RTI: An Intervention-Based Approach to Identification and Treatment of EBD

1. RTI: An Intervention-Based Approach toIdentification and Treatment of EBD Frank M. Gresham, Ph.D. Louisiana State University gresham@lsu.edu

2. Some Issues in ED Determination • Students with emotional/behavioral challenges unserved/underserved • Students often create chaotic classroom or school environments • Prevalence rate for ED projected @ 2% but always has been <1% • ED shows greatest state variability than any of 13 disability groups • ED definition: • Vague • Confusing • Contradictory (bordering on the oxymoronic)* • Estimates suggest that 20% of kids in schools need mental health services • Schools often believe they are not responsible for mental health services • Schools often see conduct problems as responsibility other agencies “The term does not include children who are socially maladjusted, unless it is determined that they are seriously emotionally disturbed.”

3. Let’s Play the Logic Game • Frank is socially maladjusted. • Frank therefore cannot be emotionally disturbed. • Frank is determined to be emotionally disturbed. • Frank is both socially maladjusted & emotionally disturbed. • ???????

4. Some Numbers27th Annual Report to Congress (2005) CA (6-21 yrs.) US (6-21 yrs.) ED SLD MR CA under-identifies (under-serves???) ED and MR and overserves SLD relative to US average

5. Prevalence Rate Relative to Population CA US ED SLD MR

6. The Real CulpritIDEIA Definition • Chronicity (“Long period of time”) • Severity (“To a marked degree”) • Outcome (“Adversely affects educational performance”) • Characteristics • Inability to learn • Inability to build or maintain satisfactory interpersonal relationships • Inappropriate types of behavior under normal circumstances • General pervasive mood of unhappiness or depression • Tendency to develop physical symptoms or fears associated with personal or school problems • Does not include social maladjustment, unless student is ED (???)

7. Social Maladjustment Exclusion Clause • Conceptually illogical • Over 20 published articles question and refute its existence • IDEIA statute provides no definition of SM • IDEIA regulations provide not guidelines for distinguishing SM from ED • About ½ of the states ignore social maladjustment exclusion • Many psychological disorders are co-morbid • Conduct Disorder + Depression • Oppositional Defiant Disorder + ADHD • Conduct Disorder + ADHD “A youngster cannot be socially maladjusted by any credible interpretation of the term without exhibiting one or more of the five characteristics to a marked degree and over a long period of time.” (Kauffman, 1997, p. 28)

8. RTI: Provision of high-quality interventions matched to student need, frequent progress monitoring to guide decisions about changes in interventions, and using student data to guide important educational decisions.* • High-Quality Instruction/Intervention • Matched to student need • Scientifically-based • Individually-based • Learning Rate and Level of Performance • Rate=Growth over time compared to peers • Level=Relative standing on dimension of achievement/behavior • Data-based decision making (decisions based on student data) • Important Educational Decisions • Based on individual response • Across multiple tiers of intervention • Decisions made about • Intensity of intervention • Special education eligibility • Exiting special education * National Association of State Directors of Special Education (2005)

9. NASP Position Statement on ED • “ED is more than a transient, expected response to stressors in the child’s or youth’s environment and would persist even with individualized interventions.” • “No single diagnosis should be used to deny services to students. The impact of the behavior on the student’s educational progress must be the guiding principle for identification.”* • “Persistence: The extent to which difficulties have continued despite the use of well-planned, empirically-based and individualized intervention strategies provided within the least restrictive environment. *Social Maladjustment Exclusion Clause

10. What is Scientifically-Based Knowledge? • Scientifically-based knowledge involves the application of rigorous, systematic, and objective procedures to obtain reliable and valid knowledge relevant to educational activities and programs • Scientifically-based knowledge is: • Objective • Involves direct measurement • Reliable and valid • Based on high quality experimental design • Rules out alternative explanations • High sensitivity (high true positive rates) • High specificity (high true negative rates) • Pseudoscience (4 out of 5 dentists recommend Crest) • Nonscience (My kid learned to read with Whole Language) • Nonsense (A child cannot be ED if he/she is socially maladjusted)

11. What Are Some Evidence-BasedBehavioral Interventions? • Group Contingencies (Good Behavior Game) • Token/Point Systems (with response cost component) • Replacement Behavior Training (teaching functionally equivalent behaviors) • Differential Reinforcement (DRO/DRA/DRI/DRL) • Antecedent-Based • Choice (preferred activities) • Task interspersal • Modification of task difficulty • Precorrection • Classroom-Based Behavioral Consultation • Performance Feedback (teachers’ integrity) • Self-Monitoring

12. Evidence-Based Treatments for DSM Categories(Journal of Clinical Child and Adolescent Psychology (2008), 37, pp. 1-301) • Disruptive Behavior Disorders (CD/ODD) • Anger Control Training (CBM-based intervention) • Behavioral Parent Training • First Steps to Success (classroom-based behavioral intervention) • Multisystemic Therapy (family/community-based treatment) • ADHD • Behavioral Parent Training • Behavioral Classroom Management • Anxiety Disorders • Individual Cognitive Behavior Therapy • Group Cognitive Behavior Therapy • Exposure-Based Therapies (specific fears/phobias) • Depression • Cognitive Behavior Therapy (Individual) • Cognitive Behavior Therapy (Group)

13. Fundamental Principles of RTI • Intensity of intervention matched to degree of unresponsiveness • Movement through tiers based on inadequate response • Decisions regarding movement based data from multiple sources • Increasing body of data collected to inform decision-making • Change in intervention considered only after inadequate response • Intervention delivery approaches • Problem solving (consultation) • Standard protocol

14. Advantages of RTI • Early identification of learning/behavior problems • Conceptualizes learning/behavior problems from riskrather than deficit model • Reduction of identification biases (overrepresentation) • Strong focus on student outcomes • Measures & domains based on relationships to child outcomes • Documents relationships to positive child outcomes • Emphasizes direct measurement of achievement, behavior, & the instructional environment • Focuses on measurable and changeable aspects of instructional environment • Identifies ABT students (Ain’t Been Taught)

15. Indirect measurement Within-child focus Nomothetic (groups) Moderate-high inference Behavioral stability Static, 1-shot assessment Lack of treatment validity Direct measurement Environmental focus Idiographic (individual) Low inference Behavioral variability Continuous progress monitoring Treatment validity Comparison of Traditional & RTI Assumptions Traditional RTI

16. What You Won’t See in a RTI Assessment • “Draw-a-Something” Measures • Apperception Tests • Rorschach Test • MMPI • WHY? • Because none of the above are directly related to child outcomes and are not useful in either planning interventions or progress monitoring the effects of interventions. • This type of information is superfluous to data-based decision making in RTI • Almost all are technically inadequate based on the Test Standards

17. Problem-Solving Logic in RTI • What is the problem? • Discrepancy between expected & current levels of performance • 100% homework completion expected but only 20% completed • Problems can be defined differently by different individuals • Why is the problem happening? • Can’ do • Won’t do • Low inference • What should be done about it? • Antecedent strategies • Consequent strategies • Instructional strategies • Did it work? • Data-based decision making • Benchmarks • Social validation

18. Assessment Principles in RTI • Purposes of Assessment • Referral • Screening • Classification • Intervention planning • Continuous progress monitoring • Program evaluation • Types of Assessment Data • Direct observations of behavior • Permanent products • Behavior ratings • Daily Behavior Reports • Assessment Principles • Problem Solving • Low Inference • Functional Assessment • Multiple Operationalism • Assessment Quality • Social Validity

19. Basic Principles of Screening for EBD in Schools • Similar logic to other fields (e.g., medicine) • PSA tests • PAP smears • Mammograms • Instruments must be technically sound • Low false negative rates • Low false positive rates (willing to tolerate higher) • Stable prediction over time • Cost beneficial (benefits outweigh costs) • Brief • Research based • Easily understood & applied

20. A Useful Behavior Screening Tool:Systematic Screening for Behavior DisordersWalker & Severson (1990) • Multiple Gating Procedure • Grades 1-6 • Combination of 3 Assessment Procedures • Teacher nominations-Gate 1 • Teacher rating scales –Gate 2 • Direct observations (classroom & playground)-Gate 3 • Nationally standardized (n=4500) • Normative data • Extensive reliability & validity data • Early Screening Project (ages 3-5 years) Published by Sopris West, Longmont, CO

21. SSBD(continued) • Gate 1 • Teachers rank order class on internalizing & externalizing behavior • Teacher select top 3 ranks for internalizing & externalizing behavior • Internalizing:Defined as overcontrolled behavior pattern characterized by social withdrawal, anxiety, and lacking self-confidence • Externalizing: Defined as an undercontrolled behavior pattern characterized by aggression, bullying, noncompliance, and impulsivity • Gate 2 • Teachers ratings & CEI checklist • Exceed normative criteria; move to next gate • Gate 3 • Direct observation in classroom & playground • Exceed normative criteria; move to intervention phase

22. Decision Rules for SSBD Screening Not At Risk At Risk Risk Indicator Present Risk Indicator Absent Accuracy=Correct Decisions/All Decisions A+D/A+B+C+D

23. Another Useful Screening Tool:Student Risk Screening Scale (Drummond, 1993) Lie, Cheat Bx Prob. Agg Beh. Peer Reject Low Ach Neg. Att. Steals Total 9-21 High Risk 4-8 Moderate Risk 0-3 Low Risk O-Never; 1-Occasionally; 2-Sometimes; 3-Frequently

24. 3-Tier Model of RTI Intervention • Universal Intervention • All students • Schoolwide or classwide • Examples (reading curriculum, school discipline procedures) • 80-85% will respond • Selected Interventions • Classroom strategies • Small group strategies • Consultation-based interventions • About 7-10% of students • Intensive Interventions • Individualized interventions • Intense & powerful (FBA-based interventions) • 3-5% of students

25. Types of RTI • Preventive RTI • Universal prevention (“primary prevention”) • Universal screening (2-3 times per year) • Reactive RTI • Selected interventions (“secondary prevention”) • Replaces refer-test-place model for ED • SPED Eligibility RTI • Intensive interventions (“tertiary prevention”) • “Disability” versus “Need” decisions

26. Multi-Tier Social Skills InterventionsSocial Skills Improvement System (Gresham & Elliott, 2008) • Classwide Intervention Program (CIP) Tier 1 Universal Intervention • Provides general education teachers with a structured efficient way to integrate opportunities 10 most important social skills for school success • CIP has 3 levels • Preschool/Kindergarten • Early Elementary (Grades 1-3) • Late Elementary/Middle (Grades 4-6) • Top 10 Social Skills (based on responses of over 800 teachers rating over 100 social skills: 0-Not important, 1-Important, 2-Critical) • Listens to others • Follows directions • Follows classroom rules • Ignores peer distractions • Asks for help • Takes turns in conversations • Cooperates with others • Controls temper in conflict situations • Acts responsibly with others • Shows kindness to others

27. Classwide Intervention Program(continued) • 6-Step Instructional Sequence • Tell (Coaching) • Show (Modeling) • Do (Behavioral Rehearsal) • Practice • Monitor Progress • Generalize • 3 lesson per week, 25 minutes per lesson X 10 weeks • Progress Monitoring Tools • Treatment Integrity Checks

28. SSIS Intervention GuideTier 2 Selected Intervention • Designed for weak responders to CIP • Teaches social skills across 6 domains • Communication • Cooperation • Assertion • Responsibility • Empathy • Self-Control • Delivered in small pullout group setting (4-6 children) • 2 sessions per week, 45 minutes per session X 15 weeks • Teaches 20 social skills • Top 10 retaught • 10 “keystone behaviors” also taught • Distinguishes acquisition from performance deficits

29. FBA Replacement Behavior TrainingTier 3 Intensive Intervention • Designed for weak responders to Tier 2 Intervention Guide • Identifies competing problem behaviors using SSIS-Rating Scales • Behaviors receiving rating of 2 (Very Often) or 3 (Almost Always) targeted to replacement • Descriptive FBA conducted to identify function of competing problem behaviors • Social skills replacement behaviors serving same function selected as target of intervention • FBA process • Records review • FBA interviews (teacher, student, parent) • Systematic direct observations • Behavior ratings • Daily behavior reports

30. FBA Replacement Behavior Training(continued) • Intervention Strategies • Antecedent Strategies • Precorrection • Prompts • Check and connect • Altering schedule of activities • Choice • Task modification • Task interspersal • Providing frequent breaks • Consequent Strategies • Differential reinforcement (DRO, DRI, DRA) • Response cost • Noncontingent reinforcement (NCR) • Behavioral contracting • School-home notes

31. Responsiveness to Intervention Model Level IV Special Education IEP Determination HIGH Level III Intensive Interventions Level II Selected Interventions Intensity of treatment Level I Universal Interventions LOW Degree of Unresponsiveness to Intervention HIGH

32. Classification of RTI Outcomes Adequate Responder Inadequate Responder Outcome Status Accuracy=Correct Decisions Relative to All Decisions A+D/A+B+C+D

33. Measurement of ResponsivenessStandards & Procedures • Academics (CBM) • Norms • Benchmark criteria • Growth criteria • Behavior • Direct observations • Behavior ratings scales • Daily behavior reports • Brief, focused behavior rating scales (weekly) • Permanent products & progress monitoring • Solutions • Social validation (peer comparisons & subjective judgments) • Visual analysis of graphed data • Effect size estimates

34. Brief Behavior Rating Scale(Weekly) Difficulty paying attention Never Sometimes Often Almost Always Difficulty organizing tasks Never Sometimes Often Almost Always Fidgets with hands or feet Never Sometimes Often Almost Always Blurts out answers Never Sometimes Often Almost Always Interrupts/intrudes on others Never Sometimes Often Almost Always

35. Treatment IntegrityAn Essential Component of RTI • Extent to which intervention is implemented as planned • Deviations from integrity compromises effectiveness • Teacher-implemented interventions high-risk for integrity lapses • Integrity can be measured by: • Direct observations of implementation • Permanent products • Self-reports (not recommended) • Treatment integrity can be improved by: • Specific performance feedback on implementation • Contingency management • Modeling of intervention implementation

36. Treatment Integrity & Behavior Change Adequate Behavior Change Inadequate Behavior Change Implemented As Planned Not Implemented As Planned

37. Ways of Expressing Integrity • Percentage of intervention steps implemented • Intervention manual • Rating of intervention implementation • Permanent products of intervention • Task analysis of intervention

38. Some RTI References • Gresham, F.M. (2002). Responsiveness to intervention: An alternative approach to the identification of learning disabilities. In R. Bradley, L. Danielson, & D. Hallahan (Eds.), Learning disabilities: Research to practice (pp. 467-519). Mahwah, NJ: Lawrence Erlbaum. • Gresham, F.M. (2006). Response to intervention. In G. Bear & K. Minke (Eds.), Children’s needs-III (pp. 439-451). Bethesda, MD: National Association of School Psychologists. • Gresham, F.M. Response to intervention: An alternative means of identifying students as emotionally disturbed. Education and Treatment of Children, 28, 328-344. • Gresham, F.M. (2004). Current status and future directions of school-based behavioral interventions. School Psychology Review, 33, 326-343. • Gresham, F.M. (2005). Response to intervention (RTI): An alternative means of identifying students as emotionally disturbed. Education and Treatment of Children, 28, 328-344. • Gresham, F.M. (2007). Best practices in diagnosis. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology-V. Bethesda, MD: National Association of School Psychologists. • Brown-Chidsey, R., & Steege, M. (2005). Response to intervention: Principles for effective practice. New York: Guilford Press. • National Association of State Directors of Special Education (2005). Response to intervention: Policy considerations and implementation. Alexandria, VA: Author. • Jimmerson, S., Burns, M., & VanDerHeyden, A. (Eds.) (2007). Handbook of response to intervention. New York: Springer. • Glover, T., DiPerma, J., & Vaughn, S. (Eds.) (2007). Special series on service delivery systems for response to intervention: Considerations for research and practice. School Psychology Review, 36 (4), 526-646. • Silverman, W., & Hinshaw, S. (Eds.) (2008). The second special issue on evidence-based psychosocial treatments for children and adolescents: A 10-year update. Journal of Clinical Child and Adolescent Psychology, 37, 1-301.

39. THANK YOUQuestions? Laizzez le bon temps rouler!