Imagine This

Imagine this.  You’re the parent or teacher of a child with social, emotional, and behavioral challenges.  You know the child’s behavior falls outside the norm (maybe it's even scary or dangerous) and that he’s not getting the help he needs.  But you don’t quite understand what’s going on with the child or how you can help.  You do know that the child is having a detrimental effect on your household, your marriage, your classroom, his peers, and/or his siblings. You’re desperate for information that will help you understand, that will help you help.  If you’re a parent, you decide to make an appointment with your family physician or counselor.  If you’re a teacher, you refer the child into your school’s assessment process.  After what can be a very long wait, you finally get the information you were waiting for:  “He has oppositional defiant disorder.”

Many who are reading this edition of The Real World aren’t having any trouble imagining this scenario.  You’ve been there, done that (though the diagnosis may not have been oppositional defiant disorder).  On first hearing the child’s diagnosis, you may remember thinking, “Good!  I knew there was something going on here.  Now he’ll get the help he needs.”  But sooner or later you came to realize that the diagnosis really didn’t provide you with very much information at all.  What the diagnosis told you is that someone else also thinks the child’s difficulties are beyond the norm.  But you didn’t need a diagnosis to tell you that.  There’s an excellent chance you already knew.

I’ve often said that parents of kids with behavioral challenges go through two developmental stages (it seems teachers may pass through these stages as well).  Phase One:  believing that a psychiatric diagnosis is going to give you the information you need to understand and help your child or student.  Phase Two:  coming to the recognition that a diagnosis didn’t give you the information you needed to understand and help your child or student.  Neither oppositional defiant disorder nor the vast majority of other psychiatric diagnoses that are commonly hung on children tell you what you really need to know.  Most diagnoses just tell you what deviant behaviors a kid is exhibiting. 

The circular thinking inherent in this process isn’t always so obvious, so here goes:

Parent or Teacher:  Doctor, why is he throwing tantrums, defying adult rules and requests, and refusing to do what he's told?Doctor:  Because he has oppositional defiant disorder.
Parent or Teacher:  How do you know he has oppositional defiant disorder?
Doctor:  Because he’s throwing tantrums, defying adult rules and requests, and refusing to do as he’s told.

Yet, these days, in the real world, the instant it becomes clear that a child has social, emotional, or behavioral challenges, the quest for the diagnostic holy grail commences.  In many school systems, a diagnosis is what a kid needs to access services it’s already clear he needs.  In many places, diagnoses influence funding decisions.  A diagnosis is what a kid needs for his mental health provider to be reimbursed by an insurance carrier.  A diagnosis is what a kid needs for his parent(s) to know that there is a support group comprised of parents whose children exhibit similar behaviors. 

But the down-side of diagnoses outweighs the up.  Diagnoses pathologize kids.  Diagnoses make it explicit that “the problem” resides within the kid.  Diagnoses make it clear that it’s the kid who needs fixing, thereby providing justification for many ineffective interventions directed solely at the kid.  Diagnoses scare off potential helpers (“He has bipolar disorder!  I don’t know anything about bipolar disorder!  That’s for someone else to deal with!”).  Diagnoses deprive kids of the help they clearly need (“I’m sorry, Mr. and Mrs. Taylor, but your daughter doesn’t meet full diagnostic criteria for Asperger’s disorder, so she doesn’t qualify for our program.”)  And, worst of all, diagnoses are distracting.  They cause potential helpers to focus more on what a child isdoing rather than on why and when he’s doing it…and on what the potential helpers can be doing to help.

Why is a child exhibiting challenging behavior?  The Collaborative Problem Solving approach provides the following answer:  Because he or she is lacking the skills not to exhibit challenging behavior.  

When does the child exhibit challenging behavior?  The CPS model has an answer to that, too:  He exhibits challenging behavior when the demands being placed upon him exceed the skills he has to respond adaptively.  Would the child prefer to respond adaptively?  Of course!  Is the child choosing to respond maladaptively?  Now why would he choose to do that? If he had the skills to respond adaptively, he would.

And what do challenging kids do when they’re having difficulty responding adaptively to the demands being placed upon them?  They exhibit the behaviors that are the basis for the diagnosis they will receive.

Now imagine this.  Imagine that we all came to our senses and decided that categories weren’t so important or meaningful after all.  Imagine that we all realized that challenging behaviors occur on a spectrum, something I refer to as the Spectrum of Looking Bad.  At the “easy” end of the spectrum we’d include behaviors like whining, sulking, pouting, and crying.  Moving in the “less easy” direction we’d find behaviors like screaming, threatening, growling, swearing, spitting, biting, kicking, hitting, head-banging, lying, and stealing.  Moving still further in the “less easy” direction would be behaviors that are harmful (sometimes fatal) to oneself or others.  But we’d recognize that all of those behaviors – irrespective of which ones a kid may be exhibiting – occurwhen the demands being placed on a kid exceed that kid’s capacity to respond adaptively.  (Just to normalize this, we all look bad when the demands being placed upon us exceed our capacity to respond adaptively.  What do most of us have that challenging kids are lacking?  Skills.)

Imagine further:  instead of trying to find the “right” diagnosis, we’d instead focus our efforts on identifying the lagging skills of each challenging child and the specific conditions (unsolved problems) in which those lagging skills were being demanded…in other words, the conditions in which the child was “looking bad.”  We’d use the Assessment of Lagging Skills and Unsolved Problems to make sure we have the right lenses on, to organize our efforts to help, and to determine what problems need to be solved.  We’d rely a lot less on punishment and a lot more on problem-solving.  And we’d solve those problems collaboratively (rather than unilaterally).  Over time, we’d have a lot of solved problems – and a lot less challenging behavior -- to show for our efforts.

In many places – families, schools, inpatient psychiatry units, therapeutic group homes, and residential and juvenile detention facilities – this is no pipe dream.  It’s the reality.  Just not enough places…yet.

* * * * * * *

I’ve received numerous emails from people asking me to weigh in on the tragedy that occurred in Tucson, Arizona.  I’ve been closely following Gabby Giffords’ amazing day-to-day progress and have dared to imagine her leading a happy, productive life when she leaves the hospital.  I’ve been watching how our leaders have responded to the tragedy, some admirably, some less so, and wondering if their newfound civility will last beyond the end of January.

And, yes, I’ve been following what there is to read about Jared Lee Loughner.  Though hard information has been lacking – we really don’t know what he was thinking -- it certainly seems reasonably clear that he wasn’t in his right mind when he began shooting.  He joins others who have committed similar horrific acts in recent memory:  John Hinckley, Mark David Chapman, and those (their names are usually less familiar) who’ve walked into their workplaces or university campuses or schools and killed co-workers or fellow students and faculty.   

Speculation has begun about what Jared’s psychiatric diagnosis might be, and apparently there’s an emerging consensus that he must be suffering from a “severe mental illness,” such as schizophrenia or bipolar disorder.  But, as Sal Gentile astutely points out in an article for PBS, that really doesn’t tell us anything.  It certainly doesn’t tell us why Jared did what he did (most individuals carrying those diagnoses don’t commit violent acts and are at only slightly increased risk for doing so).  While his behavior over the past two years was considered odd, scary, and dangerous, he apparently didn’t meet “criteria” for being “arrestable” or “hospitalizeable,” which is why he was able to purchase a gun and do what he did.

It’s always easy after a tragedy to talk about what could have been done to prevent the tragedy in the first place.  I’m not going to do that.  As things presently exist, I think such horrific events are inevitable. But shouldn't we be giving more thought to whether we can more effectively help those in our society -- kids and adults -- who are lacking skills, have problems they're having difficulty solving, and are having difficulty making it in the mainstream as a result?  Failure to do so means we're accepting the status quo...that every month or so, something like what happened in Tucson will happen again.  (By the way, in many neighborhoods, the frequency of shootings is far more often than monthly.)  It's a tough problem.  I wonder if our leaders are up to the task.

Along those lines, I’m also wondering about whether our leaders are aware that while we elect them to represent our views, those views only take on relevance in the context of trying to solve problems.  Whether Sarah Palin’s "target graphic" or the vitriol that public figures referred to after the shootings had anything to do with what happened in Tucson, the tone set by that graphic and that vitriol is not conducive to the collaborative resolution of tough problems we need from our representatives.

Ross W. Greene

Lessons from a Tragedy

Over three years ago, a 16-year old tenth grader named John Odgren stabbed to death a student – his name was James Alenson – in a high school bathroom in a Boston suburb. A few months ago, I testified as an expert witness in John’s murder trial. My role was to try to explain how John came to do what he did on January 19, 2007.

Like many kids in our schools, John had a long history of social, emotional, and behavioral difficulties, starting with early problems in peer interactions (leading to a diagnosis of Asperger’s disorder), along with inattention and hyperactivity (resulting in a diagnosis of ADHD). Like a lot of kids, John’s social difficulties didn’t get better, and he ended up being on the receiving end of some significant bullying, occasionally resulting in fighting and impulsive violent responses (jabbing a peer with a pencil), and causing him to become intermittently depressed (and, at times, suicidal). John received lots of counseling and medicine, and was placed in a variety of alternative settings; in some of these settings, the bullying persisted. In another setting, he became extremely concerned that he was being stalked by a female peer.

As is the case with many kids diagnosed with Asperger’s disorder, John had preoccupations. Early on he developed a fascination with natural disasters, but then his preoccupations took a more troubling turn: first weapons, then Stephen King novels. Indeed, in adolescence, John became increasingly preoccupied with Mr. King’s Dark Tower series, in which bad things happen on a day associated with the number 19. My professional opinion was that this preoccupation, in combination with his history of being bullied and the stalking situation, set the stage for John to become increasingly paranoid and hyper-vigilant about being attacked.

John brought a knife to school on January 19, 2007, quite convinced – my professional opinion again – that he would be attacked. According to the one “witness” to the stabbing (a student who was in a stall in the bathroom, but didn’t see anything) James did absolutely nothing to provoke John. The two had never met before. That they ended up in the same bathroom that morning was tragically coincidental.

Was John in his right mind when he stabbed James? That’s the question the jury was charged with deciding. It’s an issue on which a “jury” of mental health professionals would have had difficulty agreeing. I’m reasonably certain that no other student at the same high school was certain he or she would be attacked on that day by virtue of its association with the number 19. The jury of John’s peers – none of its members, I suspect, diagnosed with Asperger’s disorder -- wasn’t asked to decide whether John stabbed James. John’s attorneys didn’t contest that issue. Rather, the jury was asked to determine John’s state of mind at the time of the stabbing, and was left with two options: guilty…or not guilty by reason of insanity (Massachusetts does not have a “guilty but insane” option). John was found guilty and sentenced to life in prison.

Though I was an expert witness for the defense, I found myself feeling tremendous empathy for James’ parents, who were present for the trial. I can’t begin to imagine their unspeakable pain and heartbreak. Their son is gone. From what I’ve heard and read, James was a gentle, considerate, kind kid. A website has been created to commemorate his life.

I felt empathy for John’s parents as well. Over the years, they took him to countless mental health professionals. They advocated for John to be placed in alternative settings in which they hoped that his difficulties would be well understood and well-addressed. From what I could gather, they did their very best. Their pain and heartbreak is also very real. They were recently interviewed in a Boston newspaper.

The families are left to determine the meaning of this tragedy in their lives.

But what’s the meaning of this tragedy for the rest of us? If we simply write this case off as just another example of “senseless” school violence, then we won’t try to make sense out of what happened. I think we’re compelled to contemplate whether there are lessons in this situation that would prevent something similar from happening again to someone else’s child, and I’m referring here to the parents of both James and John.

Here’s my take. That tragedies like this one don’t occur more often is largely a matter of luck. There are a lot of kids with social, emotional, and behavioral challenges in our schools, and a lot of them fly under the radar because they aren’t exhibiting the types of behaviors that would cause them to access the school discipline program. We actually know very little about what these kids are thinking. And we often don’t know much about what the kids who are “frequent flyers” in the discipline program are thinking, either. In many cases, we’re too busy talking at them, teaching them lessons they already know, and administering discipline…time after time. Whether well-known or below-the-radar, a lot of these students don’t feel like school is a place where they are heard, where adults understand their concerns or what’s getting in their way. Many of these kids are alienated and hopeless and stopped talking to adults a long time ago.

A strange association, perhaps, but this scenario reminds me a bit of airport security. Most airport screening equipment detects certain things (metal, sharp objects) but not others (for example, explosive powder in someone’s underwear). Thus, airline safety is still largely based on the premise that the vast majority of airline passengers don’t want to blow up the plane. In many schools, safety still hinges largely on the premise that the vast majority of students don’t want to kill somebody. While some schools do have metal detectors, the lagging skills and unsolved problems of students with social, emotional, and behavioral challenges remain undetected and unaddressed. And sometimes our luck runs out.

Of course, there’s an important difference between airport security and school security. Airport screeners don’t have the time to get to know each passenger well. But we do have the time to get to know our students well. It all depends on whether that’s one of our priorities.

Yes, I can see some of the eye-rolling that last sentence may have elicited. I appreciate the fact that educators can’t be all things to all kids and that time is short. I understand the unreasonable demands that are placed on classroom teachers, and that federal and state governments are far more concerned with academics than with the emotional health of our kids. I understand that the 25 percent of India’s population with the highest IQs is greater than the total population of the United States, that India has more honors kids than the U.S. has kids. I understand that the top ten in-demand jobs in the U.S. in 2010 did not exist in 2004, that we are currently preparing students for jobs that do not exist, using technologies that have not yet been invented, in order to solve problems that haven’t yet been identified as problems.

I also understand that we haven’t yet solved a problem that is right in front of us, right now: How to understand and help kids with social, emotional, and behavioral challenges in our schools.

And it’s not because we’re not putting the time in. It took me weeks to go through all of the paper that had accumulated in John’s file (reminding me that there’s an inverse correlation between the amount of paper that accumulates in a kid’s school file and how well he or she is doing). Kids who aren’t doing well accumulate massive amounts of paper: reports, evaluations, placements, behavior plans, support plans, progress notes. Kids who aren’t doing well also accumulate diagnoses. And, as you’ve read, John had his share. All that paper…all those diagnoses…and still…

And it’s not that there weren’t signs of trouble that fateful school year. In the criminal forensics class in which he was enrolled prior to the stabbing (given his history of preoccupations, probably not the ideal curriculum) John announced that he knew how to commit the perfect murder. On several occasions, he’d brought sharp objects to school that year, once chasing a kid down the hallway with one and then declaring that he wouldn’t be killing him that day. Several months into the school year, John began wearing a trench-coat, fedora hat, and sunglasses as his standard garb. Typical adolescent self-expression? Not in this case.

Our students with social, emotional, and behavioral challenges need help we’re often not giving them. We're already devoting the time and effort and dollars. We need to change what we're thinking and doing.

Another school year will be starting soon. If we don’t make it a very high priority to understand what’s going on in the heads of our vulnerable, high-risk students, to solve the problems that are setting in motion challenging episodes, and teach them the skills they’re lacking, then we’re still just relying on luck for our safety.

Post-script:
Coincidentally, this tragedy is back in the news, with John's attorney moving to have John's sentence reduced. If you'd like to read more about this development, you can do so by clicking here.

B is for Bullies (and the Bullied)

Massachusetts is in the national news again, this time not because of our new U.S. Senator but rather because of the more sobering topic of bullying. This is due, in large part, to the tragic recent deaths of 15-year old Phoebe Prince and 11-year old Carl Walker-Hoover, two kids who were apparently on the receiving end of bullying from other kids at school and ended up taking their own lives as a result. 

It goes without saying that suicide isn’t the only tragic consequence of bullying, just one of the outcomes unfortunate and alarming enough to make the headlines, get people to focus on the problem, and –- in Massachusetts at the moment -- energize efforts to pass legislation mandating that schools train staff to be vigilant about bullying and intervene actively and effectively in instances in which it occurs. My reading of the legislation in Massachusetts is that it compels educators to do something about bullying but isn’t specific about what that something should be. So I thought I’d devote this rendition of The Real World to thinking about that a little.

Phoebe Prince’s very unfortunate death prompted calls for the bullies to be severely punished. A parent in the community in which the bullying took place was quoted thusly in the Boston Herald: “There needs to be some punishment for (the bullies). They need to be held accountable. If nothing is done, nothing will change.” Charges were indeed subsequently filed against numerous of those alleged to have done the bullying in Phoebe’s case.

With all due respect, I doubt that punishment is going get the job done, and I'm certain that punishment isn't the best or only way to "hold kids accountable" (though the two terms are often used interchangeably). To go down that route is to make the same mistake we’ve made before (in the form of failed zero tolerance policies) in response to other highly undesirable behaviors we wish kids wouldn't exhibit at school but often do. However, it’s quite true that if nothing is done nothing will change. Kids have disagreements, get mad at each other, notice each others’ differences, and sometimes just plain don’t get along very well, and they need continuous guidance and oversight in handling these situations adaptively rather than treating each other cruelly or ganging up on each other.

The good news is that there are data to suggest that the rates of kids who report being bullied have actually declined, possibly suggesting that, in places where something is being done, the efforts may actually be paying off. But the suicides of Phoebe Prince and Carl Walker-Hoover –- and those that have occurred elsewhere, under similar circumstance, in many places -– tell us we still have quite a ways to go.

Of course, if you really want to do something about bullying, you need to understand it first. And, like everything else in mental health, diverse explanations have been offered. One very popular explanation is that kids who bully (1) have a strong need for power and negative dominance, and/or; (2) find satisfaction in causing injury and suffering to other students, and/or (3) are often rewarded in some way for their behavior. I've seen this very conceptualization invoked to justify interventions aimed at teaching bullies that they’re not as powerful as they might think and at helping them think twice about whether bullying is satisfying and rewarding...in other words, interventions that have punishment as a hallmark ingredient.

I’ve also heard it said and seen it written that some bullies come from circumstances that make “backing down” simply inconceivable. In such instances, bullying is said to function as an act of self-preservation. For example, in a recent article in the Boston Globe, reporter Lylah Alphonse wrote that some kids become bullies because it may be their only way to assert themselves after years of feeling like victims themselves, either at home or at school.

So, how would bullying be understood within the framework of the Collaborative Problem Solving approach? Might the CPS model offer some useful alternative intervention options beyond punishment?

In the CPS model, bullying would be viewed through the same lenses as other challenging behaviors: as the byproduct of lagging skills and specific unsolved problems.

Bullies are lacking crucial cognitive skills? Yes, indeed. If they had those skills, they wouldn’t be bullying.

What skills do bullies lack? It's always helpful to refer to the Assessment of Lagging Skills and Unsolved Problems (you can find it in The Paperwork section of this website) as our guide. I’ve worked with bullies who had difficulty considering the likely outcomes or consequences of their actions, had difficulty considering a range of solutions to a problem, and had difficulty “using their words” to solve problems. I’ve worked with bullies who interpreted social information in an inflexible, inaccurate manner or had cognitive distortions or biases. Still other bullies I’ve known had difficulty with some basic social skills (starting conversations, entering groups, connecting with people), difficulty seeking attention in appropriate ways, and difficulty appreciating how their behavior was affecting other people. And I’ve crossed paths with many bullies who had difficulty empathizing with others and appreciating another person’s perspective or point-of-view.

What’s the goal of intervention? Collaboratively solve the problems setting the stage for bullying. Of course, to do that we’d need to be more specific. Those familiar with the CPS model would recognize that the term “bully” is too vague to be of much use. If all I know about a kid is that he’s a “bully”, then I really don’t understand the conditions in which “bullying” is occurring, might have a lot of trouble gathering the information I need to truly understand “bullying episodes", and would certainly have trouble making sure the concerns of the “bully” (and the “bullied”) were addressed. In this respect, “bullying” falls into the same bucket as other similarly vague descriptions, like “aggressive", “defiant", “antisocial", “sociopathic", “conduct disordered", and “psychopathic”...all too vague to know what it is that we’re actually working on. I must admit to some confusion about where the category of “bullying” ends and where similarly vague descriptors -- “mean", “bossy", “controlling", and “cruel” -- begin, though I’m pretty certain they all emanate from lagging skills and unsolved problems. I also know that when adults aren’t exactly sure what it is that they’re working on, punishment tends to be the default intervention.

And what specific unsolved problems set “bullying” in motion? Way too many to count. But here are some of those I’ve come across lately: chronic disagreements on the playground or school bus; unresolved anger over a perceived slight; the ongoing perception that one’s peers are more (or less) popular; ethnic differences and misperceptions; unresolved issues and jealousies that can arise in dating relationships.

Why should we solve the problems setting the stage for bullying collaboratively? Because if we simply impose our will on bullies (Plan A)...if we don’t hear their concerns and make sure the solutions take those concerns into account...then, like other unsolved problems to which Plan A is applied, the solution won’t be durable, the problems won’t be solved, and the lagging skills won’t be taught (and we'll run the risk of bullying the bullies and driving the problem further underground). When we apply Plan B – Collaborative Problem Solving -- to the unsolved problems of bullies and the bullied, then we come to a much clearer understanding of the factors setting the stage for their problematic interactions, ensure that the concerns of both parties are addressed, and have a much better shot at solving the problems durably.

If, in our schools, we’re applying community-building programs – like Tribes or Responsive Classroom – then we’re continuously teaching, modeling, and practicing (for all students) how to get along with each other, handle individual differences, and function as a community (what the Response to Intervention folks would call Tier 1). And we're also helping kids recognize that it’s not just the adults who are on the hook for taking action if bullying is occurring. If we’re routinely using Plan B to understand concerns and perspectives, resolve disputes, and solve problems (still Tier 1 here), then we’re continuously modeling and practicing those crucial skills as well, and keeping the lines of communication wide open. If we’re routinely using Plan B at Tier 2 to help kids solve the problems that survive beyond Tier 1, then we have a “safety net” to catch the kids who slip through the Tier 1 cracks. And if we recognize that Plan B isn’t a one-shot-deal, carefully track unsolved problems over the course of a school year, and conceive of CPS as a staff development project, then we stay on top of things over time and foster a disciplinary culture oriented toward problem-solving rather than punitive methods of intervention.

If we feel that we don’t have time to do these things, then nothing changes. And if we – and our legislators -- continue to focus almost exclusively on high-stakes testing, then we’ll make it that much harder for teachers and school leaders to remember that there are stakes that are even higher than academics.

By the way, some kids I know who were on the receiving end of bullying committed violent acts toward others instead of turning the violence on themselves. Interesting how we view the two outcomes so differently. In fact, they’re just two different indicators of problems that were never solved and skills that were never taught.