Eli Bower, a pioneer in the field of early childhood education of emotionally handicapped children, wrote, “I often thought about [these] students…they did not know how to have fun, could not separate play from reality, could not attend to concepts outside of self, and were driven by impulses unchecked by reality controls” (Bower, 1990). Like Eli Bower, professionals in the field of education and child psychology have been intrigued by this population since before the early 20th century. By the late 1950’s multiple communities were studying emotionally disturbed children (Bower, 1990). By the 1970s, researchers had conducted enough work on emotionally disturbed children to establish the special education category of Seriously Emotionally Disturbed for P.L. 94-142 (Merrell, 2007). Today, the needs and numbers of emotionally disturbed youth are growing. In 2004, there were about 450,000 emotionally disturbed students in the national student population (Wagner et al., 2005). Further, the U.S. Department of Education (2002) found that these students had the highest drop out rate of any disability group with as much as 51 percent leaving before earning a high school diploma. Children with emotional disturbance are said to experience less school success than any other subgroup of students, with or without disabilities (Landrum, Tankersley, & Kaufman, 2003). Although much work is needed to help support these students, professionals today cannot even agree on a definition of emotional disturbance. Stemming from this rudimentary issue are ancillary debates about how to assess for emotional disturbance and how to resolve differential diagnoses. In this paper, current definitions of emotional disturbance will be reviewed, inherent diagnostic difficulties in the eligibility criteria will be outlined, and best practice in assessment, given these issues, will be summarized.
Currently, there are two main perspectives conceptualizing emotional disturbance, though both acknowledge that maladaptive and distressing behaviors, emotions, and thoughts (Cullinan, 2004) are main components. The first, the dimensional classification system, holds the viewpoint that emotional and behavioral disorders are extreme forms of behavior, emotions or cognitions that exist in all people. Those less able to regulate themselves are more likely to have emotional disturbance. With the dimensional perspective, situational aspects and contexts are emphasized more than in the disease perspective (Cullinan, 2004). The IDEIA definition of emotional disturbance is a result of the dimensional classification perspective. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSM-IV-TR) is the product of those who follow the second perspective, known as the disease classification perspective. These people believe emotionally disturbed children have a collection of maladaptive and distressing behaviors, emotions, or thoughts that are different from normal children. This perspective views the dysfunction as within the person. Many mental health agencies, government organizations, insurance companies, medical providers, and other agents consider the DSM-IV-TR the official classification system (Cullinan, 2004). Often, services and reimbursements are contingent on the child receiving a DSM diagnosis. For these reasons, and many more, professional in the education field should have some knowledge of the DSM-IV-TR criteria.
With both classification systems loosely described, it is safe to move on to the subject of definitions. While classification systems beg questions about which kind of emotional or behavioral disorders exist, definitions only aim to determine if emotional or behavioral disorders exist. If the definition of emotional disturbance indicates that characteristics are present, then it can play a role in deploying financial, personnel, and other resources to children in need of them. The federal government has employed a regulation, most recently known as the Individual with Disabilities Education Improvement Act (2004), to guide educators in determining whether emotional disturbance is present. Children with emotional and behavioral disorders most likely qualify under the category of emotional disturbance if they demonstrate the following:
Section 300.8 (c)(4)(i) Emotional disturbance means a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child's educational performance:
(A) An inability to learn that cannot be explained by intellectual, sensory, or health
(B) An inability to build or maintain satisfactory interpersonal relationships with peers
(C) Inappropriate types of behavior or feelings under normal circumstances.
(D) A general pervasive mood of unhappiness or depression.
(E) A tendency to develop physical symptoms or fears associated with personal or
(ii) Emotional disturbance includes schizophrenia. The term does not apply to children
who are socially maladjusted, unless it is determined that they have an emotional
disturbance under paragraph (c)(4)(i) of this section.
As it stands, the definition of emotional disturbance does not translate into any specific diagnosis in the DSM-IV-TR. It works as a legal term that initiates a multitude of mandated services to meet the needs of emotionally disturbed children (U.S. Department of Health and Human Services ,1999). However, a DSM-IV-TR diagnosis of an emotional or behavioral disorder can help determine whether a child qualifies to receive special education services for emotional disturbance because it provides a taxonomy of mental disorders and symptoms that can be used to describe conditions that persist “over a long period of time” and “adversely affect educational performance” (House, 1999). Further, its reputation and wide use by other organizations and fields can help school psychologists communicate with mental health professionals and other non-school service providers in common terms, and help access financial resources for the child and family.
Diagnostic Difficulties Inherent in Eligibility Criteria
The federal definition has been thoroughly criticized throughout the years (Kauffman, 2001). The definition’s vagueness and subjectivity, as well as peoples’ personal philosophies toward the “label” of emotional disturbance, have made this category very unpopular (Wagner et al., 2005). The first attack on the definition typically focuses on the definition’s vague and unclear terms. They are not operational or objective, and therefore are difficult concepts to measure. Many important features are perplexing, with phrases like “long period of time,” “marked degree,” “adversely affects educational performance,” and “socially maladjusted.” Additionally, criteria A, which states the child must exhibit, “an inability to learn” and/or “inappropriate types of feelings or behaviors under normal circumstances” have been found to be vague (Cullinan, 2004). Critics also do not like the seeming circular logic and/or illogic behind many of the definition’s features. For instance, an example of a contradictory statement appears when one compares criteria B saying children must show, “interpersonal relationship problems,” yet cannot be socially maladjusted. Children who are socially maladjusted often have problems relating to other people, which make this statement confusing. Redundant phrases about the behaviors or emotions being adversely affective has also received disapproval, especially since this phrase is unclear and diffuse and hard to measure objectively (Cullinan, 2004). Lastly, the confusion about social maladjustment disqualifying a child from the emotional disturbance category, unless the child exhibits both social maladjustment and emotional disturbance has been enraging to some critics (Cullinan, 2004). This glaring issues have made critics question the source of many of these criteria, saying they seem to have been arbitrarily chosen and lack support from scientific research. At the same time, there are said to be other behavior problems not found in the emotional disturbance definition for which research support exists (Cullinan, 2004). There are also holes in the definition, which leave many educators frustrated with their idiosyncratic situations. For example, the definition makes no mention of what to do with children who are exhibiting signs of emotional disturbance, but have not had their education “adversely affected.” These children’s outbursts and disruptions may be harming their classmates’ educations, and would probably subside with targeted behavioral interventions, but are left untreated because they do not meet criteria. Yes, many diagnostic difficulties stem from the federal definition’s lack of acumen in the area of emotional and behavioral disorders, which force educators to make subjective decisions, and place some in legally precarious situations.
Critics have been particularly critical of the phrase “socially maladjusted.” The term’s ambiguity is emphasized by the many diverse interpretations that exist (Center, 1990). Policymakers, lawyers, and other stakeholders have managed to handcraft their own term in order to do their jobs. Traditionally, it entails a pattern of behavioral problems that are thought to be willful, goal oriented, and possibly reinforced as part of one’s immediate social reference group. It is typically seen as antisocial in nature, and typified by the type of behaviors exhibited in the DSM-IV-TR diagnostic categories Conduct Disorder. To add to the confusion, the current federal definition allows students who are considered to be socially maladjusted to receive special education services it “if is determined that they are also emotionally disturbed.” In commenting on this and related statements in federal definition discussion of social maladjustment, Kauffman (1999) remarked “the final addendum regarding social maladjustment is incomprehensible.” For now, professionals conducting school-related assessments of children and adolescents with behavioral, social, and emotional problems should be aware that there are no psychometrically valid and defensible assessment procedures that can be used to make the emotional disturbance versus Social Maladjustment distinction (Merrell, 2007).
Dissatisfied with the federal definition, the Council for Children with Behavioral Disorders and other professional and advocacy groups have cooperated to try to change it. Operating as the National Mental Health and Special Education Coalition, they proposed and alternative definition and petitioned Congress – so far unsuccessfully – to substitute it for the existing one (Forness & Knitzer, 1992). The Coalition proposed definition is as follows:
(i) The term emotional or behavioral disorder means a disability characterized by
behavioral or emotional responses in school so different from appropriate age,
culture, or ethnic norms that they adversely affect educational performance.
Educational performance includes academic, social, vocational, and personal
skills. Such a disability (A) is more than a temporarily, expected response to
stressful events in the environment; (B) is consistently exhibited in two different
settings, at least one of which is school-related; and (C) is unresponsive to direct
intervention in general education or the child’s condition is such that general
education interventions would be insufficient.
(ii) Emotional and behavioral disorders can coexist with other disabilities
(iii) This category may include children or youth with schizophrenic disorders,
affective disorders, anxiety disorders, or other sustained disorders of conduct or
adjustment when they adversely affect educational performance in accordance
with section (i). (Forness & Knitzer, 1992)
This definition seems many of the same mistakes as its predecessor. For one, the Coalition proposal contains ambiguous terminology. Second, insufficient attention was given to creating objective and measureable terms. As with the IDEIA definition, significant parts of the Coalition proposal should be carefully operationalized and measured in order to judge its psychometric merits (Forness & Knitzer, 1992)
Assessing for Emotional Disturbance
A promising and innovative approach to assessment and classification of social-emotional problems of children and adolescents is multiple gating. By using a sequential series of systematic and increasingly time-consuming screening procedures, multiple-gating methods allow for narrowing a large population down to a small group of candidates who are likely to exhibit behavioral and emotional problems to the point of needing further assessment and intervention (Merrell, 2007). In formulating an assessment plan for an individual child, the school psychologist considers four perspectives on emotional and behavioral disorders. One perspective views child pathology as the basis for the disorder, and seeks to identify emotional and behavioral problems that are symptoms or characteristics of psychopathology. A second perspective focuses on behavioral-environmental interactions as the basis for the disorder. Instead of identifying symptoms or characteristics of psychopathology in the child, this perspective emphasizes reciprocal interactions between the child’s behavior and the environment (Ysseldyke, Christenson, & Thurlow, 1987). A third perspective seeks to identify the functional relationship between environmental events and problem behavior. It assumes that behavior occurs within a context of antecedent and consequent events and that most behavior is a function of the reinforcing aspect of consequent events. The fourth perspective emphasizes the effectiveness of interventions for emotional or behavioral disorders, directly linking assessment of problems to intervention planning. This viewpoint defines emotional or behavioral “disorders” by the extent to which the child’s behavior proves to be resistant to interventions (McConaughy & Ritter, 2002)
It is significant to remember that doing an assessment on this population does not necessitate discovering the etiology of the problem. Rather, it should focus more on revealing the obstacles that obstruct the child’s optimal functioning. Due to the nature of emotional and behavioral difficulties these children have in school, school psychologists are often familiar with these cases long before these children are referred for a special education assessment. All known relevant history with the child and his school-related difficulties should be considered in the special education assessment. Additionally, it is important to collect data about the child from various people and settings, as children’s behavior and emotions often change from one setting to another, and with one person versus another (McConaughy & Ritter, 2002).
Standardized Rating Scales
Standardized rating scales provide quantitative information for obtaining parent, teacher, and self-reports of children’s problems and competencies. School psychologists are encouraged to select standardized rating scales because their systematic, easy to share, economical and efficient. Rating scales come in broad-band forms and narrow-band forms, measuring a wide range of potential problems or very specific areas of deficits, respectively. Examples of broad-band measures that are helpful in Emotional Disturbance assessment include the Achenbach System of Empirically Based Assessment (ASEBA, Achenbach & Rescorla, 2001) or the Behavior Assessment Scale for Children – Second Edition (BASC-II; Reynolds and Kamphaus, 2004). Narrow measures can be used in conjunction with broad-band measures to assess specific problems more extensively. Standardized self-reporting scales have also been developed to obtain children’s own views of their problems and competencies, and can be very especially useful when assessing for internalizing disorders. In a multidimensional assessment, evaluators should compare scores on self-report scales to similar scores obtained from parent and teacher rating scales (McConaughy & Ritter, 2002).
As with rating scales, interviews should be conducted with parents, teachers, and the child. Most structured diagnostic interviews have parallel forms for parents and children, and some have been adapted for teacher interviews. Interview formats can vary from highly structured to semi-structured and unstructured approaches. Examples that can be used for assessment of this population include the National Institute of Mental Health Diagnostic Interview Schedule for Children-Fourth Edition (DISC-IV; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) or the Diagnostic Interview for Children and Adolescents-Fourth Edition (DICA-IV, Reich, Welner, Herjanic, & MHS Staff, 1999). Unstructured interviews are especially appropriate because they can be tailored to each child, but also help the school psychologist not forget to ask about important information (McConaughy & Ritter, 2002).
Direct observations are an important data source for assessing emotional disturbance. Several observations should be conducted and should occur in relevant settings wherever problems are occurring. The labile nature of emotional and behavioral disorders must always be keep at the forefront when doing these observations, and so the observer should know to obtain more than one observation over different days and times. Peer comparisons provides a helpful framework from which the judge the child under assessment. Noting the antecedents and consequences are important factors to observe. The Direct Observation Form or the Student Observation System are good tools to use to structure observations (McConaughy & Ritter, 2002).
Personality assessments provide additional information on aspects of social-emotional functioning. Commonly used instrument are the Minnesota Multiphasic Personality Inventory for Children-Adolescents (MMPI-A; Butcher et al., 1992) and Personality Inventory for Children (PIC; Wirt, Lachar, Klinedinst, Seat, & Brown, 1990). However, discretion should be used when doing these assessments because of the subjective nature in their interpretation. Since different examiners often disagree in their interpretations of personality measures, and reliability and validity are limited on these measures, such procedures should not be sued as a primary source for assessment of emotional disturbance (McConaughy & Ritter, 2008).
Assessing social skills is very important for assessing for emotional disturbance. Observations of children’s behavior with peers and adults in natural settings, like the general education classroom, or recess, can provide information about social skills and relationships that is invaluable when reporting on a potential emotional disturbance case. Observing behaviors during social skills instruction or role-playing situations provides a more direct method for measuring specific social areas like social problem solving and social reasoning (McConaughy & Ritter, 2008).
For emotional disturbance classification, there must be evidence that the child’s is suffering academically because of his behaviors and emotions. Standardized tests, curriculum-based assessment, grade reports, and work samples can all provide evidence regarding current academic achievement. Evaluation of broader education performance can focus on academic behaviors, like productivity or motivation. Such evaluations are needed in conjunction with the social and emotional assessments, and cognitive testing, to judge whether educational performance is indeed being impacted (McConaughy & Ritter, 2008).
Disorders with Emotional Disturbance Overlays
Mood disorders have been well described in individuals with mental retardation. Researchers estimate that 5 to 15 percent of individuals with mental retardation have mood disorders (Meyer & Batshaw, 2002). Syndromes of disturbed mood may be hidden in people with mental retardation. Sleep or appetite problems often go unnoticed, and fluctuations in such symptoms as noncompliance, social withdrawal, aggressiveness, irritability, self-injury, or crying are often assumed to be components of a person’s personality rather than a psychiatric disorder. Fragile X syndrome is the most frequently diagnosed inherited cause of mental retardation and has many characteristics that may look like an emotional and/or behavioral disorder. What frustrations a child might feel as having delayed socialization, communication, and daily living skills may manifest itself in aggressive outbursts, hyperactivity, inattention, or levels of anxiety or depression that appear to be emotional or behavioral disorders (Meyer & Batshaw, 2002). The best way to differentiate between emotional disturbance and fragile X syndrome, is to examine medical records or the child’s medical history to see if there are references made to this disorder. Cognitive testing will also identify if a level of mental retardation is present, therefore disqualifying the child as having emotional disturbance. Adaptive measures, interviews of parents and teachers, rating scales, and behavioral observations of the child will also provide salient information for making eligibility decisions.
Children with specific learning disabilities often show impairments in emotional or behavioral functioning because of their external experiences of school failure, and are sometimes mistaken as children with emotional disturbance. Although the federal definition for a learning disability currently excludes learning problems that are primarily the result of emotional disturbance, children and adolescents identified as having learning disabilities demonstrate a high incidence of concurrent emotional and behavioral problems (McConaughy, Mattison, & Peterson, 1994). These children can exhibit a range of emotional and behavioral disturbances, including conduct disorders, withdrawal, poor self-esteem, and depression (Shapiro, Church, & Lewis, 2002). These children often exhibit chronic frustration and anxiety as they attempt to meet the demands of skills-based tasks such a phonological decoding, comprehension, spelling, and math (Shapiro, Church, & Lewis, 2002). School failure, combined with social skills impairments, possible peer rejection, and poor-self image often results in what appears to be emotional disturbance (Shapiro, Church, & Lewis, 2002). Although looking at a discrepancy between cognitive potential and academic achievement seems like a simple way to identify whether a child qualifies for emotional disturbance or specific learning disabled, this is an oversimplification of best practice assessment procedures (Shapiro, Church, & Lewis, 2002). In addition to psycho-educational testing, a complete medical, behavioral, educational, and social history should be considered when making a classification to determine which of the two eligibilities best fits the profile of the child and which would offer the best services for remediation.
A third disorder that often gets confused for emotional disturbance is attention deficit hyperactivity disorder. Emotional and behavioral problems can overlap or co-occur with inattention or hyperactive problems (Barkley, 2006) that mimic emotional disturbance. Children with this disorder display hyperactive or impulsive behaviors, and can show such disruptive behaviors that some might say they are actually demonstrating characteristics of oppositional defiant disorder or conduct disorder (Stein, Efron, Schiff, Glanzman, 2002), while others might say the child is demonstrating mood disorders. Estimates of mood disorders in children with ADHD vary considerably. Some studies say the comorbidity rate is as low as 14 percent, while others say it is as high as 80 percent (Stein, Efron, Schiff, Glanzman, 2002). Peer rejection due to their odd behaviors, difficulty in school, and regular punitive interactions with adult figures often does lead to extreme levels of anxiety and/or depression in these children (Stein, Efron, Schiff, Glanzman, 2002). As previously stated, careful examination of the child’s pattern of behavior and history, may help with the evaluation. One must always consider what is the best interest of the child, and what eligibility would facilitate the services he or she needs from school and community resources more easily.
To qualify for special education services under IDEIA 2004, it is not enough that a child exhibit a specific disability, such as emotional disturbance. An actual need for special education must also be evident. This means that previous intervention efforts have failed with little to no decrease in a child’s target behaviors. When doing an assessment on a child suspected to display emotional or behavioral disorders, it is important for an assessor to not become overwhelmed with the myriad of unsettled issues regarding the definition of emotional disturbance and its assessment, but use professional judgment and a multimethod, data-based approach to decision-making. Proper assessment may take more time due to the extensive qualitative information necessary to make a decision, but it is only with multiple sources of data that one will find it viable to make a decision as to the presence or absence of emotional disturbance.
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