1 improving evaluation practices: overcoming the emotional disturbance/social maladjustment...

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Improving Evaluation Practices:Overcoming the

Emotional Disturbance/Social Maladjustment Dichotomy

Bryan L. Euler, Ph.D.Albuquerque Public Schools

Albuquerque, New Mexico

Presented by:Jim Gyurke, PhD, Vice-President of Marketing and Sales

PAR, Inc.• Hospital Based Developmental Psychologist at

two University teaching Hospitals• CDC Consultant for Infant Nutrition and IQ

Study• Adjunct Faculty in School Psychology, Trinity University• [email protected]

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http://www.parinc.com/

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Purpose

• Assess a different approach to evaluating

Social Maladjustment (SM) which treats it as a supplemental, proportional trait (not part of

an either-or ED/SM diagnosis)

• Do this in the context of standardizing a new

instrument for Emotional Disturbance (ED) evaluation, the Emotional Disturbance Decision Tree (EDDT)

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Prevalence of ED

• 473,663 ED students in the U.S. in 2006

• The number of ED students increased 18.4 %

from 1991-92 to 2001-02 school year

• ED is now the 4th largest of the 13 Special Education exceptionalities

OSEP Technical Assistance Center, 2006

Where have they all come from?

• Is the increase in ED diagnosis real?

• Biological Factors (brain abnormalities, hormonal imbalances, etc.)

• Environmental Factors (family upheaval, natural disasters, etc.)

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What do we do for them?

• “Despite inclusion of ED within IDEA, the dedication and efforts of legions of professionals, and the investment of vast resources, students with ED fare worse than any other class of students with disabilities on many important outcomes”

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How have we failed them?

• More likely to be placed in restrictive educational settings

• More likely to drop out of school

• More likely to cause extreme financial hardship for their families

• More than 50% of these students are likely to have at least 1 arrest within 3 years of leaving school

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Why is this so?

“Although the definition of ED cannot be blamed for all of the problems related to students with ED, it certainly shares some of the culpability, because the definition determines in large measure, which students will be selected to receive services and how educational programming will be initiated.”

Merrell & Walker (2004)8

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Definition of ED (IDEA, 2004)(i) The term means a condition exhibiting one or more of the following

characteristics over a long period of time 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 factors

B) An inability to build or maintain satisfactory relationships with peers and teachers

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 school problems

(ii) The terms includes schizophrenia. The term does not apply to children who are socially maladjusted unless it is determined that they have an emotional disturbance.

Internalizing Characteristics

• (a) Internal factors characterized by:

• 1. Feelings of sadness, or frequent crying, or restlessness, or loss of interest in friends and/or school work, or mood swings, or erratic behavior; or

• 2. The presence of symptoms such as fears, phobias, or excessive worrying and anxiety regarding personal or school problems; or

• 3. Behaviors that result from thoughts and feelings that are inconsistent with actual events or circumstances, or difficulty maintaining normal thought processes, or excessive levels of withdrawal from persons or events; or

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Externalizing Characteristics

External factors characterized by:

• 1. An inability to build or maintain satisfactory interpersonal relationships with peers, teachers, and other adults in the school setting; or

• 2. Behaviors that are chronic and disruptive such as noncompliance, verbal and/or physical aggression, and/or poorly developed social skills that are manifestations of feelings, symptoms, or behaviors as specified in subparagraph (4)(a) 1.-3. of this rule.

• (c) The characteristics described in paragraph (4)(a) or (b) of this rule must be present for a minimum of six (6) months duration and in two (2) or more settings, including but not limited to, school, educational environment, transition to and/or from school, or home/community settings. At least one (1) setting must include school.

• (d) The student needs special education as defined in paragraph 6A-6.03411(1)(c), F.A.C.• (e) In extraordinary circumstances, activities prior to referral for evaluation as described in subsection (2) of this

rule and criteria for eligibility described in paragraph (4)(c) of this rule may be waived when immediate intervention is required to address an acute onset of an internal emotional/behavioral characteristic as listed in paragraph (4)(a) of this rule.

• (5) Characteristics not indicative of a student with an emotional/behavioral disability: • (a) Normal, temporary (less than six (6) months) reactions to life event(s) or crisis, or• (b) Emotional/behavioral difficulties that improve significantly from the presence of evidence based

implemented interventions, or

•(c) Social maladjustment unless also found to have an emotional/behavioral disability.

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Problems With Assessing SM in the Context of ED Evaluation:

Roots of the Controversy and Assessment Problems

• Introduction of an SM/ED dichotomy by the IDEA definition of ED“the term (ED) does not apply to children who are socially maladjusted unless it is determined that they have an emotional disturbance” (IDEA)

• Failure of IDEA to define SM as it relates to ED

• Overuse of the Internalizing/Externalizing model and the “slip” into equating SM with externalizing issues

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The Seven Deadly Sins of SM/ED Dichotomization

“SM is equivalent to DSM-IV CD and ODD”

“SM students make conscious decisions to misbehave, ED don’t”

“SM students understand consequences of behavior, ED don’t”

“SM students have control of their behavior, ED don’t”

“SM students have no guilt or remorse about their behavior”

“SM students have externalizing behavior, ED have internalizing”

“SM students are non-disabled, ED are disabled”

THE OUTCOME = Exclusion

(Olympia et al., 2004)

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Existing Arguments• “Treating disruptive behaviors of SM students as manifestations of a

disability creates difficulties with regard to student accountability,

administrative discipline, and burnout among teachers” (Tansy,

2004)

• Incarcerated youth have seven times the incidence of ED of

“normals” but are often not identified/served until after

incarceration. ED students are equally likely to be violent or non-

violent (Johnson et al., 2001)

• ED is correlated with antisocial behavior so that ED students are

often SM (Kehle et al., 2004)

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Existing Arguments (continued)

• SM students often have internalized problems too, so SM/ED overlap is common (Davis et al., 2002; Seeley e. al., 2002; Marriage et al., 1986)

• There is no discernible difference in SM and ED students (Bower, 1982 as in Tansy, 2004)

• ED and SM cannot be completely distinguished (Constenbader & Bundaine, 1999)

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Overview- the SM / ED Problem

• Dichotomy – IDEA language, Political Issues

• Internalizing/Externalizing Model

• Failure to Consider Hidden Linkages (bipolar/aggression)

• Failure to Consider Comorbidity (SM and masked ED present)

• Misdiagnosis and Exclusion

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Alternatives to Dichotomization and Exclusion

• Include SM Under the ED Umbrella (Olympia et al., 2004)

• Differentiate SM and ED but Provide SM Treatment (Hughes & Bray, 2004)

• Use a “Two Factor” Model of SM That Includes Both Behavior and Internal Attitudes, to Overcome Externalization Equivalence and Assure True SM (Gacono & Hughes, 2004, Tansy, 2004)

• Evaluate ED Based on the Actual IDEA Criteria First, Then Treat SM as a Supplemental and Relative Issue (Euler, 2007 – in press)

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Existing Assessment Measures

Broad-based Emotional Adjustment Measures:• Clinical Assessment of Behavior

(CAB; Bracken & Keith, 2004)

• Behavior Assessment System for Children 2 (BASC 2; Reynolds & Kamphaus, 2004)

• Child Behavior Checklist (CBCL; Achenbach, 2001)

Limitations:

• Not designed to specifically address the federal criteria of ED

• Clinicians must look across multiple scales/subscales to determine if specific portions of the federal criteria are met

• None of these scales were designed to directly measure SM

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Existing Assessment Measures

More Specific ED/SM Measures

• Differential Test of Conduct and Emotional Problems (Kelly, 1990)

• Conduct Disorder Scale (Gilliam, 2002)

• Scale for Assessing Emotional Disturbance (SAED; Epstein & Cullinan, 1998)

Limitations:

• Many conduct problems items are limited to observed behaviors

• Do not address all aspects of the IDEA criteria (e.g., educational impact, severity, etc.)

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Emotional Disturbance Decision Tree

The EDDT is a standardized, norm-referenced scale that assists in the identification of students who may meet IDEA (2004) criteria for Emotional Disturbance (ED). It is normed for ages 5-18.

The EDDT is criterion referenced. It is based on the criteria presented in the Individuals with Disabilities Education Act of 2004 It maps on to all the ED criteria.

The EDDT was designed to be completed by teachers or other professionals (e.g., school psychologists, clinical psychologists, diagnosticians, counselors, social workers) who have had substantial contact with the student. It is not a parent rating scale, although parents can contribute.

The EDDT takes 15-20 minutes to complete and 15 minutes to score.

Minority Overrepresentation in SPED & Potential EDDT Contribution to Reducing This

Ethnic Minorities Are Over-Represented in SPED Exceptionalities

(Hosp & Reschly, 2004 – Council for Exceptional Children)

EDDT Tries to Reduce Ethnic Statistical Bias in ED/SM Assessment:

- Norm Group Was Matched to 2000 U.S. Census by Ethnicity and Gender

-SM Sample Matches Census Within 1% for African American Students (Census =15, SM=16) and Within 7% for Hispanic (Census=11, SM=18)

-ED Sample is Matched to Census Within 4% for African American Students

(Census=15, ED=19) and Exactly for Hispanic (Census=11%, ED=11%)

Structure of EDDT Helps Also – ED Is Assessed Separately from SM

So Exclusion from Services is Reduced (compared to Int./Ext. model)

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IDEA criteria EDDT Scale/ClusterOver a long period of time Potential Exclusionary Items

To a marked degree Level of Severity (SEVERITY) cluster

Adversely affect’s a child’s educational performance

Educational Impact (IMPACT) cluster

An inability to learn that cannot be explained by intellectual, sensory, or health factors

Potential Exclusionary Items

An inability to build or maintain satisfactory interpersonal relationships with peers and teachers

Inability to Build or Maintain Relationships (REL) scale

Inappropriate types of behavior or feelings under normal circumstances

Inappropriate Behaviors or Feelings (IBF) scale

A general pervasive mood of unhappiness or depression

Pervasive Mood/Depression (PM/DEP) scale

A tendency to develop physical symptoms or fears associated with personalor school problems

Physical Symptoms or Fears (FEARS) scale

The term includes schizophrenia Possible Psychosis/Schizophrenia (PSYCHOSIS) cluster

The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance

Social Maladjustment (SM) cluster

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ED Characteristics: An inability to learn that cannot be explained by

intellectual, sensory, or health factors

• Sub-par Academic Performance (NOT just poor standard scores)

• Serious Lags/Deficits in Social Learning and Development Also

Count

• Students With Intellectual, Sensory, or Health Problems Can Conceivably Have an ED Also, but Separate Contribution of an ED is Harder to Prove: Rigorous Evidence Needed

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ED Characteristics: An inability to build or maintain satisfactory

relationships with peers and teachers

Domain Characterized By:

unstable, few-no relationships chronic hostility in interaction

social avoidance inappropriate interaction

chronic peer rejection age inappropriate friend preference

poor reciprocity lack of empathy or respect

poor “connectivity skills” poor social conversation skill

aggressiveness with peers qualitative relationship problems

Related Literature

Piaget, 1969 – Cognitive and affective-social development are inseparable

Erikson, 1963 – Well developing child is eager to make things cooperatively…profit

from teachers and emulate ideal prototypes (Initiative vs. Guilt stage)

Hay et al., 2000- Social difficulty is tied to lower frequency of desirable classroom activity like persistence, leadership

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ED Characteristics: Inappropriate types of behavior or feelings

under normal circumstances Domain Characterized By:

age inappropriate behavior attention seeking

failure to self-regulate teasing-taunting

mismatch of behavior/emotion over-aroused behavior

dramatic or strange behavior tantrums / shut down

defensiveness, defiance suspiciousness

poor coping restricted interests

distorted views &/or emotions risk taking

Related Literature – Multiple pathways and indirect but clear relationships

Crockett et al. 2006 – There are multiple pathways by which youth reach problem outcomes and express distress ( many types of behaviors reflect ED and interfere

with social/school success. Examples -Compulsion interferes with school (Piacentini et al., 2003). Poor self regulation is tied to depression- that leads to school problems.

Zeman et al. 2002 – Youth with good coping have less risk for bad outcomes. Youth

who can’t inhibit anger more likely to develop emotional symps (& school probs)

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ED Characteristics: A tendency to develop physical symptoms or fears

associated with personal or school problems


nervousness, anxiety obsessive thoughts, compulsive behavior

absorption with past events fearfulness of peers or adults

school avoidance due to fears separation anxiety re. caregivers

panic symptoms physical withdrawal from others

over-dependency self-isolation due to social discomfort

somatic complaints risk avoidance

restlessness ritualistic behavior

Related LiteratureMarch, 1997 – Socially fearful children fear embarrassment, rejection (such as from talking in class)

Black, 1995 – Separation anxiety disorder is a variant of panic disorder (and can prevent basic school attendance and participation)

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ED Characteristics: A general pervasive mood of unhappiness or depression


depressed, sad, hopeless irritability, anger, frustration

lack of interest / pleasure low animation

unexplained crying feeling rejected

deteriorated self-care low self esteem (body image also)

physiological signs lethargy

low social interest, enthusiasm preoccupation with death

self mutilation suicidality

Related LiteratureMattison et al., 1990 – Depression is correlated with lower GPA

Strauss et al., 1982 – Depression is correlated with lower standardized achievement

Puura et al. 1998 – Self reported depression is correlated with poor teacher ratings

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Special Considerations

SchizophreniaDomain as Defined by EDDT Screener Incoherence, Illogic

Hypervigilance Distorted Perception, Emotion

Poor Self Care Hallucination, Delusion Fantasy Involved Strange Behavior

Over a long period of time to a marked degree that adversely affects a child’s educational performance

Domain as Defined by EDDT Over Six Months

Educational Impact Scale

ADHDDomain as Defined by EDDT Screener Motor Agitation

Poor Attention Forgetfulness

Fidgety Poking, Prodding Others

SMDomain as Defined by EDDT Three Factor Model Conduct

Sociopathic Attitudes School Aversion

Sections of the EDDT

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Item Booklet: Sections I & II

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Item Booklet: Section III

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Item Booklet: Section IV

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Item Booklet: Section V

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Score Summary Booklet: Inconsistency Score

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Score Summary Booklet

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Score Summary Booklet: Emotional Disturbance Characteristic Profile

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Score Summary Booklet: EDDT Criteria Table

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Scale/clusterNumber of

items

Scale

Inability to Build or Maintain Relationships scale (REL) 25

Inappropriate Behaviors or Feelings scale (IBF) 19

Pervasive Mood/Depression scale (PM/DEP) 23

Physical Symptoms or Fears scale (FEARS) 26

EDDT Total scale (TOTAL) 93

Cluster

Attention Deficient Hyperactivity Disorder cluster (ADHD) 12

Possible Psychosis/Schizophrenia cluster (POSSIBLE PSYCHOSIS) 10

Social Maladjustment cluster (SM) 24

Level of Severity cluster (SEVERITY) 9

Educational Impact cluster (IMPACT) 11

Inconsistency ScorePotential Exclusionary Items (health, IQ, sensory, duration)

11 pairs4

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Metric of Scores

• Scales are based on T score

(M = 50; SD = 10)

• Clusters based on %ile ranges

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Emotional Characteristic Item Examples• Inability to Build or Maintain Relationships (REL)

– Is hostile towards peers– Is resentful, spiteful, or angry toward others

• Inappropriate Behaviors or Feelings (IBF)– Behaves in an unusual or strange manner compared to peers– Displays strange, distorted, or inappropriate emotions

• Pervasive Mood/Depression (PM/DEP)– Appears dejected or unhappy– Is emotionally flat or unanimated

• Physical Symptoms or Fears (FEARS)– Has physical complains which result in leaving or avoiding school– Expresses obsessive fear that a catastrophe (e.g., death of a parent)

will occur

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Cluster Item Examples• Attention-Deficit Hyperactivity Disorder Cluster (ADHD)

– Displays motor agitation or restlessness– Has difficulty paying attention in classroom and/or other settings

• Possible Psychosis/Schizophrenia Cluster (POSSIBLE PSYCHOSIS)– Has distorted view of situations and people– Displays deteriorated self-care, hygiene, or concern about personal

appearance

• Social Maladjustment Cluster (SM)A. Appears comfortable with rules and structure – does not act out

when these are either present or absentB. Appears to require an excessive amount of structure or rules to feel

comfortable and secureC. Appears to dislike or have low tolerance for structure or rules, and

resists by acting-out

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Cluster Item Examples (continued)

• Level of Severity Cluster (SEVERITY)– Disruption, aggression, or loss of emotional control at

schoolA. Has occurred rarely, if at allB. Has occurred on 1-2 occasionsC. Has occurred on 3 or more occasions

• Educational Impact Cluster (IMPACT)A. No behavior related absencesB. Some behavior related absences but not enough to

warrant formal reportingC. Behavior related absences are excessive, and/or have

warranted formal reporting

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Demographic Characteristics:Normative Sample (n = 601)

Age (years)

M 11.46

SD 3.99

range 5-18

Grade

M 6.0

SD 3.81

range K-12

Gender (%)

Male 49.6

Female 50.4

Ethnicity (%)

Caucasian 66.2

African American

14.8

Hispanic 10.8

Other 8.1

Region (%)

Northeast 30.0

South 38.4

North central 19.5

West 12.1

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Coefficient Alpha Reliability of the EDDT by Normative Group

Male Female

Scale 5-8 9-11 12-14 15-18 5-8 9-11 12-14 15-18

Inability to Build or Maintain Relationships scale (REL) .88 .88 .89 .86 .91 .86 .82 .84

Inappropriate Behaviors or Feelings scale (IBF) .83 .80 .81 .86 .85 .72 .81 .80

Pervasive Mood/Depression scale (PM/DEP) .86 .81 .78 .82 .82 .76 .66 .86

Physical Symptoms or Fears scale (FEARS) .81 .78 .66 .72 .78 .77 .69 .73

EDDT Total scale (TOTAL) .95 .95 .94 .94 .95 .93 .92 .94

Median .86 .81 .81 .86 .85 .77 .81 .84

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Coefficient Alpha Reliability of the EDDT Clusters for the Normative Sample

ClusterOverallSample

Social Maladjustment cluster (SM) .93

Level of Severity cluster (SEVERITY) .75

Educational Impact (IMPACT) .90

Attention Deficient Hyperactivity Disorder (ADHD) .89

Possible Psychosis/Schizophrenia cluster (PSYCHOSIS) .70

Median .89

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Additional EDDT Reliability Data

• Test Retest Stability -median = .92

-mean interval = 19 days

• Interrater Reliability - median = .84

- N = 64 pairs

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Demographic Characteristics:ED Sample (n = 404)

Age (years)

M 12.2

SD 3.35

range 5-18

Grade

M 6.5

SD 3.26

range K-12

Gender (%)

Male 73.5

Female 26.5

Ethnicity (%)

Caucasian 51.4

African American

19.4

Hispanic 10.9

Other 18.4

Region (%)

Northeast 14.6

South 41.1

North central 6.9

West 37.4

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Clinical Ranges for EDDT ED Scales

T Score Range Qualitative Label

< 54 Normal

55-59 Mild At Risk

60-69 Moderate Clinical

70-79 High Clinical

> 80 Very High Clinical

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Percentage of Standardization and ED Sample

Scoring Within Clinically Relevant T-Score Ranges

T-Score Ranges for EDDT Scales

Normal Range

Mild At Risk

Moderate Clinical

High Clinical

Very High Clinical

T-score range 0-54 55-59 60-69 70-79 >=80

% predicted from normal distribution 69.15 12.44 15.53 2.69 0.90

Scales

Inability to Build or Maintain Relationships scale (REL) 72.0 2.0 9.3 3.0 12.1 10.6 4.0 25.7 2.3 58.4

Inappropriate Behaviors or Feelings scale (IBF) 73.5 4.2 9.7 2.2 9.0 10.9 6.0 15.8 1.8 66.8

Pervasive Mood/Depression scale (PM/DEP) 71.2 2.7 11.5 3.7 11.3 14.4 4.0 22.3 2.0 56.9

Physical Symptoms or Fears scale (FEARS) 71.9 4.2 10.5 5.2 12.1 18.1 4.3 22.3 1.2 50.2

EDDT Total scale (TOTAL) 72.0 1.0 10.1 1.2 10.8 9.9 5.3 18.1 1.5 69.6

Standardization (Normals) = GOLDED Clinical Validity Group = WHITE

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Group Difference for the EDDT Score Between the Normative and ED Sample

Scale/clusterNormative

sample ED sample

tScale M SD M SDInability to Build or Maintain Relationships (REL)

50.79 10.00 81.90 12.99 -42.75

Inappropriate Behaviors or Feelings (IBF)50.76 10.23 87.85 18.90 -40.15

Pervasive Mood/Depression (PM/DEP) 50.58 10.14 85.11 19.14 -37.16

Physical Symptoms or Fears (FEARS)50.49 10.03 83.95 22.81 -31.70

EDDT Total Score (TOTAL)50.89 9.95 88.99 16.41 -45.72

Cluster

Social Maladjustment (SM) 0.71 2.46 7.03 5.87 -23.50

Level of Severity (SEVERITY) 0.42 1.35 9.93 4.38 -47.11

Educational Impact (IMPACT) 0.77 2.31 13.70 5.60 -46.33

Attention-Deficit Hyperactivity Disorder (ADHD)5.86 5.72 16.35 6.84 -25.99

Possible Psychosis/Schizophrenia (POSSIBLE PSYCHOSIS) 0.95 1.72 8.22 4.81

-33.70

All mean comparisons were significant at p < .001.

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Construct Validity:Correlations Between the EDDT Scales and the BASC-2

Teacher Form Among the Normative Sample

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Demographic Characteristics:SM Sample (n = 104)

Age

M 13.72

SD 2.35

Gender (%)

Male 75.0

Female 25.0

Race (%)

Caucasian 62.1

African American 15.5

Hispanic 17.5

Other 4.9

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Raw Score and Percentile Ranges for the SM Cluster

Raw Score Ranges

Percentile Ranges

(derived from SM sample)

Percent of Normative

Sample in Ranges

Qualitative Descriptors

0-2 <=1% 91.2% Normal

3-10 2-24% 7% Mild At Risk

11-21 25-74% 1.9% Moderate Clinical

22-24 >=75 0.0% High Clinical

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EDDT SM Cluster: Construct Validity Approach

Multifactor Model of SM– External Conduct Problem Behavior – aggressive, rule breaking– Internal Sociopathic Attitude –calloused, manipulative, narcissistic– School Averse Attitudes

SM Criterion Group Identified Using External Indicators– In a setting populated by students with these issues– Identified as having these issues by an evaluator

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Construct Validity:Correlations Between EDDT SM Cluster and

CDS Scores for the EDDT SM Sample

Conduct Disorder Scale

AggressiveConduct Hostility

DeceitfulnessTheft

Rule Violations

Conduct Disorder

Quotient

EDDT SMCluster .r(N=53) .92 .89 .86 .86 .91

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Construct Validity:Correlations Between the EDDT SM Clusterand DTCEP scores for the EDDT SM Sample

Differential Test of Conduct

and Emotional Problems

EmotionalProblems

ConductDisorder

EDDT SMCluster .r (N=51)

.84 .90

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Demographic Characteristics:Combined Clinical Sample (n = 394)

Characteristic

Specific Learning Disability

(SLD)

Speech/Lang. Impairment

(SLI)

Mental Retardation

(MR)

Attention-Deficit

Hyperactivity Disorder (ADHD)

Autism Spectrum Disorders

(ASD)

Social Maladjustment (SM)

N 97 37 53 49 54 104

AgeM 10.48 7.65 11.83 9.84 9.57 13.72

SD 3.17 2.77 3.72 3.26 3.30 2.35

Gender (%)Male 71.1 64.9 52.8 71.4 81.5 75.0

Female 28.9 35.1 47.2 28.6 18.5 25.0

Race (%)Caucasian 60.8 62.2 69.8 57.1 77.8 62.1

African American 10.3 10.8 15.1 10.2 1.9 15.5Hispanic 24.7 27 11.3 24.5 14.8 17.5

Other 4.1 0.0 3.8 8.2 5.6 4.9

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Raw Score and Percentile Ranges for the ADHD Cluster

Raw Score Ranges

Percentile Ranges

(derived from ADHD sample)

Percent of Normative

Sample in Ranges

Qualitative Descriptors

0-3 <=1% 44.3 Normal

4-15 2-24% 48.0 Mild At Risk

16-24 25-74% 6.5 Moderate Clinical

25-36 >=75 1.2 High Clinical

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Construct Validity: Correlations Between the EDDT Scales

and the BASC-2 Teacher Form Among the Combined Clinical Sample

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Case Study: Crystal (fictional)

Background

• 6-year-old Hispanic female , 1st grade

• Youngest of three children in an intact family

• Behavior : History of Trouble “Letting Go” When Dropped Off

Temporary Improvement in Kindergarten

Behavior Worsens After Asthma Hospitalization in 1st grade

-Cries the night before about having to go to school

-Clings, screams, refuses to go in building, runs out

-Inconsolable once parent leaves : anxious, cries

-Previously some friends: now isolated, teacher

dependent, won’t work in groups

-Detached, sad

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Case Study: CrystalAssessment Results

• IQ toward the top of the Low Average range

• Academic skills in Low Average range

• No speech-language delay

• CAB scores reflected clinically significant anxiety, as well as significant withdrawal and mildly significant depression and conduct problems

• High anxiety, mildly high depression, and various problems in psychological resources, including a lack of adequate self-advocacy or support and a tendency to overly rely on adults around her on Roberts2

• The Revised Children’s Manifest Anxiety Scale corroborated the presence of significant anxiety, manifested as physiological signs, worry, and social concern.

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Crystal Case Study: Pre-EDDT Profile Summary

• Possible Anxiety Disorder or Depressive Disorder (in clinical sense, match to ED criteria unclear)

• Some Relationship Issues - Severity Unclear

• Some Inappropriate Behavior/Feelings Issues - Scope, Severity Unclear

• General Impression of Severity and Educational Impact (non normative)

• Unclear if Exclusionary Criteria Such As Duration Met

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Crystal Case Study: Post EDDT Profilethe Case for Incremental Validity

Criterion Based ED Data Now Available:REL T= 83 %ile = 98 PM/DEP T= 67 %ile = 92

IBF T= 64 %ile = 88 FEARS T= 83 %ile = 98

TOTAL T= 75 %ile = 92

Evidence of the Relative Impact of Criteria on ED Related Behavior:FEARS Very High Clinical (worst)RELATIONSHIPS High Clinical (second worst) – not apparent

beforeIBF, PM/DEP Moderate Clinical (third and comparable to each

other)

Yes to the Duration Question - Based on EDDT 6 month index

Norm-Based Evidence of Severity and Educational Impact Both in the High Clinical Range, >75th %ile

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Case Study: CrystalRecommendations

1) The MDT should consider the possibility that Crystal is eligible for Special Education either as ED, or as developmentally delayed in social-emotional areas.

2) Crystal may benefit from being in a smaller class where she can get extra teacher support in making the transition from home to school everyday. The school counselor or social worker can help prepare a structured BIP for this purpose.

3) Crystal may benefit from being in a socialization group facilitated by the school counselor to help break down her tendency to isolate herself socially. Because she will probably resist initially, it also may be necessary to set up a temporary reward program for cooperation, and to gradually withdraw the extra rewards.

4) Crystal’s problems separating from her mother and her regressive behavior suggest that family support outside the school may be needed, in addition to the interventions already listed. Her parents should be referred for brief family counseling and parenting guidance with a community provider.

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Case Study: CrystalRecommendations (continued)

5) Crystal’s parents should support her becoming more comfortable being away from them.

6) Crystal also may need play therapy from a community-based child therapist if her problems with separation anxiety do not remit within a short time after services are begun.

7) If these interventions do not work, her parents also may want to consult with their health-care provider about more intensive intervention within the community. However, it is felt (by the team) that

Crystal can make this adjustment.

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Case Study: Edison (fictional) Background

• 13-year-old Native American male • Seventh grader at a middle school in a large southwestern city – 3rd

school district in a year • Previous exposure to domestic violence by father• Edison, his mother, and an 8-year-old sister are residents of a local

homeless shelter • In program as OHI-ADHD – back on meds

• Behavior:– One half of work done– Fights, Cruel– Rumored gang association– Marijuana– Disregards parent rules– “Stares off”

– Socially Marginal-Poor social skills

– Hangs with “bad” kids

– Short unstable relationships

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Case Study: EdisonAssessment Results

• Conners Rating Scale scores (ADHD) were extremely pronounced, despite the fact he is on medication

• High externalizing scores on the BASC-2 for Hyperactivity, Conduct Problems, and Aggression

• High Millon Adolescent Clinical Inventory scores for Unruliness, Oppositionality, Delinquent Predisposition, and Substance Abuse Proneness

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Edison Case Study: Pre EDDT Profile Summary

High Evidence for Social Maladjustment Based on BASC 2 , MACI, Other:

- high Conduct and Aggression Scores - picks fights, enjoys -serious disregard of authority - animal cruelty -weak in internal right - wrong - Impulsive, Delinquent

Has Relationship Issues But These Are of the SM Type: - aggressive

- calloused attitudes

Does “Stare Off” But This Could be ADHD

- is OHI-ADHD but inadequately responsive to current program and interventions

Unclear, Weak Picture as to Emotional Disturbance – Appears SM

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Edison Case Study: Post EDDT Profilethe Case for Incremental Validity

EDDT Provides Evidence That Edison Is Both ED and SM:REL T= 77 %ile = 94PM/DEP T = 68 %ile = 92IBF T = 75 %ile = 92FEARS T = 56 %ile = 67TOTAL T = 73 %ile = 94

Provides Evidence of the Relative Impact of Different ED Criteria on Behavior

REL and IBF = High Clinical (Worst)PM/DEP = Moderate Clinical (Second Worst)FEARS = Mild At Risk (Third Worst)

Clarifies the Level and Types of SM Issues He Displays-GuidesIntervention

Despite strong “sense” of SM, is in Moderate SM rangeMay be due to aggression/authority challenging vs. antisocial attitude

Gives Normative Evidence of Severity & Educational Impact – Both High

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Case Study: EdisonSM Items Endorsed

• Often acts out, but can sometimes regulate behavior to benefit self

• Likes to fight and is proud of aggressive behavior even when this is inappropriate

• Seriously violates parental rules (e.g., staying out all night without permission)

• Often dislikes school except for the socializing opportunities

• Responds to conflict with bullying, physical violence, or cruelty

• Often appears to lack an internal sense of right or wrong

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Case Study: EdisonSM Items Endorsed (continued)

• Appears to dislike or have low tolerance for structure or rules, and resists by acting-out

• Overly states that police or other authorities are stupid, illegitimate, or unfair

• Engages in risky, rule-breaking behavior for fun, to avoid boredom, or to challenge limits

• Often blames others and take no responsibility when in trouble

• School achievement suffers because student avoids success to gain peer acceptance

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Case Study: EdisonRecommendations

1) The committee should consider placing Edison in a classroom with both a lower pupil-to-teacher ratio and a focus on behavioral management, for at least part of the day.

2) Edison should have a Functional Behavior Assessment and a Behavior Intervention Plan developed that emphasizes positive behavior supports such as rewards for better school adjustment and teaching replacement behaviors to substitute for those behaviors that are problematic.

3) Edison may benefit from social skills training and counseling with a school social worker.

4) Edison has a remarkable level of ADHD symptoms considering that he is already on medication. With his mother’s permission, the school psychologist and/or social worker can provide feedback to Edison’s physician about this issue, so that the doctor will have the information she needs to review and adjust medication, if and when appropriate.

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Case Study: EdisonRecommendations (continued)

5) He should receive vocational guidance so that he can begin to relate school to his job future. He also should be encouraged to select an after-school group activity that he would be willing to try.

6) Edison will benefit from being exposed to positive adult male role models (e.g., coaches) to give him other opportunities for male identification.

7) The school district’s Indian Education Program should be contacted to see if there are any support services that they can provide to Edison. They also may be able to consult with the school team about Edison’s program to help assure that cultural issues are considered where appropriate.

8) Substance-abuse violations should be dealt with promptly by referring Edison and his mother to the school district’s after-school substance abuse parent/student education program and making this a requirement.

9) Title I “homeless services” should be continued for Edison and his family.

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Case Study: Angela (fictional) Background

• 14-year-old Caucasian female • Eighth grader • One of female twins in a highly religious, intact family• Long-history of “black sheep” behavior dating to 4th grade

“good twin / bad twin” situation early behavior:

low school interest manipulativebreaks rules “invisibly” steals, etc.

rarely caught blames others charismatic, neg. leader mostly non-aggressive

charming with adults angry when cornered

• Mid-School Behavioral Deteriorationrougher crowd tags school bathroompot smoking provocative clothing steals parent money rejects authority

peer aggression runs away, hitchhikes truck stop episode

• Parents Demand Evaluation for ED (after years of half-steps)

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Case Study: AngelaAssessment Results

• High average IQ on WISC IV, within expectancy academically

• CAB reveals Conduct Problems and a Clinically Significant score on the Externalizing composite

• CAB Depression, Anxiety, Somatization normal

• BASC 2 Internalizing scores normal, Atypicality and Withdrawal also normal

• Jessness-R reveals only a high average self-report of Social Maladjustment

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Angela Case Study Pre EDDT Profile Summary

- Normal student intellectually- learns enough incidentally to get by

- Deteriorating personal adjustment based on increasing rule-breaking, challenge to authority, and relationship breakdown. Unclear if this is “adolescent developmental” or much more serious

- Pattern of externalized behavior that may reflect Social Maladjustment but may also reflect other issues

- For example, the type of arrogant, manic, confrontational behaviorshe is displaying is sometimes seen with bipolar (manic phase)

- May also have ED eligibility due to Inappropriate Behavior- Feelings

- Possibility of SM is muddied by near normal Jessness-R SM score

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Angela Case Study: Post EDDT Profilethe Case for Incremental Validity

EDDT Provides Evidence That Angela Is Probably Not ED:

REL T= 49 %ile = 53PM/DEP T = 69 %ile = 93 These Scores Suggest No CoreIBF T = 53 %ile = 72 Basis for ED eligibility despiteFEARS T = 49 %ile = 47 Moderate Educational ImpactTOTAL T = 55 %ile = 70 and Severity Scores on EDDT

EDDT Clarifies That Angela Is Probably SM: SM raw score = 20, top of the Moderate Clinical range

EDDT Clarifies the Areas in Which Her SM Concentrates:Classic Antisocial Attitudes and Rule Breaking More Than Aggressive

narcissistic manipulative exploitative callousedlying-tricky risk-taking weak right/wrong rebellious school averse

Although Not ED, This Information Helps Intervention If Available poor candidate for group therapy in a fragile or normal process group, etc.

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Case Study: AngelaSM Items Endorsed

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Case Study: AngelaRecommendations

1) Although the MDT will make final decisions, Angela does not appear to be a student who has an ED or who is appropriate for an ED program and, therefore, she does not appear to have any Special Education eligibility at present. Instead, she appears to be SM. Because Angela is manipulative and exploits others, it is important that she not be placed in any program with fragile ED students, regardless of the MDT eligibility decision.

2) Although Angela does not appear eligible for Special Education services, she needs intervention for her SM. It is suggested that the school refer her to an after-school gang interdiction program at a local community center because she is drifting in a very negative direction.

3) It also is recommended that the family reconsider family therapy as an outside-of-the-school service. Angela’s long-term rejection of parental authority is strongly suggestive of very serious disruption in family relationships that could possibly be improved through family counseling.

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4) Although the nature of Angela’s problems suggests that she is not an optimal candidate for individual counseling, this can be tried again. It is suggested that the family take her to a nearby therapist who is highly trained and specializes in working with adolescents.

5) Because Angela has rejected her parents and teachers as role models, she has, effectively, no positive role models. She should be referred to the nearby Big Sister Program for possible services that may provide her with a point of positive adult identification and support.

6) Angela needs successful prosocial experiences so that she can move beyond acting out and overcome feelings she may have about not wanting to compete with her successful twin. To help Angela develop a positive identity and work toward successful experiences of her own, she should have vocational interest testing at the school along with guidance about high school electives and post-secondary training.

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7) Angela should have help identifying constructive after-school activities that she can get involved in to provide alternatives to the negative activities with which she is currently involved.

8) If Angela’s parents suspect ongoing marijuana use, they may want to consider random urine testing at home to discourage this behavior.

9) For Angela’s sake, if she is involved in another legal violation, it is important that this be reported to law enforcement so that she can be placed on juvenile probation or informal advisement (depending on the severity of the offense). This is important for Angela’s future because it may provide another way in which to obtain leverage if she does not respond to the intervention recommendations.

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Case Study: Conrad (fictional) Background

• 11-year-old Caucasian/Hispanic male

• Fifth grader

• Lives with mother and younger sister, step-father is currently in prison

• Academics and behavior begin to decline around 3rd grade when dad goes to prison.

• Progressive decline: 4th: Gets discipline slip weekly - growing peer problems Associating with rougher crowd, recess trouble

maker 5th: Steals bike over summer, office every day,

sexualized remarks to female peer, swears at teacher, mad parents

5th mid year : On juvenile probation. Acting like a middle schooler• Has not responded to intervention for over a year - referred for evaluation

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Case Study: ConradAssessment Results

• Low Average IQ on WISC IV, one grade level below placement academically on standardized tests

• Roberts-2, refuses to respond to several cards (content- parents talking with children). High Aggression score

• Human Figure Drawing – picture of a man in prison yardlooking up at guard tower

• BASC 2 - higher Externalizing vs. Internalizing total scores

• CDS – Scores suggest a conduct disorder

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Conrad Case Study Pre EDDT Profile Summary

Social Maladjustment Very Likely: High Conduct Disorder Scale results BASC 2 External above Internal

Projectives hint at antisocial identity Values aggression and rule-breaking

Mom losing control of him Juvenile justice system already

Emotional Disturbance Less Supported: Lower BASC2 internalizing data Little evidence he suffers Has a few antisocial

associates Teachers say:

“troublemaker”

EDDT Results: Rater #1

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Conrad Case Study: Post EDDT Profilethe Case for Incremental Validity

Two Raters On EDDT Since This Is A Very Difficult Case

EDDT Provides Evidence That Conrad Is Probably ED:Problems Building / Maintaining Relationships: High Clinical, Both Raters

Inappropriate Behavior/Feelings : High Clinical and Moderate Clinical

EDDT Total Score: High Clinical, Both RatersSeverity Score: High Severity, Both RatersEducational Impact: High Impact and Moderate ImpactED Was Obscured by Tough Guy Persona and Data Above

EDDT Clarifies That Conrad Is Probably Also SM: SM raw score = 22/24 (fulltime teacher) 17/24 (teacher 3 periods per week)

EDDT Clarifies the Areas in Which His SM Concentrates:Mixed profile with both acting out SM items and attitudinal, but more acting

out

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Case Study: ConradRecommendations

1) The MDT should consider finding Conrad eligible for Special Education as a child with an ED.

2) Despite his mother’s wish that he remain at his home school, it appears likely that Conrad may need to be placed on another campus in a self-contained classroom for students who have an ED, at least temporarily.

3) Regardless of specific placement, Conrad needs to be in a classroom that is both closely supervised and does not have a concentration of physically fragile or fragile ED students—also because of his aggressiveness and sometimes predatory behavior.

4) Besides Conrad having an individualized behavior plan, the classroom he is in should include a behavior management program (e.g., a level system) to work on his poor school adjustment and interaction with other students and staff.

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5) If at all possible, Conrad should be placed in a classroom that has a male teacher or aide. This may provide a supplement to his possible identification with the negative role model of his incarcerated stepfather, and may indirectly have a positive impact on Conrad’s antisocial behavior.

6) Conrad should be seen in a social skills/aggression replacement group by a school clinical social worker or school counselor at least once a week.

7) Conrad’s mother should be invited to participate in a parenting group offered through the school district to increase her skills at managing Conrad’s behavior.

8) A daily home-to-school journal should be implemented and included as part of Conrad’s behavioral program. This will keep his mother informed of Conrad’s school behavior and make it possible for her to get support from the school for some of his behavior problems at home.

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9) Conrad should be referred to the local Big Brother Program outside the school and to either a Boys Club or YMCA sports program for after school. The Big Brother referral will provide him with further opportunity for positive adult male role models, and the Boys Club/YMCA referral may redirect him to positive after-school activity and away from getting in trouble.

10) As Conrad moves to middle school, it will be very important to try to involve him in after-school sports or activity programs at the school to increase his positive connection to school. Early prevocational programming also should be explored if he has not reconnected with the school academically by becoming a better student in traditional classes.

1 improving evaluation practices: overcoming the emotional disturbance/social maladjustment...

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