# data[].attributes.attachment_link.readable_text
Links updated, November 2021
This information in Spanish

The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years. ( 1)

We refer to mental disorders using different "umbrella" terms such as emotional disturbance, behavioral disorders, or mental illness. Beneath these umbrella terms, there is actually a wide range of specific conditions that differ from one another in their characteristics and treatment. These include (but are not limited to):

anxiety disorders;

bipolar disorder (sometimes called manic-depression);

conduct disorders;

eating disorders;

obsessive-compulsive disorder (OCD); and

psychotic disorders.

You may be reading this fact sheet with one of these specific disorders in mind, or you may be looking for information about emotional disturbances in general. In either case, keep reading to find out what different emotional distubances have in common, how they are defined in federal law, and where to find more detailed information on specific disorders.
Quick-Jump Menu
Definition
IDEA defines emotional disturbance as follows:
We've chosen to use the term "emotional disturbance" in this fact sheet because that is the term used in the nation's special education law, the Individuals with Disabilities Education Act (IDEA).

"...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." ( 2)

As defined by IDEA, emotional disturbance includes schizophrenia but does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance. ( 3)

Characteristics

As is evident in IDEA's definition, emotional disturbances can affect an individual in areas beyond the emotional. Depending on the specific mental disorder involved, a person's physical, social, or cognitive skills may also be affected. The National Alliance on Mental Illness of Southern Arizona puts this very well:

Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. ( 4)

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

Hyperactivity (short attention span, impulsiveness);

Aggression or self-injurious behavior (acting out, fighting);

Withdrawal (not interacting socially with others, excessive fear or anxiety);

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

Learning difficulties (academically performing below grade level).

Children with the most serious emotional disturbances may exhibit distorted thinking, excessive anxiety, bizarre motor acts, and abnormal mood swings.

Many children who do not have emotional disturbance may display some of these same behaviors at various times during their development. However, when children have an emotional disturbance, these behaviors continue over long periods of time. Their behavior signals that they are not coping with their environment or peers.

Causes

No one knows the actual cause or causes of emotional disturbance, although several factors-heredity, brain disorder, diet, stress, and family functioning-have been suggested and vigorously researched. A great deal of research goes on every day, but to date, researchers have not found that any of these factors are the direct cause of behavioral or emotional problems.

According to NAMI, mental illnesses can affect persons of any age, race, religion, or income. Further:

Mental illnesses are not the result of personal weakness, lack of character, or poor upbringing. Mental illnesses are treatable. Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan. ( 5)

Frequency

Of the 74.5 million children in the United States, an estimated 17.1 million have or have had a psychiatric disorder. ( 6) Half of all psychiatric illness occurs before the age of 14, and 75% by the age of 24. The most common psychiatric disorders in childhood are anxiety disorders, AD/HD and disruptive behavior, depression and bipolar disorders, and eating disorders. ( 7)

Help for School-Aged Children

IDEA requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child's individual needs associated with the disability-in this case, emotional disturbance, as defined by IDEA (and further specified by states). In the 2016 school year, more than 349,000 children and youth with emotional disturbance received these services to address their individual needs related to emotional disturbance. ( 8)

Determining a child's eligibility for special education and related services begins with a full and individual evaluation of the child. Under IDEA, this evaluation is provided free of charge in public schools.
10 Basic Steps in Special Education Questions Often Asked by Parents about Special Education Services Evaluating Children for Disability Developing Your Child's IEP
There is a lot to know about the special education process, much of which you can learn here on the CPIR site. We invite you to read the wide range of publications we offer on the topic, especially:

A Look at Specific Emotional Disturbances

As we mentioned, emotional disturbance is a commonly used umbrella term for a number of different mental disorders. Let's take a brief look at some of the most common of these.

We all experience anxiety from time to time, but for many people, including children, anxiety can be excessive, persistent, seemingly uncontrollable, and overwhelming. An irrational fear of everyday situations may be involved. This high level of anxiety is a definite warning sign that a person may have an anxiety disorder.

The term "anxiety disorder" is a broad term covering several different disabilities that share the core symptom of irrational fear. These include such different disorders as generalized anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder (also called social phobia), and specific phobias. ( 9)

According to the Anxiety Disorders Association of America, anxiety disorders are the most common psychiatric illnesses affecting children and adults. ( 10) They are also highly treatable. Unfortunately, only about 36.9% of those affected receive treatment. ( 11)

Also known as manic-depressive illness, bipolar disorder is a serious medical condition that causes dramatic mood swings from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. ( 12)

For most people with bipolar disorder, these mood swings and related symptoms can be stabilized over time using an approach that combines medication and psychosocial treatment. ( 13)

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. ( 14) This may include some of the following behaviors:

aggression to people and animals;

destruction of property;

deceitfulness, lying, or stealing; or

truancy or other serious violations of rules. (15)

Treatment will depend on the child's symptoms, age, and general health. It will also depend on how severe the condition is. Treatment may include:

helping the child learn how to better solve problems, communicate, and handle stress, as well as how to control impulses and anger (what's known as cognitive-behavioral therapy);

family therapy;

peer group therapy (to help better social and interpersonal skills); and

medications (although these are not typically used to treat conduct disorder). (16)

Eating disorders are characterized by extremes in eating behavior-either too much or too little-or feelings of extreme distress or concern about body weight or shape. Females are much more likely than males to develop an eating disorder. ( 17)

Anorexia nervosa and bulimia nervosa are the two most common types of eating disorders. Anorexia nervosa is characterized by self-starvation and dramatic loss of weight. Bulimia nervosa involves a cycle of binge eating, then self-induced vomiting or purging. Both of these disorders are potentially life-threatening. ( 18)

Binge eating is also considered an eating disorder. It's characterized by eating excessive amounts of food, while feeling unable to control how much or what is eaten. Unlike with bulimia, people who binge eat usually do not purge afterward by vomiting or using laxatives. ( 19)

According to the National Eating Disorders Association:

Treating an eating disorder generally involves a combination of psychological and nutritional counseling, along with medical and psychiatric monitoring. Treatment must address the eating disorder symptoms and medical consequences, as well as psychological, biological, interpersonal, and cultural forces that contribute to or maintain the eating disorder... Many people utilize a treatment team to treat the multi-faceted aspects of an eating disorder. ( 20)

Obsessive-Compulsive Disorder

Often referred to as OCD, obsessive-compulsive disorder is actually considered an anxiety disorder (which was discussed earlier in this fact sheet). OCD is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors (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. ( 21)

A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain. ( 22) Treatment for most people with OCD should include one or more of the following:

therapist trained in behavior therapy;

Cognitive Behavior Therapy (CBT);

medication (usually an antidepressant). (23)

"Psychotic disorders" is another umbrella term used to refer to severe mental disorders that cause abnormal thinking and perceptions. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there. Schizophrenia is one type of psychotic disorder. ( 24) There are others as well.

Treatment for psychotic disorders will differ from person to person, depending on the specific disorder involved. Most are treated with a combination of medications and psychotherapy (a type of counseling). ( 25)

More about School

As mentioned, emotional disturbance is one of the categories of disability specified in IDEA. This means that a child with an emotional disturbance may be eligible for special education and related services in public school. These services can be of tremendous help to students who have an emotional disturbance.

Typically, educational programs for children with an emotional disturbance need to include attention to providing emotional and behavioral support as well as helping them to master academics, develop social skills, and increase self-awareness, self-control, and self-esteem. A large body of research exists regarding methods of providing students with positive behavioral support (PBS) in the school environment, so that problem behaviors are minimized and positive, appropriate behaviors are fostered. (See the resource section at the end of this fact sheet for more information on PBS.) It is also important to know that, within the school setting:

For a child whose behavior impedes learning (including the learning of others), the team developing the child's Individualized Education Program (IEP) needs to consider, if appropriate, strategies to address that behavior, including positive behavioral interventions, strategies, and supports.

Students eligible for special education services under the category of emotional disturbance may have IEPs that include psychological or counseling services. These are important related services available under IDEA and are to be provided by a qualified social worker, psychologist, guidance counselor, or other qualified personnel.

Recognizing and Addressing the Impact of COVID-19 | As young people return to in-person schooling in the 2021-2022 school year, they may bring with them the impact of the pandemic's trauma. This makes it essential that schools consider the possibility that many students will need to be re-evaluated to determine if they need additional services, especially behavioral support and mental health services, than they needed prior to COVID-19. Two resources of great relevance to reopening schools and returning students are the following:

Other Considerations

Children and adolescents with an emotional disturbance should receive services based on their individual needs, and everyone involved in their education or care needs to be well-informed about the care that they are receiving. It's important to coordinate services between home, school, and community, keeping the communication channels open between all parties involved.

The Importance of Support

Families often need help in understanding their child's disability and how to address the needs that arise from the disability. Help is available from psychiatrists, psychologists, and other mental health professionals that work in the public or private sector. There is also a network of mental health support operating in every state as well as locally.

To locate systems of support in your community or state, visit the organizations we've listed below. They can connect you with local resources, including support groups that provide connection and understanding, information, referral, and advocacy for those living with emotional disturbance.

There are also support groups available from organizations that address specific mental disorders under the umbrella term of emotional disturbance. See the resources at the end of this fact sheet to identify some of these groups.

Resources of More Information

AACAP | American Academy of Child and Adolescent Psychiatry | AACAP offers Facts for Families, a series in English, Spanish, and several other languages that includes many briefs on specific mental disorders, including the ones mentioned in this publication.

AACAP also operates different Resource Centers, which offer consumer-friendly definitions, answers to frequently asked questions, clinical resources, expert videos, Facts for Families, and much more. Visit the Resource Center home page if you are concerned with one of the following:

Anxiety Disorders

Autism

Bipolar Disorder

Conduct Disorder

Depression

Oppositional Defiant Disorder

NIMH | National Institute of Mental Health | NIMH is clearly a source of authoritative information on specific mental disorders. Phone: 1.866.615.6464. TTY: 1.866.415.8051

NAMI | National Alliance on Mental Illness | NAMI is an excellent source of information and connection on mental illness, including the individual disorders mentioned in this fact sheet. NAMI's website and toll-free helpline are available in English and Spanish.

SAMHSA is the Substance Abuse & Mental Health Services Administration. It offers many resources to consumers, including:.

Detailed information on specific emotional disturbances, or related issues such as positive behavior supports, is also available from these sources:

Anxiety Disorders Association of America | https://adaa.org/

Center on Positive Behavioral Interventions and Supports | The PBIS Center provides research-based information on how to provide behavioral supports to children who need them. | https://www.pbis.org

Conduct Disorders | A soft place to land for battle-weary parents
https://www.conductdisorders.com/community/

Encyclopedia of Mental Disorders | http://www.minddisorders.com/index.html

National Eating Disorders Association
1.800.931.2237 | www.nationaleatingdisorders.org

Something Fishy | (eating disorders)
https://www.something-fishy.org

**Highly Rated Resource! This resource was reviewed by 3-member panels of Parent Center staff working independently from one another to rate the quality, relevance, and usefulness of CPIR resources. This resource was found to be of "High Quality, High Relevance, High Usefulness" to Parent Centers.
________________________________________

References

2 | Code of Federal Regulations, Title 34, §300.8(c)(4)(i)

3 | Code of Federal Regulations, Title 34, §300.8(c)(4)(ii)

5 | Ibid.

7 | Ibid.

11 | Ibid.

13 | Ibid.

14 | American Academy of Adolescent and Child Psychiatry. (2013, August). Conduct disorder: Facts for families. Washington, DC: Author. Available online at:
http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Conduct_Disorder_33.aspx

15 | Ibid.

16 | Johns Hopkins Medicine Health Library. (n.d.). Conduct disorder in children. Baltimore, MD: Author. Online at:
https://www.hopkinsmedicine.org/healthlibrary/conditions/mental_health_disorders/conduct_disorder_90,P02560

# data[].attributes.attachment_link.description
Links updated, November 2021 This information in Spanish The mental health of our children is a natural and important concern for us all. The fact is, many mental disorders have their beginnings in childhood or adolescence, yet may go undiagnosed and untreated for years.

# data[].attributes.body
Preventive measures are often the best solution to disruptions linked to emotional disturbances. The Arizona Department of Education’s Parent Information Network mentions functional behavioral assessments (FBAs) as a preventative strategy. An FBA identifies what leads a student to act out so that an effective behavioral intervention plan (BIP) can be developed.

# data[].attributes.body
An Emotional Disturbance is a disability that is characterized by exhibiting one or more of the following five characteristics. These characteristics must be demonstrated over a long period of time and to a marked degree that adversely affects a child’s educational performance. The five characteristics are as follows: an inability to learn that cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relations with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; and/or a tendency to develop physical symptoms or fears associated with personal or school problems. Emotional disturbance includes schizophrenia. It does not apply to a child who is socially maladjusted unless the child has been found to have an emotional disturbance.

# data[].attributes.headline
How Do We Determine a Child is ED versus OHI?

# data[].attributes.subject
How Do We Determine a Child is ED versus OHI?

# data[].attributes.body
A child who is determined to have an Emotional Disturbance is one who meets one of the five characteristics outlined above. A student with an Other Health Impairment is one who has limited strength, vitality, or alertness due to a chronic or acute health problem and it adversely affects educational performance. The condition would affect the child in any of the following manners:

 Strength- decrease in bodily or muscle power, vigor, tires easily;

 Vitality-reduction of physical and/or mental strength, limited endurance, limited energy;

 Alertness-reduction of attentiveness, including heightened alertness to surroundings that leads to

a reduced alertness to the educational environment.

Note: A chronic or acute health problem does not automatically make a child eligible as a student with an Other Health Impairment. All criteria must be met.

Should the student have a chronic or acute health problem, such as Bipolar Disorder, but demonstrates one of the five characteristics of an Emotional Disturbance due to the condition, the child may be determined to meet the eligibility category of Emotional Disturbance given the criteria is met. The diagnosis of a mental health condition alone does not, in itself, determine eligibility for special education services as a student with an Emotional Disturbance.

# data[].attributes.body
One of the most important accommodations for students with EBD is to provide them with a positive and structured environment. This means discouraging negative behavior while rewarding appropriate behavior. Some ways to do this include setting clear rules and expectations, providing positive reinforcement when students display good behavior, and using a token economy system to reward positive behaviors.

# data[].attributes.body
One of the most important accommodations for students with EBD is to provide them with a positive and structured environment. This means discouraging negative behavior while rewarding appropriate behavior. Some ways to do this include setting clear rules and expectations, providing positive reinforcement when students display good behavior, and using a token economy system to reward positive behaviors.

# data[].attributes.body
It’s important to give students with EBD assignments that are within their abilities and that match their educational level. Additionally, the types of accommodations in their IEP and individualized education program can be provided to help these students succeed.

Some examples of accommodations that have been found to be effective for students with EBD include:

– Testing accommodations such as extended time on tests, and small group testing environment

-Use of a calculator on math tests and homework

-Extended time on assignments that are in the general education curriculum

– Movement breaks as needed: use a pass system for breaks

– Offer choices: for example, students can demonstrate comprehension of a subject by handing in a traditional paper, video, or poster, etc.

– Preferential seating arrangements

– Frequent check-ins with the teacher

–Alternative seating such as wiggle cushions or exercise ball seating

# data[].attributes.headline
ENSURE ACCOUNTABILITY – ACCOMMODATIONS FOR STUDENTS WITH EMOTIONAL AND BEHAVIORAL DISORDERS

# data[].attributes.subject
ENSURE ACCOUNTABILITY – ACCOMMODATIONS FOR STUDENTS WITH EMOTIONAL AND BEHAVIORAL DISORDERS

# data[].attributes.body
It’s important for students with EBD to be held accountable for their behavior and actions. This means making sure they understand the consequences of their choices. Some ways to do this include:

– Having clear rules and expectations in place

# data[].attributes.attachment_link.title
Emotional disturbance in the classroom: don't give up on Bobby

# data[].attributes.attachment_link.title
The IDEA's Special Education Categories: Emotional Disturbance

# data[].attributes.attachment_link.title
Referral to Special Education -- Emotional Disturbance

# data[].attributes.body
School counselors, nurses, psychologists and psychiatrists can connect your family to mental health services and providers in your community, and reaching out to them should be your first step.

However, there are also many national organizations that offer direct mental health support, assistance and referrals; local chapters that provide counseling, referrals, education etc.; and peer-to-peer support groups.

# data[].attributes.headline
Find Mental Health Support from National Organizations

# data[].attributes.subject
Find Mental Health Support from National Organizations

# data[].attributes.body
Warmlines (Mental Health America): Talk to someone who can provide support during hard times.

Find a Mental Health Support Group (Mental Health America): Find support groups in your area.

Behavior Health Treatment Locator (SAMHSA): Locate treatment facilities in the United States or U.S. Territories for substance use/addiction and/or mental health problems.

Self-Help Clearinghouse (National Mental Health Consumers): Connect to self-help and advocacy resources.

Mental Health Resources for Underrepresented Communities (American Foundation for Suicide Prevention): Find national resources for suicide prevention focused on supporting individuals in minority communities, reviewed for accuracy, mental health and community context, and ease of use by AFSP.

# data[].attributes.attachment_link.readable_text
Students with executive functioning challenges may also struggle with managing their emotions and maintaining appropriate behavior in the classroom. This is because the umbrella of executive functioning also includes skills for self-control, flexibility, and perseverance. Additionally, some students may not fully understand the classroom expectations to be able to follow them through.

In order to provide assistance to these kids and teens, there are a number of accommodations and supports we can put in place. As always, the goal with accommodations is to help level the playing field so students can think, learn, grow, and succeed in the way that is best for them.

Below are some accommodations to support with emotions and behavior.

Accommodations for Emotions & Behavior

Behavior Intervention Plan. Create a formal plan for an individual student that details the child's challenging behaviors and specific strategies to work through them. Making a written plan is helpful in keeping all educators on the same page.

Daily Emotions Check-In. Use a daily emotions check-in to help students understand how they are feeling and what they might need for the day. Give this free emotions check-in a try or use this executive functioning daily check-in to provide an emotions check-in with EF skills combined in one.

Visuals. Provide visuals with reminders about academic and social expectations in the classroom.

Calm Down Space. Design a calm-down area in the classroom. Add appropriate tools to help build self-regulation skills, such as coloring activities, fidgets, mindful breathing cards, books, and journal writing activities.

Predictable Routine. Arrange a highly consistent and predictable routine each day using a schedule.

Post Clear Expectations. Clearly post visual and written expectations in the classroom. These can be posted around the room and/or directly on the student's desk, if needed. A note that expectations should be written in the positive form (Raise hand to ask question vs. Don't shout out).

Provide Coping Skills List. Design a specific list with options for cool-down techniques the student can use.

Track Goals. Develop SMART goals together and track them on a weekly basis.

Use De-Escalation Strategies. Use calm-down techniques to de-escalate a situation when a child is upset or overwhelmed. While de-escalation strategies are also a good teaching practice, it may be helpful to document them as part of a student's individual accommodations and supports. Use this free list of de-escalation strategies for ideas to use in the classroom.

Weekly Check-In with Counselor. Plan a weekly check-in time with the school counselor (or other support professional) to give extra organization and planning support. This adult could also become a coach for working through challenges throughout the week.

Teach Positive Self-Talk. Encouraging words can go a long way to working through challenges. Use positive self-talk and affirmations to build confidence and find success.

Home-School Communication Log. Create a space to share messages back and forth with families on an on-going basis.

Provide breaks. Use movement, mindfulness, and other activities to give meaningful breaks throughout the day.

Daily Feedback. Give feedback in an end-of-the-day reflection. This can help students build self-awareness and improve confidence. Use these free reflection questions to start.

Social Skills Group. Lead a small social skills group to teach social skills necessary for personal and social success. A group could be taught by a special educator, school counselor, social worker, or school psychologist. Some skills targeted might include active listening, turn-taking, perspective-taking, flexibility, self-advocacy, and problem-solving.

Daily Check-In and Check-Out. Plan for a quick 5 to 10-minute check-in with a trusted adult each morning and afternoon. In the morning, the adult can ask how the student is doing, review the daily schedule, and assist the student in getting organized for the day. In the afternoon, the student can use that time to review how the day went, discuss homework expectations, and make sure they have what they need to head home.
Teaching Executive Functioning Strategies
Accommodations and supports are important, but it is also critical to make time to teach students about their executive functioning skills and strategies they can use. Use this yearlong set of Executive Functioning Lessons and Activities to teach about how to plan, stay organized, manage your time, and more.

A final thought is to be flexible with accommodations for struggling learners. Not every strategy and support is going to work perfectly. If something isn't helping the child be successful, head back to this list and give a new accommodation a try.

# data[].attributes.attachment_link.title
Executive Functioning Accommodations for Emotions and Behavior

# data[].attributes.attachment_link.description
Students with executive functioning challenges may also struggle with managing their emotions and maintaining appropriate behavior in the classroom. This is because the umbrella of executive functioning also includes skills for self-control, flexibility, and perseverance. Additionally, some students

# data[].attributes.attachment_link.readable_text
The academic past of Nikolas Cruz, the accused mass shooter at Marjory Stoneman Douglas High School in Parkland, Fla., was littered with red flags suggesting serious emotional problems.

News outlets that have reviewed Cruz's disciplinary records and interviewed his teachers paint a picture of a young man prone to violent outbursts and fascinated with weapons. In high school, he spent time in a Broward County public school that specializes in serving students with emotional and behavioral disabilities. The Associated Press has reported that a high school resource officer who was also a sheriff's deputy and two school counselors recommended in September 2016 that Cruz be committed for mental evaluation under Florida's Baker Act. That law allows for involuntary commitment for mental health examination for at least three days.

The intense focus on Cruz's mental health history in the wake of the Feb. 14 school massacre has worried some of those who work directly with students who have mental health needs, such as those receiving special education for an "emotional disturbance," the official term used in federal special education law. The classification already carries a stigma, and those students already have some of the worst outcomes among students with disabilities.

Emotional disturbances, also called emotional/behavioral disabilities, are distinguished by their intensity and impact on school performance.

Students in special education for an emotional disturbance are not more likely than their peers to be school shooters. In an exhaustive examination of targeted school shootings between 1974 and 2000, the U.S. Secret Service and the U.S. Department of Education found that while perpetrators commonly described being bullied or persecuted and had thoughts of suicide, they generally did not have a history of mental health evaluations or diagnosis with a mental disorder.

But Cruz's known struggles in school have vaulted mental health to the front pages. And the tension between a school's responsibility to support students with mental health issues and the need to keep students from harm is now on full display.

Cruz received services both in traditional public school and in a specialized program. After a rocky re-entry to Stoneman Douglas, school officials recommended he return to the alternative placement. But he waived his right to special education services at age 18 with the support of his mother, Superintendent Robert Runcie told the Sun-Sentinel newspaper.

Runcie has ordered a full evaluation of Cruz's educational record.

"While we cannot undo this heartbreaking attack on our school community ... we can and must do what we can to understand the conditions that lead to such acts, in hopes of avoiding them here and elsewhere," Runcie said in a statement.

More than 335,000 students nationwide are identified as having an emotional disturbance. Here's some of what we know about this population:
Students with emotional disturbances are a small part of the population of students with disabilities.
About 6 percent of students with disabilities are classified as having an emotional disturbance nationally. In comparison, about 39 percent have a specific learning disability, such as dyslexia, and 17 percent have speech and language impairments.

But the numbers don't tell the full story. Emotional disorders can be a part of other disabilities; for example, a student with a learning disability could also be coping with anxiety or obsessive-compulsive disorder, both of which fall under the umbrella of "emotional disturbance."

And then there are students who may have all the features of an emotional disturbance, but are never identified as having a disability. The "emotional disturbance" label does not indicate that a student's problems are more severe than some other student who never gets that label.

"There's just a lot of randomness in who is able to get through that door," said Mark Weist, a professor at the University of South Carolina and founder of the Center for School Mental Health. "It depends on the school, it depends on the leadership."

Part of the concern is money, Weist said. Schools are legitimately concerned about how to pay for some services that students might need, so they enact "these artificial barriers to slow down the process."
Students with emotional disturbances face some of the steepest challenges of students in any disability group.
Students identified with emotional disturbances have lower graduation rates and higher dropout rates than other students in special education. They are more likely than other students with disabilities to face long-term suspension or expulsion.

In the 2016-17 school year, fewer than half of students in this disability category spent most of the day in a general education classroom. And while about 3 percent of students with disabilities overall were in separate schools, 13 percent of students with emotional disturbances were.

Students with disabilities in general, and behavioral disabilities in particular, are more likely than their peers in general education to be both the victims and perpetrators of bullying. Students with emotional disturbances also face high rates of self-harm.

One school known nationally for its work for students with emotional disabilities and autism is Centennial School, in Lehigh, Pa. The school serves students from elementary through high school who are placed there by several surrounding school districts. The school serves about 100 students each year, with the goal of returning them to their home setting.

Centennial has been profiled for its elimination of restraint, seclusion, and time-out rooms. Instead, the school has clear behavioral expectations and works under the assumption that students will need to be explicitly taught those expectations, as they would be taught math or English.

When students act out, "we treat those behavior errors as if they're an academic error," said Julie Fogt, the director of Centennial School. "We need to teach them a better way. We're not going to punish it out of them."
Students with emotional disturbances can be suspended or expelled.
Critics often single out special education students in discipline discussions, saying that the law makes it hard for schools to aggressively handle disruptions from students with disabilities.

Students with disabilities are frequently suspended and expelled, however. Federal data from the Education Department found that about 12 percent of students with disabilities faced that discipline, compared with 5 percent of students overall.

Within the universe of children and youth with disabilities, 25 percent of long-term suspensions and expulsions are of students with emotional disturbances, though they represent a fraction of the special education population.

"The notion that a kid can't be disciplined if they have special needs" is incorrect, said Mark Martin, an parent attorney based in Baltimore. "A principal can go ahead and do that." But once a suspension reaches more than 10 consecutive days, the law says that students with disabilities are entitled to a "manifestation determination" to see if the problem behavior is tied to his or her disability. Certain offenses, such as carrying a weapon, using or selling drugs, or causing injury, allow schools to unilaterally make the decision to remove a student from a school.

"A manifestation meeting is not a 'get-out-of-jail free' card," Martin said.

And expulsion carries its own risks, said Joseph Erardi, the former superintendent of schools in Newtown, Conn. He joined that district in 2014, two years after the deadly mass shooting that killed 20 students and six staff members at Sandy Hook Elementary School.

He led a group of superintendents who wrote a paper offering best practices for school leaders around mental-health issues in students.

"One of the greatest takeways is that social isolation at any point for a complex youngster is clearly an opportunity for that child to move into a more difficult space in his or her life," Erardi said. Expulsion of such a student is "extraordinarily counterproductive to the best interest of that child."
There are successful tools for working with these students. But help often comes late in a student's academic career.
A little over half, 52 percent, of students with emotional disturbances are 13 to 17 years old. For the special education population overall, it's 34 percent.

There's a couple of reasons behind that, said Sharon Hoover, an assistant professor of child and adolescent psychiatry at University of Maryland School of Medicine, and the co-director of the Center for School Mental Health. Some mental-health issues manifest themselves in adolescence, and some student problems aren't officially diagnosed until they're hard to ignore-and hard to treat.

But schools have developed ways to support students with mental health needs, Hoover said. One model used in Baltimore County, Md., brings community-based mental health providers directly into the schools so that they can provide counseling and other support services.

Having more trained counselors available, plus universal screening for mental health concerns "are not easy fixes, but they're the natural solutions," Hoover said.

"There are a lot of interventions that have demonstrated success," Hoover said, and they don't involve harsh discipline or arming teachers-suggestions coming from the White House. But in the immediate aftermath of a tragedy, those interventions can be forgotten, she said.

"We need to create conditions for kids to feel connected." she said.

# data[].attributes.attachment_link.title
Students With Emotional Disabilities: Facts About This Vulnerable Population

# data[].attributes.attachment_link.description
Advocates worry students with special education needs such as "emotional disturbance" may be stigmatized in light of the intense spotlight on accused Florida school shooter Nikolas Cruz's mental health history.