If You Don’t Know, Get a Consult. . . Before You End Up in Court
As most of you concluded or have near-concluded your school year, I spent most of this past week in Court.
Not to worry. . . I was in Court as an expert witness on a due process hearing for a student who has not received appropriate services from his school district.
It is an interesting case. . . as well as an unfortunate example of how some districts refuse to accept their legal responsibilities to provide services to students with disabilities- - especially when they don’t really understand why these students sometimes exhibit some of the frustrating behaviors that are part of their disability.
Before summarizing the background of this case, understand that the focus of this week’s Blog is the difference between a social story and social skills instruction.
This focus came out of the testimony given by the special education teacher during this week’s due process hearing. Not understanding the difference between these two intervention approaches, she tried to convince the Hearing Officer that a social story could successfully teach students (with disabilities) how to demonstrate more effective interpersonal, social problem-solving, conflict prevention and resolution, and emotional coping skills.
Social Stories cannot do this - - even though they are often cited as an important intervention component especially for students on the autism spectrum.
And that will be the focus here.
When Schools Need a Psychological Consultation
I firmly believe that:
“If you don’t know, you get a consult.”
It’s a pretty simple concept, and one that the medical profession has embraced since the beginning of time.
Indeed, the first five lines of the “modern” Hippocratic Oath are:
“I swear to fulfill, to the best of my ability and judgment, this covenant:
- I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
- I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
- I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
- I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
It is this last line that I want to emphasize today. . . a line that some (many?) educators often do not practice.
This is because:
- This principle is not professionally and publicly highlighted and celebrated as important in our schools . . . not just from an ethical perspective, but from an instructional and intervention integrity perspective.
- Some educators are not encouraged to admit that they don’t know some things.
[Indeed, I have worked or consulted in countless schools where administrators create “professional” cultures and environments where an admission of “not knowing” is either a tacit admission of incompetence, or a prompt to “simply try harder.”]
- Or- - in today’s virtual, web-based world- - “not knowing” triggers a Google search, and the potential that the results of the search (“from about 15,300,000 results. . . 0.28 seconds”) have not been scientifically vetted, independently proven, or effectively transferred into the field.
Jonathan is a sixth grade African-American student who is identified as Emotionally Disturbed (under IDEA), and has mental health (DSM-V) diagnoses of Reactive Attachment Disorder (RAD) and Attention Deficit Hyperactivity Disorder (ADHD). He has average intelligence, and is an excellent reader.
Jonathan was addicted to cocaine (through his mother) at birth, his father has never been present, he was permanently taken away from his mother before 2 years old, and he continued life in a series of foster homes- - that changed periodically due to his uncontrollable behavior.
He spent a “preschool year” in a residential psychiatric treatment facility, he received early intervention services, and he was eventually adopted as he entered kindergarten.
Briefly, the clinical conditions for RAD must be present before Age 5, and they are due to “a pattern of extremes of insufficient care” that include social neglect or deprivation, repeated changes of primary caregivers, and rearing in unusual settings that limit the child’s ability to form consistent, positive, and nurturing attachments.
According to the DSM-V:
“Reactive attachment disorder is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. . . In addition, (these children’s) emotion regulation capacity is compromised, and they display episodes of negative emotions of fear, sadness, or irritability that are not readily explained.”
This pretty well summarizes Jonathan’s behavior. From early childhood on, Jonathan’s behavior was characterized by “unpredictable” anger that included throwing dangerous objects, non-compliance and running away, physical aggression toward adults and peers, and stealing and swearing.
As a sidebar, the due process case (eventually headed to federal court) involved the fact that the school district (a) refused to identify and provide Jonathan services beginning in kindergarten for his already-identified mental health disability; (b) did not identify him as Emotionally Disturbed until the beginning of 5th grade; (c) never provided IEP-driven interventions for him in the classroom, or cognitive-behavior therapies for him in school; (d) treated his disability-related behavior as a “discipline problem,” and (e) twice put him on long-term homebound placements- - again, without providing the social, emotional, and behavioral supports to address his needs.
While the school district never completed an appropriate functional behavioral assessment or Behavioral Intervention Plan (BIP), they did acknowledge (just before entering 5th grade) that Jonathan needed “social skills training.”
After delaying the delivery of this training for over a year, Jonathan’s new special education teacher decided to meet this BIP goal in October of his 6th grade year.
However, in testimony at this week’s due process hearing, this “experienced” special education teacher admitted that:
- She had never been formally trained in social skills instruction- - especially relative to students with affectively-based disorders like RAD;
- She developed her own “social skills curriculum” by pulling a bunch of material “off of the web”;
- She was teaching Jonathan these skills “whenever she got the chance”; and
- She was using “social stories” as the foundation to her curriculum; she believed that social stories were evidence-based; the stories focused on such global constructs as “friendship,” “respect,” “self-control,” and “handling frustration;” and that she did not pair the stories with any kind of behavioral instruction or role-playing.
This teacher also stated that she did not consult with any psychologist or mental health professional- - including Jonathan’s long-time private clinical social worker- - in the development or implementation of “her program.” In fact, she had just purchased a “really good book” that she found on the internet that had lots of “great social stories for Jonathan.”
The Issue: In addition to her questionable- - if not unethical - - professional behavior, and her failure to consult with others more trained and skilled, this teacher lacked the foundational training and understanding regarding the differences between social stories and social skills.
Social Stories were conceptualized by Carol Gray in 1991 as a vehicle to improve the social skills of individuals on the autism spectrum. Often written after a functional behavioral assessment- - so that they are relevant to a specific student’s status or needs- - Social Stories are intended to help decrease inappropriate or establish/enhance appropriate behavior. According to the conceptualization, in order to be successful, the student needs to both understand and relate to the content of the story.
Typically, a Social Story describes specific characters who are in a challenging social situation- - where the story breaks the resolution of the challenge into specific steps. It includes “who, what, when, where, and why” questions, and may include both print and pictures.
Social Stories are written in a positive and reassuring tone, and they may focus on how to (a) analyze a social, interpersonal, emotional, or conflictual situation; (b) take another’s point of view, or another perspective of the situation; and (c) resolve the situation through some behavior, action, or social skill interaction.
It is assumed that, by virtue of hearing, discussing, and understanding the story, the target student’s behavior and interactions will improve.
And so, it is critical to note: Unless added by the clinician, the Social Story methodology does not include behavioral instruction, practice, mastery, or application.
Think of the Social Story as the plays in a basketball team’s playbook that are taught by the coach on the blackboard in the locker room, but are never practiced to mastery on the actual basketball court during multiple practices.
What Does the Research Say ?
Quite simply, the “jury” is still out relative to the empirical effectiveness of Social Stories and their independent ability to change students’ behavior.
Indeed, on the National Registry of Evidence-based Programs and Practices (NREPP) of the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA), there is no single evidence-based program that involves or includes Social Stories.
In 2010, two meta-analytic studies on Social Stories were published. A meta-analysis is a statistical technique that pools the data from many other well-designed research studies into a single analysis that summarizes the overall effect of a specific strategy or intervention.
In one study, Reynhout and Carter analyzed 62 well-designed Social Story studies. They concluded their analysis and paper stating that,
“While there was considerable variation, on average, Social Stories appear to have only a small clinical effect on behaviour and practitioners should factor this consideration into decisions about appropriate interventions” and that
“Social Stories may be attractive to practitioners because they are easy to implement and require very limited resources. Nevertheless, given the limited potential for improvements, in many cases time may be better invested in more intensive interventions that are likely to yield more substantial gains.”
In the second study, Kokina and Kern analyzed 18 Social Story studies involving 47 students. They found that the stories appeared to either work well or not at all.
Overall, 51% of the individual study outcomes were classified as “highly effective,” while 44% were considered “ineffective” and the remaining 4% were considered “questionable” in the behavioral effects.
Kokina and Kern’s conclusions included the following:
- Social Stories used to reduce inappropriate behaviors were more successful than those for improving social skills.
- Stories used to describe single behaviors were more effective than those describing complex behaviors.
- A child may perfectly understand social situations (e.g. be able to answer questions about a social situation), but lack the actual skills to apply their knowledge.
- Stories were more effective when they were read just before the child had to engage in a target situation, than when the child was expected to remember and apply the social story to a time-delayed or unexpected situation.
- Stories that used additional visual illustrations were more effective than written text alone.
- Studies that first used a functional behavioral assessment to guide the creation of the social stories were substantially more successful than those that did not.
- Comprehension checks improved the effectiveness of the social stories, and children with high levels of communication skills performed better with social stories than those with low levels.
Relative to Jonathan and the complexity, intensity, and history of his social, emotional, mental health, and behavioral challenges, a Social Story approach by itself was largely inappropriate. Jonathan needed a multi-faceted behavioral, clinical, and chemically-enhanced therapeutic approach to address his 24/7 well-being.
He needed social, emotional, and cognitive-behavioral skills training.
While Social Stories may have increased his awareness of appropriate behavior, the fact that he did not have the skills to perform these behaviors were causing such a level of increased frustration that the strategy was having unintended negative and counterproductive effects.
Social Skills Training
There are many evidence-based social skills curricula: Positive Action, Second Step, PATHS, and the Stop & Think Social Skills Program- - which I wrote and help to implement across the country.
Similar to training a basketball team on the court to run the specific plays in its playbook, an effective social skill program teaches the sequential steps and the related behaviors to specific skills.
For example, in the Stop & Think Social Skills Program, we sequentially and developmentally teach 20 essential skills at the preschool through Grade 1, Grades 2 to 3, Grades 4 to 5, and Middle/High school levels, respectively . . . skills like:
Listening, Following Directions, Asking for Help, Ignoring Distractions, Dealing with Teasing, Accepting a Consequence, Apologizing, Dealing with Anger, Handling Rejection, Dealing with Peer Pressure, Walking away from a Fight
All of the skills are taught using a social learning theory approach of Teach, Model, Roleplay and Performance Feedback, and Transfer of Training.
When Teaching and Modeling: Teachers need to make sure that students:
- Have the prerequisite skills to be successful
- Are taught using language that they can understand
- Are taught in simple steps that ensure success
- Hear the social skills script as the social skills behavior is demonstrated
When Practicing or Roleplaying: Teachers need to make sure that students:
- Verbalize (or repeat or hear) the steps to a particular social skill as they demonstrate its appropriate behavior
- Practice only the positive or appropriate social skill behavior
- Receive ongoing and consistent practice opportunities
- Use relevant practice situations that simulate the “emotional” intensity of the real situations so that they can fully master the social skill and be able to demonstrate it under conditions of emotionality
- Practice the skills at a developmental level that they can handle
When Giving Performance Feedback: Teachers need to make sure that the feedback is:
- Specific and descriptive
- Focused on reinforcing students’ successful use of the social skill, or on correcting an inaccurate or incomplete social skills demonstration
- Positive--emphasizing what was done well and what can be done well (or better) next time
When Transferring or Applying Social Skills after Instruction: Teachers need to make sure that they reinforce students’ prosocial skills steps and behavior when students:
- Have successfully demonstrated an appropriate social skill
- Have made a “bad” choice, demonstrating an inappropriate social skill
- Are faced with a problem or situation but have not committed to, nor demonstrated, a prosocial skill
- Must use the skill in situations that are somewhat different from those used when the skill was originally taught and practiced
What Does the Research Say ?
The social skills research clearly demonstrates its effectiveness with students.
In 2011, Durlak and his colleagues published a meta-analysis involving 213 studies of school-based social, emotional, and behavioral learning programs involving 270,034 kindergarten through high school students.
When compared with schools that were not teaching a social skills curriculum, the results indicated that the students learning these skills demonstrated significantly improved social and emotional skills, attitudes, and behaviors, and significantly fewer problem behaviors when compared to control students.
These results occurred at all age levels: elementary, middle school, and high school. Moreover, these students being taught these skills demonstrated academic gains that reflected an improvement of 11 percentile points when compared to the control students.
Summary: Back to the Case
Two of my favorite workshop sayings are:
Intervention is a strategic act; Not a benign act.
Every time you do an intervention that doesn’t work, you potentially make the student more resistant to the next intervention.
As uncovered through this due process hearing, Jonathan’s special education teacher was “practicing” in wholly inappropriate ways.
- She had never been formally trained in social skills instruction- - especially relative to students with affectively-based disorders like RAD;
- She did not consult with an expert who understood the science and practice of social skills instruction, and she did not have the ability to discriminate what was evidence-based (or not) in the material she pulled “off of the web”;
- She chose to use a not-yet validated Social Story approach - - rather than an evidence-based social skills instruction approach; and
- She may have made Jonathan’s behavioral problems worse, because he got frustrated when he could not independently use the information being taught- - given the complexity and history of his challenges.
Regardless of her good intentions, this teacher was unethically practicing outside her areas of expertise, and her practice was potentially compounding Jonathan’s challenges and making his more resistant to future social skill interventions.
As you can tell: I AM critical of this teacher. But she is not alone.
Consulting with other experts when we ourselves do not have expertise in specific areas must be an expected, routine, and celebrated practice.
A Google search just does not cut it. . . for a doctor, a psychologist, or an educator.
End of story. . . all rise. . . Court dismissed.
While I know the importance of taking a break, please also use your summer to expand a specific, needed area of knowledge, understanding, or skill.
In this context, I hope you will process through my message today, reflect on your current practices (and those within your work setting), and think about ways to improve. . . on behalf of your students, clients, and others.
You do not have to agree with everything that has been said here, but your thoughtful analysis is important.
Meanwhile, I look forward to your thoughts and comments. Feel free to contact me at any time. Let me know how I can help your school, district, regional cooperative, or state move to the “next level of excellence”- - so that all of the “Jonathans” in our midst receive better, more effective, and more successful services, support, and interventions.
Feel free to forward this Blog link to your colleagues.