As summer wanes and children return to school, it is a natural time to reconsider the relationship of child psychiatry and the schools. For the past 25 years, I have consulted to the Gifford School, a therapeutic day school in Weston, Mass, as well as to the Brookline, Massachusetts, public schools.
I am writing for outpatient clinicians, about children for whom it is important to have contact between the school and the clinician. Of course, there are many children whose treatment does not merit school/clinician contact, and there are others for whom such contact might be helpful, but whose parents, for whatever reasons, refuse it.
The Role of Money Of all the factors that can cause tension between psychiatrists, schools, and parents, the most significant one tends to be money. By mandating in PL 94-142 (the 1975 law governing education of handicapped children, now called the Individuals with Disabilities Education Act, or IDEA) that the public school must provide education to all, regardless of disability, Congress essentially handed public schools an enormous expense.
A practitioner would be naive to approach an Individualized Education Program (IEP) meeting without an awareness that local budget constraints are a powerful and unspoken reality of the IEP process. To put it simply, some schools may not necessarily approve the educational plan that is best for the child, but rather offer only what’s needed to show a small amount of academic progress. I have seen this happen when a child is provided with an aide, for example, when he or she really needs (much more expensive) therapeutic school placement.
A related issue is that insurance companies do not reimburse us for time spent talking directly to teachers and administrators. Most of us just absorb the cost of this consultation, since it is sometimes vital to our patients’ well being. In my state, at least, an enlightened legislator is working on a bill to get insurance companies to cover this collateral time.
Clash of Professional Cultures As mental health practitioners, we uphold the importance of confidentiality. Without signed releases, we are unable to exchange any information with the school. Good schools, however, need to have very permeable boundaries. Teachers are a resource to one another, sharing observations of mutual students.
Children with behavioral problems may shuttle from the classroom to the vice-principal to the guidance counselor—it would be counter-productive for those individuals to keep their observations or ideas private. For an example, a child may reveal signs of abuse at home, being bullied at school, or self-harming thoughts or actions to a teacher he or she trusts, but not to other staff members.
In cases like these, schools need to have porous boundaries—allowing and encouraging the sharing of information between educators, guidance counselors, and administrators. When these kinds of concerns arise in schools, decisions need to be made about informing family or treaters or involving social service agencies.
The Psychiatrist as Part of a Team Child psychiatrists typically work in multidisciplinary teams. The psychiatrist focuses on medication management, while the therapist works with the child and collaborates with the family and school. But this role separation can leave psychiatrists vulnerable. If the therapist does not have time for school and parent meetings, or for communicating social information to the psychiatrist, we may end up prescribing without important feedback.
Even when we see parents, their reports about a child’s school life may be distorted in the context of a brief education visit. School information provided by parents is second-hand, and parental feelings about medication may affect their rendition of the school’s feedback. Clearly, everyone has feelings when it comes to the use of medication in children—teachers included—but I suggest personally reading any documentation the school has recorded about the child’s difficulties in order to evaluate the veracity of the parent’s version.
The Psychiatrist as Sole Practitioner If you do not work in a clinic situation, you need to have more direct involvement with the family and teachers. I recommend that you make time for first-hand classroom observation.
For a young child especially, an educational mismatch may account for behaviors that might explain school phobia, apparent attention deficit, mood swings, or a host of other problems.
Attend IEP meetings if possible. This will allow you to assess how attuned educators are to your patient’s learning disability and to what degree they are truly making the accommodations recommended in the IEP.
In some situations, you must take an active role in advising schools. In treating children with school phobia, for instance, clinicians should coach school personnel as to how to handle separation anxiety at school. While we may treat phobic anxiety with medication, we cannot neglect the behavioral reality of the parent-child dyad unhappily stuck at the school entry.
Children with pervasive developmental disorders often need our direct advocacy to make sure they get all the pieces of the treatment they need. If the mainstream class is not providing occupational therapy, social skills training, and academic supports, you may need to meet directly with teachers or principals to encourage a change in educational plan.
When children threaten themselves or others, we may be lulled into believing that an emergency room referral is necessary—and it often is. However, the psychiatrist is usually more able to handle such crises because of familiarity with a child and his or her family. True, we don’t have a crystal ball when it comes to predicting future behavior, yet it is fair for schools to ask us to determine which children merit hospital evaluation or placement in more restrictive settings than the general classroom, and which can be safely returned to school.
Tips for Effective Consultation Most often, contacts with schools are less urgent and more elective in nature. Over the years, in my clinic and private work with children, I have developed some practices to facilitate routine contacts. Because it is impractical to connect with multiple educators and/or administrators at a child’s school, I ask parents to nominate one point person they trust to be my contact. I then ask that person to organize school feedback from multiple sources to me.
While schools often use email quite productively for academic and behavioral feedback to parents, I am uncomfortable with email with schools because of its lack of confidentiality. I favor feedback via confidential voicemail or (often better) faxes to my office. When following a child’s medication progress I find it can be helpful to have rating scales faxed to me on a regular basis by the point person. These scales then become a part of the chart and enter into the conversation I have with parents when doing medication follow-up.
When a child has a learning disability, neuropsychological testing offers customized recommendations for school accommodations. At times when such tests are pending or will not be available for whatever reason, I have turned to other resources for help in considering school based accommodations and to think critically about what the special educators may be offering. Clinicians can find considerable online help in suggestions for school accommodations at www2.massgeneral.org/schoolpsychiatry, a website geared to help clinicians, parents, and educators improve this complicated collaboration.
While child psychiatrists draw upon many traditions in their efforts as helping professionals, the past decades have been dominated by the expansion of the biological treatment we have offered children—as well as the cautionary reevaluations of some of those therapies. Despite those important controversies, our role in offering psychiatric medication is unlikely to end.
The fall may be good times to remind ourselves of the power of the other roles that we may play that clearly have potency in the life of a child, those of advising and helping a child’s family and school. Children have no choice but to return to school when the summer ends. We can predict that over the ensuing months as the school year progresses youngsters will present to us with problems related to their lives at school. The children we treat will be rewarded over time for our efforts when we can, as allowed and appropriate, advise and collaborate with the educators with whom they share their school days.