School staff can play an important role in helping children with psychotic disorders live more normal lives, according to Dr. Jonathan R. Stevens and Dr. Jefferson B. Prince.
"School interventions often involve optimizing the environment to minimize undue stress to the patient, which increases vulnerability to psychotic episodes, and to match the level of stimulation with the patient’s level of arousal. Across conditions contributing to psychosis, school staff efforts to identify precipitants surrounding episodes or deterioration can be useful in determining appropriate home and classroom expectations," they wrote in the January issue of Child and Adolescent Psychiatric Clinics of North America.
They noted several early warning signs of psychosis that may present at school: changes in thinking; mood; behavior; physicality; social changes, including withdrawal or isolation from friends and family; changes in functioning; students’ perception; and persistent false beliefs (delusions), suspicion, and paranoia.
"Although data on psychosocial treatments in youth psychotic disorders in schools are scant, psychosocial treatment remain a mainstay of the overall treatment plan, and school staff have an essential role in caring for a child with psychosis," wrote Dr. Stevens and Dr. Prince, both of the pediatric inpatient psychiatry unit of MassGeneral for Children at North Shore in Lynn, Mass (Child Adolesc. Psychiatric Clin. N. Am. 2012;21:187-200 [doi:10.1016/j.chc.2011.09.008]).
In the school setting, the goals of psychosocial interventions are largely to anticipate problems and to develop strategies that better allow the student to cope. Interventions include developing trust and rapport among the student, family, treatment team, and school staff; developing strategies that support and enhance reality testing for the student; developing strategies that support academic, psychological, and social adjustment; developing a monitoring system to reduce the likelihood of relapse and to respond if it occurs; identifying barriers to treatment; and supporting the student’s autonomy, relatedness, and competency.
"Parents and other caregivers can help identify the patient’s progression toward psychosis, which may provide specific topics for school staff to ‘check in’ with the patient to monitor the patient’s reality testing," the researchers wrote. Strategies should address both positive (delusions, hallucinations) and negative (withdrawal, decreased interactions) symptoms. Treatment for positive symptoms may include anchoring activities with others as part of their daily routine. "When a patient with psychotic symptoms is agitated, distressed, or unsure of what is and is not ‘real,’ simplifying the environment, decreasing expectations, and diminishing stimulation are often required," they wrote. For negative symptoms, regular social interactions with others and structured familiar activities can help diminish isolation. These interactions need to be carefully configured and supported by staff because these students may be inclined to withdraw or avoid interactions.
Psychosocial treatments for students with psychosis typically involve either multimodal treatment programs or specific psychosocial interventions. Multimodal treatments programs can provide a comprehensive array of service, such as community outreach/early detection efforts; inpatient and outpatient treatment; individual, group, or family therapy; and case management.
Specific psychosocial interventions have been studied, including individual cognitive behavioral therapy, group programming, and family interventions. "Providing youth suffering psychosis with ‘cognitively oriented’ individual psychotherapy appears to help these youth adjust to their condition, resume usual developmental tasks, as well as improve symptoms of anxiety and depression," wrote Dr. Stevens and Dr. Prince. CBT can help students target specific thoughts and beliefs that intensify their symptoms and compromise their function at school.
In particular, a "safe and private space" can be designated, which allows the student to decompress initially as practice with CBT techniques can then more easily be internalized and generalized. The more specific and frequent the practice sessions are, the more likely they will take hold and be helpful to the student.
Family and school intervention programs can emphasize psychoeducation, the need to identify warning signs, stress management techniques, the importance of attributing maladaptive behavior to the illness rather than to "bad behaviors" or "laziness," communication skills training, and the reduction of high expressed emotion, the researchers noted.
Dr. Stevens and Dr. Prince outlined specific tasks for the school team, teachers and support staff, and administrators. The school team needs to stay connected; stay positive; remember that children dealing with psychosis are children first, and often unable to understand their perceptions or why they are changing so differently from peers; and refer children who show early warning signs to mental health clinicians.
Teachers and support staff should break tasks down into smaller steps, minimize distractions, and have a plan to redirect the student to help him or her return to the task at hand; give short, concise directions; assist with planning and organizational skills; provide modifications and accommodations to the school; and provide support with social problems.