**Factors Instigating Emotional, Behavioral, and Learning Problems**
Environment (E) Type I Problem	Person (P) Type II Problems	Interactions and Transactions Between E & P* Type II Problems
1. Insufficient stimuli (e.g., prolonged periods in impoverished environments; deprivation of learning opportunities at homes or school such as lack of play and practice situations and poor instruction; inadequate diet)	1. Physiological insult (e.g., cerebral trauma, such as accident or stroke, endocrine dysfunctions and chemical imbalances; illness affecting brain or sensory functioning)	1. Severe to moderate personal vulnerabilities and environmental defects and deference (e.g., person with extremely slow development in a highly demanding environment, all of which simultaneously and equally instigate the problem)
2. Excessive stimuli (e.g., overly demanding home, school, or work experiences, such as overwhelming pressure to achieve and cameralistic expectations; overcrowding)	2. Genetic anomaly (e.g., genes which limit, slow down, or lead to any atypical development)	2. Minor personal vulnerabilities not accommodated by the situation (e.g., person with minimal CNS disorders resulting in auditory perceptual disability trying to do auditory-loaded tasks; very active person forced into situations at home, school, or work that does not tolerate this level of activity)
3. Intrusive and hostile stimuli (e.g., medical practices, especially at birth, leading to physiological impairment; contaminated environments; conflict in home, school, work place; faulty child-rearing practices, such as long standing abuse and reject	3. Cognitive activity and affective states experienced by self as deviant (e.g., lack of knowledge or skills such as basic cognitive strategies; lack of ability to cope effectively with emotions, such as low self-esteem)	3. Minor environmental defects and differences not accommodated by the individual (e.g., person is in the minority racially or culturally and is not participating in many social activities because he or she thinks others may be unreceptive)
	4. Physical characteristics shaping contact with environment and/or experiences by self an deviant (e.g., visual, auditory, or motoric deficits; secession or reduced sensitivity to stimuli; easily fatigues; factors such as race. sex. age, or unusual a
	5. Deviant actions of the individual (e.g., performance problems, such as excessive errors in performing; high or low levels of activity)

Factors Instigating Emotional, Behavioral, and Learning Problems

Environment (E)
Type I Problem

Person (P)
Type II Problems

Interactions and Transactions
Between E & P*
Type II Problems

1. Insufficient stimuli (e.g., prolonged periods in impoverished environments; deprivation of learning opportunities at homes or school such as lack of play and practice situations and poor instruction; inadequate diet)

1. Physiological insult (e.g., cerebral trauma, such as accident or stroke, endocrine dysfunctions and chemical imbalances; illness affecting brain or sensory functioning)

1. Severe to moderate personal vulnerabilities and environmental defects and deference (e.g., person with extremely slow development in a highly demanding environment, all of which simultaneously and equally instigate the problem)

2. Excessive stimuli
(e.g., overly demanding home, school, or work experiences, such as overwhelming pressure to achieve and cameralistic expectations; overcrowding)

2. Genetic anomaly
(e.g., genes which limit, slow down, or lead to any atypical development)

2. Minor personal vulnerabilities not accommodated by the situation
(e.g., person with minimal CNS disorders resulting in auditory perceptual disability trying to do auditory-loaded tasks; very active person forced into situations at home, school, or work that does not tolerate this level of activity)

3. Intrusive and hostile stimuli
(e.g., medical practices, especially at birth, leading to physiological impairment; contaminated environments; conflict in home, school, work place; faulty child-rearing practices, such as long standing abuse and reject

3. Cognitive activity and affective states experienced by self as deviant (e.g., lack of knowledge or skills such as basic cognitive strategies; lack of ability to cope effectively with emotions, such as low self-esteem)

3. Minor environmental defects and differences not accommodated by the individual
(e.g., person is in the minority racially or culturally and is not participating in many social activities because he or she thinks others may be unreceptive)

4. Physical characteristics shaping contact with environment and/or experiences by self an deviant
(e.g., visual, auditory, or motoric deficits; secession or reduced sensitivity to stimuli; easily fatigues; factors such as race. sex. age, or unusual a

5. Deviant actions of the individual
(e.g., performance problems, such as excessive errors in performing; high or low levels of activity)

Here's what one school-based psychiatrist has to say. Do you agree or disagree with him?

It happens several times a week in my practice of community child and adolescent psychiatry: Our society's overwhelming belief in medically controlling our kids' behavior finds expression in ever more Huxleyesque demands on the psychiatrist to prescribe. This week's winners are the school district, the juvenile court, and a religious shelter for homeless families with children. Their respective would-be victims are LaShondra, Trevor, and Jimmy.

Jimmy is a 9 year old boy with a long history of treatment for severe emotional disturbance. He's in a school-based day treatment program and seems to be making terrific progress on self-managing his behavior. This turnaround has occurred just in the past few weeks, following an acute psychiatric hospital stay during which the many psychotropic medications he'd been taking without apparent benefit were tapered and discontinued. He was discharged to the day treatment facility and is receiving case management and therapeutic services at home in the community. Unfortunately, the grandmother with whom he lives has been evicted from her residence, and has applied for assistance to a homeless family program. She and Jimmy are scheduled to be admitted to a shelter program next week, but the shelter has made it a condition of receiving services that Jimmy be on medication.

LaShondra is 14. She is in special education classes at her junior high school because of mild mental retardation and emotional disturbance. She bears both physical and psychic scars of early prolonged abuse, and has symptoms of borderline personality pathology and PTSD. She likes school and wants to learn, but keeps getting expelled for behavioral outbursts. The school, too, has made it a condition of her readmittance to classes that she be on medication. LaShondra experiences psychotropic medication as inimical to her emerging adolescent autonomy, and has had negative therapeutic effects during past trials of treatment.

Trevor, at 15, is incarcerated in the Juvenile Detention Center, awaiting a hearing on certification to stand trial as an adult on two charges of capital murder. We have evaluated him for fitness to proceed and determined that he's not mentally ill, but are involved in providing services to Trevor in consultation with the juvenile authorities because he is persistently threatening suicide. We think the best plan is to keep him closely supervised in detention, but the juvenile department is concerned about their liability and petition the court to transfer him to a psychiatric hospital. Two hearings are held on the same day. At the first hearing Trevor is committed to a private facility, on condition that the facility accepts the admission. The facility refuses. At the second hearing, Trevor is committed to the state hospital on condition that the hospital certifies that they can guarantee security. The hospital can't. The Court then orders that Trevor be involuntarily administered unspecified psychotropic agents by injection.

I am not making these things up. These three cases have so far occupied the last three days of my week, and I'm telling you about them not to garner sympathy for the kids (only two of whom have any sympathy coming in any case), or for me (despite my clearly deserving some), but to focus attention on the astonishing degree to which everyone in our society has come to believe in the prescribing of psychotropic medication as a cure, or at least a control, for disturbing behavior in kids.

How did we arrive at this state of affairs? Though a very complex interaction among a myriad of scientific, social, and historical factors, of which I want to mention just two of the scientific ones: progress in psychiatric nosology, and progress in biological psychiatry.

Since 1980, we've trained a generation or two of psychiatrists in the phenomenological approach to diagnosis. The last three editions of the DSM (III-R, and IV) are determinedly atheoretical and empirical in their approach (the majority of members of the Work Groups on Child and Adolescent Disorders for the last three DSM's have been pediatric psychopharmacology researchers), and I think we have long since abandoned trying to teach residents to think about the meanings of symptoms to patients (and ourselves), about the dynamics of intrapsychic structure and interpersonal process. During the same time, the explosive growth of neuroscience and pharmacology has given us many new tools with which to work (if only we knew how: my friend and teacher Bob Beavers used to say, "if the only tool you have is a hammer, everything looks like a nail to you!").

In short, I think we've unwittingly relinquished our most powerful and proven tool: appropriately affectionate, professionally respectful, intimate personal engagement of the patient in mutual exploration of inner meanings. We're frittering our therapeutic potency away on serial trials of psychotropic drugs, and we're prescribing for patients when we don't know the person. There are too many kids on too many drugs, and many of the kids have been given medication as a substitute for engagement and exploration of personal issues.

The point I'm trying to make is that every sector of today's society contributes to this pressure to prescribe. Parents believe medication will cure, schools believe it, courts believe it. even nonpsychiatric mental health professionals believe it. Well, I don't believe it, and it's been my experience with ASAP that most of our members don't believe it either. And, if not only do we not believe that medicine cures, but also we do believe that we have a more powerful and effective treatment which provides an essential context for medication to be helpful, let's stand up and say so. I look forward to hearing from y'all: agree or disagree.

Psychiatrist Glen Pearson is president of the American Society for Adolescent Psychiatry (ASAP).
Reprinted with permission.

From Primary Prevention to Treatment of Serious Problems: A Continuum of Community-School Programs to Address Barriers to Learning and Enhance Healthy Development Intervention Examples of Focus and Types of Intervention Continuum (Programs and services aimed at system changes and individual needs) Primary prevention 1. Public health protection, promotion, and maintenance to foster opportunities, | positive development, and wellness | • economic enhancement of those living in poverty (e.g., work/welfare programs) | • safety (e.g., instruction, regulations, lead abatement programs) | • physical and mental health (incl. healthy start initiatives, immunizations, dental | care, substance abuse prevention, violence prevention, health/mental health | education, sex education and family planning, recreation, social services to access | basic living resources, and so forth) | | 2. Preschool-age support and assistance to enhance health and psychosocial | development | • systems' enhancement through multidisciplinary team work, consultation, and | staff development | • education and social support for parents of preschoolers | • quality day care | • quality early education Early-after-onset • appropriate screening and amelioration of physical and mental health and intervention psychosocial problems | | 3. Early-schooling targeted interventions | • orientations, welcoming and transition support into school and community life for | students and their families (especially immigrants) | • support and guidance to ameliorate school adjustment problems | • personalized instruction in the primary grades | • additional support to address specific learning problems | • parent involvement in problem solving | • comprehensive and accessible psychosocial and physical and mental health | programs (incl. a focus on community and home violence and other problems | identified through community needs assessment) | | 4. Improvement and augmentation of ongoing regular support | • enhance systems through multidisciplinary team work, consultation, and staff | development | • preparation and support for school and life transitions | • teaching "basics" of support and remediation to regular teachers (incl. use of | available resource personnel, peer and volunteer support) | • parent involvement in problem solving | • resource support for parents-in-need (incl. assistance in finding work, legal aid, | ESL and citizenship classes, and so forth) | • comprehensive and accessible psychosocial and physical and mental health | interventions (incl. health and physical education, recreation, violence reduction | programs, and so forth) | • Academic guidance and assistance | • Emergency and crisis prevention and response mechanisms | | 5. Other interventions prior to referral for intensive and ongoing targeted treatments | • enhance systems through multidisciplinary team work, consultation, and staff | development | • short-term specialized interventions (including resource teacher instruction | and family mobilization; programs for suicide prevention, pregnant minors, | substance abusers, gang members, and other potential dropouts) | Treatment for 6. Intensive treatments severe/chronic • referral, triage, placement guidance and assistance, case management, and problems resource coordination • family preservation programs and services • special education and rehabilitation • dropout recovery and follow-up support • services for severe-chronic psychosocial/mental/physical health problems

1. Insufficient stimuli (e.g., prolonged periods in impoverished environments; deprivation of learning opportunities at homes or school such as lack of play and practice situations and poor instruction; inadequate diet)

1. Physiological insult (e.g., cerebral trauma, such as accident or stroke, endocrine dysfunctions and chemical imbalances; illness affecting brain or sensory functioning)

1. Severe to moderate personal vulnerabilities and environmental defects and deference (e.g., person with extremely slow development in a highly demanding environment, all of which simultaneously and equally instigate the problem)

2. Excessive stimuli (e.g., overly demanding home, school, or work experiences, such as overwhelming pressure to achieve and cameralistic expectations; overcrowding)

2. Genetic anomaly (e.g., genes which limit, slow down, or lead to any atypical development)

3. Intrusive and hostile stimuli (e.g., medical practices, especially at birth, leading to physiological impairment; contaminated environments; conflict in home, school, work place; faulty child-rearing practices, such as long standing abuse and reject