CA Dept. of Education


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Mental Health Archive 2015-16


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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  • New Problems in Students with Multiple Diagnoses - Part 1


Dear Marji,

I’m a speech and language pathologist and I’m concerned about one of my 8th grade students.  Although he has multiple diagnoses and a long history of difficulties, he is fully included in general education classes. However supporting him in his program is a continuous challenge. It seems as though each time we get effective supports in place, a previously minor problem flares up or a new problem emerges. Then new diagnoses are considered and the team reviews priorities and figures out how to proceed. I like this student a great deal and admire his courage and spirit in persisting with school despite the increasing obstacles he faces. I would like some help in understanding his latest behavioral difficulty, either in the context of his current diagnoses or a potential new one.

Diagnoses to Date:
This student has long-term diagnoses of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). Symptoms of anxiety and depression as well as obsessive-compulsive behaviors have also been noted. A couple of years ago, he started having vocal and motor tics which increased to the point of interfering with his school functioning and led to an additional diagnosis of Tourette’s syndrome. The tics are very loud, sometimes disruptive, and quite embarrassing to the student, which seems to have increased his anxiety.

The Latest Challenge:
As if all that is happening to this student isn’t enough, there is an additional behavior   that plagues him this year: whenever he can, he attempts to get access to female  shoes. This actually began when he was very young, 2-3 years old, when he appeared drawn to women’s shoes, desiring to touch and remove them. This urge seemed to subside and the behavior seemed minor in 6th and 7th grade. Since the beginning of 8th grade, the urges have increased to a point that the student cannot control them. His team has decided to refer to this behavior as “perseverative,” given that it has not been diagnosed as “obsessive compulsive.”  

He started by dropping items to gain access to shoes and touch them. Recently this escalated to removing shoes, even when the “victims” told him “NO, STOP.” This urge and lack of control has required the student to be escorted during transitions and remain in a “safe” environment, e.g. no temptation or access to females or their shoes during lunch and other breaks. He comes to the special education room with the goal of gradually returning to monitored lunch and breaks with the general education students.

The student is very aware of being observed, appears anxious, and sometimes requests the adult to remain close. He has also been noted to continuously glance around to see whether he is being watched.  On two occasions when he thought no adult was watching he approached young girls and attempted to touch their shoes.  When asked following one incident whether he knew the girl and could describe what she looked like, he said that he did not know her, nor what she looked like, only what kind of shoes she had on. The student acknowledges that he has these urges frequently and thinks about whether he can risk doing something without getting caught. He says that he does not feel aroused by female shows. But he appeared confused when asked if he has urges during PE, in the locker room, stating “What, it’s all boys.” He is aware that this

behavior potentially could get him trouble with the police needing to be involved. This appears to heighten his anxiety; however it is an urge that he cannot control all the time.

Are there any diagnoses that might account for the behavior -- either the conditions he is already diagnosed with or potential additional diagnoses?  If so, are there any implications for intervention?

Thanks for any information you can provide.

Teacher Who Wants to Help

Answer (Part 1):

Dear Teacher Who Wants to Help,

Your care, concern, and respect for your student shines through in your letter. Your student is lucky to have you as his teacher and you are probably learning a great deal from one another.

Despite the many other challenges your student experiences, his persistent attempts to gain access to female shoes is an immediate priority. This behavior has escalated to the point that he requires increased supervision and behavioral restrictions, resulting in substantial loss of opportunities to practice independence and social interaction. In addition, his behavior makes others uncomfortable, further decreasing his chances of developing positive social relationships. It could end up being more stigmatizing than his Tourette’s and, as you mentioned, it could even lead to trouble with the police. In short, it limits his current opportunities to participate in school and may jeopardize future opportunities.

Your letter provides a nice description of your student’s problematic behavior as well as some relevant historical information.  Unfortunately, without further assessment data, it is impossible to identify the underlying psychological factors or most appropriate diagnosis.  As a starting point, I will briefly describe the three diagnostic categories that seem to fit the described behavior and merit further exploration. This will be followed by suggested next steps, including the type of information to focus on getting and potential strategies for getting it.

Potential Diagnostic Categories

Your student’s persistent attempts to gain access to female shoes may represent:

  • Perseverative thoughts and repetitive behaviors associated with a highly specialized and narrow focus of interest.

This interpretation of female shoe-seeking behavior is based on the assumption that it is associated with his autism spectrum disorder (ASD). This explanation is consistent with the long-standing nature of his fixation on female’s shoes. The all-encompassing interests of individuals with autism can gradually shift or wax and wane over time, but often persist over many years.

However, overall it appears unlikely that your student’s behavior is a manifestation of his autism. The repetitive play with objects that is generally associated with autism appears to supply a level of sensory stimulation that the individual finds comforting. The choice of objects seems to be completely asocial; level of interest in a particular object is based on the sensory properties of the object itself rather than on an association between the object and the people, or type of people, who have used or worn the object. For instance, shoes might be selected on the basis of smooth texture or opportunity to tie and untie with shoe laces, but not on the basis of the gender of the wearer.

  • A compulsion to engage repeatedly in a particular pattern of behaviors.

This would likely be associated with an obsessive-compulsive condition or disorder (OCD).

Students with obsessive-compulsive behaviors have unwanted, anxiety-producing thoughts that they cannot get rid of (obsessions). They sometimes find that completing a particular sequence of behavior results in an immediate reduction in anxiety and feel compelled to repeat these behavioral rituals (compulsions), especially when feeling anxious. Sometimes there is a clear relationship between the anxiety (e.g., fear of encountering germs) and the behavior (e.g., repetitive hand-washing) and sometimes there is no logical relationship.  Adults (and your middle school student, if this applies to him) know that their behaviors are irrational, but this does not lessen the compulsion to engage in them.

OCD very commonly co-occurs with attention-deficit/ hyperactivity disorder (ADHD) and Tourette’s syndrome (TS).  In fact, they are so commonly diagnosed in the same individual that a number of scientists are actively seeking to identify a common genetic or neurological factor.  Therefore, an OCD pattern of behavior would be highly consistent with your student’s current diagnostic profile.

  • A fetish (from “fetico,” meaning obsessive fascination), a term for an unusual object that has become the target of persistent sexual interest.

If your student’s behavior is associated with a shoe fetish, the goal of his behavior is to obtain opportunities to touch or handle objects that evoke pleasurable sexual feelings.

Among the substantial minority of males who report having fetishes, female feet and shoes are two of the most, if not the most, common objects of attraction. Having a fetish is considered a type of paraphilia, or atypical sexual interest, but is not necessarily a disorder. However, it can be considered a disorder when the behavior associated with the fetish causes significant distress to self or others or interferes with daily functioning, which may be the case for your student.

Your student’s repetitive attempts to touch, hold, or acquire females’ shoes could be viewed as either an obsessive-compulsive pattern of behavior or an expression of a shoe fetish.. However, the explanations generated by these diagnoses involve very different assumptions about the reasons for this pattern of behavior. Selection of the best explanation requires accurate identification the function of the behavior. In other words, what needs are getting met, or what needs are your student trying to get met, when he engages in the behavior? Understanding of the function, or reason for the behavior is the key to figuring out which, if either, of these diagnostic categories offers the “best fit.” Further, determination of the function of the behavior will help generate feasible intervention strategies regardless of whether there is a corresponding diagnosis.

Next month in Answer, Part 2 I will discuss strategies for selecting the best diagnostic category and potential interventions.

Best wishes,
Marji Stivers