(p. 395) Collaborating with the Educational Community
Private practitioners have an array of opportunities available to them to collaborate and interact with the educational community. We define the educational community here as any practitioner or organization that supports the continued learning and education of the individual client (e.g., parents, teachers, administrators, tutors, developmental therapists, special education advocates). We focus primarily on roles of a psychologist and neuropsychologist interfacing with the school system, though being involved in the educational community is not limited to psychologists (Laundy, 2015). We chose a four-stage problem-solving model (Castillo, Cohen, & Curtis, 2007) as a framework to highlight how clinical work in private practice may be aligned with the embedded structure that many educators use in public schools. Integrating the perspectives and strengths of various disciplines, all bound by a common goal of promoting well-being for a client in the educational arena, facilitates a holistic approach. We include a case vignette to provide a concrete example of how this model applies, and the conceptual challenges that may be faced.
Key Points for a Collaborative Process
We will start by describing the following factors that are important to consider as an outside consultant in private practice.
(p. 396) Accessing the Educational Community
There are many ways to network within the educational community before direct collaboration occurs. We recommend the following:
1. Develop a list of neighboring schools, their culture, and educational philosophy so you are prepared to understand the overarching mission.
2. Contact school psychologists or administrators to find out whether there are needs that have not been met within their system that you could provide.
3. Tour schools and meet the key stakeholders who make referrals; consider offering an in-service related to your specialty so the staff learns about you, your work, and your paradigm.
4. Send out flyers or emails about your service specialty and your vision of educational collaboration.
5. Write blogs or tweets on social media that speak to educational issues, and share them with the educational community.
Rapport with schools is based upon trust, mutual understanding of common goals, and a shared agreement that the client’s best interest is forefront in the consultation process. Depending on who initiates contact with the mental health provider for consultation-liaison service in the school domain, the client can vary. Clients can include individual children, families, school administrators, teachers, and other support personnel. At the inception of treatment and/or consultation, informed consent must be obtained to identify who the client is, who holds rights to the file, and how confidentiality is maintained within the working relationship.
Building rapport should be considered a strategic and time-focused engagement whereby relationships, if possible, are built prior to entering a school. We recommend meeting with staff, administrators, and other personnel through pre-service lectures, onsite professional training, and/or scheduled introductory meetings. By maintaining a presence at a school, you can glean important information about the school’s hierarchy, culture, and climate. As such, when the time arises for collaborative consultation about a student, you will be better able to understand how to navigate within a particular school.
Relationships may be enhanced and maintained by ensuring transparency of communication and identifying who ultimately the clinician is responsible to for deliverables. Even if the client is the family, the school may feel ownership or feel privy to the tangible strategies and outcomes of the assessment and/or therapeutic process. However, families may not want to provide full disclosure, which places the clinician in a bind in terms of collaboration and communication. Relationships are sometimes strained if, from the get go, a clinician does not state openly the holder of privacy and degree of disclosure that is authorized. That being said, including the school throughout the process and gathering information helps to align the parties. The way in which you communicate and collaborate from the start sets the tone throughout the treatment.
(p. 397) Key Stakeholders
Schools, like other organizations, are political arenas that require an understanding of who maintains the power and ability to make and implement decisions, both explicitly and implicitly. Key stakeholders are important to know in order to forge relationships and understand how they use their power and authority to manage decision making for children and school personnel. This varies from school to school. Furthermore, recognizing key stakeholders’ preferences (e.g., curriculum-based measurement vs. psychoeducational battery) will afford a more successful collaboration.
Roles and Responsibilities
The questions of who, what, when, and where are critical to address during a collaborative problem-solving process as educators are frequently overburdened with multiple roles (e.g., lunch duty, supervision after school) and therefore, despite good intentions, assessment and/or intervention may not be achieved as planned. Thus, at each interdisciplinary meeting, explicit expectations should be clarified and any barriers to execution should be identified. Documentation of roles and responsibilities in the meeting notes is likewise important to maintain accountability for all team members.
Districts and schools can vary in the availability of resources, including finances, personnel, and equipment. While the child’s needs rather than available resources should dictate provision of services, in reality, institutional constraints may place a family and school in a quandary regarding service provision. Understanding the available resources before getting started allows the practitioner to connect an assessment to realistic setting-specific interventions and/or consider alternative educational placements.
That being said, understanding available resources is a challenging endeavor. This can be achieved formally by reviewing statistics for schools (e.g., progress toward meeting annual yearly goals and minimum donation expectations) or informally by gaining insights while networking with the broader educational community via an information interview on the number of special education support personnel and staffing constraints across schools.
Forum for Communication
Communication may take many forms during collaborative consultation, including parent to teacher, teacher to practitioner, and so on. Regardless of the reason for communication or the manner in which information is disseminated, all parties involved in the student’s care must be involved so that members of the team maintain an active role. Communication may transpire via scheduled phone check-ins on progress, email updates including data collection, or through collaboration at Student Study Team Meetings, 504 Plan Meetings or Individualized Educational (p. 398) Plan meetings. Additionally, for members to feel comfortable expressing dissenting opinions, establishing a set of common values for the interdisciplinary process is recommended prior to ongoing team engagement. Core values may include topics of team process, vision for growth for the student, and/or general educational aspirations.
The Collaborative Problem-Solving Model
The collaborative problem-solving model we are discussing in this chapter has four stages: Problem Identification, Problem Analysis, Plan Implementation, and Plan Evaluation. For each stage we will provide an overview, school involvement, and application to a case. We will first discuss general variables that impact each stage and then will offer specific applications to our case vignette so the reader can visualize the complexities when working within a school system.
The approaches taken by the two authors of this chapter will be compared and contrasted. Stephanie Mihalas, PhD, NCSP, ABPP is a licensed psychologist and nationally certified school psychologist in private practice in Los Angeles, as well as an Assistant Clinical Professor at the David Geffen School of Medicine at UCLA. Mihalas is also a Board Certified Psychologist in the sub-specialty of School Psychology. She primarily works with children and families with comorbid psychiatric and neurodevelopmental differences as well as children who have experienced complex trauma and bullying. While maintaining a full-time practice, she mentors and supervises students, consults with professionals and organizations, and is actively involved with Psychologists in Independent Practice, a division of the American Psychological Association. Lev Gottlieb, PhD, is a neuropsychologist in private practice in Los Angeles, as well as a Clinical Instructor at the David Geffen School of Medicine at UCLA. He assesses youth with neurodevelopmental differences and/or acquired brain injuries, and coordinates their care. He also disseminates research to clinicians, educators, and parents via writing and speaking.
While it is understandable that clients would discuss slightly different concerns with the two of us based on our disciplines, we have found it interesting that the referral concerns were often quite different (sometimes even for the same client). For example, LG’s clients typically express referral concerns related to memory, learning, or task performance, whereas SM’s clients relay concerns pertinent to behavior, emotion, or affect regulation. We have come to appreciate that how the referral concern is presented may narrowly shape the course of action a clinician follows, yet with input collected from educators, a wider lens may be used for case conceptualization through treatment.
Susan1 is a nine-year-old Caucasian girl who is enrolled in the third grade at a public school. Susan was referred to a private-practice clinician by her family physician for primary concerns related to (p. 399) daydreaming in class, disobedience at home, and difficulty sustaining meaningful friendships. The parents reported that Susan is a “good student” and receives Bs, but she appears “agitated” in the mornings at home or whenever school is discussed.
The problem identification stage involves addressing the nature of the referral and the situational variants involved, as well as understanding what the client envisions for the goals of assessment and treatment. Routes toward making referrals to families and the types of referrals made depend upon whether you are working with a private versus a public school. Generally speaking, educators notice a deviation from the norm in terms of academic performance or behavior, which is discussed in a parent–teacher conference or on a report card. When progress continues to decline or is halted, schools will hold a team meeting (public school) or an upper-level administrator will make formal recommendations to parents (private school) for outside services. Information is co-constructed; rather than the clinician serving in a solely expert role, information is gleaned from the educational community (pending consent), the identified student, and the family to build a narrative of the presenting concerns.
To frame the referral concern, history is obtained in the following domains: family, birth/developmental, medical/psychiatric, psychosocial, trauma, and educational. Working in concert with other educational providers can help you avoid the common pitfalls of problem identification, including vague definitions of referral concerns or excluding persons who may provide unique information.
School Reflection on Problem Identification
Obtaining prior records naturally opens a discussion about collaboration with the broader educational community by conveying that it is essential to collect data from numerous sources. Authorization for release and exchange of information may be initiated by the clinician and/or educational community at the request of the legal guardian. Often both parties will want to maintain their own release to meet specific ethical and legal guidelines, and for documentation and recordkeeping. The parenting dynamic dictates who is required to sign the release. We recommend that if parents are in a contentious relationship, both parents should be made privy to information sharing and a release should be signed by both parties. Further, if the parents are divorced, the custodial paperwork should be reviewed to determine who may grant authority for medical and psychological care. Finally, if the identified client is over 12 years of age (in California; note that state laws vary), he or she should also be included in the release of information process through active consent.
We also encourage open dialog through interviews with educators and clinicians. If the family is not open to this idea, we make a note of the resistance for future reference and exploration, noting that the closed relationship with the school system may indicate a larger systemic issue (p. 400) impacting learning or emotional stress for the child and family. Generally, we begin to see very early on in the intake process a bidirectional relationship between the school environment and the behavioral and emotional concerns at home.
Application of Problem Identification
We use a “funnel-down” approach during our interviews with everyone who is part of the system. Both general and specific questions are important to the problem identification phase. Here are some questions that we asked in Susan’s case:
1. What are the concerns, and how might assessment and intervention be helpful?
2. How is Susan currently functioning with regards to academics, emotion-behavior, and socialization, and has a trend been evident over time (i.e., is it the same, improving, or worsening)?
3. What are the expectations for Susan held by the family and educational community? If Susan has not met them, what steps have been taken to address functioning, and with what outcome?
4. What is the preference and status of collaboration between Susan’s family and the educational community?
Based on the answers obtained in problem identification, we developed hypotheses in various domains for Susan. Hypothesis testing in the clinical rather than the statistical sense takes on a functional approach whereby the clinician explores various reasons for behavior. This is completed by functional eco-behavioral assessments, narrative observations, teacher reports via interview or survey instruments, psychometric testing (e.g., of cognition and academics), and direct testing of discrete skills (e.g., taking turns, how to start a conversation).
SM tests specific hypotheses, as her treatment approach is practical and attempts to target specific symptomatology. Given Susan’s primary referral concerns, below are possible reasons for her behavior that, if confirmed, could lead to direct intervention:
Academic: The instructional third-grade curriculum is more difficult than previous years, revealing specific areas of academic weakness for Susan. Alternatively, the curriculum might be too easy for her, or her attentional capacity interferes with her ability to focus on the curriculum.
Individual Within Family System: Susan may be experiencing family conflict at home that is manifesting in mood/anxiety symptoms that are limiting her socialization at school. Other family system issues that could be impacting the referral concern include parental time spent on academics and an increase in parental stress.
Social: Susan may be experiencing bullying by her peers at school, which would negatively impact the social, emotional, and academic domains. Alternatively, her interests may be different from her peers, or she is isolating rather than trying to engage in social relationships.
(p. 401) In contrast, LG develops hypotheses in a broader manner, taking a bottom-up approach to encompass all possibilities and honing in on what can be distilled from the data. Given Susan’s primary referral concerns, below are possible explanations for her difficulties that neuropsychological testing can confirm or deny in order to develop a coordinated plan:
Individual: Susan has an attentional, anxiety, mood, learning and/or language disorder. Or, Susan does not have a diagnosable disorder but some features of these conditions that interact together, and/or a unique learning style.
Contextual: Susan has no problematic processing characteristics; rather, something about the expectations for her age, school culture, and/or family constellation is not a good fit currently.
Combination: Individual and contextual; that is, a combination of individual and contextual factors interact to explain Susan’s presenting concerns.
The cornerstone of problem analysis is collaboration among individuals within the client’s system. Assessments are conducted across multiple environments, domains, and times to inform intervention development. This critical period calls upon the consultative relationships that have been built previously. If you have a reputation for providing excellent service and “being a team player” with your educational constituents, the likelihood of obtaining data with integrity is increased.
School Reflection on Problem Analysis
The hypotheses in question are discussed during team meetings, and the type of data collection methodology or assessment procedures are outlined. All parties agree to a timeframe and how data will be submitted. The importance of contextualizing the assessment cannot be overstated, in that the problem analysis must be connected to and inform everyday functioning at home, in the community, and at school. When school concerns are identified, problem analysis transpires on an ongoing basis via phone or password-protected emails, and/or in-person meetings for training and standardization.
Application of Problem Analysis
Hypotheses developed from problem identification are outlined below and showcase how school personnel may be included in the treatment process to inform ongoing assessment (if needed) and intervention development. Of note, problem identification and problem analysis are recursive and iterative processes, so there is some overlap in procedures administered across stages. That is, the stages fluidly inform one another and can be revisited as needed. Sometimes when the assessment results are provided or the intervention recommendations are made to the school, the parties feel (p. 402) like the answer has been provided and the route has been paved. However, we argue that without constant reevaluation and inquiry, the student’s progress will be halted rather than observed and measured.
Hypothesis testing by SM is targeted to determine the discrepancy between the environmental expectations and Susan’s present performance:
Academic data plan: A special education resource specialist will complete a curriculum-based assessment in all subjects with Susan. Testing will occur on different times and days, and results will be sent to SM. SM will interview Susan with a semistructured interview related to her perception of academics and self-efficacy. SM will conduct classroom observation of Susan’s behavior compared to peers using the Behavior Observation of Students in Schools (BOSS; Shapiro, 2011). The interview and the observational data will be discussed with the classroom teacher to ascertain the representativeness of the data.
Individual Within Family System data plan: Susan’s teacher will complete the Children’s Depression Inventory and the Depression and Anxiety in Youth Scale (DAYS; Newcomer, Barenbaum, & Bryant, 1994) at multiple points to assess for mood and anxiety symptoms. The teacher will also complete the Social Skills Rating System (SSRS; Gresham & Elliott, 1990). SM will interview the teacher about Susan’s peer relationships. SM will complete a recess, lunch, and/or playground observation to assess Susan’s interactions with peers, with consultation from teacher. The Parent Stress Index Short Form (PSI-SF; Abidin, 1995) will be provided to Susan’s parents to ascertain dyadic functioning in the home.
Social data plan: The school psychologist will interview recess/lunch personnel and students to develop a peer social network map. SM will interview the school psychologist to determine bullying culture on campus and whether Susan and/or her peer network have been involved in office referrals related to bullying. Given the importance of self-perception as it relates to the social milieu, Susan will complete the My Life in School Checklist (Arora & Thompson, 1999) and the California Bullying Peer Victimization Scale (CBVS; Felix, Sharkey, Green, Furlong, & Tanigawa, 2011).
A broad-based approach to neuropsychological assessment dictates that all domains of functioning are explored without too much influence of prior hypotheses. This means that while LG often has an a priori idea of the primary reasons for problematic presentation, he is open to the data dictating alternatives. For example, with Susan there appears to be an attention deficit identified during problem identification (i.e., the “daydreaming”); however, data may reveal that language deficits actually preclude her from attending to language-based instruction, and/or that preoccupying anxiety drives the inattention. Hypothesis testing by LG includes gathering a developmental history, collecting standardized ratings of functioning, making contextual observations, and conducting psychometric and/or projective testing. All domains of functioning are assessed with a relatively fixed battery, and then specific areas of concern are flexibly explored further, with an eye toward both the psychometrics (i.e., the data) and the process (i.e., how the client approaches tasks). Considering problem analysis as it applies to Susan and the potential (p. 403) hypotheses, attention, anxiety, mood, learning, and language will be specifically explored in greater depth.
First, LG will gather a developmental history and complete a record review of symptoms across settings since early childhood, extending from the history gathered in problem identification. LG will examine specifically for patterns of challenges with attention, anxiety, mood, learning, and/or language. Second, LG will collect standardized ratings from Susan, her parents, and educators. Forms may be broad-based (e.g., Behavior Assessment System for Children-3 [BASC-3]; Kamphaus & Reynolds, 2015) and/or more specific to the concerns (e.g., Conners Rating Scales-3rd Edition [Conners-3]; Conners, 2008). Next, LG will make contextual narrative observations of the referral concerns across settings. Finally, LG will conduct psychometric testing to explore areas of challenge, comparing Susan’s performance to both the general population and her own performance across tests. In addition to overarching measures (e.g., Wechsler Intelligence Scale for Children-V [WISC-V]; Wechsler, 2014), specific tests will focus upon attention and executive functioning (e.g., A Developmental NEuroPSYchological Assessment-II [NEPSY-II]; Korkman, Kirk, & Kemp, 2007), anxiety or mood (e.g., Rotter Incomplete Sentence Blank [RSIBS]; Rotter, Lah, & Rafferty, 1992), learning and memory for rote versus contextual and verbal versus visual materials (e.g., California Verbal Learning Test-Children’s Version [CVLT-C]; Delis, Kramer, Kaplan, & Ober, 1994; Rey Complex Figure Test [RCFT]; Meyers & Meyers, 1995), rote, speeded, and conceptual academics (e.g., Woodcock-Johnson Tests of Achievement-IV [WJ-IV]; Schrank, Mather, & McGrew, 2014), and receptive, expressive, and social language (e.g., Clinical Evaluation of Language Fundamentals-5 [CELF-5]; Wiig, Semel, & Secord, 2013). The entirety of data will be analyzed within a developmental context of expectations for Susan’s age, school, and family.
Plan implementation involves selecting and clarifying interventions, monitoring progress, and planning interventions across settings. After data collection, results are analyzed and integrated to develop an accessible compendium (SM) or a neuropsychological report (LG). LG then coordinates care, whereas SM (in conjunction with other providers) implements interventions. Coordinating care means “quarterbacking” the intervention plan across providers without providing treatment directly. In essence, LG serves as an intermediary and consultant to all the team members so they have a common understanding of how to orient treatment for the family. Once the team has been established, LG is no longer an active part of the process. A rationale is provided for treatment recommendations to the interdisciplinary team, which includes the family, in order to motivate and facilitate treatment plan integrity and accountability. Furthermore, the importance of data collection is discussed to obtain quantifiable information on progress (or lack thereof) among parties, and methods for collection are agreed upon. Data collection may differ for each party (e.g., surveys, frequency counts) based on time, accessibility, and background experience in data collection.
(p. 404) School Reflection on Plan Implementation
The way in which the plan is implemented within public schools depends upon how the presenting problem directly impacts access to academic and social curriculum, school-based funding, and available resources/staffing on site. Once resolved, the challenges of this phase when working within schools are at least threefold: (1) stray from the original intended intervention because of varying beliefs or expertise; (2) motivation to continue once some positive change has been observed; and (3) completion of ongoing data collection because of time constraints.
To circumvent some of these challenges, private practitioners are advised to do the following:
1. Visit the classroom to observe the intervention and provide feedback on the integrity of the intervention. Inform the educational party that you are planning to do this, and link the rationale in support of the educator and student.
2. Frequently and honestly acknowledge the educator’s efforts and offer support, as needed.
3. Follow up with the people who are collecting data with graphs or other visuals to highlight behavior change, if any.
The point is to circle back with meaningful information regarding progress monitoring so that educators are not merely “reporting” to the clinician. Educators are an important part of the assessment team and should be treated as such. Again, the educational collaborative model should consist of a flow of information back and forth, rather than being unidirectional.
Application of Plan Implementation
Confirmation of numerous hypotheses was intentionally chosen so the reader could see different plans that result from a problem-solving model. General recommendations (SM) are given below to highlight the importance of institutional barriers and their impact on the type and intensity of an intervention. Specific recommendations (LG) also follow to provide a tangible example of what might be reflected in a neuropsychological report for Susan.
Intervention Plans and Recommendations Driven by Hypothesis Testing
Academic Intervention Plan/Recommendations
Frequently, advocacy is required when students’ academic functioning is compromised but has not been acknowledged by the public school system. Consultation with parents may include a request for a Student Study Team meeting or Section 504 Plan, or an assessment for an Individualized Education Plan (IEP) for further instructional remediation. Private practitioners may be involved in informing parents about special education law and rights; however, if legal support is required, a (p. 405) referral to a special education attorney is warranted. Further, clinicians may provide feedback and commentary on assessments that are completed by the school to support parental understanding. Finally, clinicians may attend meetings to advocate on behalf of the youth to obtain services and render an expert opinion.
Depending on the nature of the skill deficit, families may also be referred to an in-house resource specialist or community learning specialist with expertise in the psychology of education and academic remediation. The resource specialist in schools is an important player to collaborate with when academic deficits are identified. The resource specialist will be able to consult with the teacher on educational strategies as well as provide group intervention. Outside learning specialists frequently work with psychologists and schools to provide guidance on a student’s stress levels and ability to perform at grade level by providing recommendations that may be used in the classroom, as well as guide schools regarding educational accommodations.
Individual Within Family System Intervention Plan/Recommendations
Depending on the transparency a family desires with the school, home–school logs serve as tools for parents and teachers to communicate on a daily basis about a child. Parents may be able to report to the teacher events that arose at home that can impact a student’s school performance. Likewise, teachers might report to parents about school happenings to encourage parental understanding of what the student may exhibit emotionally or behaviorally at home.
When an IEP is developed, students could receive psychological services in the school system either via individual or group psychotherapy. Consultation with the school psychologist also may be productive to determine if the school has an organized social skills group on campus that uses programs like the Prepare Curriculum (Goldstein, 1988). Such school-based groups provide meaningful and realistic interactions for the client. Typically, this provider and the private practitioner collaborate, especially when there are major events that will affect treatment in either environment. This wraparound model frequently provides the enhanced support that students need when they are experiencing psychological distress by providing multiple support personnel who are focused on different but overlapping goals.
If groups will not be provided at school, outside clinicians might recommend that teachers support social skill development through natural activities on campus (e.g., line leader, class homework collector, and mentoring of younger students) where the client can receive positive reinforcement. Additionally, antecedent management (e.g., environmental manipulation of variables that promote success before a problematic behavior occurs) may be appropriate for educational professionals, such as establishing routines or specific rules and procedures, or using prompting and modeling to facilitate social skill development. Again, in working with the psychologist, teachers can make fairly minor changes that will have a major impact on the student.
Social Support Intervention Plan/Recommendations
Bullying is for the most part a systemic issue in schools. When one child reports bullying, often there is a pervasive concern impacting not only the client but also other peers, the client’s parents, (p. 406) and even school staff. Recommendations and intervention planning for bullying behavior on school grounds can be categorized into three domains: individual, parent, and school.
The etiology of the bully–victim paradigm needs to be ascertained before an individual intervention is implemented. Individualized approaches may include assertiveness training, social skills training, and/or enhancement of self-esteem. A key feature is providing psychoeducation to the school about the student’s needs and why the accommodations could have a positive impact on the client and the entire educational forum (both for teachers and other peers).
Parents frequently request information on their role as an advocate for their child when bullying is reported. Providing parents insight into how to discuss and document the nature of the problem with the school is critical. Second, guiding parents to state legislation related to the scope of due diligence in schools provides justification to parents for requests of enhanced supervision. Finally, it is important to coach parents on how to speak to their children about the incidents in a manner that does not compound hysteria.
Private clinicians may speak to the school about general teaching approaches and how they promote or deflate bullying (e.g., modeling prosocial behavior and respect for diversity and differences; positive behavior support). Private clinicians might also speak with administrators about school policies and procedures specific to bullying (e.g., annual training, procedure manual for bullying, incident reporting system). If the school does not address bullying in a systematic way, there is an opportunity for organizational consulting and in-service training for outside providers with this expertise, as an adjunct to clinical practice.
These plans were general in nature so the reader may understand the multitude of variables involved in hypothesis testing and the possible avenues to explore for children in school. Next we will list specific recommendations by LG to provide a tangible example of what might be reflected in a neuropsychological report for Susan.
Intervention Plans and Recommendations Driven by Neuropsychological Testing
Susan has a language disorder that is impeding her progress at school (i.e., specifically in reading-writing) and is generating angst, confusion, and conflict across settings. Recommendations may encompass additional assessment (e.g., by language and learning specialists), treatment/remediation, accommodations, educational programming (e.g., via an IEP), and general considerations. This plan focuses upon treatment and accommodations.
Treatment recommendations are prioritized by importance given Susan’s current stage of development and functioning. Note, however, that these interventions should work synergistically, in that a substantial amount of Susan’s emotionality stems from her language and learning deficits, and her language and learning capacity are diminished when dysregulated.
Three primary treatments are offered for Susan:
1. Begin language therapy for weaknesses in expression and verbal working memory. Exercises that may be helpful for expression include “mapping” words by category, (p. 407) subcategory, similarities/differences or other associations, as well as practicing scripts that allow for more fluent expression. Build Susan’s verbal working memory through practice of practical tasks, such as following multistep directions, listening while taking notes, and proofreading with several ideas in mind. Teach her strategies that functionally improve expression and verbal working memory in everyday life. Some cultivation of organizational learning strategies (e.g., paired-associate, chunking, chaining, semantic networks, graphic organizers) would also be beneficial given Susan’s tendency to take a serial or haphazard approach to her learning when overwhelmed.
2. Start psychotherapy support for emotional regulation. Nonverbally model and teach coping skills for Susan to self-monitor and regulate, drawing upon cognitive-behavioral therapy and mindfulness techniques. Also foster Susan’s verbal expression of emotions but do not expect Susan to communicate that effectively verbally, especially when upset.
3. Initiate learning specialist direct instruction in phonics and orthography to address Susan’s underlying reading-spelling weaknesses. Multicomponent programs are most effective. These programs provide direct, multisensory instruction in decoding coupled with explicit strategy training on identifying and retrieving words (or word segments) and their meaning, with integration of cognitive-behavioral techniques to optimize motivation and self-esteem.
For accommodations, Susan’s language disorder substantially limits her ability to address academics and activities of daily life. This is in concordance with the major life activities defined in Section 504. The following accommodations will allow Susan to access her environment and will ensure a valid assessment of her skills and ability:
1. Tap Susan’s nonverbal strengths by teaching visually and kinesthetically whenever possible, and by pairing verbal with visual material. Verbal instruction should be delivered in short chunks (i.e., to accommodate Susan’s learning profile and limited verbal working memory).
2. Provide Susan visual outlines for multistep activities and/or discreetly check in with her to make sure she remembers the steps (i.e., to accommodate Susan’s limited verbal working memory).
3. Encourage active participation from Susan and speaking in full, grammatically correct sentences while also allowing for alternative means of communication (e.g., shorter phrases, nonverbal gestures). Avert withdrawal due to limited expressive language, both in class and on the playground.
4. Assess Susan’s learning via recognition more than recall formats (i.e., because she knows much more than she can demonstrate via spontaneous retrieval and expression), and provide cues and scripts for writing (i.e., to accommodate limited retrieval of language).
5. If Susan’s reading-spelling cannot be fully remediated, provide audible presentation for academic text, allow use of spell check, and grant Susan 50% extra time for assignments, tests, and exams that require reading.
(p. 408) Plan Evaluation
Plan evaluation examines the effectiveness of the treatment plan and determines whether the goals have been met. Plan evaluation may reevaluate problem analysis if goals are not attained within the expected time. Decisions on generalization and fading of the treatment protocol are the final steps of this phase, pending improvement. Plan evaluation may take the form of readministering initial survey instruments and/or reviewing the data for a stable change in the target behavior. The team may have dissenting opinions on the need for further treatment and/or how and when to end the protocol during this phase.
School Reflection on Plan Evaluation
Unless a client has a documented deficit on record through a Section 504 or IEP, this stage might not be formalized. Frequently, when clients partially meet their goals, the incentive to maintain the protocol or collect data wanes because of the following: (1) initial excitement that the client has progressed; (2) time constraints that limit data collection and ongoing discussion of the client; and/or (3) the needs of other students supersede the client’s needs because of the presumed improvement. Unfortunately, the overarching sentiment often results in premature termination of a treatment protocol and/or a lack of insight into why a child regresses to baseline functioning. This sentiment should be addressed, and if dissenting opinions remain, educational advocacy, consideration of private services, and review and presentation of the data may be helpful.
Moreover, it is important to consider that serving as an offsite consultant to schools presents challenges different than those experienced by school-based clinicians. The degree of case management to stay apprised of a client’s progress, with possibly multiple-school based informants, can become overwhelming when carrying a large caseload of clients requiring collaboration, ongoing communication, and data collection. Furthermore, when a client ceases to make progress, families frequently attribute challenges to the school (rather than other variables like the treatment program, client and family motivation, therapist fit), which creates further tension in this phase. As such, plan evaluation sometimes takes the form of multiple meetings with different subsets of the interdisciplinary team prior to meeting as a whole.
Application of Plan Evaluation
Plan evaluation may vary depending upon the data and process outcomes from plan implementation, as well as the parties and resources involved.
Plan Evaluation (SM)
Plan evaluation begins with a review of the treatment plan and the progress made, which is conducted on a monthly basis with Susan’s family. The review includes degree of goal attainment, (p. 409) which is ascertained from qualitative and quantitative information provided by the family and the educational community, as well as direct feedback from SM. This is also an opportunity to process the collaborative relationship more directly so that the practitioner, Susan’s family, and educators can openly share concerns that may come to light through the review of progress. Often, a family may become uneasy about continuing services; this can be expressed by the following cues: commentary about client progress and concern over the impact of continued treatment; frequent missed sessions, with little to no information provided to the clinician for the absences; and/or diminished interest in ongoing data collection or the therapeutic relationship.
Given standard therapeutic issues like transference and interference of defense, frequent plan evaluation promotes communication in a structured way if either therapist or client develops conscious or unconscious barriers during the treatment phase. Once the family has had the privacy within the office setting to share and discuss progress, the school is then contacted. The same process ensues with the school in terms of each member sharing his or her impressions (and data) of progress and any concerns that may be impeding the student’s progress.
Plan Evaluation (LG)
Neuropsychological assessment as a billable service does not entail plan evaluation because the assessment process naturally ends once recommendations are made, and there is no ongoing treatment relationship with Susan and other parties. However, neuropsychologists in private practice may structure their services to maintain some ongoing consultation with the client and educational community so they can field questions as they arise given the assessment. There are also opportunities to monitor progress by reassessing targeted areas and/or doing a more complete reassessment years later at major life transitions and/or following a change in mental status.
Growing Opportunities for Private Practitioners in Schools
Over the past several years, we have engaged in discussions about the nuances and complexities of working with children who present with psychological symptoms related to (1) the emerging pressures of private school and college applications; (2) peer-to-peer academic competition; and (3) media portrayals that focus on academic rigor and excellence rather than personal well-being. These pressures necessitate extra support for the individual, family, and organization. There are myriad opportunities for private practitioners, including applied research, organizational change projects, teacher in-services, consultation to administration for threat assessments and crisis management, and/or consultation focused on larger systemic school concerns such as teacher turnover and satisfaction.
(p. 410) Ecological Considerations
Global, national, state, local, and school-specific trends directly impact the roles and responsibilities of private practitioners working in school systems. To enable success and promote a cross-discipline understanding, clinicians may consider the following questions facing the educational community:
1. What global issues impact educational decision making (e.g., social media, globalization, outsourcing of jobs)?
2. What national issues impact educational decision making (e.g., Response to Intervention vs. IEP implementation, Common Core, transgender student equality)?
3. What state issues impact educational decision making (e.g., special education eligibility criteria, intersection of state with federal funding mechanisms, privacy laws)?
4. What local issues impact educational decision making (e.g., socioeconomic strata, taxation, funding sources)?
5. What school issues impact educational decision making (e.g., changes in administration, alternations in curriculum, school climate)?
By defining and understanding the roles that educators may play, we can lay the foundation for an active partnership whereby clients maintain the ability and autonomy to make decisions in their own care. Private practitioners should aim to support families holistically by acknowledging the importance of the educational community within the ecological context. By doing so, practitioners can help clients consider the clinical gestalt as well as identify the systems of care that may improve outcomes during the assessment and treatment process. The role of private practitioners in the educational community is to serve all parties in a collaborative way by providing education, enhancing communication, and promoting well-being.
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1. Case vignette does not represent an actual client but is indicative of a typical pediatric case.