Abstract
Schools are seeing an influx of disruptive behaviors related to an increase in emotional and behavioral issues. In the adolescent population, emotional and behavioral problems are manifested in a variety of forms and often result in some form of discipline within the school setting. Although discipline punishes the unwanted behavior, it does nothing to address the reason for the behavior. This study examined the prevalence of emotional and behavioral problems among middle school students who have been suspended. Students who are suspended are the very children at risk for social, emotional, and mental health problems. Results from the study indicate significance in some of the 14 subcategories of the Student Behavior Survey tool, lending support toward the conclusion that emotional and behavioral problems may be associated with suspensions. Advocating for assessment of emotional and behavioral needs should be considered for students with discipline problems that lead to suspension.
Keywords
INTRODUCTION
The emotional and behavioral needs of children and adolescents have become a dilemma for health care professionals and school districts. The American Academy of Pediatrics (AAP) estimates that 20% of school-age children have mental health needs (AAP, 2004). One in 10 children are burdened with a level of mental illness so severe that it impairs his or her emotional, behavioral, and developmental needs (U.S. Public Health Service [USPHS], 2001). The National Association of School Nurses (NASN) has recognized the importance of positive mental health in successful academic achievement. Without skills to promote positive mental health, students experience barriers in learning (NASN, 2000). If left untreated, emotional and behavioral problems can affect learning and school performance, relationships and social interaction, self-esteem, and life skills (Goldman, 2000). The National Action Agenda for Children’s Mental Health identifies assessment and recognition of mental health problems as the tools necessary to provide mitigation of emotional and behavioral problems (USPHS, 2001).
With an increase in emotional and behavioral problems, schools are seeing an influx of disruptive behaviors (Nelson, Benner, Reid, Epstein, & Currin, 2002). For adolescents, emotional and behavioral issues manifest themselves in a variety of forms. Students may be argumentative or may show (a) moodiness, (b) anger, (c) sensitivity, (d) aggressiveness, (e) ambivalence, (f) poor concentration, (g) lack of participation, (h) increased risk-taking activities, or (i) fatigue. Many of these behaviors can lead to some form of discipline within the school setting. Although the goal of discipline is to punish the unwanted behavior, it does not address the reason for the behavior.
Other organizations have raised similar concerns surrounding the emotional and behavioral needs of suspended students. The AAP notes that students who are suspended are the very children at risk for social, emotional, and mental health problems (2003). These students are also more likely to be left unsupervised at home, leading to other high-risk behaviors. The American Academy of Child and Adolescent Psychiatry’s (AACAP) Call to Action (2002) addresses the increased demand for child and adolescent mental health services through 2020.
LITERATURE REVIEW
Prevalence
The prevalence of school violence, high dropout rates, bullying, high suicide and homicide rates, and increased levels of high-risk behaviors substantiate the magnitude of emotional and behavioral problems experienced by youth (AAP, 2004). The pediatric population receiving psychosocial care has increased from 7% to 19%, with 20% needing mental health intervention, 11% having significant functional impairment, and 5% having extreme functional impairment (AAP). Currently there are over 15 million children and adolescents in need of services from a child–adolescent psychiatrist (AACAP, 2002). This number is expected to increase with more children in need of services and fewer psychiatric services to meet the demand.
An increase in mental health problems is confirmed by Achenback and Howell’s (1993) 13-year longitudinal study from 1976–1989. The Child Behavior Checklist and the Teacher Report Form showed that children had more untreated mental health needs in 1998 than in 1976. Scoring revealed that 10% of students 7–16 years of age needed mental health treatment in 1976 compared with 18% in 1989. These scholars have set the groundwork for comparative studies of behavioral and emotional problems in school-age children that will reveal the rising unmet mental health needs of youth in the United States.
Barriers
While socioeconomic, environmental, demographic, and parental factors have been linked as predictive risk factors in emotional and behavioral problems, early identification of mental health problems can change the trajectory of problematic adult functioning (Eamon & Altshuler, 2004). Access to early treatment is critical for successful life adjustment. When families and children identify available services for emotional and behavioral problems, the services are not always used. Financial barriers, health insurance coverage, transportation, and stigma related to a mental health diagnosis prevent children and their families from accessing services. Those families that begin therapy attend only one to two sessions, with 40–60% terminating early (AAP, 2004). Access to medical services places pediatricians at the front line to address this concern. The AAP challenges pediatricians to place attention on the quality of outcomes, management of chronic disease, and psychosocial needs of patients (AAP, 2001). The academy also states that existing educational, economic, and time management barriers must be overcome.
When families and children identify available services for emotional and behavioral problems, the services are not always used. Financial barriers, health insurance coverage, transportation, and stigma related to a mental health diagnosis prevent children and their families from accessing services.
Discipline and Punishment
Consequences of emotional and behavioral problems in school result in many students being punished. The punishment serves to protect other students, alert parents, and discourage continued unwanted behavior (AAP, 2003). However, punishment does nothing to address the problem behind the behavior. The AAP advocates for emotional, social, and mental health services for students to decrease school suspensions. They also recommend that schools and pediatricians work together to determine the cause of emotional and behavioral problems and to find alternate discipline as warranted.
Nelson and colleagues (2002) addressed this issue by using office referrals as an index for determining mental health needs. Office referrals serve as an early screening process for intervention programs. Their study revealed a high number of false negatives, suggesting that large numbers of referred students might not be identified for mental health needs. Based on the findings of their study, evaluating every referral may not be effective; however, the use of a screening tool for continued disruptive behavior that leads to discipline and suspension would be useful. School discipline for students with attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder can begin as early as elementary school. School transitions and peer relations may be factors contributing to problem behaviors (DeSocio & Hootman, 2004). Early assessment and intervention are necessary to diffuse long-term consequences to debilitating conditions.
Behavioral Support
In an attempt to alter the trajectory of emotional and behavioral problems, schools are implementing programs to reduce disruptive behavior. This preventive approach stems from increased attention on school violence, lack of discipline, and zero-tolerance policies (Sugai & Horner, 2002). The challenge for schools is to provide an assessment strategy for dealing with emotional and behavioral problems within the school setting with emphasis placed on positive preventive approaches. The use of positive behavioral support is an approach developed as an alternative to the practice of negative punishment (Sugai & Horner, 2002). This positive approach is a preventive method that can be used with all students, including students in special education. The goal of behavioral support programs is to promote positive social skills through the use of specific behavioral expectations of students; active school supervision before, during, and after school; and explicit school district disciplinary policies (Nelson, Martella, & Marchand-Martella, 2002).
The challenge for schools is to provide an assessment strategy for dealing with emotional and behavioral problems within the school setting with emphasis placed on positive preventive approaches.
Student Behavior Survey
Recommendations from research evaluating emotional and behavioral problems confirm that early intervention services for at-risk behavior are beneficial (Fox, Dunlap, & Cushing, 2002). Students with behavioral problems require significant time and attention from school staff members (Eber, Sugai, Smith, & Scott, 2002). Wingenfeld, Lachar, Gruber, and Kline’s (1998) Student Behavior Survey allows for individual teacher assessment or multi-informant evaluations to be used in conjunction with the tool. When creating the SBS, Wingenfeld and colleagues (1998) believed teachers had a unique vantage; teachers view students in a variety of settings and situations, both academically and socially. This perspective allows teachers to make contributions that are vital regarding child and peer behavior and age appropriateness (Wingenfeld, 2002). The value of a multiscaled behavioral rating tool, like the SBS, is that it allows teachers to assess the student’s function in relation to the school environment (Lachar, Wingenfeld, Kline, & Gruber, 2004).
CONCEPTUAL FRAMEWORK
Children react to life’s stresses with a myriad of responses. They may display moodiness, anger, aggression, defiance, or act out. Behavior is one index that can be used in assessing a child’s coping mechanisms. As students mature, to achieve social, academic, and developmental appropriateness they attempt to balance these life changes with other stressors. Increasing family stress, personal pressures, and limited coping skills leave many children feeling vulnerable and unable to adapt. These behaviors manifest themselves in the school environment as emotional and behavioral problems (AAP, 2003).
Students with behavioral problems require significant time and attention from school staff members.
The Resiliency Model of Family Stress, Adjustment, and Adaptation (Double ABCX Model) examines adjustment and adaptation as a goal for families and individuals in dealing with crisis (Murata, 1995). As stressors accumulate, the individual becomes overwhelmed with the situation. The resiliency model examines family adaptability and determines what patterns of functioning are used. Individual and family strengths are evaluated, including family support through spirituality, financial stability, and open communication (Malone, 1998).
When emotional and behavioral problems become apparent, assessment can focus on specific stressors. The SBS is a multiscaled tool intended to assess for a student’s emotional and behavioral problems. Like the Resiliency Model of Family Stress, Adjustment, and Adaptation, the SBS identifies problematic areas (stressors) and strengths (resources) of the individual through assessment of the student. Such variables as personal and family perception of the event and stressor can alter the trajectory of an individual’s coping skills. The goal for the individual is to build on strengths and promote the problem-solving skills needed for long-term adaptation. Review of assessment data from the SBS provides families and schools with options for positive change or appropriate intervention.
METHODOLOGY
This quantitative, nonexperimental study used the SBS to assess 23 middle school students who were suspended and verify the prevalence of emotional and behavioral problems that may have led to their suspension. The SBS identifies the (a) academic achievement, (b) adjustment problems, and (c) behavioral assets of the student in relation to the classroom; specifically measuring aggression, hyperactivity, conduct problems, and social skills (Lachar et al., 2004). The SBS is a 102-item tool using a Likert scale that takes school personnel 15 minutes to answer. The SBS is appropriate for assessing students in kindergarten through 12th grade. Of those students participating in the study, demographic information was solicited, including grade, gender, socioeconomic status, and ethnicity. For the purpose of this study, low socioeconomic background was defined as those students who participate in the free breakfast/lunch program at school.
The SBS is organized into three categories: academic resources, adjustment problems, and disruptive behavior. Various scales are used in each category, with a total of 14 subcategories. The academic resources category assesses strengths in regards to academic performance, academic habits, social skills, and parent participation. Parent participation is defined as school personnel’s perception of parent involvement. Adjustment problems are recorded in the next category and include (a) health concerns, (b) emotional distress, (c) unusual behavior, (d) social problems, (e) verbal aggression, (f) physical aggression, and (g) behavior problems. Disruptive behavior, the last category, comprises questions related to attention deficit hyperactivity, oppositional defiant, and conduct problems as defined by the DSM-IV(Lacher, Wingenfeld, Kline, & Gruber, 2000).
The SBS is reliable with a Cronbach’s alpha range of 0.86–0.93 and is internally consistent (median alpha is 0.88) both over time (median retest reliability over 1–2 week intervals is 0.86) and across observers (median interrater correlation is 0.73). Validity correlates with concurrent parents’ and clinician’s observations and other teacher report forms (Lachar et al., 2004).
Subjects and Sampling
This study was conducted in a rural middle school of 932 students, 11–14 years of age, enrolled in the 6th–8th grades. This school district comprises 14 schools with an approximate enrollment of 9,500 students. Twenty-three students participated of the 85 students who had been suspended in the 2004–2005 school year. The investigator contacted the students’ families by phone and/or mail to inform them and then obtained written parental or guardian consent for the student to participate in the study. Bilingual school staff provided language specific information to Spanish-speaking parents. Parental or guardian permission was obtained from the English or Spanish consent form for families wishing to participate. The parental consent form was translated and back translated by the District Translator for the school district. For each suspended student with signed parental consent, one school personnel member familiar with the student also completed the SBS. Participant school personnel included 12 teachers whose specialty included language and reading, social studies, computers, or math. Teacher consent was obtained before student assessment.
Twenty-three student assessments were completed; two of the students had individual education plans. Participants in the study included 8 females (34% of the study population) and 15 males (65%); 6 were 6th-graders (26%), four were 7th-graders (17%), and 13 were 8th-graders (56%). Participants included 16 Hispanic students (69%), 2 African American students (1%), and 4 Caucasian students (17%). Seventeen of the students (73%) participated in the free breakfast/lunch program.
Data Analysis
Responses from the SBS were scored for each student by using the self-score format provided by the survey. Responses were summed for each of the 14 subcategories to derive a raw score. The SBS tool provided conversion from the raw score to a t score (percentile of norm). The SBS tool defines t scores from 41 to 59 as normal with the norm as a t score of 50, 60 to 69 as above norm, 70 and above as significantly above norm, 35 to 40 as below norm, and 34 and below as significantly below norm. Each of the SBS’s 14 subcategories had average t scores calculated for each defined attribute. Each of the subcategories average t scores were plotted for all groups.
To determine whether any subgroup had significantly influenced survey results, each subgroup mean was statistically compared to the population mean with a null hypothesis stating the means were equivalent. To minimize the probability of an unobserved behavioral influence, a conservative two-tail alpha of 0.30 was selected. This tighter control limit allows detection of subtle deviant influences. Because sample sizes were small, Student’s t tables provided values to calculate upper and lower control limits.
RESULTS
Academic Resources
Results from the academic resources category (Figure 1) confirm average t scores below the norm (35–40) or significantly below the norm (34 and below) as defined by the SBS tool. An overall average of 36 for academic performance subcategory was noted to be below the norm for the sample. Significance in this subcategory reveals Caucasian students (44) and students not participating in the free breakfast/lunch program (44) scored higher than those students participating in the free breakfast/lunch program (34) and Hispanic students (34). Sixth-grade students scored well in academic habits (43) and social skills subcategories (42) compared with the overall scores (34 and 32, respectively). Significance was noted in the parents’ participation subcategory for all students (27). The decreased level of parents’ participation noted for female students (18) may be attributed to the low number of survey participants (n = 8).
Adjustment Problem
Adjustment problem’s subcategories (Figure 2) indicate elevated average t scores above the norm (60–69) or significantly above the norm (70 and above) as defined by the SBS tool. Overall scoring for the verbal aggression subcategory was elevated (68), compared with 6th-grade students who scored closest to the norm (61). Significance was noted in the physical aggression subcategory for 8th-grade students (71) compared with the overall sample (66) and students not participating in free breakfast/lunch program (57). Eighth-grade students (75) and the overall sample 69) exhibited significant scores in the behavior problems subcategory in contrast to Caucasian students (61).
Disruptive Behavior
Average t scores in the disruptive behavior subcategory (Figure 3) were all above the norm (60–69) or significantly above the norm (70 and above) as defined by the SBS tool. The overall sample for the oppositional defiant subcategory denotes scores above the norm (68), with 6th-grade students scoring closest to the norm (61). Significance was noted for 8th-grade students (76) and the overall sample (71) in the conduct problems subcategory, compared with 6th-grade students (62), Caucasian students (59), and those students not participating in the free breakfast/lunch program (63).
Limitations
This study did not predict problem-behavior students but, rather, identified the emotional and behavioral needs of those students who are most problematic. There were several limitations related to this study. First, participants were not a random sample; identification for assessment was based on preset criteria. Qualifying criteria included student suspension; suspended students limited the available participants. Another limitation was the single assessment done on each student. One member from school personnel familiar with the suspended student completed the SBS; multiple assessments from other informants using the SBS or other tools were not completed because of budget constraints and time limitations. Because of the limitation of one assessor per suspended student, only one perspective of the assessed student was used. The Likert scale used within the SBS does not allow for a “not applicable” or “not known” response for the evaluator to consider, which is a limitation of the tool.
DISCUSSION
Results from the study indicate significance in some of the 14 subcategories, lending support toward the conclusion that emotional and behavioral problems may be associated with suspended students. Academic resources, adjustment problems, and disruptive behavior categories confirm significant results below and above the norm threshold as defined by the SBS. In examining the data 6th-grade students faired better than their older peers (i.e., 7th- & 8th-graders) in most subcategories. For these younger students, unwanted behaviors or specific emotional needs may not be addressed early in the school setting; as these students mature, the disruptive behavior continues to escalate during the middle school years. Disruptive school behavior has been linked to poor school achievement (Eamon & Altshuler, 2004). These behaviors may become barriers to students’ learning, having long-term consequences as adolescents mature.
Eamon and Altshuler (2004) identified parenting practices as predictive indicators of a student’s behavior problems at school. Findings from this study indicated that participants from all grade levels, genders, all ethnicities, and socioeconomic status were deviant from the norm in the parents’ participation subcategory. The connection between low parent involvement and behavior problems needs further evaluation.
Those students participating in the free breakfast/lunch program had scores deviant from the norm in all areas of academic resources. Also of concern are the elevated scores for verbal and physical aggression, and behavior problems subcategories. Predictive sociodemographic factors of behavioral problems include students living in poverty (Eamon & Altshuler, 2004). Barriers often prevent lower socioeconomic families from accessing services; the schools then become the primary source of services for these students (DeSocio & Hootman, 2004). Schools are appropriately placed to intervene; current economics, including inadequate funding and cutbacks, may limit the school’s ability to provide assistance to this needy population.
Identification of the factors associated with the disruptive behavior is necessary to improve academic success and to treat students’ emotional and behavioral needs.
The findings from this study indicate value in further research, including a larger control sample and experimental sample of suspended and nonsuspended students, for a comparative study of the defined attributes of this sample. Age, gender, ethnicity, and socioeconomic status may be contributing factors to the behavior–suspension relationship and should be analyzed further in future research. It would seem evident that students who are suspended are dealing with a plethora of issues that influence their coping ability, thus manifesting itself as problematic behavior. Identification of the factors associated with the disruptive behavior is necessary to improve academic success and to treat students’ emotional and behavioral needs. Definitive conclusions should not be made based on the results from a single survey, and the SBS assessment information should be used with other evaluative information to plan further interventions.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
Advocating for assessment of emotional and behavioral needs should be considered for students with discipline problems that lead to suspension. School nurses see an array of physical and psychological symptoms and may have contributory information concerning a student’s behavior. School nurses must then advocate for students’ needs by collaborating with school personnel responsible for school discipline. When repeated emotional or behavioral problems are observed, school nurses must be more proactive initiating student study team meetings. These meetings allow for the discussion of behavioral problems, emotional concerns, and academic problems with parents, teachers, and administrators. This interdisciplinary collaboration with school team members provides needed insight into classroom behavior. The NASN (2000) promotes services that support prevention and early identification of emotional and behavioral concerns. The source or stimulus for the behavior or stressor needs to be addressed before unwanted conduct escalates. Incorporation of an assessment tool that is affordable and manageable, such as the SBS, has merit. School nurses could use the tool as part of their assessment for student study teams or for assessment of students exhibiting frequent discipline problems. In conjunction with other evaluative information from school personnel, family, and the student, a more complete understanding of the student’s needs can then be identified.
The AAP (2003) believes schools should provide resources to students whose behavior will result in disciplinary action. School nurses need to encourage partnerships between schools and community agencies to provide intervention strategies to treat a student’s emotional and behavioral needs. With respect to school nurses’ knowledge of their community resources, NASN (2000) promotes and endorses the school nurse as a liaison among the school, family, and community. The role of the school nurse must also encompass assisting school districts to promote policy that provides positive social skills through behavioral support programs. School personnel should be encouraged and supported in providing conflict resolution skills to their students; these skills provide valuable tools for problem solving while promoting consistent behavioral expectations. Continuity, feasibility, and cost-effectiveness all play a role in how schools will manage students with behavioral problems and suspensions. Recognizing issues associated with disruptive behavior could prove to be a significant factor in improving academic success and identifying a student’s emotional and behavioral needs.