Chapter 8: Emotional and Behavior Disorders

For the purpose of special education, IDEA classifies all emotional and behavior disorders under the category of emotional disturbance. While students with other disabilities may also exhibit the behaviors listed in the definition, for students with an emotional disturbance these difficulties are the primary indicators of their disability, are present to a degree that is markedly discrepant from their peers, and are present for a significant length of time (NASET, 2024).

Emotional disturbance is not one specific disability, but rather a catch-all category for a number of mental health and behavior disorders including anxiety, depression, eating disorders, obsessive-compulsive disorder (OCD), and conduct disorders (CPIR, 2024). Emotional disturbance may also be comorbid with other conditions. Students with emotional disturbance exhibit thoughts, feelings, and behaviors that are poorly regulated and extreme in magnitude as compared to their typical same-age peers (NASET, 2024).

The IDEA definition of Emotional Disturbance is:

(4)(i) Emotional disturbance means a condition exhibiting one or more of the following characteristics over a long period of time and 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 interpersonal 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.

(4)(ii) Emotional disturbance includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance under paragraph (c)(4)(i) of this section (IDEA, 2007) .

There is some debate around the wording used by IDEA to describe this disorder. One area of disagreement is in regard to the title of the category itself. Many parents and teachers object to the use of the word “disturbance” in the name of this category. They would prefer that the term “emotional or behavior disorder” be used instead. While this change has been proposed several times, it has not yet been adopted (NASET, 2024).

Definition of Emotional Disturbance

To qualify for special education under the category of emotional disturbance, a student must have at least one of the five characteristics listed in the definition: an inability to learn not explained by other factors, a lack of satisfactory relationships, inappropriate behavior or feelings, general unhappiness or depression, and physical symptoms or fears around personal or school problems. These characteristics must have been present for a long period of time, which is generally interpreted to mean at least six months, must be displayed across settings, and must be significant enough that it is apparent to others including school staff. These characteristics must also be displayed with greater frequency, duration, and/or intensity than is generally seen in typical same-age peers (NASET, 2024).

The characteristics of the emotional disturbance must also be manifested to such an extent that they interfere with the learner’s educational achievement. This means that the student’s educational performance is not just below what might be considered an optimal level, it is markedly below a level which could be reasonably expected. When an emotional disturbance is suspected, academic indicators that should be considered include daily classroom performance as well as performance on course assessments, past and current grades, and standardized test scores. Any evaluation for emotional disturbance should also consider the student’s home situation and any recent stresses that may have come into the child’s life (NASET, 2024).

Documentation should take into account the student's ability to initiate and maintain friendships and to engage in positive relationships with teachers, peers, and others. For example, the student may react with aggression when others initiate social interactions. The student may display a lack of emotion or unusual emotions compared to peers in similar situations. The student may constantly vie for attention or may withdraw from social interaction all together. Students with emotional disturbance may also make threats of harm toward people or animals, have a low frustration tolerance, be impulsive, seek out fights, have difficulty regulating emotions, and exhibit rapid changes in mood or behavior, all of which can impact one’s ability to build relationships (NASET, 2024).

Students with emotional disturbance may also have characteristics of depression and general unhappiness. These characteristics may include low self-esteem, feeling sad, hopeless or helpless, feeling inadequate, or having excessive guilt or suicidal thoughts. These students may also develop physical symptoms such as headaches, stomach aches, panic attacks, and anxiety associated with school situations or personal problems. It must be noted again that to be considered an emotional disturbance, these symptoms must negatively impact learning (NASET, 2024).

It is interesting that schizophrenia is specifically mentioned in the IDEA definition of emotional disturbance. While schizophrenia is a very disabling mental disorder, childhood schizophrenia is very rare, only affecting about 1 in 40,000 children (Gochman et al., 2011). Typical symptoms of schizophrenia include delusions, hallucinations, and disordered thinking. The child may confuse dreams or stories with reality, have strange fears, and engage in bizarre behavior. However, schizophrenia does not mean that the child has multiple personalities (Mayo Clinic, 2021; NASET, 2024).

The definition of emotional disturbance also specifically excludes those who are socially maladjusted, unless they are also found to have an emotional disturbance. The inclusion of this phrase in the IDEA definition is another major cause for criticism and debate. While there is no definition of social maladjustment in the statute, it is generally considered to refer to students who are capable of following the rules and social norms, but who consciously choose to break them. Students who are socially maladjusted purposefully engage in delinquent, destructive, and antisocial behavior (Office of Special Education, 2015). In contrast, students with emotional disturbance do not purposefully choose to break the rules but do so as a result of their disability (NASET, 2024).

Causes of Emotional Disturbance

No specific causes have been identified for emotional disturbance. Although extensive research has been done on potential factors such as heredity, stress, family dysfunction, diet, and brain disorders, researchers have not found a direct link between any of these factors and emotional disturbance. (Division for Emotional & Behavioral Health, 2020; CPIR, 2024; NASET, 2024). Also, as noted in the IDEA definition, an emotional disturbance results in learning struggles which are not primarily related to intellectual, sensory, or health causes (IDEA, 2017).

Even though researchers have not identified specific causes of emotional disturbance, they have recognized protective and risk factors that can influence the development and severity of mental health disorders in school age children. It should be noted that risk factors are not causes. Rather, they are individual, family, or community characteristics that have been associated with a higher likelihood of a specific outcome. In the same way, protective factors are individual, family, or community characteristics that are associated with a lower likelihood of a particular outcome or that reduce the impact of a risk factor on a given outcome (Youth.gov, 2024).

Even though risk factors are not causes, it is important for educators to be aware of potential risk and protective factors. Risk factors for anxiety are low self-esteem, shyness, school failure, and a history of aggression toward peers. Family risk factors for anxiety include family conflict, parental drug or alcohol abuse, and parental unemployment. Community-based risk factors are limited community investment in the schools and community norms that favor drug and alcohol use (Youth.gov, 2024)

Individual risk factors for depression include early puberty, inflexibility, low self-esteem, insecure attachment, and poor social, communication, and problem-solving skills. Family risk factors include parental depression and anxiety, poor parenting, negative family environment, and child abuse. School and community based risk factors include peer rejection, poor academic achievement, poverty, community or school violence, and traumatic events occurring in the school or community (Youth.gov, 2024)

An individual risk factor specific to behavior disorders is exposure to neurotoxins such as lead or mercury. Family risk factors specific to behavior disorders include poor parental supervision, parental depression, and child abuse. Community, neighborhood, and school-based factors include associating with deviant peers, the loss of a close relationship, and the loss of close friends (Youth.gov, 2024).

Protective factors for emotional disturbance are characteristics that are associated with a lower likelihood of the child developing an emotional or behavior disorder or that reduce the impact of a risk factor on that potential outcome. Individual protective factors include positive academic, intellectual, and physical development, high self-esteem, good coping and problem-solving skills, and the ability to self-regulate emotions. Additionally, individuals who develop connections and engagement in two or more contexts are less likely to develop an emotional or behavior disorder. These contexts include school, athletics, employment, peers, religion, and cultural connections (Youth.gov, 2024)

Families can put protective factors in place by providing structure, limits, and predictability. Ensuring that expectations for behavior and values are clear and that compliance with rules is monitored are also protective factors. In addition, fostering supportive relationships amongst family members was associated with lower incidence of emotional and behavior disorders. Protective community factors include opportunities for engagement within the school and the community, positive school and community norms, clear expectations for behavior, and an environment that provides both physical and psychological safety. The opportunity for youth to connect with mentors who can support them in developing their skills and interests also provides a protective factor against emotional and behavior disorders (Youth.gov, 2024).

Prevalence of Emotional Disturbance

The percentage of school-age children identified with emotional disturbance has held steady for the past decade at between 5 and 6 percent. Students with emotional disturbance are twice as likely to drop out of school as students with other disabilities. They are also less likely than students with other disabilities to be included in general education for 80% or more of the school day and more likely to be educated in a separate school setting. In addition, students with emotional disturbance receive more disciplinary removals such as suspension and expulsion than student with other disabilities (Office of Special Education Programs, 2020).

There are more males than females in all the major disability groups; however, one of the largest disparities is in the category of emotional disturbance where males outnumber females 4:1. (Office of Special Education Programs, 2020; NASET, 2024). One theory for this disparity is that girls with emotional disturbance are more likely to have internalizing behaviors and boys with emotional disturbance are more likely to have externalizing behaviors. Therefore, since externalizing behaviors are more disruptive to the learning of other students, males are more likely to be referred for an evaluation and consequently identified as having the disability (NASET, 2024).

Most students who receive special education under the emotional disturbance classification are between 12 and 17 years of age. Rarely are students in this category identified before they enter school nor are they likely to receive early intervention. As mentioned earlier, many parents and teachers are put off by the name of this category, which may lead to students with emotional and behavior disorders being referred later than students in other disability categories (NASET, 2024).

Student Characteristics

Most children will occasionally act out, get in fights, or have anxiety. For the child with an emotional disturbance, the difference is that these behaviors occur with a frequency, duration, and/or magnitude that is very discrepant from typical peers. Common characteristics of children with emotional disturbance include one or more of the following: hyperactivity, impulsivity, aggression towards themselves or others, anxiety, social withdrawal, and immature behavior. Students with emotional disturbance are also likely to have learning struggles and be performing below grade level academically, despite not having an intellectual or learning disability. Students with more severe emotional impairments may also exhibit abnormal mood swings and extremely distorted thinking (CPIR, 2024).

As mentioned earlier, the characteristics exhibited by children with emotional disturbance can be categorized as either internalizing or externalizing behaviors. Some children with emotional disturbance will have mainly internalizing symptoms and other will have mainly externalizing symptoms, but many of the children will exhibit both of these types of behavior. Internalizing behaviors are less obvious to the casual observer and therefore harder to detect. These behaviors are mainly directed towards the self and include depression, anxiety, sadness, loneliness, and social withdrawal. As has been mentioned, girls with emotional disturbance may be more likely to display internalizing behaviors and therefore be under identified. Externalizing behaviors are harder to ignore and are more outward directed. These include aggression, acting out, destruction of property and other disruptive behaviors. If boys are more likely to display externalizing behaviors, this could be the reason that the majority of children identified with emotional disturbance are male (NASET, 2024).

Common Types of Emotional Disturbance

According to the American Psychiatric Association (APA), anxiety disorders are the most common mental health disorder (APA, 2023). Approximately 7% of school-age children have been diagnosed with anxiety and nearly 30% of adults will be affected by an anxiety disorder at some point in their lives (APA, 2023; CDC, 2023). Anxiety is a feeling of fear or worry about something that could happen in the future. Fear and anxiety are common emotions and under normal circumstances they can be beneficial to us. They can motivate us to be prepared for an upcoming event. They can also help us pay attention and be alert to potential dangers. Anxiety moves beyond the ordinary and becomes a disorder when these emotions are out of proportion to the situation or negatively affect our ability to complete daily tasks and comply with typical expectations. People with anxiety disorders will go to great lengths to avoid or escape situations that may cause them anxiety. Unfortunately, these avoidance behaviors can negatively impact academic learning, social relationships, and job performance (APA, 2023)

While the situations and reasoning behind the anxiety are typically irrational, just telling oneself not to be anxious is not an effective remedy. A child with anxiety cannot simply reason away their anxiety on the basis that it is not logical. Some common examples of anxiety disorders include feeling extremely fearful when separated from one’s parents, being anxious in social situations, being fearful of specific circumstances such as being in confined spaces or around specific things such as spiders or germs, being worried about bad things happening in the future, and repeated experiences of sudden, unexpected, intense panic. Obsessive-Compulsive Disorder (OCD), which is characterized by recurring obsessive thoughts and compulsive repetitive behaviors, is also an anxiety disorder. Children with anxiety may not feel comfortable sharing their fears and, instead, may internalize their worries. However, these children will often display physical symptoms of this internal distress such as headaches, stomachaches, and irritability (CDC, 2023).

Depression is another common mental health disorder. Rates of both anxiety and depression have increased in children over the past 10 years. Recent statistics show that just over 3% of school-age children have been diagnosed with depression and more than 70% of those with depression have also been diagnosed with anxiety. Rates of both depression and anxiety in children and teens increase as age increases and are much higher in secondary students than in elementary aged students (CDC, 2023). While times of sadness and even hopelessness occur as a normal part of growing up, when sadness or hopelessness persists over an extended period of time, the child may have depression. Other symptoms of depression include changes in eating or sleeping patterns, changes in energy levels, increased irritability, and episodes of self-injurious behavior. Extreme depression can even result in suicidal thinking. Suicide is one of the leading causes of death in young people ages 10-24 (CDC, 2023).

Eating disorders have, unfortunately, also become more common, particularly in teens. The prevalence of eating disorders among adolescents ages 14 to 18 is 2.7%. More than twice as many females (3.8%) in this age group have eating disorders as males (1.5%), with prevalence in both groups increasing with age. Anorexia nervosa, bulimia nervosa, and binge eating are all classified as eating disorders (Eating Disorder Hope, 2021). Anorexia nervosa is an extreme restriction of caloric intake resulting in a drastic, unhealthy amount of weight loss. Bulimia nervosa is characterized by a cycle of excessive eating followed by self-induced vomiting or purging. Both anorexia nervosa and bulimia nervosa are potentially life-threatening conditions. Binge eating also involves compulsive eating of excessive amounts of food, but it is not typically followed by vomiting or purging (CPIR, 2024).

Behavior disorders also fall into the category of emotional disturbance. More than 7% of children between 3 and 17 years of age have been diagnosed with a behavior disorder. Of these, 36% also have anxiety and 20% also have depression. The prevalence of behavior disorders is highest in children between 6 and 11 years of age (CDC, 2023). Children with behavior disorders may behave aggressively toward people or animals, destroy property, lie, steal, run away, skip school, and otherwise violate the accepted of rules of society (CPIR, 2024).

Behavior disorders include conduct disorder and oppositional defiant disorder. Conduct disorder is indicated when a child demonstrates a regular pattern of significant rule violation such as staying out all night without permission, skipping school, and breaking the law. It also includes bullying as well as aggressive acts that cause harm to other people or to animals. Children with oppositional defiant disorder (ODD) are often angry, lose their temper, argue with adults, and are noncompliant. They may deliberately annoy other people and often blame others for their own mistakes or for their own poor behavior. These oppositional or defiant behaviors are usually evident by the time the child is 8 years old and, by definition, these characteristics must be evident before a child reaches 12 years of age. Children with ODD are more likely to engage in oppositional or defiant behaviors with those they know well such as teachers and family members (CDC, 2023).

Educational Implications

Students with emotional disturbance generally perform significantly below expectations academically and are twice as likely to drop out of school as students with other disabilities. They are also more likely to be educated in more restrictive settings (OSEP, 2020; NASET, 2024). However, schools can provide interventions and supports which address these concerns and contribute to the protective factors known to reduce the risk for emotional and behavior disorders. Providing good academic instruction is a good place to begin as positive academic achievement is a protective factor. Students can also be taught strategies for self-regulation, problem-solving, and coping skills. To foster engagement and connections, students can be encouraged to participate in extracurricular activities in school and in community and faith-based activities outside of school (Kern et al., 2016; NASET, 2024; Youth.gov, 2024).

Schoolwide positive behavior support is a school-based program that can have protective effects for students at risk for emotional or behavior disorders. A positive behavior support approach emphasizes the importance of teaching behavior expectations across school settings and having those expectations be consistently upheld and reinforced by all staff throughout the school. In addition to teaching the school rules, teachers are expected to increase structure and predictability in the classroom setting by establishing consistent classroom routines and expectations. These factors are all part of establishing a positive school environment that promotes connectedness. Other aspects of a positive school atmosphere include supportive and caring teachers, clean and pleasant conditions, positive relationships among staff and students, and consistent, positive classroom management (Kern et al., 2016; NASET, 2024; Youth.gov, 2024).

Students come to school with varying levels of risk for emotional disturbance, but teachers play an important protective role in reducing the impact of those risks. Teachers are critical to developing the positive, nurturing relationships with their students that encourage connectedness. Schoolwide positive behavior support is a framework that can also enhance connectedness, reduce risk, and promote protective factors. In addition, consistent classroom management and effective instruction improve protective factors that contribute to student success. When more serious emotional or behavior problems occur, teachers must work in coordination with mental health professionals to provide the individualized supports the student needs (Kern et al., 2016; NASET, 2024).

Chapter 8: Sources

American Psychiatric Association. (2023, June). What are anxiety disorders? https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders