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Learners with Emotional or Behavioral Disorders Topics • • • • • • Terminology Definition Classification Prevalence Causes Identification Topics (cont’d) • Psychological and behavioral characteristics • Educational considerations • Assessment of progress • Early intervention • Transition to adulthood • People with emotional or behavioral disorders are not good at making friends. • They fail to establish good, close, satisfying relationships with other people. • Deviant friendship • They are isolated not because they are withdrawn, but because they are abusive, destructive, unpredictable, irresponsible, irritable, jealous, defiant…. • Where does the problem start? • Does it start with the behavior that frustrates, irritates other people? • Does it start with an inappropriate social environment that the child can only withdrawn or attack? • Not just the behavior or environment… Terminology • Emotionally disturbed – as used in the Individuals with Disabilities Act (IDEA) • Behaviorally disordered – used by many professionals and Council for Exceptional Children • Emotional or behavior disorder – introduced in 1990 by National Mental Health and Special Educational Coalition; generally accepted terminology of the field Definition • Definitional problems Lack of precise definitions of mental health and normal behavior Differences among conceptual models Imprecise measurement of emotion and behavior Emotional or behavioral disorders often overlap other disabilities Differences in the professionals who diagnose and serve children and youths Possible combinations of terms. Choose one or more in set A combined with one in set B. Fig. 8.1 Definition (cont’d) • Current definitions Behavior is extreme Problem is chronic Behavior unacceptable because of social or cultural expectations Definition (cont’d) • Federal definition Long period of time, to a marked extent Adversely affects education Includes schizophrenia Excludes social maladjustment which some states interpret as conduct disorder-aggressive, disruptive, antisocial behavior An inability to learn cannot be explained by intellectual, sensory, heath factors An inability to build or maintain relationship Inappropriate behaviors/feelings under normal circumstances A pervasive mood of unhappiness/depression A tendency to develop physical symptoms or fears associated with personal or school problems • National Mental Health and Special Education Coalition definition A disability characterized by behavioral or emotional responses that adversely affect educational performance Acknowledges multiple disabilities Does not have arbitrary exclusions Exhibited in two different settings Unresponsive to direct intervention Can co-exist with other disabilities Includes affective/anxiety disorder Classification • Two broad dimensions of disordered behavior Externalizing Internalizing • Co-morbidity – the occurrence of two or more conditions in the same individual • Schizophrenia Examples of motional and Behavior Disorders from a Medical Perspective • Schizophrenia • Anxiety Disorders: Cannot stop worrying about a specific concern (e.g., germs) – Obsessive Compulsive Disorders (OCD) – Phobias – Post Traumatic Disorder • Disruptive Behavior Disorders: – Attention Deficit-Hyperactivity Disorder – Oppositional Defiant Disorder: – Conduct Disorder • Eating Disorders: – Anorexia Nervosa – Bulimia • Mood Disorders – Bipolar Disorder (manic depressive) – Depression • Tic Disorder – Tourette’s Syndrome (TS) • Schizophrenia: – Have delusions (Bizarre ideas), hallucinations (seeing or hearing imaginary things) – Severe disorder of thinking – Inappropriate emotions – Tend to withdraw • Children with autism do not have delusions, hallucinations, etc… • Children with schizophrenia tend to have psychotic episodes, then periods of near-normal behavior. • Autistic children tend to have more constant behaviors • 25% of autistic children have seizures, schizophrenic children seldom have seizures. Obsessive Compulsive Disorders (OCD) • Obsessions Obsessions are thoughts, images, or impulses that occur over and over again and feel out of your control. • The person does not want to have these ideas. • He finds them disturbing and intrusive, and usually recognizes that they don't really make sense. • People with OCD worry excessively about dirt and germs and become obsessed with the idea that they are contaminated or contaminate others. obsessions • They may have obsessive fears of having inadvertently harmed someone else even though they usually know this is not realistic. • Obsessions are accompanied by uncomfortable feelings, such as fear, disgust, doubt, or a sensation that things have to be done in a way that is "just so." Compulsions • People with OCD try to make their obsessions go away by performing compulsions. • Compulsions are acts the person performs over and over again, often according to certain "rules." • People with an obsession about contamination may wash constantly to the point that their hands become raw and inflamed. • A person may repeatedly check that she has turned off the stove or iron because of an obsessive fear of burning the house down. • She may have to count certain objects over and over because of an obsession about losing them. • Unlike compulsive drinking or gambling, OCD compulsions do not give the person pleasure. • Rather, the rituals are performed to obtain relief from the discomfort caused by the obsessions. – My 11-year-old daughter got a diagnosis of obsessive-compulsive disorder (OCD) about six months ago. – She is not currently on any medication but has been regularly seeing a therapist. – While she does have compulsive routines, which we have been successfully working on with exposure and response prevention therapy (ERP) (very long showers, bedtime routines, etc.), these routines do not appear to be compulsions to relieve anxiety. – And when they are focused on, it is fairly easy to change them. cases – However, the bigger problems crop up over decision-making. – When there are two options of equal weight in her mind (buy or pack lunch, flip-flops or sneakers) it can, on occasion, cause a massive panic attack and major tantrums. – However, this does not happen consistently. – Additionally, some serious anxiety-ridden episodes can occur when something doesn't happen the way she wants it to or thinks it should. – Again, there does not appear to be any specific obsession or thoughts relating to bad or harmful things that might happen if the wrong decision is made. – Just an extreme need to make sure she makes the right decision and a lack of control to move beyond the issue at that time. – She often asks for help in making decisions but doesn't want someone else to make the decision for her. cases • I couldn’t do anything without rituals. • They invaded every aspect of my life. Counting really bogged me down. • I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. • It took me longer to read because I’d count the lines in a paragraph. • When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.” • “I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.” • “Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. • I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.” http://www.cnn.com/2009/HEALTH/expert.q.a/10/27/ocd.decision.making.raison/ • many people with OCD do primarily manifest classic symptoms such as fear of contamination, • a need to count or a need for things to be symmetrical, it is just as common for individuals with OCD to suffer most from symptoms that are less well-known, none of which is more common than indecision. • And indecision is always at its worst when the patient is presented with two options that are equally desirable. • Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). • Repetitive behaviors such as handwashing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. • Performing these so-called "rituals," however, provides only temporary relief, and not performing them markedly increases anxiety • Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. • The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. • Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary. • It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. • One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families. • The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. • If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. • People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.4 • OCD usually responds well to treatment with certain medications and/or exposurebased psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them Phobias http://www.phobics-awareness.org/schoolphobia.htm • School phobia (known to professionals as school refusal), a complex and extreme form of anxiety about going to school (but not of the school itself as the name suggests. • Symptoms include stomachaches, nausea, fatigue, shaking, a racing heart and frequent trips to the toilet. • Young children (up to age 7 or 8) with school phobia experience separation anxiety and cannot easily contemplate being parted from their main care giver, • whereas older children (8 plus) are more likely to have it take the form of social phobia where they are anxious about their performance in school (such as in games or in having to read aloud or answer questions in class). • Children with anxieties about going to school may suffer a panic attack if forced which then makes them fear having another panic attack and there is an increasing spiral of worry with which parents often do not know how to deal. School phobias • Possible triggers for school phobia include: • 1. Being bullied. 2. Starting school for the first time. 3. Moving to a new area and having to start at a new school and make new friends or just changing schools. 4. Being off school for a long time through illness or because of a holiday. • 5. Bereavement (of a person or pet). 6. Feeling threatened by the arrival of a new baby. 7. Having a traumatic experience such as being abused, being raped, having witnessed a tragic event. • 8. Problems at home such as a member of the family being very ill. 9. Problems at home such as marital rows, separation and divorce. 10. Violence in the home or any kind of abuse; of the child or of another parent. • 11. Not having good friends (or any friends at all). 12. Being unpopular, being chosen last for teams and feeling a physical failure (in games and gymnastics). 13. Feeling an academic failure. • How Does School Phobia Start? • Going to school for the first time is a period of great anxiety for very young children. • Many will be separated from their parents for the first time, or will be separated all day for the first time. • This sudden change can make them anxious and they may suffer from separation anxiety. • They are also probably unused to having the entire day organized for them and may be very tired by the end of the day, causing further stress and making them feel very vulnerable. • For older children who are not new to the school, who have had a long summer break or have had time off because of illness, returning to school can be quite traumatic. • They may no longer feel at home there. Their friendships might have changed. • Their teacher and classroom might have changed. • They may have got used to being at home and closely looked after by a parent, suddenly feeling insecure when all this attention is removed; and suddenly they are under the scrutiny of their teachers again. • Other children may have felt unwell on the school bus or in school and associate these places with further illness and symptoms of panic, and so want to avoid them in order to avoid panicky symptoms and panic attacks fearing, for example, vomiting, fainting or having diarrhea. • Other children may have experienced stressful events. Post Traumatic Stress Disorder (PTSD) http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-easy-to-read/index.shtml • What is Post-Traumatic Stress Disorder? • Post-Traumatic Stress Disorder, PTSD, is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. • Traumatic events that may trigger PTSD include violent personal assaults, natural or humancaused disasters, accidents, or military combat. What Causes PTSD • • • • • • Being a victim of or seeing violence The death or serious illness of a loved one War or combat Car accidents and plane crashes Hurricanes, tornadoes, and fires Violent crimes, like a robbery or shooting. • Signs & Symptoms • People with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. They may experience sleep problems, feel detached or numb, or be easily startled. • Treatment • Effective treatments for post-traumatic stress disorder are available, and research is yielding new, improved therapies that can help most people with PTSD and other anxiety disorders lead productive, fulfilling lives If you have PTSD • • • • • • • • • • Bad dreams Flashbacks, or feeling like the scary event is happening again Scary thoughts you can't control Staying away from places and things that remind you of what happened Feeling worried, guilty, or sad Feeling alone Trouble sleeping Feeling on edge Angry outbursts Thoughts of hurting yourself or others. • Children who have PTSD may show other types of problems. • These can include: – Behaving like they did when they were younger – Being unable to talk – Complaining of stomach problems or headaches a lot – Refusing to go places or play with friends. • Attention Deficit-Hyperactivity Disorder – Oppositional Defiant Disorder (ODD): – Conduct Disorder Oppositional Defiant Disorder (ODD): http://www.aacap.org/cs/root/facts_for_families/children_with_oppositional_defiant_disorder • persistent pattern of tantrums, arguing, and angry or disruptive behaviors toward you and other authority figures, • The symptoms are usually seen in multiple settings, but may be more noticeable at home or at school. • One to sixteen percent of all school-age children and adolescents have ODD. • The causes of ODD are unknown, but many parents report that their child with ODD was more rigid and demanding that the child’s siblings from an early age. • Biological, psychological and social factors may have a role. Symptoms • • • • Frequent temper tantrums Excessive arguing with adults Often questioning rules Active defiance and refusal to comply with adult requests and rules • Deliberate attempts to annoy or upset people Cont’d • Blaming others for his or her mistakes or misbehavior • Often being touchy or easily annoyed by others • Frequent anger and resentment • Mean and hateful talking when upset • Spiteful attitude and revenge seeking Conduct Disorder http://www.aacap.org/cs/root/facts_for_families/conduct_disorder • Conduct disorder" refers to a group of behavioral and emotional problems in youngsters. • Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. • They are often viewed by other children, adults and social agencies as "bad" or delinquent, rather than mentally ill. Aggression to people and animals http://www.aacap.org/cs/root/facts_for_families/conduct_disorder • Bullies, threatens or intimidates others • often initiates physical fights • has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun) • is physically cruel to people or animals • steals from a victim while confronting them (e.g. assault) • forces someone into sexual activity Destruction of Property • Deliberately engaged in fire setting with the intention to cause damage • deliberately destroys other's property Deceitfulness, lying, or stealing • has broken into someone else's building, house, or car • Lies to obtain goods, or favors or to avoid obligations • steals items without confronting a victim (e.g. shoplifting, but without breaking and entering) Serious violations of rules • often stays out at night despite parental objections • runs away from home • often truant from school • Eating Disorders: – Anorexia Nervosa – Bulimia Anorexia Nervosa • Eating disorder, psychological • Begins with dieting to lose weight • Endless cycle of restrictive eating, excessive exercising, overuse of diuretics, laxatives • Females are at risk, • Males can develop this disorder as well. • No definite causes • Demands from families and society • Poor self-image Bulimia • Eating disorder • Binging (eating a lot), purging (get rid of food) • Unhappy with body size and figure • Mood Disorders – Bipolar Disorder (manic depressive) – Depression Bipolar Disorder (manic depressive) • Manic depressive, unusual shift in energy, mood, activity levels • Damaged relationships, poor job, schools performance • Develops in late teens or young adults Symptoms http://www.nimh.nih.gov/health/publications/bipolar-disorder/completeindex.shtml • Mood Changes • A long period of feeling "high," or an overly happy or outgoing mood • Extremely irritable mood, agitation, feeling "jumpy" or "wired." Behavioral Changes • Talking very fast, jumping from one idea to another, having racing thoughts • Being easily distracted • Increasing goal-directed activities, such as taking on new projects • Being restless • Sleeping little • Having an unrealistic belief in one's abilities • Behaving impulsively and taking part in a lot of pleasurable, high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments. Depression http://www.nimh.nih.gov/health/publications/depression/completeindex.shtml • it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. • Depression is a common but serious illness, and most who experience it need treatment to get better. Symptoms • Persistent sad, anxious or "empty" feelings • Feelings of hopelessness and/or pessimism • Feelings of guilt, worthlessness and/or helplessness • Irritability, restlessness • Loss of interest in activities or hobbies once pleasurable, including sex • Fatigue and decreased energy • Difficulty concentrating, remembering details and making decisions • Insomnia, early–morning wakefulness, or excessive sleeping • Overeating, or appetite loss • Thoughts of suicide, suicide attempts • Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment Depression • Mood Changes • A long period of feeling worried or empty • Loss of interest in activities once enjoyed, including sex. • Behavioral Changes • Feeling tired or "slowed down" • Having problems concentrating, remembering, and making decisions • Being restless or irritable • Changing eating, sleeping, or other habits • Thinking of death or suicide, or attempting suicide. Tourette’s Syndrome (TS) – A disturbance in the balance of neurotransmitters — chemicals in the brain that carry nerve signals from cell to cell — may play a role in TS. – Tourette syndrome is not contagious. – The tics associated with Tourette Syndrome tend to get milder or go away entirely as kids grow into adulthood http://www.ninds.nih.gov/disorders/tourette/detail_tourette.h tm • average onset between the ages of 7 and 10 years • Males are more affected than females • Some of the more common simple tics include eye blinking and other vision irregularities, facial grimacing, shoulder shrugging, and head or shoulder jerking. • Simple vocalizations might include repetitive throatclearing, sniffing, or grunting sounds. • Complex tics are distinct, coordinated patterns of movements involving several muscle groups. • Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. • Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. • Simple vocal tics may include throat-clearing, sniffing/snorting, grunting, or barking. • More complex vocal tics include words or phrases. • Perhaps the most dramatic and disabling tics include motor movements that result in self-harm such as punching oneself in the face or vocal tics including coprolalia (uttering swear words) or echolalia (repeating the words or phrases of others). Prevalence • Estimates of 6 to 10 percent of schoolage population • Less than 1 percent identified as emotionally disturbed Most identified students exhibit externalizing behavior Boys outnumber girls about 5 to 1 Juvenile delinquency Causes • Some physiological factors • Biological disorders and diseases Medication helpful but not the only intervention needed genetics, temperament, malnutrition, brain trauma, substance abuse, poorly understood medical intervention, • Undesirable experiences at school Spiral of negative interactions • insensitivity to individuality, inappropriate expectations, inconsistent or inappropriate discipline, unintentional rewards for misbehavior, and undesirable models of conduct, • Pathological family relationships Parents need positive support resources • disorganization, parental abuse, and nconsistent discipline) • affect individual family members in different ways. Very good parents sometimes have children with serious emotional or behavioral disorders, and incompetent, abusive parents sometimes have children with no signification emotional or behv.diff., • Negative cultural influences Increase in level of violence, drug abuse, and changing social standards • influences of the media, values, and standards of the community and peer group, and social services available to children and their families). • One of the myths surrounding students with emotional or behavioral disorders is that they are usually very bright. Are they? • * In fact, most children with emotional or behavioral disorders score in the dull-normal range of IQ tests and achieve below their age level on standardized tests. • * How emotional or behavioral disorders may affect learning, others’ expectations, and testing rsults? • What is “comorbidity”? • Two or more disorders exist simultaneously in an individual. Recent research indicates that comorbidity is extremely common; single disorders may in fact be the exception rather than the rule. Path to Success at School Fig. 8.3 Source: Reprinted with the permission of Merrill Prentice Hall from An introduction to students with high incidence disabilities, by J. P. Stichter, M. A. Conroy, & J. M. Kauffman. Copyright © 2008 by Pearson Education, Inc. EDUCATIONAL CONSIDERATIONS • No consensus on the type of the educational program for children and youths with emotional or behavioral disorders. • For youngers: early identification and prevention, • For adolescents: individualized intervention to meet the differences in intelligence, behavioral characteristics, achievement, and circumstances of the students. • • • • They typically - have low grades and other unsatisfactory academic outcomes, - have higher dropout and lower graduation rates, - and are frequently involved with the juvenile justice system. • Credible conceptual models that guide most educational programs today have two objectives: • 1) controlling misbehavior, • 2) and teaching students the academic and social skills they need. • DISCUSSION: • During their elementary and high school years, have you encountered students or teachers whom you believed had emotional or behavioral disorders? • Why did you believe these individuals had emotional or behavioral disorders? • How would you describe these people’s behavior? Identification • Difficult to identify When the child is young, problems may be undetected When there is an error in teacher judgment When the child does not exhibit problems at school • Importance of teacher’s informal judgment Identification (cont’d) • Three step screening system for elementary schools Teacher lists and ranks students Completes two checklists for three highest ranked pupils Pupils whose scores exceed norms are observed by other professionals Psychological and Behavioral Characteristics • Intelligence and achievement Typically, below average IQ (less than 90) • Social and emotional characteristics Aggressive, acting-out behavior (externalizing) Immature, withdrawn behavior and depression (internalizing) Hypothetical frequency distribution of IQ for students with emotional or behavioral disorders as compared to a normal frequency distribution. Fig. 8.4 Source: Reprinted with permission of Merrill Prentice Hall from Characteristics of emotional and behavioral disorders of children and youth (9th ed.) by James M. Kauffman and Timothy J. Landrum. Copyright © 2009 by Pearson Education, Inc. Educational Considerations • Objectives: Controlling misbehavior Teaching academic and social skills • Balancing behavioral control with academic and social learning • Importance of integrated services Educational Considerations (cont’d) • Strategies that work Systematic, data-based interventions Continuous assessment and progress monitoring Provision for practice of new skills Treatment matched to the problem Multicomponent treatment Programming for transfer and maintenance Commitment to sustained intervention Educational Considerations (cont’d) • Service delivery Trend toward inclusion Different needs require different placements • Instructional considerations Need for social skills Needs of juvenile delinquents Special challenges for teachers Educational Considerations (cont’d) • Disciplinary considerations Functional behavioral assessment (FBA) Positive behavioral supports and behavioral intervention plans • Moreover,they tend to have multiple and complex needs, a variety of services • - family-oriented services, counseling, • • • • • • • • - successful strategies include: (1) systematic, data-based interventions, (2) continuous assessment and monitoring of progress, (3) provision for practice of new skills, (4) treatment matched to the problem, (5) multicomponent treatment, (6) programming for transfer and maintenance, (7) commitment to sustained intervention. • FIRST STEP TO SUCCESS- BAŞARIYA İLK ADIM: İBRAHİM DİKEN, ANADOLU UNIVERSITY, ESKISEHIR. Assessment of Progress • Progress monitoring and outcome measures Evaluating the progress and outcomes of behavioral interventions Measuring progress and outcomes in academic skills • Testing accommodations Early Intervention • Identification Diagnosis in very young children challenging Children’s behavior responsive to social conditions • Prevention problems Parents and teachers trained in behavior management Costliness of programs and personnel needed Professionals do not always agree upon the behaviors that should be prevented Transition to Adulthood • Programs available Regular public high school classes Consultant teachers who provide individualized work and behavior management Resource rooms and self-contained classes Work-study programs Special private schools, alternative schools, private or public residential schools Transition to Adulthood (cont’d) • Incarcerated youth neglected • Employment difficulty due to academic skills • May require intervention throughout life • • • • • * The programs designed for adolescents with EBD are varied and must be highly individualized to meet the differences in - students’ intelligence, - behavioral characteristics, - achievement, - and circumstances. • * Students with EBD are among those most likely to drop out of school, yet many of them lack the basic academic and social skills necessary for successful employment. • * Many individuals grow up to be adults who have difficulty leading independent, productive lives and many require intervention throughout their lives. •