The Behavioral/Clinical Spectrum
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In order for educators to effectively target their interventions to have maximum success, it is important for them to recognize where a student is on the behavioral/clinical spectrum, and to intervene accordingly.
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Behavioral problems are common in the student population, and, for some students, these behaviors are severe and chronic. Clinical disorders such as Depression, ADHD, Autism, Anxiety disorders, etc. are also common, and they may have behavioral manifestations. On one end of the spectrum of problematic behaviors is the planned and volitional misbehavior that is executed by a student who has no evidence of any clinical disorder. On the other end are behaviors that are direct manifestations of psychiatric disorders (e.g., the agitation of mania) that are not under the student’s control, and that are not likely to respond to traditional “behavioral” interventions. In order for educators to effectively target their interventions to have maximum success, it is important for them to recognize where a student is on the behavioral/clinical spectrum, and to intervene accordingly.
The difficulty of identifying appropriate and effective interventions is confounded by a lack of communication and collaboration across the providers of student services and supports, especially between mental health and behavioral practitioners.
Behavioral practitioners use many terms to describe behavior profiles and problems. The word, “behavior” refers to one’s responses and the ways that one acts or conducts oneself. The term, “behavioral,” however, when used in the formal context of analysis of behavior change, refers to the scientific approach dealing with assessment and intervention of behaviors. An assessment of a student’s behavior hypothesizes the function of the behavior (why the behavior occurs) in an effort to identify appropriate interventions. This practice, based on operant conditioning, requires an orderly correlation between the student and the environment. Such an approach to behavioral assessment renders little opportunity to address the effects of emotions and mood on behaviors. Although behavioral practitioners understand that emotions may play a role in one’s behavior, they focus their attention on measurable, quantifiable behaviors, rather than on internal emotional states that are difficult to define or measure.
Conversely, mental health professionals refer to a “clinical disorder” as a specific diagnostic category of abnormal thinking, emotion and/or behavior that is beyond the realm of normal functioning that causes significant dysfunction for the affected individual. Thus, a people suffering from Clinical Depression have a constellation of symptoms (disturbance of sleep, appetite, energy, concentration, self-worth, mood, etc.), that significantly interfere with their ability to function. The diagnosis of clinical disorders is partially based on internal emotional and cognitive states, which are inferred from direct observation, patient self-report, and corroborative information.
The term “emotion” refers to feelings (e.g., anger, joy, fear, etc.) that are distinguished from cognitive states of mind. Both mental health and behavior practitioners understand that emotions may manifest in physiological changes (e.g., increased heartbeat, respiration, crying, etc.) and may accompany a student’s misbehaviors. However, while emotional states frequently accompany behaviors, the existence of emotions would not be considered “clinical” unless the emotions were a manifestation of a psychiatric disorder.
Although both medical and mental health professionals make clinical diagnoses, medical diagnoses often have correlates of physical signs and symptoms, and abnormalities of laboratory tests, X-rays, EKGs, etc. Unfortunately, although there is clear evidence of the biological basis of many psychiatric disorders, medical tests have not yet been developed with adequate sensitivity and specificity to confirm psychiatric diagnoses. Mental health disorders are often invisible to others, despite the suffering and dysfunction that they can cause those who are afflicted with them.
It may be difficult for educators to recognize how these “invisible disorders” are influencing students’ behaviors, and how an understanding of this process can lead to more effective educational interventions. This can lead to an over reliance on behavioral approaches, even for students whose mental health disorders are severe and are the direct cause of the problem behaviors. If educators appreciate that behaviors may manifest from causes that span a spectrum, then successful interventions can be tailored to each student’s specific situation.
The Spectrum
The Behavioral/Clinical Spectrum is a conceptual model that assists this process. It has five categories that can be visualized along a continuum as:
Behavioral------------------Predominately--------------------Mixed--------------------Predominately--------------------Clinical
Behavioral Clinical
These categories are useful in identifying the nature of a student’s behavioral difficulties, and in identifying interventions that are most likely to be successful.
The Ends of the Spectrum:
In general, students who have behavioral difficulties would not typically be placed at either extreme end (“purely behavioral” or “purely clinical”) of the spectrum, but such situations do occur. On one end of the spectrum is:
“Behavioral”
This student is an individual whose behaviors are clearly functional, and are not related to any mental health clinical disorder. The behaviors are planned, volitional, and serve a function such as gaining tangibles, seeking attention, avoiding work, etc. Medication interventions are not effective, as medications are to be used for disorders of attention, mood, thinking, anxiety, etc. that are not present in this individual. Feelings-oriented psychotherapy is also ineffective. Behavioral interventions are the interventions of choice, and these students require “a narrow path with high walls” of contingency.
Example:
Jason is a 14-year-old student in the ninth grade. He has a history of stealing, lying, destruction of property, fire setting and aggression towards others. The behavioral profile is pervasive, dating back to early childhood. He was raised in a home by parents who were antisocial and who encouraged him to engage in antisocial behaviors such as shoplifting. Jason has a probation officer, and, under the threat of incarceration, he has demonstrated the ability to refrain from disruptive behaviors.
The other end of the spectrum is:
“Clinical”
This is an individual who has no history of behavioral problems prior to the onset of a mental health disorder. Psychiatric symptoms such as the delusions and hallucinations of Schizophrenia or the agitation of the manic phase of Bipolar Mood Disorder are severe and not under the student’s control. The symptoms are the direct cause of the behavior, and, as such, there is no “function” to the behavior any more than there is a “function” of the irritable behavior of a diabetic whose blood sugar is low. Behavioral interventions are not effective. Appropriate clinical treatment can result in the amelioration of not only the psychiatric symptoms but the accompanying behaviors as well.
Example:
Mark is an 18-year-old high school senior who was recently diagnosed with Schizophrenia. He had no history of behavioral difficulties, and had done well academically through his tenth grade year. In the last year, he has had deterioration in his grades, social isolation, unusual interpersonal interactions and poor personal hygiene. His mental state deteriorated to the point that he was experiencing auditory hallucinations and paranoid delusions. He was hospitalized after threatening a school bus driver who he believed was kidnapping him. He demonstrated improvement with medication treatment, but has had poor compliance. When he doesn't take medication, he becomes hostile, paranoid and agitated. Behavioral interventions have not improved the behavior, and his parents have gone to court to file commitment papers for hospitalization.
The Intermediate Parts of the Spectrum:
The majority of students will fall within this part of the Spectrum. It is important for school personnel to recognize the complexity of the mixture of behavioral and clinical contributors to behavior, and to respond accordingly.
“Predominately Behavioral”
This is an individual who has a mental health disorder, but whose behaviors are, for the most part, not due to the disorder. This student may use the disorder as an excuse for inappropriate behaviors, saying that he or she cannot control them, e.g., “Because I have ADHD”. In fact, the student’s behaviors tend to be planned and volitional, and the student is well aware of the impact of the behavior on others. For some students, the behavioral problems predated the onset of mental health problems.
Example:
Jerrod is a 10-year-old fifth grader who has a long history of behavioral problems in the home, school and the community. He recognizes the consequences of his behaviors, but believes that they are justified “if I don’t get caught”. He has been on various medications for ADHD that have improved his on-task behavior when he is interested in a subject, but behavior problems have continued. When asked, for example, why he hit a child on the playground that day, he said, “I decided when I was walking to school this morning that he needed to be taught a lesson.” Essentially, given his antisocial tendencies, medication for ADHD will not reduce behavioral problems, but will, instead, “help him plan his crimes better.”
The predominately behavioral student primarily needs a behavioral approach to address behavioral problems. Searching for the ideal medication in order to extinguish behavioral problems will be in vain, given that the behavioral problems do not directly stem from the mental health disorder. This is not to say that the mental health disorder should not be treated, but rather that professionals, both in education and in mental health, should avoid the misconception that the disorder is the primary causal factor in his behavioral difficulties.
“Predominately Clinical”
These individuals have some component of behavioral contributors to their acting out, in that there are some identifiable antecedents to behavioral problems, and some degree of function to their behaviors. However, these are overshadowed by the presence of a clinical disorder that is a far greater contributor to the behavioral problems. In some students, mild oppositionality or conduct disordered behavior was present prior to the onset of the mental health disorder, and the symptoms of the disorder greatly magnified the behavioral difficulties.
For these students, clinical treatment is the predominate component leading to behavioral improvement. Behavioral principles should be applied as needed, but by themselves, they are not likely to ameliorate dysfunctional behaviors that stem directly from the core symptoms of the student’s mental health disorder.
Example:
Kim is a 16-year old 11th grade student who recently began having symptoms of Bipolar Mood Disorder. She has started taking mood stabilizing medication, but symptoms of mania are not fully under control. She demonstrates rapid shifts in mood, anger outbursts, agitation, impulsivity and irritability, and has been verbally intrusive. Prior to the onset of her illness, she had demonstrated some teenage rebellious behavior, with mild oppositionality towards her parents and she had violated curfew on two occasions. Overall, she had been a good student. Behavioral interventions need to focus on recognizing the source of her behavioral difficulties, and should provide her with enough “safe space” to be able to avoid situations where these behaviors could be problematic. As her medication response improves, her behavioral problems would be expected to improve as well.
“Mixed”
Students in the “mixed” category pose significant challenges to both mental health clinicians and to educators. They have both major psychiatric disorders and significant behavioral contributors to their behavioral difficulties.
It is not uncommon for students in the “mixed” category to be placed in self-contained school settings for students who have severe behavioral problems (e.g., “Emotionally Disturbed/ED,” “Seriously Emotionally Disturbed/SED” or “Emotionally or Behaviorally Disturbed/EBD” special education programs). Often, their mental health disorders such as ADHD, Depression, Bipolar Mood Disorder, Post-Traumatic Stress Disorder, etc. go unrecognized and untreated, even if they had been diagnosed in the past. In fact, the majority of students seen at the time of a special education evaluation for the Emotional/Behavioral category may fit this “mixed” category. This population often has poor outcomes in education, employment, rates of arrest, etc. They pose a challenge to mental health professionals who may tend to focus on the mental health disorders without fully recognizing the impact that the behavioral contributors have on the student’s behavior. Education professionals, on the other hand, may not recognize the underlying contributions of these students’ mental heath disorders, and may become frustrated when behavioral approaches are used with little or no success. These students are often viewed by school staff as “Behavioral,” with minimal understanding of the role of clinical contributors to the problem. Many of these students are not being treated for their mental health disorder(s), or, may be inappropriately treated or misdiagnosed by medical or mental health professionals. School professionals are often frustrated by the challenges faced in addressing these students’ clinical disorders, given that schools are educational and not clinical settings.
This “mixed” category population poses significant challenges to all professionals, and successful intervention requires collaboration, communication and shared perspectives from professionals in all fields of services and supports: Education, Corrections, Mental Health, Medical and Social Services.
Example:
Nick is a 14-year old ninth grade student in a self-contained (Federal Setting 4) Special Education program. He has a multitude of disabilities, and a long history of delinquent behaviors. His mother used drugs and alcohol during her pregnancy with him, and neglected him during his infancy. After living with his mother until the age of six, when she was arrested for selling drugs, he was placed in multiple foster homes, and was sexually abused in one home by a foster brother. He has a full scale I.Q. of 78, and has been diagnosed with Fetal Alcohol Spectrum Disorder, Post Traumatic Stress Disorder, ADHD, Reactive Attachment Disorder and Mood Disorder Not Otherwise Specified. Antisocial behaviors date back to the age of three, and have included fire setting, cruelty to animals, stealing, lying, aggression and destruction of property. He has benefited from medication for his ADHD and mood disorder, but continues to engage in significant delinquent behaviors. He has a County Social Services mental health case manager and a Juvenile Corrections probation officer.
Nick will require a great deal of services from multiple systems for many years. He is not an “either-or” student, but rather “both-and”, in terms of the clinical and behavioral contributors and the combination of clinical and behavioral solutions to his acting out behaviors.
The Importance of the Behavioral/Clinical Spectrum Concept
Understanding where an individual falls on the Behavioral/Clinical spectrum is an important first step in designing interventions that are most likely to be effective.
The Spectrum can also contribute to a common understanding among the professionals providing services and support, especially if they are viewing the student from vastly different perspectives. For example, if a school social worker sees a student as being “Clinical” or “Predominately Clinical”, whereas the teacher sees the student as being “Behavioral” or Predominately Behavioral,” the recognition of this discrepancy can be the first step in understanding why interventions have not been successful to date, and in creating more effective accommodations and modifications for the student.
While clinical disorders may tend to be “invisible”, behaviors are obvious and observable. As such, there can be a tendency to overemphasize behavioral versus clinical contributions to the spectrum. This problem can be magnified if school staff feel constrained in addressing mental health issues, if there is pressure to not identify mental health problems due to potential payer of last resort school concerns, or if there is a pro-behavioral, anti-medical model bias within the school environment. Given the substantial research indicating the very poor outcomes of special education for emotionally disturbed individuals, and the fact that poor outcomes are often associated with the lack of attention to students’ mental health, it is important to encourage an emphasis on the continuum of student support needs that includes mental health components.
Identifying the Correct Category
The Spectrum provides a perspective that allows educational staff the opportunity to broaden their conceptions about students’ behavioral difficulties and of the interventions that will most likely be successful. As school professionals are not clinicians, they may feel uncomfortable assigning a category to a student, especially given the fact that many students who have mental health disorders have not been diagnosed, and that many who have, have been incorrectly diagnosed. The Spectrum should be viewed not as a diagnostic tool but as a working hypothesis. It is useful to consider, especially when educational interventions have not been successful for students who have been diagnosed with, or have evidence of, mental health disorders.
Some guidelines that can be helpful in the process of assigning a category are:
For the clinical end of the spectrum:
Advantages of Using the Spectrum Concept
The difficulty of identifying appropriate and effective interventions is confounded by a lack of communication and collaboration across the providers of student services and supports, especially between mental health and behavioral practitioners.
Behavioral practitioners use many terms to describe behavior profiles and problems. The word, “behavior” refers to one’s responses and the ways that one acts or conducts oneself. The term, “behavioral,” however, when used in the formal context of analysis of behavior change, refers to the scientific approach dealing with assessment and intervention of behaviors. An assessment of a student’s behavior hypothesizes the function of the behavior (why the behavior occurs) in an effort to identify appropriate interventions. This practice, based on operant conditioning, requires an orderly correlation between the student and the environment. Such an approach to behavioral assessment renders little opportunity to address the effects of emotions and mood on behaviors. Although behavioral practitioners understand that emotions may play a role in one’s behavior, they focus their attention on measurable, quantifiable behaviors, rather than on internal emotional states that are difficult to define or measure.
Conversely, mental health professionals refer to a “clinical disorder” as a specific diagnostic category of abnormal thinking, emotion and/or behavior that is beyond the realm of normal functioning that causes significant dysfunction for the affected individual. Thus, a people suffering from Clinical Depression have a constellation of symptoms (disturbance of sleep, appetite, energy, concentration, self-worth, mood, etc.), that significantly interfere with their ability to function. The diagnosis of clinical disorders is partially based on internal emotional and cognitive states, which are inferred from direct observation, patient self-report, and corroborative information.
The term “emotion” refers to feelings (e.g., anger, joy, fear, etc.) that are distinguished from cognitive states of mind. Both mental health and behavior practitioners understand that emotions may manifest in physiological changes (e.g., increased heartbeat, respiration, crying, etc.) and may accompany a student’s misbehaviors. However, while emotional states frequently accompany behaviors, the existence of emotions would not be considered “clinical” unless the emotions were a manifestation of a psychiatric disorder.
Although both medical and mental health professionals make clinical diagnoses, medical diagnoses often have correlates of physical signs and symptoms, and abnormalities of laboratory tests, X-rays, EKGs, etc. Unfortunately, although there is clear evidence of the biological basis of many psychiatric disorders, medical tests have not yet been developed with adequate sensitivity and specificity to confirm psychiatric diagnoses. Mental health disorders are often invisible to others, despite the suffering and dysfunction that they can cause those who are afflicted with them.
It may be difficult for educators to recognize how these “invisible disorders” are influencing students’ behaviors, and how an understanding of this process can lead to more effective educational interventions. This can lead to an over reliance on behavioral approaches, even for students whose mental health disorders are severe and are the direct cause of the problem behaviors. If educators appreciate that behaviors may manifest from causes that span a spectrum, then successful interventions can be tailored to each student’s specific situation.
The Spectrum
The Behavioral/Clinical Spectrum is a conceptual model that assists this process. It has five categories that can be visualized along a continuum as:
Behavioral------------------Predominately--------------------Mixed--------------------Predominately--------------------Clinical
Behavioral Clinical
These categories are useful in identifying the nature of a student’s behavioral difficulties, and in identifying interventions that are most likely to be successful.
The Ends of the Spectrum:
In general, students who have behavioral difficulties would not typically be placed at either extreme end (“purely behavioral” or “purely clinical”) of the spectrum, but such situations do occur. On one end of the spectrum is:
“Behavioral”
This student is an individual whose behaviors are clearly functional, and are not related to any mental health clinical disorder. The behaviors are planned, volitional, and serve a function such as gaining tangibles, seeking attention, avoiding work, etc. Medication interventions are not effective, as medications are to be used for disorders of attention, mood, thinking, anxiety, etc. that are not present in this individual. Feelings-oriented psychotherapy is also ineffective. Behavioral interventions are the interventions of choice, and these students require “a narrow path with high walls” of contingency.
Example:
Jason is a 14-year-old student in the ninth grade. He has a history of stealing, lying, destruction of property, fire setting and aggression towards others. The behavioral profile is pervasive, dating back to early childhood. He was raised in a home by parents who were antisocial and who encouraged him to engage in antisocial behaviors such as shoplifting. Jason has a probation officer, and, under the threat of incarceration, he has demonstrated the ability to refrain from disruptive behaviors.
The other end of the spectrum is:
“Clinical”
This is an individual who has no history of behavioral problems prior to the onset of a mental health disorder. Psychiatric symptoms such as the delusions and hallucinations of Schizophrenia or the agitation of the manic phase of Bipolar Mood Disorder are severe and not under the student’s control. The symptoms are the direct cause of the behavior, and, as such, there is no “function” to the behavior any more than there is a “function” of the irritable behavior of a diabetic whose blood sugar is low. Behavioral interventions are not effective. Appropriate clinical treatment can result in the amelioration of not only the psychiatric symptoms but the accompanying behaviors as well.
Example:
Mark is an 18-year-old high school senior who was recently diagnosed with Schizophrenia. He had no history of behavioral difficulties, and had done well academically through his tenth grade year. In the last year, he has had deterioration in his grades, social isolation, unusual interpersonal interactions and poor personal hygiene. His mental state deteriorated to the point that he was experiencing auditory hallucinations and paranoid delusions. He was hospitalized after threatening a school bus driver who he believed was kidnapping him. He demonstrated improvement with medication treatment, but has had poor compliance. When he doesn't take medication, he becomes hostile, paranoid and agitated. Behavioral interventions have not improved the behavior, and his parents have gone to court to file commitment papers for hospitalization.
The Intermediate Parts of the Spectrum:
The majority of students will fall within this part of the Spectrum. It is important for school personnel to recognize the complexity of the mixture of behavioral and clinical contributors to behavior, and to respond accordingly.
“Predominately Behavioral”
This is an individual who has a mental health disorder, but whose behaviors are, for the most part, not due to the disorder. This student may use the disorder as an excuse for inappropriate behaviors, saying that he or she cannot control them, e.g., “Because I have ADHD”. In fact, the student’s behaviors tend to be planned and volitional, and the student is well aware of the impact of the behavior on others. For some students, the behavioral problems predated the onset of mental health problems.
Example:
Jerrod is a 10-year-old fifth grader who has a long history of behavioral problems in the home, school and the community. He recognizes the consequences of his behaviors, but believes that they are justified “if I don’t get caught”. He has been on various medications for ADHD that have improved his on-task behavior when he is interested in a subject, but behavior problems have continued. When asked, for example, why he hit a child on the playground that day, he said, “I decided when I was walking to school this morning that he needed to be taught a lesson.” Essentially, given his antisocial tendencies, medication for ADHD will not reduce behavioral problems, but will, instead, “help him plan his crimes better.”
The predominately behavioral student primarily needs a behavioral approach to address behavioral problems. Searching for the ideal medication in order to extinguish behavioral problems will be in vain, given that the behavioral problems do not directly stem from the mental health disorder. This is not to say that the mental health disorder should not be treated, but rather that professionals, both in education and in mental health, should avoid the misconception that the disorder is the primary causal factor in his behavioral difficulties.
“Predominately Clinical”
These individuals have some component of behavioral contributors to their acting out, in that there are some identifiable antecedents to behavioral problems, and some degree of function to their behaviors. However, these are overshadowed by the presence of a clinical disorder that is a far greater contributor to the behavioral problems. In some students, mild oppositionality or conduct disordered behavior was present prior to the onset of the mental health disorder, and the symptoms of the disorder greatly magnified the behavioral difficulties.
For these students, clinical treatment is the predominate component leading to behavioral improvement. Behavioral principles should be applied as needed, but by themselves, they are not likely to ameliorate dysfunctional behaviors that stem directly from the core symptoms of the student’s mental health disorder.
Example:
Kim is a 16-year old 11th grade student who recently began having symptoms of Bipolar Mood Disorder. She has started taking mood stabilizing medication, but symptoms of mania are not fully under control. She demonstrates rapid shifts in mood, anger outbursts, agitation, impulsivity and irritability, and has been verbally intrusive. Prior to the onset of her illness, she had demonstrated some teenage rebellious behavior, with mild oppositionality towards her parents and she had violated curfew on two occasions. Overall, she had been a good student. Behavioral interventions need to focus on recognizing the source of her behavioral difficulties, and should provide her with enough “safe space” to be able to avoid situations where these behaviors could be problematic. As her medication response improves, her behavioral problems would be expected to improve as well.
“Mixed”
Students in the “mixed” category pose significant challenges to both mental health clinicians and to educators. They have both major psychiatric disorders and significant behavioral contributors to their behavioral difficulties.
It is not uncommon for students in the “mixed” category to be placed in self-contained school settings for students who have severe behavioral problems (e.g., “Emotionally Disturbed/ED,” “Seriously Emotionally Disturbed/SED” or “Emotionally or Behaviorally Disturbed/EBD” special education programs). Often, their mental health disorders such as ADHD, Depression, Bipolar Mood Disorder, Post-Traumatic Stress Disorder, etc. go unrecognized and untreated, even if they had been diagnosed in the past. In fact, the majority of students seen at the time of a special education evaluation for the Emotional/Behavioral category may fit this “mixed” category. This population often has poor outcomes in education, employment, rates of arrest, etc. They pose a challenge to mental health professionals who may tend to focus on the mental health disorders without fully recognizing the impact that the behavioral contributors have on the student’s behavior. Education professionals, on the other hand, may not recognize the underlying contributions of these students’ mental heath disorders, and may become frustrated when behavioral approaches are used with little or no success. These students are often viewed by school staff as “Behavioral,” with minimal understanding of the role of clinical contributors to the problem. Many of these students are not being treated for their mental health disorder(s), or, may be inappropriately treated or misdiagnosed by medical or mental health professionals. School professionals are often frustrated by the challenges faced in addressing these students’ clinical disorders, given that schools are educational and not clinical settings.
This “mixed” category population poses significant challenges to all professionals, and successful intervention requires collaboration, communication and shared perspectives from professionals in all fields of services and supports: Education, Corrections, Mental Health, Medical and Social Services.
Example:
Nick is a 14-year old ninth grade student in a self-contained (Federal Setting 4) Special Education program. He has a multitude of disabilities, and a long history of delinquent behaviors. His mother used drugs and alcohol during her pregnancy with him, and neglected him during his infancy. After living with his mother until the age of six, when she was arrested for selling drugs, he was placed in multiple foster homes, and was sexually abused in one home by a foster brother. He has a full scale I.Q. of 78, and has been diagnosed with Fetal Alcohol Spectrum Disorder, Post Traumatic Stress Disorder, ADHD, Reactive Attachment Disorder and Mood Disorder Not Otherwise Specified. Antisocial behaviors date back to the age of three, and have included fire setting, cruelty to animals, stealing, lying, aggression and destruction of property. He has benefited from medication for his ADHD and mood disorder, but continues to engage in significant delinquent behaviors. He has a County Social Services mental health case manager and a Juvenile Corrections probation officer.
Nick will require a great deal of services from multiple systems for many years. He is not an “either-or” student, but rather “both-and”, in terms of the clinical and behavioral contributors and the combination of clinical and behavioral solutions to his acting out behaviors.
The Importance of the Behavioral/Clinical Spectrum Concept
Understanding where an individual falls on the Behavioral/Clinical spectrum is an important first step in designing interventions that are most likely to be effective.
The Spectrum can also contribute to a common understanding among the professionals providing services and support, especially if they are viewing the student from vastly different perspectives. For example, if a school social worker sees a student as being “Clinical” or “Predominately Clinical”, whereas the teacher sees the student as being “Behavioral” or Predominately Behavioral,” the recognition of this discrepancy can be the first step in understanding why interventions have not been successful to date, and in creating more effective accommodations and modifications for the student.
While clinical disorders may tend to be “invisible”, behaviors are obvious and observable. As such, there can be a tendency to overemphasize behavioral versus clinical contributions to the spectrum. This problem can be magnified if school staff feel constrained in addressing mental health issues, if there is pressure to not identify mental health problems due to potential payer of last resort school concerns, or if there is a pro-behavioral, anti-medical model bias within the school environment. Given the substantial research indicating the very poor outcomes of special education for emotionally disturbed individuals, and the fact that poor outcomes are often associated with the lack of attention to students’ mental health, it is important to encourage an emphasis on the continuum of student support needs that includes mental health components.
Identifying the Correct Category
The Spectrum provides a perspective that allows educational staff the opportunity to broaden their conceptions about students’ behavioral difficulties and of the interventions that will most likely be successful. As school professionals are not clinicians, they may feel uncomfortable assigning a category to a student, especially given the fact that many students who have mental health disorders have not been diagnosed, and that many who have, have been incorrectly diagnosed. The Spectrum should be viewed not as a diagnostic tool but as a working hypothesis. It is useful to consider, especially when educational interventions have not been successful for students who have been diagnosed with, or have evidence of, mental health disorders.
Some guidelines that can be helpful in the process of assigning a category are:
For the clinical end of the spectrum:
- Has the student been diagnosed, or has evidence of, a mental health disorder other than Conduct Disorder or Oppositional Defiant Disorder?
- If so, do the DSM* criteria of that disorder match the behaviors observed?
- Were behavioral problems present prior to the onset of the mental health disorder?
- Is there a previous history of treatment in which behavior problems were reduced or disappeared as a result of treatment?
- Is there evidence that behaviors are planned, volitional and under full control of the student?
- Is there clear evidence of antecedents and/or social functions to the behaviors?
- Is there evidence that behaviors have responded to behavioral-based programmatic interventions in the past?
- Is there a chronic history of behavioral problems dating to early childhood?
Advantages of Using the Spectrum Concept
- It creates a common language, bridging the gap between various educational disciplines.
- It raises mental health awareness, encouraging educational teams to reframe their thinking about behaviors that stem from internal, clinical symptoms of mental health disorders.
- It helps educational teams unify their approaches, and to recognize when there are polarized viewpoints from team members regarding the source of a student’s behaviors.
- It helps mental health staff reconsider situations where behavioral issues were thought to be due to a mental health disorder when, in fact, they were planned and volitional.
- It directs educational interventions to be maximally effective, achieving the best academic and behavioral outcomes.
Further Readings:
P C Friman, et. al. (1998). Why behavior analysts should study emotion: the example of anxiety. J Appl Behav Anal. 31(1): 137–156.
Miltenberger, R., (2011). Behavior Modification: Principles and Procedures. Wadsworth *Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (2000) |