Wednesday, February 13, 2013

Mental Health Services and School Psychologists



According to the U.S. Surgeon General, over the course of a year, approximately 20% of children and adolescents in the U.S. experience signs and symptoms of a mental health problem and 5% experience “extreme functional impairment.” Although more than 2 million adolescents aged 12 to 17 suffered a major depressive episode in the past year, nearly 60% of them did not receive treatment. Statistics also suggest that the dropout rate for students with severe emotional and behavioral needs is approximately twice that of other students. 

Most children with mental health problems receive no services and of those who do, 70 to 80% receive them from school-based providers. School psychologists are among the school-based personnel (e.g., guidance counselors, school social workers) who are typically called upon to provide mental health services. In order for school psychologists to be effective mental health service providers, they must be competent to fulfill that role and function. This article discusses education and training issues, and related ethical and professional practice issues associated with school psychologists’ role in providing mental health services in the schools.
 Role and Function of School Psychologists
Surveys consistently indicate that school psychologists spend a majority of their time in assessment activities rather than delivering direct mental health services (e.g., counseling) to students. This includes determining special education eligibility and working with youth within the context of special education. Indeed, the majority of school psychologists report spending less than 10% of their time per week providing evidence-based mental health services to children and adolescents. Despite the limited amount of time devoted to mental health service delivery, school psychologists are increasingly being called on to serve in this role.  Moreover, school psychologists themselves report wanting to spend more time doing activities such as counseling and direct intervention, further supporting the profession’s desire to serve in the mental health service provider role. However, role expansion may prove to be problematic due to training issues and lack of administrative support.
 Training and Preparation
Research suggests that training in the diagnosis and treatment of mental disorders and counseling are determinates of the provision of mental health services by school psychologists. According to National Association of School Psychologists (NASP), the term “child psychologist” refers to doctoral-level clinical psychologists who specialize in children. “School psychologist” specifically refers to professionals who bridge psychology and education to address school related issues, including those that concern children, teachers, parents and families, as well as school organizations. School psychologists' training includes study in education and special education, but compared to clinical psychology, there is less emphasis on psychopathology and counseling. The majority of states require the completion of a 60 graduate semester master’s or specialist-level program in school psychology, including a 1200-hour internship, along with passing a Teacher Certification Test, which has a specialty component for school psychology. In contrast, a doctoral degree (e.g., PhD) generally requires about 5 years of full-time graduate study, culminating in a dissertation based on original research. Doctoral programs in child clinical-school psychology usually include further training and coursework and preparation in child and adolescent psychopathology, behavioral and child therapy, pediatric pharmacology, neuropsychology, advanced research, and a clinical practicum.
Ethical Considerations
Ethical issues are especially important in this discussion. School psychologists must be familiar with the ethical codes that apply to their specialization, as well as to psychology in general. For example, school psychologists must practice within the boundaries of their experience and training. Professional competency standards require school psychologists to recognize the strengths and limitations of their training and experience, and only practice in areas for which they are "qualified." In fact, the issue of practitioner competence is paramount in the ethics codes of the American Psychological Association (APA), American Counseling Association (ACA), and National Association of School Psychologists (NASP). The parameters of competence involve (a) recognizing one's professional limitations and needs, (b) understanding one's professional strengths, (c) confining consultation practice to one's competence, (d) knowing when to decline work and when to refer to other professionals, (e) ensuring that recommended interventions have an empirical basis, and (f) maintaining a high level of professionalism. Practitioners should seek continuing education and training in areas in which they lack competence and experience and refer to colleagues with the requisite experience and/or community resources.
 Implications
While the domains of professional school psychology practice include competencies in "prevention, wellness promotion, and crisis intervention," most school-based practitioners have not received intensive training in child and adolescent psychopathology, counseling and therapeutic intervention. Nor are most school psychologists licensed in another mental health specialty. Consequently, it is especially important for administrators, teachers, and parents to understand the limitations and parameters of school psychology practice and not assume that school psychologists possesses the clinical training to assess and intervene with complex childhood disorders. Schools often do not draw a distinction made between the specialist and the doctoral level school psychologist. Distinctions may not be critical when school psychologists are performing psychoeducational assessment services, as both sub-doctoral and doctoral level school psychologists receive comparable preparation for these important services. However, the academic and professional preparation of doctoral level school psychologists typically emphasizes clinical issues important to children's mental health, including methods for working with children and youth, their parents and teachers. In fact, research suggests that school psychologists with a specialist degree provide fewer mental health services than individuals with doctorates.
Recommendations
The educational setting is the most likely setting for students to receive mental health services. Unfortunately, a majority of children and youth who are in need of mental health services do not actually receive them.  If psychological services are to be expanded in schools to include a major focus on mental health services, school psychologists must be trained as broadly as possible, so that they are capable of working in different settings and prepared to address a range of issues.  In this regard, changes must be made in the graduate-level curriculum of school psychology programs. For example, graduate training programs should provide additional preparation in evidence based mental health services, including individual and group counseling, to ensure school psychologists have the tools they need to help students be successful. Training programs also need to provide practice experiences in the application of evidence-based therapeutic interventions, with a practicum supervised by school psychologists who are competent in the application of these services. A viable service model may call for subdoctoral school psychologists to assume leadership for continuing to provide psychoeducational assessment services for special education and for doctoral level school psychologists to assume leadership for initiatives aimed at promoting children's mental health. While students in nondoctoral programs may receive a basic introduction to mental health services, they will likely need to pursue further postgraduate training and continuing education/professional development in mental health services. Simply stated, school psychologists cannot be expected to provide mental health services without adequate, appropriate training.
Perfect, M. M., & Morris, R. J. (2011). Delivering school-based mental health services by school psychologists: Education, training, and ethical issues. Psychology in the Schools, 48, 1049–1063. doi: 10.1002/pits.20612

Lee A. Wilkinson, PhD, NCSP,CCBT is a nationally certified school psychologist, licensed school psychologist and certified cognitive-behavioral therapist. He is also a university educator and serves on the school psychology faculty at Nova Southeastern University. His research and professional writing has focused primarily on behavioral consultation and therapy, and children and adults with autism spectrum disorders. He has published widely on these topics, both in the US and internationally. Dr. Wilkinson is the author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also the editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHis latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Sunday, February 10, 2013

Early Detection Critical for Autism



It is well established that early intervention is a critical determinant in the course and outcome of autism spectrum disorders (ASD). Nevertheless, it is estimated that the US is facing $90 billion annually in costs related to autism. Research suggests that costs can be reduced by 2/3 with early diagnosis and treatment/intervention. The signs and symptoms of autism do not generally appear suddenly, but rather develop gradually during the first three years of life. The earlier the child is identified and intensive intervention can begin, the better the outcomes tend to be for children with ASD. In fact, numerous studies have described the benefits of early identification and intervention for children with developmental disabilities and, particularly, for children on the autistic spectrum. There is strong empirical support for the use of intensive behavioral programs for young children with ASD. In addition to increasing cognitive, linguistic, social, and self-help skills, early intervention helps to minimize the potential for secondary behavioral and emotional problems (e.g., anxiety, depression). Because most children with ASD are educated in public school settings, early identification and intervention also help to insure the implementation of appropriate and effective teaching methods to address the core social-communication deficits of ASD. While the components of intervention programs might vary, it is generally agreed that program intensity combined with early identification can lead to substantial improvement in child functioning.
At present, early intensive behavioral intervention (EIBI) is considered the central feature of intervention programming for children with autism. EIBI programs are among the most and best researched of the psychoeducational interventions. Several research publications and meta-analysis indicate that early intensive behavioral intervention (EIBI) may improve the quality of life and level of functioning for children with autism spectrum disorders (ASD). EIBI programs are based on applied behavior analysis (ABA), a behavioral approach that is well supported in the research literature.  Although there is general professional agreement that EIBI is an effective treatment, on average, for children with autism, we should be mindful that it does not produce significant changes in all areas of children’s functioning or result in similar gains for all children. Moreover, EIBI may not be appropriate for all children. Because no two children are alike, no one program exists that will meet the needs of every child with autism. 
There are no interventions or treatments that can cure autism, and there are very few which have been scientifically shown to produce significant, long-term benefits. At the present time, the most effective treatment is a comprehensive and intensive program consisting of educational interventions, developmental therapies, and behavior management with a focus on reducing symptom severity and improving the development course of the child. Unfortunately, intervention research cannot predict, at the present time, which particular intervention approach works best with which children. No single approach, intervention strategy, or treatment is effective for all children with ASD, and not all children will receive the same level of benefit. Generally, it is best to integrate scientifically validated approaches according to a child’s unique needs and abilities.
Despite the increased awareness and prevalence of ASD and the benefits of early intervention, studies continue to indicate a delay in identification and acquisition of services. Because many children are not identified until well after five years of age, future efforts should place an emphasis on recognition and diagnosis among school-aged children, not just among young children. Accurate differential identification and provision for services are critical since a high proportion of children may be overlooked, misdiagnosed with another psychiatric condition, or present with comorbid psychiatric disorders such as depression and anxiety.
The following resources provide important information about early identification and intervention. 
American Academy of Pediatrics. Understanding Autism Spectrum Disorders [pamphlet]. Elk Grove Village, IL: American Academy of Pediatrics; 2005. http://www.pediatrics.org
Autism Society of America  http://www.autism-society.org
Best Practice Autism  http://bestpracticeautism.com
National Autism Center  http://www.nationalautismcenter.org/
National Institute of Child Health and Human Development Autism Site
National Professional Development Center on Autism Spectrum Disorders
Organization for Autism Research
Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers.














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