Emotional and behavioural disorders

It can be challenging for teachers to know how best to support students with emotional and behavioural disorders. The issues that these students face directly impact their learning and achievement and can also affect social interactions within the classroom. Often classroom teachers feel under-prepared and under-equipped to provide the support necessary for students with emotional and behavioural disorders to succeed. In order to effectively design and carry out instruction, teachers need to understand the most common emotional and behavioural disorders that affect children in the classroom, and to be aware of teaching strategies that can be utilised to reach students who are experiencing these issues. Although a student may require therapy or counseling outside of school, there are many things that teachers and school staff can do to support students with emotional and behavioural disorders.

The most common disorders in childhood include neurodevelopmental conditions such as attention-deficit/hyperactivity disorder (ADHD), disruptive behaviour problems, oppositional, defiant or conduct disorders, and later in childhood, anxiety and depression. Emotional and behavioural disorders can be broadly classified as ‘externalising’, like conduct disorder, or ‘internalising’, like anxiety or depression, although some conditions have both externalising and internalising characteristics. The New Zealand Health Survey in 2012-2016, which collected data on children in New Zealand ages 3-14, found that, according to parents, 8% of children were experiencing significant emotional, social, or behavioural problems. Girls were more likely to experience difficulties that were emotional and internalising in nature, while boys were more likely to have issues with hyperactivity, peer conflict, and conduct disorders[i].

The link between environmental factors and emotional and behavioural disorders

Many environmental factors have been linked to certain childhood emotional and behavioural disorders, including parental psychopathology and substance use, unfavourable perinatal factors, poor family relationships, adverse family life, household exposure to tobacco and other substances, unfavourable socioeconomic conditions, and personal factors such as temperament and gender[ii]. Children with environmental exposure to substance abuse, toxic stress, trauma or adverse childhood experiences may enter the school system with various labels.A variety of genetic or temperamental factors may also play a role in the development of certain emotional and behavioural disorders in students who have not experienced any adverse environmental factors. For example, a tendency to withdraw from situations and peers may put students at a greater risk of developing anxiety disorders. In addition, modeling can play a role in the development of anxiety as parents with anxiety tend to have children with anxiety[iii].

There are two main categories of emotional and behavioural disorders that are directly linked to environmental factors: fetal alcohol spectrum disorders and disorders associated with toxic stress, trauma and adverse childhood experiences.

Fetal alcohol spectrum disorders

Some children grow up in environments that affect their development and make them more likely to develop emotional and behavioural disorders. For example, children with prenatal exposure to alcohol can develop fetal alcohol spectrum disorders (FASD) including a neurobehavioural disorder associated with prenatal alcohol exposure (ND-PAE). Recent studies show that 2% to 5% of children in the United States have FASD, although few are identified or diagnosed[iv]. The New Zealand Ministry of Health estimates that this suggests that around 30,000 children in New Zealand may have FASD with 1,800 more babies born each year who are also affected by FASD[v].

Children with FASD have impaired cognition, self-regulation and adaptive functioning. This can include a variety of issues with problem solving, abstract reasoning, executive function, learning, memory, visual-spatial reasoning, mood and behaviour regulation, attention, and impulse control. Children with ND-PAE tend to have difficulty with nonverbal aspects of cognition such as visual-motor skills, retention of recently learned material and executive function. They demonstrate both cognitive impairments and behavioural problems. Children with FASD experience attention problems but, unlike children with ADHD, they have higher rates of social behavioural problems due to issues with understanding and effectively processing social situations and their emotions. When children are exposed to alcohol prenatally and then also experience trauma, the effects of this prenatal alcohol exposure are greatly worsened. Families with substance abuse problems are more likely to also deal with financial instability, poverty, various forms of trauma, and high levels of stress[vi].

Toxic stress, trauma, and adverse childhood experiences

Toxic stress, trauma, and adverse childhood experiences (ACES) affect the way that children respond in the classroom and at home. The neural circuits for dealing with stress are malleable and can easily be changed during early childhood. Children who grow up in extremely stressful or traumatic environments have a stress response that is constantly activated. This toxic level of stress can affect the way that hormonal systems and brain circuits develop, leading to systems that are overactive or underactive to stress. This may cause children to become impulsive, feel threatened, or shut down when they are faced with perceived threats. They may also see anger, hostility, or danger in a situation that is neutral or may display excess anxiety. For this reason, exposure to ACES and trauma can lead to an increased risk of developing a multitude of behavioural disorders such as anxiety disorders, depression and substance abuse. It can also affect physical health through an increased likelihood of diabetes, stroke and cardiovascular disease. In addition, when children experience toxic stress, it elevates their cortisol levels. Long-term elevations in cortisol levels can suppress immune function, alter neural systems, and change the makeup of regions of the brain that are crucial to memory, learning and stress response regulation. However, individual responses to stress can vary widely.

It is also important to note that there are several ways that teachers can help students who have experienced trauma or ACES or who are at risk. High quality early childhood education and highly supportive childcare can play an integral role in child development and response to stressful environments. Positive experiences like being exposed to an engaging learning environment with many opportunities for social play and exploration have been shown to reverse some of the negative effects of adversity and the resulting stress hormone output. In addition, the presence of a supportive and caring individual in a child’s life can help to buffer them against stress hormone exposure. Because children who are abused or neglected show elevated levels of cortisol production even once they have been moved to a safe and loving home, social programmes that address poverty and economic hardship, as well as education and early intervention programmes that prevent child maltreatment, are crucially important. School and community-based interventions that provide structure, consistency, and a nurturing and supportive environment can help children to adapt and prevent poor outcomes[vii].

‘Externalising’ disorders

Some of the most common ‘externalising’ disorders among children and young people are oppositional defiant disorder and conduct disorder.

Oppositional defiant disorder

Oppositional defiant disorder (ODD) is the mildest form of disruptive behaviour problem. Children with ODD may demonstrate defiant behaviour towards authority figures, quickly lose their temper, or display irritable, angry, or spiteful and vindictive behaviour. To be diagnosed, this behaviour must be persistent and ongoing, causing a negative impact on their lives at school, home, and in the community.

Conduct disorder

Conduct disorders are characterised by more extreme behaviours against people, animals or property, where the rights of other people, age-appropriate societal norms, rules or laws are violated. This may include an ongoing pattern of behaviours like excessive fighting or bullying, stealing, lying, intentional injury, and being defiant, destructive, or physically cruel. Children with conduct disorders may lack age-appropriate social skills and have difficulty making and maintaining friendships. They may misinterpret the communication and actions of others as mean or aggressive even when they are not. About 30-75% of children with conduct disorder also have ADHD, and 50% meet the criteria for at least one other disorder, including anxiety, post-traumatic stress disorder (PTSD), substance abuse, learning problems, and other mental health disorders. Most children grow out of conduct disorders, although some develop antisocial personality disorder as adults[viii].

ADHD

ADHD is very common, affecting between 5% and 12% of children in developed countries. ADHD is characterised by an ongoing pattern of hyperactive, impulsive, and inattentive behaviour that is extreme and interferes with everyday functioning. Individuals with ADHD can manifest both externalising and internalising factors[ix]. See additional information about ADHD including classroom strategies here.

‘Internalising’ disorders

The most common ‘internalising’ disorders among children and young people are anxiety and depression.

Anxiety

It is normal for children to worry before a big test, during a fire or severe weather drill, or when they are separated from their parents. Anxiety can be considered ‘adaptive’ if it results in the individual taking an action that helps them to avoid a threat. However, when there is generalised fear or worry that is not triggered by a specific situation, or if anxiety becomes so severe that the child is consistently worried to the point where it interferes with their everyday functioning, they may have an anxiety disorder.

Anxiety disorders are the most common psychiatric illnesses in children and usually emerge during early childhood or adolescence. Around 10% to 20% of children and adolescents report significant levels of anxiety and at any time 6% to 10% of school-age children meet the criteria for an anxiety disorder[x]. In addition, anxiety symptoms are much more prevalent in females than males, with twice as many girls experiencing an anxiety disorder by age six. Anxiety symptoms can also change with age. As children grow older, some studies have found that separation anxiety usually diminishes but social anxiety can increase[xi].

There are many types of anxiety that may affect children in the classroom. Here are some of the more common varieties that children can struggle with:

• Separation anxiety: Students with separation anxiety have a difficult time being apart from caregivers
• Phobias: Students with phobias fear specific things like storms, fire drills, or heights
• Social anxiety: Students with social anxiety are extremely self-conscious, causing difficulty socialising with peers and participating in classroom activities
• Selective mutism: Students with selective mutism find it difficult speaking in certain settings
• Obsessive Compulsive Disorder: Students with this disorder have stressful or unwanted intrusive thoughts that they try to get rid of through rituals like counting to a certain number or handwashing
• Generalised anxiety: Students with generalised anxiety tend to be perfectionists or worry about school performance, although generalised anxiety can affect students throughout the day in many different areas

Depression

Depression is not simply feeling down or being in a bad mood. Even though we often use the word in this way, being depressed is not to do with having a normal reaction to a significant life event like a death in the family or bad break up. Depression is classified as an adult disorder and does not usually occur in really young children: the most common age when children develop depression is middle to late adolescence, around age 14[xii]. Depression is characterised by persistent and ongoing sad or irritable moods. Students with depression often have other disorders, such as anxiety disorders, conduct disorders, or ADHD. If depression is recognised early, students can be supported to function better at and outside of school.

Depression has a major impact on academic performance. Students with depression are more likely to struggle academically, have difficulty with social interactions in the school setting, have low grades, and rate their own academic performance and competence as low. They are also less likely to graduate from high school. Schools can support students with depression by providing information about depression, helping parents and teachers to know the signs of depression so that it can be identified early, monitoring students at risk for depression, and creating a supportive environment where students receive the help that they need.

What do anxiety and depression look like in the classroom?

Since anxiety and depression are internalising disorders, they can be difficult for teachers and caregivers to identify. Anxiety may look like many different things including inattention, disorganisation, apathy, shyness, learning problems, or behavioural issues. Some researchers have also suggested that anxiety often goes unnoticed by teachers as students with mild to moderate anxiety are unlikely to have disruptive behaviour, although studies show that teachers are able to accurately identify children with anxiety, especially those with somatic complaints (see below), social anxiety, and separation anxiety. However, they may miss children with anxiety related to perfectionism common in those with generalised anxiety disorder. This may be because these symptoms are in line with appropriate classroom behaviour, and students may be rewarded for striving for perfection, avoiding risky situations, and people-pleasing[xiii].

Anxiety and depression may not always look the way that you would expect. In addition, depression can manifest differently in children than in adolescents and adults.  The following can be signs that a student is experiencing anxiety or depression:

• Somatic complaints: Students with anxiety may ask to see the nurse or go to the bathroom often. They may complain of headaches, nausea, stomachaches, sleepiness, heart palpitations or light-headedness without any underlying medical cause. Children with depression may appear sad, lethargic, or tired. They may have more complaints of illness.
• Academic difficulty: When they become anxious, students may have difficulty processing and retrieving information. They may try to avoid being called on or not be able to answer questions in front of the class even when they know the answer. Children with depression may display a lack of follow-up on school related tasks or have poor academic performance. They may have difficulty planning and organising tasks and may fail to complete academic tasks.
• Distorted thinking: Students with anxiety may be afraid of making mistakes and display a tendency towards perfectionism. They may be very critical of themselves and intolerant of errors, always wanting to get everything right or constantly requiring reassurance from the teacher. Sometimes they may only engage in tasks where they know they can do well. Teachers may also notice students with anxiety thinking in extremes, such as all-or-nothing or catastrophic thinking. Students with depression may fear failure or express doubt in their abilities. In addition, because they view experiences more negatively, they often have difficulty persevering when faced with a difficult task and may even refuse to attempt it. Adolescents may demonstrate a lack of interest in activities, even those that they previously enjoyed. They may have a negative view of their current situation, as well as the past and future, and may express self-esteem and self-worth issues.
• Difficulty concentrating: When a child is feeling anxious, he or she may have a difficult time focusing on the lesson because they are preoccupied by their own thoughts. Although this may appear similar to ADHD, this inattention is actually caused by anxiety. Students with depression may also have difficulty concentrating and remembering information.
• Attendance issues and truancy: Difficulty in a class, combined with being very self-critical, can make anxious students dread or avoid certain tasks, classes, or school in general. Students with anxiety may try to avoid situations that cause anxiety, like a particular class or a test. They may also avoid situations where they do not think they can perform perfectly. They may stop turning in assignments because they are concerned that they are not done correctly or avoid participating because they are feeling anxious about the content. Some students may refuse to go to school or have a difficult time transitioning back to school after vacations or sick days. Children with depression may seem unwilling or reluctant to attend school or may miss many days of school due to feeling unwell. Older students may be late for school or truant.
• Difficulty interacting with peers: Students with anxiety may have difficulty making and sustaining friendships, initiating social interactions, or participating in classroom activities with their peers. Some students who have anxiety may withdraw socially and attempt to avoid social situations with peers. Children with depression may appear irritable and be easily agitated by peers. They may be more sensitive than other students to criticism and less likely to engage in social interactions. Adolescents with depression may be argumentative and as a result could experience rejection by peers.
• Disruptive and risky behaviour: Some children who have anxiety may become irritable because they feel upset, out of control, or threatened. This can manifest as throwing things, pushing over furniture, or physically fighting. In addition, anxious students might do things like repetitively tap a desk, kick a chair in front of them, or ask a lot of questions for reassurance in a way that could be perceived as disruptive in the classroom. Adolescents with depression may demonstrate impulsive or risky behavior and have issues with substance use and abuse.

Teaching strategies for supporting children with emotional and behavioural disorders

Teachers can set up a classroom environment where all students can learn and thrive. Explicitly teaching strategies that students can use when they feel overwhelmed, anxious or out of control supports them to become successful and independent, because they are able to carry the tools they learn with them as they continue their schooling. By educating and involving peers, school staff can create a classroom and school culture that is encouraging, supportive and accepting of all students. Teachers can use teacher-mediated, self-mediated, or peer-mediated interventions to support students with emotional and behavioural disorders in the classroom[xiv].

Teacher-mediated interventions

• Use a positive approach: Negative techniques like punishment, sarcasm or criticism are ineffective. Instead, teachers and school staff should offer support or additional help. The student may be doing the best that they are able to do at the time. Collaborate with other school personnel such as the special education teacher, school psychologist or social worker to make an effective plan. It is important that students with emotional and behavioural disorders feel like they have an important role in the classroom and acceptance from their teacher and peers, so look for and create opportunities within the classroom to set the student up for academic and social success. Some students may need accommodations like a peer helper, a copy of the notes, extended time, or advance notice of upcoming changes in order to be successful in the classroom. The teacher should hold high expectations but provide accommodations to give all students a fair opportunity to succeed.
• Manage transitions: Consider starting class with a light activity like a game, video or review to help students make the transition from one subject to another. Providing an easy way to get started can make it possible for students to tackle more difficult tasks later in the class period. In addition, it is important to have clear expectations when transitioning from one activity to another and strategies to keep students busy and engaged if they finish a task early.
• Provide structured breaks: Allow students to take a break when they are feeling overwhelmed. Students can think about activities that help them to feel better. Consider having them do something that they enjoy but that also keeps the mind and body busy. This keeps the break from turning into another chance to ruminate on their thoughts. For example, students can play music, complete a challenging puzzle, draw or paint, exercise, or knit. Brain breaks to move, dance or do yoga can also be incorporated into instruction as a whole-class activity since they will benefit most students. Students should choose activities that work best for them.
• Create a predictable routine: When the teacher establishes a basic routine that remains the same even when activities change, students feel more secure. Rather than force students to participate in group work when assigning a project, allow students options to demonstrate what they know. In addition, if an issue arises, address the problem one-on-one rather than in front of the whole class. Students with emotional and behavioural disorders often benefit from having a certain trusted teacher that they meet with daily or weekly to set goals, review assignments and workload, and receive support, who can also act as a liaison between the student and their regular classroom teachers.
• Have clear expectations: Teachers may also want to consider providing a rubric so that students know what is expected on assignments. In addition, providing ongoing feedback instead of only several marks per term gives students more opportunities for growth. When students will be tested, the teacher can help students to create a study guide and suggest ways that they can prepare so that they will know what to do. 
• Develop a system for communicating with parents or guardians: Daily communication with parents or guardians is crucial to the success of students with emotional and behavioural disorders. Having a system in place allows teachers and parents to communicate about a student’s academic, social and behavioural progress throughout the day. They can share positive experiences and collaborate to find solutions to any problems that may arise.

Self-mediated interventions (with teacher support)

• Make a plan: Students can be taught to monitor and label their feelings. If they are able to identify the physical signs of their emotions and possess the language to label their feelings or describe their fears, then they are in a better position to respond. Have anxious students think about times that they feel anxious or situations that act as stressors, then help them to walk through what they can do when they encounter one of these obstacles. In some cases, students with depression should be monitored for suicidal ideations and assisted in developing a ‘no-harm contract’ when necessary. Students with ongoing behavioural issues may work with teachers and other school staff to create a behaviour intervention plan. This plan teaches the student more productive behaviours and strategies, sets up rewards for positive behaviour, and outlines what the teacher and student will do when a problem behaviour occurs. Help students to identify supportive people that they can seek out and activities that help them to feel more at ease. This will help students to recognise patterns in their behaviour, seek proactive solutions, and feel more in control. When students have thought through potentially difficult or stressful scenarios in advance, they can respond to their emotions rather than reacting to them.
• Teach students how to make assignments manageable: Students can learn to make a checklist of classroom assignments and homework. For larger projects, learning to work backwards from the deadline and break the project into manageable steps helps students not to become overwhelmed. Students can learn to give each mini-step its own deadline and then schedule a time to complete it. Avoidance is a natural reaction to stress and sometimes students need help getting started. They may avoid starting on a task because they are anxious about it. Teachers can help with this by showing students the upcoming assignment in advance, working through a few problems with them, or beginning the assignment together.
• Teach self-monitoring strategies: Students can be taught to set and monitor their own goals so that they are working towards something that is important to them. They can observe and record their own behaviour, compare their performance to previously set criteria, and assess their own progress. They can also be taught strategies or specific sets of actions that they can implement in order to solve a problem or when faced with a particular situation. 

Peer-mediated interventions

• Provide opportunities for positive social interactions: Students with emotional and behavioural disorders may withdraw from their peers, so it is important to provide increased opportunities for positive social interactions. Students may benefit from working with supportive peers or attending a social skills group. Teachers can encourage students to participate in cooperative group activities and select group members that will help to make group participation a positive experience.
• Use peer tutors or mentors: Students may also benefit from peer tutoring or support from another student who is several years older. Older peers can help to model and reinforce appropriate responses as well as remediate academic difficulties. This can provide a source of support, mentorship, and positive social interaction.

Often teachers may suspect that a student is struggling with emotional or behavioural issues but have no clear diagnosis. If possible, teachers should plan to seek out additional support for that student following the procedures in place at their school. In the meantime, the teacher may wish to provide the interventions listed above as many of these strategies are beneficial for a wide variety of students who for one reason or another require a little extra support in the classroom in order to be successful.

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References

Crundwell, R. M., & Killu, K. (2007). Understanding and accommodating students with depression in the classroom. Teaching Exceptional Children, 40(1), 48-54. https://doi.org/10.1177/004005990704000106

Ehmke, R. (n.d.). Anxiety in the classroom. Retrieved April 24 2020, from https://childmind.org/article/classroom-anxiety-in-children/

Fischer, M. (2014, October). Students with depression: Help them find their way out. ASCA School Counselor, 18–22.

McKibben, S. (n.d.). Helping ease student anxiety. ASCD Education Update, 59(8). Retrieved from http://www.ascd.org/publications/newsletters/education-update/aug17/vol59/num08/Helping-Ease-Student-Anxiety.aspx

Ryan, J. B., Pierce, C. D., & Mooney, P. (2008). Evidence-based teaching strategies for students with EBD. Beyond Behavior, 17(3), 22–29.

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Endnotes

[i]  Ministry of Health (2018). Social, emotional and behavioural difficulties in New Zealand children: Technical report. Wellington: Ministry of Health.

[ii] Ogundele M. O. (2018). Behavioural and emotional disorders in childhood: A brief overview for paediatricians. World Journal of Clinical Pediatrics, 7(1), 9–26. https://doi.org/10.5409/wjcp.v7.i1.9

[iii] Killu, K., Marc, R., & Crundwell, A. (2016). Students with anxiety in the classroom: Educational accommodations and interventions. Beyond Behaviour, 25(2), 30–40. https://doi.org/10.1177/107429561602500205

[iv] Hagan, J. F., Balachova, T., Bertrand, J., Chasnoff, I., Dang, E., Fernandez-Baca, D., … Zubler, J. (2016). Neurobehavioural disorder associated with prenatal alcohol exposure. Pediatrics, 138(4), 1–17. doi: https://doi.org/10.1542/peds.2015-1553

[v] Ministry of Health (2018). Fetal alcohol spectrum disorder. Retrieved June 7, 2020, from https://www.health.govt.nz/our-work/diseases-and-conditions/fetal-alcohol-spectrum-disorder

[vi] Hagan et al., 2016.

[vii] National Scientific Council on the Developing Child. (2005/2014). Excessive stress disrupts the architecture of the developing brain: Working paper 3. Updated edition. http://www.developingchild.harvard.edu

[viii] Ogundele, 2018.

[ix] Kang, N. R., & Kwack, Y. S. (2019). Temperament and character profiles associated with internalizing and externalizing problems in children with Attention Deficit Hyperactivity Disorder. Psychiatry Investigation, 16(3), 206–212. https://doi.org/10.30773/pi.2019.01.10.1

[x] Killu, Marc, & Crundwell, 2016.

[xi] Layne, A. E., Bernstein, G. A., & March, J. S. (2006). Teacher awareness of anxiety symptoms in children. Child Psychiatry & Human Development, 36(4), 383–392. https://doi.org/10.1007/s10578-006-0009-6

[xii] Crundwell, M. A., & Killu, K. (2010). Responding to a student’s depression. Educational Leadership, 68(2), 46–51.

[xiii] Layne et al., 2006.

[xiv] Ryan, J. B., Pierce, C. D., & Mooney, P. (2008). Evidence-based teaching strategies for students with EBD. Beyond Behavior, 17(3), 22–29.

By Nina Parrish