Transcript Slide 1

Improving Evaluation Practices:
Overcoming the
Emotional Disturbance/Social
Maladjustment Dichotomy
Bryan L. Euler, Ph.D.
Albuquerque Public Schools
Albuquerque, New Mexico
1
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]
2
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)
3
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
4
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.)
5
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”
6
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
7
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
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.
9
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
10
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
11
.
(c) Social maladjustment unless also found to have an emotional/behavioral disability
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
12
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)
13
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)
14
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)
15
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
16
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)
17
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 18
SM
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 takes 1520 minutes to
complete and 15
minutes to score.
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.
20
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)
IDEA criteria
Over a long period of time
EDDT Scale/Cluster
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 personal
or 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
22
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
23
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
chronic peer rejection
poor reciprocity
poor “connectivity skills”
aggressiveness with peers
inappropriate interaction
age inappropriate friend preference
lack of empathy or respect
poor social conversation skill
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
24
ED Characteristics:
Inappropriate types of behavior or feelings
under normal circumstances
Domain Characterized By:
age inappropriate behavior
attention seeking
failure to self-regulate
mismatch of behavior/emotion
dramatic or strange behavior
defensiveness, defiance
poor coping
distorted views &/or emotions
teasing-taunting
over-aroused behavior
tantrums / shut down
suspiciousness
restricted interests
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
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who can’t inhibit anger more likely to develop emotional symps (& school probs)
ED Characteristics:
A tendency to develop physical symptoms or fears
associated with personal or school problems
Domain Characterized By:
nervousness, anxiety
obsessive thoughts, compulsive behavior
absorption with past events
school avoidance due to fears
panic symptoms
over-dependency
somatic complaints
restlessness
fearfulness of peers or adults
separation anxiety re. caregivers
physical withdrawal from others
self-isolation due to social discomfort
risk avoidance
ritualistic behavior
Related Literature
March, 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)
26
ED Characteristics:
A general pervasive mood of unhappiness or depression
Domain Characterized By:
depressed, sad, hopeless
irritability, anger, frustration
lack of interest / pleasure
unexplained crying
deteriorated self-care
physiological signs
low social interest, enthusiasm
self mutilation
low animation
feeling rejected
low self esteem (body image also)
lethargy
preoccupation with death
suicidality
Related Literature
Mattison 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
27
Special Considerations
Schizophrenia
Domain as Defined by EDDT
Screener
Hypervigilance
Poor Self Care
Fantasy Involved
Incoherence, Illogic
Distorted Perception, Emotion
Hallucination, Delusion
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
ADHD
Domain as Defined by EDDT
Screener
Poor Attention
Fidgety
Motor Agitation
Forgetfulness
Poking, Prodding Others
SM
Domain as Defined by EDDT
Three Factor Model
Sociopathic Attitudes
Conduct
School Aversion
28
Sections of the EDDT
29
Item Booklet: Sections I & II
30
Item Booklet: Section III
31
Item Booklet: Section IV
32
Item Booklet: Section V
33
Score Summary Booklet:
Inconsistency Score
34
Score Summary Booklet
35
Score Summary Booklet:
Emotional Disturbance Characteristic Profile
36
Score Summary Booklet:
EDDT Criteria Table
37
Scale/cluster
Number 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 Score
Potential Exclusionary Items (health, IQ, sensory, duration)
11 pairs
4
38
Metric of Scores
• Scales are based on T score
(M = 50; SD = 10)
• Clusters based on %ile ranges
39
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
40
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 absent
B. Appears to require an excessive amount of structure or rules to feel
comfortable and secure
C. Appears to dislike or have low tolerance for structure or rules, and
resists by acting-out
41
Cluster Item Examples (continued)
•
Level of Severity Cluster (SEVERITY)
– Disruption, aggression, or loss of emotional control at
school
A. Has occurred rarely, if at all
B. Has occurred on 1-2 occasions
C. Has occurred on 3 or more occasions
•
Educational Impact Cluster (IMPACT)
A. No behavior related absences
B. Some behavior related absences but not enough to
warrant formal reporting
C. Behavior related absences are excessive, and/or have
warranted formal reporting
42
Demographic Characteristics:
Normative Sample (n = 601)
Age (years)
Ethnicity (%)
M
11.46
Caucasian
66.2
SD
3.99
African American
14.8
range
5-18
Hispanic
10.8
Other
8.1
Grade
M
6.0
SD
3.81
range
K-12
Gender (%)
Male
49.6
Female
50.4
Region (%)
Northeast
30.0
South
38.4
North central
19.5
West
12.1
43
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
44
Coefficient Alpha Reliability of the EDDT
Clusters for the Normative Sample
Overall
Sample
Cluster
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
45
Additional EDDT Reliability Data
• Test Retest Stability
-median = .92
-mean interval = 19 days
• Interrater Reliability
- median = .84
- N = 64 pairs
46
Demographic Characteristics:
ED Sample (n = 404)
Age (years)
Ethnicity (%)
M
12.2
SD
3.35
range
5-18
Grade
Caucasian
51.4
African American
19.4
Hispanic
10.9
Other
18.4
M
6.5
SD
3.26
Region (%)
range
K-12
Northeast
14.6
South
41.1
Gender (%)
Male
73.5
North central
6.9
Female
26.5
West
37.4
47
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
48
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
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
72.0 1.0
10.1 1.2
10.8 9.9
5.3 18.1
1.5 69.6
Scales
EDDT Total scale (TOTAL)
Standardization (Normals) = GOLD
ED Clinical Validity Group = WHITE
49
Group Difference for the EDDT Score Between
the Normative and ED Sample
Normative
sample
ED sample
M
SD
M
SD
t
50.79
10.00
81.90
12.99
-42.75
50.76
10.23
87.85
18.90
-40.15
50.58
10.14
85.11
19.14
-37.16
50.49
10.03
83.95
22.81
-31.70
50.89
9.95
88.99
16.41
-45.72
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)
Attention-Deficit Hyperactivity Disorder (ADHD)
0.77
2.31
13.70
5.60
-46.33
5.86
5.72
16.35
6.84
-25.99
0.95
1.72
8.22
4.81
Scale/cluster
Scale
Inability to Build or Maintain Relationships (REL)
Inappropriate Behaviors or Feelings (IBF)
Pervasive Mood/Depression (PM/DEP)
Physical Symptoms or Fears (FEARS)
EDDT Total Score (TOTAL)
Cluster
Possible Psychosis/Schizophrenia (POSSIBLE
PSYCHOSIS)
All mean comparisons were significant
at p < .001.
-33.70
50
Construct Validity:
Correlations Between the EDDT Scales and the BASC-2
Teacher Form Among the Normative Sample
51
Demographic Characteristics:
SM Sample (n = 104)
Age
M
13.72
SD
2.35
Male
75.0
Female
25.0
Caucasian
62.1
African American
15.5
Hispanic
17.5
Other
4.9
Gender (%)
Race (%)
52
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
53
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
54
Construct Validity:
Correlations Between EDDT SM Cluster and
CDS Scores for the EDDT SM Sample
Conduct Disorder Scale
EDDT SM
Cluster .r
(N=53)
Aggressive
Conduct
Hostility
Deceitfulness
Theft
.92
.89
.86
Rule
Violations
.86
Conduct
Disorder
Quotient
.91
55
Construct Validity:
Correlations Between the EDDT SM Cluster
and DTCEP scores for the EDDT SM Sample
Differential Test of Conduct
and Emotional Problems
Emotional
Problems
Conduct
Disorder
.84
.90
EDDT SM
Cluster .r
(N=51)
56
Demographic Characteristics:
Combined Clinical Sample (n = 394)
Specific
Learning
Disability
(SLD)
97
Speech/Lang.
Impairment
(SLI)
37
Mental
Retardation
(MR)
53
AttentionDeficit
Hyperactivity
Disorder
(ADHD)
49
M
SD
10.48
3.17
7.65
2.77
11.83
3.72
9.84
3.26
9.57
3.30
13.72
2.35
Gender (%)
Male
Female
71.1
28.9
64.9
35.1
52.8
47.2
71.4
28.6
81.5
18.5
75.0
25.0
60.8
62.2
69.8
57.1
77.8
62.1
10.3
24.7
4.1
10.8
27
0.0
15.1
11.3
3.8
10.2
24.5
8.2
1.9
14.8
5.6
15.5
17.5
4.9
57
Characteristic
N
Autism
Spectrum
Disorders
(ASD)
54
Social
Maladjust
ment (SM)
104
Age
Race (%)
Caucasian
African
American
Hispanic
Other
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
58
Construct Validity:
.65
.63
.74
-.75 -.74 -.63 -.41
-.23
-.73
IBF
.72
.80
.74
.81
.20
.76
-.07
.49
.52
.21
.40
.69
.54
.80
-.73 -.66 -.48 -.36
-.22
-.65
PM/DEP
.54
.63
.65
.66
.26
.73
-.03
.51
.41
.23
.37
.59
.51
.67
-.73 -.68 -.55 -.36
-.19
-.67
FEARS
.42
.40
.41
.44
.29
.50
-.04
.39
.39
.37
.43
.56
.63
.54
-.57 -.57 -.51 -.32
-.33
-.59
EDDT
Total
.65
.73
.70
.75
.23
.75
-.05
.50
.50
.28
.44
.70
.64
.76
-.77 -.74 -.61 -.40
-.27
-.73
59
Adaptive Skills
.40
Functional
Communication
.25
Study Skills
.46
Leadership
.45
Social Skills
-.02
Adaptability
.70
BSI
.15
Withdrawal
Learning Problems
.72
Atypical
Attention Problems
.68
School Problems
Composite
Somatization
Internalizing Problems
Composite
Depression
.72
Conduct Problems
.61
Aggression
REL
EDDT
Scale
Hyperactivity
Anxiety
Externalizing Problems
Composite
Correlations Between the EDDT Scales
and the BASC-2 Teacher Form Among the Combined
Clinical Sample
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
60
Case Study: Crystal
Assessment 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.
61
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
62
63
64
65
Crystal Case Study: Post EDDT Profile
the Case for Incremental Validity
Criterion Based ED Data Now Available:
REL
PM/DEP
IBF
FEARS
TOTAL
T= 83
T= 67
T= 64
T= 83
T= 75
%ile = 98
%ile = 92
%ile = 88
%ile = 98
%ile = 92
Evidence of the Relative Impact of Criteria on ED Related Behavior:
FEARS
RELATIONSHIPS
IBF, PM/DEP
Very High Clinical (worst)
High Clinical
(second worst) – not apparent before
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
66
Case Study: Crystal
Recommendations
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 counseling67
and parenting guidance with a community provider.
Case Study: Crystal
Recommendations (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.
68
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
69
Case Study: Edison
Assessment 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
70
Edison Case Study:
Pre EDDT Profile Summary
High Evidence for Social Maladjustment Based on BASC 2 , MACI, Other:
- high Conduct and Aggression Scores
-serious disregard of authority
-weak in internal right - wrong
- picks fights, enjoys
- animal cruelty
- 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
71
72
73
74
Edison Case Study: Post EDDT Profile
the Case for Incremental Validity
EDDT Provides Evidence That Edison Is Both ED and SM:
REL
PM/DEP
IBF
FEARS
TOTAL
T= 77
T = 68
T = 75
T = 56
T = 73
%ile = 94
%ile = 92
%ile = 92
%ile = 67
%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-Guides
Intervention
Despite strong “sense” of SM, is in Moderate SM range
May be due to aggression/authority challenging vs. antisocial attitude
Gives Normative Evidence of Severity & Educational Impact – Both High
75
Case Study: Edison
SM 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
76
Case Study: Edison
SM 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
77
Case Study: Edison
Recommendations
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.
78
Case Study: Edison
Recommendations (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.
79
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
manipulative
breaks rules “invisibly”
steals, etc.
rarely caught
blames others
charismatic, neg. leader mostly non-aggressive
charming with adults
angry when cornered
•
Mid-School Behavioral Deterioration
rougher crowd
pot smoking
steals parent money
peer aggression
truck stop episode
•
tags school bathroom
provocative clothing
rejects authority
runs away, hitchhikes
Parents Demand Evaluation for ED (after years of half-steps)
80
Case Study: Angela
Assessment 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
81
Angela Case Study
Pre EDDT Profile Summary
-
Normal student intellectually- learns enough incidentally to get by
-
Deteriorating personal adjustment based on increasing rulebreaking, 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 behavior
she 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
82
83
84
85
Angela Case Study: Post EDDT Profile
the Case for Incremental Validity
EDDT Provides Evidence That Angela Is Probably Not ED:
REL
PM/DEP
IBF
FEARS
TOTAL
T= 49
T = 69
T = 53
T = 49
T = 55
%ile = 53
%ile = 93
%ile = 72
%ile = 47
%ile = 70
These Scores Suggest No Core
Basis for ED eligibility despite
Moderate Educational Impact
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
lying-tricky
school averse
manipulative
risk-taking
exploitative
weak right/wrong
calloused
rebellious
Although Not ED, This Information Helps Intervention If Available
poor candidate for group therapy in a fragile or normal process group, etc.
86
Case Study: Angela
SM Items Endorsed
87
Case Study: Angela
Recommendations
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
88
relationships that could possibly be improved through family counseling.
Case Study: Angela
Recommendations
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.
89
Case Study: Angela
Recommendations
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.
90
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
th
mid
year : On juvenile probation. Acting like a middle
5
schooler
•
Has not responded to intervention for over a year - referred for evaluation
91
Case Study: Conrad
Assessment Results
• Low Average IQ on WISC IV, one grade level below
placement academically on standardized tests
• Roberts-2, refuses to respond to several cards (contentparents talking with children). High Aggression score
• Human Figure Drawing – picture of a man in prison yard
looking up at guard tower
• BASC 2 - higher Externalizing vs. Internalizing total scores
• CDS – Scores suggest a conduct disorder
92
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”
93
EDDT Results: Rater #1
94
EDDT Results: Rater #2
95
EDDT Results: Rater #1
96
EDDT Results: Rater #2
97
Conrad Case Study: Post EDDT Profile
the 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 Raters
Severity Score: High Severity, Both Raters
Educational Impact: High Impact and Moderate Impact
ED 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
98
Case Study: Conrad
Recommendations
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
99
other students and staff.
Case Study: Conrad
Recommendations
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
100
from the school for some of his behavior problems at home.
Case Study: Conrad
Recommendations
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.
101