What Are Emotional and Behavioral Disorders?1
Students with emotional and behavioral disorders have serious and persistent difficulties that can be described by a psychiatric diagnosis. When special educators identify a student as having an emotional or behavioral disorder, they are assisted by a psychologist or psychiatrist who conducts a thorough evaluation and makes a diagnosis of the disorder, using the categories listed in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). This medical manual, known as the DSM, groups behaviors in clusters corresponding to common clinical disorders.
A great deal of controversy exists among those who work with children with behavioral disorders regarding the practice and method of diagnosis. Professionals disagree about whether and how to label children; some use a medical perspective and others prefer an ethnographic understanding of psychological and behavioral difficulties. Some researchers believe that almost all emotional and behavioral disorders can be traced to a difference in the chemical makeup of the child’s brain, and that such children need medication assistance. Others claim that the majority of psychiatric disorders result from environmental factors such as diet, abuse, neglect, or other traumatic experiences or relationships and that psychosocial and behavioral interventions can better resolve the student’s difficulties. Most mental health professionals resolve this version of the “nature versus nurture” debate by referring to the ample evidence that biology and experience are equally powerful and mutually influential contributors to emotional and behavioral health. Although the specific cause(s) of a child’s emotional and behavioral problems may never be identified, a combination of medical and psychosocial treatments helps many individuals.
In discussing emotional and behavioral disorders, the Individuals with Disabilities Education Act (IDEA) uses the term serious emotional disturbance and defines it as follows:
… a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects educational performance—
- An inability to learn that cannot be explained by intellectual, sensory, or health factors;
- An inability to build or maintain satisfactory interpersonal relationships with peers and teachers;
- Inappropriate types of behavior or feelings under normal circumstances;
- A general pervasive mood of unhappiness or depression; or
- A tendency to develop physical symptoms or fears associated with personal or school problems.
[Code of Federal Regulations, Title 34, Section 300.7(b)(9)]
As defined by the IDEA, the condition includes schizophrenia but does not apply to children who are socially “maladjusted.”
Students who have behavioral or emotional disorders can exhibit widely varied types of behavior, including both internalized behavior (such as depression or an eating disorder) and externalized behavior (such as verbal outbursts). Other common characteristics and behaviors include these:
- Hyperactivity (short attention span, impulsiveness)
- Aggression or self-injurious behavior (acting out, fighting)
- Withdrawal (failure to initiate interaction with others; retreat from exchanges of social interaction, excessive fear or anxiety)
- Immaturity (inappropriate crying, temper tantrums, poor coping skills)
- Learning difficulties (academic performance below grade level)
Children with behavioral disorders do not necessarily have learning disabilities. Estimates show, however, that approximately 60 to 80 percent of students with EBD also have some form of learning disability (Weinberg et al., 1995).
Children with the most serious disorders may exhibit distorted thinking, excessive anxiety, bizarre motor acts, and abnormal mood swings. Medically, they are sometimes identified as having a psychotic disorder. Psychoses can range in severity from temporary and mild to recurring and severe (as in schizophrenia). Many children without emotional disturbances may display some of these same behaviors at various points in their development. However, when children have serious emotional disturbances, problematic thinking and behavior continues over a long period of time. Their behavior signals that they are not coping with their environment or peers; indeed, a child with a severe psychological disturbance will have great difficulty acting or interacting effectively.
Types of Emotional and Behavioral Disorders
Defining and classifying emotional and behavioral disorders is a challenging task. The fourth edition of the DSM contains eighteen major classification areas, into which are grouped more than two hundred specific disorders. In the following sections we will discuss the emotional and behavioral diagnoses you are most likely to encounter as a teacher.
The diagnosis of conduct disorder is based on antisocial behavior, and it says little about the child’s inner life, motives, and disabilities. <MN3>The disorder is classified by type: aggressive versus nonaggressive, and overt (with violence or tantrums) versus covert (with lying, stealing, and/or drug use).
A distinction between “socialized” and “under-socialized” activity is common. For example, much serious adolescent misconduct takes place in street gangs, many of whose members are loyal to their friends and able to make a reasonable social adjustment as adults. The situation is much more serious when the misbehavior begins early and the child has no friends. Such children are more likely to develop “antisocial personality disorder” as adults, continuing a pattern of socially maladjusted behavior. Early symptoms include stealing, running away from home, habitual lying, cruelty to animals, and fire setting. As the child grows older, the pattern may develop into vandalism, malicious mischief, truancy, drug and alcohol use, and various forms of violence, from school bullying to robbery, assault, and rape.
Children, and especially adolescents, with conduct disorders seem callous, hostile, and manipulative. As students such children can present a real challenge to teachers, who often feel frustrated and angered by their noncompliance and disregard for others. The support of the school counselor is helpful, as well as that of school-based therapists or outside professionals who are involved with the child, Developing a working relationship with parents can be important, too.
Emotional disturbances can include eating disorders, depression, excessive stress reactions, and many others. Sometimes the disturbance is not readily visible.
Emotional disturbances that manifest themselves in violence and similar extreme behavior occur less frequently than those with a more complex and subtle effect. And some disorders, such as eating disorders and substance abuse, are deliberately—and often successfully—hidden by the child. Some children develop a negative or maladaptive pattern of behavior and interaction that becomes deeply entrenched and seems to be part of their personality.
The DSM defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” The following descriptions of a few categories of personality disorder illustrate these maladaptive patterns:
- Schizotypal personality disorder: “a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.”
- Borderline personality disorder: “a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.”
- Dependent personality disorder: “a pattern of submissive and clinging behavior related to an excessive need to be taken care of.”
Anxiety disorders are a prevalent form of emotional difficulty, sharing with depression the dubious honor of most pervasive emotional disorder. Children with anxiety may be fearful, nervous, shy, and preoccupied, and they often strive to avoid the source of the anxiety—if there is a specific source.
Anxiety disorders include generalized anxiety disorder, phobias, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. Separation anxiety disorder specifically affects children and adolescents and can make separation from home and loved ones extremely distressing.
Doubtless, the most prevalent behavioral disorder in schools today is attention-deficit/hyperactivity disorder (ADHD), sometimes referred to as attention deficit disorder (ADD). According to the U.S. Department of Education (2000), approximately 3 to 5 percent of the school-aged population have ADHD. So what is ADHD? The official description in the DSM reads in part as follows:
The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.
ADHD can include nine specific symptoms of inattention and nine symptoms of hyperactivity/impulsivity. Individuals with ADHD may know what to do, but do not consistently do what they know because of their inability to efficiently stop and think prior to responding, regardless of the setting or task.
The DSM describes four subtypes of ADHD: inattentive, hyperactive/impulsive, combined (showing both inattention and hyperactivity), and “not otherwise specified.” See the feature “Types of ADHD” for a list of the specific symptoms for each type.
In most cases, the characteristics of ADHD become evident in early childhood. Children and adults who have ADHD are often restless and easily distracted, they struggle to sustain attention, and they are impulsive and impatient. These characteristics can result in serious social problems and impairment of family relationships, and of course can block success at school.
In addition to the 3 to 5 percent of the school-aged population who have the full ADHD syndrome, without symptoms of other disorders, another 5 percent to 10 percent have a partial ADHD syndrome or one that includes other problems, such as anxiety and depression.
Another 15 to 20 percent of the school-aged population may show transient symptoms that resemble ADHD, but ADHD is not diagnosed if these behaviors produce no impairment at home and school or are clearly identified as symptoms of other disorders.
Gender and age affect the ways in which people with ADHD express their symptoms. Boys are about three times more likely than girls to have symptoms of ADHD. Symptoms of ADHD decrease with age, but symptoms of associated features and related disorders increase with age. Between 30 and 50 percent of ADHD children still manifest symptoms into adulthood.
A significant percentage of children who have ADHD also have a learning disability, such as dyslexia. It can be difficult to sort out which of their learning difficulties stem from processing deficits for specific learning tasks, such as letter identification or phonemic awareness, and which are due to distractibility and attention problems. As a teacher, you must approach each child’s learning profile individually, because you will find variations in strengths and weaknesses among all children, regardless of whether they carry the same diagnosis.
Issues of Identification and Treatment
One of the most pressing issues facing parents and teachers of students with emotional and behavioral disorders is the use of medications to help control behavior. You have probably heard of children who take Ritalin, a drug often used to treat ADHD.
According to a study published in the Journal of the American Medical Association, Ritalin prescriptions to children of ages two to four have increased dramatically in recent years (Zito et al., 2000). In 1996, the United Nations released a report stating that 10 to 12 percent of all male school children in the United States take Ritalin, a rate far surpassing that in any other country in the world (International Narcotics Control Board, 1996). The concern is that such medications may be overprescribed and that they may not have long-term effectiveness.
In light of this concern, what position should a teacher take? If a child consistently “acts out” in your classroom, should you assume that some kind of medication is necessary? If you see that one child who is taking a medication like Ritalin shows improved behavior, should you suggest that another child could benefit from the same treatment? The fact is that diagnosis of ADHD and other behavioral disorders requires careful assessment and ongoing evaluation. Although you may believe that something is definitely “different” about a particular student’s behavior, you must consider carefully before labeling that student or coming to your own conclusions about the sort of treatment that would work best.
In addition to medications, treatment options include psychotherapy (particularly of the cognitive or behavioral management type) and social skills training. Even if it is determined that a child needs medication, behaviorally based treatment is often important as well.
Families of children with emotional disturbances may also need help in understanding their child’s condition and in learning how to work effectively with the child. In fact, recognition is growing that many families, as well as their children, need support, respite care, intensive case management services, and a multi-agency treatment plan. More and more communities are working toward providing these “wrap-around services,” and a growing number of agencies and organizations are actively involved in establishing support services in the community. Parent support groups are also important, and organizations such as the Federation of Families for Children’s Mental Health and the National Alliance for the Mentally Ill (NAMI) have parent representatives and groups in every state.
Teaching Children with Emotional and Behavioral Disorders
Children who have had neuropsychological or psycho-educational testing have a distinct advantage in planning an optimal educational program. Skilled evaluators will include a list of detailed recommendations for teaching strategies and remedial activities for the child. As a teacher, you may want to consult with the evaluator or with the school psychologist regarding those specific recommendations. The child’s IEP may include psychotherapy or counseling as a related service. Speech and language therapists and occupational therapists can also make significant contributions. The more data that converge to support conclusions and recommendations for a specific child, the more certain you can be that your educational program will target that child’s needs and tap his or her abilities.
Children with EBD may receive treatment in the regular education classroom or in a residential treatment center. As in chapter 2 describes the series of steps a teacher must take before deciding on the treatment environment. These decisions are made with the input and relevant evaluations of the entire IEP team.
Educational programs for students with EBD must include attention to mastering academics, developing social skills, and increasing self-awareness, self-esteem, and self-control. Career education (both academic and vocational) is also a major part of secondary education and should be a part of the transition plan in every adolescent’s IEP.
(Please see the the link to "A Brief Look at Tourette Syndrome" to see how this disorder is treated in the classroom.)
Among the successful school-based techniques are these:
- Life Space Crisis Intervention (Fescer and Long, 1998) is a program in which teachers and other caregivers learn to identify and defuse classroom crises by being supportive of students’ emotions and understanding the cycle of a crisis. This program has proved successful with nondisabled students as well as those with emotional and behavioral disorders. The program identifies specific strategies that can help teachers and students work through problems.
- The Conflict Resolution Program (Crawford and Bodine, 1996) is designed to help students work through conflicts by creating safe classrooms and focusing the curriculum on principles of problem solving. The program helps schools select students and adults to act as mediators, focuses on peer-to-peer conflict resolution, and builds on the support of the greater community. Research on conflict resolution and mediation programs show that they can be effective in reducing violence in schools and helping students feel more confident about solving problems (Carpenter, 1993, 1994; Smith, 1996).
It is difficult to be knowledgeable about every intervention being promoted for use with EBD students. Many teachers and school administrators lack the time required for intensive review of research. Furthermore, they often lack easy access to sources that publish research supporting or refuting intervention effectiveness. The field of EBD is not immune to what Achenbach (1996) calls “Bad Information.” In his essay on the pervasiveness and types of misleading, incomplete, and just plain wrong information in our society, Achenbach argues that it is becoming increasingly difficult to distinguish bad information from good. One reason is that bad information looks a lot like good information. Another is that bad information can be widely disseminated and endorsed by apparently reputable professionals.
Green (1996) offers a set of guidelines to help families determine the soundness of a given intervention for autistic children. These suggestions are also helpful for teachers and school administrators who determine interventions for students with EBD:
If it sounds too good to be true, it probably is. Professionals need a healthy skepticism about new interventions, particularly those offering dramatic results. As Achenbach (1996) says, “It takes an extremely practiced eye, a kind of controlled skepticism that never quite slides into abject nihilism, to spear Good Information from the thick bog of Bad.”
- Be cautious when the only evidence given is testimonials, particularly when those promoting the intervention stand to gain financially from sales of the program.
- Ask to see published research supporting the intervention.
- Ask someone skilled in reading and interpreting research for help in understanding the research.
- Ask many questions, such as these:
How do you know this works?
What is the basis for your claim?
Who has conducted the research?
Where is the research published? Are these peer-reviewed, scientific journals?
How many children with EBD have been included in the studies? How many improved? What specifically were the improvements?
The most basic criterion is this: Avoid interventions that pose a risk of harm to the student, either directly by use of the procedure or indirectly as a result of nonuse of other procedures (Freeman, 1993; Kauffman, 1996). Hippocrates, referring to the treatment of diseases, said, “Make a habit of two things—to help, or at least, to do no harm” (cited in Bartlett, 1992). Educators should adhere to these words of wisdom when selecting interventions for students with disabilities.
On a more basic level, you can take steps to make your classroom suitable for children with EBD. Establish clear rules and a regular routine, for instance. Offer many hands-on, creative activities to provide outlets for the children’s energy. The accompanying feature, “Focal Points for Teaching Students with EBD in Your Classroom,” offers some additional guidelines. Think about which of these techniques you can put into practice in your own teaching.
Academic and Social Problems: A Vicious Cycle
Behavioral and emotional difficulties can lead to academic failure, just as academic frustration can lead to behavioral and emotional problems. Sometimes students fall into a vicious cycle: frustration and failure trigger maladaptive behavior that further obstructs learning and increases the likelihood of failure.
When you teach a student identified as having an emotional or behavioral disorder, you may puzzle about where the cycle began. Take a look at the times of day that the child acts out or is unruly; is it always during math period or during PE? Perhaps the behavior is the result of frustration with algebra. Maybe it stems from a poor physical self-concept. Context and timing can provide clues to improve your understanding of the problem.
The interaction between student and teacher can also affect a child’s behavior: does he or she do better or worse with a specific teacher? You can ask yourself whether you have feelings or responses toward this child that differ in a distinct way from your feelings and responses toward other children. Does he or she make you feel more concerned, frustrated, nurturant, or angry than most of your students? Do you change your way of relating when it comes to this student? Answering these questions can lead you to positive change.
Typically, programs that focus on children with behavioral disorders attend first to the child’s behavior problems, and academics run a distant second. In residential treatment, for example, the focus of “school” is on getting along in a group setting, not necessarily on the curriculum. An additional problem for students with behavioral and emotional disorders is that this is the area of special education in which the greatest number of teachers have emergency or alternative certification, rather than specialized training and certification in the field of Emotional and Behavioral Disorders. This is unfortunate, especially since these are the children who stand to benefit most from quality academic education.
These intensive programs work to help children function in everyday life, and many achieve that goal. Nevertheless, children with behavioral disorders can and do benefit from quality academic instruction. In programs where classroom conditions are inadequate, children not only suffer from diminished academic content and opportunity, but they often learn negative behaviors in response to problems in the classroom environment.