School Psychiatrists at Work
(Names have been changed to protect privacy)
Mr. Jones reports that 9-year-old Spencer, a previously successful student, is no longer paying attention as consistently in his classroom. At times, Spencer appears to be looking off into space and does not answer questions when asked to participate. At other times, he appears attentive, but is no longer functioning well. Mr. Jones has already spoken with the child’s parents who have taken the child the pediatrician. Attention-deficit Hyperactivity Disorder was diagnosed, and a stimulant medication was prescribed, with little improvement.
Consulting Psychiatrist’s Response: A child with a track record of academic success is unlikely to develop ADHD at the age of 9. Psychiatric observation of Spencer corroborated the inattentiveness noted by Mr. Jones, the quality of which resembled staring spells seen with a type of epilepsy. The consulting psychiatrist spoke with the pediatrician to facilitate referral to a neurologist for an electroencephalograph (EEG), and prescription of an anti-seizure medication. Spencer’s attention and academic performance improved.
Belinda is a 14-year-old below-average student whose behaviors have begun to worsen in the past couple of years, consisting of swearing, storming out of classrooms, and knocking over desks. She has been suspended a few times. Because Belinda interacts minimally with other students, except when provoked, school teachers believe she is anxious around others, and recommend psychiatric treatment in discussions with her parents. Parents say her behavior is fine a home, and that the classroom teachers don’t know how to handle her. They request an evaluation. The evaluation does not indicate a need for further services, other than counseling. Parents reject the Individualized Educational Plan (IEP).
Consulting Psychiatrist’s Response: Further discussions with parents indicate that, although there are no outward behavioral problems at home, Belinda is withdrawn, dour, and appears depressed, as were both parents during their adolescence. Parents’ concerns about their own psychiatric treatment are elicited and discussed, and Belinda begins counseling and medication, with improvement noted in her behavior and interactions with staff and peers at school.
Oliver is a 7-year-old boy who hates to do work, even though the work is easy for him, and has stopped responding to a carefully-crafted reward system implemented by his compassionate but firm classroom teacher. He now only works when the guidance counselor comes into the classroom to support and coax him. His teacher, with three decades of experience, appreciates the guidance counselor’s help, but she resents the much younger colleague’s inexplicable ability to motivate Oliver. Perhaps out of this frustration, she alternates between calling the guidance counselor excessively, or not calling her at all and allowing Oliver’s obstinacy to escalate to require in-house suspensions.
Consulting Psychiatrist’s Response: Oliver has learned that if he resists doing work, he will be rewarded by the presence of his warm, encouraging guidance counselor. This relationship is more important to him than the rewards of increased computer time or small prizes that would reward independent work. Three factors help explain the dynamics of the interactions:
- Oliver’s parents, separated for 3 years, have reunited recently, and Oliver now spends less time with his mother. He craves the undivided attention she lavished on him during father’s absence.
- His classroom teacher must manage the entire classroom, of which Oliver is only one student. Despite decades of teaching and classroom management experience, increasing curricular demands burden her, and she worries that she is no longer keeping up with the latest developments and techniques. She feels threatened by a younger peer’s apparent success with a challenging student.
- The guidance counselor, a competent, though junior professional, is eager to demonstrate her ability to succeed with students. She spends so much time building her relationship with Oliver, with whom she is friendly and affectionate, that he now does schoolwork only for her, reinforcing for her the time she spends with him. It is fortunate that he has not yet balked at her encouragement, because she would likely have difficulty setting firm limits.
The behavioral plan is re-written such that time spent with the guidance counselor is the reward for work completed, rather than a means of encouragement. Teacher and guidance counselor are coached to work together, each playing an important part in the plan’s successful implementation. In collaboration with parents, time spent with mother is also included in the plan as a special reward for good effort in school.