Education Policy Brief Emotional and Behavioral Disorders: Promoting Prevention and Positive Interventions in School Settings Paulo Tan, Potheini Vaiouli, and Theresa A. Ochoa VOLUME 9, NUMBER 5, FALL 2011 Proactive and positive behavioral plans CONTENTS INTRODUCTION for students with disabilities focus on externalizing and disruptive student Introduction.........................................1 The 1997 Individuals with Disabilities behaviors. However, these plans fail to Positive Behavior Interventions Education Act (IDEA) called for educa­ adequately address the needs of students and Supports........................................2 tors to create a new paradigm in school who struggle from internalizing disor­ environments through the addition of ders such as anxiety and depression. Left Policy Perspective positive behavior interventions and sup­ unattended, internal struggles sometimes Sarah Montminy .............................4 ports (PBIS). Specifically, IDEA encour­ evolve into externalizing behaviors like Internalizing Behavior Disorders .....5 ages schools to create and foster positive bullying and physical violence. For supports and prevent disruptive and vio­ example, in 1999 two teenagers killed 13 Physical Restraints and Seclusion lent student behaviors. To date, PBIS has people and themselves at Columbine Practices ..............................................7 been implemented in over 13,000 High School in Colorado. Both adoles­ Conclusions and schools across 49 states (Illinois PBIS cents were subsequently found to have Recommendations .............................10 Network, 2010). Maryland and Illinois suffered from depression and suicidal are examples of states with a strong com­ thoughts (Toppo, 2009). Major tragedies Authors...............................................10 mitment to PBIS. Since the introduction such as the Columbine massacre under­ Acknowledgements............................10 of Maryland’s statewide PBIS initiative score the importance of identifying stu­ in 1998, approximately one third of dents with internalizing behaviors so References ..........................................11 Maryland’s schools have received PBIS appropriate early interventions can be training (Barrett, Bradshaw, & Lewis- provided. The 2004 reauthorization of Web Resources...................................12 Palmer, 2008). Likewise, since 1999, the IDEA in its use of response to inter­ over 1,300, or one third of Illinois’ vention (RTI) language presents a possi­ schools, are implementing PBIS (Illinois bility for providing early intervention for PBIS Network, 2010). such disorders. In Indiana, PBIS is not coordinated by a This Education Policy Brief provides an statewide initiative. However, since update on the PBIS efforts in Indiana by  1999, Indiana University’s Center for showcasing an Indianapolis school dis­ Education and Lifelong Learning at Indi­ trict’s endeavors in the implementation ana Institute on Disability and Commu­ of PBIS; explores strategies for schools UPCOMING POLICY BRIEFS . . . nity has provided training in PBIS to to expand efforts to identify children and An Update on Childhood Obesity over 55 schools and 15 school corpora­ adolescents with internalizing disorders Trends and Student Nutrition tions in Indiana. A total of 17 additional and to develop and implement interven­ Issues schools are receiving training this school tions within school settings; examines The Latest News on STEM year (2011-12) (Cassandra Cole, per­ the national debate and Indiana’s poli­ Initiatives sonal communication, September 22, cies on the use of physical restraints and 2011). The number of PBIS schools in seclusion in the context of school set­ Trends and Outcomes of Alternative Teacher Certification Indiana and elsewhere indicate a grow­ tings for dangerous and disruptive stu­ Programs ing movement toward adopting proac­ dents generally and with students with tive and positive behavioral plans for disabilities in particular; and discusses students with disabilities. implications and recommendations for educational policy. interventions are available at the third resources for ongoing professional POSITIVE BEHAVIOR level for a small percentage of students development. INTERVENTIONS AND with greater needs. At this level, an indi­ SUPPORTS vidualized behavior support plan is cre­ ated which may include the delivery of Encouraging Signs Four years have passed since the Center specialized services (e.g., mental health) for Evaluation & Education Policy and/or the initiation of more structured (CEEP) published a policy brief address­ programs such as Systems of Care. PBIS PBIS encourages shared responsibility ing the concept of PBIS and describing relies on data to help schools continu­ through greater teamwork and collabora­ Indiana’s disciplinary practices and out­ ously evaluate the program and guide tion across all school personnel. During comes (Washburn, Stowe, Cole, & Rob­ decisions. In this section, we discuss an training, MSDLT personnel were inson, 2007). The previous brief called Indianapolis school district’s accom­ informed of the positive results experi­ for a shift in disciplinary approaches from plishments and challenges in its efforts enced by other schools utilizing PBIS. reactive to proactive by delineating those to implement PBIS across all of its ele­ Encouraged by the success of other components that would allow PBIS to be mentary schools. schools, MSDLT personnel worked effective and sustainable. Such compo­ under a common mission to build a pos­ nents include: 1) long-term commitment itive environment that would benefit across district and school personnel, 2) everyone. Prior to the implementation of Call for District-wide Change evidence-based practices, 3) systematic PBIS, some teachers in the MSDLT’s external support, and 4) the formation of schools viewed their singular role as leadership teams to coordinate imple­ The Metropolitan School District of teaching academics and they routinely mentation and sustain the program. These Lawrence Township (MSDLT) is located deferred students’ behavioral problems recommendations are consistent with in northeast Indianapolis. MSDLT is one to administrators. those of Sugai and Horner (2006). They of 11 school districts that serve students describe PBIS as a system of preventive in the city of Indianapolis. According to Principals, teachers, and staff now real­ and proactive measures and actions the Indiana Department of Education ize they must all share responsibility for designed by the schools to provide appro­ (IDOE), in the 2010-11 school year, helping students with problematic priate levels of support and interventions MSDLT served close to students, of behaviors in order to provide consis­ to their students. whom 39 percent were White, 39 percent tency. Monthly professional develop­ were African American, 7 percent multi­ ment meetings on PBIS were often racial, 14 percent were Hispanic, and 1 charged with energy and enthusiasm as percent other (IDOE, 2011). Addition­ various personnel came to learn and ally, 50 percent of the students qualified embrace new important roles under for free and reduced lunch. We sought to PBIS. Another reported area of accom­ According to the Director, ascertain MSDLT’s efforts to implement plishment was realized when principals the majority of teachers, PBIS and conducted two phone inter­ fully embraced the components of PBIS. staff, and principals at views with the Director of Elementary The dedication and leadership of these MSDLT were very Education, Dr. Denna M. Renbarger principals permeated throughout their enthusiastic about this (here forth referred to as Director). respective schools to help the process of program and believed that reforming a system that was punitive- PBIS was the right system to The Director reported an increase in dis­ based into one that is strength-based, have in MSDLT’s ciplinary issues in MSDLT in the last proactive, and preventative. According elementary schools. several years. The alarming number of to the Director, the principals’ strong discipline issues became a catalyst in the leadership was also instrumental in decision for MSDLT to implement PBIS establishing the environment of shared in its 11 elementary schools in 2002. responsibilities. During the summer of 2002, a team of The first level of support is applied individuals with extensive knowledge of school-wide. Support at this level PBIS provided training to all MSDLT Challenges includes reinforcing positive student elementary principals. In turn, principals behaviors and explicitly teaching pro- trained their teachers and staff. Accord­ social behaviors that conform to school ing to the Director, the majority of teach­ Despite efforts at MSDLT schools, there rules and behavioral expectations. The ers, staff, and principals at MSDLT were were also challenges during PBIS imple­ second level applies to a subset of stu­ very enthusiastic about this program and mentation. The Director noted that one dents who do not positively respond to believed that PBIS was the right system significant challenge was instituting the support provided at the first level. to have in MSDLT’s elementary schools. appropriate fidelity of implementation More intense and highly individualized The district allocated funding and both at the school-level and the teacher- EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 2 level. At the school-level, some elemen­ school practices, inconsistencies in data securing funding, visibility, and political tary schools in MSDLT did not follow collection, and a failure to maximize the support (Sugai & Horner, 2006). Mem­ specified guidelines in developing and use of available resources. bers of this team should include repre­ maintaining a consistent behavioral sys­ sentatives from the community, special tem. For example, some schools utilized Despite the challenges MSDLT has faced and general educators, mental health ser­ rules with negative language (e.g., “No in PBIS implementation, the Director vice providers, family members, and yelling in halls” vs. “Talk quietly in remains optimistic that PBIS will be school administrators. At the school halls”) in contravention of PBIS tenets. established in all schools. Changing a cul­ level, a leadership team that includes the At the teacher-level, unilateral decisions ture of punitive systems is difficult and school, principal, counselor, teachers, were sometimes made to respond to stu­ requires time — in some cases up to five and staff is also crucial to the success of dent behavior in a manner not consistent years, according to Bradshaw, Reinke, PBIS by managing and providing more with PBIS protocol. For example, some Brown, Bevans, and Leaf (2008). immediate day-to-day decisions. teachers ordered misbehaving students out of the classroom and into the hallway Several recent events hold promise in or office despite the PBIS guideline to helping MSDLT achieve its goals with keep misbehaving students in the class­ The Future of PBIS in MSDLT PBIS. One of these undertakings is the room. Thus, despite a shift in written successful implementation of a district- school procedures, in practice, punitive Considering the accomplishments and wide anti-bullying curriculum. This pro­ disciplinary measures continued to be challenges faced by MSDLT in imple­ gram, which emphasizes prevention, used bin some situations. Schools that menting PBIS, we offer several recom­ empathy, and pro-social behavior, is struggled to maintain fidelity of imple­ mendations drawn from the work of complementary to the PBIS framework. mentation continued to see increases in McIntosh, Filter, Bennett, Ryan, and Another recent occurrence is the renewed the number of suspensions. Although Sugai (2010). One recommendation is to focus from the schools that did not appro­ other explanations are possible, the use those elementary schools that have priately implement PBIS during the first Director indicated that the elementary achieved some success as exemplars to 8-year period to recommit themselves to schools that consistently countered the the other schools. Several of MSDLT’s implementing some components of PBIS principles of PBIS were also the ones elementary schools showed signs of in their schools. For example, these that appeared to have a higher number of accomplishments in the implementation schools are beginning to once again focus office referrals and suspensions. of PBIS. These exemplars suggest that on and reward positive behaviors. Cur­ high-quality implementation can occur rently, the goal of MSDLT is that these in MSDLT’s other elementary schools. features will eventually become part of the fabric in the schools’ culture and will Another recommendation is to provide serve as a basis for any future plans to One recommendation is to ongoing coaching and evaluation from implement PBIS. Calls for more teacher use those elementary knowledgeable district- or state-level accountability also mean that data collec­ schools that have achieved experts in order to help and sustain high- tion and analysis will soon be common some success as exemplars fidelity implementation. One avenue practices in the classroom. This will cer­ to the other schools. through which schools and districts can tainly help with efforts to appropriately seek support is the PBIS Indiana implement and sustain PBIS in MSDLT Resource Center, which is a part of the for the long term. Indiana Resource Network. PBIS-Indi­ ana could also help the district better We also recommend other critical ele­ Data collection was another area of diffi­ manage their data collection efforts. ments needed to ensure implementation culty. Data were often inconsistently col­ McIntosh and colleagues underscore the fidelity and sustainability of PBIS at lected by principals and teachers. importance of data collection and analy­ MSDLT. These include: developing and According to the Director, teachers did sis in ensuring sustainability of PBIS. conducting surveys to better assess the not always report how they handled cer­ They argue that school districts should effectiveness of training and the attitudes tain disciplinary actions. In the Direc­ require consistent and ongoing data pro­ of school personnel toward PBIS, col­ tor’s opinion, this was mainly cedures from all the schools in order to lecting data on the school’s disciplinary attributable to a lack of communication help guide, evaluate, and adapt the com­ practices and analyzing how the data between school personnel. In addition, ponents of PBIS. relate to the fidelity of implementation, although funding and resources were and examining the data on student demo­ available to schools to offset the finan­ PBIS implementation at MSDLT may graphics and the resulting impact on the cial costs of implementing PBIS pro­ also be improved by the formation of a number of disciplinary issues. grams, these monies were often left leadership team. The central role of the untapped. Taken together, implementa­ PBIS leadership team is to coordinate tion fidelity was affected by conflicting training, coaching, and evaluation while (continued on page 5) EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 3 Policy Perspective RESTRAINT AND SECLUSION PRACTICES IN SCHOOLS CAN BE SAFE AND SHOULD BE INCLUDED IN IEPS Sarah Montminy The policy of our corporation is to use physi­ When trained staff are vigilant and cautious cal restraint and seclusion only when abso­ with students who are in crisis, seclusion and lutely necessary. The frequency of use physical restraint are safe options for keeping depends on the intensity of harmful behaviors potentially dangerous students in their least exhibited by the current student population. restrictive environment. Any legislation that In my current class of 16 students, the major­ might strip educators of their ability to inter­ ity has never been restrained, despite the fact vene through the use of physical restraint and that they do engage in physical aggression, seclusion with special education students because systems are in place such that the who are prone to aggressive and/or dangerous physical aggression does not escalate nor is it behaviors may mean that these students will persistent to the point of needing seclusion or no longer be able to be included in public restraints. A few of my students routinely education. I fear that the progress made As a special education teacher working with engage in behaviors that can escalate in inten­ toward inclusion of students with high-sup­ students with high support needs in Illinois sity until a physical restraint is necessitated. I port needs may be lost. and Indiana, I have encountered many stu­ have had students who were restrained daily, dents who engage in dangerous behaviors. If a student on my caseload has a behavior sometimes multiple times a day, because their Over the course of nine years, I have been intervention plan that includes physical acts behaviors were so intense in nature. In my part of hundreds of restraints involving stu­ of harm toward self or peers, I include the career I have only used seclusion in one case dents with disabilities. I have often been con­ procedures for restraints and seclusion in that involved repeated nudity. If an incident cerned with the lack of federal and state their IEP (individualized education program). arises where a physical restraint becomes oversight in the use of physical restraints and Professionally, I feel strongly that parents necessary, trained staff from the SCM team seclusion practices in schools and have who are informed of the options we have for are notified to respond and assist the staff worked diligently with the administrators in keeping their child safe are more likely to ask already engaged in the restraint. Per corpora­ the schools where I have worked to ensure questions and voice concerns proactively. In tion policy and SCM best practice proce­ that policies and documentation in my school cases where communication with parents is dures, the process begins with the least corporation examine all aspects of physical minimal, using the student’s annual case restrictive hold necessary. Additional posi­ restraint and seclusion procedures in order to review as an opportunity to discuss options tions and increased staff may be employed, if ensure that safety for all students remains our for ensuring the safety of their child and his or needed. Moreover, the process requires a staff central focus in crisis situations. her classmates is important. I want my stu­ member to document the student’s vital signs dents’ parents to understand the interventions In our school corporation, a Safe Crisis Man­ at 5-minute intervals and to write notes on that may be used and that they are never agement (SCM) team consisting of 5-20 peo­ verbalizations and behaviors during the phys­ employed as a punishment. ple, depending on the size of the student body ical restraint. Following the restraint, the staff and number of students with high-support involved meets to debrief, assess the function needs, are trained by JKM, Inc. to respond to of the behavior, and reevaluate the effective­ situations where physical risk of harm to the ness of current accommodations and modifi­ student or others is apparent. The SCM team cations, positive behavior supports, and includes principals, assistant principals, spe­ visual supports. cial education teachers, general education teachers, and paraprofessionals. This team takes part in a two-day initial training that focuses on prevention, promoting positive behaviors and supports, and strategies in addressing dangerous behaviors. Once certi­ fied, members of the SCM team are required to be recertified annually. Sarah Montminy is a special education teacher in Spencer-Owen Community School Corporation EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 4 (continued from page 3) into externalized aggression against self In January 2011, Indiana’s House of and others. Depression affects almost Representatives took note of the high In sum, despite PBIS training, adminis­ eight percent of school-aged children rate of school-age students suffering trator and staff buy-in, and some level of and is closely related to violent acts from depression and other internalizing accomplishment in the initiative, (Fröjd et al., 2008; Zayfert, Becker, & behavioral disorders and also pointed to MSDLT has experienced difficulties in Gillock, 2002). the limited level of teacher awareness of maintaining fidelity in its implementa­ the nature of the disorder. As a result, tion of PBIS. The previous CEEP Educa­ The National Institute of Mental Health House Bill 1019 was introduced as an tion Policy Brief called for statewide (NIMH), reports that violence against attempt to ameliorate teachers’ lack of initiatives in PBIS to better ensure fidel­ self (e.g., suicide) is the third-leading knowledge about internalizing disorders ity of implementation (Washburn et al., cause of death for children, youth, and such as depression. 2007). Barrett, Bradshaw, and Lewis- young adults between 10 and 24 years of Palmer (2008) emphasize the importance age (NIMH, 2002). Also, data from the This bill would have required the state’s of long-term commitment to statewide National Survey on Drug Use and Health Division of Mental Health and Addiction coordination of evaluation, training, and (Johnston, Bachman, & Schulenberg, to work with the IDOE to develop a basic coaching in order to achieve high levels 2006) indicate that approximately in-service course on the prevention of of fidelity in implementation. Bradshaw 900,000 youth between the ages of 12 student suicide that aims to prepare and et al. (2008) found that schools that pro­ and 17 considered suicide during epi­ train teachers to recognize the warning vide PBIS training for educators are sodes of depression. In practical terms, signs of a student considering suicide. more likely to implement PBIS with high these data show how likely it is for a typ­ While passing in the House by a 97-1 fidelity within one or two years. How­ ical high school classroom to have three vote, this bill did not receive a hearing in ever, schools should expect a 3-to-5-year students with internalizing behavioral the Senate Committee on Health and window before program changes trans­ disorders who have attempted suicide. Provider Services. Efforts like those pro­ late to changes in student behaviors. posed under House Bill 1019 to increase the knowledge teachers have about inter­ Although a statewide model is not yet nalizing disorders and provide sugges­ available in Indiana, schools may still tions on the role schools can play in take advantage of other PBIS training addressing students’ mental health needs The National Institute of opportunities. For example, in the sum­ are encouraged. Mental Health (NIMH), mer of 2011, PBIS Indiana began provid­ ing training and technical support to reports that violence against Indiana schools. Even without formal self (e.g., suicide) is the PBIS training, schools may begin to third-leading cause of death School-based Mental Health immediately implement components of for children, youth, and Interventions PBIS such as teaching and reinforcing young adults between 10 positive student behaviors and moving and 24 years of age (2006). Services for internalizing disorders are away from punitive disciplinary models available to students primarily within through the adoption of preventative schools or through clinics. However, practices sensitive to cultural, social, and research indicates that many students linguistic differences. with depression do not receive effective services due to lack of access or because Research also shows that students with of a desire to avoid the social stigma that internalizing behavior disorders experi­ often accompanies treatment for inter­ INTERNALIZING BEHAVIOR ence a number of negative outcomes in nalizing disorders (Weisz, McCarty, & DISORDERS their academic and personal lives. Social Valeri, 2006). In cases in which students withdrawal, diminished self-esteem, and are identified by schools as being at risk As noted previously, the perpetrators of poor physical health are often reported in for depression, substance abuse, and/or violent acts in Columbine High School students who suffer from anxiety, social suicide, these students may participate in suffered from significant emotional dis­ phobia, and depression (Maag, 2002; counseling programs both within the tress; but, unfortunately, awareness of Zayfert et al., 2002). According to school setting and through out-of-school the link between this distress and the Kauffman (2005), anxiety is the most mental health services; however, there is potential for violent actions occurred too common type of internalizing disorder typically little to no communication and/ late. Therefore, we advocate for early affecting students, as about 20 to 30 per­ or interaction between schools and the intervention and encourage schools to cent of children and adolescents referred service providers, possibly resulting in expand the scope of PBIS to target stu­ to health clinics for behavioral disorders minimal intervention benefits. Clearly it dents who suffer from internalizing dis­ are referred for anxiety (Merry, McDow­ is important to promote communication orders which, if untreated, can develop ell, Wild, Bir, & Cunliffe, 2004). between community-based service pro- EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 5 viders and the mental health services learning and academic performance, Special programs and services need to be provided by schools. school-based mental health services are structured to enable students to benefit as marginalized as auxiliary to learning much as possible from instructional Generally, school-based psychotherapy (Maag, 2002). That is, school personnel time. Also, schools need to collaborate interventions include cognitive behavior tend to see any activity not directly with mental health services and commu­ therapy (CBT) and interpersonal psycho­ related to instruction as a deviation from nity clinics in order to foster and empha­ therapy (Michael & Crowley, 2002; educators’ primary role of knowledge size the integrated treatment of students Michael, Huelsman, & Crowley, 2005). transmission. Concerns are also raised who experience acute and/or chronic Interventions following the cognitive when school resources and instructional internalizing behavioral disorders. behavior therapy model focus on two time are consumed by issues perceived general areas: behavior and cognition to be the sole responsibilities of mental We believe that the school setting repre­ (Maag & Swearer, 2005). Components health and social services (Maag, 2002). sents a suitable environment for provid­ include training on self-instruction, Although opportunities are available for ing mental health services in two problem-solving, and cognitive re-struc­ psychosocial services in schools, avail­ important ways. First, educators can be turing of reality through the use of strat­ able professionals are often insuffi­ highly involved in the design and imple­ egies such as modeling, role-playing, ciently trained to appropriately deliver mentation of effective psychosocial and positive reinforcement (Maag, psychosocial interventions. interventions intended to support stu­ 1988). The aim of CBT is to help stu­ dents struggling with internalizing dents who present depressive symptoms behavioral disorders. For example, elevate their moods and facilitate their teachers can incorporate cognitive- emotional, social, and behavioral growth behavioral techniques and psychosocial by teaching them self-management skills strategies during the time spent with stu­ In order for schools to work (Hughes & Adera, 2006). dents either in the classroom or during effectively with mental extracurricular activities. Interpersonal Psychotherapy (IPT) is a health services and to short-term therapy based on the theory address the psychosocial Furthermore, special educators can that interpersonal conflicts or transitions needs of their students, design school activities that encourage maintain depression (Curry, 2001). greater efforts must be self-expression and offer a creative emo­ Unlike CBT, IPT is less concerned with made for comprehensive tional outlet to all students and especially teaching cognitive restructuring behav­ and integrated intervention to those who suffer from anxiety, depres­ iors to students who suffer from mal­ sion, and suicidal ideas. Finally, for stu­ approaches. adaptive internalizing behaviors. dents with internalizing behavioral Instead, IPT’s emphasis is on the impor­ disorders, intervention techniques such tance of a therapeutic relationship as social skills training, self-management between the educator/therapist, the stu­ training, and cognitive and behavioral dents, and their families. approaches can also be implemented by Taken together, limitations in training general and special educators to address a The focus of IPT is on assisting students and time constraints often prevent variety of challenging behaviors of stu­ in overcoming interpersonal conflicts; schools from successfully implementing dents in the classroom (Maag, 2005). handling peer pressure, social isolation, psychosocial interventions, and this may self-image; and dealing with feelings of consequently result in fragmented, iso­ A second and important way school set­ grief, loss, or death. IPT offers support so lated, or inadequate interventions for stu­ tings may be suitable for providing men­ that students can adapt to changes in life dents struggling with internalizing tal health services is that schools can situations and improve their social func­ behavioral disorders (Adelman & Tay­ provide mental health services to students tioning (Ruffolo & Fischer, 2009). lor, 2000). who do not access clinic-based services. Despite differences in principles and Mental health professionals can collabo­ foci, both CBT and IPT can be delivered In order for schools to work effectively rate with educators within the school set­ by mental health professionals, school with mental health services and to ting either with students who present psychologists, or special educators address the psychosocial needs of their symptoms of internalizing disorders but (Curry, 2001; Mufson, Dorta, Olfson, students, greater efforts must be made whose depression does not reach clinical Weissman, & Hoagwood, 2010; Rufollo for comprehensive and integrated inter­ levels or for students who, for various & Fischer, 2009). vention approaches. According to Adel- reasons (e.g., stigma), do not go to com­ man and Taylor (1999), initiatives for munity-based intervention settings. Even with the long-term acknowledg­ mental health provisions need to be ment that school-based psychosocial developed and integrated within each We encourage school and community interventions can be the answer for stu­ school’s policy to address the needs of programs to become integrated by dents whose emotional struggles impede students with internalizing disorders. expanding existing school resources and EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 6 creating opportunities for interaction, RTI, teachers integrate classroom-based schools around the country generally and communication, and exchange of infor­ interventions of various intensity and Indiana in particular, some students con­ mation between mental health agencies duration in order to support learning and tinue to engage in disruptive behaviors. and school personnel. Some means of inclusion for all students. Given the edu­ Many schools around the country use integrating community and school pro­ cational reform efforts to intervene early procedures known as restraints and grams include: classroom-based activi­ and reduce the number of students iden­ seclusion in response to students who ties that enhance learning and tified for special education services, RTI pose a threat to others or to themselves. socialization, parent involvement in reflects the current focus on early inter­ According to the Council for Children schooling, and consistency in the psycho­ vention. with Behavioral Disorders (CCBD), social services offered. By developing restraints refer to anything that limits, coordinated intervention methods, the More specifically, primary prevention restricts, or keeps an individual in con­ fragmented and isolated mental health (or Tier 1) in the school setting can foster trol and prevents him or her from demon­ services can become part of a compre­ opportunities for positive development strating or expressing harmful or hostile hensive educational approach that may and wellness of all students. During this behavior (CCBD, 2009b). Seclusion is succeed in breaking down the barriers to tier of RTI, educators can consult with the involuntary confinement of an indi­ student learning and emotional growth. school mental health specialists to dis­ vidual alone in a room or in an area from cuss concerns about the initial signs of which the individual is physically pre­ The preparation of school personnel is an internalizing behavioral disorders. Stu­ vented from leaving (CCBD, 2009a). important factor in the integration of dents who fail to respond to the early psychosocial support within the school intervention efforts in Tier 1 are identi­ However, the use of restraints and seclu­ context. Based on their extensive, daily fied as at-risk and are provided with sion has come under criticism by child interaction with students, teachers can be more intense interventions that can be and adolescent advocates in consort with an invaluable source of information and delivered by special education teachers parent organizations who urge policy­ important allies to the mental health pro­ who may already possess the required makers to entirely ban the use of these fessionals, the students, and the students’ skills. The aim of early school-targeting practices in schools (Diament, 2010). families. Although teachers are not men­ interventions in Tier 2 can focus on sup­ Critics of restraints and seclusion argue tal health providers, they can be the first port and guidance to ameliorate behav­ that these practices are not only lacking to note emotional imbalances, such as ioral problems and school adjustment in effectiveness but, more importantly, anxiety and depression, based on their issues for the students who need addi­ they are traumatic at best, and deadly at everyday interaction with students. tional support. Tier 3 can ensure that stu­ worst (Diament, 2010). Moreover, teachers can discuss with the dents with severe and chronic emotional students and their families the challeng­ and behavioral problems are referred and The national debate surrounding ing emotional behaviors they have receive psychological services as well as restraints and seclusion procedures has observed and the impact of the emotional guidance and assistance to experience forced educators, parents, advocacy struggles on the academic growth of academic success. groups, and professional organizations their students. Thus, educators can sup­ on both sides to weigh in on this concern. port students’ interaction with mental In essence, the success of school-based The issues associated with the use of health professionals and encourage fam­ mental health services depends on the restraints and seclusion practices in ily involvement in the process of mental effective collaboration between school schools are divided along two lines. First, health services because of the existing personnel and community mental health some argue that these practices should be trusting relationship that can be estab­ services. Collaboration between commu­ completely banned without any excep­ lished in the school setting. nity resources and the school can tions. Others argue that the use of enhance early intervention approaches, restraints and seclusion in schools should Response to Intervention (RTI) is a and can intensify care and individual be restricted and used only under limited three-tier model that can provide stu­ support to respond to the needs of stu­ circumstances and with regulatory proce­ dents who experience internalizing dents with severe internalizing behav­ dures in place. Critics charge that these behavioral disorders with timely and ioral disorders. practices are barbaric, while advocates of gradually intensified access to mental seclusion and restraints argue that with­ health support. RTI is designed to sup­ out access to these tools, schools are port students by using the expertise of defenseless against students who display different professionals and combining PHYSICAL RESTRAINTS AND dangerous behaviors. emotional strategies with learning inter­ SECLUSION PRACTICES ventions and objectives. The RTI model in schools can serve to guide delivery of Despite school-wide efforts to create and a continuum of services between school maintain a safe learning environment for personnel and their counterparts in com­ all students through the development and munity-based agencies. According to implementation of PBIS programs in EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 7 students were secluded or restrained a zona, Florida, Georgia, Idaho, Indi­ total of 18,741 times over a period of one ana, Kansas, Kentucky, Louisiana, Federal and State Laws on school year, from September 2007 to Mississippi, Missouri, Nebraska, Restraints and Seclusion June 2008. The GAO investigation also New Jersey, North Dakota, Okla­ found hundreds of allegations of abuse homa, South Carolina, South Dakota, Fueled in large measure by allegations and death related to the use of restraints Vermont, Wisconsin, and Wyoming; and findings of gross misconduct in the and seclusion over a 2-year period in treatment of troubled teens in residential schools across the country. Notably, a 7­ • 7 states have some restrictions on the facilities, the Committee on Education year-old died after being held facedown restraints but have no regulations on and Labor and the House of Representa­ for hours by school staff, and a 13-year seclusion: Alaska, Colorado, Hawaii, tives charged the Government Account­ old hanged himself in a seclusion room Michigan, Ohio, Utah, and Virginia; ability Office (GAO) with conducting a after prolonged confinement. In other close examination of school settings to cases that were non-fatal but similarly • 8 states specifically prohibit the use determine the extent to which children egregious, a 5-year-old reportedly suf­ of prone restraints that impede a and adolescents are exposed to physical fered broken arms and a bloody nose as a child’s ability to breathe: Colorado, restraints and seclusion practices (U.S. result of being tied to a chair with bungee Connecticut, Iowa, Massachusetts, GAO, 2009). In May of 2009, the GAO cords and duct tape by a teacher (U.S. Pennsylvania, Rhode Island, Tennes­ released a report of selected cases of GAO, 2009). see, and Washington; death and abuse involving both public and private schools in which it found Although these numbers represent a rel­ • 17 states require that selected staff hundreds of allegations of schools harm­ atively small percentage of the overall receive training before being permit­ ing and causing the death of children school population, the fact that children ted to restrain children: California, under their care. Furthermore, the GAO are at risk for serious physical harm or Colorado, Connecticut, Illinois, Iowa, found that there is widespread use of can die in schools as a result of disciplin­ Maine, Maryland, Massachusetts, restraints and seclusion practices in ary procedures warrants immediate Nevada, New Hampshire, New Mex­ schools across the country but no federal attention from policymakers. Further­ ico, New York, Oregon, Pennsylva­ laws to regulate their use. In this section more, given that few states (California, nia, Rhode Island, Texas, and we highlight the absence of federal pol­ Kansas, Pennsylvania, Rhode Island, Virginia; icy regulating the use of seclusion and and Texas) collect data on the use of restraints and conclude by noting Indi­ restraints and seclusion practices, it is • 13 states require that schools obtain ana’s effort to adopt policies guiding possible that the number of restraint and parental consent before using school personnel in the use of these prac­ seclusion cases resulting in serious restraints: Colorado, Delaware, tices with students in general and for stu­ bodily harm or death is higher than Maryland, Massachusetts, Montana, dents with disabilities specifically. reported in the GAO investigation. The New Hampshire, New York, North GAO investigation also states that very Carolina, Oregon, Pennsylvania, Ten­ young children and children with dis­ nessee, Virginia, and Washington; abilities are being restrained and secluded in schools (U.S. GAO, 2009). • 19 states require parents to be notified after their child has been restrained: In May of 2009, the GAO The Children’s Health Act of 2000 California, Colorado, Connecticut, released a report of selected amended Title V of the Public Health Illinois, Iowa, Maine, Maryland, cases of death and abuse Service Act regulates the use of Massachusetts, Minnesota, Nevada, involving both public and restraints and seclusion on residents of New Mexico, New York, North Caro­ private schools in which certain hospitals and healthcare facili­ lina, Oregon, Pennsylvania, Rhode it found hundreds of ties, as well as residential, non-medical, Island, Tennessee, Texas, and Vir­ allegations of schools community-based facilities that receive ginia; and harming and causing the any type of federal funds, but these regu­ lations do not apply to school settings. • 2 states require annual reporting on death of children The GAO investigation found state-level the use of restraints: California and under their care. policies regarding the use of restraints Connecticut. and seclusion varies widely. The only federal law indirectly dealing The GAO reported: with the use of restraints or seclusion practices in school settings applies to The GAO investigation noted that the • 19 states have no laws or regulations students with disabilities. The IDEA use of restraints and seclusion practices related to the use of restraints or mandates that schools develop and is common. For example, in Texas 4,202 seclusion practices in schools: Ari­ implement an individualized education EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 8 program (IEP) that explains the educa­ tricts across the state have been revising With regard to seclusion, NISEC’s regu­ tional goals for the student and the types or developing district-level policies lations require that any enclosure or of services to be provided. If the student since the GAO report in 2009. As an room used to seclude a student be similar has behavioral goals that may include the example, the Northwest Indiana Special to other rooms in the school with respect use of restraints or seclusion practices, Education Cooperative (NISEC) Board to materials, construction, height of ceil­ then procedures for their implementation of Managers developed and adopted pol­ ings, lighting, ventilation, and tempera­ must be noted in the student’s IEP. icies outlining the conditions under ture. NISEC prohibits any labeling of the which physical restraints and seclusion room which may cause a stigma and fur­ As a step toward developing federal pol­ practices are to be used in school set­ ther prohibits the use of external locks on icy on the use of restraints and seclusion tings. seclusion room doors. The room must in schools, in March of 2010, the U.S. also allow for both visibility of the stu­ House of Representatives passed a mea­ NISEC limits the use of restraints to dent and communication with the stu­ sure limiting the use of these practices to emergency situations in which staff dent at all times. In cases where two or cases in which there is imminent danger members believe the student may cause more students are concurrently placed in and prohibiting the practices from being harm to self or others. The NISEC regu­ the same room, the staff supervising the included in the IEP if a student has a dis­ lations clearly indicate restraints are not seclusion room must ensure students are ability. to be used as a form of punishment for not close enough to injure each other. minor infractions such as a verbal threat, Seclusion of any student must end as At the Senate level, however, a bill was a refusal to comply with an issued soon as the student is calm. introduced at the close of the 2010 con­ request, or the use of profanity. gressional session that would allow the Restraints under the NISEC model must The regulations prohibit the seclusion of use of restraints and seclusion to be also ensure student blood flow and respi­ any student 30 minutes after the student included in the IEP of students with dis­ ration are not inhibited and must con­ stops the specific behavior for which abilities. Critics of the use of restraints sider medical contraindications. seclusion was imposed. Moreover, if the and seclusion argue that the new mea­ student secluded has a disability, the sure “legitimizes” practices that the Alli­ NISEC restraints must also be adminis­ duration of the seclusion must be consis­ ance to Prevent Restraint, Aversive tered and supervised by school personnel tent with the student’s IEP (NISEC, Interventions and Seclusion (APRAIS) trained in approved restraint techniques. 2010). seeks to prevent. It remains to be seen In cases where the restraint involves a whether the Senate bill allowing educa­ student with a disability, the restraint pol­ In sum, schools within the NISEC region tors to include the use of restraints and icies require the method of restraint to be of Indiana have responded to U.S. Secre­ seclusion procedures in IEPs will gain consistent with the student’s IEP. NISEC tary of Education Duncan’s charge since enough congressional support to pass. requires written documentation (i.e., an the GAO 2009 report to review, develop, incident report) no later than one day and, where necessary, revise state poli­ after the restraint was used, with copies cies on the use of restraints and seclusion of the documentation forwarded to the in schools by adopting policies to guide Indiana’s Guidelines and director of special education; the parents; these practices in schools. It should be District-level Policies on and, if the student has a disability, the noted that NISEC’s newly adopted pol­ Restraints and Seclusion IEP team (NISEC, 2010). icy regarding students with disabilities is Practices in line with the U.S. Senate’s bill, which NISEC’s policy also specifically outlines would allow restraint and seclusion pro­ Following the GAO report, U.S. Secre­ the use of mechanical restraints. cedures to be included in the student’s tary of Education Arne Duncan sent a Mechanical restraints are only allowed if IEP. letter to the states urging them to authorized by a treating physician. develop, review, and, if necessary, revise Moreover, the physician must conduct an policies and guidelines on the use of examination of the student following restraints and seclusion practices to each restraint as soon as possible. While ensure that children in all schools across in a mechanical restraint, students must the country are safe from being unneces­ be given an opportunity to move freely sarily or inappropriately restrained or and exercise use of any body part that is secluded (U.S.DOE, 2010). At the time restrained. The supervising staff member of this policy brief, Indiana does not is required to loosen the mechanical have a state-level policy on the use of restraint every 10 minutes to determine if restraints or seclusion; instead it pro­ the restraint is still necessary and to vides guidance for the use of these prac­ ensure the restraint is not harming the tices (see IDOE, 2009). Despite the student (NISEC, 2010). absence of a state-level policy, some dis­ EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 9 counselors, social workers, and fami­ CONCLUSIONS AND lies to provide early intervention to ACKNOWLEDGEMENTS RECOMMENDATIONS students who display symptoms of depression and or suicide. The authors would like to thank the many We have highlighted Indiana’s progress people who have made this policy brief pos­ sible. We would like to acknowledge the in implementing PBIS in Lawrence • At the policy level, although we contributions of Patricia Pierce, former Township schools by describing its applaud efforts by individual school Director of NISEC, whose expertise has accomplishments, challenges, and con­ corporations (e.g., NISEC) to provide been invaluable in composing this brief. We tinued efforts to promote positive behav­ guidelines for the use of physical would also like to thank Diana Rogers- ioral interventions in the manner in restraints and seclusion practices in Adkinson, Ph.D. Professor and Chair which schools approach school-wide schools, we recommend that Indiana Department of Special Education, Univer­ discipline. In addition, we have noted adopt a single set of guidelines for the sity of Wisconsin-Whitewater, who gra­ that the school setting can ensure acces­ use of these practices in schools and ciously served as an external reviewer. Dr. sibility as well as timely, appropriate collect data on these practices as a Rogers-Adkinson has published widely in interventions for students who exhibit way of monitoring their effectiveness the area of PBIS. She has been an active maladaptive externalizing and internal­ and safety. We also recommend that member of the field and is currently serving as President of the Council for Children izing behaviors. Effective collaboration separate data be gathered to indicate with Behavior Disorders. We would also with community services can intensify the extent to which children with dis­ like to thank Rebecca Billick, a former these efforts so that the students in need abilities are more susceptible to expo­ Center for Evaluation & Education Policy and their families can experience consis­ sure to these extreme disciplinary (CEEP) graduate research assistant for her tency in the delivery of the interventions. practices. Most importantly, we thoughtful review of the brief draft. Ms. Bil- strongly endorse the development and lick is a licensed school counselor; a regis­ Indiana continues to strive to be proac­ adoption of state-level policies to reg­ tered domestic relations mediator; a tive and positive in its disciplinary ulate and monitor the use of restraints therapeutic foster parent; and an attorney school policies, which include efforts to and seclusion practices in schools. with Andrews, Harrell, Mann, Carmin, and prevent and treat anxiety and depression. Parker, PC. in Bloomington, Indiana. In cases where students’ behavior needs Additionally, we would like to thank the are extreme and emergency procedures AUTHORS Director of CEEP, Dr. Jonathan Plucker, are required to prevent or diminish risk for his support during this project, as well as of physical harm, some school districts Paulo Tan several CEEP faculty and staff who pro­ in Indiana have established guidelines ([email protected]) is a doctoral vided constructive feedback including: for the use of restraints and seclusion student in special education at Terry Spradlin, Director of Education Pol­ practices when warranted. Indiana University. icy, Leigh Kupersmith, Publications Coor­ dinator, Greta Gard, Director of Project In closing: Potheini Vaiouli Implementation. and Hallie Robbins, under­ ([email protected]) is a doctoral graduate Research Associate. • Based on the initial success of PBIS student in special education at when it is implemented in schools, we Indiana University. She is also a We are immensely appreciative of the expert insights that these individuals brought to the recommend that funding remains Board Certified Music Therapist. project. available to schools to allow them to promote the use of non-punitive Theresa A. Ochoa, Ph.D. responses to misbehavior. We espe­ ([email protected]) is an Associ­ cially encourage school principals to ate Professor and Special Education determine why funds available to Program Coordinator at Indiana implement PBIS remain untapped, University. since it is unlikely that funding will continue to be allocated if it is not used. • Given the current focus on preven­ tion, we recommend schools extend the application of RTI as a framework of multi-tiered service delivery to stu­ dents with internalizing emotional disorders. We especially promote the collaboration between general and special education teachers and school EMOTIONAL AND BEHAVIORAL DISORDERS: PROMOTING PREVENTION AND POSITIVE INTERVENTIONS IN SCHOOL SETTINGS — 10