Disruptive Behavior Disorders

Students who meet criteria for disruptive, impulse control, and conduct disorders generally present with a wide range of challenging behaviors that impede their ability to function appropriately at school and at home. Understanding the differential diagnosis and comorbid manifestations of these disorders—particularly the two most common disruptive disorders (i.e., oppositional defiant disorder and conduct disorder)—can assist school practitioners in addressing students’ behavior and socioemotional well-being in school. It is also important that school practitioners are knowledgeable about Individuals with Disabilities Education Act (IDEA) categories for which students exhibiting the symptoms of these disorders are most likely to qualify for school-based services. This chapter provides resources to assist schools and school-based practitioners in implementing universal screening, progress monitoring, and rapid assessment of students, as well as evidence-based psychosocial interventions to meet the needs of students with disruptive, impulse control, and conduct disorders.

Elimination Disorders

Elimination disorders are sometimes considered the ugly step-child in psychiatry. Nocturnal enuresis is the voiding of urine at night and is always involuntary. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) specifically mentions antipsychotic medications as a potential cause. Encopresis is the repeated elimination of feces into inappropriate places, whether voluntary or involuntary. All children with elimination problems should see a pediatrician to rule out medical/physical causes. The prevalence of enuresis has been found to be higher in large or crowded families or in families that practice co-sleeping. A multitiered system of support approach begins with good toilet training and addresses occasional accidents. Simple behavioral treatments can usually resolve the problems. A case example illustrates a typical case.

Specific Learning Disorder

Students with specific learning disorder (SLD) account for 35% of all students receiving special education services. In the DSM-5, SLD combines four previous diagnoses into one. The Individuals with Disabilities Education Act (IDEA) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) agree that children should be excluded from being diagnosed if the disorder is primarily due to environmental, cultural, or economic disadvantage. They differ on the DSM-5’s exclusion for the lack of proficiency in the language of instruction. Schools can screen for SLD using the testing or the dual-discrepancy model of response to intervention (RTI). Assessment requires a comprehensive evaluation by the school. Students with SLD often suffer from poor social skills and low self-esteem. Intervention may be titrated according to the student’s level of need using multitiered systems of support. Collaborating with teachers, parents, and community providers is especially important for these students. A case example illustrates how an ecological approach can help students grow and learn.

Introduction

Approximately 10–20% of students experience a mental health problem during their school-age years. The Every Student Succeeds Act (ESSA) assumes school-based mental health providers will serve these students in schools. The DSM-5 made five significant changes from previous editions. Enabling students with mental disorders to be eligible for school-based services requires familiarity with the assessment requirements of the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act. School counseling can be provided using a multitiered system of supports ranging from universal prevention to intensive intervention. The best way to serve students is to collaborate with teachers, parents, community providers, and even school administrators. Finally, students’ progress toward general education goals should be monitored regularly so that they can graduate on time, become employed, and be engaged citizens.

Trauma- and Stress-Related Disorders

The chapter outlines the prevalence of traumatic events in the lives of our nation’s children and adolescents and highlights populations that are particularly vulnerable to trauma exposure. The chapter outlines the clinical features of pediatric posttraumatic stress disorder (PTSD) and describes considerations for differential diagnosis. Common comorbid diagnoses are described, as are the short- and long-term academic consequences of trauma exposure. Screening tools for trauma exposure and PTSD are presented. The chapter provides an overview of the strategies and interventions used in schools to mitigate the impact of trauma on students and describes approaches to monitoring the impact of these efforts at the micro, macro, and mezzo levels. Resources for school staff supporting trauma exposed students are provided.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) and related disorders can be debilitating to children and adolescents. Childhood onset of OCD occurs in about 1–3% of all children. When childhood OCD symptoms are particularly sudden and/or suddenly more severe, clinicians should investigate if it is precipitated by infectious or immune problems. The most common comorbid diagnoses are anxiety disorders, followed by oppositional defiant disorder. The Child Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is the gold standard clinician-completed assessment. Intervention can be titrated using a multitiered system of supports framework. Collaborating with teachers, parents, and community providers is essential for these students. A case study is provided to illustrate chapter recommendations.

Anxiety Disorders

Anxiety disorders have the highest prevalence of any group of mental disorders. This chapter primarily focuses on three of these anxiety disorders: generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. These three anxiety disorders have shared characteristics, are often comorbid, can continue into adulthood, and are predictors of other adulthood anxiety disorders. In schools, where many children and adolescents spend large quantities of time, anxiety can hinder academic performance, inhibit social relationships, and impact other important areas of functioning. Anxiety disorders in children or adolescents should be assessed using tools with empirical support and should include information triangulated from several sources. Treatment should cater to the level of need, such as cognitive-behavior therapy with individuals or groups. Collaborating with teachers, parents, and other community members is important for addressing anxiety thoroughly. A case example portrays these aspects of anxiety disorders in school-age youth.

Early-Onset Schizophrenia

Early-onset schizophrenia (EOS) is a serious psychotic disorder that affects children as young as 12 years of age. Although EOS is typically diagnosed in the specialty mental health sector, increasing the mental health literacy of school personnel is a Tier 1 intervention that can help identify youth at high risk. Tier 2 intervention could include group psychoeducation for youth at high risk and their families. Mental health treatment of EOS occurs in acute, stabilization, and maintenance phases. Youth who are experiencing EOS likely will need accommodations in school. School mental health personnel should educate teachers about accommodations and help them prepare to identify and avoid distressing stimuli, allow alternative schoolwork and activities to avoid provoking delusions, and provide safety for de-escalation. Collaboration with parents and community providers also is critical for students with EOS. A case example illustrates multitiered supports for an adolescent from diagnosis to returning to core classes.

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is marked by problems with functioning or development that are related to symptoms of a persistent pattern of inattention and/or hyperactivity-impulsivity. It is the most common mental health problem in children, affecting as many as 1 in 20 children. It affects both boys and girls, but it is more predominant in boys. For males, prevalence rates are estimated to be three times that of females, 12.9% compared to 4.3%. Prevalence rates of ADHD in school-age children in the United States are estimated at 5% by the America Psychiatric Association. This chapter will focus on diagnosing and assessing ADHD from a differential diagnosis and comorbidity perspective. Evidenced-based ADHD interventions will be presented along with a discussion around the importance for school personnel to collaborate with the many other systems that impact children and youth with ADHD.

Self-Harm Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists both suicidal behavior disorder and nonsuicidal self-injury as conditions for further study. The essential feature of suicidal behavior disorder is that the individual has at least some intent to die. The essential feature of nonsuicidal self-harm is that the individual repeatedly inflicts superficial injuries to the body. Controversy continues to exist about whether the proposed disorders are part of a continuum of self-harm or distinct categories. Suicidal behavior is growing fastest in pre- and early adolescent girls. Nonsuicidal self-injury should be distinguished from stereotypic self-injury. Screeners can help to identify students who need a thorough assessment. Full assessments should utilize a crisis team. Recommendations are made for each tier using a multitiered system of supports framework. A case example illustrates school-based intervention for nonsuicidal self-injury.