This is the first part in a two-part series. Come back next week to learn more from our experts and authors. Katherine is an 8 year old who attends public school. Following a traumatic event, she began to insist on wearing a helmet to school and during class. When school personnel requested she remove the helmet, she adamantly refused, expressing fear that the ceiling would fall and they would all be killed. Her grades have dropped considerably, and she is having problems socializing with peers. Her mother reports similar disruptions at home. Katherine’s grades have dropped to Ds and Fs, and her behavior has become disruptive in class. She cries frequently and has most recently expressed a desire to stay home from school. Jeremy is a fifth grader who currently receives special education services under the category of emotional disturbance (ED) and other health impaired (OHI). One year after his initial ED diagnosis, he was diagnosed with autism spectrum disorder (ASD). His original ED eligibility was based on violent behavior in kindergarten and first grade. Once it became evident that his violent outbursts were related to characteristics associated with his ASD diagnosis and appropriate interventions were put into place, Jeremy was able to function more effectively at school. His grades are above average, and he has not experienced any behavioral outbursts since second grade. His parents are planning to place him in a private school and have requested an evaluation to eliminate the ED diagnosis. They believe the OHI eligibility is the most appropriate eligibility for him; the school administration and teachers agree. Brian is a 15 year old who was expelled from his last school for calling in a bomb threat. The administration at his home school considers him occasionally volatile and “a constant liar.” His mother confirms the lying and additionally reports daily fights between Brian and her live-in boyfriend. She states that “he hangs with a bad crowd, and his behavior is out of control.” Brian’s teachers describe him as a loner who appears sad throughout the school day. His grades have dropped from Bs to Ds and Fs. These three cases exemplify the diversity and difficulty inherent with evaluating students who have been referred for a comprehensive assessment due to academic and/or behavioral concerns. History of ED Prevalence In the 2001-2002 school year, there were 6.3 million students in special education programs. Of these, 473,663 were classified as emotionally disturbed, according to the National Center for Education Statistics —a number that had increased 18.4% from the previous 10 years (1991-1992). By 2002, ED had become the fourth most prevalent of the 13 exceptionalities served by special education, and there was every indication that an increase in both number and proportion for this group would continue to occur. Instead, we began to see a decline. By the 2011-2012 school year, only 373,000 students were classified as having ED. It appeared the numbers were dwindling. Yet, recent research has reported that parents and caregivers of more than 8 million school-aged children ages 4 to 17 years have sought help from a mental health professional or school staff member about their child’s emotional or behavioral difficulties. Clearly, questions arise. What accounts for the disparity between those asking for help and those receiving services? How do we account for what appears to be an under-identification of ED in the schools? What can we put in place to stop the decline and get those who require help the services they need? The Difficulty with ED Eligibility Students with emotional disturbance are especially difficult to assess and identify, and the evaluation itself is time consuming. Whether determining, changing, or removing eligibility, clinicians usually have an idea of who needs help emotionally. However, determining whether a student qualifies for special education services within the Individuals with Disabilities Education Act (IDEA) category of ED can be complicated . One of the greatest challenges in determining eligibility services involves the social maladjustment/emotional disturbance dichotomy. The term socially maladjusted (SM) has not been defined by IDEA. The federal definition of ED, which was written in 1957 and remains virtually unchanged, leaves the operationalization of the criteria set forth by IDEA to individuals and organizations in the field along with state and local educational agencies, who are responsible for implementing special education services. To further complicate matters, we have only recently begun to question the longstanding belief that SM students externalize their behaviors, while ED students internalize their behaviors. However, since ED was defined in 1957, neuroscience has shown that “brain differences underlie both internalizing and externalizing behaviors,” says Richard M. Marshall, EdD, PhD, author of the Pediatric Behavior Rating Scale (PBRS) . “From a neurobiological perspective, therefore, the only difference between the two is the expression of behavior. There is little evidence that students with externalizing behaviors are any more capable of controlling their emotions or behavior than students with internalizing disorders. Yet students with internalizing disorders are provided with interventions, while students with externalizing behaviors are punished.” In addition to the difficulties defining and determining SM versus ED, the federal criteria definition includes two potential areas of ED eligibility that are very broad and have no clinical definition: “An inability to build and maintain satisfactory interpersonal relationships with peers and teachers.” “Inappropriate types of behavior or feelings under normal circumstances.”Also, the Office of Special Education Programs (OSEP) has never provided official guidelines for potential exclusionary criteria for an ED diagnosis such as severity, educational impact, and duration. Although some feedback on these issues has been provided, no formal guidelines have been published. The federal definition does allude to some clinical conditions (e.g., depression, anxiety, and schizophrenia), but it doesn’t provide guidelines for how these conditions should be diagnosed.Lastly, we cannot negate the fact that in the past, psychologists lacked psychometrically sound instruments to provide them with the hard data needed to substantiate a well-informed decision in regards to ED eligibility. Come back next week to learn more on this topic from our experts.