ISSN: 0976-3759

Journal of School Social Work Price Rs 20.00

A National School Social Work monthly dedicated to networking of parents and teachers.

Hony. S e i l E i o : Dr Thirumoort y A pca dtr h Associate Professor, Dept. of Psychiatric Social Work, NIMHANS.

December 2011 Page Dr Thirumoorthy A 02 Editorial Efficacy of Psychoeducation in Alleviating Caregiver Jyothi Kiran V 03 Burden of Schizophrenics Psychosocial Care for Children Dr. Lakshmanapathi V and SunderArumugam 12 Treatment of Schizophrenic Patients: A Psychoeducational Dr Emmanuel Janagan Johnson 17 Approach Psychoeducation An Overview Ijas Abdul Majeed and Jeyaram S 21 Psychoeducation to Overcome Test Anxiety and Depression among School Children Muniyappan D and Dr Sivakumar P 26 Psychoeducating Parents of Mentally Retarded Children Arthur Julian Joseph and Dr Indiramma V 29

Volume VIII Issue 07 Contents

Focus: Psychoeducation
Hony. S e i l E i o : Dr Thirumoort y A pca dtr h Associate Professor, Dept. of Psychiatric Social Work, NIMHANS. Journal of School Social W o k r,
8 (New 14), Sridevi Colony, Seventh Avenue, Ashok Nagar, Chennai 600 083 Mobile: 98406 02325 E-mail: jssw.india@gmail.com and PJ.Naidu@yahoo.in
Note: Views expressed by the contributors are not necessarily the official view of the Journal.

Dr Sinu E Asst Profesoor, Prof Paramesvaran S Dept of Psychiatry Manipal Journal of SCHOOL SOCIAL W O R K December 2011

Journal of SCHOOL SOCIAL W O R K December 2011

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Eioil dtra

Psychoeducation: Evidence-based Approach!

therapeutic environment. In order to increase the knowledge and understanding of the illness and treatment, a systematially designed psychoeducational programme is necessary at individual and family level so as to not only impart knowledge but also enable them to cope effectively with their illness, prevent relapse and readmission, expedite discharge, ensure medication compliance as well as reduce the length of hospital stay. So, it is imperative to provide a comprehensive psychoeducational programme by well-trained mental health professionals to promote their reentry into their home and community with particular regard to their social and occupational functioning.

Efficacy of Psychoeducation in Alleviating Caregiver Burden of Schizophrenics

Jyothi Kiran V*
*Jyothi Kiran V, CPO (Institutional care), Integrated Child Protection Scheme, ICDS, SPRS Nellore.

Psychoeducation is one of the psychosocial interventions, we often use in our day-to-day clinical practice with different diagnostic groups of persons with psychiatric disorders as well as their family members. Available evidence shows that psychoeducation is efficacious. Studies related to psychoeducation report that psychoeducational group programme is effective in helping parents to establish a positive emotional climate in their relationship with their children. It also addresses the various cultural beliefs, myths and misconceptions and explanatory models of illness. It is really a challenge for mental health professional to address the culturally predetermined belief system in the

Attention Contributors
We request the contributors to include in the references cited the name(s) of author(s), publishers, year and place of publication of the book without fail. In case of journal references, please mention the volume and issue apart from date of publication. Two hard copies of the articles and a soft copy in CD may please be sent to Journal of School Social Work, 14, Sridevi Colony, Seventh Avenue, Ashok Nagar, Chennai 600083. Please mention the subscription number in all your communications. ~Ed. Journal of SCHOOL SOCIAL W O R K December 2011 0 2

(Dyck et al., 1999). Moreover, addition of the caregiving role to the already existing family role may make the key caregiver become stressful, both psychologically and economically (Srivastava, 2005). Burden indicates the presence of problems, difficulties or adverse events that affect the lives of caregivers or significant others of the patient (Platt,1985). Since the early 1960s the expression family burden has been adopted to identify the objective and subjective difficulties experienced by relatives of people with long-term mental disorders (Brand, 2001). From the 1970s to 1980s the adverse consequences of psychiatric disorders for family caregivers are being highlighted (Chien et al 2007). The objective burden include the effects on finance, health, routine and leisure of the family, while the subjective burden was the perception of the adverse effects of illness. Journal of SCHOOL SOCIAL W O R K December 2011 0 3

Introduction: There is considerable research evidence on the high levels of financial burden, strain and distress related to caring for an ill family member. The extent and determinants of burden among the caregivers of persons with a chronic mental illness, such as schizophrenia has been well researched. Literature provides compelling evidence that caregivers of psychiatric patients are exposed to high levels of burden and distress (Chandrasekhar et al 2002). Primary caregivers of schizophrenia patients frequently report psychological and emotional strain, social isolation and stigma, physical and financial burden associated with caring process of their patients. Burden of care in schizophrenia also correlates with patients illness variables (Dyck, Short, and Vitaliano., 1999) and availability of caregivers resources as well as coping skills

As a result of deinstitutionalization and the increasing shift of psychiatric care to the community, the role of family caregivers gains importance. Today, after their relatively short stay at inpatient care, most schizophrenia patients are sent back to their homes. On the other hand, living with a patient with schizophrenia can place considerable burden and restrictions on the rest of the family. The resources to support families are beginning to develop, but are very limited in the face of the huge demand. The reduction of family burden can help the families to sustain their caring role. This would mean lesser trips to the hospital as relapse is minimised. Family intervention is designed to reduce the risk of relapse and to ensure family support. Psychoeducation refers to educating the family members of patients with schizophrenia on the various aspects of the illness not only to help them cope better, but also to bring about more definite improvements in the clinical status and functioning of the patients (Thara et al 2005). 0 4

The family psychoeducational interventions have demonstrated reduction in family burden and in the severity of symptoms. The psychoeducational approach strives to empower family members to participate actively in the treatment of the patient (Bauml et al,2006). Family psychoeducation interventions have repeatedly demonstrated reductions in illness relapse, negatives symptoms and inpatient service utilization (Dyck, Hendryx, Short, et al., 2002). As a result, family psychoeducation and support interventions are considered a best practice in the treatment of schizophrenia (Lehman and Steinwachs, 1998b). The addition of psychoeducation to pharmacological interventions brings benefits for the patient and the family. However presently in India intervention studies are rare. The following is a humble attempt to examine and report on the efficacy of psychoeducation on alleviating caregiver burden in Schizophrenia. Methodology : Aim of the study: To determine the efficacy of psychoeducation in alleviating

Jyothi Kiran V

Efficacy of Psychoeducation in Alleviating Caregiver Burden ...

Journal of SCHOOL SOCIAL W O R K December 2011

or current psychiatric consultation and prior exposure to any structured psychosocial intervention were excluded. Data collection: Over a period of 9 months, patients and corresponding caregivers who satisfied the criteria were interviewed after obtaining their oral informed consent. The data were recorded and further aspects were studied as described below. Instruments used for data collection: Socio-demographic details of the caregivers: At first a demographic information questionnaire was used to collect information regarding the demographic characteristics of the caregiver. The details included age, sex, education, marital status, income and relationship with the patient. Burden Assessment Schedule (BAS): The Burden Assessment schedule developed by Thara et al (1998) was administered with caregivers measuring burden in nine areas: (a) Spouse related 0 5 Journal of SCHOOL SOCIAL W O R K December 2011

caregiver burden in schizophrenia. Objectives of the study: 1. To ascertain the sociodemographic characteristic of the caregivers. 2.To determine the efficacy of psychoeducational intervention in alleviating caregiver burden Sample details A total of 50 volunteer caregivers of persons suffering from schizophrenia were selected from the psychiatry unit of SVRR General Hospital, Tirupati. They were seen weekly once individually as a part of intervention process during which they received psychoeducation. Intervention with each caregiver lasted for a period of nine months which included assessment, intervention and followup. Criteria for selection of the sample. For caregiver: 1) Age: 18 years or older. 2) He/ she is an adult relative living with the patient, in the same environment, for at least 12 months and was involved directly in giving care to the patient. 3) Caregivers with history of past

(b) Physical and mental health (c) External support (d) Caregivers routine (e) Support of patient (f) Taking responsibility (g) Other relations (h) Patients behaviour (i) Caregivers strategy. There are 40 items rated on a three point scale. The reliability is .80. The validity ranges from .71-.80. Psychoeducation intervention package: Existing intervention programmes were reviewed in order to develop a brief and need-based intervention package that would be relevant and suitable for the Indian setting. Intervention content for this study was drawn from Family Intervention and Support in Schizophrenia A Manual on Family Intervention for the Mental Health Professional (Varghese et al 2002). Intervention procedure: 50 intervention cases were taken up in three batches of caregivers (18, 14 and 18 cases respectively) met every week. Session 1: Engaging and maintaining the caregiver in treatment. 0 6

Session 2: Assessment of the caregivers knowledge about the caregivers knowledge about the affected members illness. Session 3: General information about schizophrenia. Session 4: Information regarding diagnosis, symptoms and causes of illness. Session 5: Importance of pharmacological treatment process. Session 6: Course and prognosis of schizophrenia. Session 7-8: Training in daily living skills of the schizophrenic patients. Session 9: Termination and followup. Follow-up visitswere conducted once in 15 days. Then monthly visits were conducted for three months. The goals of the sessions: a) to enhance the caregivers knowledge and understanding of the illness, b) develop a realistic appraisal of the situation and outcome, c) facilitate acceptance of the illness and disability, d) reduce caregivers burden and

Jyothi Kiran V

Efficacy of Psychoeducation in Alleviating Caregiver Burden ...

Journal of SCHOOL SOCIAL W O R K December 2011

developed an understanding of the caregivers attitudes and beliefs about the illness of the patient. The third session focused on providing information to caregiver about schizophrenia, - general information about schizophrenia and accurate information about illness and how it affects the persons thoughts, emotions and behaviour. A detailed account of symptoms was provided. Disturbances in sensory perception and their effects on the bahaviour of the patient were explained. The fourth session provided information about diagnosis of schizophrenia, its nature, symptoms and causes of illness. Schizophrenia was explained as syndrome affecting thoughts and emotions, which in turn results in disturbed behaviour. The distinction between positive and negative symptoms was explained so that relatives could understand the illness. Family members usually have theories of their own as to why the illness may have occurred. It is problematic when the family acts upon such beliefs as the sole cause of the illness. Hence the necessary details were provided to the Journal of SCHOOL SOCIAL W O R K December 2011 0 7

burnout, e) improve overall quality of life for the caregiver. The caregivers of the patients who received psychoeducation attended a total of nine therapeutic sessions, which was held weekly. Sessions were interactive and participation was encouraged which gave rise to further discussions. Caregivers were encouraged to ask questions. In 4 follow-up sessions, the first one was after 15 days and remaining 3 were monthly formal contacts with the caregiver. The intervention begins with rapport building with caregiver or in other words developing a working relationship with caregiver and taking details of the patients illness. Engagement of caregiver consisted of offering positive pleasant, polite contact, while sharing appropriate care and concern for the caregivers problem. In the second session, assessment of the caregivers knowledge about the affected members illness was carried out. In this session researcher gathered details of the patients past and present symptoms and also

Jyothi Kiran V

caregiver. The fifth session carried out on pharmacological treatment; information about side-effects and the likely benefits of medication in acute and maintenance phase were described. The family members may feel that the medications are like sleeping tablets and are addictive if used for a long time. Hence, it was emphasized that the family must not stop the medication even when the patient appears better. The medications control the symptoms. The role of medication in relapse prevention was outlined. The sixth session aimed to provide information regarding course and prognosis of illness. Most families think that they require no further treatment and that there is no possibility of the illness recurring. The information to caregiver that schizophrenia can have remissions and relapses and treatment is needed for a long time enlightened the caregiver that there were good chances that the patient can recover from an episode and have a near normal life and patients may recover upto 60-70% with medicines. 0 8

The seventh and eighth sessions focused on another important component namely the daily living skills. Because of chronic schizophrenia, patients at times lose or are unable to perform their daily routine activities such as grooming and bathing without assistance. To regain these skills, the caregivers have to train the patient. The main objective of the session was to assess the areas of daily functioning in which the patient lags behind. Focus was on educating, training and guiding the caregiver to prepare the patient to perform these daily tasks by himself. The intervention emphasized the role the caregiver in helping the patient to stay well. The ninth session is termination and follow-up. Initially sessions were held once a week and later held once in two weeks and later once a month. The caregivers were prepared ahead of the leaving time so that they could prepare themselves for it. The researcher reviewed with the caregiver the changes that have occurred as a result of the intervention. In follow-up visits she identified the positive changes in

Efficacy of Psychoeducation in Alleviating Caregiver Burden ...

their attitudes, behaviour and communication with the patient and highlighted their ability to resolve their problems, identified the positive changes in the patients activity levels, his independence in doing tasks related to his personal care and household chores. Statistical analysis: Descriptive statistical procedures were adopted to describe the sociodemographic characteristics. Paired t-test was used to compare the pre and post intervention scores and to determine the efficacy of psychoeducation in alleviating caregiver burden. Results: Table 1: Socio-demographic characteristic of caregiver: Characteristic Sex Male Female Age Upto 37 37-55 Above 55 N 24 26

Table 1: (Contd.) Characteristic Education Illiterate Primary Secondary College Relationship to the patient Mother Father Wife Husband Siblings Others Marital status Single Married Income per month in Rs. Below 2000 2000-4000 4000-6000 6000-8000 Above 8000

N 27 3 13 7

19 9 5 13 3 1 1 49

7 20 13 6 4

Journal of SCHOOL SOCIAL W O R K December 2011

From the above table showing the socio-demographic characteristics of 7 caregivers, it can be seen that most 25 of the caregivers are females who are 18 also mothers and parents, Journal of SCHOOL SOCIAL W O R K December 2011 0 9

are illiterate and belong to low factors of Burden Assessment socio-economic groups. Majority of Schedule (BAS) were compared them are in the age range of 37-55 score before intervention were years. relatively high. Statistical analysis To examine the efficacy of the was done using paired t-test to psychoeducation intervention in compare the pre- and postreducing family burden in caregivers intervention scores. There were of patients with schizophrenia all the statistically significant differences in 50 caregivers were inducted into a post-intervention measures of burden psychoeducation programme. in most categories as shown in above (Details have been provided under table. The results show a significant the methodology section) When pre reduction in the level of burden in and post intervention scores of mean caregivers who received and, standard deviations on the nine psychoeducation as compared to Tablepre-intervention scores. 2: Analysis of pre-and post intervention
Factors of BAS PostPre(Burden Intervention intervention Assessment Schedule) Mean(SD) Mean (SD) Spouse related 3.92(3.78) 5.82(4.67) Physical and Mental health 6.58(.85) 16.10(2.50) External support 7.44(2.14) 12.92(2.41) Caregivers routines 4.28(0.53) 10.90(1.70) Support of the patient 5.42(1.03) 7.30(1.46) Taking responsibility 6.48(1.46) 11.02(1.42) Other relations 3.30(0.67) 7.86(1.77) Patients behaviour 4.54(0.54) 11.10(1.55) 7.32(1.15) 9.68(0.89) Caregivers strategy

Jyothi Kiran V

Efficacy of Psychoeducation in Alleviating Caregiver Burden ...

t-value p-value 0.00 10.23** 0.00 30.01** 0.00 17.71** 0.00 27.71** 0.00 9.84** 0.00 20.31** 0.00 18.65** 0.00 27.60** 11.37** 0.00

selected from those who attended OPD at SVRRGG Hospital. The findings of the present study showed that caregivers receiving psychoeducation reported significantly lower burden compared with pre-intervention scores. It is clear that caregivers feel over- burdened and find it difficult to cope with schizophrenia. They often lack knowledge about the nature of the patients illness and receive little help from professionals for the management of the patients behaviour . Coping with the patients problems frequently results in adverse effects on physical and psychological health of the caregivers and so caregivers should be provided with sufficient information regarding

illness and also adequate support to alleviate the distress they feel. Conclusion: The evidence suggests that brief psychoeducation intervention can yield significant gain in knowledge of the caregivers, who will then be better equipped in dealing with patients with schizophrenia. The advantages of a psychoeducation is an increase in knowledge, an opportunity for brainstorming, sharing and subjective sense of well- being of caregivers. Hence, as part of the team approach in a psychiatric setting, psychiatric social workers can use psychoeducation as a part of their intervention process at the individual and group levels.

Note: Low score is a good score Discussion: The present study examined the role of psychoeducation in alleviating 1 0 Journal of SCHOOL

caregiver burden. Caregivers of patients with schizophrenia were purposively SOCIAL W O R K December 2011

References: Bauml Josef, Frobose Teresa, Kraemer Sibylle, Rentrop Michael and WalzGabriele Pitschel ( 2006):Psychoeducation: A Basic Psychotherapeutic Intervention for Patients with Schizophrenia and Their Families. Schizophrenia Bulletin . 32 (Spl issue): s1-s9. Brand U (2001): European Perspectives: A Carers View. Acta Psychiatrica Scandinavica 104 (suppl 410): 96-101. Dyck D G., Hendryx M S, Short R A, Voss, W D and McFarlane,W R(2002): Service Use among Patients with Schizophrenia in Psychoeducational MultipleFamily Group Treatment. Psychiatric Services, 53(6), 749-754. Lehman, A F and Steinwachs D M (1998): At Issue: Translating Research into Practice: The Schizophrenia Patients Outcomes Research Team (PORT) Treatment Recommendations. Schizophrenia Bulletin, 24(1): 1-10.

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Psychosocial Care for Children

Psychosocial Care for Children

Lakshmanapathi V* SunderArumugam* *
*Dr Lakshmanapathi V, Assistant Professor of Social Work, Arignar Anna Govt. Arts College, Karaikal. ** SunderArumugam, Assistant Professor of Social Work, Arignar Anna Govt. Arts College, Karaikal.

Introduction: Psychosocial care is a vital part of human socialization because it is a course of gathering social, mental and spiritual needs. Many things can impact on a childs psychosocial wellbeing, including poverty, conflict, neglect, abuse, isolation, rejection, illness, death of parents and so on. Fitting psychosocial support helps children and their families to overcome these challenges, and builds coping mechanisms, trust and hope in their future. Psychosocial support helps to build resiliency in children and enable their families to understand and deal with them effectively. Student-teacher relationship: Students experiencing positive teacher-student relationships in their primary and middle schools report low conflict and a high degree of closeness with the teaching faculty when they go for higher studies. With minimum support these students Journal of SCHOOL 1 2

adjust to the demands of higher education. They develop social skills and with resiliency face academic problems. Improving students relationships with teachers is a very basic requirement and has important, positive and long-lasting implications for students academic and social development. It is established by empirical studies that those students who have close, positive and supportive relationships with their teachers attain higher levels of achievement than those students with conflicting relationships. Some tips to help children: Children, especially adolescents, require psychosocial care which can be offered in many ways without any extra effort by the teachers. The following are some of the time-tested tips to help children in their classrooms. Assess the situation: Try and spend time with children in classroom to find out whats going SOCIAL W O R K December 2011

on. It will also help assessing your childs performance. Find out whether he is being teased or not or frightened. This basic dynamic can make or break a childs experience in the classroom. Often when a child is having behaviour problems in school, it comes down to a feeling that the teacher doesnt like her, says Ehara-Brown. Strategize: When a child is feeling frustrated and restless and is about to start acting out; at these times, the teacher could give her something special to do, such as taking papers to the principals office. Or the teacher could think of a signal, such as a tap on childs shoulder, to remind her to behave without embarrassing her in front of the class. Give the child a break. The teacher can also move emotionally closer to the child by visiting when he is sick and pay special attention to him. Try to have an outing with children once in a while. Expression of parental love: Knowing that he is loved can pull a child out of a downward spiral. It can sometimes work to give your child a special reminder of you, something

he can put in his pocket, like a little note that says I love you and youre great. Best use of time: If your child is having a miserable time at school, he can think of you, or of the fun hes going to have after school, rather than stay trapped in bad feelings. A great example of this idea is in Harry Potter and the Prisoner of Azkaban, where Harry encounters some monsters called demeanors who suck all the happiness out of their victims. The antidote that a powerful wizard gives Harry is to think of the best time he ever had; this allows him to gain power over the monsters. Get outside help: If you think its necessary, get recommendations for a good therapist for your child. Talk with possible professionals on the phone, and tell them youre looking for someone who can help your child work through the emotional issues that are making him act out at school. Teacher and psychoeducation: Teachers have specific academic activities which keep them busy through out the day. It is unjust to expect a teacher to be a counsellor. 1 3

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Dr. Lakshmanapathi V and SunderArumugam

Teachers vary in their ability to create positive teacher-student relationships. Some teachers simply have an easier time developing positive relationships with students personality, feelings toward students, their own relationship histories may all play a role. In spite of all such hurdles teachers are the first persons to note those children who have difficulty in coping with the normal curriculum. Parents should be made aware of any difficulties being experienced by their child in school, long before there is any question of a psychological assessment. The parents should be encouraged to make arrangements for a check up on the childs general health, hearing and sight. If the school decides that an assessment is required for a particular child, the principal or a nominated teacher should arrange a personal interview with both parents and/or legal guardians before moving on to the next programme. So, given the situation we expect a psychologist or a school social worker be appointed by the school to deal with all psychosocial problems. 1 4 Journal of SCHOOL

Psychological programmes: The concept of psychosocial recovery helps in coming to terms with the wide range of emotionally traumatic events most children face in emergency situations. Psychoeducational programmes support the childs cognitive, emotional, and social development by strengthening the childs social support systems. Other benefits that accrue are: Nurturing childrens healthy psychosocial development at various levels, with the family, community, and children themselves. Restoring the normal flow of development. Protecting children from the accumulation of distressful and harmful events; Enhancing the capacity of families to care for their children. Enabling children to be active and positive agents in rebuilding their communities. Uses of counselling: Counselling helps children to discuss, explore and manage important personal, social and

Psychosocial Care for Children

SOCIAL W O R K December 2011

educational issues, such as: delivery in the schools, while at the Anxiety. same time supporting the learning Depression. process, child development and Anger management. understanding of educational Friendship issues. systems. School psychologists serve Exam stress. as a vital part of the pupil personnel Study skills. services team and work closely in And many others. conjunction with school counsellors, School services: nurses and administrators in the Mental health professionals like delivery of services to address the social workers and psychologists educational, emotional, social and provide a range of services to assist c a r e e r n e e d s o f s t u d e n t s children and adolescents in their and families. learning, growth and development by The primary intent of the provision providing supportive services to help of school psychological services is to students meet academic and promote mental and physical emotional challenges. School wellness and facilitate learning of Psychological services consist of students. School psychologists are in direct and indirect interventions that a strong position to help support the require involvement with the entire attainment of the goals outlined in the educational system, including the Strategic Plan. The overall goal of the students, teachers, counsellors, psychological services program is to administrators, other school increase student capacity to personnel, families, community overcome academic, personal, and agencies, and a variety of others. social problems that could hinder their School support services: attainment of educational success School psychologists are unique and a satisfying and productive life. in the educational setting, because Conclusion: their training equips them to provide It is high time that school social psychological evaluation and workers are appointed to take care facilitate mental health service of the psychosocial needs of our Journal of SCHOOL SOCIAL W O R K December 2011 1 5

young generation on whose incur additional costs to the shoulders the future of the nation lies. exchequer, then they are bound to If the policy makers feel that it would pay a very heavy price in future.
References: Miller-Keane (2003): Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. Saunders: Elsevier, Inc. Editorial Team (2002): Concise Dictionary of Modern Medicine. New York: The McGraw-Hill Companies, Inc. Kazdin, A. (1993): Treatment of Conduct Disorder: Progress and Directions in Psychotherapy Research. Development and psychotherapy, 5,277-310. Walker, H., Colvin, G., and Ramsey, E. (1995): Antisocial behaviour in school: Strategies and best practices. Pacific Grove, CA: Brooks/Cole Publishing Company. Walker H M et al. (1996): Integrated Approaches to Preventing Antisocial Behaviour Patterns among School-Age Children and Youth. Journal of Emotional and Behavioural Disorders, 4(4), 194-209.

Dr. Lakshmanapathi V and SunderArumugam

Treatment of Schizophrenic Patients: A Psychoeducational Approach

Emmanuel Janagan Johnson*
*Dr Emmanuel Janagan. Johnson PhD, Lecturer/ Field work Practicum Coordinator in Social Work, Department of Behavioural Sciences, Faculty of Social Sciences, University of West Indies, St. Augustine Campus. Trinidad

Correction Slip For November 2011 Issue

PKV

P. No
04 05 06 17 18 18 21 28

For
the forthcoming issue social more made to practice in social evils which are called to be social deviance. pampered more CBT causing the problem they may Opening sentence

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a forthcoming issue social mores made to practise in social evils and social deviance. pampered much CBT (Cognitive Behaviour Therapy) causing the problem. They may not Juvenile delinquency refers to antisocial or illegal behaviour, activities . For dealing with juveniles there are juvenile detention centres. There are also different theories causative Bonger and Fomasiri aver widely used methods

28 29 31

causating Bonger and Fomasiri advocate widely used method

1 6

Focus for the next issue is CBR for Children. HSE: Dr. Royadurgam Narasimham Journal of SCHOOL SOCIAL W O R K December 2011

qualified health educator as well as Introduction: Psychoeducation refers to the health professionals such as social education offered to people who live workers, psychologists, nurses and with a psychological disturbance or physicians. In the groups several deficiency. Frequently patients are informed about their psychoeducational training involves illnesses and exchanges of patients with schizophrenia, clinical experience among the concerned depression, anxiety disorders, patients and mutual support are psychotic illnesses, eating disorders encouraged. and personality disorders, as well as Purpose of psychoeducation: patient training courses in the context The purpose of psychoeducation of the treatment of physical illnesses. is to increase patients knowledge and Family members are also included. A understanding of their illness and goal is for the patient to understand treatment. It has been found that and be better able to deal with the increased knowledge enables people prevailing illness. Also, the patients with schizophrenia to cope more own strengths, resources and coping effectively with their illness. skills are reinforced, in order to avoid Psychoeducational interventions relapse and contribute to their own involve interaction between the health and wellness on a long-term information provider and the mentally basis. The theory is, with better ill person (Xia, 2011). Most knowledge the patient has of their psychoeducational programmes illness, the better the patient can live have been designed for family with their condition. Psychoeducation members of schizophrenic patients. can take place in one-on-one This programme is constructed to discussion or in groups and by any Journal of SCHOOL SOCIAL W O R K December 2011 1 7

Dr Emmanuel Janagan Johnson

Treatment of Schizophrenic Patients: A Psychoeducational Approach

systematically educate inpatients/ outpatients about their disorder and to address their concerns and misperceptions in order to increase compliance with medical regimen and improve patients self-management (Haya Ascher, 1989). Psychoeducation has a positive effect on a persons wellbeing and promotes better social function. Treating people with schizophrenia with psychoeducation in addition to standard care results in greater clinical improvement (Xia, 2011). Psychoeducational approach: Educational approaches are employed in all aspects of the programme but are most extensively used in the transitional employment service, through work readiness seminars and a graduated continuum of volunteer service, training and employment(James, 1984). Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients knowledge of and insight into their illness and its treatment. It is supposed that this Journal of SCHOOL 1 8

increased knowledge and insight will enable people with schizophrenia to cope effectively with their illness, thereby improving prognosis (Pekkala, 2002). The psychoeducational approach to psychiatric illness addresses the need for better information about mental illness and its treatment for the patient and family. Most programmes focus on the family and its involvement with the patient. Treatment requirements for schizophrenic patients are shaped by a knowledge base which includes a host of biological, psychological and environmental factors. Indicators: Indications for participating in such a psychoeducational group are wide ranging. There are only few mandatory contraindications, including massive formal thought disorders, manic elevated mood, hearing imperative voices, or acute suicidal tendency with generally reduced stress resilience. Patients can be integrated within the treatment as soon as they are capable of taking part in group activities for a period of 60 minutes in one sitting. SOCIAL W O R K December 2011

Ideally, only patients suffering from clients birth issues, developmental schizophrenic psychoses should milestones, health concerns and participate in the group in order not history, medications, injuries, vision, to evoke unnecessary confusion in hearing, development of motor skills, other patients through the speech and language development schizophrenia-specific informational or problems, ability to pay attention, content. hyperactivity, emotional concerns, Group sittings last approximately ability to listen to and follow an hour at a time taking place once directions, social development and or twice a week and lasting for 4 and role in the family. It helps to reveal 16 sessions in all. Group leaders are any traumatic events that may be in most cases doctors, psychiatric impacting the client. Based on the social workers or psychologists, that information gathered at this interview, is, those drawn from all relevant and additional testing in several of these complementary occupational groups. areas may be performed (Barbara, The superordinate goal can be 2008) seen in patients and their relatives Key considerations for a acquiring basic competency to reach psychoeducational well-informed and self-competent assessment: decisions to choose from modern Expect direct observation in therapeutic options natural and/or clinical settings medicamentous, psychotherapeutic (when appropriate), the and psychosocial are completion of behaviour rating recommendable and suitable in their scales and personal interviews. own case (Josef, 2006). Testing should include comprehensive evaluation of The psychoeducational assessment: psychological, social-emotional, A psychoeducational assessment attention and learning issues, a will involve extensive interview by a review of prior school and medical social worker or psychologist. This records along with possible career interview will include discussion of the and educational profiles. Journal of SCHOOL SOCIAL W O R K December 2011 1 9

Make sure that the clinician is an expert in the area being evaluated - ask about credentials, experience and perhaps even references where relevant professional degree alone is not necessarily mean expertise. Referrals to other professionals may also prove beneficial All results are strictly confidential and are only released with the clients consent (Richard, 2011) Components of a good psychoeducational assessment: Referral question(s). Referral source. Background information. Assessment procedures. Relevant test procedures.

Assessment results. Interpretation of results. Summary and recommendations. (Sherry Mee, 2011) Conclusion: As of now the patient-directed approaches are common in clinical practice. Therefore, future research must focus on patient-directed psychoeducation and especially on integrating the outpatients, who too appear to profit more from psychoeducation. Medical and psychiatric social workers should be encouraged to practice and apply the psychoeducational approach. And more social work students should be encouraged to do active research in the field of application of psychoeducational approach.

Dr Emmanuel Janagan Johnson

Psychoeducation An Overview
Ijas Abdul Majeed* Jeyaram S**
*Ijas Abdul Majeed, M. Phil Psychiatric Social Work, Department of Psychiatric Social Work, NIMHANS, Bangalore 560 029 ** Jeyaram S, Ph D Scholar, Department of Psychiatric Social Work, NIMHANS, Bangalore 560 029

References: Barbara L. Minton (2008): Psychoeducational Assessments Can Reveal Childrens Hidden Strengths: Natural News retrieved from http://www.naturalnews.com/ 022888 on 1st November 2011 HayaAscher-Svanum (1989): A Psychoeducational Intervention for Schizophrenic Patients: Patient Education and Counselling, Volume 14, Issue 1, Pages 81-87 James T Barter, James F Queirolo; Stephen P Ekstrom (1984): A Psychoeducational Approach to Educating Chronic Mental Patients for Community Living : Psychiatric Services;35:793-797. Josef Buml, Teresa Frobse, Sibylle Kraemer, Michael Rentrop and Gabriele Pitschel-Walz (2006):Psychoeducation: A Basic Psychotherapeutic Intervention for Patients With Schizophrenia andTheir Families Schizophr Bull 32(suppl 1): S1-S9

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Introduction: EE (expressed emotion) have poorer The family can be a source of prognosis and higher relapse rates. personal gratification and social The vicious circle of tension and support; at the same time, it can also conflict in the family can be effectively be a source of stress and frustration. vitiated by psychoeducation. At one time, the professional Definition: perspective looked at families as The term psychoeducation has contributing to the onset of mental been defined as the education of a illness. But the tide has shifted and person with psychiatric disorder in families are now understood as subject areas that serve the goal of critical to recovery and relapse- treatment and rehabilitation (Pekkala prevention. and Merinder, 2002). The relationship between mental Psychoeducation comprises of illness and families is bilateral. Mental both informational and therapeutic illness of a family member can have components. It includes: Information about mental a devastating effect on the whole family, with emotional, economic and illness including scientific information concerning social implications. Conversely, the family environment is an important neurophysiologic functioning, epidemiological information, determinant of the course of mental illness. A stressful home environment information about psychosocial stressors and the use of and interpersonal conflict within the family can negatively affect recovery. medication. Helping in the development of Research has shown that patients a problem-solving approach exposed to families with high negative Journal of SCHOOL SOCIAL W O R K December 2011 2 1

Ijas Abdul Majeed and Jeyaram S

Psychoeducation An Overview

within the family. Intervention designed to modify interpersonal relationships that are characterized by hostility, intrusiveness or critical judgement, within the family. Steps in psychoeducation: The following steps are the commonly used strategies for psychoeducation that can be applied in a wide variety of mental disorders: 1. Stating the diagnosis: It is important that client and family member be aware of the diagnosis. Having this information is their right. Stating the diagnosis as described in the ICD or DSM may not always be helpful for clients and their families to understand the illness but it helps to simplify and explain it to them in a way that they understand. 2. Assessing what client and family already know: Clients and families have their own explanatory models for the illness, based on their social, cultural and religious norms and beliefs. Understanding these allows the practitioner to tailor-make further sessions in a culture-sensitive 2 2

way. It also clarifies clients and families expectations from treatment. 3. Talking about the disorder: In this step, the practitioner may discuss very elaborately in terms of defining the illness, the prevalence, the course of illness, possible causes of illness, treatment options, medication and side-effect profiles. Defining the illness would help the client and family members to recognise and understand the symptoms which they experience in current or future episodes. Portraying the mental illness as similar to the medical illness of diabetes and hypertension would reduce the stigma associated with them. Sharing with them the knowledge of others who have suffered from similar illnesses and have recovered will give them the feeling that they are not alone, and consequently feel reassured. 4. Clarify questions: It is always good to give time to the client and their family to think on the information and come up with their queries. Encourage the client and family members to think Journal of SCHOOL SOCIAL W O R K December 2011

particularly in their context and their challenges in management and offer specific suggestions. 5. Provide written educational material: Giving written educational material to your client and family members allows them to understand in detail and helps towards further clarifications. This procedure may amount to an essential and effective tool. Principles of psychoeducation (Rockville, 2009): 1. Let the clients define their kith and kin: This may include everyone who is supportive in the recovery process like friends, colleagues, employers, in addition to actual family members. 2. The practitioner-client-family alliance is essential: A strong and professional alliance with the client and family is essential to understand and support the clients personal recovery goals. 3. Education and resources help families to support clients personal recovery goals: Families educated about the illness are better able to identify symptoms, recognize warning signs of relapse, support treatment goals

and promote recovery. 4. Clients and families who receive ongoing guidance and skills training are better able to manage mental illnesses: Teaching techniques to reduce stress, improve communication and coping skills and teaching how to recognize precipitating factors and prodromal symptoms can help prevent relapses. 5. Problem-solving helps clients and families define and address current issues: Using a structured problem-solving approach helps clients and families break complicated issues into small, manageable steps that are easier to address. Guidelines on providing psychoeducation (Mathew Varghese, et. al. 2002): 1. Even if the family members do accept most of the information, they rarely change their beliefs about causation. 2. The familys view of the affected members condition may change only gradually in response to psychoeducation. 3. Clients and family members take time to ask questions and so 2 3

Journal of SCHOOL SOCIAL W O R K December 2011

pause after each theme to allow them to respond. 4. Some families need encouragement to ask questions or voice their disagreements with the information provided. 5. Always discuss and clarify the information with the family. 6. Avoid too much information or medical jargon. 7. Use analogies to explain concepts that are difficult to understand. Use examples from the history of the affected member. 8. Listen and understand the familys view of the illness. 9. Be sensitive to the distress experienced by the family members, such as when the affected member is violent, suspicious or has delusions that the spouse is unfaithful. Be alert to this and address it in future sessions. 10. If you do not know the answers to their questions, admit uncertainty. Assure them that you will provide the information in the next session and do so. 11. Patiently answer even when they ask the same questions again and again. 2 4

Psychoeducation in groups: It is acceptable to provide psychoeducation in groups when two or more families have similar problems. It is not only time-saving, but also has multiple benefits for the group, some of them being: Families understand that they are not alone when they see others facing similar problems and challenges. It facilitates sharing of solutions that others have found. It aids in developing a social network which helps both families and the mental ly ill person. Challenges in psychoeducation: 1. Clients are often sceptical about involving family members because they are afraid that sessions might be stressful and may throw up family conflicts. This resistance can be dealt with by explaining the benefits of this intervention which focuses on learning new positive skills. 2. Relatives frustration at the prospect of having to invest a lot of time and effort can be dealt with by emphasizing the contributions that others may be able to make.

Ijas Abdul Majeed and Jeyaram S

Psychoeducation An Overview

3. There will always be clients who even after extensive psychoeducation may not adhere to recommended duration of treatment. These clients and their families should be suggested alternate source of help in case they need at later stage due to poor drug compliance. Conclusion: Psychoeducation has become an evidence-based practice today in working with persons with mental illness and their families. Evidence

from researches which backs the involvement of family in treatment shows that psychoeducation has a positive impact on the outcome of psychiatric intervention. This type of intervention takes into consideration the family as the immediate milieu in which the individual lives and is supported and recognizes the family as an ally in the treatment process. It can improve a patients willingness to take medication as well as add to the effects of medication to improve symptoms by reducing family stress.

References: Carlet, Danial J. (2005): The Psychiatric Interview A Practical Guide, Philadelphia: Lippincott Williams and Wilkins. Crane D R and Marshall E S (2006): Handbook of Families and Health. US: Sage Publications. Herz M I and Marder S R (2002): Schizophrenia Comprehensive Treatment and Management. US: Lippincott Williams and Williams. King R, Lloyd C and Meehan T (2007): Handbook of Psychosocial Rehabilitation, Oxford: Blackwell Publicating Ltd. Rockville (2009): Family Psychoeducation: Building Your Program., retrieved from Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Retrieved from: http://www.samhsa.gov/shin. Sekar K (Ed.) (2007): Handbook of Psychaiatric Social Work, Bangalore: NIMHANS Publication. Singer B J (Producer) (2007): Family Psychoeducation: Interview with Carol Anderson, Ph.D. Podcast retrieved from: http://socialworkpodcast.blogspot.com/ 2007/10/family-psychoeducation-interview-with.html Varghese Mathew et al., (2002):Family Intervention and Support in Schizophrenia; A Manual on Family Intervention for The Mental Health Professionals, Bangalore: NIMHANS.

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Psychoeducation to Overcome Test Anxiety and Depression

Psychoeducation to Overcome Test Anxiety and Depression among School Children

Muniyappan D* Sivakumar P**
* Muniyappan D, Research Scholar Dept of Education, Alagappa University. Karaikudi ** Dr Sivakumar P, Professor of Education, DDE, Alagappa University. Karaikudi

Introduction: Psychoeducation is a process by which a professional imparts knowledge of the illness to the family and with continual assistance, modify their attitudes. He also formulates and implements better coping skills and other preferred interactions with the affected member. It is a specific form of education about a certain situation or condition that causes psychological stress. It is not a treatment but part of an overall treatment plan. Important elements in psychoeducation are information transfer, emotional discharge and support of a medication or psychotherapeutic treatment, as cooperation is promoted between the mental health professional and patient. In this paper an attempt has been made to overcome the two major problems namely test anxiety and depression among children 2 6

through psychoeducation. Test anxiety: Anxiety is defined as distress or uneasiness caused by fear of danger or misfortune. At some point every person has experienced anxiety over a specific situation or circumstances. Test anxiety is actually a type of performance anxiety a feeling someone might have in a situation where performance really counts and the pressures on to do well. Test anxiety is not the same as doing poorly on a certain test because our mind is on something else. Most people know that having other things on their minds such as death of someone close can also interfere with their concentration and prevent them from doing their best on a test. Ways to reduce test anxiety: Test anxiety is one of problems faced by children. The following suggestion would be useful to

overcome the test anxiety. Feeling ready: Feeling ready to meet the challenge, can keep test anxiety at a manageable level. Turn stress to advantage: Stress is our bodys warning mechanism its a signal that helps one to prepare for something important thats about to happen. Instead of reacting to the stress by dreading, complaining, or fretting about the test with friends let stress remind you to study well in advance of a test. Ask for help: It is always useful to get advice or suggestions from the teacher, school guidance counsellor, or any elder persons to overcome the test anxiety. Be prepared: Many students find that their test anxiety is reduced when they start to study better or more regularly. Replacing negative thoughts: The negative thoughts about the test should be replaced with positive affirmations such as I have studied well and so I am ready to do the best I can. Accept mistakes: Learning to

tolerate small failures and mistakes would always reduce test anxiety. Healthy practices: The healthy practices such as getting enough sleep, exercise, and healthy food before a test will reduce anxiety. Depression: Depression is a state of low mood and aversion to activity that can affect a persons thoughts, behaviour, feelings and physical wellbeing. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless. They may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, or problems concentrating, remembering details or making decisions; and may contemplate or attempt suicide. Effects of depression: Depression leads to various problems among school children. The following are the major problems faced by school children due to depression. Depression can cause low energy and concentration difficulties. 2 7

Journal of SCHOOL SOCIAL W O R K December 2011

Journal of SCHOOL SOCIAL W O R K December 2011

Muniyappan D and Dr Sivakumar P

Depressed students run away and means to reduce depression among school children. from home or talk of suicide. Providing proper support for Students may use alcohol or the depressed children is essential drugs in an attempt to selfto realize them that you are with medicate their depression. them, fully and unconditionally. It Depression can trigger and is suggested that we should avoid intensify feelings of ugliness, raising a lot of questions. shame, failure, and unworthiness. It is always useful to follow the Students may go online to gentle approach towards a escape from their problems. depressed child. Depressed students may Resist any urge to criticize or engage in dangerous or high-risk pass judgment when the behaviours. depressed child begins to talk. The Some depressed boys become important thing is that the child violent. communicates. Avoid offering Students depression is also unsolicited advice. associated with a number of other Do not try to talk teens out of mental health problems, including their depression, even if their eating disorders and self-injury. feelings or concerns appear silly Conclusion: or irrational. Simply acknowledge The following are some the ways the pain and sadness they feel.
References: Chapell, M.S., Blanding, Z.B., and Silverstein, M. E. (2005). Test Anxiety and Academic Achievement in Undergraduate and Graduate Students. Journal of Education Psychology, 97(2), 268-278. Bergmans Y, Links PS (2002): A Description of A Psychosocial/ Psychoeducational Intervention for Persons with Recurrent Suicide Attempts. Crisis. 2002; 23(4): 156-160. Fristad MA (2006): Psychoeducational Treatment for School-aged Children with Bipolar Disorder. Development and Psychopathy. 2006; 18(4): 1289-1306. Cummings CM, Fristad MA.(2007): Medications Prescribed for Children with Mood Disorders: Effects of A Family-Based Psychoeducation Program. Experimental and clinical psychopharmacology. 2007; 15(6): 555-562.

Psychoeducating Parents of Mentally Retarded Children

Arthur Julian Joseph* Indiramma V**
*Arthur Julian Joseph, Psychiatric Social Worker, Department of Psychiatric Social Work, NIMHANS, Bangalore-29. **Dr. Indiramma V, Associate Professor, Department of Psychiatric Social Work, NIMHANS, Bangalore-29.

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Journal of SCHOOL SOCIAL W O R K December 2011

Introduction: few years this approach/philosophy According to the WHO (1994); has been developed focusing on just approximately 156 million people or four aspects as the fundamentals for 3 percent of the worlds population the management of mental have mental retardation. In Asia alone retardation. there are 97,710,000 people reported Normalizing principle. to be diagnosed with mental Home based family care retardation. Prevalence of mental approach with parents and retardation in India is around 2% for partners in care. mild mental retardation and 0.5% for Early detection and the severe variety. A majority of them intervention. are rural males. At least one-third of Family intervention: children attending Child Psychiatry Two essential components of OPDs or Child Guidance Clinics have family-focused interventions are mental retardation (Srinath S, and parent counselling and parent Girimaji SR 1999). According to training, which are described below. Madhav M (2001) the national A. Parent counselling: prevalence rate for mental retardation Initial counselling: In this step had a median of 4.2 and a range of following thorough investigation and 1.4 to 25.3. assessment by the mental health Interventions while working with team, the news regarding the this population are focused on the diagnosis of the child needs to be parents of the children with special shared. Care must be taken to ensure needs and hence many packages that both the parents are present for target on the parents. Over the past the session. They are educated Journal of SCHOOL SOCIAL W O R K December 2011 2 9

Psychoeducating Parents of Mentally Retarded Children

about the signs and symptoms of the problems faced by the child followed by the diagnosis and the prognosis. Next would be to handle the reactions and emotions such as shock, denial, guilt, grief and frustration. The therapist needs to pay attention to these emotions and once this is done the myths and misconceptions are addressed and they are given a realistic picture of the illness. Then they would be educated about the available treatment including pharmacological management, if any, and psycho-social management. Briefing regarding the welfare benefits and parent training management is also done. Lastly parent associations, special schools and organisations working in the field of mentally retarded children are also addressed, not forgetting institutionalization for the child as per need. Group counselling: Here sessions regarding the normal childs development, nature of mental retardation, parental reactions, communication patterns, treatment options, individualized training, demonstration and role plays are held . This also creates opportnities Journal of SCHOOL 3 0

Arthur Julian Joseph and Dr Indiramma V

for sharing of experiences among parents and professionals and to learn new ideas which can be put to use. Issues such as adverse social consequences, altered social life, social embarrassment and stigma are also addressed as part of educating the parents of the mentally retarded children. B. Parent training: Parent training is the second important aspect for parents. It is a continuous process of intervention which can be done through various strategies such as explanations, instructions, discussion, modeling, rehearsal, video viewing,recording, use of manuals and flashcards to assist parents in training their child. Process of parent training: Depending on the childs developmental age, the training needs to be initiated. Example 1: In case the self-help skills of a child needs to be developed, the target areas could include holding a cup and drinking by oneself. In order to achieve this parents are taught how to carry out the process by breaking down the process into smaller steps and SOCIAL W O R K December 2011

using the techniques of role playing, modelling, prompting, shaping and rewards repeatedly at proper intervals for achieving the goal. Example 2: In the case of a child with behavioural problems, target areas for parents would be to stop the temper tantrums of the child. Parents can be educated about the techniques such as ignoring, disregarding the childs behaviour, time outs and differential reinforcement. It has been repeatedly demonstrated that parents of children with special needs can be effectively trained to implement developmental interventions at home itself. (Cunningham C. 1985). In addition, knowledge of the community facilities and resources is necessary. This will entail direct contact with schools, parent groups, and state hospitals for the retarded as well as state and local agencies which deal with the retarded child. Effective psychoeducation: A study was conducted by Xia, Merinder, Belgamwar (2011), to assess the effects of psychoeducational interventions compared with standard levels of

knowledge provision involving a total of 5142 participants from 44 trials conducted between 1988 and 2009 (median study duration ~ 12 weeks). This review compares the efficacy of psychoeducation added to standard care as a means of helping severely mentally ill people with that of standard care alone. The evidence shows a significant reduction of relapse or readmission rates. The findings showed that psychoeducation has a positive effect on a persons wellbeing and promotes better social function. Conclusion: Apart from educating and training the parents of mentally retarded children, other areas covered by mental health professionals include networking through various parent associations with the help of the government run associations and the private associations and also to liaison with the families of the mentally retarded children to access community resources, governmental resources and benefits. The following recommendations on the management for parents of children with mental retardation given by Girimaji (1998) can be used while 3 1

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Arthur Julian Joseph and Dr Indiramma V

Journal of School Social Work English Monthly. ISSN: 0976-3759 Registered with Registrar of Newspapers for India underNo.TNENG/2004/14389. Postal Registration TN/CC(S) Dn/ 47 / 09-11. Licensed to post under WPP No. TN/CC(S) Dn/ 34/09-11. educating parents: family and the environment. Parental and genetic Referrals for special education, counselling, parent training for occupational therapy, speech home-based management. therapy, vocational training, and Treatment of the underlying parent organizations. disorder wherever possible. Discussion about parental Early intervention and the concerns such as social security, management of co-morbid guardianship, menarche, marriage psychiatric and medical problems and providing appropriate Individualized training guidance. programme for the child based on Helping parents to access social assets and liabilities in the child, welfare benefits.
References: Cunningham, C. (1985): Training and Education Approaches for Parents of Children with Special Needs. British Journal of Medical Psychology 1985; 58; 285-305. Girimaji SR (1998): Counsellors Manual for Family Intervention in Mental Retardation. ICMR, published at NIMHANS, 1998. Girimaji.SR (1990): Early Diagnosis and Management of Mental Retardation An Update. Indian Journal of Psychological Medicine 1990; 13: 209-213. Madhav, M (2001): Epidemiological Study of Prevalence of Mental Disorders in India. Indian Journal of Community Medicine 2001; Vol. 26(4). Srinath, S., and Girimaji, S.R (1999): Epidemiology of Child and Adolescent Mental Health Problems and Mental Retardation. NIMHANS Journal, 1999; 17(4): 355-366.

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Journal of SCHOOL SOCIAL W O R K December 2011