Sunday, 15 January 2012

Inclusive Education and Conduct Disorders

For the first time ever I have been faced with the question, is mainstream inclusive education for all? Working with disruptive adolescents that show signs of mental health disorders throws the inclusion debate into unchartered territory.

Conduct Disorder
According to the ICD 10 Conduct Disorder is the repetitive and persistent pattern of dissocial, aggressive and defiant conduct. Now to most of us, this sounds like any 16 Year old having a night out on the town. However the authors of the ICD 10 (and the DSM IV for our friends across the pond) had the wisdom to mention that age appropriate defiance triggered by a scourge of hormones, however pathological it may seem, does not mean the young person has a disorder. Only when there are excessive levels of fighting and bullying, cruelty to animals or people, severe destructiveness to property, repeated lying and severe temper tantrums and persistent and severe disobedience do psychologists start to think of conduct disorder. As a teacher of 17 years, I have to admit this did sound like many of the teens that have passed my way and most of them have ended up making a huge success in their early adult lives. But then there was Ricky.

The Case of the Runaway Train
When Ricky came to us we had some idea what to expect. He had a troubled past and for the last couple of years he was educated in an isolated learning unit outside of mainstream education. His parents and the school believed he was ready to be reintegrated into mainstream education. I had been working on my PhD for two years (my research was based on the reintegration of students back into mainstream education from such learning units) and I was innocently confident that I would be able to provide Ricky with the support he needed. I volunteered to include Ricky in the team I was working with.

My first introduction to Ricky was not in person but rather walking into a mountain of paperwork meticulously gathered to prove that this young person was un-teachable. The piles of files were strenuously held together by thick rubber bands to prevent the contents of Ricky’s character to spill out onto my office floor. I systematically started reading from the bottom of the pile to gain an understanding of where the discord in Ricky’s life started - the details of which I am not going to explore today; however, may it suffice to say, like many other children in our school, Ricky experienced adversity from the very start of his life.

Day one arrived and I could not have met a more charmingly delightful 11 Year old. Ricky was well spoken, kind and helpful. I took the current charm with a pinch of salt: I had read his file and I was ready. By the second month I had eaten my hat, and secretly tapped myself on the shoulder. It was clear to me that the well-designed intervention machine that I had put into place had been working: Ricky was part of the nurture group, which focussed on self-esteem; he received one-on-one attention to bolster his literacy; he had a weekly session with a behaviour management specialist; I introduced cognitive behaviour strategies to the mix during his weekly session with me and he had a “Time Out” pass to allow his some space if he needed to take a breather. His teachers met every so often to encourage consistency in teaching and learning strategies that enabled Ricky to learn. The plan had worked.

Of Mice and Men
It was a Thursday morning and by this time I had carried Ricky’s past, file by file, to the school archive room. No day at our school is every quiet (we just don’t work in a school with boring moments) and I was not surprised to see the duty manager at my office door to ask for support. There was a tone in his voice that I had not heard for some time… “It’s Ricky…” By the time I reached the Science Lab, the remainder of a class of 26 students were lined up outside. Inside, in a corner, I found Ricky hyperventilating while spitting out expletives.
“Hi Ricky.” My voice was friendly and caring. “It’s me, Mr Mostert. Do you mind if I come a bit closer?” The answer was explosive and it was clear that I did not have permission to come closer. I walked closer, mindful of the distance between us. There was a copy of Jock of the Bushveld on the teacher’s desk. I opened on page one and started reading out loud, keeping a steady rhythm to the words.  By page three Ricky’s breathing slowed down and I had reached a position next to him on the floor.

In the coming year and a half, I would have to repeat this several times. Ricky’s oppositional defiant behaviour increased and soon it became clear that his playground behaviour had also deteriorated. Needless to say, all strategies and battle plans quickly converged into full-scale gorilla war. Soon teachers quoted health and safety regulations as reasons why Ricky was not allowed back into lessons and the school version of musical chairs started. “Whose turn is it to have Ricky this half term?” the Head of the English Department started the meeting after Easter. My strategies had all failed miserably and something had to be done. The situation was not fair on Ricky, his mother, teachers or me…  

Ricky had become very dependent on my proximity at school. Every time we met I had to ensure that he understands the role each of us play. I had to establish the boundaries again and again; even then he continued to push the boundaries (as one would expect from any teenager). We had been working to reduce this dependency through interventions and support from the Student Support Team and Special Education Needs coordinator.  However, in an attempt to contain Ricky, he was often sent to me. My office became a bazaar of fantasy, blatant wide-eyed lies and manipulation. I spent days on end investigating bullying incidents, rude and abusive behaviour towards staff and destruction of property; Ricky's behaviour became part of my weekly ritual.  After every incident, Ricky’s justifications became a hodgepodge of tales of destruction, racism, gang wars - he even claimed that he had stabbed an old man in the street.  It was clear to me that he needed a level of intervention that I could not provide. By this time I had referred him to three different mental health agencies, none of which could see my concerns after their initial meetings with Ricky. He was indeed a charming young lad.

The Switch
Ricky was always greatly concerned about how people viewed him. He was set on being in control of situations and remained oppositional defiant, in all classroom situations. Outside of school, Ricky acted in ways to ensure that he remained the centre of attention: he was feared among his peers and at home, even though he has a capable parent and older brother, he assumed the role of the responsible adult. Ricky had become increasingly paranoid in his perceptions. At the age of 13 he slept in his mother’s bed (he had his own bedroom) to keep control over her personal life. She once had a boyfriend and Ricky attacked the man on a regular basis until the relationship ended. He had also attacked a co-worker of his mother when she came into their home one morning to wait for Ricky’s mum before leaving for work. His reason was that the co-worker had “no right to be there.”

On the day he attacked the co-worker, Ricky arrived at school in a state of distress. He looked for me, however I was at a professionals meeting for a child protection case. Ricky immediately started hitting walls with his fist and once again had to be taken to an office to calm him down. He eventually calmed down and returned to lessons. I had heard about his outburst on arrival at school (news travels fast). Our negotiated boundaries included that Ricky must use his exit card effectively (we’ve had little success in this) and that he had to remain in lessons unless he felt that he was losing control. I thus left him in lesson to continue with his learning. During the third lesson he came to me, quite upset, and claimed that the teacher doesn’t like him. This was a regular and often incorrect perception of Ricky’s and all of his teachers, at one time or the other had been accused of picking on him or not liking him. There was no consistent pattern and it was clear that this was one of his many strategies to escape from the learning situation. I listened to his concerns, reiterated the agreed strategies to deal with the situation (a CBT approach to managing behaviour, I call it Making Positive Choices) and he agreed to return to lesson. He was completely calm when he left my office. Ricky returned three minutes later in a heightened state of distress and cried “See, I have proof”.  Ricky had called the teacher outside of the class and in a very calm voice asked her why she didn’t like him (not part of the strategy). The teacher replied that she did like him but that she could not allow him to disrupt lessons. Ricky continued to ask why she didn’t like him over and over again until the teacher said he must return to my office and remain with me. He then became agitated and started yelling at her “Why the f@£$% don’t you like me?” Ricky had secretly recorded the conversation in order to prove to me that he was right. I listened to the conversation (stepping very close to the border of acceptable practice, I know. I did tell the teacher later that I listened and she was relieved that I did because she thought that people would think she was actually picking on him). I could not find any fault in the way the teacher had addressed Ricky. She was calm, collected and caring. Ricky was the person that became more and more agitated in the recording. I discussed the recording with him. I developed the suspicion that Ricky “heard another conversation” during the time he was talking to the teacher. When I would not agree with him about the content of the conversation he started to hyperventilate himself, clenched his fists and go into his “rage”. He picked up the chair and threw it at me. It hurt.

During all this time I had kept copious notes of our discussions, his behaviour reports and interventions. Convincing my line-manager, Ricky’s parents and outside agencies that Ricky’s game of defiance and charm was not in his best interest, was a challenge.  For the first time ever I began to question my own views on the policy of inclusive education.

In the end
Dealing with Mental Health disorders in the mainstream is the most challenging part of working with Disruptive adolescents. As teachers we can see the warning signs, but we also have a duty of care, within an inclusive education environment where Every Child Matters. Working with Ricky has left me with more questions than answers. He has received a Statement of Special Education Needs and is currently educated in a smaller environment, aimed at working with students with behavioural, emotional and social needs.