Research Based Practice
Best Practices in Working With Students With Emotion Dysregulation
By Jennifer Cunningham, Linda M. Raffaele Mendez, & Ashley N. Sundman-Wheat
Students with emotion dysregulation have significant difficulty modulating emotional reactions, particularly in response to frustration or challenge. These children can present with a variety of DSM diagnoses in schools, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), major depressive disorder (MDD), and bipolar disorder (BD). Our previous article (Raffaele Mendez, Hoy, Sundman-Wheat, & Cunningham, 2011) examined research advances in understanding emotional dysregulation in youth. Here, we focus on practical suggestions for working with these students. Some of our recommendations come from sources that specifically address pediatric bipolar disorder (PBD; a disorder where emotion dysregulation is particularly prominent; e.g., Papolos & Papolos, 2006), whereas others come from research examining effective interventions for children with combined disruptive behavior and mood disorders (e.g., Greene et al., 2004).
Consultation, Psychoeducation, and Intervention Development
Youth with emotion dysregulation face a variety of challenges in schools, including coping with irritability in the classroom, maintaining alertness while taking medica- tions that can produce sedation and cognitive dulling, and organizing themselves in the classroom given deficits in executive functioning (see Papolos & Papolos, 2006). Because children with emotion dysregulation are often misunderstood in schools, a critical role for the school psychologist is to educate school personnel about disorders involving emotion dysregulation, including their etiology (e.g., PBD and ADHD often run in families), symptoms, and effective treatments. Teachers, in particular, need consultation on classroom-based behavioral strategies that are likely to work (and not work) with these children. Children with emotion dysregulation often experience considerable irritability that, if not dealt with appropriately, can escalate into a rage or explosive tantrum. Papolos and Papolos (2006) suggest proactively addressing this issue by assigning the student a specific person or place that he or she can access when unable to cope. This is very different than the typical strategy of invoking a punishment for a student once the behavior gets out of control. Papolos and Papolos also offer a number of other excellent suggestions for working with children with PBD in schools, including how to develop a comprehensive Individualized Education Program (IEP) that effectively addresses problems with emotion regulation (see Chapter 9 in their 2006 book). Even for students who do not have an IEP, putting into place specific strategies for de-escalating behavioral reactions is an important preventive strategy for these students. School psychologists should make sure these strategies are communicated to all who might come in contact with the student at school, including the nurse, guidance counselor, principal, assistant principal, bus driver, and afterschool care providers.
School psychologists also have an important role to play in educating parents about emotion dysregulation. For parents grappling with the challenges of raising a child with emotion dysregulation, providing psychoeducation and demystifying the child's symptoms can be extremely helpful (Chesno-Grier, Wilkins, & Pender, 2007). Psychoeducation efforts are frequently aimed at providing families with important information regarding their child's diagnosis, which can include specific information about symptoms, behavior management strategies, and different treatment options (Fristad, Goldberg-Arnold, & Gavazzi, 2003). Information provided as a part of psychoeducation to families can also include how to advocate for appropriate interventions and/or accommodations in school as well as how to access community resources and support groups. Given that psychotropic medications are one of the most common treatment strategies for children with mood disorders (particularly PBD; Killu & Crundwell, 2008), many families who have children with emotion dysregulation will be seeking services through a psychiatrist or neurologist. School psychologists can assist these families by providing timely referrals to reputable medical providers in the local community.
In terms of recommended treatment approaches for working with youth with emotion dysregulation, one intervention that holds considerable promise is Collaborative Problem Solving (CPS; Greene et al., 2004). The goal of CPS is to assist caregivers and children to work together to solve problems as opposed to imposing adult will on children, which often leads to behavioral escalation in children with mood disorders. Greene and colleagues (2004) studied the effectiveness of a manualized CPS treatment in comparison to another evidence-based intervention, parent training, with a total of 47 families whose children (ages 4–12) met the diagnostic criteria for ODD and also had subclinical symptoms of either major depressive disorder or bipolar disorder. The 19 families who completed the parent training condition met weekly for 10 sessions during which they were instructed in Barkley's (1997) parent training program. The 28 families in the CPS condition met for 11 sessions. Results indicated that, whereas both groups showed treatment gains from pretreatment to posttreatment (and 4 month follow-up), 88% of the CPS group versus 44% of the parent training group was “much improved” or “very much improved” at the 4-month follow-up. Additional information about CPS is available at www.ccps.info.
Another important role for the school psychologist who serves students with emotion dysregulation relates to case management. Many children with mood disorders take psychiatric medications (i.e., mood stabilizers, antipsychotic medications) to address the symptoms of the mood disorder and their comorbid conditions (e.g., ADHD). It is not uncommon for these children to require multiple medications to achieve significant symptom relief (Lofthouse & Fristad, 2006). Unfortunately, many of these medications are associated with side effects, such as decreased focus and attention, nausea, and drowsiness, which can impact students' abilities to effectively function in the classroom (Killu & Crundwell, 2008). Moreover, medication changes (with regard to dose or type of medication) are not uncommon in this population of students, and temporary side effects as the student adjusts to these changes should be anticipated. School psychologists can assist the student and family by facilitating communication between parents and teachers to ensure that teachers are aware that the student is receiving medication that might result in side effects so that teachers can respond appropriately. Additionally, school psychologists can help teachers to monitor both changes in behavior and side effects associated with varying types and dosages of medication by providing rating scales to teachers to capture important information. This information can then be reported back to the parents, or with the parent's permission, to the prescribing physician. School psychologists also can assist the classroom teacher and parents in implementing accommodations to address the student's particular medical needs. Examples of simple accommodations that can be implemented in the classroom for students taking medication include extended time to complete assignments and tests, decreasing workload or altering assignments, unlimited drinking fountain breaks, seating close to classroom door to have easy access to the restroom without disrupting others, and keeping snacks close by to combat nausea. The reader is referred to Killu and Crundwell (2008) for additional suggestions.
Direct Services to Students
Many children with emotion dysregulation may also benefit from counseling by the school psychologist to help them cope with the educational implications of their disorder. School phobia, limited academic persistence, problems with organization, and difficulty building and maintaining friendships are relatively common among these students (see Papolos & Papolos, 2006). To assist students in building friendships, school psychologists can recommend and/or directly implement interventions targeting social skills development and affective education, including correctly identifying facial expressions. Recent research indicates that facial expression recognition is an area of weakness both for children with PBD and severe mood dysregulation (Rich et al., 2007). Providing assistance in the form of organizational coaching to address executive functioning deficits also is recommended.
Students with emotion dysregulation, whether chronic or episodic, are at significant risk for educational failure. School psychologists who understand how to work with this population of students can foster educational environments that are most likely to facilitate success. Toward this end, school psychologists can: (a) educate parents, educators, and students about emotional dysregulation, its symptoms, and medication side effects; (b) provide behavioral and social skills interventions to students; and (c) serve as liaisons between medical professionals, educational professionals, and families. Those interested in learning more about emotion dysregulation are encouraged to read Papolos and Papolos (2006) for comprehensive information on bipolar disorder; Fristad, Verducci, Walters, and Young (2009) regarding multifamily intervention for families of children with mood disorders; Carlson (2009) for differential diagnosis of ADHD and bipolar disorder; and Kowatch and colleagues (2005) for treatment guidelines for bipolar disorder.
Barkley, R. A. (1997). Defiant children: A clinician's manual for assessment and parent training. New York, NY: Guilford Press.
Carlson, G. A. (2009). Treating the childhood bipolar controversy: A tale of two children. American Journal of Psychiatry, 166, 18–24.
Chesno-Grier, J. E., Wilkins, M. L., & Stirling Pender, C. A. (2007, April). Bipolar disorder: Educational implications for secondary students. Principal Leadership, 12–15.
Fristad, M., Goldberg-Arnold, J. S., & Gavazzi, S. M. (2003). Multi-family psychoeducation groups in the treatment of children with mood disorders. Journal of Marital and Family Therapy, 29, 491–504.
Fristad, M. A., Verducci J. S., Walters, K., & Young, M. E. (2009). Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Archives of General Psychiatry, 66, 1013–1021.
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Killu, K., & Crundwell, M. A. (2008). Understanding and developing academic and behavioral interventions for students with bipolar disorder. Intervention in School and Clinic, 43, 244–251.
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Papolos, D., & Papolos, J. (2006). The bipolar child: The definitive and reassuring guide to childhood's most misunderstood disorder. New York, NY: Broadway Books.
Raffaele Mendez, L. M., Hoy, B. D., Sundman- Wheat, A. N., & Cunningham, J. (2011). Research advances in understanding emotion dysregulation in youth. Communiqué, (40), 3, 1, 6.
Rich, B. A., Schmajuk, M., Perez-Edgar, K. E., Fox, N. O., Pine, D. S., & Leibenluft, E. (2007). Different psychophysiological and behavioral responses elicited by frustration in pediatric bipolar disorder and severe mood dysregulation. American Journal of Psychiatry, 164, 309–317.
Jennifer Cunningham is in the PhD program at the University of South Florida completing her internship at the University of Maryland School of Medicine in 2011–2012. Linda M. Raffaele Mendez, PhD, is an associate professor in the school psychology program at the University of South Florida. Ashley N. Sundman- Wheat is a PhD candidate at the University of South Florida completing her internship in the Pasco County Public Schools and the Department of Pediatrics at the University of South Florida in 2011–2012.