Transcript Slide 1

EDDT/EDDT-PF
Effective Assessment of Emotional
Disturbance
1
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
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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)
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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)
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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)
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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
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“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)
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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 selfworth, 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)
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Summary of the Major Risk Factors Associated With Conduct Disorder
• Dispositional risk factors
Contextual risk factors
• Neurochemical abnormalities
Pre-natal exposure to toxins
• Autonomic irregularity
Early exposure to poor quality
child care
• Birth complications
Parental psychopathology
• Difficult child temperament
Family conflict
• Impulsivity
Inadequate parental
supervision and discipline
• Preference for dangerous and
Lack of parental involvement
and novel activities
and neglect
• Reward dominant response style
Peer rejection
• Low verbal intelligence
Association with a deviant
peer group
• Academic underachievement
Impoverished living conditions
• Deficits in processing social info
Exposure to violence
Frick (2004)
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Developmental Pathways
• 1. Childhood Onset – high CU
• 2. Childhood Onset – low CU
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3. Adolescent Onset
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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)
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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)
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ED: Internalizing,
depressed,
anxious
SM:
Externalizing,
callous and
unemotional,
psychopathy
ED: Externalizing,
emotional and not
calloused,
affectively
disregulated,
emotionally
overreactive
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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
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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,
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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 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 takes 1520 minutes to
complete and 15
minutes to score.
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
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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.
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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, Hearingvision, Health, Duration Checklist)
II. Emotional Disturbance Characteristics
III.Social Maladjustment (SM) Cluster
IV.Level of Severity (SEVERITY) Cluster
V. Educational Impact (IMPACT) Cluster
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IDEA criteria
Over a long period of time
EDDT Scale/Cluster
Potential Exclusionary Items
To a marked degree
Level of Severity (SEVERITY) cluster
Adversely affect’s a child’s educational
performance
Educational Impact (IMPACT) cluster
An inability to learn that cannot be explained
by intellectual, sensory, or health factors
Potential Exclusionary Items
An inability to build or maintain satisfactory
interpersonal relationships with peers and
teachers
Inability to Build or Maintain
Relationships (REL) scale
Inappropriate types of behavior or feelings
under normal circumstances
Inappropriate Behaviors or Feelings
(IBF) scale
A general pervasive mood of unhappiness or
depression
Pervasive Mood/Depression
(PM/DEP) scale
A tendency to develop physical symptoms or
fears associated with personal
or school problems
Physical Symptoms or Fears
(FEARS) scale
The term includes schizophrenia
Possible Psychosis/Schizophrenia
(PSYCHOSIS) cluster
The term does not apply to children who are
socially maladjusted, unless it is determined
that they have an emotional disturbance
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
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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
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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
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of desirable classroom activity like persistence, leadership
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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
EDDT
EDDTPF
.88
.88
Inappropriate Behaviors or Feelings
scale (IBF)
.83
.92
Pervasive Mood/Depression scale
(PM/DEP)
.81
.87
Physical Symptoms or Fears scale
(FEARS)
.75
.86
EDDT Total scale (TOTAL)
.94
.96
Scale
Inability to Build or Maintain
Relationships scale (REL)
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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
EDDTPF
.93
.83
.90
.89
.91
.70
.87
.88
.91
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EDDT: Group differences between the
Normative and ED sample
ED Scale
Norm
ED
Cluster
(raw score)
Norm
ED
REL
50.79
81.90
SM
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
RES
49.96 68.32
50.32 75.50
Cluster
(raw score)
ADHD
12.18 29.80
IBF
PM/DEP
49.82 74.61
FEARS
50.45 71.21
TOTAL
49.53 77.37
POSSIBLE
PSYCHOSIS
SM
2.63 12.44
SEVERITY
1.27
MOTIVATION
5.65 22.74
8.99
21.32 17.53
Percentage of Normative and ED Sample Scoring
Within Clinically Relevant T-Score Ranges
Scales
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
73.5 4.2
9.7 2.2
9.0 10.9
6.0 15.8
1.8 66.8
71.2 2.7
11.5 3.7
11.3 14.4
4.0 22.3
2.0 56.9
71.9 4.2
10.5 5.2
12.1 18.1
4.3 22.3
1.2 50.2
72.0 1.0
10.1 1.2
10.8 9.9
5.3 18.1
1.5 69.6
REL
IBF
PM/DEP
FEARS
TOTAL
Standardization = GOLD
ED Group = WHITE
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Case Study: Edison
Background
• 13-year-old male, 7th 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
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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
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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
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Treatment
Frick (2004)
Developmental Pathways
• 1. Childhood Onset, high callous and
unemotional (CU)
• Increase empathetic concern
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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.
55
Treatment
Kazdin (1998)
Socially Maladjusted:
Cognitive Problem-Solving Training
Parent Management Training
Functional Family Therapy
Multisystematic Therapy
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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
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