EDDT/EDDT-PF

Effective 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.

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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) 5

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) 6

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 7

“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) 8

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) 9

Summary of the Major Risk Factors Associated With Conduct Disorder

• Dispositional risk factors • Neurochemical abnormalities • Autonomic irregularity Contextual risk factors Pre-natal exposure to toxins Early exposure to poor quality child care • Birth complications • Difficult child temperament • Impulsivity Parental psychopathology Family conflict Inadequate parental supervision and discipline • Preference for dangerous and and novel activities • Reward dominant response style • Low verbal intelligence Lack of parental involvement and neglect Peer rejection Association with a deviant peer group • Academic underachievement • Deficits in processing social info Impoverished living conditions Exposure to violence Frick (2004) 10

Developmental Pathways

• 1. Childhood Onset – high CU • • 2. Childhood Onset – low CU 3. Adolescent Onset 11

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) 12

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) 13

ED: Internalizing, depressed, anxious ED: Externalizing, emotional and not calloused, affectively disregulated, emotionally overreactive SM: Externalizing, callous and unemotional, psychopathy 14

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 15

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, 16 2007)

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 takes 15 20 minutes to complete and 15 minutes to score.

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.

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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

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 19

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. 20

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.

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Sections of the EDDT

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 22

IDEA criteria Over a long period of time To a marked degree Adversely affect’s a child’s educational performance An inability to learn that cannot be explained by intellectual, sensory, or health factors An inability to build or maintain satisfactory interpersonal relationships with peers and teachers Inappropriate types of behavior or feelings under normal circumstances A general pervasive mood of unhappiness or depression A tendency to develop physical symptoms or fears associated with personal or school problems The term includes schizophrenia The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance EDDT Scale/Cluster Potential Exclusionary Items Level of Severity (SEVERITY) cluster Educational Impact (IMPACT) cluster Potential Exclusionary Items Inability to Build or Maintain Relationships (REL) scale Inappropriate Behaviors or Feelings (IBF) scale Pervasive Mood/Depression (PM/DEP) scale Physical Symptoms or Fears (FEARS) scale Possible Psychosis/Schizophrenia (PSYCHOSIS) cluster Social Maladjustment (SM) cluster

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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 24

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 25

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 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

Domain Characterized By: unstable, few-no relationships social avoidance chronic peer rejection preference poor reciprocity poor “connectivity skills” aggressiveness with peers problems chronic hostility in interaction inappropriate interaction age inappropriate friend lack of empathy or respect poor social conversation skill qualitative relationship Item Examples – Is hostile towards peers – Is resentful, spiteful, or angry toward others 27

ED Characteristics:

Inappropriate types of behavior or feelings under normal circumstances

Inappropriate Behaviors or Feelings (IBF)

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 28 emotional symps (& school probs)

Domain Characterized By: age inappropriate behavior failure to self-regulate mismatch of behavior/emotion dramatic or strange behavior defensiveness, defiance poor coping distorted views &/or emotions attention seeking teasing-taunting over-aroused behavior tantrums / shut down suspiciousness restricted interests risk taking Item Examples – Behaves in an unusual or strange manner compared to peers – Displays strange, distorted, or inappropriate emotions 29

ED Characteristics:

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

Physical Symptoms or Fears (FEARS)

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) 30

Domain Characterized By: nervousness, anxiety absorption with past events school avoidance due to fears panic symptoms over-dependency somatic complaints restlessness compulsive behavior obsessive thoughts fearfulness of peers or adults separation anxiety re. caregivers physical withdrawal from others self-isolation due to social discomfort risk avoidance ritualistic 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 occur 31

ED Characteristics:

A general pervasive mood of unhappiness or depression

Pervasive Mood/Depression (PM/DEP)

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 32

Domain Characterized By: depressed, sad, hopeless lack of interest / pleasure unexplained crying deteriorated self-care physiological signs low social interest, enthusiasm self mutilation irritability, anger, frustration low animation feeling rejected low self esteem lethargy preoccupation with death suicidality Item Examples – Appears dejected or unhappy – Is emotionally flat or unanimated 33

Possible Psychosis/Schizophrenia Cluster (POSSIBLE PSYCHOSIS)

Screener Incoherence Hypervigilance Emotion Hallucination Fantasy Involved Illogic Distorted Perception Poor Self Care Delusion Strange Behavior Item Examples – Has distorted view of situations and people – Displays deteriorated self-care, hygiene, or concern about personal appearance 34

Attention-Deficit Hyperactivity Disorder Cluster (ADHD)

Screener Motor Agitation Forgetfulness Poking Poor Attention Fidgety Prodding Others Item Examples – Displays motor agitation or restlessness – Has difficulty paying attention in classroom and/or other settings 35

Social Maladjustment Cluster (SM)

Related Literature – Frick and Hare (2001) a) Callous/unemotional b) Lack of guilt c) Egocentricity d) Lack of empathy e) Impulsivity f) Use of others for personal gain Three Factor Model Conduct Sociopathic Attitudes School Aversion 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 adequately B) Tries to meet own needs through dependency, attention-seeking, or bizarre behavior C) Meets own needs by skillfully and selfishly manipulating others 37

Level of Severity Cluster (SEVERITY)

Areas assessed: Frequency and setting Need for restraint Need for a safety plan Suspension Outside treatment Marked problems Response to intervention Example: 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 38

Educational Impact Cluster (IMPACT)

Areas Assessed: Work completion Compliance with direction Quality of work Behavior related absences Working without redirection Suspension Counseling BIP developed?

Interventions effective?

Example: 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 39

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)

Metric of Scores

• Scales are based on

T

score (M = 50; SD = 10) • Clusters based on %ile ranges

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Coefficient Alpha Reliability by Normative Group

Scale Inability to Build or Maintain Relationships scale (REL) Inappropriate Behaviors or Feelings scale (IBF) Pervasive Mood/Depression scale (PM/DEP) Physical Symptoms or Fears scale (FEARS) EDDT Total scale (TOTAL) EDDT EDDT PF .88

.83

.81

.75

.94

.88

.92

.87

.86

.96

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Coefficient Alpha Reliability for the Normative Sample

Cluster Social Maladjustment cluster (SM) Level of Severity cluster (SEVERITY) Educational Impact (IMPACT) Attention Deficient Hyperactivity Disorder (ADHD) Possible Psychosis/Schizophrenia cluster (PSYCHOSIS) Resilience (RES) Motivation EDDT .93

.75

.90

.89

.70

EDDT PF .93

.83

.91

.87

.88

.91

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EDDT: Group differences between the Normative and ED sample ED Scale

REL

Norm ED

50.79

81.90

Cluster (raw score)

SM

Norm ED

0.71

7.03

IBF 50.76

87.85

SEVERITY 0.42

9.93

PM/DEP 50.58

85.11

IMPACT 0.77

13.70

FEARS 50.49

83.95

ADHD 5.86

16.35

TOTAL 50.89

88.99

PSYCHOSIS 0.95

8.22

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

REL 50.14 77.21

49.96 68.32

IBF PM/DEP FEARS TOTAL 50.32 75.50

49.82 74.61

50.45 71.21

49.53 77.37

RES Cluster (raw score) ADHD POSSIBLE PSYCHOSIS SM SEVERITY MOTIVATION 12.18 29.80

2.63 12.44

5.65 22.74

1.27

8.99

21.32 17.53

Percentage of Normative and ED Sample Scoring Within Clinically Relevant T-Score Ranges Scales REL Normal Range Mild At Risk Moderate Clinical High Clinical Very High Clinical 72.0

2.0 9.3

3.0

12.1

10.6

4.0

25.7

2.3

58.4

IBF 73.5

4.2

9.7

2.2

9.0

10.9

6.0

15.8

1.8

66.8

PM/DEP 71.2

2.7

11.5

3.7

11.3 14.4

4.0

22.3

2.0 56.9

FEARS TOTAL 71.9

4.2

72.0

1.0

10.5

5.2

12.1

18.1

4.3

22.3

10.1

1.2

10.8 9.9

Standardization = GOLD ED Group = WHITE

5.3

18.1

1.2

50.2

1.5

69.6

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Case Study: Edison Background

• 13-year-old male, 7 th 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 47

Case Study: Edison Assessment 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 48

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

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EDDT/EDDT-PF Results

EDDT: • 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 Results

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

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Edison Case Study: Post EDDT Profile the Case for Incremental Validity

EDDT Provides Evidence That Edison Is Both ED and SM IBF: Anger reactions REL: Pervasive lack of social skills PM/DEP: Indicates limited self-esteem, unhappiness Despite strong “sense” of SM, is in Moderate SM range Endorsement 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 medication Needs ongoing medication review Normative Severity & Educational Impact – Both High 52

Treatment

Frick (2004) Developmental Pathways • 1. Childhood Onset, high callous and unemotional (CU) • Increase empathetic concern 53

Treatment

• 2. Childhood Onset, low CU • Inhibit impulsive and angry responses 54

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 Training Parent Management Training Functional Family Therapy Multisystematic Therapy 56

Treatment

• Theodore and Little (2004) • Anxiety – Cognitive behavioral therapy – Individual psychotherapy – Family therapy – Medications 57

Treatment

• Depression – Cognitive behavioral therapy – Behavioral therapy – Family approaches – Medications 58