Emotional and Behavioral Functioning

     a. Emotional Behavioral Disability and Social-Emotional LD

     b. Executive Function Disability

     c. Attention Deficit and Hyperactivity Disorder (ADHD)

 

Emotional Behavioral Disability and Social-Emotional LD

 

Diagnostic Features

An Emotional Behavioral Disability (EBD) is a condition that, over a long period of time and to a marked degree, consistently interferes with a student's learning process and adversely affects the student's educational performance.

 

There are students with an LD for whom social and emotional skills are an area of strength and who are able to negotiate challenges without needed support.  However, there are also students with an LD who struggle with academic learning, and have trouble with “skills needed for social interaction.” Hence, the diagnosis of Social-Emotional LD.

 

The U.S. federal regulations define an emotional disturbance as a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects 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; or

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

Some of the characteristics and behaviors seen in children who have an emotional disturbance include:

  • Hyperactivity (short attention span, impulsiveness).

  • Aggression/self-injurious behavior (acting out, fighting).

  • Withdrawal (failure to initiate interaction with others; retreat from exchanges of social interaction, excessive fear or anxiety).

  • Immaturity (inappropriate crying, temper tantrums, poor coping skills); and

  • Learning difficulties (academically performing below grade level). 

Assessment

The process of identification should be accomplished by systematic screenings at regular intervals to identify specific academic, behavioral, or developmental needs through school-wide achievement, health and sensory testing. See ref.: Public schools of North Carolina.

 

Differential Diagnosis

The degree of Emotional Behavioral Disability should be differentiated, with the more severe ones characterized by serious impairment in social and academic functioning.  Students with the most serious EBD may exhibit distorted thinking, unusual motor acts, excess anxiety or mood swings (e.g., bipolar disorders). Some persons with severe EBD could have psychosis or schizophrenia.

 

A person with an emotional disability has symptoms that are mild to moderate. Mild to moderate symptoms can be present when the person is able to function with some assistance in school, home and with peers.  In addition, anxiety, depression, and behavioral problems can be mediated by medication, behavior therapy or counseling as needed.

 

Intervention and Strategies

A Cognitive-Behavioral approach is frequently seen as useful in shaping behaviours that are more acceptable to social settings and that are prerequisites to academic learning in the classroom. This technique can be utilized to help individuals develop the ability to pay attention, follow directions, and carry through assignments.  Other techniques that are found to be useful include medical, nutritional, and non-directive, or analytical approaches.

 

Etiology

The causes of emotional disturbance can be exogenous or endogenous in origins.  Possible exogenous factors include family functioning, being bullied in school or experiencing stress, while endogenous factors include heredity factors and brain disorders.

 

References

Jordan D. R.  (2000).  Understanding and managing learning disabilities in adults.  Malabar: FL. Krieger Publishing Company. 

 

Public schools of North Carolina. Screening and evaluation for serious emotional disability. http://www.ncpublicschools.org/ec/supportprograms/resources/screening/

 

 

Executive Functions Disability

 

Diagnostic Features

Impairment in executive functions (EF) impact on a person’s mental processes which enable him or her to plan ahead, evaluate the past, start and finish a task and manage time. Executive functions can affect what he or she does in the present and also how she or he plans and organizes for the future. These skills affect one’s ability to access and juggle many thinking skills at the same time.  This function of the brain organizes the other functions, and tells the brain what to do, and how and when to work together.  Overall, executive function refers to the ability to do all it takes to keep the mind focused in order to execute specific tasks.  

 

A person with an impairment in EF could be lacking some of the following abilities:

  • Focusing, maintaining and shifting attention: e.g., getting stuck on a thought.

  • Engaging in mental planning (e.g., future events) and problem-solving. 

  • Regulating alertness, sustaining effort and processing speed: e.g., fine-motor skills being affected

  • Activation: organizing materials, prioritizing and getting started on tasks. 

  • Managing and regulating emotions: e.g., low tolerance for frustration and overly sensitive to criticism.   

  • Time management: e.g., estimating the time needed to complete tasks.   

  • Using memory and accessing recall: e.g., having trouble remembering and following directions.

 

Differential diagnosis

Executive functions difficulties are often reflected in other primary difficulties, such as learning problems that are not readily diagnosed.  Executive functions also play a role in social behavior.  In addition, executive function deficits are associated with a number of medical, psychiatric and developmental disorders, including obsessive-compulsive disorder, schizophrenia, attention-deficit/hyperactivity disorder, and autism. Chronic heavy users of drugs and alcohol show impairments on tests of executive function. Some of these deficits appear to result from heavy substance use, but there is also evidence suggesting that problems with executive functions may contribute to the development of substance use disorders. People with frontal lobe injuries also have difficulties with the higher level processing that underlies executive functions. Finally, some executive functions appear to decline with age.

 

Assessment

Many of the tests used to measure other abilities, particularly tests that look at more complex aspects of these abilities, can be used to evaluate executive functions.  For example, a person with executive function deficits may perform well on tests of basic attention, such as those that simply ask the individual to look at a computer screen and respond when a particular shape appears, but they may have trouble with tasks that require divided or alternating attention, such as when giving a different response depending on the stimulus presented. Verbal fluency tests that ask people to say a number of words in a certain period of time can also reveal problems with executive function. One commonly used test asks individuals to name as many animals or as many words beginning with a particular letter as they can in one minute.

 

Executive functions also influence memory abilities by allowing people to employ strategies that can help them remember information. Standardized tests that are designed to assess cognitive function more directly include the Behavior Rating Inventory of Executive Function (BRIEF), the Delis-Kaplan Executive Function System, Trail Making Test (TMT), the Wisconsin Card Sorting Test, and the Stroop Test. 

 

Etiology

Both frontal lobes oversee thinking, problem-solving, and creativity. The executive in charge of all this community activity is the prefrontal cortex “upstairs” in the higher brain. The power station that regulates flow of energy, emotional surges, and the community alarm system is housed “downstairs” in the limbic system.  Like all successful communities, brain activity must stay organized, correctly synchronized, well-maintained though good heath, and protected from threatening events. All of this is accomplished through collaboration between the executive functions of the prefrontal cortex and the filtering, regulatory work of the limbic system.  

 

Interventions/Strategies

Phillips Keeley’s book, the source for executive functions disorders, offers a number of strategies for persons with executive functions difficulties.  For example, there are strategies listed for managing materials (e.g., establishing a daily routine for school organization that includes a version of it in a workbook), managing space (e.g., having separate work areas with complete sets of supplies for different activities), managing time (e.g., breaking long assignments into chunks with frames for completing each chunk), and managing work (e.g., identifying strategies that would help a person start and finish projects). 

 

There is software to help persons with executive functions.  For instance, Brain Builder, Sound Smart, The Deciders, and Locus-Tour Multimedia, as well as Audiblox, Brain Gym, and Brain Skills.  Audiblox is a multisensory cognitive enhancement program to develop foundational learning skills such as concentration, perception, memory, and logical thinking. It claims to improve performance in reading, spelling, writing and math by systematically creating a “pyramid of repetition.

 

References

Phillips Keeley, Susanne.  (2003).  The source for executive functions disorders. East Moline: IL. LinguiSystem.

 

Dawson, P& Guare, R.  (2009). Smart but Scattered.  New York: NY. The Guilford Press. 

 

Dawson, P& Guare, R.  (2009).  Executive skills in children and adolescents: A practical guide to assessment and intervention (2nd Ed.)  New York: NY. The Guilford Press. 

 

 

Attention Deficit and Hyperactivity Disorder (ADHD)

 

Diagnostic Features

ADHD is characterized by a persistent pattern of attentional difficulties and/or hyperactive and impulsive behavior that is more severe than is typically seen in other people of the same age.

 

The symptom categories of ADHD in children yield three potential classifications of ADHD—predominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met. 

 

Predominantly inattentive type symptoms may include: 

  • Being easily distracted, missing details, forgetting things, and frequently switching from one activity to another.

  • Having difficulty focusing on one thing.

  • Becoming bored with a task after only a few minutes, unless doing something enjoyable.

  • Having difficulty focusing attention on organizing and completing a task or learning something new.

  • Having trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities.

  • Not seeming to listen when spoken to.

  • Daydreaming, becoming easily confused, and moving slowly.

  • Having difficulty processing information as quickly and accurately as others.

  • Struggling to follow instructions.

 

Predominantly hyperactive-impulsive type symptoms may include:

  • Fidgeting and squirming while seated

  • Talking nonstop

  • Dashing around, touching or playing with anything and everything in sight

  • Having trouble sitting still during dinner, school, and story time

  • Being constantly in motion

  • Having difficulty doing quiet tasks or activities.

 

Manifestations primarily of impulsivity include:  

  • Being very impatient.

  • Blurting out inappropriate comments, showing emotion without restraint, and acting without regard for consequences.

  • Having difficulty waiting for things one wants or waiting one's turn during games.

 

Symptoms of ADHD can entail long-term effects on academic performance, vocational success, and emotional-social development. Also, persons with ADHD have functional impairment across multiple settings, including home, school, and peer-relationships.

 

Prognosis

For most children with ADHD, symptoms begin before the age of seven and last through adolescence. And for many teens and/or adults, the impact of ADHD continues into adulthood.  However, the proportion of children meeting the diagnostic criteria for ADHD drops by about 50% over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD.  These persons affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD. 

 

Those with ADHD as children are at increased risk of a number of adverse life outcomes once they become teenagers. These include a greater risk of auto accidents, injuries, earlier sexual activity, and teen pregnancy. Persons with ADHD can self-medicate themselves and become drug abusers. They may also display antisocial behavior. 

 

Differential Diagnosis

Many other conditions and situations can trigger behavior that resembles ADHD.  It is estimated that one third of children with ADHD have one or more coexisting conditions.  For example, a child might show ADHD symptoms when experiencing:

  • A death or divorce in the family, a parent’s job loss, or other sudden change.

  • Undetected seizures (epilepsy). 

  • An ear infection that causes temporary hearing problems.

  • Problems with schoolwork caused by a learning disability.

  • Anxiety or depression. 

  • Insufficient or poor quality sleep.

  • Hyperthyroidism, lead poisoning, anemia, cluttering (Tachyphemia).

  • Family dysfunction and child abuse.

 

Etiology

A genetic predisposition has been demonstrated in (identical) twin and sibling studies.  If one identical twin is diagnosed with ADHD, there is at 92% probability of diagnosis with the twin sibling. When comparing nonidentical twin sibling subjects, the probability falls to 33%.  There are at least 20 candidate genes that might contribute to ADHD, but no single gene stands out as the gene causing the condition.

 

Approximately 9% to 20% of the variance in hyperactive-impulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared environmental (nongenetic) factors.  These include poor maternal nutrition, viral infections, or maternal substance abuse. In early childhood, exposure to lead or other toxins can cause ADHD-like symptoms. Traumatic brain injury or neurological disorders may also trigger ADHD symptoms.

 

Management-Interventions

Methods of treatment often involve some combination of behavior modification, life-style changes, counseling, and medication.

 

Behavior Therapy: This refers to techniques that are geared to improving behavior, usually by rewarding and encouraging desirable behavior and by discouraging unwanted behavior and pointing out the consequences.

 

Cognitive Therapy: This is psychotherapy designed to help a child change thinking patterns so that he or she can build self-esteem, stop having negative thoughts and improve problem-solving skills.

 

Social Skill Training: This refers to improving social skills to help children with ADHD make and keep friends.

 

Medication:  Medications used in the treatment of ADHD are psycho-stimulants.

 

Complementary and alternative medicine:  Such therapies can benefit ADHD persons. These include diet, omega-3 supplementation, and acupuncture or biofeedback that helps relieve stress.

 

References

Barkley, R. (1990). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.  New York, NY: Guilford Press.  

 

Barkley, R. (1995). Taking Charge of ADHD: The Complete, Authoritative Guide for Parents.  New York, NY:  Guilford Press.