Good morning and welcome to the Supporting Children in Education session. Before we get started with this session, we would like to take a few minutes to honor an individual, my program director, a great mentor, and it's an honor to be working with her. I have the distinct pleasure of presenting Dr. Cecilia De Vargas with the Agnes Purcell McGavin Award for Distinguished Career Achievement in Child and Adolescent Psychiatry. This award was first established in 2000 and is presented to a child and adolescent psychiatrist who has been noted for outstanding contributions to the advancement of child and adolescent psychiatry in activities such as teaching, research, writing, clinical care, advocacy, and policy. Dr. De Vargas is an associate professor at Texas Tech University Health Sciences Center at El Paso in the Department of Psychiatry and the program founder and director of the Child and Adolescent Psychiatry Fellowship. Becoming a child and adolescent psychiatrist was her dream come true as she believes children are the essence of life and deserve safety and well-being. Dr. De Vargas teaches residents, fellows, and medical students, supervises clinical work to clinically diverse underserved population, and participates in research studies on impact of violence in children, trauma and resilience, TMS of the brain, and pediatric obesity and mental health. Please join me to congratulate Dr. De Vargas. Thank you. I am not going to take too much of your time. I am delighted that you all are here. I'm proud of the work we do at Texas Tech in El Paso. The Child and Adolescent Psychiatry Fellowship is doing great. He's 11 years old, almost a teenager, but he's working very, very well, thank God. Dr. Mejia is one of the fellows, the chief fellow this year, and I hope I am not dreaming. If this is a dream, I'm so glad that you are all in it, and I am so glad to wake up in a beautiful place in the United States, New Orleans. Thank you. Wow, what a lovely way to start our presentation. Thank you all for being here. My name is Kristen Pearson, and I'm here with Dr. Black and Dr. Stevens. Can you all hear me okay? And we are all a part of the Department of Psychiatry and Behavioral Sciences at Tulane University here in New Orleans. We are all psychologists, primarily work with children. So I want to give you a little bit of background for why we're here today. We actually all share in common a place in New Orleans called the Center for Resilience. It is a day treatment program, a therapeutic program for children who primarily have experienced trauma. Dr. Stevens is the founding psychologist and founding clinical director for the Center for Resilience, and she is still involved in some ways implementing an intervention called Preventing Long-Term Anger and Aggression in Youth, and she's off doing other great work as well. Dr. Black was a post-doc for a couple of years as a clinician at the Center for Resilience, and now he is primarily working in early childhood consultation work. So we all kind of stay at this intersection of education and mental health, and that's kind of how we've all connected, and we care a lot about this work. So that's what we are here for today, and we're really glad to have you all. Thank you for being here. Okay, so we have, I don't know, about an hour or so to talk to you all about what I just described, and within this hour, we want to accomplish these things. So Dr. Stevens is going to give us a little bit of background on why we should care about the intersection of education and mental health, and then we'll also mention why it's important to include educators in treatment planning. Then we'll spend a little bit of time talking about the systems in education and common language. It's quite a vast system, so we just want to help us all be working from the same knowledge base with the same lingo. So we'll spend a little bit of time there, and then Dr. Black will lead us through a couple of examples, thinking through cases in problem-solving with families and how to support them. So that is our plan for today, and I'll bring Dr. Stevens up now to get us started. Thanks, Dr. Pearson. I think I can safely speak on behalf of all of us, too, that we're a pretty informal crowd. So we just talked about ourselves. We want to hear about you a little bit. So I want to know who's in the room. How many of you are psychiatrists? Is that like almost everybody? Okay. If you're not a psychiatrist, then what are you? Social work? Hey, social work. Social work. Professional therapy. Okay. All right. Cool, cool, cool. Trainees? Anybody in training right now? Yeah, trainees. Okay, cool, cool. Anything else that I missed? You just wandered in. Yes, ma'am? Educator. Educator. Okay. All right. Hats off to our educator. Thank you for being here. Any other psychologists? We're the lone wolves. Oh, man. Okay. All right. Well, y'all can eat us alive if you like, but we're at least being very collaborative, so hopefully you'll come off that way. Also, I want to know regionally, where are we from? Louisianians? Well, welcome, y'all. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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So we want to rewrite the narrative for kids who are having hard times in education or not. But basically, one thing we know is if you think you're a good person, if you think that there's nothing you can do to really make me mad at you, as one of my favorite colleagues said, nothing that you can do that really makes me think you're bad goes a long way. Medication goes a long way too, but that sort of self-reflection, that narrative about yourself and knowing that an adult thinks that is huge. I mean, I'm sure we all know about ACEs. Do we know about PACEs? Protective factors. So if we outweigh the protective factors, no matter how many of the ACEs that we have, the balance shifts and that's what we're trying to do. And one other way that we found helpful to kind of communicate this stuff, talking about that language barrier between our different disciplines is this iceberg model. So we all know the story of the Titanic. Titanic hit the iceberg because they didn't see what's underneath the surface. Boom, that was that. So we use this analogy to think about really like, a lot of times when we're reviewing, say referrals to our clinics, you see page after page after page of behavior problem. Kiddo ran out of the class. Kiddo hit somebody, threw a chair across the room, whatever, whatever. Useless information. You could just tell me one time, this kid has behavior problems. I don't really need to know every single thing he's ever done in his life. What I wanna know is like, what is contributing to the behavior and how can we help our colleagues think about that as well? Not only because it helps us do our job better, like I don't know what to do about throwing a chair across the room. One of you throws a chair across the room at me right now. I don't know if it's called security, I don't know. But if I know like you're having a really bad time and if I can figure out why, I could probably be more helpful. So that's one thing. It just makes us more effective, all of us. But the other is I think it enhances empathy. So again, if I think you're just this badass kid who wants to like make everything hard, it's harder for me to fight my burnout, my stress, my whatever, and really think about you as a person. When I think about you as somebody that like, maybe hasn't had a full meal in a while and maybe that's why you're stealing food from the cafeteria, it's a different story, right? So that's where we're at. And I'll turn it back over to Dr. Pearson. Thank you, Dr. Stephens. And just one more thing on that is, and Dr. Stephens, you alluded to it earlier that there are disparities in education. And I think we just included this here because we want you to know that it's a reality in the education system that black students are disproportionately disciplined, students of color, minority students are disproportionately disciplined. So you might be finding that you're working with students who have been expelled, who have multiple suspensions. And for example, in New Orleans, black students are twice as likely as white students to be suspended. The rate is three times the rate for white. Yes. Thank you. And in 2017, 303 kids were detained and of those 96% were African American. So there is an over-representation of black students. And I think we just tell you that to know that it is a reality and that this is what kids are facing in many education systems across the United States. Okay, so now we'll get into some of the systems in language and education. We're just gonna try to get through some of those so that we're all on the same page. Please interrupt us with questions. Dr. Stephens, Dr. Black, please jump in if I miss something. So we'll start here. This is provided to us by one of our colleagues and it's just here to exemplify the complexity of the education system and serving children with mental health concerns. So this is just like to show you all the different steps, all the different things that go into it. And I guess maybe just to validate that it is a difficult system to push into very easily. So a lot happening on the background behind the scenes for mental health and education. So how familiar are we with response to intervention? Do people, just some of us know? Okay, so this is the main system for intervention in most schools. So it is a multi-tiered approach to... Can you hear me now? Okay, multi-tiered approach to supporting and identifying students that need more services. So at the base of it, we are providing all students with an evidence-based approach to learning and to receiving mental health services. And then as we screen and as students fail to respond to certain interventions, we move them up to higher level of services. So it's a way of approaching the entire population of students in your school. This is implemented better in some places than others. So it looks very different in many different places. This might help, this graphic here might help to explain it a little bit better. So the bottom tier of the triangle is all of the students. And it works, the universal interventions that we implement at this bottom tier works for most students, about 80 to 90% of students will respond perfectly fine to our evidence-based interventions, our universal curriculums that have been scientifically validated. It works for most of our students. But then there's a group of students through screening and through other assessments that we find aren't responding to the interventions that we're implementing at the first tier. And that's about five to 10% of students. So the schools will then implement certain interventions that are empirically validated at that tier. And then again, as we assess, we find that about one to 5% need to go up to the more intensive, individualized, intensive interventions, high intensity. Some people think about the top tier as being special education. Some people think that you can still have that level of intense intervention without actually having a child in special education. Sound good, Dr. Black? Can I just add one thing? Yes, please. I think that if you're looking at these percentages and you get to a place where the number of kids who have significant challenges are outside of the five to 10% or the one to 5%, then you need to go to a place or recommend to people go back to a place where they're reevaluating the universal intervention. Because if the majority of your kids are falling in the secondary intervention place, then that means another approach needs to be taken to address the bulk of the needs. And I know, at least in my experience, I've seen that in schools in New Orleans where the majority of the students do have significant trauma history, so they do have to implement universal interventions that are more targeted, that you would typically maybe do in a secondary or tertiary level. But it's more appropriate for universal because you have so many kids who have experienced things or would respond to those interventions. Exactly. Yeah, this is definitely the ideal scenario, but it certainly is not what a lot of our schools look like in New Orleans and in other places. And have y'all found that parents don't often know to ask about this? Of course. Yeah, yeah, definitely. Okay, we'll go into it a little bit more just to make sure you're understanding the first here. There are systems for academics and systems for behavior. For academics, this would be your empirically validated curriculums, your culturally responsive curriculums. For behavior, you want to have very clearly and positively defined expectations so kids know what they should be doing. You're teaching them the desired behavior. You're recognizing when they're using the desired behavior, you're reinforcing it, and then you also might have a social-emotional learning curriculum. Again, this is great in some schools and really other schools are struggling with this. If you could speak up a little bit. Yes, thank you, so sorry. Okay. Okay, so then we have tier two. So the students that are failing to respond at the first tier go into these smaller groups. In academics, that would be like a small group instruction, like a pull-out, they go into a smaller classroom for a little bit more intensive intervention. For behavior, one that's frequently used is check-in, check-out. That's like where a student checks in with an adult that you've built a relationship with in the morning, you go over your goals, and then at the end of the day, you check in with that same adult to see how you did for the day. So that's an empirically validated intervention that's implemented regularly on the second tier. We might also have social skills groups. So if you do some kind of universal screening where you're finding that there's a group of students who are maybe behind in their ability to connect with their peers, then you might pull those students for a little bit of intervention and connecting with other kids. There might also be mentoring programs. So a little bit more intense. And then finally, at the third tier, you have very individualized intensive interventions academically and behaviorally. This is, like I said earlier, oftentimes where you might start to consider evaluating a student for special education. You do individual counseling. We'll talk about an FBA and BIP, which are probably words that you hear a lot. Yes, please. There's a question. For the check-in, check-out program, are they actually supposed to be describing their mood? Is that part of the check-in complaint? My patients are describing it to me. That's how I understand it to be. But you kind of describe it a little bit differently. So I'm kind of curious what the program actually says is supposed to happen during that. Yeah, Dr. Black, I don't know if you know better than me, but I think you can individualize it to the student. So if mood is a part of what that child needs, then maybe they would make that a part of the check-in. Say a little bit more about what you mean, like they're talking about the mood. Is that like a goal that they're working towards? I guess my biggest issue is that my kids don't understand what their mood is. That's why they have their expressions and behaviors. They're asking them to do something they're not prepared to do, so they kind of make up a word, say, I'm good, so that they're allowed just to go do their thing. But so that's where I kind of get that hiccup, so I didn't know specifics of the program. I guess I also didn't even realize it was an evidence-based program. I just thought it was something that was just kind of used. Well, yeah, and I think it is, absolutely. It is sometimes used as it is meant to be implemented, and then other schools have adapted it, and I think that that is really good feedback, though. I mean, if I were a teacher, I think I would love to hear that from a mental health professional, that actually this is asking the student to do a little bit more than they're capable of right now, and ideas for how to get them to that point. But that's a really, really great point. Thank you. Which I agree with, but I find that it's overwhelmingly negative data. I've seen my parents get burnt out, because they're like, I don't even hear a good thing about my kid. Exactly. And when you're setting up check-in and check-out, you're supposed to do the behavior that the kid is working on, but also two things that they already do great. So it's not they're coming in, and they have three things that they aren't being successful with, but it's two things they already do, and that's added on there, so they have the motivation, and the percentage for which they are able to do the thing that is difficult. Should start level, like 60%, should be what they're shooting for, and then eventually increase to 70 or 80. But you're right, it shouldn't be morale, like, I don't know, not boosting, something with the other word. Like, it shouldn't bring down their morale or make them less motivated. It should be something that's encouraging them, and that they have a hand in developing. So, like, what are they motivated by? Like, I've had kids that did it for hot chips. So every weekend, I'll go buy a big box of hot chips and have a bunch of them in my office, and that's what we would do. Like, they would work for them, and that's what their motivator was, and eventually you pull it away. I mean, just like the way behavior works, but yeah, it should be something that's like motivating them, and they feel successful, because if they feel discouraged at the beginning, then why the hell engage in it, you know? That's where I see a lot of failure. Yeah, it seems like a really great opportunity for consultation with your understanding of mental health and being able to work on fine-tuning some of the interventions, like check-in, check-out. Because yeah, I think it's, I mean, maybe they're just given a form, you know? I don't think they're necessarily trained in administering check-in, check-out, so. Yeah, so the FBA and BIP, these are words that you probably hear a lot in schools, this is at the third tier, when we're having consistent behaviors from a child that we need to understand and address. And there are certain points in special education that require the, like the evaluation and the implementation of an FBA and BIP, but they're also used as just a way to understand. So the functional behavioral assessment, that's where you're looking at the specific behavior, you're defining the behavior, and you're trying to understand what the antecedents of the behavior are and what the consequences of the behavior are, so that you can try to intervene in those ways. So what things are contributing to the behavior, is there any potential for changing those, and then what things might be sustaining the behavior? A lot of times, what they will determine with an FBA is that a child is engaging in some behavior that's more for attention, to escape. Those are big, big underlying things that come up, attention and escape. And we know, there's more to the picture usually, a lot of times, so like Dr. Stephens had her iceberg up, we know that maybe there's trauma behind the attention and escape, maybe there's anxiety, depression, I mean there's so many different things that could be going on in the background, that this is a little bit reductive of what the actual issue might be, but it is still good data. So from the assessment, they then use that data to implement a behavior intervention plan that's individualized, and usually that involves manipulating the antecedents and the consequences. So if the behavior only happens after the student is called out in class, then maybe you try not to call on the student in class. Or if the student receives a clip moved down every time that they are yelled at or something, then maybe we don't do that, we try a different way to reduce the problem behavior. Absolutely, thank you for saying that. I think in schools, everything does tend to be way more behavioral than understanding what might be behind the behavior. So it could very well be that that's not developmentally where they are right now, but I think schools, their approach tends to be more, let's think about what's sustaining or creating the behavior. There is a component of teaching the behavior, so if it does seem like there is something that the student can't do, and there's opportunities to teach or work with an individual counselor in some way, then that could definitely be a part of it. To that point, though, I think it's important for us also as advocates to make sure that's a known fact. Because if I'm thinking a kid wants to earn a bunch of stickers, and they can't earn the stickers, because they can't do it, then to Dr. Black's point, we're just setting you up for failure. So the reward systems only kind of work if that's actually within your zone of proximal development. And I don't know that our educational colleagues have the time or capacity to even do that deep level of thinking about it. They're not often supported in spending a whole lot of time on these issues. Yeah, I think that goes back to your point about check in, check out. If it's a goal that they're just not capable of doing, they won't ever achieve. So I think you're bringing up really great spots for consultative work to be able to work through some of these things, because it shouldn't be assumed that everyone's on the same understanding and page about it. It all depends. Yeah, yeah. It all depends. It depends on your setting, and what sort of resources you have, and how your school system is set up. Oftentimes, at least in my experience in South Louisiana, schools have SATs, which is the Student Assessment Team. And the FBA and BEP is just done by somebody on campus who has that knowledge. Oftentimes, it's a psychologist, but it could be school social workers. It could also be a special education teacher, because it is composed of collecting that data, determining the antecedents and consequences. It's great that it's done by mental health professionals in your setting. I would love to see that across many other settings, but it also just depends. And I think that also speaks to the fact that sometimes it may not be done with fidelity, or done in a way that actually considers all of the aspects, because a lot of people don't have a mental health brain, or don't think about things from that perspective, and only see what's in front of them. So I think it's great that, in your experience, it has been with some professionals, but that's not always the case. Now, if we're finding that the child is not responding at any tier in the RTI system, that is usually when a referral to special education, a referral for an evaluation is typically made. There are special education categories. Some people call them diagnoses, but they're different from mental health diagnoses. And that's why sometimes we might provide a school with a diagnosis, but that doesn't necessarily mean that they'll qualify automatically for a special education category. The criteria are different. But these are the different categories. Other health impairment is one that captures like ADHD a lot of times. We see that one a lot. Can I say something? Yes, please. As Africans, I think it's really important for us to know that oftentimes parents will come to mental health professionals looking for evaluations that they want to take to schools. For all school systems, but in Louisiana, that evaluation does not even have to be looked at by the school. Because if they don't qualify based on Bulletin 1508, which is Louisiana's sort of like handbook for qualifying for special education, then your clinical evaluation that either insurance paid for or parent paid like a pretty penny out of pocket for does not necessarily mean anything to the school system. So I think that's important in us understanding the system so we can refer and give parents like actual information on what they are afforded. Because when we talk about public school systems, actually even kids I think who are in private school or who homeschooled who live in that parish or county, the school system is required to evaluate them if they suspect some sort of disability. Because I know parents often pay like a few thousand dollars for private evaluations and a school would look at it and it would never leave their file, it plays no role in them actually getting services. So I think it's important to, and I mean I'll talk about this a little bit more when we talk about collaborating, but to better understand what is available in your area and best guiding your parents. Because often times the kids who need these supports, parents aren't able to afford an evaluation that will not necessarily lead to any change in the school setting. No definitely. So true. I've encouraged many parents to actually put things in writing to school systems. Of course you write it down and say, I want my kid, evaluate if I suspect a difficulty or disability in my kid, at least in Louisiana they have 10 days to respond to that. It's not necessarily that the evaluation will happen then, but they have to address it legally. Not to say that every school will, but it does kind of like try to address that timeline piece and actually get something rolling. And I come from a place of understanding how schools are taxed. I've worked in them, lots of family members who are in school settings, so I think it's important for everybody to understand everybody's perspective and what they're able to do, but also the limits of what they can do in trying to make sure that they address the needs of the kids and families. I've seen so many times where parents will ask the school and the school will say, no your kid's fine, they don't need that, they don't need the evaluation, other keywords, something they should be writing it down. Like if they write, put it in writing, and also looking to see what local advocacy groups are available in your area, because they have groups that actually advocate for families to support them in those ways. Because also schools can be scary places, not necessarily knowing what is available or parents who have their own crappy experiences in special education or with those same schools, depending on if they grew up in that area. So like putting things in writing, and I would also like communicate it to multiple people. And I'm glad that you're able to advocate for those parents, because a lot of times they're like going through this system blindly. I mean, it's confusing for us as professionals to understand and think about a parent who has their own stressors and their own stuff going on, to try to figure it out for their kid who is also having difficulties. Because parents and a kid who has their own difficulties is not an easy feat. Like both of my sons probably benefit from some supports, but we have to make sure that we advocate for those. And I'm assuming that's why everybody's here, because we want to learn ways to best support them. And I mean, probably for real reasons, too. I mean, I think you described it in a real way, but I guess one way is to try to have them. Oh, sorry. We need everyone to speak into the microphone, please. Okay. Sorry. Oh, for questions. I guess one way is to have them maybe check in with other people who have experienced similar things. I know many of the schools that I work with, if there was a certain population in the school, the community looked the same way. In one of my schools in New Orleans, it was a heavy Vietnamese population, and I knew a lot of community resources and a lot of people who really supported them. And I think trying to find those community advocates or people who may share their same cultural backgrounds, but also have had experiences. And also not to sugarcoat it, because yeah, some school systems really are screwed up, and they don't necessarily have families' best interests at heart for different reasons. But then also you have those people in those school systems who can affect change and do want to work with them. So I think it's just like asking the right questions and finding the right people. Probably tell them about the resources and the advocacy. You don't have a lot of advocates, but there is a group, and the parents definitely need that help, because they are completely lost. Right. And that just adds another barrier when you have a language barrier, because even for English-speaking families, it's confusing. It's like you're both, I think, bringing up the systemic problems that really need addressed that are overwhelming. I'm going to do microphone duty. I'm going to try not to monopolize this. But I tell you one thing that's incredibly motivating for parents that are debating whether to get special ed is the protection that you get if you're in special ed. So a kid with ADHD who tap dances on the table cannot get expelled if it relates back to the reason why they have their IEP. So it is, in fact, very, very helpful. After 10 days, you have to have a manifestation. After 10 days of suspension, then you have to have a hearing and decide. And if whatever they did relates to the reason they have an IEP, it is incredibly protective. Thank you. And that seems to be something that they can hold on to. Yeah, definitely. Sorry. Thank you so much for that. I'm just going to be back here and come around. You finding someone else, Dr. Stephens? Nope. I'm going to wait. Oh, you're waiting. She's ready. Okay. Thank you. Okay. Thank you for that discussion, everyone. Okay. So if the child qualifies for special education, then an IEP, an Individualized Education Program, is formulated. This includes the special education teacher, a general education teacher, the principal, the parent, and the child. They are all members of the IEP team. And the IEP includes present levels of functioning, goals, how you'll track the goals, related services, accommodations. And you have an IEP meeting held annually where everything is updated, but a parent can request, any member of the IEP team can request an IEP meeting at any time for any reason. And like our attendee over here said, that there are protections from disciplinary actions for children who qualify for special education related to if there are behaviors or concerns that are a manifestation of their disability, then you're right. It is very difficult to expel the student. Dr. Pearson, we have a question. Yes. I guess a little more of a statement. Another part that I do to educate, because I work at a community mental health center, so we have case managers or skills trainers. And in addition to telling my parents that they can request the meeting any time they want, they can invite anyone that they want to, which they're almost often surprised by. And so when my case manager is there, they're actually asking for those services because the parents are overwhelmed. And in one case, the ABA therapist was there. At the end of the meeting, he literally asked the educators, okay, so you said all this fancy stuff, what does that mean? And it was silent. So they're doing all these check boxes, but they didn't know what that actually pragmatically meant. So you say, okay, these students can go. My students have given up on going because they hear all the negative stuff that they're doing and how they're not engaging, especially my older ones. And so that's the other part. And then the last part, I encourage my parents to reach out to the Department of Public Instruction in my state. They tend to be one of the best advocates, and I tell them they can speak to them anonymously and say, hey, this is kind of the situation my kid is facing at their school because I do telemedicine across the state. So I don't know each individual school district or how they're doing things. And so I tell them that's kind of the umbrella that they can look to is, this is what my kid is getting. Is that appropriate? Is there something else I could be asking for for my child? But then the last thing is I run into a lot of schools not being willing to implement the 504 or IEP, so we don't have those protections. Like I tell my families, this is why you want it. But I get a lot of schools trying to get the kids off IEPs and 504s very quickly or not starting them in the first place. Wow, I know. Those systemic issues are really, really frustrating. And thank you for the comment about finding, like, an umbrella kind of resource because I know in New Orleans every system, every school is totally different from the next, and families can enroll in any of the schools, I mean, depending on how they match there. But it is, I mean, parents can be trying to navigate several different systems within their own family, so that's a very real difficulty. Okay. So you mentioned 504 plans. So this is a separate system from special education. Children don't typically have both an IEP and a 504 plan, but this falls under the ADA, Americans with Disabilities Act, and it is broader than education. So it can follow you into your workplace. It can follow you to college. And the difference, the main difference is that a child with a 504 plan requires only modifications of the curriculum. They don't, or I'm sorry, accommodations of the curriculum. They don't necessarily need modifications. So in special education, you might have a fifth grader who needs the curriculum modified down to a third grade level because that's where they're performing. With 504s, you would have the fifth grade level with some accommodations to help you access that curriculum. So that's the main difference between the two. It tends to be for maybe less severe kinds of situations academically. Yeah. Yeah, modification is the individualized approach. So if you need to change the curriculum in order for the child to access it in any way, then that is more of the specialized, individualized education program. If you're only providing modifications or accommodations, so like if a child needs access to a microphone because they aren't able to hear as well, that's an accommodation. You're accommodating the child so that they can access the curriculum. Yeah, so that would probably be more of a modification. That would probably fall under the IEP, the special education, so that you're modifying the curriculum so you're not giving that student an 11th grade curriculum when they're in the 11th grade technically. So you're making it accessible for them. Just some other notes about Section 504, that there's no federal funding, so there might be sometimes a push to do special education over 504 plan because schools aren't provided funding for this. There are some disciplinary protections, not as much as special education. If you're wondering about a 504 plan, you'll contact the 504 coordinator. At least that's what we call it in Louisiana, but I think that can vary. Yeah, so that's 504. Any other questions about the distinction? Okay. All right, so I just want to spend a couple minutes. How are we on time? All right. On some of the access points, and I think we've already brought up a lot of great areas for consultative work where we see things a little bit different just based on our training and our backgrounds than educators might and where we might be able to assist. But these are just some tips and things to remember. Relationships, we're really huge on relationships, the three of us. That is the basis for the day treatment program that I mentioned. It used to be called the relationship-based day treatment program because we know how important that is for change. So I know this is impossible for all of us, but as much as we can build relationships with our patients, teachers, and administrators and become a source of support, a source of knowledge, I think that that can go a long way. Helping to contact the correct people is a big way that we can help. And like we've said over and over that the methods are different, so as much as you can just ask questions, it's going to go a long way. So you know that this system exists in some way, tell me how it works in this school. And yeah, if the school is not satisfactorily responsive, then maybe partnering or helping the family partner with an advocacy center would be helpful. There's also really lots of sample letters that you can find now to help parents request the things that they're needing from their child's school. So really you can just Google it, and there's tons of examples. Parent Center Hub is one. So again, asking questions. Who runs the meetings? How often do they meet? What kinds of mental health services are provided in the school? Sometimes 504 only covers certain services, and you need special education to access others. So it's really about asking questions to the people at the schools to know what's really going on. And like I said earlier, the interventions in schools do tend to be more behavioral. So some schools are really well-resourced, and they can really try to get at what's going on behind the scenes, but there's a lot of potential for our partnership in helping to explore those things further. And we've also talked a little bit about this already, but there are certain rights that parents are entitled to under special education law. These are specific to Louisiana, but every state has their own. I think one thing that someone was getting at a bit was there might be a tendency to hold up an evaluation in going through the RTI system. That's technically not legal. So I think the questions to ask are what is the timeline? What interventions are we implementing? What data are we collecting? What are we expecting to see? So really trying to hold schools accountable to defining what that period of time is going to look like. Otherwise it can have a tendency to really drag on and on and on when this child might just need more intensive services. So that's something that we can really help iron out in meeting with schools. Parents have the right to request the RTI data at any time. So that's a really important thing that I think a lot of parents and families don't know. And parents can request an evaluation, but a lot of times we're needing to go through the entire RTI process before we can eventually get to an evaluation. Okay. So any questions about any of the terms or systems that we've gone over so far? Okay. Jump in if anything comes up. Dr. Black is going to take it from here. Some of this we've already talked about, so I just want us to sort of just bring everything together and think about how we problem solve with families and the best way we can support them in supporting their kids in the school system. So where we want to start is clearly identifying the problem. So what is the actual issue? What I want us to keep in mind is that we want to understand what the difficulty is and not necessarily the symptoms of it. So the behaviors that we see or the outcome that we see may not actually be the problem, and we want to get to the root of what is actually going on. Is it a lack of services being provided? Is it a poor teacher-child relationship? Is it things that can change at home to try to help the kids be successful in school? So as opposed to understanding the symptoms, better understand what is causing those symptoms and supporting our patients or clients or families and actually addressing the issues that they're having. So if it is a lack of resources, trying to help them find community resources that may help their child be more successful in school. If a kid has already been evaluated in a school setting in the past, making sure that those actual interventions are being implemented. Or if there are things available in your community or in that school system, making sure that the parents are aware of the things that they can be doing or the people who can be supporting them. All right, so who are the most important players? We've had a lot of discussion today just thinking about all the people involved, and I think it was a great point that you brought up that parents often don't know that they can bring other people with them to IEP meetings. So being a mental health provider or working with them in a school system, you know the other people that are involved in their services and how important they are in those services being successful. So I think working with them to better understand who can support them or who is involved in their care, but also better understanding who plays a role in maintaining the difficulties. So if there's one particular area where a kid has problems at school, maybe brainstorming and working with that family to check in with the school about that particular setting or that particular individual, or in trying to make changes in those areas. So like Dr. Pearson was saying, maybe addressing the modification, I'm sorry, the accommodation side as opposed to the modifications. If we're thinking about behavioral challenges or is a kid having behavioral difficulties because they can't grasp the curriculum and it's getting in the way of them being able to actually like engage in school and they exhibit that frustration behaviorally. So just better understanding who are all the people involved in helping support that kid, but also who's involved in them maintaining the difficulties that they're having. Because that can also be a conversation with the parents to work with the school to help support that kid. And it may not even go to the place of having a kid who needs special education supports or things like that. It could come from one of those tier one or tier two interventions that are based on how the kid interacts with a certain adult in their setting. So thinking through possible solutions, this may seem like an obvious step, but I think it's important to think about more than just one way to address that kid and that family's challenge. So working with the actual family to think about ways that they can, one, advocate for themselves and making them active participants and how to think about ways that they can support their kids. Because we have a wealth of knowledge of how to interact with kids and what works behaviorally and mental health related. But that family may also know more, one, about their own specific kid, but also about other resources that they may have heard from other parents in the school. And they may just need the motivation to actually think about it because they have a lot going on. They're making appointments and coming to check in with us about things and they may not actually take a step back to think about, okay, what do I know that can work, but I haven't either had the opportunity to think about it and share it or I don't feel comfortable sharing it at school for a different number of reasons. So just helping them be advocates in determining what works best for them. And again, considering the current support. So a lot of times kids who have had difficulties for a while may or may not already have behavior intervention plans written or may already have tier two interventions that have been developed but aren't being implemented. For example, sometimes schools change special education directors and those things may have not carried over or a kid may be bouncing from district to district or school to school and they just haven't even checked the file for things that may have already been developed. So there's no need for us to reinvent the wheel if somebody has already taken the time to develop those interventions and the parents just haven't thought to tell the school, well, when you came from this school, I remember somebody saying something about a 504 or an IEP because schools are really overwhelmed and they may not check for that specific child and they may not know that that kid has had an intervention that's already been developed. I know in an ideal world, we have all of these interventions and documents laid out in a system where different schools are able to access them but that's not the reality all the time. So advocating and helping parents advocate for themselves to let the schools know that this kid had something before they came here and maybe this was working in that setting but they transferred for a completely different reason. So just seeing what has worked in the school can maybe try that. And thinking about additional resources. So like we said before, like local advocacy groups, thinking about community referrals for the kids we work with because a lot of us may interact with parents and children in a consultation role and not actually provide direct services but these may be kids who would benefit from a direct service outside of the school or something that the school isn't able to provide. For example, a lot of kids that I've worked with in New Orleans meet criteria for PTSD but their schools aren't in a place to actually address that on an individual basis or to treat the kid and the parent for their trauma. So a community referral to a place that is able to work with them on that and then put them in a better place for the school to implement those supports may be necessary or they may benefit from additional assessments. I've worked with kids who have clearly exhibited difficulties related to the autism spectrum but schools have not been able to see that or haven't said anything about it for a different number of reasons or parents may not even be aware that like, hey, like my kid is a little bit different, it may be benefit from this assessment. So us putting that out there, if we're able to see these things, can help that kid get services in a different way that isn't directly related to an IEP or 504 or they could enhance what an IEP or 504 is meant to do. And we're thinking about treatment planning, so including the caregiver and school personnel. I think this can look a different number of ways. So having caregiver input definitely but also talking to that caregiver, who do you feel close to at the school or who have you been working with? Because as Dr. Pearson and Dr. Sigerson both alluded to, relationships are the biggest piece of this and I think that's often why families come to us and give us this information and look for our help because they trust us. So I think helping them identify those other relationships that are positive, especially in the school system can go a long way for them. One, making them feel more comfortable but also helping them help their child and maybe in the future helping other children who have similar difficulties. So I had a vignette but I think we'll skip that for right now because we're having discussion and everything and I want people to sort of think about their own experiences and things that they've actually encountered in real life. So think about a recent client who expressed concerns that were either directly or indirectly impacted their school functioning. So I want you to, based on our discussion today, what would you have possibly done differently? Two, what steps could you take to support families with similar challenges? And also, what challenges did you anticipate when supporting families with school supports in the future based on what we've talked about? So is anybody willing to share about a particular client or family that they may have seen that comes to mind? And I'll give you some time. Give me a five second setup to get to the front row. All right. All right, here we go. Well, I now know that after eight weeks of RTI, I could have the parent go forward maybe and push for an evaluation sooner so we don't lose quite so much time. Yeah, definitely. So thinking about those things that are in place to try to keep that timeline going. And again, because it seems like a school year is long, but once you start getting into evaluation and data collection, it's May before you know it. So the earlier we can get it done, the quicker we can get it done. One of the things I did was enroll my son in a research study. It was a study of dyslexia, but it was a full phenotype study with intense, extensive cognitive assessments and fMRI. And was able to have one of the neuropsychologists present that information to the IEP, which of course the school psychologist was really fascinated by that. And it's probably not the usual way, but I work, I'm a researcher, and I coordinate, collaborate with this research project. And one of the things they do is, they do give a pretty good report to families, and they'll meet with schools, with their partner schools. So it's another, it's probably not the most common opportunity, but sometimes having a child involved in a research study that can give some of that information might be good. No, and it's awesome that they had a research study that kind of focused on those areas that are directly related to success in school. So I think that's a great point. And you're right, yeah, that's not necessarily something that's extremely common, or that we often hear about, but it sounds like it was really beneficial for you and your kid. I was thinking too, Dr. Stephens thought a lot about how institutions like Tulane University can partner with schools, and how that can be really useful. Difficult thing to establish, but for schools that are not well-resourced, it can be a huge asset. Is there someone? Oh, I see you, I thought I saw the mic over here. Hi, so I'm a first year child fellow, so I'm very much learning the ropes as quickly as I can. I was hoping you guys could speak to some of the shared, or not shared language, I guess it's separate language. I'm thinking, I was recently reviewing a kid's IEP, and they did a lot of great testing, but then the language they use for writing impairment, well, that's helpful, but it doesn't help me diagnostically without IQ testing, and they didn't talk about specific learning disability versus IQ. How do you bridge some of that gap? Really good question. I guess one thing is, and I think it works both ways, is understand that the school assessments can only give you so much information in your clinical impression, the same way that yours can only give the school so much information, so I think it's like bridging, bringing both of them together, because a lot of time, the way the school documents are written is for schools, so it make it easier to implement, easier for school personnel to understand exactly what to do, because like we said at the beginning, it takes it from a place of like, okay, this is great, this is what's happening, but what do I do right now? What does this actually mean? What can I do to help this kid and to actually intervene? And I think maybe communication back and forth, because I don't know, we didn't talk about this directly, but the collaboration and the whole ecosystem of that kid, so medical facility, psychologist, school, family, community, all those working together and better understanding everybody else's perspective and the language that they use and what is most beneficial in those settings, I think is a learning opportunity to help it be more useful the next time. So I don't know if that helped at all, or just muddied it even more, but I think that the communication back and forth between, to better educate each other, because my partner's actually a psychologist who works in a pediatric clinic, and her work involves working with the pediatricians to better understand mental health and what those referrals look like, because while they have a lot of knowledge, they don't necessarily have knowledge in that area of pediatric mental health. So while schools have a wealth of knowledge, they don't necessarily have knowledge from the psychiatric side, and vice versa. So psychiatrists who don't necessarily put themselves in school settings or expose themselves to education about a school setting may not necessarily know what's happening. So I think taking those opportunities on those one-off opportunities to communicate and educate with each other, but also when thinking about continuing education, like maybe taking furthest up to better understand other settings that we work in. I would just add that the, so the IEP might not have all of the evaluation results. This is maybe a more logistical thing, but you wanna make sure that if you're getting access to the IEP, there should be an accompanying evaluation, and also that those are typically done every three years. So there might be a history of evaluation results that you could look at. Because technically, a school can't diagnose anyway. They have a classification. So a kid qualifies for special services based on a classification of specific learned disability or other health impairment related to ADHD, and vice versa, so a diagnosis from you doesn't necessarily mean anything to the school if those difficulties aren't seen in that same way in a school setting. So, no, yeah. Real quick before we get to our next question, I know some folks have to get to other sessions, so if you want a copy, I don't know where the slides are gonna go, if you want to stay in touch with us, I'm just gonna have a little sign-up sheet in the back on your way out. Yeah, because this place is like bigger than the Atlanta airport, so you know. Yeah, we accidentally thought our presentation room was 209, so we started walking to the other end. We got our steps in today. Yeah, I had a comment slash question about involving the child in this process because I think it's important that their voice is heard, yet at my own daughter's IEP meeting, which we could never get an IEP, you're talking about all of the child's struggles to try to get help, and it feels like you're kind of putting down the child in these meetings, and it's the same struggle if I meet with the family as a child and adolescent psychiatrist, do you have any ways to approach or advise parents to approach this issue? Because sometimes they have the child sit in the whole meeting, but maybe advanced planning, okay, let's bring the child in at this point in the meeting rather than the entire meeting, because it's just so, it feels so horrible having to state what your child's struggling with when your child's right there, and wondering how your child's gonna deal with this. I think that's a great point, and I agree with you, having a specific time for the kid to come in and make it more strengths-based, like these are things that we're gonna be doing to help you be successful in school, because oftentimes kids who have IEPs understand that they're not having some level of success in school, either through suspensions or poor grades or frustration in class, so I think bringing them in at a point where it's focused on the things that they're gonna be doing to help them be successful as opposed to this is why you have an IEP, because I mean, I think it's similar to when we talk about like diagnoses and supporting families in treating like maybe, I don't know what I'm trying to say, like anxiety or depression, like we wouldn't necessarily talk about every single piece of it in front of the kid, but we would bring them in at a part that's appropriate for them, so I mean, I don't see school meetings to be much different. Sorry, again, mine's just more personal experience, but it's that even within a school district, the differences within individual schools, so we moved from England about three years ago. My son has anxiety. It got made worse by the first school he went to because the psychologist said he just needs desensitization. There's nothing wrong with him. Teacher really wasn't paying attention. Principal didn't. We pulled him out after three weeks because he was left basically crying all day and all the rest of it. We went to another school. We got a 504, and everything is much better, but it's one highlighting the differences even within district, and this is a well-funded district, and also it's the lack of awareness that parents can actually get 504s and get help and get support because they just don't know, or we didn't know. We had to really find out from neighbors and things like that and get assessments, and we're paying for a private psychologist, but I also agree with your point about involving the child, that it's really hard to give feedback when he's sitting next to you, and you have to say, well, he still has anxiety, and then he starts twitching. No, and I completely agree. I think it's the advocacy part in giving people information. We don't know what we don't know, and families don't know what they don't know, so letting them know about the opportunities and all the supports available, I mean, at least that's the first step in actually getting it done, you know what I mean? You know, we've talked a lot about things we should want from the school, but two things that I've gotten from schools that have really supported my private practice of child psychiatry over the years is having a nurse that will let my panic disorder patient sit there a few minutes rather than call the parents to remove him from the property. That has been wonderful, and the other thing is hospital homebound, where rather than putting the child on a list to get into a psychiatric hospital, let him have rest and reprieve from a week at school with the hospital homebound teacher going there, and that, I think, has saved me a lot of admissions. Yeah, that's a great point. Thank you for that. Yeah, definitely, and I'm assuming that came from your communication and relationship with the school and letting them know about those options, because I'm assuming they probably go to whatever the handbook states or whatever people before them did, so again, the relationship building between the different folks involved. I think we are at time. Maybe one more comment. Just one real quick, because I'm a medical student, so I'm still learning. Rising forth, you're trying to get into psychiatry. For me, well, if they'll take me, you just put in a good word. So my question is, especially with the children with ADHD, a lot of them have the tendency to mask it, and growing up in an Asian household, a lot of, I know, students in medical school found out that they probably have ADHD in medical school because a lot of their impairments come out, and they did well in school, they got to this point, and now they're like, maybe I should have done something about it early on. How do you help those kids who are able to mask and still do Excel at things in school and sports? I think at least part of that might be captured through screening. So broad evidence-based screening measures that you can't mask. So proper data collection, I think, can capture some of those students. That's just one thought. Yeah, no, I think that's great, and it makes me think about your point of asking the schools what interventions are they doing, but I think that's another question, what sort of screening are they doing for everybody? And I mean, the other side of the story with screening is that once you find out, you do have to do something to address it, and I think that's often why a lot of schools don't necessarily go that route, but I think the screening piece is, and then somehow, if that kid is having challenges in a school setting, finding a way to make the wheel squeakier, so for caregivers to speak up and say something, because oftentimes, kids who have the behavior difficulties are the ones who are addressed first for the right reasons, because we want to keep everybody safe, but it doesn't mean that kids with internalizing disorders don't also need the support, so I think in empowering the families to actually talk about it and bring it up with the help of all the professionals who are working with them. Okay. Thank you all so much. Thank you. Thank you for being here. Thank you. Thank you.

Dr. Cecilia De Vargas

child and adolescent psychiatry

Center for Resilience

educators

response to intervention

functional behavioral assessment

behavior intervention plan

disparities in education

special education

504 plans

collaboration