Diagnosis & Assessment - What's Appropriate for My Role?

Before examining the different types of dysfunctional behaviors in depth, you should understand the nature of the role of the school counselor in serving students with mental health concerns. 

Professional school counselors are in a unique position within schools to implement comprehensive guidance programs that provide prevention and early intervention strategies, education and support for students, staff, parents, and the community, and collaboration with mental health professionals to ensure that needs are met.  

While school counselors are in a position to recognize signs and symptoms of emotional disturbances, because their certifications do not include expertise in the area of diagnosis and treatment of disorders, it is not appropriate for school counselors to diagnose these behaviors or carry out long term counseling or therapy in the school setting to address these disorders. For a quick chart of appropriate and inappropriate activities for school counselors, see the attached PDF below created by the American School Counselor Association (ASCA). There are also resources available in the reading list to help you understand your role. 

When working to recognize dysfunctional behavior / emotional disturbance, a school counselor must be able to identify the appropriate entity for referral, such as a licensed professional counselor (LPC), a licensed specialist in school psychology (LSSP), a medical practitioner (doctor), or a psychiatrist. Counselors can support students' mental health needs by appropriately referring, acting as a supporting connection between the student and parent, family and mental health referral, and mental health professional and school personnel, and by ensuring the school environment and staff is equipped to best serve the student. As we explore the different behaviors in this course, you will be provided with resources to help you solidify your understanding of your role in serving students with dysfunctional behaviors. For this introductory module, you may find the resource  What Do Mental Health Professionals Do in Schools? helpful. 

In addition, you will see several resources referring to the Diagnostic and Statistical Manual, 5th ed. (DSM-V).  It is important that you understand how diagnoses are made and what information is available in the DSM.  You may see this information in ARD/IEP meetings, as well as on information from private counselors or others.  Several resources have been included with this information and it would behoove you to become familiar with it, knowing that it is not for you as a school counselor to make diagnoses. The resource  ASCA Appropriate Activities for School Counselors may also help you understand some of the basic activities appropriate for school counselors. 

Lyons, K. (2020). Module 1: Intro to dysfunctional behavior. https://blackboard.angelo.edu/webapps/blackboard/content/listContent.jsp?course_id=_67112_1&content_id=_2695047_1&mode=reset

James Morrison. (2014). DSM-5® Made Easy : The Clinician’s Guide to Diagnosis. The Guilford Press.

Eating disorders : mind, body, and society. (2009). Films Media Group.

Eating Disorders : The Hunger Within. (2010). Films Media Group.

Eating Disorders. (2012). Films Media Group.

Carney, J. M., & Scott, H. L. (2012). Eating Issues in Schools: Detection, Management, and Consultation With Allied Professionals. Journal of Counseling & Development, 90(3), 290–297. https://doi.org/10.1002/j.1556-6676.2012.00037.x


Bob Palmer. (2015). Helping People with Eating Disorders : A Clinical Guide to Assessment and Treatment: Vol. Second edition. Wiley-Blackwell.

Sarah Edison Knapp, Arthur E. Jongsma, J., & Catherine L. Dimmitt. (2014). The School Counseling and School Social Work Treatment Planner, with DSM-5 Updates, 2nd Edition: Vol. Second edition. Wiley.

Emotional disability includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance.

A student who receives special education services under the category of Emotional Disability has emotional problems of some kind that are adversely affecting his/her educational performance. Usually schools look at grades, discipline records, and performance on achievement tests to quantify educational impact. In determining eligibility for Emotional Disability, several evaluations are typically completed. A school will conduct psychological testing by a school psychologist, which will include cognitive testing and social/emotional measures (rating scales, interviews, observations). Educational testing is typically completed to determine current levels of achievement in reading, writing, math, and other educational areas. Additionally, a Sociocultural evaluation or interview by a school social worker is typically completed with a parent to rule out environmental factors and obtain a developmental history. (See SPED testing for more information)

Often, the most difficult part of determining eligibility for special education services in this category is determining if the student has an emotional disability or social maladjustment. The following is adapted from a chart that was shown at a training I attended by Bruce Bracken. He adapted it from Social Maladjustment: A Guide to Differential Diagnosis and Educational Options (Wayne County Regional Educational Service Agency – Michigan, 2004).

Behavior Area | Emotional Disturbance | Socially Maladjusted
School Behavior | Unable to comply with teacher requests; needy or has difficulty asking for help | Unwilling to comply with teacher requests; truancy; rejects help
Attitude Toward School | School is a source of confusion or angst; does much better with structure | Dislikes school, except as a social outlet; rebels against rules and structure
School Attendance | Misses school due to emotional or psychosomatic issues | Misses school due to choice
Educational Performance | Uneven achievement; impaired by anxiety, depression, or emotions | Achievement influenced by truancy, negative attitude toward school, avoidance
Peer Relations and Friendships | Difficulty making friends; ignored or rejected | Accepted by a same delinquent or socio-cultural subgroup
Perceptions of Peers | Perceived as bizarre or odd; often ridiculed | Perceived as cool, tough, charismatic
Social Skills | Poorly developed; immature; difficulty reading social cues; difficulty entering groups | Well developed; well attuned to social cues
Interpersonal Relations | Inability to establish or maintain relationships; withdrawn; social anxiety | Many relations within select peer group; manipulative; lack of honesty in relationships
Interpersonal Dynamics | Poor self-concept; overly dependent; anxious; fearful; mood swings; distorts reality | Inflated self concept; independent; underdeveloped conscience; blames others; excessive bravado
Locus of Disorder | Affective disorder; internalizing | Conduct disorder, externalizing
Aggression | Hurts self and others as an end | Hurts others as a means to an end
Anxiety | Tense; fearful | Appears relaxed; �cool�
Affective Reactions | Disproportionate reactions, but not under student’s control | Intentional with features of anger and rage; explosive
Conscience | Remorseful; self critical; overly serious | Little remorse; blaming; non-empathetic
Sense of Reality | Fantasy; naïve; gullible; thought disorders | �Street-wise�; manipulates facts and rules for own benefit
Developmental Appropriateness | Immature; regressive | Age appropriate or above
Risk Taking | Avoids risks; resists making choices | Risk taker; �daredevil�
Substance Abuse | Less likely; may use individually | More likely; peer involvement
Adapted from Social Maladjustment: A Guide to Differential Diagnosis and Educational Options (Wayne County Regional Educational Service Agency – Michigan , 2004)

Adults may also assume that anxiety in a child is just a phase to be outgrown. A certain amount of anxiety is a normal aspect of development for young children — consider separation anxiety, for example — and it can even be protective, since children need to learn to keep themselves safe and anticipate certain kinds of dangers. But when worrying or avoiding possible threats gets in the way of a child’s functioning or a child’s enjoyment, it should be a signal to parents that help is needed, not just watching and waiting, not arranging the child’s life to avoid the occasions of anxiety.

Kathleen Merikangas, the senior investigator and chief of the Genetic Epidemiology Research Branch at the National Institute of Mental Health, said, “To me, anxiety is one of the most underrecognized or under-treated conditions of childhood and adolescence.” These children can get missed, she said, because they may seem to be functioning well; many don’t have the kinds of developmental problems or attention issues that draw attention in school, though they may be suffering.

Consider the child whose anxiety about speaking in public gets in the way of participating in class. The child may be silent out of a fear of being laughed at or otherwise rejected, Dr. Merikangas said, but to the teacher, it may look like the child is just not interested. Environmental modifications can really help these children thrive in school, she said; for example, working in small groups with children they know.

The new report, released in September, summarizes the evidence that early temperament in children predicts their later behavior patterns around anxiety; toddlers who show what are called “behaviorally inhibited” behaviors, which parents are likely to perceive as extreme shyness, or anxiety around new people, are more likely to develop social anxiety later on. That doesn’t mean that shyness is pathological (as with all varieties of temperament, there’s a wide range of function), but it does suggest how important it is to help a child with this temperament who develops difficulties.

The tendency toward anxiety — and toward some specific forms of anxiety, like phobias — may persist throughout childhood and adolescence and into adulthood. And anxiety is closely tied to depression, Dr. Merikangas said. Although there have been reports that anxiety rates among American teenagers have soared, she cited evidence that the international rates of the underlying disorders had stayed consistent from 1998 to 2013; there is no global “epidemic” of clinical anxiety disorders, she said.
But with rates of suicide and suicidal ideation on the rise, it’s particularly important to provide information to schools and to parents about recognizing anxiety and getting children help.

Dr. Harold Koplewicz, the president of the Child Mind Institute, said that when anxiety disorders in children are left untreated, anxiety can inhibit their lives, making standard daily activities difficult, from attending school to sleeping in their own beds, and lead to many extra visits to the school nurse or the pediatrician.

But beyond that, he said, “people underestimate that this is a gateway disorder.” If children don’t get help with these disorders, they may be at risk to develop other mental health problems; the child with severe separation anxiety may develop panic disorder, he said; the child with untreated general anxiety may be at greater risk for depression.

Dr. Merikangas was a co-investigator on a national study of mental disorders in adolescents, which has shown both that anxiety disorders were the most common mental health problems in adolescents in the United States, and also the problems that showed up earliest in those children’s lives — the mean age of onset for anxiety disorders was 6. But many adolescents had never received treatment. That makes it essential to get the word out, Dr. Merikangas said, that anxiety is “one of the most treatable symptoms and syndromes, we can really change their lives with minimal intervention.”

“All these disorders are remarkably treatable,” Dr. Koplewicz said. There are highly effective behavioral and psychosocial therapies, including cognitive behavioral therapies, to help children cope with the demands of daily life. For children who don’t respond to psychosocial therapies, he said, medications can be added.

But perhaps because anxiety is a normal response, parents often believe that even severe and disabling anxiety symptoms are just a phase, and on average, there is a two-year lag between the time children develop anxiety and the time they get help. “It’s bad for these children’s brains,” he said. “Having your brain’s thermostat miss-set is not good for your brain.”

“Anxiety can manifest itself along a continuum,” said Rachel Busman, the senior director of the anxiety disorders center at the Child Mind Institute. The report shows that there is some overlap with physical illnesses, such as chronic headaches or stomach aches, often coordinated with school. “That could be a kid’s way of saying, ‘I’m anxious,’” she said.

And when a child who is having a lot of difficulty with separation gets into the classroom, Dr. Busman said, that child may start throwing things, or running and hiding, and that “bad behavior” may represent the fight or flight response of anxiety. “We’ve also seen kids who have intense social anxiety and their way of managing it is to be class clown,” she said.

Treating children with anxiety always means working with their parents. Jerry Bubrick, senior clinical psychologist at the anxiety disorders center of the Child Mind Institute, said that when children are little, it’s normal for parents to operate in “fix-it mode,” blocking the staircase so a toddler doesn’t tumble down, averting problems before they happen.

As children get older, parents normally pull back, helping children find solutions of their own. “But anxious parents of anxious children remain in fix-it mode,” he said, helping their children avoid the situations that make them anxious. Therapy involves exposing children to those situations and helping them develop strategies to manage them; with treatment, Dr. Bubrick said, parents can “let the child experience the anxiety and learn to tolerate and overcome it on their own.”

“If you see things you’re not sure about, talk to the preschool, talk to the pediatrician, be open to the idea that maybe there is anxiety,” even in a young child, Dr. Busman said. Separation anxiety can be a problem even in children who are able to go to school, she said. Parents should pay attention if a child can’t be left with a babysitter, a child can’t sleep alone at home.  “These are the kids, they go into the bathroom, and they’re like, are you still there?” she said. “We do see really young anxious children.”

“If your child is suffering distress and dysfunction, reach out to your pediatrician,” Dr. Koplewicz said. When you get to a mental health professional, “make sure you ask the right questions,” he said, including asking whether that person has specific experience with treating anxiety and how long the treatment is expected to take.

“You want a professional who understands what they’re doing and can explain to you what they’re doing.”

By: Klass, P. (2018). https://www.nytimes.com/2018/10/01/well/family/how-to-help-a-child-with-an-anxiety-disorder.html

Information about Emotional/Behavioral Disorders

Definition
IDEA defines emotional disturbance as follows:

“…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.”

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.


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 (NAMI) 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.

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.


Frequency
According to the CDC (Centers for Disease Control and Prevention), approximately 8.3 million children (14.5%) aged 4–17 years have parents who’ve talked with a health care provider or school staff about the child’s emotional or behavioral difficulties. (6) Nearly 2.9 million children have been prescribed medication for these difficulties.



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.

Anxiety Disorders

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.

As with the term emotional disturbance, “anxiety disorder” is an umbrella term that actually refers to several distinct disabilities that share the core characteristic of irrational fear: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder (also called social phobia), and specific phobias.

According to the Anxiety Disorders Association of America, anxiety disorders are the most common psychiatric illnesses affecting children and adults. They are also highly treatable. Unfortunately, only about 1/3 of those affected receive treatment.


Bipolar Disorder

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.

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.


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.

Although conduct disorder is one of the most difficult behavior disorders to treat, young people often benefit from a range of services that include:
     ◾training for parents on how to handle child or adolescent behavior;
     ◾family therapy;
     ◾training in problem solving skills for children or adolescents; and
     ◾community-based services that focus on the young person within the context of family and community     influences.


Eating Disorders

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.

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.

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.

According to the National Eating Disorders Association:


The most effective and long-lasting treatment for an eating disorder is some form of psychotherapy or counseling, coupled with careful attention to medical and nutritional needs. Some medications have been shown to be helpful. Ideally, whatever treatment is offered should be tailored to the individual, and this will vary according to both the severity of the disorder and the patient’s individual problems, needs, and strengths.


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.

A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain. 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).


Psychotic Disorders

“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. 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).


Source Material
National Institute of Mental Health (NIMH)
Code of Federal Regulations, Title 34, §300.8(c)(4)
National Alliance on Mental Illness
U.S. Department of Education
Anxiety Disorders Association of America
American Academy of Adolescent and Child Psychiatry
National Mental Health Information Center
National Eating Disorders Association
National Dissemination Center for Children with Disabilities