Parting Reflections on Education of Children with Emotional or Behavioral Disorders

There are three areas that to me seem not only critical for the future of our field but to which we also need to pay more attention, as we enter a new era of evidence-based practice. These involve topics that may serve to move us beyond our traditional behavioral approaches into interdisciplinary collaboration in the larger enterprise of school mental health. They are (1) developmental psychopathology, (2) psychiatric comorbidity, and (3) psychopharmacology. What follows are brief reflections on each. As special educators, we usually care for children already referred for emotional or behavioral disorders. These disorders, however, have usually been long evident to their families through expression of mild functional impairments and/or early symptoms (Forness & Kavale, 2001a). Such disorders, in their earliest stages, however, are not always recognized as such. Developmental psychopathology holds that the trajectory of such disorders is determined by a variety of early genetic, biologic, and/ or environmental etiologies (Pennington, 2002). Parents and even professionals may have been concerned by these earlier signs yet did not necessarily view them as prodromal, as early symptoms of a possible psychiatric diagnosis. Inherent in the concept of developmental psychology is the need for early detection, instead of just early identification or diagnosis, and primary prevention, instead of just early intervention. Also inherent is the implication that, as special educators, we are "back-loading" most of our efforts, long after the diagnosis is fully realized, as opposed to "front loading" at the earliest signs of difficulty. We thus need to focus much more on this concept of developmental psychopathology since it puts a much greater emphasis on early trajectories of psychopathology and on the diffuse nature of symptoms of very early risk. My colleagues and I have been extremely interested in this concept and have shown how early emotional or behavioral disorders have not only been significantly underidentified in special education but also misidentified as learning disabilities or related disorders (Duncan, Forness & Hartsough, 1995; Lopez et al., 1996; Redden et al., 1999; 2002). We have also shown how primary prevention or classroom-wide interventions in preschool can not only significantly improve both functional behavior and symptoms in children at risk (Serna, Lambros, et al., 2000; Serna et al, in press) but also possibly forestall actual psychopathology in those youngsters at highest risk (Serna et al., 2003). Such preventative approaches, as well as our usual functional behavioral analyses and positive behavioral supports, may not be entirely adequate, however, if such disorders are accompanied or even preceded by significant psychiatric comorbidity. The gradual emergence of such comorbidity may not always be readily apparent, unless we are prepared to recognize its developmental trajectory as well. One interesting example is children with disruptive disorders who also have comorbid depression or anxiety disorders. In sequential behavioral observations of adult-child interactions, children with such a mixed pattern are often significantly less likely to pursue adaptive responses and much more likely to revert to impulsive responding without regard to consequences of their actions than children with just disruptive behavior disorders (Granic & Lamey; 2002). They simply do not respond to our usual behavioral approaches. Both prospective and retrospective follow-up of children with mixed disorders also suggests very different developmental patterns of adjustment, with implications for differential treatment involving much more emphasis on cognitive-behavioral and emotional-regulation approaches than needed for children with simple disruptive behavioral disorders (Capaldi & Stoolmiller, 1999; Jaffee, et al., 2002). Finally, it is becoming clear that children with such mixed disorders (externalizing and internalizing) may show very different patterns of perturbation on neuroimaging in the anterior cingulate gyrus (governing some aspects of emotion or motivation) and the orbitofrontal cortex (governing some aspects of impulse control) than children with "pure" externalizing disorders (Luu, Collins & Tucker, 2000). …