Evidence Based Practice University of Utah

1. Evidence Based Practice University of Utah Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious Emotional Disturbance/Behavior Disorders By Mary Beth Pummel 2.18.2009 US Office of Education 84.325K H325K080308

2. Prevention and Intervention with Young Children’s Challenging Behavior: Perspectives Regarding Current Knowledge • Center for Evidence-based Practice: Young Children with Challenging Behaviors

3. Center for Evidence-based Practice: Young Children with Challenging Behaviors • Attempts to bridge the gap between what is known about effective practices and what practices children with challenging behavior actually receive • “serious and persistent challenging behaviors in early childhood are associated with subsequent problems in socialization, school adjustment, school success, and educational and vocational adaptation in adolescence and adulthood”

4. Early Challenging Behaviors • “Any repeated pattern of behavior, or perception of behavior, that interferes with or is at risk of interfering with optimal learning or engagement in pro-social interactions with peers and adults.” (Smith & Fox 2003) • Important to identify, prevent and resolve challenging behaviors as early as possible • Limited understanding across disciplines regarding what is known about early challenging behaviors with respect to prevention and intervention • May be difficult to distinguish serious problem behaviors if one is not aware of the course of typical behavioral topographies (tantrums)

5. Center for Evidence-based Practice: Young Children with Challenging Behaviors • Created to promote research, training and the dissemination of knowledge pertaining to challenging behaviors • The purpose of the center was “to establish a concise, data-based summary of the most prominent features of current knowledge as they relate to the presence and impact and, in particular, intervention with and prevention of young children’s challenging behaviors” • Reviews of current literature • Summarize current knowledge • Increase awareness across professional disciplines, researchers, policy makers and advocates

6. General Approach to Developing Summary Statements • Focus on practical peer-reviewed descriptive, experimental, and quasi-experimental research • Data were examined based on replicability, generality, and utility and weighed in relation to internal validity, external validity, and social and ecological validity • The statements were considered in relation to cultural, ethnic, geographic, and economic representativeness

7. Focus of Concern • Challenging behaviors of young children • 3 content areas • Presence and Impact • Prevention • Intervention • Definition of challenging behaviors: “Any repeated pattern of behavior, or perception of behavior, that interferes with or is at risk of interfering with optimal learning or engagement in pro-social interactions with peers and adults” (Smith & Fox 2003) • Definition of Young Children: Birth through 5 • Included social, environmental, educational, therapeutic, and interactional variables

8. Degrees of Evidence • Evidence-based Practice • “Practices that are informed by research, in which the characteristics and consequences of environmental variables are empirically established and the relationship directly informs what a practitioner can do to produce a desired outcome” (Dunst, Trivette, & Cutspec, 2002) • Presence of evidence depended on the extent to which a preponderance of data clearly and consistently supported a discernable message related to the content area

9. Literature Review and Consensus Building Procedures • Reviews of the Literature • Search of data bases (ERIC, PsycINFO, Medline) using keywords such as prevention, intervention, challenging behaviors, maladaptive behavior, etc. • Hand searches using reference sections from source documents and journals that were likely to include articles related to challenging behaviors and young children • Internet search engines (Google) • Summaries of finding were sent to authorities in the field with requests to point out any sources that may have been missed

10. Literature Review and Consensus Building Procedures • Consensus Building Procedures • Participants were asked to select one content area as their primary focus • 3 content area teams were formed based on the primary focus • Teams generated 3 to 5 summary statements for their content area • Summary statements were independently reviewed by the other two teams

11. Presence and Impact of Challenging Behaviors • Summary Statement 1 • When children with significant problems are neither identified in a timely manner nor given appropriate education and treatment, their problems tend to be long lasting, requiring more intensive services and resources over time. Moreover, when the challenging behavior of young children is not addressed in an appropriate and timely way, the future likelihood increases for poor academic outcomes, peer rejection, adult mental health concerns, and adverse effects on their families, their services providers, and their communities

12. Presence and Impact of Challenging Behaviors • Increased risk of school failure, marginalized adult lives characterized by violence, abuse, loneliness and anxiety • National Longitudinal Transition Study – 2 (Wagner, Cameto, & Newman, 2003) • A longitudinal post-high school follow-up study of students who received special education services • Those with severe behavior disorders had the lowest grade point average • 50% failed one or more courses in their most recent school year • 66% failed the competency exam for their grade level • Only 1/3 completed high school • Subgroup of severe behavior disorders had the highest dropout rate of any disability category

13. Presence and Impact of Challenging Behaviors • Development and remediation of these severe behavioral problems • Early appearing behavior problems in a child’s preschool career are the single best predictor of delinquency in adolescence, school dropout, gang membership, adult incarceration and early death • The stability of challenging behavior over a decade is equal to that for intelligence • If challenging behavior toward other and property is not altered by the end of 3rd grade it should be treated as a chronic condition • Children with challenging behaviors of families characterized by coercive interactions are the most likely subgroup to develop a life course of antisocial behavior

14. Presence and Impact of Challenging Behaviors • Costs of unchecked challenging behavior include • Early and persistent peer rejection • Mostly punitive contacts with teachers • Unpleasant family interaction patterns • Predictable school failure • Lack of community integration • Macro- and Micro-level Variables • Maternal depression • Poverty • Community violence • Seldom praise for appropriate behavior • Seldom afforded effective academic instruction • Often subject to ineffective, reactive, punitive interventions from teachers

15. Presence and Impact of Challenging Behaviors • Summary Statement 2 • Although some systems and tools for early identification of children with challenging behaviors are available, the actual identification of these children and provision of appropriate services are very low • The best estimates indicate 10-20% of the preschool population experiences significant challenging behaviors • Factors contributing to underidentification and lack of intervention for young children with challenging behaviors • Fewer than 1/3 of children eligible to receive mandated Medicaid screening actually receive a full Early and Periodic Screening, Diagnostic and Treatment and even fewer receive a screen that includes behavioral health • More than 50% of states report that few or no behavioral health services are offered under Medicaid

16. Presence and Impact of Challenging Behaviors • More factors contributing to underidentification and lack of intervention for young children with challenging behaviors • Most pediatricians don’t have the time nor the expertise to detect and refer for behavioral issues • Studies that have followed Head Start children suggest there may be a bias against identifying children with behavioral problems • Only 1-2% of preschoolers access any mental health services • Longitudinal research on birth through 2 children with special needs indicates a wide discrepancy between caregivers’ ratings of behavioral issues and eligibility based on social/behavioral concerns • Underuse of mental health services is expanded by race and ethnicity

17. Prevention of Challenging Behaviors • A variety of child and family risk factors contribute to early onset conduct disorders including: • Lack of prenatal care • Low birth weight • Maternal depression • Early temperament difficulties in infants • Developmental disabilities • Early behavioral and adjustment problems • Inconsistent and harsh parenting

18. Prevention of Challenging Behaviors • Summary Statement 1 • Children and their families who access mental and physical care are less likely to have behavioral and social problems • Follow-up data (15 years later) from a randomized study that provided the provision of prenatal and early intervention services to single, poor mothers showed lower rates of child abuse or neglect, less reliance on public assistance, fewer instances of running away, fewer arrests and convictions.

19. Prevention of Challenging Behaviors • Summary Statement 2 • Children who experience nurturing and positive parenting are more likely to have healthy relationships and reduced problem behavior • Low income families that were provided child and family development services through Early Head Start • children that are more engaged with their parents • fewer negative interactions during structured play • children had less aggressive behavior • parents were more emotionally supportive • parents provided more support for language development • these effects were strongest when Early Head Start was applied using a mixed approach with both home-based and center-based services

20. Prevention of Challenging Behaviors • Summary Statement 3 • Children who experience high quality early education environments and caregiver interactions are more likely to have better social competence outcomes and fewer behavior problems • 61% of children birth to 6 spend part of their day in a home care or early education environment • Longitudinal data suggest that children who experienced higher teacher-child closeness in kindergarten demonstrated higher levels of social and behavioral competence in 2nd grade

21. Intervention with Challenging Behaviors • Intervention refers to procedures that caregivers use to reduce the challenging behaviors of individual young children • Statements provided are derived mostly from experimental single-subject designs. Therefore, the number of participants and the process of selection raise some concerns about the generalizability of the findings

22. Intervention with Challenging Behaviors • Summary Statement 1 • Intervention based on a functional assessment of the relation between the challenging behaviors and the child’s environment are effective for reducing challenging behaviors of young children • Challenging behaviors are usually predictable responses to specific antecedent and consequent events in the environment • Functional assessment is used to gather information about the antecedent and consequent events associated with, motivational purpose and function of the challenging behavior

23. Intervention with Challenging Behaviors • Interventions can be individualized based on the assessment information • Modify antecedent events • Modify consequences • Provide instruction on specific communication or social interaction skills • Interventions designed to address the function of the behavior are more durable and effective

24. Intervention with Challenging Behaviors • Summary Statement 2 • Teaching procedures have been demonstrated to be effective in developing children’s skills and reducing challenging behaviors • Teaching young children skills that can replace the challenging behaviors are the most effective, scientifically based interventions available • Language or social skills • Self-management skills • Replacement behaviors are also an essential part of a comprehensive behavioral intervention plan

25. Intervention with Challenging Behaviors • Summary Statement 3 • Interventions involving alterations to features of the child’s activities and the child’s social and physical environment have been demonstrated to reduce challenging behaviors • Antecedent-based interventions increase the probability that appropriate behaviors will occur and reduce the probability that challenging behaviors will occur • Antecedent-based interventions also increase the opportunities to reinforce appropriate behavior • Antecedent-based interventions • Use of choice • Embedding preferences into difficult activities

26. Intervention with Challenging Behaviors • Antecedent-based interventions • Use of choice • Embedding preferences into difficult activities • Changes in classroom environmental arrangement • Changes in instructional variables • Implementing an activity schedule • Altering instructions

27. Intervention with Challenging Behaviors • Summary Statement 4 • Multicomponent interventions implemented over time and across multiple relevant environments can produce durable, generalized increases in prosocial behavior and reductions in challenging behaviors • Multicomponent interventions include antecedent-based and consequent-based intervention strategies to decrease the occurrence of challenging behaviors

28. Intervention with Challenging Behaviors • Summary Statement 5 • Family involvement in the planning and implementation of interventions facilitates durable reductions in challenging behaviors of young children • Family members have a significant role in the social, emotional and behavioral development of young children • Parent training and family support are important mechanisms for resolving challenging behaviors • Parent involvement and family support have been mandated as necessary to service delivery under Part C of Individuals with Disabilities Education Act (IDEA)

29. Discussion: Status of Research • Little empirical work related to intervention strategies for infants and toddlers • Little is known about the subgroup of children who have good behavioral outcomes in the absence of obvious intervention • Most of the current research is based on small-scale studies that include relatively few settings, intervention agents, and child/family participants. Concerns about the generalizability of findings to diverse populations and within natural settings. • Little is known about the influence of culture, language and ethnicity on challenging behaviors, prevention & intervention

30. Discussion: Status of Research • A reasonable fraction of empirically based studies have relied on indirect measures of behavior such as ratings of child behavior by caregivers • Little research has been conducted on the long-term outcomes of intervention on challenging behaviors • The majority of intervention research has focused on individual variables rather than systems components, program procedures, and public policies that support the use of evidence-based practices

31. Discussion: Future Directions • A quest for meaningful impact, so that solutions identified in the research will benefit large portions of society or single individuals in life-altering ways • Direct observation of challenging behaviors • Assessment of social validity of intervention goals • Assessment of positive life style changes associated with the reduction of challenging behaviors • A commitment to placing solutions about the strictures of science, and obliging research designs to conform to the situation • Matching the questions, contexts, and the designs will ensure the most meaningful results • An emphasis on ecological validity, with a recognition that solutions in analog contexts are not solutions to real human problems • Interventions should be made deliverable in real world contexts

32. Discussion: Future Directions • A commitment to collaborate with colleagues, students, the community, and particularly research participants, reflecting an understanding that ideas and solutions are social, communal phenomena • Child, family and service provider consumers helped articulate the challenging behaviors of concern, interventions to be used and the means for determining success • An assertion that ideas and data are more important than ideologies – implying an openness to all potentially useful perspectives, conceptualizations, and the knowledge from divergent disciplines • The future research agenda should encourage and support multidisciplinary efforts