What are Child and Adolescent Mental Health Services (CAMHS)?

Introduction

Child and Adolescent Mental Health Services (CAMHS) is the name for NHS-provided services in the United Kingdom for children, generally until school-leaving age, who are having difficulties with their emotional well-being or are deemed to have persistent behavioural problems.

CAMHS are organised locally, and the exact services provided may vary, often by local government area.

Brief History

In Europe and the United States child-centred mental health did not become a medical specialty until after World War I. In the United Kingdom children’s and young people’s mental health treatment was for decades the remit of the Child Guidance Movement increasingly working after World War II with local educational authorities and often influenced by psychoanalytic ideas. Provision in NHS hospitals was piecemeal across the country and disconnected from the youth justice system. However opposition to Psychoanalysis with its pioneering research work into childhood and adolescence, which was poorly understood by proponents of the Medical model, caused the service to be abandoned in favour of evidence-based medicine and evidence-based education. This led to the eclipse of the multidisciplinary child guidance approach in the 1990s and a public policy-motivated formal take-over by the NHS.

The development of CAMHS within a four-tiered framework started in 1995. In 1998, 24 CAMHS Innovation Projects started, and the Crime and Disorder Act 1998 established related youth offending teams. In 2000 the NHS Plan Implementation Programme required health and local authorities to jointly produce a local CAMHS strategy.

In November 2008 the independent CAMHS Review was published.

From about 2013 onward major concerns have been expressed about reductions in CAMHS, and apparently increasing demand, and in 2014 the parliamentary Health Select Committee investigated and reported on provision. In 2015 the government published a review, and promised a funding increase of about £250 million per year. However the funds were not ring-fenced and as of 2016 only about half of England’s Clinical commissioning groups had increased local CAMHS funding. CAMHS funding remains a popular topic for political announcements of funding and the current aim is to increase funding to the level that 35% of young people with a disorder are able to receive a specialist service. Different models of service organisation are also advocated as part of this transformation.

In Scotland, between 2007 and 2016 the number of CAMHS psychologists had doubled, reflecting increased demand for the service. However in September 2020, 53.5% of CAMHS patients in Scotland had waited for an appointment longer than the 18 weeks target, and in Glasgow the average waiting time was 26 weeks.

131 new CAMHS beds were commissioned by NHS England in 2018, increasing the existing 1,440 bed base by more than 10%. 56 will be in London, 12 at Bodmin Hospital and 22 at St Mary’s Hospital in Leeds.

Service Framework

In the UK CAMHS are organised around a four tier system:

TierDescription
1General advice and treatment for less severe problems by non-mental health specialists working in general services, such as GPs, school nurses, social workers, and voluntary agencies.
2Usually CAMHS specialists working in community and primary care, such as mental health workers and counsellors working in clinics, schools and youth services.
3Usually a multi-disciplinary team or service working in a community mental health clinic providing a specialised service for more severe disorders, with team members including psychiatrists, social workers, board certified behaviour analysts, clinical psychologists, psychotherapists and other therapists.
4Highly specialist services for children and young people with serious problems, such as day units, specialised outpatient teams and in-patient units.

Specialist CAMHS – Tiers 3 and 4

Generally patients cannot self-refer to Tier 3 or 4 services, which are sometimes called specialist CAMHS. Referrals can be made by a wide range of agencies and professionals, including GPs and school nurses.

The aim is to have a team led by a consultant psychiatrist, although other models exist and there is limited evidence of what system works best. It is suggested that there should be a consultant psychiatrist for a total population of 75,000, although in most of the UK this standard is not met.

The Tier 4 service includes hospital care, with about 1,450 hospital beds provided in England for adolescents aged 13 to 18. Typical conditions that sometime require hospital care include depression, psychoses, eating disorders and severe anxiety disorders.

The service may, depending on locality, include:

  • Art therapy.
  • Child psychiatry.
  • Clinical psychology.
  • Educational psychology.
  • Family therapy.
  • Music therapy.
  • Occupational therapy.
  • Psychiatric nursing.
  • Social worker interface.
  • Speech therapy.
  • Child psychotherapy.
  • Forensic CAMHS, working with young offenders or those at risk of offending.

Performance

As of December 2016, some young English people with eating disorders were being sent hundreds of miles away to Scotland because the services they required were not available locally. Not withstanding good care in Scotland it was said that being away from friends and family compromised their recovery. In response the government had adopted a policy of ending such arrangements by 2021, and had allocated a cumulative £150M to improve local availability of care. There are concerns that not enough is being done to support people at risk of taking their own lives. 1,039 children and adolescents in England were admitted to beds away from home in 2017-2018, many had to travel over 100 miles (160 kilometres) from home. Many had complex mental health issues frequently involving a risk of self-harm or suicide, like severe depression, eating disorders, psychosis and personality disorders.

In 2017-2018 at least 539 children assessed as needing Tier 3 child and adolescent mental health services care waited more than a year to start treatment, according to a Health Service Journal survey which elicited reports from 33 out of the 50 mental health trusts.

What is Conduct Disorder?

Introduction

Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behaviour that includes theft, lies, physical violence that may lead to destruction and wanton breaking of rules, in which the basic rights of others or major age-appropriate norms are violated.

These behaviours are often referred to as “antisocial behaviours.” It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and can be treated with family therapy, as well as behavioural modifications and pharmacotherapy. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.

Signs and Symptoms

One of the symptoms of conduct disorder is a lower level of fear. Research performed on the impact of toddlers exposed to fear and distress shows that negative emotionality (fear) predicts toddlers’ empathy-related response to distress. The findings support that if a caregiver is able to respond to infant cues, the toddler has a better ability to respond to fear and distress. If a child does not learn how to handle fear or distress the child will be more likely to lash out at other children. If the caregiver is able to provide therapeutic intervention teaching children at risk better empathy skills, the child will have a lower incident level of conduct disorder.

Increased instances of violent and antisocial behaviour are also associated with the condition; examples may range from pushing, hitting and biting when the child is young, progressing towards beating and inflicted cruelty as the child becomes older.

Conduct disorder can present with limited prosocial emotions, lack of remorse or guilt, lack of empathy, lack of concern for performance, and shallow or deficient affect. Symptoms vary by individual, but the four main groups of symptoms are described below.

Aggression to People and Animals

  • Often bullies, threatens or intimidates others.
  • Often initiates physical fights.
  • Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
  • Has been physically cruel to people.
  • Has been physically cruel to animals.
  • Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery).
  • Has forced someone into sexual activity (rape or molestation).
  • Feels no remorse or empathy towards the harm, fear, or pain they may have inflicted on others.

Destruction of Property

  • Has deliberately engaged in fire setting with the intention of causing serious damage.
  • Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

  • Has broken into someone else’s house, building, or car.
  • Often lies to obtain goods or favours or to avoid obligations (i.e. “cons” others).
  • Has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering; forgery).

Serious Violations of Rules

  • Often stays out at night despite parental prohibitions, beginning before age 13 years.
  • Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period).
  • Is often truant from school, beginning before age 13 years.

The lack of empathy these individuals have and the aggression that accompanies this carelessness for the consequences is dangerous – not only for the individual but for those around them.

Developmental Course

Currently, two possible developmental courses are thought to lead to conduct disorder. The first is known as the “childhood-onset type” and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviours. Specifically, children in this group have greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction and higher likelihood of aggression and violence.

There is debate among professionals regarding the validity and appropriateness of diagnosing young children with conduct disorder. The characteristics of the diagnosis are commonly seen in young children who are referred to mental health professionals. A premature diagnosis made in young children, and thus labelling and stigmatising an individual, may be inappropriate. It is also argued that some children may not in fact have conduct disorder, but are engaging in developmentally appropriate disruptive behaviour.

The second developmental course is known as the “adolescent-onset type” and occurs when conduct disorder symptoms are present after the age of 10 years. Individuals with adolescent-onset conduct disorder exhibit less impairment than those with the childhood-onset type and are not characterised by similar psychopathology. At times, these individuals will remit in their deviant patterns before adulthood. Research has shown that there is a greater number of children with adolescent-onset conduct disorder than those with childhood-onset, suggesting that adolescent-onset conduct disorder is an exaggeration of developmental behaviours that are typically seen in adolescence, such as rebellion against authority figures and rejection of conventional values. However, this argument is not established and empirical research suggests that these subgroups are not as valid as once thought.

In addition to these two courses that are recognised by the DSM, there appears to be a relationship among oppositional defiant disorder, conduct disorder, and antisocial personality disorder. Specifically, research has demonstrated continuity in the disorders such that conduct disorder is often diagnosed in children who have been previously diagnosed with oppositional defiant disorder, and most adults with antisocial personality disorder were previously diagnosed with conduct disorder. For example, some research has shown that 90% of children diagnosed with conduct disorder had a previous diagnosis of oppositional defiant disorder. Moreover, both disorders share relevant risk factors and disruptive behaviours, suggesting that oppositional defiant disorder (ODD) is a developmental precursor and milder variant of conduct disorder. However, this is not to say that this trajectory occurs in all individuals. In fact, only about 25% of children with oppositional defiant disorder will receive a later diagnosis of conduct disorder. Correspondingly, there is an established link between conduct disorder and the diagnosis of antisocial personality disorder as an adult. In fact, the current diagnostic criteria for antisocial personality disorder require a conduct disorder diagnosis before the age of 15. However, again, only 25-40% of youths with conduct disorder will develop an antisocial personality disorder. Nonetheless, many of the individuals who do not meet full criteria for antisocial personality disorder still exhibit a pattern of social and personal impairments or antisocial behaviours. These developmental trajectories suggest the existence of antisocial pathways in certain individuals, which have important implications for both research and treatment.

Associated Conditions

Children with conduct disorder have a high risk of developing other adjustment problems. Specifically, risk factors associated with conduct disorder and the effects of conduct disorder symptomatology on a child’s psychosocial context have been linked to overlapping with other psychological disorders. In this way, there seems to be reciprocal effects of comorbidity with certain disorders, leading to increased overall risk for these youth.

Attention Deficit Hyperactivity Disorder

ADHD is the condition most commonly associated with conduct disorders, with approximately 25-30% of boys and 50-55% of girls with conduct disorder having a comorbid ADHD diagnosis. While it is unlikely that ADHD alone is a risk factor for developing conduct disorder, children who exhibit hyperactivity and impulsivity along with aggression is associated with the early onset of conduct problems. Moreover, children with comorbid conduct disorder and ADHD show more severe aggression.

Substance Use Disorders

Conduct disorder is also highly associated with both substance use and abuse. Children with conduct disorder have an earlier onset of substance use, as compared to their peers, and also tend to use multiple substances. However, substance use disorders themselves can directly or indirectly cause conduct disorder like traits in about half of adolescents who have a substance use disorder. As mentioned above, it seems that there is a transactional relationship between substance use and conduct problems, such that aggressive behaviours increase substance use, which leads to increased aggressive behaviour.

Substance use in conduct disorder can lead to antisocial behaviour in adulthood.

Schizophrenia

Conduct disorder is a precursor to schizophrenia in a minority of cases, with about 40% of men and 31% of women with schizophrenia meeting criteria for childhood conduct disorder.

Cause

While the cause of conduct disorder is complicated by an intricate interplay of biological and environmental factors, identifying underlying mechanisms is crucial for obtaining accurate assessment and implementing effective treatment. These mechanisms serve as the fundamental building blocks on which evidence-based treatments are developed. Despite the complexities, several domains have been implicated in the development of conduct disorder including cognitive variables, neurological factors, intraindividual factors, familial and peer influences, and wider contextual factors. These factors may also vary based on the age of onset, with different variables related to early (e.g. neurodevelopmental basis) and adolescent (e.g. social/peer relationships) onset.

Risks

The development of conduct disorder is not immutable or predetermined. A number of interactive risk and protective factors exist that can influence and change outcomes, and in most cases conduct disorder develops due to an interaction and gradual accumulation of risk factors. In addition to the risk factors identified under cause, several other variables place youth at increased risk for developing the disorder, including child physical abuse, in-utero alcohol exposure, and maternal smoking during pregnancy. Protective factors have also been identified, and most notably include high IQ, being female, positive social orientations, good coping skills, and supportive family and community relationships.

However, a correlation between a particular risk factor and a later developmental outcome (such as conduct disorder) cannot be taken as definitive evidence for a causal link. Co-variation between two variables can arise, for instance, if they represent age-specific expressions of similar underlying genetic factors. For example, the tendency to smoke during pregnancy (SDP) is subject to substantial genetic influence, as is conduct disorder. Thus, the genes that dispose the mother to SDP may also dispose the child to CD following mitotic transmission. Indeed, Rice et al. (2009) found that in mother-fetus pairs that were not genetically related (by virtue of in-vitro fertilisation), no link between SDP and later conduct problems arose. Thus, the distinction between causality and correlation is an important consideration.

Learning Disabilities

While language impairments are most common, approximately 20-25% of youth with conduct disorder have some type of learning disability. Although the relationship between the disorders is complex, it seems as if learning disabilities result from a combination of ADHD, a history of academic difficulty and failure, and long-standing socialisation difficulties with family and peers. However, confounding variables, such as language deficits, SES disadvantage, or neurodevelopmental delay also need to be considered in this relationship, as they could help explain some of the association between conduct disorder and learning problems.

Cognitive Factors

In terms of cognitive function, intelligence and cognitive deficits are common amongst youths with conduct disorder, particularly those with early-onset and have intelligence quotients (IQ) one standard deviation below the mean and severe deficits in verbal reasoning and executive function. Executive function difficulties may manifest in terms of one’s ability to shift between tasks, plan as well as organise, and also inhibit a prepotent response. These findings hold true even after taking into account other variables such as socioeconomic status (SES), and education. However, IQ and executive function deficits are only one piece of the puzzle, and the magnitude of their influence is increased during transactional processes with environmental factors.

Brain Differences

Beyond difficulties in executive function, neurological research on youth with conduct disorder also demonstrate differences in brain anatomy and function that reflect the behaviours and mental anomalies associated in conduct disorder. Compared to normal controls, youths with early and adolescent onset of conduct disorder displayed reduced responses in brain regions associated with social behaviour (i.e. amygdala, ventromedial prefrontal cortex, insula, and orbitofrontal cortex). In addition, youths with conduct disorder also demonstrated less responsiveness in the orbitofrontal regions of the brain during a stimulus-reinforcement and reward task. This provides a neural explanation for why youths with conduct disorder may be more likely to repeat poor decision making patterns. Lastly, youths with conduct disorder display a reduction in grey matter volume in the amygdala, which may account for the fear conditioning deficits. This reduction has been linked to difficulty processing social emotional stimuli, regardless of the age of onset. Aside from the differences in neuroanatomy and activation patterns between youth with conduct disorder and controls, neurochemical profiles also vary between groups. Individuals with conduct disorder are characterised as having reduced serotonin and cortisol levels (e.g. reduced hypothalamic-pituitary-adrenal (HPA) axis), as well as reduced autonomic nervous system (ANS) functioning. These reductions are associated with the inability to regulate mood and impulsive behaviours, weakened signals of anxiety and fear, and decreased self-esteem. Taken together, these findings may account for some of the variance in the psychological and behavioural patterns of youth with conduct disorder.

Intra-Individual Factors

Aside from findings related to neurological and neurochemical profiles of youth with conduct disorder, intraindividual factors such as genetics may also be relevant. Having a sibling or parent with conduct disorder increases the likelihood of having the disorder, with a heritability rate of .53. There also tends to be a stronger genetic link for individuals with childhood-onset compared to adolescent onset. In addition, youth with conduct disorder also exhibit polymorphism in the monoamine oxidase A gene, low resting heart rates, and increased testosterone.

Family and Peer Influences

Elements of the family and social environment may also play a role in the development and maintenance of conduct disorder. For instance, antisocial behaviour suggestive of conduct disorder is associated with single parent status, parental divorce, large family size, and the young age of mothers. However, these factors are difficult to tease apart from other demographic variables that are known to be linked with conduct disorder, including poverty and low socioeconomic status. Family functioning and parent-child interactions also play a substantial role in childhood aggression and conduct disorder, with low levels of parental involvement, inadequate supervision, and unpredictable discipline practices reinforcing youth’s defiant behaviours. Peer influences have also been related to the development of antisocial behaviour in youth, particularly peer rejection in childhood and association with deviant peers. Peer rejection is not only a marker of a number of externalizing disorders, but also a contributing factor for the continuity of the disorders over time. Hinshaw and Lee (2003) also explain that association with deviant peers has been thought to influence the development of conduct disorder in two ways: 1) a “selection” process whereby youth with aggressive characteristics choose deviant friends, and 2) a “facilitation” process whereby deviant peer networks bolster patterns of antisocial behaviour. In a separate study by Bonin and colleagues, parenting programmes were shown to positively affect child behaviour and reduce costs to the public sector.

Wider Contextual Factors

In addition to the individual and social factors associated with conduct disorder, research has highlighted the importance of environment and context in youth with antisocial behaviour. However, it is important to note that these are not static factors, but rather transactional in nature (e.g. individuals are influenced by and also influence their environment). For instance, neighbourhood safety and exposure to violence have been studied in conjunction with conduct disorder, but it is not simply the case that youth with aggressive tendencies reside in violent neighbourhoods. Transactional models propose that youth may resort to violence more often as a result of exposure to community violence, but their predisposition towards violence also contributes to neighbourhood climate.

Diagnosis

Conduct disorder is classified in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM). It is diagnosed based on a prolonged pattern of antisocial behaviour such as serious violation of laws and social norms and rules in people younger than the age of 18. Similar criteria are used in those over the age of 18 for the diagnosis of antisocial personality disorder. No proposed revisions for the main criteria of conduct disorder exist in the DSM-5; there is a recommendation by the work group to add an additional specifier for callous and unemotional traits. According to DSM-5 criteria for conduct disorder, there are four categories that could be present in the child’s behaviour: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violation of rules.

Almost all adolescents who have a substance use disorder have conduct disorder-like traits, but after successful treatment of the substance use disorder, about half of these adolescents no longer display conduct disorder-like symptoms. Therefore, it is important to exclude a substance-induced cause and instead address the substance use disorder prior to making a psychiatric diagnosis of conduct disorder.

Treatment

First-line treatment is psychotherapy based on behaviour modification and problem-solving skills. This treatment seeks to integrate individual, school, and family settings. Parent-management training can also be helpful. No medications have been FDA approved for Conduct Disorder, but Risperidone (a second-generation antipsychotic) has the most evidence to support its use for aggression in children who have not responded to behavioural and psychosocial interventions. Selective Serotonin Reuptake Inhibitors (SSRIs) are also sometimes used to treat irritability in these patients.

Prognosis

About 25-40% of youths diagnosed with conduct disorder qualify for a diagnosis of antisocial personality disorder when they reach adulthood. For those that do not develop ASPD, most still exhibit social dysfunction in adult life.

Epidemiology

Conduct disorder is estimated to affect 51.1 million people globally as of 2013. The percentage of children affected by conduct disorder is estimated to range from 1-10%. However, among incarcerated youth or youth in juvenile detention facilities, rates of conduct disorder are between 23% and 87%.

Sex Differences

The majority of research on conduct disorder suggests that there are a significantly greater number of males than females with the diagnosis, with some reports demonstrating a threefold to fourfold difference in prevalence. However, this difference may be somewhat biased by the diagnostic criteria which focus on more overt behaviours, such as aggression and fighting, which are more often exhibited by males. Females are more likely to be characterised by covert behaviours, such as stealing or running away. Moreover, conduct disorder in females is linked to several negative outcomes, such as antisocial personality disorder and early pregnancy, suggesting that sex differences in disruptive behaviours need to be more fully understood.

Females are more responsive to peer pressure including feelings of guilt than males.

Racial Differences

Research on racial or cultural differences on the prevalence or presentation of conduct disorder is limited. However, according to studies on American youth, it appears that African-American youth are more often diagnosed with conduct disorder, while Asian-American youth are about one-third as likely to develop conduct disorder when compared to White American youth. It has been widely theorised for decades that this disparity is due to unconscious bias in those who give the diagnosis.

What is Oppositional Defiant Disorder?

Introduction

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as “a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness” in children and adolescents.

This behaviour is usually targeted toward peers, parents, teachers, and other authority figures. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. It has certain links to Attention Deficit Hyperactivity Disorder (ADHD) and as much as one half of children with ODD will also diagnose as having ADHD as well.

Brief History

Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when conduct disorder is present. According to Dickstein, the DSM-5 attempts to:

“redefine ODD by emphasizing a ‘persistent pattern of angry and irritable mood along with vindictive behavior,’ rather than DSM-IV’s focus exclusively on negativistic, hostile, and defiant behavior.’ Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is ‘angry/irritable mood’—defined as ‘loses temper, is touchy/easily annoyed by others, and is angry/resentful.’ This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD”.

Epidemiology

ODD, is a pattern of negativistic, defiant, disobedient and hostile behaviour, and is one of the most prevalent disorders from preschool age to adulthood. ODD is marked by defiant and disobedient behaviour towards authority figures. This can include: frequent temper tantrums, excessive arguing with adults, refusing to follow rules, acting in a way to purposely upset others, getting easily irked, having an angry attitude, and acting vindictive. Children with ODD usually begin showing symptoms around 6 to 8, although the disorder can emerge in younger children, too. Symptoms can last throughout the teen years. The pooled prevalence is approximately 3.6% up to age 18. There has been research to support that ODD is more common in boys than girls with a 2:1 ratio.

ODD has a prevalence of 1% to 11%. The average prevalence is approximately 3.3%. Gender and age play an important role in the rate of the disorder. In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old. However, it is very unlikely to emerge following early adolescence. There is difference in prevalence between boys and girls. The ratio of this prevalence is 1.4 to 1 with it being more prevalent in boys than in girls, before adolescence. On the other hand, girls’ prevalence tends to increase after puberty. When researchers observed the general prevalence of oppositional defiant disorder throughout cultures, they noticed that it remained constant. However, the sex difference in ODD prevalence is only significant in Western cultures. There are two possible explanations for this difference which are that in non-Western cultures there is a decreased prevalence of ODD in boys or an increased prevalence of ODD in girls. Other factors can influence the prevalence of the disorder. One of these factors is the socioeconomic status. Youths living in families of low socioeconomic status have a higher prevalence. Another factor is based on the criteria used to diagnose an individual. When the disorder was first included in the DSM-III, the prevalence was 25% higher than when the DSM-IV revised the criteria of diagnosis. The DSM-V made more changes to the criteria grouping certain characteristics together in order to demonstrate that ODD display both emotional and behavioural symptomatology. In addition, criteria were added to help guide clinicians in diagnosis because of the difficulty found in identifying whether the behaviours or symptoms are directly related to the disorder or simply a phase in a child’s life. Consequently, future studies may obtain results indicating a decline in prevalence between the DSM-IV and the DSM-V due to these changes.

Signs and Symptoms

DSM-IV-TR) (now replaced by DSM-5) stated that a child must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder. These symptoms include:

  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
  4. Often argues with authority figures or for children and adolescents, with adults.
  5. Often actively defies or refuses to comply with requests from authority figures or with rules.
  6. Often deliberately annoys others.
  7. Often blames others for his or her mistakes or misbehaviour.
  8. Has been spiteful or vindictive at least twice within the past 6 months.

These behaviours are mostly directed towards an authority figure such as a teacher or a parent. Although these behaviours can be typical among siblings, they must be observed with individuals other than siblings for an ODD diagnosis. Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behaviour observed in conduct disorder. Furthermore, they must be perpetuated for longer than six months and must be considered beyond a normal child’s age, gender and culture to fit the diagnosis. For children under 5 years of age, they occur on most days over a period of 6 months. For children over 5 years of age they occur at least once a week for at least 6 months. It is possible to observe these symptoms in only one setting, most commonly home. Thus the severity would be mild. If it is observed in two settings then it would be characterised as moderate and if the symptoms are observed in 3 or more settings then it would be considered severe.

These patterns of behaviour result in impairment at school and/or other social venues.

Aetiology

There is no specific element that has yet been identified as directly causing ODD. Researchers looking precisely at the etiological factors linked with ODD are limited. The literature often examines common risk factors linked with all disruptive behaviours, rather than specifically about ODD. Symptoms of ODD are also often believed to be the same as CD even though the disorders have their own respective set of symptoms. When looking at disruptive behaviours such as ODD, research has shown that the causes of behaviours are multifactorial. However, disruptive behaviours have been identified as being mostly due either to biological or environmental factors.

Genetic Influences

Research indicates that parents pass on a tendency for externalising disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. Research has also shown that there is a genetic overlap between ODD and other externalising disorders. Heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behaviour is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolising enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behaviour following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.

Prenatal Factors and Birth Complications

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead, and mother’s use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance use prior to birth has also been associated with developing disruptive behaviours such as ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological Factors

Deficits and injuries to certain areas of the brain can lead to serious behavioural problems in children. Brain imaging studies have suggested that children with ODD may have hypofunction in the part of the brain responsible for reasoning, judgment, and impulse control. Children with ODD are thought to have an overactive behavioural activation system (BAS) and an underactive behavioural inhibition system (BIS) (both discussed here). The BAS stimulates behaviour in response to signals of reward or non-punishment. The BIS produces anxiety and inhibits ongoing behaviour in the presence of novel events, innate fear stimuli, and signals of non-reward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.

Social-Cognitive Factors

As many as 40% of boys and 25% of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behaviour, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act. Children with ODD have difficulty controlling their emotions or behaviours. In fact, students with ODD have limited social knowledge that is based only on individual experiences, which shapes how they process information and solve problems cognitively. This information can be linked with the social information processing model (SIP) that describes how children process information to respond appropriately or inappropriately in social settings. This model explains that children will go through five stages before displaying behaviours: encoding, mental representations, response accessing, evaluation, and enactment. However, children with ODD have cognitive distortions and impaired cognitive processes. This will therefore directly impact their interactions and relationship negatively. It has been shown that social and cognitive impairments result in negative peer relationships, loss of friendship, and an interruption in socially engaging in activities. Children learn through observational learning and social learning. Therefore, observations of models have a direct impact and greatly influence children’s behaviours and decision-making processes. Children often learn through modelling behaviour. Modelling can act as a powerful tool to modify children’s cognition and behaviours.

Environmental Factors

Negative parenting practices and parent-child conflict may lead to antisocial behaviour, but they may also be a reaction to the oppositional and aggressive behaviours of children. Factors such as a family history of mental illnesses and/or substance use disorders as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behaviour disorders. Parenting practices not providing adequate or appropriate adjustment to situations as well as a high ratio of conflicting events within a family are causal factors of risk for developing ODD.

Insecure parent-child attachments can also contribute to ODD. Often little internalisation of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance use. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.

In a number of studies, low socioeconomic status has also been associated with disruptive behaviors such as ODD.

Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.

Externalising problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighbourhoods. Studies have also found that the state of being exposed to violence was also a contribution factor for externalizing behaviours to occur.

Diagnosis

For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Management

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioural therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents.

Children with oppositional defiant disorder tend to exhibit problematic behaviour that can be very difficult to control. An occupational therapist can recommend family based education referred to as Parent Management Training (PMT) in order to encourage positive parents and child relationships and reduce the child’s tantrums and other disruptive behaviours. Since ODD is a neurological disorder that has biological correlates, an occupational therapist can also provide problem solving training to encourage positive coping skills when difficult situations arise, as well as offer cognitive behavioural therapy (CBT).

Psychopharmacological Treatment

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medications to control ODD include mood stabilisers, anti-psychotics, and stimulants. In two controlled randomised trials, it was found that between administered lithium and the placebo group, administering lithium decreased aggression in children with conduct disorder in a safe manner. However, a third study found the treatment of lithium over a period of two weeks invalid. Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

The effectiveness of drug and medication treatment is not well established. Effects that can result in taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention.

In one case, a 16-year-old boy was given oestrogen at an L.A. juvenile jail due to allegedly having ODD due to somewhat elevated testosterone levels, developing gynecomastia and requiring breast reduction surgery as a result.

Individual Interventions

Individual interventions are focused on child-specific individualised plans. These interventions include anger control/stress inoculation, assertiveness training, and child-focused problem-solving skills training programme, and self-monitoring skills.

Anger control and stress inoculation help prepare the child for possible upsetting situations or events that may cause anger and stress. It includes a process of steps they may go through.

Assertiveness training educates individuals in keeping a balance between passivity and aggression. It is about creating a response that is controlled, and fair.

A child-focused problem-solving skills training programme aims to teach the child new skills and cognitive processes that teach how to deal with negative thoughts, feelings, and actions.

Parent and Family Treatment

According to randomised trials evidence shows that parent management training is most effective. It has strong influences over a longer period of time and in various environments.

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases. The first phase being child-directed interaction, whereby it is focused on teaching the child non-directive play skills. The second phase is parent-directed interaction, where the parents are coached on aspects including clear instruction, praise for compliance, and time-out for noncompliance. The parent-child interaction training is best suited for elementary-aged children.

Parent and family treatment has a low financial cost, which can yield an increase in beneficial results.

Multimodal Intervention

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighbourhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behaviour programmes. The intervention is intensive and addresses barriers to individuals’ improvement such as parental substance use or parental marital conflict.

An impediment to treatment includes the nature of the disorder itself, whereby treatment is often not complied with and is not continued or stuck with for adequate periods of time.

Comorbidity

ODD can be described as a term or disorder with a variety of pathways in regard to comorbidity. High importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.

In the context of oppositional defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-occurs with an ADHD, anxiety disorders, emotional disorders as well as mood disorders. Those mood disorders can be linked to major depression or bipolar disorder. Indirect consequences of ODD can also be related or associated with a later mental disorder. For instance, conduct disorder is often studied in connection with ODD. Strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relation to ODD can be seen. For instance, children or adolescents who have ODD with coexisting ADHD will usually be more aggressive, will have more of the negative behavioural symptoms of ODD and thus, inhibit them from having a successful academic life. This will be reflected in their academic path as students.

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments with academics and language disorders in which problems can be observed related to language production and/or comprehension.

What is Resignation Syndrome?

Introduction

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal; Swedish: uppgivenhetssyndrom) is a possibly factitious, dissociative syndrome that induces a catatonic state, first described in Sweden in the 1990s. The condition affects predominately psychologically traumatised children and adolescents in the midst of a strenuous and lengthy migration process.

Refer to Pervasive Refusal Syndrome (PRS).

Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family.

More recently, this phenomenon has been called into question, with two children witnessing that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam, and witnessed parents who actively refused aid for their children but remained silent at the time. Later Sveriges Television, Sweden’s national public television broadcaster, were severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said “There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works.”

Signs and Symptoms

Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function.

Nosology

Refusal syndrome and pervasive refusal syndrome shares common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems.

Pervasive refusal syndrome (also called pervasive arousal withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness. It was also suggested to be on the ‘refusal-withdrawal-regression spectrum’.

Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognised the novel diagnostic entity resignation syndrome in 2014. While others argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder.

Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking.

Causes

Resignation syndrome appears to be a very specialised response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years.

Experts proposed multifactorial explanatory models involving individual vulnerability, traumatisation, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver’s expectations to interplay in pathogenesis. Severe depression or conversion/dissociation disorder has been also suggested (as best diagnostic alternatives).

However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden’s experience raises concerns about “contagion”. Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma.

A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioural systems in particularly vulnerable individuals.

Epidemiology

Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005; and 2.8% of all 6547 asylum applications submitted for children were diagnosed in 2004.

It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may be suffering from traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven were suffering from refusal syndrome, and three were psychotic.

What is Pervasive Refusal Syndrome?

Introduction

Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized paediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognised mental disorder in the World Health Organisation’s current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Refer to Resignation Syndrome.

Purported Signs and Symptoms

According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors), current psychiatric classification schemes, such as the DSM cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.

Hypothesized Causes

Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.

Mechanism

Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.

Hypothesized Epidemiology

Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7-15.

What is a School Psychological Examiner?

Introduction

In the United States education system, School Psychological Examiners assess the needs of students in schools for special education services or other interventions.

The post requires a relevant postgraduate qualification and specialist training. This role is distinct within school psychology from that of the psychiatrist, clinical psychologist and psychometrist.

Role of Psychological Examiners in Schools

School Psychological Examiners are assessors licensed by a State Department of Education to work with students from pre-kindergarten to twelfth grade in public schools, interviewing, observing, and administering and interpreting standardised testing instruments that measure cognitive and academic abilities, or describe behaviour, personality characteristics, attitude or aptitude, in order to determine eligibility for special education services, placement, or conduct re-evaluation, or occupational guidance and planning.

The work of the School Psychological Examiners is both qualitative and quantitative in nature. They prepare psychoeducational evaluation reports based on test results and interpretation. Integrated with case history, the evaluation reports should present an accurate and clear profile of a student’s level of functioning or disability, strengths and weaknesses, compare test results with the standards of the evaluation instruments, analyse potential test biases, and develop appropriate recommendations to help direct educational interventions and services in a most inclusive and least restrictive environment. Evaluation reports are framed by laws and regulations applicable to testing and assessment in special education, and must follow school district policies and the codes of ethics applicable to education, special education, and psychological assessment.

School Psychological Examiners also provide psychoeducational interventions such as consultation services, collaboration in behaviour management planning and monitoring, and devising social skills training programmes in public schools.

Unless additionally trained and licensed, School Psychological Examiners do not offer or provide psychotherapy or clinical diagnostic/treatment services, which are attributions of licensed psychiatrists and clinical psychologists, as provided by law and professional regulations.

Qualifications

School Psychological Examiners are highly trained and experienced educators who hold a master’s or higher degree in education or school counselling and at least one endorsement in special education. In addition to school district policies, School Psychological Examiners are bound by professional regulations, as well as by the ethical codes of testing and measurement. Other designations for School Psychological Examiners include ‘Educational Examiners’ or ‘Psychoeducational Examiners.’ Designation of this specialty varies among different school districts.

‘Psychometrist,’ from the term psychometrics, is an occupational designation not inclusive of the broader faculties of School Psychological Examiners. Psychometrists deal exclusively with quantitative test administration, do not require coursework beyond the bachelor’s level, or licensure by a state department of education. Training of psychometrists is primarily done on-the-job, and their services are valuable in mental health community agencies, assessment and institutional research, or test-producing companies, etc., rather than in K-12 schools.

Graduate Training and Licensure of School Psychological Examiners

Typical training includes coursework beyond the Master of Education, Master of Science in Education, or Master of Arts in Teaching degrees. Currently, School Psychological Examiners complete the courses required by their state department of education rather than by a prescribed self-contained programme of studies. The coursework is equivalent to an entire Specialist or Doctoral Degree; unfortunately just a handful of institutions of higher education offer this kind of self-standing graduate programme. Graduate courses of a psychological nature include:

  • Special Education Law.
  • Advanced Child and Adolescent Growth and Development.
  • Psychology of Students with Exceptionalities.
  • Abnormal Child and Adult Psychology.
  • Advanced Statistics and Research in Education and Psychology.
  • Tests and measurements.
  • Assessment and Evaluation of the Individual.
  • Individual Intelligence quotient.
  • Group Assessment.
  • Diagnostics and Remedial Reading.
  • Ethical issues in education and psychological measurement and evaluation reporting.
  • Methods of Instructing Students with Mild/Moderate Disabilities.
  • Methods of Instructing Students with Severe to Profound Disabilities.
  • Survey of Guidance and Counselling Techniques.
  • Practicum for School Psychological Examiners (150 supervised contact hours).

Licensure as School Psychological Examiner demands experience in a special education or school counselling setting, satisfactory completion of the required graduate coursework and practicum, plus a passing score on the ‘Praxis II Special Education: Knowledge-Based Core Principles’. Graduate school recommendation and verification of experience by the employing school district complete the requirements. In addition to the practicum, on-the-job mentoring supervision for at least two school years, sometimes four years, allows the transition from initial licensure to standard professional licensure. An annual professional development plan and ongoing performance-based evaluation ensure ‘High Quality’ professionalism as required by the No Child Left Behind law and related regulations.

Competencies

The clinical and technical skills needed to be a competent behavioural and clinical assessor include the abilities to do the following (Sattler & Hoge, 2006):

  • Establish and maintain rapport with children, parents, and teachers.
  • Use effective assessment techniques appropriate for evaluating children’s behaviour.
  • Use effective techniques for obtaining accurate and complete information from parents and teachers.
  • Evaluate the psychometric properties of tests and other measures.
  • Select an appropriate assessment battery.
  • Administer and score tests and other assessment tools by following standardised procedures.
  • Observe and evaluate behaviour objectively.
  • Perform informal assessments.
  • Interpret assessment results.
  • Use assessment findings to develop effective interventions.
  • Communicate assessment findings effectively, both orally and in writing.
  • Adhere to ethical standards.
  • Read and interpret research in behavioural and clinical assessment.
  • Keep up with laws and regulations concerning the assessment and placement of children with special needs.

Additionally, high quality School Psychological Examiners exhibit proficiency-level knowledge on:

  • The provisions of the Individuals with Disabilities Act and the Section 504 of the Civil Rights Act and related legislation.
  • State and federal laws, and all the applicable regulations, policies, and standards pertaining the provision of psychosocial and educational services to disabled individuals.
  • Children and adolescents’ advanced development and behaviour.
  • Multicultural factors in attitudes and behaviours.
  • Analysis and diagnosis of learning problems including special consideration of low incidence populations.
  • Integration of knowledge, facts, and theory on classroom environment, psychosocial principles, and test results, to plan for prescriptive instruction, management, and education of students with special needs.
  • Focused and methodical psychoeducational evaluation reporting, providing sound and accurate information and research-based remediation recommendations to improve individual student’s learning, achievement, and behavioural performance.
  • Teamwork and collaboration for the process of staffing with other school professionals and collaborative development of instructional strategies for students with special needs.
  • Provision of assistance with instructional modifications or accommodations, and programming or transition recommendations for the Individualised Education Programme (IEP).
  • Accountability for the monitoring and outcome assessment of services and interventions.

Evaluation Standards

Evaluation standards provide guidelines for designing, implementing, assessing, and reporting the psychoeducational evaluation reported by school psychological examiners. The evaluation is informed by professional codes of ethics.

  • Standards for Qualifications of Test Users.
  • Code of Fair Testing Practices in Education.
  • Standards for Multicultural Assessment.
  • Standards for Educational and Psychological Testing.

Reference

Sattler, J. M. & Hoge, R. D. (2006). Assessment of Children: Behavioral, Social, and Clinical Foundations. 5th Ed. San Diego, CA: Jerome M. Sattler Publisher, Inc. p.2.

What is a School Counsellor?

Introduction

A school counsellor is a professional who works in primary (elementary and middle) schools or secondary schools to provide academic, career, college access/affordability/admission, and social-emotional competencies to all students through a school counselling programme.

Academic, Career, College, and Social-Emotional Interventions and Services

The four main school counselling programme interventions include school counselling curriculum classroom lessons and annual academic, career/college access/affordability/admission, and social-emotional planning for every student; and group and individual counselling for some students. School counselling is an integral part of the education system in countries representing over half of the world’s population and in other countries it is emerging as a critical support for elementary, middle, and high school learning, post-secondary options, and social-emotional/mental health.

An outdated, classist, racist term for the profession was guidance counsellor; school counsellor is used as the school counsellor’s role is advocating for every student’s academic, career, college access/affordability/attainment, and social-emotional competencies and success in all schools. In the Americas, Africa, Asia, Europe, and the Pacific, some countries with no formal school counselling programmes use teachers or psychologists to do school counselling emphasizing career development.

Countries vary in how a school counselling programme and services are provided based on economics (funding for schools and school counselling programmes), social capital (independent versus public schools), and school counsellor certification and credentialing movements in education departments, professional associations, and local, state/province, and national legislation. School counselling is established in 62 countries and emerging in another seven.

An international scoping project on school-based counselling showed school counselling is mandatory in 39 countries, 32 US states, one Australian state, 3 German states, 2 countries in the United Kingdom, and three provinces in Canada. The largest accreditation body for Counsellor Education/School Counselling programmes is the Council for the Accreditation of Counselling and Related Educational Programmes (CACREP). International Counsellor Education programmes are accredited through a CACREP affiliate, the International Registry of Counsellor Education Programmes (IRCEP).

In some countries, school counselling is provided by school counselling specialists (for example, Botswana, China, Finland, Israel, Malta, Nigeria, Romania, Taiwan, Turkey, United States). In other cases, school counselling is provided by classroom teachers who either have such duties added to their typical teaching load or teach only a limited load that also includes school counselling activities (India, Japan, Mexico, South Korea, Zambia). The IAEVG focuses on career development with some international school counselling articles and conference presentations. Both the IAEVG and the Vanguard of Counsellors promote school counselling internationally.

History, School Counsellor-to-Student Ratios, and Mandates

Armenia

After the collapse of the Soviet Union, the post-Soviet Psychologists of Armenia and the government developed the School Counsellor position in Armenian Schools.

Australia

While national policy supports school counselling, only one Australian state requires it. The school counsellor-to-student ratio ranges from 1:850 in the Australian Capital Territory to 1:18,000 in Tasmania. School counsellors play an integral part in the Australian schooling system; they provide support to teachers, parents, and students. Their roles include counselling students and assisting parents/guardians to make informed decisions about their child’s education for learning and behavioural issues. School counsellors assist schools and parents/guardians in assessing disabilities and they collaborate with outside agencies to provide the best support for schools, teachers, students, and parents.

Austria

Austria mandates school counselling at the high school level.

Bahamas

The Bahamas mandate school counselling.

Belgium

Although not mandated, some school counselling occurs in schools and community centres in three regions of the country.

Bhutan

Bhutan mandates school counselling programme for all schools. All schools have fulltime school guidance counsellors.

Botswana

Botswana mandates school counselling

Brazil

School Counsellors in Brazil have large caseloads.

Canada

The roots of school counselling stemmed from a response to the conditions created by the industrial revolution in the early 1900s. Originally, school counselling was often referred to as vocational guidance, where the goal of the profession was to help individuals find their path in a time where individuals previous ways of making a living had been displaced. As people moved towards industrialised cities, counselling was required to help students navigate these new vocations. With a great discrepancy between the rich and the poor, vocational counselling was initiated to help support disadvantaged students. After World War II, vocational guidance began to shift towards a new movement of counselling, which provided a theoretical backing. As the role of school counsellors progressed into the 1970s, there has become more uncertainty as to what the role entails. This role confusion continues into the 21st century, where there is a lack of clear consensus between counsellors, other teachers, administration, students and parents on what school counsellors should be prioritising.

Throughout Canada, the emerging trend among school counselling programmes is to provide a comprehensive and cohesive approach. These programmes address the personal, social, educational and career development of students. A comprehensive programme consists of 4 components, including developmental school counselling classroom lessons, individual student planning, responsive services, and school and community support.

  • Developmental School Counselling lessons involve small group and class presentations about valuable life skills, which is generally supported through classroom curriculum.
  • Individual student planning involves assessing students abilities, providing advice on goals and planning transitions to work and school.
  • Responsive services includes counselling with students, consulting with parents and teachers, and referrals to outside agencies.
  • Support from the school and community includes such things as professional development, community outreach and program management.

The process to become a school counsellor varies drastically across each province, with some requiring a graduate level degree in counselling while others require a teaching certification or both. Some provinces also require registration with the relevant provincial College of Registered Psychotherapists. These differences highlight the vast range of expertise required within the role of a school counsellor. Regardless of the professional requirements, all school counsellors are expected to advise students within the realm of mental health support, course choices, special education and career planning. The Canadian Counselling and Psychotherapy Association, Canada’s leading association for counselling and psychotherapy, is working towards alignment among the provinces through partnership and collaboration between provinces. Recent conferences share information on the differences and similarities within each province and how progress is being made to ensure proper regulations are in place at a national level.

In the province of Ontario, Canada, school counsellors are found in both elementary and secondary settings, to varying degrees. The Greater Toronto Area, the largest metropolis in the country, has school counsellors in 31% of elementary schools, however the remainder of the province averages 6%. Additionally, the elementary schools that have a school counsellor are scheduled for an average of 1.5 days per week. These counsellors are generally classroom teachers for the remainder of the time. In secondary schools in Ontario, Canada, the average ratio of students to school counsellors is 396:1. In 10% of Ontario schools, this average increases to 826:1. There is concern among administration that these staffing levels are not sufficient to meet the needs of students. This has been proven in recent articles appearing in the news featuring student stories of frustration as they prepare for graduation without the support they expected from school counsellors. Considering the extensive expectations placed on school counsellors, future research needs to address whether or not they can be met within one profession while effectively equipping students with support and information.

School counsellors reported in 2004 at a conference in Winnipeg on issues such as budget cuts, lack of clarity about school counsellor roles, high student-to-school counsellor ratios, especially in elementary schools, and how using a comprehensive school counselling model helped clarify school counsellor roles with teachers and administrators and strengthened the profession. More than 15 years later, the profession is continuing to evolve and meet the changing needs of 21st century students in Canada.

China

China has put substantial financial resources into school counselling with strong growth in urban areas but less than 1% of rural students receive it; China does not mandate school counselling.

In China, Thomason & Qiong discussed the main influences on school counselling as Chinese philosophers Confucius and Lao-Tzu, who provided early models of child and adult development who influenced the work of Abraham Maslow and Carl Rogers.

Only 15% of high school students are admitted to college in China, so entrance exams are fiercely competitive. Students entering university graduate at a rate of 99%. Much pressure is put on children and adolescents to study and attend college. This pressure is a central focus of school counselling in China. An additional stressor is that there are not enough places for students to attend college, and over one-third of college graduates cannot find jobs, so career and employment counselling and development are also central in school counselling.

In China, there is a stigma related to social-emotional and mental health issues; therefore, even though most universities and many (urban) primary and secondary schools have school counsellors, many students are reluctant to seek counselling for issues such as anxiety and depression. There is no national system of certifying school counsellors. Most are trained in Western-developed cognitive methods including REBT, Rogerian, Family Systems, Behaviour Modification, and Object Relations. School Counsellors also recommend Chinese methods such as qi-gong (deep breathing) and acupuncture, as well as music therapy. Chinese school counsellors work within a traditional Chinese world view of a community and family-based system that lessens the focus on the individual. In Hong Kong, Hui (2000) discussed work moving toward comprehensive school counselling programs and eliminating the older remediation-style model.

Middle school students are a priority for school counselling services in China.

Costa Rica

Costa Rica mandates school counselling.

Croatia

School counselling is only available in certain schools.

Cyprus

In 1991 Cyprus mandated school counselling with a goal of a 1:60 school counsellor-to-student ratio and one full-time school counsellor for every high school but neither of these goals has been accomplished.

Czech Republic

The Czech Republic mandates school counselling.

Denmark

Denmark mandates school counselling.

Egypt

School counselling services are delivered by elementary school psychologists with a ratio of 1 school psychologist to every 3,080 students.

Estonia

School counselling is only available in certain schools.

Finland

In Finland, legislation has been passed for a school counselling system. The Basic Education Act of 1998 stated that every student must receive school counselling services. All Finnish school counsellors must have a teaching certificate, a master’s degree in a specific academic subject, and a specialised certificate in school counselling. Finland has a school counsellor-to-student ratio of 1:245.

France

France mandates school counselling in high schools.

Gambia

Gambia mandates school counselling.

Georgia

The school counsellor-to-student ratio in Georgia is 1:615.

Germany

Two German states require school counselling at all education levels; high school counselling is established in all states.

Ghana

Ghana mandates school counselling.

Greece

There are provisions for academic and career counselling in middle and high schools but school counselling is not mandated. Social-emotional and mental-health counselling is done in community agencies. The National Guidance Resources Centre in Greece was established by researchers at Athens University of Economics & Business (ASOEE) in 1993 under the leadership of Professor Emmanuel J. Yannakoudakis. The team received funding under the European Union (PETRA II Programme): The establishment of a national occupational guidance resources centre in 1993-1994. The team organised seminars and lectures to train the first career counsellors in Greece in 1993. Further research projects at Athens University of Economics & Business were implemented as part of the European Union (LEONARDO Programme):

  • A pilot project on the use of multimedia for career analysis, 1995-1999;
  • Guidance toward the future, 1995-1999;
  • On the move to a guidance system, 1996-2001; and
  • Eurostage for guidance systems, 1996-1999.

Netherlands

School counselling is present in high schools.

Hong Kong

Hong Kong mandates school counselling.

Iceland

Iceland mandates school counselling.

India

In India, the Central Board of Secondary Education guidelines expect one school counsellor appointed for every affiliated school, but this is less than 3% of all Indian students attending public schools.

Indonesia

Indonesia mandates school counselling in middle and high school.

Iran

Middle school students are the priority for school counselling in Iran. It is mandated in high schools but there are not enough school counsellors particularly in rural areas.

Ireland

In Ireland, school counselling began in County Dublin in the 1960s and went countrywide in the 1970s. However, legislation in the early 1980s severely curtailed the movement due to budget constraints. The main organization for the school counselling profession is the Institute of Guidance Counsellors (IGC), which has a code of ethics.

Israel

In Israel, a 2005 study by Erhard & Harel of 600 elementary, middle, and high school counsellors found that a third of school counsellors were delivering primarily traditional individual counselling services, about a third were delivering preventive classroom counselling curriculum lessons, and a third were delivering both individual counselling services and school counselling curriculum lessons in a comprehensive developmental school counselling programme. School counsellor roles varied due to three elements: the school counsellor’s personal preferences, school level, and the principal’s expectations. Erhard & Harel stated that the profession in Israel, like many other countries, is transforming from marginal and ancillary services to a comprehensive school counselling approach integral in the total school’s education program. In 2011-2012, Israel had a school counsellor-to-student ratio of 1:570.

Italy

School counselling is not well developed in Italy.

Japan

In Japan, school counselling is a recent phenomenon with school counsellors being introduced in the mid-1990s and often part-time focused on behavioural issues. Middle school students are the priority for school counselling in Japan and it is mandated.

Jordan

Jordan mandates school counselling with 1,950 school counsellors working in 2011-2012.

Latvia

School counselling was introduced in Latvia in 1929 but disappeared in World War II.

Lebanon

In Lebanon, the government sponsored the first training of school counsellors for public elementary and middle schools in 1996. There are now school counsellors in 1/5 of the elementary and middle schools in Lebanon but none in high schools. School counsellors have been trained in delivering preventive, developmental, and remedial services. Private schools have some school counsellors serving all grade levels but the focus is individual counselling and remedial. Challenges include regular violence and wartime strife, not enough resources, and a lack of a professional school counselling organisation, assigned school counsellors covering two or more schools, and only two school counselling graduate programmes in the country. Last, for persons trained in Western models of school counselling there are dangers of overlooking unique cultural and family aspects of Lebanese society.

Lithuania

School counselling was introduced in 1931 but disappeared during World War II.

Macau

Macau mandates school counselling.

Malaysia

Malaysia mandates school counselling in middle and high school.

Malta

In Malta, school counselling services began in 1968 in the Department of Education based on recommendations from a UNESCO consultant and used these titles: Education Officer, School Counsellor, and Guidance Teacher. Through the 1990s they included school counsellor positions in primary and trade schools in addition to secondary schools. Guidance teachers are mandated at a 1:300 teacher to student ratio. Malta mandates school counselling.

Nepal

Nepal mandates school counselling.

New Zealand

New Zealand mandates school counselling but since 1988 when education was decentralised, there has been a decline in the prevalence of school counsellors and the quality and service delivery of school counselling.

Nigeria

In Nigeria, school counselling began in 1959 in some high schools. It rarely exists at the elementary level. Where there are federally funded secondary schools, there are some professionally trained school counsellors. However, in many cases, teachers function as career educators. School counsellors often have teaching and other responsibilities that take time away from their school counselling tasks. The Counselling Association of Nigeria (CASSON) was formed in 1976 to promote the profession, but there is no code of ethics. However, a certification/licensure board has been formed. Aluede, Adomeh, & Afen-Akpaida (2004) discussed the over-reliance on textbooks from the US and the need for school counsellors in Nigeria to take a whole-school approach, lessen individual approaches, and honour the traditional African world view valuing the family and community’s roles in decision-making as paramount for effective decision-making in schools.

Norway

Norway mandates school counselling.

Oman

There are some school counselling services at the high school level.

Philippines

The Philippines mandates school counselling in middle and high school. The Congress of the Philippines passed the Guidance and Counselling Act of 2004 with a specific focus on Professional Practice, Ethics, National Certification, and the creation of a Regulatory Body, and specialists in school counselling are subject to this law.

Poland

School counselling was introduced in 1918 but disappeared during World War II.

Portugal

Portugal mandates school counselling at the high school level.

Romania

Romania mandates school counselling.

Rwanda

School counselling focuses on trauma-based counselling. It focuses on academic performance, prevention, and intervention with HIV/AIDS, and establishing peace-building clubs.

Saudi Arabia

School counselling is developing in Saudi Arabia. In 2010, 90% of high schools had some type of school counselling service.

Serbia

School counselling is available in certain schools.

Singapore

Singapore mandates school counselling.

Slovakia

Slovakia mandates school counselling.

South Korea

In South Korea, school counsellors must teach a subject besides counselling, but not all school counsellors are appointed to counselling positions, even though Korean law requires school counsellors in all middle and high schools.

Spain

Spain provides school counselling at the high school level although it is unclear if mandated. There was around one counsellor for every 1,000 primary and secondary (high school) students as of 2018.

St. Kitts

St. Kitts mandates school counselling.

Sweden

Sweden mandates school counselling. In Sweden, school counsellors’ work was divided into two work groups in the 1970s. The work groups are called “kurator” and “studie -och yrkesvägledare.” They worked with communication methodology but the kurator’s work is more therapeutic, often psychological and social-emotional issues, and the studie-och yrkesvägledare’s work is future-focused with educational and career development. Studie- och yrkesvägledaren work in primary, secondary, adult education, higher education and various training centres and most have a Bachelor of Arts degree in Study and Career Guidance.

Switzerland

School counselling is found at the high school level.

Syria

School counselling has focused on trauma-based counselling of students. Prior to the war it was done in schools but it is now found in either a school club or refugee camp sponsored and staffed by UNICEF.

Taiwan

In Taiwan, school counselling traditionally was done by “guidance teachers.” Recent advocacy by the Chinese Guidance and Counselling Association pushed for licensure for school counsellors in Taiwan’s public schools. Prior to this time, the focus had been primarily individual and group counselling, play therapy, career counselling and development, and stress related to national university examinations.

Tanzania

Tanzania mandates school counselling.

Thailand

The Thai government has put substantial funding into school counsleling but does not mandate it.

Trinidad and Tobago

Trinidad and Tobago mandate school counselling.

Turkey

Turkey mandates school counselling and it is in all schools.

Uganda

Uganda mandates school counselling.

United Arab Emirates

There is some school counselling at the high-school level in the United Arab Emirates.

United Kingdom

School counselling originated in the UK to support underachieving students and involved specialist training for teachers. Head of Year (e.g. Head of Year 7, Head of Year 8, etc.) are school staff members, usually teachers, who oversee a year group within a secondary school. These Heads of Year ensure students within the year cohort behave properly within the school, but these Heads also support students in their social and emotional well-being and course and career planning options. Wales and Northern Ireland require school counselling.

United States

In the United States, the school counselling profession began with the vocational guidance movement in the early 20th century now known as career development. Jesse B. Davis was the first to provide a systematic school counselling programme focused on career development. In 1907, he became the principal of a high school and encouraged the school English teachers to use compositions and lessons to relate career interests, develop character, and avoid behavioural problems. Many others during this time focused on what is now called career development. For example, in 1908, Frank Parsons, “Father of Career Counselling” established the Bureau of Vocational Guidance to assist young people transition from school to work.

From the 1920s to the 1930s, school counselling grew because of the rise of progressive education in schools. This movement emphasized personal, social, and moral development. Many schools reacted to this movement as anti-educational, saying that schools should teach only the fundamentals of education. Combined with the economic hardship of the Great Depression, both challenges led to a decline in school counselling. At the same time, the National Association for College Admission Counselling was established as the first professional association focused on counselling and advising high school students into college. In the early 1940s, the school counselling movement was influenced by the need for counsellors to help assess students for wartime needs. At the same time, researcher Carl Rogers’ emphasized the power of non-directive helping relationships and counselling for all ages and the profession of counselling was influenced to shift from directive “guidance” to non-directive or person-centred “counselling” as the basis for school counselling.

In the 1950s the government established the Guidance and Personnel Services Section in the Division of State and Local School Systems. In 1957, the Soviet Union launched Sputnik I. Out of concern that the Russians were winning the space race and that there were not enough scientists and mathematicians, the government passed the National Defence Education Act, spurring growth in vocational and career counselling through larger funding. In the 1950s the American School Counsellor Association (ASCA) was founded as one of the early divisions of what is now known as the American Counselling Association (ACA).

In the 1960s, new legislation and professional developments refined the school counselling profession (Schmidt,[40] 2003). The 1960s continued large amounts of federal funding for land-grant colleges and universities to establish Counsellor Education master’s and doctoral programmes. School counselling shifted from a primary focus on career development to adding social-emotional issues paralleling the rise of social justice and civil rights movements. In the early 1970s, Dr. Norm Gysbers’s research and advocacy helped the profession shift from school counsellors as solitary professionals focused on individual academic, career, and social-emotional student issues to a comprehensive developmental school counselling programme for all students K-12 that included individual and group counselling for some students and classroom lessons and annual advising/planning and activities for every student. He and his colleagues’ research evidenced strong correlations between fully implemented school counselling programmes and student academic success; a critical part of the evidence base for the school counselling profession was their work in Missouri. Dr. Chris Sink & associates showed similar evidence-based success for school counselling programmes at the elementary and middle school levels in Washington State.

School counselling in the 1980s and early 1990s was not influenced by corporate educational reform efforts. The profession had little evidence of systemic effectiveness for school counsellors and only correlational evidence of the effectiveness of school counselling programmes. In response, consulted with elementary, middle, and high school counsellors and created the American School Counsellor Association (ASCA) Student Standards with three core domains (Academic, Career, Personal/Social), nine standards, and specific competencies and indicators for K-12 students. There was no research base, however, for school counselling standards as an effective educational reform strategy. A year later, Whiston & Sexton published the first systemic meta-analysis of school counselling outcome research in academic, career, and personal/social domains and individual counselling, group counselling, classroom lessons, and parent/guardian workshop effectiveness.

In the late 1990s, former mathematics teacher, school counsellor, and administrator Pat Martin, was hired by corporate-funded educational reform group, The Education Trust, to focus the school counselling profession on equity issues by helping close achievement and opportunity gaps harming children and adolescents of colour, poor and working class children and adolescents, bilingual children and adolescents, and children and adolescents with disabilities. Martin, under considerable heat from Counsellor Educators who were not open to her equity-focused message of change, developed focus groups of K-12 students, parents, guardians, teachers, building leaders, and superintendents, and interviewed professors of School Counsellor Education. She hired Oregon State University School Counsellor Education professor emeritus Dr. Reese House, and after several years of work in the late 1990s they created, in 2003, the National Centre for Transforming School Counselling (NCTSC).

The NCTSC focused on changing school counsellor education at the graduate level and changing school counsellor practice in state and local districts to teach school counsellors how to help recognise, prevent, and close achievement and opportunity gaps. In their initial focus groups, they found what Hart & Jacobi had indicated years earlier – too many school counsellors were gatekeepers for the status quo instead of advocates for the academic success of every child and adolescent. Too many school counsellors used inequitable practices, supported inequitable school policies, and were unwilling to change.

This professional behaviour kept many students from non-dominant backgrounds (i.e. students of colour, poor and working class students, students with disabilities, and bilingual students) from receiving challenging coursework (AP, IB, and honours classes) and academic, career, and college access/affordability/admission skills needed to successfully graduate from high school and pursue post-secondary options including college. In 1998, the Education Trust received a grant from the DeWitt Wallace/Reader’s Digest to fund six $500,000 grants for Counsellor Education/School Counselling programmes, with a focus on rural and urban settings, to transform School Counsellor Education programmes to teach advocacy, leadership, teaming and collaboration, equity assessment using data, and culturally competent programme counselling and coordination skills in addition to counselling: Indiana State University, the University of Georgia, the University of West Georgia, the University of California-Northridge, the University of North Florida, and, the Ohio State University were the recipients. Over 25 additional Counsellor Education/School Counselling programmes nationwide became companion institutions in the following decade with average grants of $3000. By 2008, NCTSC consultants had worked in over 100 school districts and major cities and rural areas to transform the work of school counsellors nationwide.

In 2002, the American School Counsellor Association released Dr. Trish Hatch and Dr. Judy Bowers’ work: the ASCA National Model: A framework for school counselling programmes comprising key school counselling components: ASCA National Standards, and the skill-based focus for closing achievement and opportunity gaps from the Education Trust’s new vision of school counselling into one document. The model drew from major theoreticians in school counselling with four key areas: Foundation (school counselling programme mission statements, vision, statements, belief statements, and annual goals); Delivery (direct services including individual and group counselling; classroom counselling lessons; planning and advising for all students); Management (use of action plans and results reports for closing gaps, small group work and classroom lessons; a school counselling programme assessment, an administrator-school counsellor annual agreement, a time-tracker tool, and a school counselling data tool; and Accountability (school counsellor annual evaluation and use of a School Counselling Programme Advisory Council to monitor data, outcomes, and effectiveness). In 2003, Dr. Jay Carey and Dr. Carey Dimmitt created the Centre for School Counselling Outcome Research and Evaluation (CSCORE) at the University of Massachusetts-Amherst as a clearinghouse for evidence-based practice with regular research briefs, original research projects, and eventual co-sponsorship of the annual Evidence-Based School Counselling conference in 2013.

In 2004, the ASCA Ethical Standards for School Counsellors was revised to focus on issues of equity, closing achievement and opportunity gaps, and ensuring all K-12 students received access to a school counselling programme. Also in 2004, an equity-focused entity on school counsellors’ role in college readiness and admission counselling, the National Office for School Counsellor Advocacy (NOSCA) emerged at The College Board led by Pat Martin and Dr. Vivian Lee. NOSCA developed scholarships for research on college counselling by K-12 school counsellors taught in School Counsellor Education programmes.

In 2008, the first NOSCA study was released by Dr. Jay Carey and colleagues focused on innovations in selected College Board “Inspiration Award” schools where school counsellors collaborated inside and outside their schools for high college-going rates and strong college-going cultures in schools with large numbers of students of non-dominant backgrounds. In 2008, ASCA released School Counselling Competencies focused on assisting school counselling programmes to effectively implement the ASCA National Model.

In 2010, the Centre for Excellence in School Counselling and Leadership (CESCAL) at San Diego State University co-sponsored the first of four school counsellor and educator conferences devoted to the needs of lesbian, bisexual, gay, and transgender students in San Diego, California. ASCA published a 5th edition of the ASCA Ethical Standards for School Counsellors.

In 2011, Counselling at the Crossroads: The perspectives and promise of school counsellors in American education, the largest survey of high school and middle school counsellors in the United States with over 5,300 interviews, was released by Pat Martin and Dr. Vivian Lee by the National Office for School Counsellor Advocacy, the National Association of Secondary School Principals, and the American School Counsellor Association. The study shared school counsellors’ views on educational policies, practices, and reform, and how many of them, especially in urban and rural school settings, were not given the chance to focus on what they were trained to do, especially career and college access and readiness counselling for all students, in part due to high caseloads and inappropriate tasks.

School counsellors suggested changes in their role to be accountable for success of all students and how school systems needed to change so school counsellors could be key advocates and leaders for every student’s success. Implications for public policy and district and school-wide change were addressed. The National Centre for Transforming School Counselling released a brief, Poised to Lead: How School Counsellors Can Drive Career and College Readiness, challenging all schools to utilise school counsellors for equity and access for challenging coursework (AP, IB, honours) for all students and ensuring college and career access skills and competencies as a major focus for school counsellors K-12.

In 2012, CSCORE assisted in evaluating and publishing six statewide research studies assessing the effectiveness of school counselling programmes based on statewide systemic use of school counselling programmes such as the ASCA National Model and published their outcomes in the American School Counsellor Association research journal Professional School Counselling. Research indicated strong correlational evidence between fully implemented school counselling programmes and low school counsellor-to-student ratios provided better student academic success, greater career and college access/readiness/admission, and reduced social-emotional issue concerns included better school safety, reduced disciplinary issues, and better attendance.

Also in 2012, the American School Counsellor Association released the third edition of the ASCA National Model.

From 2014-2016, the White House, under the Office of the First Lady Michelle Obama, partnered with key school counsellor educators and college access professionals nationwide to focus on the roles of school counsellors and college access professionals. Their collaboration resulted in a series of national Reach Higher/School Counselling and College Access convenings at Harvard University, San Diego State University, the University of North Florida, and American University. Michelle Obama and her staff also began the Reach Higher and Better Make Room programmes to focus on college access for underrepresented students, and she began hosting the American School Counsellor Association’s School Counsellor of the Year awards ceremony at the White House. The initiatives culminated in an unprecedented collaboration among multiple major professional associations focused on school counselling and college access including the American Counselling Association, the American School Counsellor Association, the National Association for College Admission Counselling, the College Board, and ACT raising the profile and prominence of the role of school counsellors collaborating on college access, affordability, and admission for all students.

In 2015, ASCA replaced the ASCA National Student Standards with the evidence-based ASCA Mindsets & Behaviours for Student Success: K-12 College and Career Readiness Standards for Every Student, created from meta-analyses done by the University of Chicago’s Consortium on Educational Reform showing key components of raising student academic success over multiple well-designed research studies. While an improvement over the lack of research in the ASCA student standards that they replaced, school counsellors shared feedback that they do not go into enough depth for career, college access/admission/affordability, and social-emotional competencies.

In 2016, ASCA published a newly revised sixth version of the ASCA Ethical Standards for School Counsellors using two rounds of feedback from practicing school counsellors in all 50 states; it also included, for the first time, a Glossary of ethical terms for heightened clarity.

In 2019, ASCA released the 4th edition of the ASCA National Model, a Framework for School Counselling Programmes. Changes included fewer templates and combined templates from the 3rd edition after school counsellor feedback that the 3rd edition had become too complex and onerous. The four outside-the-diamond skills from the first three editions: advocacy, leadership, teaming and collaboration, and systemic change were incorporated throughout the model and no longer part of the diamond graphic organiser. The four quadrants of the model were changed to verbs and action-oriented words to better clarify the key components:

  1. Define (formerly Foundation).
  2. Deliver (formerly Delivery System).
  3. Manage (formerly Management System).
  4. Assess (formerly Accountability System).

The three types of data collected by school counsellors in school counselling programmes have shifted in name to:

  1. Participation data (formerly process).
  2. Mindsets & Behaviours data (formerly perception, i.e. learning).
  3. Outcome data (results).

The 4th edition, while easier to read and use than prior editions, did not cover the history of how the model changed over time and neglected any mention of the original authors, Drs. Trish Hatch and Judy Bowers.

Venezuela

School counselling is mandated in Venezuela and it has focused on cultural competency.

Vietnam

School counselling is mandated in Vietnam.

Roles, School Counselling Programmes, Ethics, and School Counselling Professional Associations

Professional school counsellors ideally implement a school counselling programme that promotes and enhances student achievement (Hatch & Bowers, 2003, 2005; ASCA, 2012). A framework for appropriate and inappropriate school counsellor responsibilities and roles is outlined in the ASCA National Model (Hatch & Bowers, 2003, 2005; ASCA, 2012). School counsellors, in US states, have a master’s degree in school counselling from a Counsellor Education graduate programme. China requires at least three years of college experience. In Japan, school counsellors were added in the mid-1990s, part-time, primarily focused on behavioural issues. In Taiwan, they are often teachers with recent legislation requiring school counselling licensure focused on individual and group counselling for academic, career, and personal issues. In Korea, school counsellors are mandated in middle and high schools.

School counsellors are employed in elementary, middle, and high schools, in district supervisory settings, in Counsellor Education faculty positions (usually with an earned Ph.D. in Counsellor Education in the USA or related graduate doctorates abroad), and post-secondary settings doing academic, career, college access/affordability/admission, and social-emotional counselling, consultation, and programme coordination. Their work includes a focus on developmental stages of student growth, including the needs, tasks, and student interests related to those stages(Schmidt,[40] 2003).

Professional school counsellors meet the needs of student in three basic domains: academic development, career development and college access/affordability/admission, and social-emotional development (Dahir & Campbell, 1997; Hatch & Bowers, 2003, 2005; ASCA, 2012). Knowledge, understanding and skill in these domains are developed through classroom instruction, appraisal, consultation, counselling, coordination, and collaboration. For example, in appraisal, school counsellors may use a variety of personality and career assessment methods to help students explore career and college needs and interests.

Schools play a key role in assessment, access to services, and possible referral to appropriate outside support systems. They provide intervention, prevention, and services to support students’ academic, career, and post-secondary education as well as social-emotional growth. The role of school counsellors is expansive. School counsellors address mental health issues, crisis intervention, and advising for course selection. School counsellors consult with all stakeholders to support student needs and may also focus on experiential learning, cooperative education, internships, career shadowing, and entrance to specialised high school programmes.

School counsellor interventions include individual and group counselling for some students. For example, if a student’s behaviour is interfering with his or her achievement, the school counsellor may observe that student in a class, provide consultation to teachers and other stakeholders to develop (with the student) a plan to address the behavioural issue(s), and then collaborate to implement and evaluate the plan. They also provide consultation services to family members such as college access/affordability/admission, career development, parenting skills, study skills, child and adolescent development, mental health issues, and help with school-home transitions.

School counsellor interventions for all students include annual academic/career/college access/affordability/admission planning K-12 and leading classroom developmental lessons on academic, career/college, and social-emotional topics. The topics of mental health, multiculturalism (Portman, 2009), anti-racism, and school safety are important areas of focus for school counsellors. Often school counsellors will coordinate outside groups to help with student needs such as academics, or coordinate a program that teaches about child abuse or drugs, through on-stage drama.

School counsellors develop, implement, and evaluate school counselling programmes that deliver academic, career, college access/affordability/admission, and social-emotional competencies to all students in their schools. For example, the ASCA National Model (Hatch & Bowers, 2003, 2005; ASCA, 2012) includes the following four main areas:

  • Foundation (Define as of 2019) – a school counselling programme mission statement, a vision statement, a beliefs statement, SMART Goals; ASCA Mindsets & Behaviours & ASCA Code of Ethics;
  • Delivery System (Deliver as of 2019) – how school counselling core curriculum lessons, planning for every student, and individual and group counselling are delivered in direct and indirect services to students (80% of school counsellor time);
  • Management System (Manage as of 2019) – calendars; use of data tool; use of time tool; administrator-school counsellor agreement; school counselling programme advisory council; small group, school counselling core curriculum, and closing the gap action plans; and
  • Accountability System (Assess as of 2019) – school counselling program assessment; small group, school counselling core curriculum, and closing-the-gap results reports; and school counsellor performance evaluations based on school counsellor competencies.

The school counselling programme model (ASCA, 2012, 2019) is implemented using key skills from the National Centre for Transforming School Counselling’s Transforming School Counselling Initiative: Advocacy, Leadership, Teaming and Collaboration, and Systemic Change.

Many provinces in Canada offer a career pathway programme, which helps to prepare students for the employment market and support a smooth school-to-work transition.

School Counsellors are expected to follow a professional code of ethics in many countries. For example, In the US, they are the American School Counsellor Association (ASCA) School Counsellor Ethical Code, the American Counselling Association (ACA) Code of Ethics, and the National Association for College Admission Counselling (NACAC) Statement of Principles of Good Practice (SPGP).

Some school counsellors experience role confusion, given the many tasks they are expected to perform. The demands on the school counsellor to be a generalist who performs roles in leadership, advocacy, essential services, and curriculum development can be too much if there is not a clear mission, vision, and comprehensive school counselling programme in place. Additionally, some school counsellors are stretched too thin to provide mental health support on top of their other duties.

The role of a school counsellor is critical and needs to be supported by all stakeholders to ensure equity and access for all students, particularly those with the fewest resources. The roles of school counsellors are expanding and changing with time. As roles change, school counsellors help students prosper in academics, career, post-secondary, and social-emotional domains. School counsellors reduce and bridge the inequalities facing students in educational systems.

School Counsellors around the world are affiliated with various national and regional school counselling associations, and abide by their guidelines.

Elementary School Counselling

Elementary school counsellors provide academic, career, college access, and personal and social competencies and planning to all students, and individual and group counselling for some students and their families to meet the developmental needs of young children K-6. Transitions from pre-school to elementary school and from elementary school to middle school are an important focus for elementary school counsellors. Increased emphasis is placed on accountability for helping close achievement and opportunity gaps at the elementary level as more school counselling programmes move to evidence-based work with data and specific results.

School counselling programmes that deliver specific competencies to all students help to close achievement and opportunity gaps. To facilitate individual and group school counselling interventions, school counsellors use developmental, cognitive-behavioural, person-centred (Rogerian) listening and influencing skills, systemic, family, multicultural, narrative, and play therapy theories and techniques. released a research study showing the effectiveness of elementary school counselling programmes in Washington state.

Middle School Counselling

Middle school counsellors provide school counselling curriculum lessons on academic, career, college access, and personal and social competencies, advising and academic/career/college access planning to all students and individual and group counselling for some students and their families to meet the needs of older children/early adolescents in grades 7 and 8.

Middle School College Access curricula have been developed to assist students and their families before reaching high school. To facilitate the school counselling process, school counsellors use theories and techniques including developmental, cognitive-behavioural, person-centred (Rogerian) listening and influencing skills, systemic, family, multicultural, narrative, and play therapy. Transitional issues to ensure successful transitions to high school are a key area including career exploration and assessment with seventh and eighth grade students. Sink, Akos, Turnbull, & Mvududu released a study in 2008 confirming the effectiveness of middle school comprehensive school counselling programmes in Washington state.

High School Counselling

High school counsellors provide academic, career, college access, and personal and social competencies with developmental classroom lessons and planning to all students, and individual and group counselling for some students and their families to meet the developmental needs of adolescents (Hatch & Bowers, 2003, 2005, 2012). Emphasis is on college access counselling at the early high school level as more school counselling programmes move to evidence-based work with data and specific results that show how school counselling programmes help to close achievement, opportunity, and attainment gaps ensuring all students have access to school counselling programmes and early college access/affordability/admission activities. The breadth of demands high school counsellors face, from educational attainment (high school graduation and some students’ preparation for careers and college) to student social and mental health, has led to ambiguous role definition. Summarising a 2011 national survey of more than 5,330 middle school and high school counsellors, researchers argued:

“Despite the aspirations of counselors to effectively help students succeed in school and fulfill their dreams, the mission and roles of counselors in the education system must be more clearly defined; schools must create measures of accountability to track their effectiveness; and policymakers and key stakeholders must integrate counselors into reform efforts to maximize their impact in schools across America”.

Transitional issues to ensure successful transitions to college, other post-secondary educational options, and careers are a key area. The high school counsellor helps students and their families prepare for post-secondary education including college and careers (e.g. college, careers) by engaging students and their families in accessing and evaluating accurate information on what the National Office for School Counsellor Advocacy calls the 8 essential elements of college and career counselling:

  1. College Aspirations.
  2. Academic Planning for Career and College Readiness.
  3. Enrichment and Extracurricular Engagement.
  4. College and Career Exploration and Selection Processes.
  5. College and Career Assessments.
  6. College Affordability Planning.
  7. College and Career Admission Processes.
  8. Transition from High School Graduation to College Enrolment.

Some students turn to private college admissions advisors but there is no research evidence that private college admissions advisors have any effectiveness in assisting students attain selective college admissions.

Lapan, Gysbers & Sun showed correlational evidence of the effectiveness of fully implemented school counseling programs on high school students’ academic success. Carey et al.’s 2008 study showed specific best practices from high school counsel.ors raising college-going rates within a strong college-going environment in multiple USA-based high schools with large numbers of students of nondominant cultural identities.

Education Credentials, Certification, and Accreditation

The education of school counsellors around the world varies based on the laws and cultures of countries and the historical influences of their educational and credentialing systems and professional identities related to who delivers academic, career, college readiness, and personal/social information, advising, curriculum, and counselling and related services.

In Canada, the educational requirements to become a school counsellor vary by province.

In China, there is no national certification or licensure system for school counsellors.

Korea requires school counsellors in all middle and high schools.

In the Philippines, school counsellors must be licensed with a master’s degree in counselling.

Taiwan instituted school counsellor licensure for public schools.

In the US, a school counsellor is a certified educator with a master’s degree in school counselling (usually from a Counsellor Education graduate programme) with school counselling graduate training including qualifications and skills to address all students’ academic, career, college access and personal/social needs. Once you have completed your master’s degree you can take one of 2 certification options in order to become fully licensed as a professional school counsellor.

Over half of all Counsellor Education programmes that offer school counselling are accredited by the Council on the Accreditation of Counselling and Related Educational Programmes (CACREP) and all in the US with one in Canada. In 2010 one was under review in Mexico. CACREP maintains a current list of accredited programmes and programmes in the accreditation process on their website. CACREP desires to accredit more international counselling university programmes.

According to CACREP, an accredited school counselling programme offers coursework in Professional Identity and Ethics, Human Development, Counselling Theories, Group Work, Career Counselling, Multicultural Counselling, Assessment, Research and Programme Evaluation, and Clinical Coursework – a 100-hour practicum and a 600-hour internship under supervision of a school counselling faculty member and a certified school counsellor site supervisor.

When CACREP released the 2009 Standards, the accreditation process became performance-based including evidence of school counsellor candidate learning outcomes. In addition, CACREP tightened the school counselling standards with specific evidence needed for how school counselling students receive education in foundations; counselling prevention and intervention; diversity and advocacy; assessment; research and evaluation; academic development; collaboration and consultation; and leadership in K-12 school counselling contexts.

Certification practices for school counsellors vary internationally. School counsellors in the US may opt for national certification through two different boards. The National Board for Professional Teaching Standards (NBPTS) requires a two-to-three year process of performance based assessment, and demonstrate (in writing) content knowledge in human growth/development, diverse populations, school counselling programmes, theories, data, and change and collaboration. In February 2005, 30 states offered financial incentives for this certification.

Also in the US, The National Board for Certified Counsellors (NBCC) requires passing the National Certified School Counsellor Examination (NCSC), including 40 multiple choice questions and seven simulated cases assessing school counsellors’ abilities to make critical decisions. Additionally, a master’s degree and three years of supervised experience are required. NBPTS also requires three years of experience, however state certification is required (41 of 50 states require a master’s degree). At least four states offer financial incentives for the NCSC certification.

Job Growth and Earnings

The rate of job growth and earnings for school counsellors depends on the country that one is employed in and how the school is funded – public or independent. School counsellors working in international schools or “American” schools globally may find similar work environments and expectations to the US. School counsellor pay varies based on school counsellor roles, identity, expectations, and legal and certification requirements and expectations of each country. According to the Occupational Outlook Handbook (OOH), the median salary for school counsellors in the US in 2010 was (USD) $53,380 or $25.67 hourly. According to an infographic designed by Wake Forest University, the median salary of school counsellors in the US was $43,690. The US has 267,000 employees in titles such as school counsellor or related titles in education and advising and college and career counselling. The projected growth for school counsellors is 14-19% or faster than average than other occupations in the US with a predicted 94,000 job openings from 2008-2018. In Australia, a survey by the Australian Guidance and Counselling Association found that school counsellor salary ranged from (AUD) the high 50,000s to the mid 80,000s.

Among all counselling specialty areas, public elementary, middle and high school counsellors are (2009) paid the highest salary on average of all counsellors. Budget cuts, however, have affected placement of public school counsellors in Canada, Ireland, the United States, and other countries. In the United States, rural areas and urban areas traditionally have been under-served by school counsellors in public schools due to both funding shortages and often a lack of best practice models. With the expectation of school counsellors to work with data, research, and evidence-based practice, school counsellors who show and share results in assisting to close achievement, opportunity, and attainment gaps are in the best position to argue for increased school counselling resources and positions for their programmes.

Notable School Counsellors

  • Jamaal Bowman, US politician.
  • Fernando Cabrera, US politician.
  • Ern Condon, Canadian politician.
  • Derrick Dalley, Canadian politician.
  • Susie Sadlowski Garza, US politician.
  • François Gendron, Canadian politician.
  • Steve Lindberg, US politician.
  • Lillian Ortiz-Self, US politician.
  • Tony Resch, US lacrosse player.
  • Tom Tillberry, US politician.
  • Tom Villa, US politician.

What is School Psychology?

Introduction

School psychology is a field that applies principles from educational psychology, developmental psychology, clinical psychology, community psychology, and behaviour analysis to meet the learning and behavioural health needs of children and adolescents.

It is an area of applied psychology practiced by a school psychologist. They often collaborate with educators, families, school leaders, community members, and other professionals to create safe and supportive school environments.

School psychologists primarily work with students who have learning disabilities, behavioural difficulties, mental disorders, and other health issues. They carry out psychological testing, psychoeducational assessment, intervention, prevention, counselling, and consultation in the ethical, legal, and administrative codes of their profession.

Background

School psychology dates back to the beginning of American psychology in the late 19th and early 20th centuries. The field is tied to both functional and clinical psychology. School psychology actually came out of functional psychology. School psychologists were interested in childhood behaviours, learning processes, and dysfunction with life or in the brain itself. They wanted to understand the causes of the behaviours and their effects on learning. In addition to its origins in functional psychology, school psychology is also the earliest example of clinical psychology, beginning around 1890. While both clinical and school psychologists wanted to help improve the lives of children, they approached it in different ways. School psychologists were concerned with school learning and childhood behavioural problems, which largely contrasts the mental health focus of clinical psychologists.

Another significant event in the foundation of school psychology as it is today was the Thayer Conference. The Thayer Conference was first held in August 1954 in West Point, New York in Hotel Thayer. The 9 day-long conference was conducted by the American Psychological Association (APA). The purpose of the conference was to develop a position on the roles, functions, and necessary training and credentialing of a school psychologist. At the conference, forty-eight participants that represented practitioners and trainers of school psychologists discussed the roles and functions of a school psychologist and the most appropriate way to train them.

At the time of the Thayer Conference, school psychology was still a very young profession with only about 1,000 school psychology practitioners. One of the goals of the Thayer Conference was to define school psychologists. The agreed upon definition stated that school psychologists were psychologists who specialise in education and have specific knowledge of assessment and learning of all children. School psychologists use this knowledge to assist school personnel in enriching the lives of all children. This knowledge is also used to help identify and work with children with exceptional needs. It was discussed that a school psychologist must be able to assess and develop plans for children considered to be at risk. A school psychologist is also expected to better the lives of all children in the school; therefore, it was determined that school psychologists should be advisors in the planning and implementation of school curriculum. Participants at the conference felt that since school psychology is a specialty, individuals in the field should have a completed a two-year graduate training program or a four-year doctoral programme. Participants felt that states should be encouraged to establish certification standards to ensure proper training. It was also decided that a practicum experience be required to help facilitate experiential knowledge within the field.

The Thayer Conference is one of the most significant events in the history of school psychology because it was there that the field was initially shaped into what it is today. Before the Thayer Conference defined school psychology, practitioners used seventy-five different professional titles. By providing one title and a definition, the conference helped to get school psychologists recognised nationally. Since a consensus was reached regarding the standards of training and major functions of a school psychologist, the public can now be assured that all school psychologists are receiving adequate information and training to become a practitioner. It is essential that school psychologists meet the same qualifications and receive appropriate training nationwide. These essential standards were first addressed at the Thayer Conference. At the Thayer Conference some participants felt that in order to hold the title of a school psychologist an individual must have earned a doctoral degree.

The issues of titles, labels, and degree levels are still debated among psychologists today. However, APA and NASP reached a resolution on this issue in 2010.

Social Reform in the Early 1900s

The late 19th century marked the era of social reforms directed at children. It was due to these social reforms that the need for school psychologists emerged. These social reforms included compulsory schooling, juvenile courts, child labour laws as well as a growth of institutions serving children. Society was starting to “change the ‘meaning of children’ from an economic source of labour to a psychological source of love and affection”. Historian Thomas Fagan argues that the preeminent force behind the need for school psychology was compulsory schooling laws. Prior to the compulsory schooling law, only 20% of school aged children completed elementary school and only 8% completed high school. Due to the compulsory schooling laws, there was an influx of students with mental and physical defects who were required by law to be in school. There needed to be an alternative method of teaching for these different children. Between 1910 and 1914, schools in both rural and urban areas created small special education classrooms for these children. From the emergence of special education classrooms came the need for “experts” to help assist in the process of child selection for special education. Thus, school psychology was founded.

Important Contributors to the Founding

Lightner Witmer

Lightner Witmer has been acknowledged as the founder of school psychology. Witmer was a student of both Wilhelm Wundt and James Mckeen Cattell. While Wundt believed that psychology should deal with the average or typical performance, Cattell’s teachings emphasized individual differences. Witmer followed Cattell’s teachings and focused on learning about each individual child’s needs. Witmer opened the first psychological and child guidance clinic in 1896 at the University of Pennsylvania. Witmer’s goal was to prepare psychologists to help educators solve children’s learning problems, specifically those with individual differences. Witmer became an advocate for these special children. He was not focused on their deficits per se, but rather helping them overcome them, by looking at the individual’s positive progress rather than all they still could not achieve. Witmer stated that his clinic helped “to discover mental and moral defects and to treat the child in such a way that these defects may be overcome or rendered harmless through the development of other mental and moral traits”. He strongly believed that active clinical interventions could help to improve the lives of the individual children.

Since Witmer saw much success through his clinic, he saw the need for more experts to help these individuals. Witmer argued for special training for the experts working with exceptional children in special educational classrooms. He called for a “new profession which will be exercised more particularly in connection with educational problems, but for which the training of the psychologist will be a prerequisite”.

As Witmer believed in the appropriate training of these school psychologists, he also stressed the importance of appropriate and accurate testing of these special children. The IQ testing movement was sweeping through the world of education after its creation in 1905. However, the IQ test negatively influenced special education. The IQ test creators, Lewis Terman and Henry Goddard, held a nativist view of intelligence, believing that intelligence was inherited and difficult if not impossible to modify in any meaningful way through education.] These notions were often used as a basis for excluding children with disabilities from the public schools. Witmer argued against the standard pencil and paper IQ and Binet type tests in order to help select children for special education. Witmer’s child selection process included observations and having children perform certain mental tasks.

Granville Stanley Hall

Another important figure to the origin of school psychology was Granville Stanley Hall. Rather than looking at the individual child as Witmer did, Hall focused more on the administrators, teachers and parents of exceptional children He felt that psychology could make a contribution to the administrator system level of the application of school psychology. Hall created the child study movement, which helped to invent the concept of the “normal” child. Through Hall’s child study, he helped to work out the mappings of child development and focused on the nature and nurture debate of an individual’s deficit. Hall’s main focus of the movement was still the exceptional child despite the fact that he worked with atypical children.

Arnold Gesell

Bridging the gap between the child study movement, clinical psychology and special education, Arnold Gesell, was the first person in the United States to officially hold the title of school psychologist, Arnold Gesell. He successfully combined psychology and education by evaluating children and making recommendations for special teaching. Arnold Gesell paved the way for future school psychologists.

Gertrude Hildreth

Gertrude Hildreth was a psychologist with the Lincoln School at Teacher’s College, Columbia then at Brooklyn College in New York. She authored many books including the first book pertaining to school psychology titled, “Psychological Service for School Problems” written in 1930. The book discussed applying the science of psychology to address the perceived problems in schools. The main focus of the book was on applied educational psychology to improve learning outcomes. Hildreth listed 11 problems that can be solved by applying psychological techniques, including: instructional problems in the classroom, assessment of achievement, interpretation of test results, instructional groupings of students for optimal outcomes, vocational guidance, curriculum development, and investigations of exceptional pupils. Hildreth emphasized the importance of collaboration with parents and teachers. She is also known for her development of the Metropolitan Readiness Tests and for her contribution to the Metropolitan Achievement test. In 1933 and 1939 Hildreth published a bibliography of Mental Tests and Rating Scales encompassing a 50-year time period and over 4,000 titles. She wrote approximately 200 articles and bulletins and had an international reputation for her work in education.

Issues Related to School Psychology

Intervention

One of the primary roles and responsibilities of school psychologists working in schools is to ensure the interventions they utilise effectively address students’ behaviour problems. Issues arise when school psychologists do not select interventions with sufficient research-based evidence in being effective for the individual with whom they are working. School psychologists, as researchers and practitioners, can make important contributions to the development and implementation of scientifically based intervention and prevention programmes to address learning and behavioural needs of students (National Association of School Psychologists (NASP).

There is a concern with implementing academic and behavioural interventions prior to the determination for special education services, and it has also been proposed that MTSS (Multi-Tiered Systems of Support) may address these concerns. The National Association of School Psychologists (NASP) recognises the need for evidence-based prevention and intervention practices to address student learning, social emotional development, behavioural performance, instructional methodology, school practices, classroom management, and other areas salient to school-based services and improving student outcomes (National Association of School Psychologists (NASP). Intervention and prevention research needs to address a range of questions related not only to efficacy and effectiveness, but also to:

  • Feasibility given resources (e.g. time, money, staffing);
  • Acceptability (e.g. teacher, student, and community attitudes toward intervention strategies);
  • Social validity (the relevance of targeted outcomes to everyday life of students);
  • Integrity or fidelity (the extent to which individuals responsible for implementing an intervention can do so as intended by its designers); and
  • Sustainability (extent to which school staff can maintain the intervention over time, without support from external agents).

A specific example of an intervention that has recently become popular among school psychologists is the School-wide Positive Behavioural Interventions and Supports (PBIS). Authorised under IDEA, the PBIS offers a “preventative, positive, and systemic framework or approach to affect educational and behavioural change” and can be used in the support of Tiers 1-3 in the education system. Research from single-case design studies and group studies demonstrates that the intervention can result in a reduction of major disciplinary infractions and aggressive behaviour, improvement in academic achievement, an increase in prosocial behaviour, a reduction in bullying behaviour reported by teachers, and much more. Through consistent and strong implementation fidelity, PBIS can provide school psychologists opportunities to assist the administration, teaching staff, and students in broad and specific ways.

Prevention

A way in which school psychologists can help students is by creating primary prevention programmes. Information about prevention should also be connected to current events in the community.

Issues with Assessment Process

Empirical evidence has not confirmed biases in referral, assessment, or identification; however, inferences have been made that the special education process may be oversimplified. The National Research Council has called attention to the questionable reliability of educational decision making in special education as there can be vast numbers of false positives and/or false negatives. Misidentified students in special education is problematic and can contribute to long term negative outcomes.

During the identification process, school psychologists must consider ecological factors and environmental context such as socioeconomic status. Socioeconomic status may limit funding and materials, impact curriculum quality, increase teacher-to-student ratios, and perpetuate a negative school climate.

Technological Issues

With the ever growing use of technology, school psychologists are faced with several issues, both ethical and within the populations they try to serve. As it is so easy to share and communicate over technology, concerns are raised as to just how easy it is for outsiders to get access to the private information that school psychologists deal with everyday. Thus exchanging and storing information digitally may come under scrutiny if precautions such as password protecting documents and specifically limiting access within school systems to personal files.

Then there is the issue of how students communicate using this technology. There are both concerns on how to address these virtual communications and on how appropriate it is to access them. Concerns on where the line can be drawn on where intervention methods end and invasion of privacy begin are raised by students, parents, administrators, and faculty. Addressing these behaviours becomes even more complicated when considering the current methods of treatment for problematic behaviours, and implementation of these strategies can become complex, if not impossible, within the use of technology.

To incorporate topics in a school, utilise lesson plans for students and staff because the teachers need to ensure the content is connected to other meaningful topics covered in the class/school.

Racial Disproportionality in Special Education

Disproportionality refers to a group’s under or overrepresentation in comparison to other groups within a certain context. In the field of school psychology, disproportionality of minority students in special education is a concern. Special Education Disproportionality has been defined as the relationship between one’s membership to a specific group and the probability of being placed in a specific disability category. Systemic prejudice is believed by some to be one of the root causes of the mischaracterisation of minority children as being disabled or problematic.

“Research on disproportionality in the U.S. context has posited two overlapping types of rationales: those who believed disproportionate representation is linked to poverty and health outcomes versus those who believed in the systemwide racist practices that contributed to over-representation of minority students.”

The United States Congress recently received an annual report on the implementation of IDEA which stated that proportionally Native Americans (14.09%) and African Americans (12.61%) were the two most highly represented racial groups within the realm of special education. In particular, African American males have been overidentified as having emotional disturbances and intellectual disabilities. They account for 21% of the special education population with emotional disturbances and 12% with learning disabilities. American Indian and Alaska Native students are also overrepresented in special education. They are shown to be 1.53 times more likely to receive services for various learning disabilities and 2.89 more likely to obtain services targeting developmental delays than all other Non-Native American student groups combined.] Overall, Hispanic students are often overidentified for special education in general; however, it is common for them to be under-identified for Autism Spectrum Disorder and speech and language impairments in comparison to White students.

Minority populations often have an increased susceptibility to economic, social and cultural disadvantages that can affect academic achievement. According to the US Department of Education, “Black children were three times as likely to live in poor families as white children in 2015. 12 percent of white and Asian children lived in poor families, compared with 36 percent of black children, 30 percent of Hispanic children, 33 percent of American Indian children, and 19 percent of others.” There may be other alternative explanations for behaviour and academic performance as well. For example, Black children are twice as likely as Whites to experience heightened levels of lead in the blood due to prolonged lead exposure. Lead poisoning can be known to affect a child’s behaviour by increasing their levels of irritability, hyperactivity, and inattentiveness even in less severe cases.

Cultural Biases

Some school psychologists realise the need to understand and accept their own cultural beliefs and values in order to understand the impact it may have when delivering services to clients and families. For example, these school psychologists ensure that students who are minorities, including African Americans, Hispanics, Asians, and Native Americans are being equally represented at the system level, in the classroom, and receiving a fair education.

For staff, it is important to look at one’s own culture while seeing the value in diversity. It is also vital to learn how to adapt to diversity and integrate a comprehensive way to understand cultural knowledge. Staff members should keep the terms race, privilege, implicit bias, micro aggression, and cultural relevance in mind when thinking about social justice.

Services

Behaviour Interventions

School psychologists are involved in the implementation of academic, behavioural, and social/emotional interventions within a school across a continuum of supports. These systems and policies should convey clear behaviour expectations and promote consistency among educators. Continuous reinforcement of positive behaviours can yield extremely positive results. Schoolwide positive behaviour supports A systematic approach that proactively promotes constructive behaviours in a school can yield positive outcomes. These programs are designed to improve and support students’ social, behavioural, and learning outcomes by promoting a positive school climate and providing targeted training to students and educators within a school. Data should be collected consistently to assess implementation effectiveness, screen and monitor student behaviour, and develop or modify action plans.

Academic Interventions

Academic interventions can be conceptualised as a set of procedures and strategies designed to improve student performance with the intent of closing the gap between how a student is currently performing and the expectations of how they should be performing. Short term and long term interventions used within a problem-solving model must be evidence-based. This means the intervention strategies must have been evaluated by research that utilised rigorous data analysis and peer review procedures to determine the effectiveness. Implementing evidence-based interventions for behaviour and academic concerns requires significant training, skill development, and supervised practice. Linking assessment and intervention is critical for determining that the correct intervention has been chosen. School psychologists have been specifically trained to ensure that interventions are implemented with integrity to maximise positive outcomes for children in a school setting.

Systems-Level Services

Leaders in the field of school psychology recognise the practical challenges that school psychologists face when striving for systems-level change and have highlighted a more manageable domain within a systems-level approach – the classroom. Overall, it makes sense for school psychologists to devote considerable effort to monitoring and improving school and classroom-based performance for all children and youth because it has been shown to be an effective preventive approach.

Universal Screening

School psychologists play an important role in supporting youth mental wellness, but identifying youth who are in distress can be challenging. Some schools have implemented universal mental health screening programs to help school psychologists find and help struggling youth. For instance, schools in King County, Washington are using the Check Yourself digital screening tool designed by Seattle Children’s Hospital to measure, understand, and nurture individual students’ well-being. Check Yourself collects information about lifestyle, behaviour, and social determinants of health to identify at-risk youth so that school psychologists can intervene and direct youth to the services they need. Mental health screening provides school psychologists with valuable insights so that interventions are better fitted to student needs.

Crisis Intervention

Crisis intervention is an integral part of school psychology. School administrators view school psychologists as the school’s crisis intervention “experts”. Crisis events can significantly affect a student’s ability to learn and function effectively. Many school crisis response models suggest that a quick return to normal rituals and routines can be helpful in coping with crises. The primary goal of crisis interventions is to help crisis-exposed students return to their basic abilities of problem-solving so the student can return to their pre-crisis level of functioning.

Consultation

Consultation is done through a problem solving method that will help the consultee function more independently without the intensive support of a school psychologist.

Social Justice

The three major elements that comprise social justice include equity, fairness, and respect. The concept of social justice includes all individuals having equal access to opportunities and resources. A major component behind social justice is the idea of being culturally aware and sensitive. American Psychological Association (APA) and the National Association of School Psychologists (NASP) both have ethical principles and codes of conduct that present aspirational elements of social justice that school psychologists may abide by. Although ethical principles exist, there is federal legislation that acts accordingly to social justice. For example, the Elementary and Secondary Education Act of 1965 (ESEA) and the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) address issues such as poverty and disability to promote the concept of social justice in schools.

Schools are becoming increasingly diverse with growing awareness of these differences. Cultural diversity factors that can be addressed through social justice practice include race/ethnicity, gender, socioeconomic status (SES), religion, and sexual orientation. With the various elements that can impact a student’s education and become a source of discrimination, there is a greater call for the practice of social justice in schools. School psychologists that consider the framework of social justice know that injustices that low SES students face can sometimes be different when compared to high SES students.

Advocacy

A major role of school psychologists involves advocating and speaking up for individuals as needed. Advocacy can be done at district, regional, state, or national level. School psychologists advocate for students, parents, and caregivers.

Consultation and collaboration are key components of school psychology and advocacy. There may be times when school personnel may not agree with the school psychologist. Differing opinions can be problematic because a school psychologist advocates for what is in the best interest of the student. School psychologists and staff members can help facilitate awareness through courageous conversations.

Multicultural Competence

School psychologists offer many types of services in order to be multiculturally competent. Multicultural competence extends to race, ethnicity, social class, gender, religion, sexual orientation, disability, age, and geographic region. Because the field of school psychology serves such a diverse range of students, maintaining representation for minority groups continues to be a priority. Despite such importance, history has seen an underrepresentation of culturally and linguistically diverse (CLD) school psychologists. which may appear alarming given that the diversity of our youth continues to increase exponentially. Thus, current professionals in the field have prioritised the acquisition of CLD school psychologists. School psychologists are trained to use their skills, knowledge, and professional practices in promoting diversity and advocating for services for all students, families, teachers, and schools. School psychologists may also work with teachers and educators to provide an integrated multicultural education classroom and curriculum that allows more students to be represented in learning. Efforts to increase multicultural perspectives among school psychologists have been on the rise to account for the increased diversity within schools. Such efforts include establishing opportunities for individuals representative of minority groups to become school psychologists and implementing a diverse array of CLD training programmes within the field.

Education

In order to become a school psychologist, one must first learn about school psychology by successfully completing a graduate-level training programme. A B.A. or B.S. is not sufficient.

United States

School psychology training programs are housed in university schools of education or departments of psychology. School psychology programmes require courses, practica, and internships.

Degree Requirements

Specific degree requirements vary across training programmes. School psychology training programs offer masters-level (M.A., M.S., M.Ed.), specialist-level degrees (Ed.S., Psy.S., SSP, CAGS), and doctoral-level degrees (Ph.D., Psy.D. or Ed.D.) degrees. Regardless of degree title, a supervised internship is the defining feature of graduate-level training that leads to certification to practice as a school psychologist.

Specialist-level training typically requires 3-4 years of graduate training including a 9-month (1200 hour) internship in a school setting.

Doctoral-level training programs typically require 5-7 years of graduate training. Requirements typically include more coursework in core psychology and professional psychology, more advanced statistics coursework, involvement in research endeavours, a doctoral dissertation, and a one-year (1500+ hour) internship (which may be in a school or other settings such as clinics or hospitals).

In the past, a master’s degree was considered the standard for practice in schools. As of 2017, the specialist-level degree is considered the entry-level degree in school psychology. Masters-level degrees in school psychology may lead to obtaining related credentials (such as Educational Diagnostician, School Psychological Examiner, School Psychometrist) in one or two states.

International

In the UK, the similar practice and study of School Psychology is more often termed Educational Psychology and requires a doctorate (in Educational Psychology) which then enables individuals to register and subsequently practice as a licensed educational psychologist.

Employment in the United States

In the United States, job prospects in school psychology are excellent. Across all disciplines of psychology, the abundance of opportunities is considered among the best for both specialist and doctoral level practitioners. They mostly work in schools. Other settings include clinics, hospitals, correctional facilities, universities, and independent practice.

Demographic Information

According to the NASP Research Committee, 74% of school psychologists are female with an average age of 46. In 2004-2005, average earnings for school practitioners ranged from $56,262 for those with a 180-day annual contract to $68,764 for school psychologists with a 220-day contract. In 2009-2010, average earnings for school practitioners ranged from $64,168 for those with a 180-day annual contract to $71,320 for school psychologists with a 200-day contract. For university faculty in school psychology, the salary estimate is $77,801.

Based on surveys performed by NASP in 2009-2010, it is shown that 90.7% of school psychologists are white, while minority races make up the remaining 9.3%. Of this remaining percentage, the next largest populations represented in school psychology, are African-Americans and Hispanics, at 3% and 3.4% respectively.

Shortages in the Field

There is a lack of trained school psychologists within the field. While jobs are available across the country, there are just not enough people to fill them.

Due to the low supply and high demand of school psychologists, being a school psychologist is very demanding. School psychologists may feel under pressure to supply adequate mental health and intervention services to the students in their care. Burnout is a risk of being a school psychologist.

Bilingual School Psychologists

Approximately 21% of school-age children ages 5-7 speak a language other than English. For this reason, there is an enormous demand for bilingual school psychologists in the United States. The National Association of School Psychologists (NASP) does not currently offer bilingual certification in the field. However, there are a number of professional training opportunities that bilingual LSSPs/School Psychologists can attend in order to prepare to adequately administer assessments. In addition, there are 7 NASP-Approved school psychology programs that offer a bilingual specialisation:

  • Brooklyn College-City University of New York- Specialist Level.
  • Gallaudet University- Specialist Level.
  • Queens College-City University of New York- Specialist Level.
  • San Diego State University- Specialist Level.
  • Texas State University- Specialist Level.
  • University of Colorado Denver- Doctoral Level.
  • Fordham University- Lincoln Centre – Doctoral Level.

New York and Illinois are the only two states that offer a bilingual credential for school psychologists.

International School Psychology

The role of a school psychologist in the United States and Canada may differ considerably from the role of a school psychologist elsewhere. Especially in the United States, the role of school psychologist has been closely linked to public law for education of students with disabilities. In most other nations, this is not the case. Despite this difference, many of the basic functions of a school psychologist, such as consultation, intervention, and assessment are shared by most school psychologists worldwide.

It is difficult to estimate the number of school psychologists worldwide. Recent surveys indicate there may be around 76,000 to 87,000 school psychologists practicing in 48 countries, including 32,300 in the United States and 3,500 in Canada. Following the United States, Turkey has the next largest estimated number of school psychologists (11,327), followed by Spain (3,600), and then both Canada and Japan (3,500 each).

Credentialing

In order to work as a school psychologist, one must first meet the state requirements. In most states (excluding Texas and Hawaii), a state education agency credentials school psychologists for practice in the schools.

The Nationally Certified School Psychologist (NCSP) credential offered by the National Association of School Psychologists (NASP). The NCSP credential is an example of a non-practice credential as holding the NCSP does not make one eligible to provide services without first meeting the state requirements to work as a school psychologist.

State psychology boards (which may go by different names in each state) also offer credentials for school psychologists in some states. For example, Texas offers the LSSP credential which permits licensees to deliver school psychological services within public and private schools.

Subspecialisations

  • Paediatric School Psychology.
  • Systems Level Consultation.
  • School Based Mental Health.
  • Behavioural School Psychology.

Professional Organisations in the United States

  • National Association of School Psychologists.
  • American Psychological Association.

Journals

  • Psychology in the Schools.
  • School Psychology Quarterly.
  • School Psychology Review.
  • School Psychology Forum: Research in Practice.
  • School Psychology International.
  • Canadian Journal of School Psychology.
  • International Journal of School & Educational Psychology.
  • Journal of Psychoeducational Assessment.

What is Child Psychoanalysis?

Introduction

Child psychoanalysis is a sub-field of psychoanalysis which was founded by Anna Freud.

Freud used the work of her father Sigmund Freud with certain modifications directed towards the needs of children. Since its inception, child psychoanalysis has grown into a well-known therapeutic technique for children and adolescents.

Brief History

For many years, the work of Sigmund Freud was considered revolutionary in his creation of psychotherapy, or talk therapy, and his theories regarding childhood experiences affecting a person later in life. His legacy was continued by his daughter Anna Freud in her pursuit of psychotherapy and her fathers theories as applied to children and adolescents.

In 1941, Anna help found the Hampstead Nursery in London and there she treated children for several years until it was shut down in 1945. Anna, with the help of Kate Friedlaender, soon opened the Hampstead Child Therapy Course and Clinic to continue her work and to continue sheltering homeless children. Anna was the director of the clinic from 1952 until her death in 1982. The clinic was renamed the Anna Freud Centre following her death as a memorial for the care and support she provided to hundreds of children over the decades.

Much of Anna’s published papers and books reference her work at the Hampstead Nursery and Clinic. Some of her more famous books are “The Ego and Defense Mechanisms”, which explored what defence mechanisms are and how they are used by adolescents, and “Normality and Pathology in Childhood” (1965), which directly summarizes her work at the Hampstead Clinic and other facilities. In fact, it was her work at the Nursery and the Clinic which allowed Anna to perfect her techniques and establish a therapy specifically designed for improving child and adolescent mental health.

Techniques

Anna’s first task in developing a successful therapy for children was to take Sigmund’s original theory regarding the psycho-social stages of development and create a timeline by which to grade normal growth and development. Using this line, a therapist would be able to observe a child and know whether they were progressing as other children or not. If a certain aspect of development lagged, such as personal hygiene or eating habits, the therapist could then assume that some trauma had occurred and could then address it directly through therapy.

Once a child was in therapy, techniques had to continue to change. Foremost, Anna knew that she could not expect to create situations of transference with the children as her father had done with his adult patients. The parents of a child in psychotherapy are typically still very active in their lives. Even when children were being housed at the Clinic, Anna encouraged mothers to visit frequently to ensure a stable attachment was formed between parent and child. In fact, one of the most important features of child psychotherapy is the active role parents play in their child’s therapy, knowing exactly what the therapist is doing, and their lives outside of therapy by helping the child implement the techniques taught by the therapist. So, to avoid becoming a replacement parent and avoid having the child view her as an authoritative adult, Anna did her best to take on the role of a caring and understanding adult figure. To this day, child psychotherapists aim to be viewed by the patient as a person analogous to a teacher.

The goal of any psychotherapist is for the patient to find comfort in their stable presence and eventually have no issue with speaking whatever comes to their mind. With children, this involves a high frequency of visits with the child, possibly even daily sessions. Anna also saw child’s play as their way of adapting to reality and confronting problems they faced in their real lives. For this reason, therapy sessions are intended to suspend the rules of reality and allow the child to play and speak whatever they want. This play allows therapists to see where the child’s traumas lie and help the child overcome these traumas. However, Anna also realised that children’s play does not reveal some unconscious revelation. Children, unlike adults, have not yet repressed events or learned how to cover up their true emotions. Often, in therapy what a child says is what a child means. This differed greatly from the original practices of psychotherapy that often had to decode meaning out of the patient’s words.

Newest Developments

In recent years there has been a shift in analytic technique for severely disturbed or traumatised children from a conflict- and insight-oriented approach to a focused, mentalisation-oriented therapy. Furthermore, the importance of parent work in the context of child psychoanalysis has been emphasized. Short-term psychoanalytic therapy which combines focus oriented techniques in the psychoanalytic work with the child with focused parent work has been shown to be effective especially in children with anxiety disorders and depressive comorbidity.