling is helping him deal better with his frustration and fears about school work. His teacher told us that his classroom participation is gradually improving and that he is starting to complete more of his work.

The counselor he sees is from our county mental health department and we do not have to pay for therapy. It was all set up through part of the IEP process which the school district staff called “3632.” We just heard that all 3632 services will stop at the end of this school year due to a state funding problem here in California. Needless to say, we’re very concerned. What if my son still needs counseling to cope with school and keep up with his class? We don’t have insurance coverage for this and I’m not sure we can afford to pay for it every week.


Answer:

Thank you for your timely question. Many parents of students receiving services through AB 3632 in California are concerned about whether their children will continue to have access to the mental health services they need.

The good news

By federal law, under the Individuals With Disabilities Education Act, if an IEP team determines that a student needs mental health services to benefit from his or her educational program, then those services must be provided free of charge to the family.

What has changed?

Although the rights of special education students to receive the services they need to benefit from their educational programs is mandated by federal law, state regulations govern many aspects of service delivery, responsibility, and accountability. California regulations pertaining to mental health services for special education students have recently been revised. Implementation of the revisions has been postponed until the 2012-2013 school year in order to give districts time to plan and set up new procedures.

To understand the revision, some background information may be useful. Back in the 1970s, individualized special education programs, based on services determined through the IEP process, first became a federal mandate. School districts directly provided, or contracted for, all of the services designated in their students’ IEPs. In California, this process was modified by state regulation with the passage of AB 3632 (also known as 26.5) in 1984. School districts continued to be responsible for identifying students who might need mental health services to benefit from their educational programs. But under AB 3632, the district IEP team referred the students to the local county mental health department. The county was then responsible for assessing each student’s eligibility, determining appropriate mental health services, and providing those services. State funds were transferred from the special education budget to the mental health budget to cover the additional county staff needed to fulfill these duties.

The most recent change in regulations rescinds AB 3632, so that full responsibility for mental health assessment and services once again resides with the school districts. Funds for providing the mental health services are to be transferred back to the local SELPA.

How will this change affect services to students?

It is very hard to predict the various ways in which students may be affected by these shifts in responsibilities and funding. The ways in which the regulation is implemented is likely to vary considerably from one school district to the next. Some districts will probably continue their partnerships with county mental health departments, by using the mental health funds to contract for continued services. It is likely that some districts will use the funds to increase their staffing levels in order to directly provide mental health services to their students. Other districts may contract with a variety of qualified local agencies and professionals. Many districts may adopt a combination of these strategies.

In summary, if your son’s IEP team determines that he continues to need mental health services to benefit from his educational program, then by law, he will continue to receive services. However, depending on your school district, there may be some changes in the ways services are delivered, where, and by whom. All of us who are concerned about children’s mental health are hoping that there will be minimal disruption and that quality and coordination of services will be at or above the current levels.

I hope that your son can continue his counseling with minimal disruption, as long as he needs it to progress in school. He can gradually fade the support as he internalizes the emotional coping skills he is learning.