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EDDT/EDDT-PFEffective Assessment of Emotional

Disturbance

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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)

• Accomplish this in the context of a standardized instrument that addresses all areas of the IDEA definition of Emotional Disturbance (ED)

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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.

Characteristics Typically Associated with ED

• Behavior is involuntary or reactive• Disruptive behaviors are emotionally-driven• Student feels remorseful• Student is self-critical• Student experiences feelings of inadequacy• Student tends to be anxious and guilt-laden• Student has few if any friends

(Clarizio, 1992b; Constenbader & Buntaine, 1999)4

DSM-IV Diagnoses That May Be Associated With ED

• Affective Disorders (Depression, Dysthymia, Bipolar Disorder, Cyclothymia)

• Eating Disorders• Generalized Anxiety Disorders• Obsessive-Compulsive Disorders• Panic Disorders• Phobias• Post Traumatic Stress Disorder• Reactive Attachment Disorder• Schizophrenia• Separation Anxiety Disorder• Somatization Disorder

(Tansy, 2007)

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Characteristics Typically Associated with SM

• Knows and understands rules and norms, but intentionally breaks and rejects conventions

• Perceives self to be “normal” and able to behave “normally” when needed

• Views rule-breaking as normal and acceptable• Misbehavior does not result in anxiety or remorse

unless caught

(Clarizio, 1992a; Clarizio, 1992b; Kelly, 1990)

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DSM-IV Diagnoses Typically Associated with SM

• Oppositional Defiant Disorder– Defiance

• Conduct Disorder– Violate rights of others and societal rules

• Anti-Social Personality Disorder– CD characteristics since age 15– Diagnosed after age 18

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“Concept Drift” for Psychopathy

• DSM and DSM-II: Specific personality variables were central to the diagnosis of “psychopathic personality disturbance”

• DSM-III and DSM-IV: Psychopathy was redefined as antisocial personality disorder and was defined behaviorally to increase reliability

(Hare, Hart, & Harpur, 1991)

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Characteristics of Psychopathy• Deficient Affective Experience: Callous, low remorse,

weak conscience, low guilt, low empathy, shallow affect, failure to accept responsibility

• Arrogant Interpersonal Style: Glibness or superficial charm, self-centeredness, grandiose sense of self-worth, lying, conning, manipulative, deceitful

• Impulsive/Irresponsible Behavioral Style: Boredom, excitement seeking, reward-dominant response style, lack of long-term goals, impulsivity, parasitic lifestyle

(Cleckley, 1941; Cooke and Michie, 2001; Cooke et al, 2004; Farrington, 2005; Hare, 1990; Salekin et al., 2003, 2005; Yochelson & Samenow,

1976)

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Summary of the Major Risk Factors Associated With Conduct Disorder•Dispositional risk factors Contextual risk factors•Neurochemical abnormalities Pre-natal exposure to toxins•Autonomic irregularity Early exposure to poor quality child care•Birth complications Parental psychopathology•Difficult child temperament Family conflict•Impulsivity Inadequate parental supervision and discipline•Preference for dangerous and Lack of parental involvement and novel activities and neglect•Reward dominant response style Peer rejection•Low verbal intelligence Association with a deviant peer group•Academic underachievement Impoverished living conditions•Deficits in processing social info Exposure to violence

Frick (2004)

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Developmental Pathways

• 1. Childhood Onset – high CU

• 2. Childhood Onset – low CU•

3. Adolescent Onset

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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” (Gacono & Hughes, 2004)

• ED and SM are distinctive enough that they need and benefit from different types of programs (Theodore et al., 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)

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Existing Arguments (continued)

• ED is correlated with antisocial behavior so that ED students are often SM (Kehle et al., 2004)

• 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 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; Frick, Barry, & Bodin, 2000; Harpur et al., 1989)

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

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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.

Emotional Disturbance Decision Tree – Parent Form

• Provides a standardized approach to gathering parent information about children’s functioning in the areas that make up the federal ED criteria.

• Normed for ages 5-18• 15-20 minutes to complete, 15 minutes to score• When considered with data from the EDDT,

promotes a comprehensive assessment of the student across both school and home environments

• Promotes integration of parent input in the eligibility process

• Spanish Version

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Measuring Never-Defined Criteria:The Development of the EDDT

The original items were based on:

•Literature on ED and SM (heavily considered)

•Author’s experience with regard to how ED characteristics are manifested by students

•Key features of conduct problems and antisocial attitudes observed by the author in both school and correctional settings

Next, two pilot studies were conducted:

– First study: 2-year period in multiple schools during which the working group and author met regularly for feedback about items and the overall measure.

– Second study: Assessed effectiveness of the measure. School psychologists, educational diagnosticians, and other professionals rated the degree to which the EDDT items accurately reflected ED and SM. Results also analyzed in terms of internal consistency and correlations with other published measures.

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Development of the EDDT (continued)

Standardization version:•Further input from practicing school psychologists•Select items were rewritten for clarity•Following data gathering, the scales were further modified with the goal of reducing the number of items to a more reasonable level while maintaining excellent score reliability and validity•Frequency distributions, item-with-total correlations, and consistency coefficients were examined. Items with low specificity and low correlations were eliminated, as well as items were reassigned to scales depending on its best fit.

Sections of the EDDT

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Section

I.Potential Exclusionary Items (IQ, Hearing-vision, Health, Duration Checklist)

II.Emotional Disturbance Characteristics

III.Social Maladjustment (SM) Cluster

IV.Level of Severity (SEVERITY) Cluster

V.Educational Impact (IMPACT) Cluster

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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

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

educational performance

•Over Six Months

•Addressed in Section I

•Based on DSM criteria that differentiates

adjustment problems from a diagnosis

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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 AlsoCount

• 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

Inability to Build or Maintain Relationships (REL)Related Literature Piaget, 1969 – Cognitive and affective-social development are inseparableErikson, 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

Domain Characterized By:unstable, few-no relationships chronic hostility in interactionsocial avoidance inappropriate interaction chronic peer rejection age inappropriate friend preferencepoor reciprocity lack of empathy or respectpoor “connectivity skills” poor social conversation skillaggressiveness with peers qualitative relationship problems

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

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ED Characteristics: Inappropriate types of behavior or feelings

under normal circumstances

Inappropriate Behaviors or Feelings (IBF)Related Literature – Multiple pathways and indirect but clear

relationshipsCrockett 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)

Domain Characterized By:age inappropriate behavior attention seekingfailure to self-regulate teasing-tauntingmismatch of behavior/emotion over-aroused behaviordramatic or strange behavior tantrums / shut downdefensiveness, defiancesuspiciousnesspoor coping restricted interestsdistorted views &/or emotions risk taking

Item Examples– Behaves in an unusual or strange manner

compared to peers– Displays strange, distorted, or inappropriate

emotions29

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ED Characteristics: A tendency to develop physical symptoms or fears

associated with personal or school problems

Physical Symptoms or Fears (FEARS)

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)

Domain Characterized By:nervousness, anxiety obsessive thoughtsabsorption with past events fearfulness of peers or adultsschool avoidance due to fears separation anxiety re. caregiverspanic symptoms physical withdrawal from othersover-dependency self-isolation due to social discomfortsomatic complaints risk avoidancerestlessness ritualistic behaviorcompulsive behavior

Item Examples– Has physical complains which result in leaving or

avoiding school– Expresses obsessive fear that a catastrophe (e.g.,

death of a parent) will occur31

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ED Characteristics: A general pervasive mood of unhappiness or depression

Pervasive Mood/Depression (PM/DEP)

Related LiteratureMattison et al., 1990 – Depression is correlated with lower GPAStrauss et al., 1982 – Depression is correlated with lower standardized achievementPuura et al. 1998 – Self reported depression is correlated with poor teacher ratings

Domain Characterized By:depressed, sad, hopeless irritability, anger, frustrationlack of interest / pleasure low animationunexplained crying feeling rejecteddeteriorated self-care low self esteemphysiological signs lethargylow social interest, enthusiasm preoccupation with deathself mutilation suicidality

Item Examples– Appears dejected or unhappy– Is emotionally flat or unanimated

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Possible Psychosis/SchizophreniaCluster (POSSIBLE PSYCHOSIS)

ScreenerIncoherence IllogicHypervigilance Distorted PerceptionEmotion Poor Self CareHallucination DelusionFantasy Involved Strange Behavior

Item Examples– Has distorted view of situations and people– Displays deteriorated self-care, hygiene, or concern about

personal appearance

Attention-Deficit Hyperactivity Disorder Cluster (ADHD)

Screener

Motor Agitation Poor AttentionForgetfulness FidgetyPoking Prodding Others

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

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Social Maladjustment Cluster (SM)Related Literature – Frick and Hare (2001)a) Callous/unemotionalb) Lack of guiltc) Egocentricityd) Lack of empathye) Impulsivityf) Use of others for personal gain

Three Factor Model Conduct

Sociopathic AttitudesSchool Aversion

Item ExamplesA. 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 36

A) Has reasonable self-esteem & respect for others

B) May perceive self as abnormal, damaged, or inferior compared to peers

C) Perceives self and inappropriate behavior as normal, or even superior to compliant peers

A) Meets own needs appropriately and adequatelyB) Tries to meet own needs through dependency,

attention-seeking, or bizarre behaviorC) Meets own needs by skillfully and selfishly

manipulating others

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Level of Severity Cluster (SEVERITY)

Areas assessed:Frequency and setting Outside treatmentNeed for restraint Marked problemsNeed for a safety plan Response to interventionSuspension

Example: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

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Educational Impact Cluster (IMPACT)

Areas Assessed:Work completion SuspensionCompliance with direction CounselingQuality of work BIP developed?Behavior related absences Interventions effective?Working without redirection

Example: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 reporting39

EDDT-PF• No Educational Impact Scale

• Addition of Resiliency Scale (RES)– Personal strength, adult connections, social

skills, other individual resources

• Addition of Motivation Cluster (MOT)– Tangible/Consumable Motivators (TC)– Independence/Escape Motivators (IE)– Positive Attention Motivators (PA)

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Metric of Scores

• Scales are based on T score (M = 50; SD = 10)

• Clusters based on %ile ranges

Scale EDDTEDDT-

PFInability to Build or Maintain Relationships scale (REL) .88 .88Inappropriate Behaviors or Feelings scale (IBF) .83 .92Pervasive Mood/Depression scale (PM/DEP) .81 .87Physical Symptoms or Fears scale (FEARS) .75 .86EDDT Total scale (TOTAL) .94 .96 42

Coefficient Alpha Reliability by Normative Group

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Coefficient Alpha Reliabilityfor the Normative Sample

Cluster EDDTEDDT-

PFSocial Maladjustment cluster (SM) .93 .93Level of Severity cluster (SEVERITY) .75 .83Educational Impact (IMPACT) .90Attention Deficient Hyperactivity

Disorder (ADHD) .89 .91Possible Psychosis/Schizophrenia

cluster (PSYCHOSIS) .70 .87Resilience (RES) .88Motivation .91

EDDT: Group differences between the Normative and ED sample

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ED Scale Norm ED

REL 50.79 81.90

IBF 50.76 87.85

PM/DEP 50.58 85.11

FEARS 50.49 83.95

TOTAL 50.89 88.99

Cluster (raw score)

Norm ED

SM 0.71 7.03

SEVERITY 0.42 9.93

IMPACT 0.77 13.70

ADHD 5.86 16.35

PSYCHOSIS 0.95 8.22

EDDT-PF: Group differences between the Normative and ED sample

ED Scale Norm ED

REL 50.14 77.21

IBF 50.32 75.50

PM/DEP 49.82 74.61

FEARS 50.45 71.21

TOTAL 49.53 77.37

Cluster Norm ED

RES 49.96 68.32

Cluster (raw score)ADHD 12.18 29.80

POSSIBLE PSYCHOSIS

2.63 12.44

SM 5.65 22.74

SEVERITY 1.27 8.99

MOTIVATION 21.32 17.53

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Percentage of Normative and ED Sample Scoring Within Clinically Relevant T-Score Ranges

ScalesNormal Range 

Mild At Risk  

Moderate Clinical  

High Clinical 

 Very High Clinical

REL72.0 2.0 9.3 3.0 12.1 10.6 4.0 25.7 2.3 58.4

IBF73.5 4.2 9.7 2.2 9.0 10.9 6.0 15.8 1.8 66.8

PM/DEP71.2 2.7 11.5 3.7 11.3 14.4 4.0 22.3 2.0 56.9

FEARS71.9 4.2 10.5 5.2 12.1 18.1 4.3 22.3 1.2 50.2

TOTAL72.0 1.0 10.1 1.2 10.8 9.9 5.3 18.1 1.5 69.6

Standardization = GOLDED Group = WHITE

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Case Study: EdisonBackground

• 13-year-old male, 7th grade • Previous exposure to domestic violence by father• Edison, his mother, and an 8-year-old sister have been

residents of a local homeless shelter for 8 months• Previous state of residence IEP indicated OHI-ADHD,

recently back on stimulant meds and typical ADHD behavior improved

• Behavior:– One half of work done– Fights, Cruel– Marijuana use?– Disregards parent rules– Stares off

– Hangs with “bad” kids

– Short unstable relationships– Poor social skills– Bragging about gang affiliation– Threw rocks at a dog

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Case Study: EdisonAssessment Results

• Refused to go to community-based therapy

• FBA and BIP for increasing work output and reducing aggression were not successful

• 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

Evidence for Social Maladjustment:• High Conduct and Aggression Scores • Weak in internal right - wrong• Impulsive, Delinquent• Picks fights, enjoys• Animal cruelty• Serious disregard of authority• Aggressive• Some of the behaviors such as staring off could be ADHD

Unclear, Weak Picture as to Emotional Disturbance

EDDT/EDDT-PF ResultsEDDT:•REL, IBF, Severity, Impact = High Clinical•PM/DEP, ADHD, SM = Moderate Clinical Additional considerations:•SM items suggest irresponsibility, resistance to authority, aggressiveness, and school aversion. Manipulative and “user” of others items were not endorsed.•Spacey behavior – PTSD?•Rock throwing – modeling?

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EDDT/EDDT-PF ResultsEDDT-PF•REL, IBF, PM/DEP, ADHD, Severity = High Clinical•SM = Moderate Clinical•RES = Significantly Below Average•Motivated by Tangible/Consumable MotivatorsAdditional considerations•Depression is expressed externally through irritability and negativism•Masked ED?

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Edison Case Study: Post EDDT Profilethe Case for Incremental Validity

EDDT Provides Evidence That Edison Is Both ED and SMIBF: Anger reactionsREL: Pervasive lack of social skillsPM/DEP: Indicates limited self-esteem, unhappiness

Despite strong “sense” of SM, is in Moderate SM rangeEndorsement of aggressive and authority challenging behaviors (dislikes school, violates rules, fights) but little evidence of antisocial attitude (manipulation to meet own needs)

Moderate Clinical ADHD symptomology despite medicationNeeds ongoing medication review

Normative Severity & Educational Impact – Both High

Treatment

Frick (2004)

Developmental Pathways•1. Childhood Onset, high callous and unemotional (CU)

•Increase empathetic concern

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Treatment

• 2. Childhood Onset, low CU

• Inhibit impulsive and angry responses

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Treatment

• 3. Adolescent Onset

• Involvement in extracurricular activities given its potential positive effects on the student’s identity development and the focus on increasing contact with prosocial peers in a structured setting.

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Treatment

Kazdin (1998)Socially Maladjusted:

Cognitive Problem-Solving TrainingParent Management TrainingFunctional Family TherapyMultisystematic Therapy

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Treatment

• Theodore and Little (2004)• Anxiety

– Cognitive behavioral therapy– Individual psychotherapy– Family therapy– Medications

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Treatment

• Depression– Cognitive behavioral therapy– Behavioral therapy– Family approaches– Medications

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