In January, I read an article published in ASHA’s SIG 16 Perspectives December 2012 issue by Alexandra Hollo from the Department of Special Education, at Vanderbilt University in Nashville, Tenn., titled “Language and Behavior Disorders in School-Age Children: Comorbidity and Communication in the Classroom.” She brought up some really good points that I think we, as SLPs, need to keep in mind when discussing, assessing and treating children who are labeled with behavior disorders.
Hollo discusses how often times children labeled with EBD (emotional and behavioral disorders) also have undiagnosed LI (language impairment). According to this article, “Four out of five students with EBD are likely to have an unidentified language deficit,” which may result in children resorting to physical communication rather than effective use of expressive language to resolve issues. In fact, it is estimated that 80.6 percent of students with EBD also have LI however, more than 50 percent of those LI diagnoses remain unidentified. If staff members fail to recognize the child’s inability to functionally communicate, negative feelings and interactions between the student and staff members may result, which in turn negatively affects academic achievement. What is known about children with EBD is that they “have the most negative short- and long-term outcomes” (Hollo, 2012).
So what does EBD look like in children? Well Hollo explains the two subcategories of EBD according to the DSM-IV, difficulties with internalizing and externalizing. Deficits in internalizing include emotional withdrawal behaviors such as depression, anxiety or mood disorders. Academic trends for these students with internalizing problems include high rates of absenteeism and low academic achievement. Deficits in externalizing include disruptive behavior as in ADHD, ODD or conduct disorder. Students with externalizing deficits tend to be more easily identified and receive services possibly due to the fact that their behavior is disruptive in the academic setting and can more easily be determined to interfere with learning. Academic trends for students with externalizing issues: disruptive behavior tends to interrupt and/or terminate instruction and therefore affect learning. More importantly, it was stated that although students with EBD do perform similarly to those with other disorders on standardized tests, their academic performance tends to be BELOW that of other students with disabilities.
In addition to academic deficits, children with EBD also demonstrate deficits in language and social skills. These children more often exhibit expressive language deficits rather than deficits in receptive language, and they tend to use simplified language within the classroom environment resulting in teachers grossly overestimating the student’s expressive language abilities. It is important to note that based on Hollo’s research, the CELF and TOLD were the only two language tests that were able to consistently identify LI in children already diagnosed with EBD.
Socially, children with EBD tend to have negative teacher interactions, are often times rejected or victimized by peers, and struggle with use of effective conversational skills due to difficulties in initiating and maintaining friendships, problem solving deficits, and difficulties cooperating and collaborating with peers and adults. In addition, students with EBD tend to be impulsive and struggle with the use of “inner dialogue” to effectively reason prior to responding to their emotions within various situations. Their ability to control their emotions, follow directions, and transition between activities, classes and subjects is also affected.
Why is this information important for us as SLPs to know? Well we must first be educated on the comorbidity between EBD and LI to effectively screen, assess, and treat these students. We also have the responsibility to train staff members on the child’s communication and social skills deficits so as their behaviors may not be misconstrued. We as SLPs can be instrumental in implementing linguistic supports for these children which include direct (i.e. teaching emotional language, using self-talk for regulation and problem solving skills, provide opportunities to practice negotiations with peers, etc.) and indirect instruction (i.e. collaborate with staff, train teachers on effective communication styles, teach use of slow rate of speech, etc.). In addition, we can work with behavioral specialists to follow and enforce the behavioral supports that are deemed necessary to help students with EBD be successful in their daily environments.
So the next time you are in your weekly RTI meeting discussing a “problem child” or a “shy, quiet student,” pay attention, and keep in mind that EBD does not look the same in every child. Some behaviors may in fact be linked to language deficits. Only we, as SLPs will be able to make that determination effectively in order to ensure students receive the services and support they require.
Note: This entire article was not discussed in detail here. I discussed the information I felt was important based on my personal clinical experiences. I refer you to Hollo’s complete article in the December 2012 SIG 16 issue for further information and details.
Maria Del Duca, M.S. CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona. She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name. Maria received her master’s degree from Bloomsburg University of Pennsylvania. She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues. She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in NJ, MD, KS and now AZ. Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech. For more information, visit her blog or find her on Facebook.