Emotional and Behavioral Disorders: Causes and Prevention

Home and Community

Environment and culture are the context in which behavior unfolds (Maag, 2000). No one lives in a social vacuum. Everyone is a member of an immediate family, an extended family, or a community network (neighborhood, church, clubs). All of these environments shape and influence each individual's growth and development, whether positively or negatively. Rarely does a single negative experience lead to or aggravate emotional problems, but combinations of poverty, abuse, neglect, parental stress, inconsistent expectations and rules, confusion, and turmoil over long periods of time can do so. Being poor is a contributing factor (CDF, 2004; Hosp & Reschly, 2002). So are lack of supervision, erratic and punitive discipline, low rate of positive interactions, high rate of negative interactions, lack of interest and concern, and poor adult role models (Reid & Patterson, 1991). For example, children whose parents are violent and have arrest records also tend to become violent and to find themselves in trouble with the law (Hallahan & Kauffman, 2006; Rudo, Powell, & Dunlap, 1998). Another link with poverty is clear: Students whose family incomes are in the bottom 20 percent of American families are five times more likely to drop out of school than their peers whose family incomes are in the top 20 percent of American families (NCES, 2001).

School

Teachers and schools can have a tremendous influence on students (Tolan, Gorman-Smith, & Henry, 2001). Teachers' expectations affect the questions they ask students, the feedback they give, and the number and character of their interactions with students. Problems can get better because of teachers' actions—and they can get worse for the same reason. In other words, what educators do makes a difference. For example, a teacher who is unskilled in managing the classroom or insensitive to students' individual differences may create an environment wherein aggression, frustration, and withdrawal are common responses to the environment or the teacher. But, teachers skilled at managing classroom behavior can systematically select interventions that match the students' behavior and apply them consistently. When effective teaching and behavior management methods are in place, students' outcomes improve (Rivera & Smith, 1997; Smith & Rivera, 1993). Good teachers are able to analyze their relationships with their students and the learning environment, and they keep close watch on problems and potential problems. Here are some key components of safe and effective schools (McLane, 1997; Walker & Gresham, 1997; Walker, Ramsey, & Gresham, 2004; Walker & Sprague, 2000):

• Consistency of rules, expectations, and consequences across the school
• Positive school climate
• Schoolwide strategies for resolving conflict
• High level of supervision in all school settings
• Cultural sensitivity
• Strong feelings of identification and involvement on the part of students
• High levels of parent and community involvement
• Well-utilized space and lack of overcrowding

Prevention

One of the first steps in preventing the development of emotional or behavioral disorders is determining which children exhibit behaviors that are often predictive of later problems. Astute adults almost universally and immediately identify even very young children with emotional or behavioral disorders, particularly in cases of individuals with externalizing behavior patterns. Why might this be so? Standards for normal behavior change as children grow up and move througl1 the stages of their lives. When children behave quite differently from what is expected for their age group, it becomes a cause for concern. For example, the behavior of an 8-year-old who suddenly begins to wet the bed, clings to his mother, and stops talking creates great concern. Even though almost identical behavior would be totally acceptable for a toddler, an 8-year-old who acts in this way is perceived as having a problem. Think of examples of behavior that provoke concerns about children of one age but, when demonstrated by a child of a different age, raise no questions at all.

The fact that behavior inappropriate for an individual's age draws attention and can result in the individual's being identified as having an emotional or behavioral disorder makes some experts worry about subjectivity in the assessment process. Also, students with internalizing behaviors are often missed when only teacher referrals are used. Experts recommend that standardized tests or procedures be used in the identification process (Gresham et al., 1999). Some such methods are available. For example, the Student Risk Screening Scale and the Systematic Screening for Behavior Disorders are assessment instruments that take some of the subjectivity out of the identification process.

Some concerns about this category of special education focus on the disproportionate number of African American males, particularly children who are disruptive, identified as having emotional or behavioral disorders (Townsend, 2000; U.S. Department of Education, 2005b). Whereas these boys are overrepresented, other groups, such as Asian Americans and girls, are underrepresented. The possible explanations for this disproportionate representation include a lack of reliable methods for identifying these children, particularly those with internalizing behaviors. Current knowledge can guide educators' actions until more accurate assessment procedures are available:

• Evaluation measures should come from at least two different settings.
• Performance in both academics and social skills should be considered.
• Information should come from a range of people in the child's life.
• Many methods to assess students' behavior should be used (behavior rating scales, ecological assessments, interviews, standardized tests, social work evaluations, psychiatric analyses, functional assessments).

Overcoming Challenges

Prevention and treatment of emotional or behavioral disorders can be accomplished in many different ways, but the implementation of three different approaches could cause a substantial reduction in the prevalence of this disability:

1. Medical management
2. Reducing overrepresentation
3. School-based interventions

Medical management can attack issues of prevention on at least two different fronts. For example, the behavioral effects of fetal alcohol syndrome can be prevented if pregnant women do not drink. In other cases, prevention consists of eliminating or ameliorating the symptoms of the disability at its initial onset. And in yet other cases, the condition can be treated through medication. Considerable controversy exists about the use of prescription drugs to reduce hyperactivity and the disruption that the condition causes (Zametkin & Earnst, 1999). Considering the fact that American children are being prescribed and taking drugs such as Ritalin at a rate some five times higher than children elsewhere in the world, many educators have been calling for a greater use of classroom management interventions and interventions based on the reason why problem behaviors occur (functional assessment-based interventions) to reduce both inappropriate behavior and the use of medication (Pancheri & Prater, 1999; Umbreit, Lane, & Dejud, 2004). Some experts who have studied this issue believe that medication is effective (Forness & Kavale, 2001). However, they have also concluded that medication is even more powerful when used in combination with behavior management techniques. In the same study, Steve Forness and Ken Kavale found that the majority of children with school behavior problems have treatable psychiatric disorders, such as mood disorders, anxiety disorders, or schizophrenia. Antidepressants are effective in some of these cases.

The overrepresentation of African American boys in special education concerns educators, policymakers, and parents (National Alliance of Black School Educators [NABSE] & ILIAD Project, 2002). More so than any other group, these youngsters are clearly overrepresented in the emotional or behavioral disorders category (U.S. Department of Education, 2005b). Although the number of youth held in the juvenile justice system is small-less then 1 percent of all youths-more than half of them—58 percent—are diverse (CDF, 2004). In particular, the following data are most alarming: Although Black youths represent some 15 percent of all youths under age 18, they represent 26 percent of juvenile arrests, 31 percent of referrals to the court system, and 40 percent of those in residential placements. One reason for their disproportionate representation is that these students are three times more likely to be suspended from school (Townsend, 2000). Being suspended is part of a vicious cycle that compounds students' problems at school. Specifically, students who are suspended cannot participate in the academic learning opportunities at school. They also miss learning more about the norms of the school culture and the behavior expected there, because they are "on the streets" engaging in unsupervised activities. This situation then leads to lower academic achievement and higher probability of future misbehavior. All of these factors contribute to special education referrals. It is important that educators become more culturally sensitive and help students understand rules of conduct and what is considered appropriate behavior at school, in the neighborhood, and with authority figures (Cartledge, Kea, & Ida, 2000).

In recent years, school-based interventions have focused on building three-tiered models of positive behavior support (PBS) containing primary (schoolwide), secondary (more focused, often small groups), and tertiary (highly focused, individualized) levels of support. The goal of PBS is to meet all students' needs by providing progressively more intensive levels of support to ensure that all students know and are recognized for meeting the given expectations (Lewis & Sugai, 1999). PBS programs have been associated with decreases in office referrals, improved social interactions, and improved academic outcomes (Hunter & Chopra, 2001; Tolan, Gorman-Smith, & Henry, 2001). One important premise of such programs is prevention (Horner et al., 2001). The aim is to create a school culture where positive behavioral support, social skills instruction, and consistency serve as the foundation for direct intervention when it actually needs to be applied. All students are taught what behaviors teachers and the school community expect. They are also taught what they should expect from each other. Expectations are clear, concise, and simple (e.g., follow directions, be responsible, be safe, be prepared). For those who cannot meet these expectations, more focused intervention (e.g., secondary and tertiary levels) is provided (Lane, Wehby, Menzies, et al., 2003). In some cases, successful programs include intense and individualized consequences. Such programs apply functional behavioral assessments to determine the cause of the behavior and to help identify actions that -,ill effectively remediate extreme patterns of behavior. Some educators add a mentorship element, where successful secondary students with emotional or behavioral disorders help elementary students understand classroom expectations and how '0 act appropriately (Burrell et al., 2001).

It is well documented that early intervention can change patterns of behavior that eventually develop into long-term problems for both the individual and society (Bullis, Walker, & Sprague, 2001; Feil, Walker, & Severson, 1995; Strain & Timm, 1998; Walker & Sprague, 2000). Very young children who exhibit antisocial behavior, set fires, are cruel to animals, and are highly aggressive are most at risk for having serious externalizing behavioral disorders, and they are identified by elementary or middle school. The predictors of this outcome are now known, and structured and intensive preschool programs can in most cases provide the early intervention necessary to prevent disastrous results and reduce the need for disciplinary actions in the school setting.

However, even though knowledge exists about how to ::-educe or prevent some problems associated with emotional or behavioral disorders, the necessary actions are usually not taken. In a provocative commentary, Jim Kauffman (1999) points out that despite discussions about the importance of prevention efforts, actions in the last decade of the 20th Century did not keep pace. Possibly for fear of misidentifying children, public systems tend to provide intervention services too late, when the chance of success is reduced. Intervention must begin early and proceed deliberately. Clearly, for most children, particularly those at low risk, classroom interventions can be successful. However, Kauffman estimates that some 5 to 10 percent of students in general education may require intensive, intrusive, individualized help. But the way the education system is set up "prevents prevention." Here is how Jim Kauffman thinks it should work:

• Reward desirable behavior.
• Punish, through nonviolent means, undesirable behavior.
• Provide direct instruction for both social and academic skills.
• Correct the environmental conditions that foster deviant behavior.
• Give students clear expectations.
• Standardize responses to children across the entire school setting.
• Monitor students' behavior closely.

In addition to Kauffman's suggestions, other methods can prevent inappropriate behavior. Functional behavioral assessments can help teachers determine what events cause the behavior to occur and what other events contribute to the behavior's increase or maintenance (Tobin, Sugai, & Colvin, 1996). Many teachers use a less complicated system that employs the antecedent, behavior, and consequence events to target behavior for specific interventions.

What teachers do in school and classroom settings can make a real difference in reducing and preventing behavior problems for both those at risk for emotional or behavioral disorders and those already so identified (Kamps et al., 1999). Here's what works:

• Behavior Management. Include a point system for appropriate behavior and task completion, wherein good behavior is charted and students earn rewards.
• Systematic Intervention Plans. Use a hierarchy of tactics, depending on students' behavior.
• Home-School Communication. Include notes to the home and home-based reward systems.
• Peer Involvement. Have classmates remind each other of classroom expectations.
• Classroom Structure. Employ guided practice and well-organized transitions from activity to activity.
• Supervised Free Periods. Have adults monitor unstructured parts of the school day (recess, hall changes, lunch).
• Consistent Standards. Be sure all school staff members use the same standards for acceptable behavior and hold high expectations for academic performance.