Which one is not an example of how best to help a student with an emotional and behavior disorder

Educating students with emotional and behavioral disorders (EBD) continues to be a challenge for many general and special education professionals. Students with EBD can exhibit behaviors such as chronic classroom disruption, aggression, and general maladaptive behavior toward peers and adults. Some students exhibit depression, obsessive/compulsive behavior, and excessive fears and phobias that merit special education programming. Estimates of those served for EBD are approximately 1% of the school population. The causes can include student biological factors and environmental influences such as family, school, and culture. Educators and researchers are focusing on preventing problematic behaviors and special educators are developing powerful intervention strategies to reduce these behaviors and replace them with more constructive ones.

4 ‘Unlearning’ in Classical Conditioning

Once one accepts a role for conditioning in behavioral and emotional disorders, the question becomes how to eliminate it. Pavlov studied ‘extinction’: conditioned responding decreases if the CS is presented repeatedly without the US after conditioning. Extinction is the basis of many therapies that reduce pathological conditioned responding through repeated exposure to the CS. Another elimination procedure is ‘counterconditioning,’ in which the CS is paired with a very different US/UR. Counterconditioning was the inspiration for ‘systematic desensitization,’ a behavior therapy technique in which frightening CSs are deliberately associated with relaxation during therapy (Wolpe 1958).

Although extinction and counterconditioning reduce unwanted conditioned responses, they do not destroy the original learning, which remains in the brain, ready to return to behavior under the right circumstances. For example, conditioned responses that have been eliminated by extinction or counterconditioning can recover if time passes before the CS is presented again (‘spontaneous recovery’). Conditioned responses can also recover if the patient returns to the original context of conditioning (the general situation, mood, or state in which conditioning occurred), or if the current context is associated with the US (Bouton 2000). All of these phenomena are potential mechanisms for relapse. Techniques that may minimize relapse include conducting therapy in the contexts where the disorder is a problem, conducting therapy in multiple contexts, or providing the client with retrieval cues or retrieval strategies that help recall therapy (Bouton 2000). In the long run, contemporary research on extinction and counterconditioning may suggest ways to optimize their clinical effectiveness.

9.22.7 Conclusions and Implications

Youth in foster care have disproportionately high rates of emotional and behavioral disorders, and they are at increased risk of not receiving the services necessary to address their needs. This is particularly true for children and youth in rural foster care given the shortage of mental health providers in their communities. To improve mental health treatment and outcomes among rural populations in general, and children and youth in rural foster care specifically, access to telehealth and internet-based therapies needs to be increased—among other strategies presented in this chapter. For example, service access can be expanded through the passage of policies that promote telehealth uptake like the Bipartisan Budget Act of 2018 which included provisions to improve access to telehealth services (Wynne and LaRosa, 2019). Or more recently and in response the COVID-19 Public Health Emergency, the Department of Health and Human Services took steps to make it easier for providers to offer telehealth services (Health Resources and Services Administration and U.S. Department of Health and Human Services, n.d.).

3.4.3 Developmental Disabilities

Learning disabilities, speech and language disorders, and emotional and behavioral disorders are the three largest groups in this category. Learning disabilities are defined in the Individuals with Disabilities Education Act (IDEA) as “disorders in one or more of the basic psychological processes” that are evident in an “imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.” Some intervention strategies seek to improve academic outcomes by targeting underlying deficits in basic psychological processes. For example, a student may receive training in visual processing. However, to date, such indirect approaches have demonstrated little or no effect on academic achievement. Although it is possible that such approaches have merit, further development of accurate measures of basic psychological processes, as well as interventions that are designed to address these issues, will be required before such instruction is likely to be effective. In addition, although the modality-matched approach (e.g., programs for “visual learners”) and the multisensory approach (e.g., using visual, auditory, and/or kinesthetic cues in instruction) are popular with many teachers, they have not been supported empirically.

In contrast, explicit, intensive, and supportive academic interventions have received substantive empirical support as successful methods for addressing academic failure. Effective instructional approaches include controlling task difficulty, using small interactive groups, teaching metacognitive strategies and problem-solving skills, using direct instruction, improving reading skills (e.g., phonemic awareness) and writing skills (e.g., organization and mechanics), and providing ongoing and systematic feedback. Such approaches improve academic achievement with students in both inclusion and special education classrooms, with students in a variety of disability categories, and with at-risk general education students.

Students with speech and language disorders, often referred to as communication disorders, may exhibit deficits in any of the following areas: receptive and expressive language, language development, articulation, fluency, and voice features. Speech and language pathologists provide a range of services in either private or classroom contexts to remediate these difficulties. Instruction may be targeted solely at learning the physical movements required for clear articulation (speech) or at developing language-related elements required for communication such as vocabulary and grammar.

Students with emotional or behavioral disorders may display inappropriately excessive or deficient behavior, possess unsatisfactory interpersonal relationships, and demonstrate academic learning problems. Intervention approaches used with these students include various psychotherapies, behavioral contingencies, family therapies, and segregation in residential programs. Behavioral and cognitive–behavioral approaches that include examining and altering antecedents and consequences associated with inappropriate behavior (e.g., functional behavioral assessments [FBAs]) and training in social skills have been shown to be effective in decreasing inappropriate behavior and increasing appropriate behavior. Because behavioral issues are central for most students labeled as emotionally disturbed, less research has been directed to identifying academic (vs behavioral) interventions specifically for students with emotional or behavioral disorders. However, instructional strategies that promote academic engagement and responding along with self-monitoring procedures have been shown to be effective. Because interventions for these students often require highly structured environments and more intensive instruction than is available in general education, this group of students is likely to receive direct services in a special classroom or school.

Students with emotional and behavioral disorders often become involved with the school disciplinary process. This can result in a conflict between the legitimate disciplinary needs of the school and the student’s right to FAPE, particularly when the relevant behavior is severe or dangerous. In such cases, the school must conduct a “manifestation determination” to determine whether the behavior is a manifestation of the child’s behavioral disability. If it is, then the child should not be punished for manifestations of the disability. Instead, an FBA should be conducted to determine the situational and behavioral factors underlying the misconduct, and the student’s IEP and/or placement should be changed to better meet the identified behavior management needs. If the misconduct is not a function of the student’s disability, the student is subject to the normal disciplinary procedures.

9.15.8.2 Research Findings

According to Kauffman (1997), 3–6% of children in our schools probably have emotional and behavioral disorders that require some form of intervention. Although the data are limited, there is a good general indication that children with SED form a culturally diverse group. For example, an analysis of nine recent studies on the characteristics of children in systems of care shows that, on average, the age of the children ranges from about 8 to 16 years, about 70–75% of them are boys, and between 50% and 75% are Caucasians, followed by about 25–30% African-Americans, 10% Hispanic Americans, and others, including native Americans, Asians, Pacific Islanders, and those of mixed races (Barber et al., 1992; Cullinan, Epstein, & Quinn, 1996; Epstein, Cullinan, Quinn, & Cumbald, 1994, 1995; Landrum et al., 1995; Quinn et al., 1996; Quinn, Newman, & Cumbald, 1995; Silver et al., 1992; Singh et al., 1994).

These data indicate that even when only three indicators of cultural diversity (age, gender, and ethnicity/race) are taken into account, there is a broad spectrum of children with SED who are being served in various systems of care in this country. Of course, virtually no data are available on some of the other aspects of cultural diversity in these children and their families, such as their nationality, language, religious beliefs, spirituality, socioeconomic status, social class, sexual preference, politics, and disability, among others. The reporting of these data are crucial in future research because it may well be that some of these variables will be found to be highly correlated not only with the nature of the services needed or sought by children with SED and their families, but also with the types of services that are most appropriate.

A related issue is the lack of similar data reported in outcome studies from various systems of care. Such data provide an indication of cultural diversity of the sample that is being provided with services. In addition, the reporting of these data indirectly indicates that mental health professionals are aware of the unique needs of children and families from different cultural groups. For example, it is well established that clinical psychologists may need to use assessment instruments and diagnostic methods that are culturally appropriate for children from different racial and ethnic groups. Further, children from diverse cultural backgrounds may need additional interventions that are different from the generic programs used with white, middle-class children and their families (Singh, Ellis, Oswald et al., 1997; Singh, Williams, & Spears, in press).

Current research suggests that professionals have culturally laden interactions with families and their children throughout the process of providing psychological, educational, and mental health services (Harry, 1992; Kalyanpur & Harry, 1997; Singh, 1995). Singh (1998) has detailed the nature and extent of these interactions and the pitfalls that professionals should be aware of. These interactions range from collecting sociodemographic and intake information, assessment, cultural formulation of the presenting problems, and interventions to the evaluation of treatment outcome, cultural influences on data analysis and interpretation, and family satisfaction. Space precludes a detailed discussion and interested readers are referred to this source for further information.

Finally, there is the issue of whether mental health professionals, such as clinical psychologists, can ever be competent enough to deal with the cultural nuances of the myriad of culturally diverse families who will seek their services. Although this question has not been subjected to rigorous research, intuitively we feel that the answer is no. However, we believe that sensitivity, understanding, and compassion will bridge the gap between culturally sensitive professionals and families who seek their services. Above all, good listening skills and understanding the issues from the perspective of the families are critical skills that all professionals should have. Fortunately, Kleinman, Eisenberg, and Good (1978) have provided us with a list of eight simple questions that professionals can ask, and the family's answers provide the professionals with the family's explanatory model of their problems. When professionals do not appreciate the cultural underpinnings of their own actions and that of the families, at best, their efforts will be only partially effective and, at worst, they will have to assume some of the responsibility for the tragic outcomes that can occur (see Fadiman, 1997).

Given the pervasive effects of culture on human behavior, mental health professionals will find it difficult to be cognizant of and respond appropriately to all cultural variables in every facet of service provision to families with a child with SED. Obviously, the effects of even the major cultural variables can neither be assessed fully nor controlled with any one family. Our research efforts and clinical practice should focus on finding assessment and intervention principles and methods that are universal and would apply across cultures, as well as those that are specific to different cultural groups.

Abstract

Behavior and emotions are regulated by neurotransmitters within the brain reward circuit. Alterations in this circuit relate to behavioral and emotional disorders, and gut microbiota signals seem to influence the brain reward functionality. Bidirectional communication between the gastrointestinal system and the brain, ensure the proper function of the intestine. At the same time, gut bacteria metabolites activate brain structures that regulate behavior and emotions. The endocrine and immune systems, both influence the brain–gut communication. Unhealthy lifestyles contribute to gut microbiota dysbiosis that jeopardizes the functionality of the brain reward circuit, and therefore increases the risk of behavioral and emotional disorders. Different strategies with prebiotics, probiotics, and dietary interventions have been tested to promote gut microbiota diversity and mental health. Overall, dietary interventions that consider the genetic background of the host, local foods, and food culture can be the basis of personalized-medicine and genome-based strategies, to prevent or alleviate gut microbiota-related diseases.

Affective Assessments in School Settings

Many individuals have argued for a need for early identification of and intervention for children who are at risk for emotional and behavioral disorders (EBD). In this context, EBD could be defined as low levels of EI and above normal levels of neuroticism, for example. Current legislation has required school personnel to become proactive in their identification of children who display problem behavior. Specifically, the Individuals with Disabilities Education Act has mandated that children in the United States who are in need of specific early intervention or special-education services be identified through the statewide, comprehensive Child Find System. The increased emphasis on early identification and prevention encourages professionals to intervene with children before problem behaviors develop into EBD. As a result, many preschool and school personnel have incorporated the use of positive behavioral-support programs to address children's behavioral difficulties.

Behavior-checklist measures from parents or teachers are helpful in identifying children who might be at risk for EBD and in need of systematic intervention. The use of measures such as the CBCL has appeared to be a proactive step to identify children and to provide them with early intervention. A behavioral measure for use at a universal level is dependent on several features. The measure must be reliable, developmentally appropriate for preschool and kindergarten-age children, economical in terms of time and resources, and relatively easy to administer with large numbers of children.

The collaborative for academic, social, and emotional learning (see e.g., Zins and Elias, 2007) aims to reduce EBD through after-school program interventions. Such ideas and their practical implementation are collectively referred to as social and emotional learning (SEL), a broadly defined term encompassing understanding affect in school and social settings. Zins and Elias (2007) categorize SEL competencies as “the capacity to recognize and manage emotions, solve problems effectively, and establish positive relationships with others” (p. 2). SEL programs tend to be heterogeneous, broad ranging, and diffuse in their approaches to learning and to the goals of the learning itself. However, the goals of an SEL program are generally to increase children's self-awareness, social and emotional knowledge, ability to make responsible decisions, and level of competency in self- and relationship-management. Over the past decade, numerous published studies have demonstrated that SEL is a crucial factor to academic success as well as life outside of the school environment. SEL plays an important role both in learning and in understanding issues related to school retention–attrition. For example, the National Center for Education Statistics (2002) reports that students cite social and emotional factors as the main reason for dropping out of school (e.g., 35% of students report that they dropped out of school because they do not get along with teachers or peers, and 23% of students said they dropped out because of feeling left out).

With the increasing awareness of SEL influence in school, the need for more affective-based assessments are needed to evaluate how these interventions impact students. Measures such as EI, mood, and stress and coping are key affective traits that should be affected by SEL interventions. With the growth in using affective-based assessments, counselors and school administrators can more easily understand how to diagnose and ameliorate social and emotional problems in school.

Beyond use as diagnostic and evaluation tools, affective assessments also play a role in educational policy both at the micro- and macro-level. Various accreditation agencies demand, for example, levels of accountability concerning student's level of stress and coping, and there is a move to replace anecdotal evidence with firmer metrics such as might be possible with some of the assessments currently reviewed. In addition, various large-scale assessments such as the National Assessment of Educational Progress (NAEP) and the Programme of International Student Assessment (PISA) have included assessments of affect such as anxiety and self-efficacy along with cognitive measures in every test cycle, with these ultimately influencing economic and political decisions at the local, state, national, and international levels.

Menstrual Disorders

Premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), and primary dysmenorrhea (PD) consist of a spectrum of physical, emotional, and behavioral disorders in premenopausal women that predominate during the luteal (PMS and PMDD) and early follicular (PD) phases of the menstrual period. Whereas only 3 to 8% of women experience symptoms severe enough to be diagnosed with PMDD,69 PMS affects as many as 75% and PD affects approximately 50% of women who are menstruating, with higher rates in younger women.70 The diagnostic criteria for PMS include: 1) majority of menstrual cycles are symptomatic during the last week of the luteal phase; 2) at least 5 of 9 categories of symptoms: marked affective lability; persistent/marked anger or irritability; marked anxiety or tension; decreased interest in usual activities; easy fatigability; marked change in appetite; hypersomnia or insomnia; other physical symptoms.71 Symptoms of PMDD are similar to those of PMS, but are more severe and cause marked social impairment. PMDD may or may not be superimposed upon an underlying psychiatric disorder.69 PD is a common gynecological complaint of painful menstrual cramps of uterine origin due to increased endometrial prostaglandin production and occurs without an identifiable pathological condition.70 Although conventional treatments (non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives) are effective in most women, 20 to 25% of women do not receive adequate symptom relief.70

Mind–body and manipulative modalities: Relatively few controlled clinical studies have been conducted on the use of mind–body CAM approaches for menstrual disorders. A review of RCTs on CAM indicated that most studies have been small, definitive efficacy studies are lacking, and mechanisms have been relatively unexplored.72 However, a few studies on PMS and PD indicate some symptomatic relief, particularly for PMS. For example, PMS scores decreased to a greater extent with reflexology versus placebo,73 and also physical symptoms improved to a greater degree in the active 5-month treatment compared with two controls.74 Chiropractic treatment consisting of adjustments and soft-tissue therapy produced a decrease in global PMS symptoms compared with baseline, but the sham group also improved from baseline.75 A recent review74 of acupuncture (6 trials, n=673) and acupressure (4 trials, n=271) for PD indicated pain relief from acupuncture versus placebo (4 trials), NSAIDs (3 trials), and/or Chinese herbs (1 trial). This review also reported pain relief from acupressure versus placebo (2 trials), as assessed by a visual analogue scale or self-reported menstrual symptom relief (e.g., nausea, tiredness). An emerging area of CAM research is focused on polycystic ovarian syndrome, although it is difficult to draw conclusions given the paucity of data. The exception is recent promising evidence from one research group that electro-acupuncture improved hyperandrogenism and menstrual frequency,76 as well as reduced high sympathetic nerve activity,77 in women with this common endocrine disorder.

Natural products: A comprehensive review of RCTs72 indicated that among 25 studies examining dietary supplements (predominantly vitamins and minerals), there is modest evidence that calcium, magnesium, and B6 supplements may play a role in relieving PMS, and that fish oil supplements, due to their influence on prostaglandin production, may relieve PD symptoms. A recent systematic review reported that there is promising evidence to support the use of Chinese herbal medicine for PD, although the findings should be interpreted with caution because in general the studies were of low methodological quality.78 Hence, well designed, adequately powered clinical trials on key promising CAM modalities (mind–body, manipulative, non-pharmacological) for menstrual disorders, incorporating suitable placebo controls, should be conducted.

Clinical Disorder

A functional abnormality or disturbance in one or more parts of the human body. Clinical disorders can be categorized into mental disorders, physical disorders, genetic disorders, emotional and behavioral disorders, and functional disorders. The term disorder is often considered more value-neutral and less stigmatizing than the terms disease or illness, and therefore is often the preferred terminology. In mental health, the term mental disorder is used as a way of acknowledging the complex interaction of biological, social, and psychological factors in psychiatric conditions.

Abdominal and pelvic pain

Abdominal aortic aneurysm (AAA)

Abnormal uterine bleeding

Above the knee amputation (AKA)

Acute kidney injury (AKI)

Acute myocardial infarction (AMI)

Alcohol abuse (EtOH)

Alzheimer disease

Anemia

Anxiety

Aortic aneurysm

Aortic stenosis (AS)

Arteriosclerosis

Arthralgias

Atelectasis

Atherosclerosis

Atrial fibrillation (Afib)

Atrial septal defect (ASD)

Attention deficit hyperactivity disorder (ADHD)

Autism spectrum disorder (ASD)

Back pain

Below the knee amputation (BKA)

Benign neoplasms

Blind

Bone pain

Cardiovascular disease (CVD)

Cervical cancer

Chest pain

Chronic condition

Chronic disease

Chronic illness

Chronic kidney disease (CKD)

Chronic obstructive pulmonary disease (COPD)

Chronically ill

Cognitive impairment

Coma

Complicated pregnancy

Congenital anomalies

Congestive heart failure (CHF)

Constriction

Coronary artery disease (CAD)

Cough

Crying

Deafness

Deep vein thrombosis (DVT)

Delirium

Delirium tremens (DTs)

Dementia

Dependence

Depression

Developmental disability (DD)

Diabetes mellitus (DM)

Diabetic ketoacidosis (DKA)

Diarrhea

Dilation

Disability

Dysphagia

Dyspnea

Dysuria

Edema

Embolism

Embolus

End-stage renal disease (ESRD)

Erectile dysfunction (ED)

Etiology

Extremity pain

Facial flushing

Facial pain

Fatigue

Fever

Fixation

Flank pain

Frustration

Functionally disabled

Funny Looking Kid (FLK)

Gallbladder disorders

Genital skin lesion

Genital ulcer

Handicapped

Hard of Hearing (HOH)

Headache

Hearing loss

Heart failure (HF)

Hematuria

Hernia

Homebound

Homicide

Hydrops fetalis

Hypertension (HTN)

Hypotension, shock

Impairment

Indication infarct

Intrauterine hypoxia

Ischemia

Labile

Labor/Delivery complications

Learning disability (LD)

Leg pain

Lesion

Lethargy

Limp

Low back pain (LBP)

Lymphadenopathy

Malaise

Malignant

Malignant neoplasms

Memory loss

Mental health

Mental illness/impairment

Mentally retarded/developmentally disabled (MR/DD)

Minimally conscious state

Mitral regurgitation (MR)

Morbid

Muscle cramps

Myalgias

Myocardial infarction (MI)

Nausea

Neonatal hemorrhage

Numbness

Nutritional deficiencies

Obsessive compulsive disorder (OCD)

Occlusion

Oppositional defiant disorder (ODD)

Otalgia

Parkinson disease (PD)

Patent ductus arteriosus (PDA)

Patent foramen ovale (PFO)

Perinatal period

Permanent vegetative state (PVS)

Petechiae

Postpartum depression (PPD)

Pregnancy

Premature atrial contractions (PACs)

Proteinuria

Pruritus

Pulmonary embolism (PE)

Pulmonary hemorrhage

Rash, generalized

Red eye

Scrotal pain

Seizure

Senility

Sensory loss

Seriously emotionally disturbed

Short gestation

Shortness of breath (SOB)

Shoulder pain

Sinus tachycardia

ST elevation myocardial infarction (STEMI)

Suicide

Syncope

Tachypnea

Tinnitus

Torticollis

Transient

Transient ischemic attack (TIA)

Traumatic brain injury (TBI)

Tremor

Tumor

Turgid

Twitch

Vasoconstriction

Venous thromboembolism (VTE)

Ventricular septal defect (VSD)

Vomiting

Weakness

Weight loss

1.3.3 1982–present

In 1982, Jane Knitzer's monograph, Unclaimed Children, documented what practitioners such as Fritz Redl had been arguing all along. She found that most children with serious emotional and behavioral disorders were not getting the services they needed. Neither the new special education nor the old mental health services were reaching the great majority of these children and adolescents. Furthermore, even when these children and adolescents were provided special services, they still were getting neither a proper education nor proper care.

The result of Knitzer's ‘call to arms’ was the development of a new paradigm and approach to mental health programing, an approach called ‘Systems of Care.’ Several features define its identity (Stroul and Friedman 1996). First, the systems of care approach calls for extraordinary hierarchic organization between federal, state, and local agencies. Second, the systems of care approach pushes for ‘wraparound services,’ that is, for sets of services designed to meet the special needs of individual families. Third, the systems of care approach provides support for families lost in a confusing array of services—mostly through the efforts of case managers who help families set goals, make plans, and advocate for needed services. Fourth, the systems of care approach requires professionals and agencies to be culturally competent—to value diversity and to develop skills for establishing positive relationships with those from different cultures. To understand the significance of this new paradigm and approach, we need mention only a few comparisons with old ways of programing.

Children with serious emotional and behavioral problems often come from families with serious problems as well. In the past, this fact led to the practice of separating children from their families, on the assumption that the children would have a better chance of improving. However, this practice ignored the fact that problematic families often remain committed to their children long after the commitments by professionals have ended. This practice also ignored the fact that dysfunctional families have strengths to enlist in helping their children. Most important, this practice ignored the fact that with additional supports, dysfunctional families can become better able to meet the needs of their children. The systems of care approach has taken these facts to heart by making family support central.

Older approaches to mental health programing also ignored cultural differences or treated cultures as being disadvantaged,' even dysfunctional. As a result, minority groups were subjected to subtle and not-so-subtle prejudice when being ‘helped’ by mental health professionals. For example, single mothers from cultures which value extended family members (grandparents, aunts, etc.), which feel that young children at night should be in their parents' bed, which feel children need occasional physical reminders (i.e., spanks) to behave properly—these mothers often found themselves being judged harshly or unfairly as professionals referred to their ‘broken homes,’ their fostering overly dependent relationships between themselves and their children, and their authoritarian parenting styles. With the systems of care approach, the trend has been away from this kind of cultural insensitivity and toward providing services in culturally sensitive ways (Issaacs-Shockley et al. 1996).

Older approaches to programing also presented few options for treatment: outpatient office-based therapy, inpatient hospital care, and residential treatment. Furthermore, educational, welfare and mental health programs often functioned separately and sometimes in conflict with one another. With the systems of care approach, the effort has been to coordinate work done by different agencies and different professionals. This effort at coordination shows in a variety of ways. It shows in the increase in interagency teams. Most especially, it shows in professional–family relationships as case managers and home visitors work to get families and children the services they need. In the systems of care approach, then, old barriers between mental health and other kinds of child-related programs are broken down. For example, child welfare programs designed to protect abused and neglected children—often by removing children from their homes—now work to have mental health programs train parents and foster parents so that children temporarily removed from their homes can return safely to their families.

The systems of care approach and the advent of managed health care has dramatically changed the nature and functions of inpatient and residential treatment for children and adolescents (Woolston 1996). Now, the average length of stay in inpatient facilities has been reduced considerably—from several months to two weeks. The result has been a change in how inpatient facilities function. Where before, therapy was central, now inpatient facilities focus solely on crisis management (stabilization), assessment, and doing what they can to help establish the community-based system of care that children and adolescents will need when they leave the hospital. Residential treatment centers, too, are being hard-pressed to reduce length of stay and to turn outward toward the family and community. Financial constraints, public policy, and the difficulty of demonstrating empirically that inpatient and residential treatment are more effective, all have conspired to change the mental health programing landscape and to turn professionals toward developing community-based systems of care.