Children and adolescents with emotional disturbance (ED) exhibit
chronic and diverse academic, emotional, behavioral, and/or medical
difficulties that pose significant challenges for their education and
treatment in schools. Historically, children with ED have received
fragmented inadequate interventions and services that often yielded
unfavorable school and community outcomes. Numerous child/family,
diagnostic, and organizational barriers limit access to appropriate and
effective treatment. Given this information, two U.S. Presidential
commissions (U.S. Surgeon General Report, 2000; President's Freedom
Commission on Mental Health, 2003) have called for the transformation of
the mental health system emphasizing the early identification and
intervention of children at risk for and with ED in school and public
health care settings. In this manuscript, three school-based prevention
and intervention programs for children at risk for and with ED are
presented as examples of exemplary programs. These programs were
selected based on a review of over 26 published school-based outcome
studies with this population and the availability of at least three
published outcome studies (including follow-up data) for each.
Considerations for future school prevention and intervention programs
are offered. Finally, priorities for training school personnel are
Children with emotional disturbance (ED) are one of the most
underidentified and untreated child clinical subpopulations (Wagner,
1995; Forness & Kavale, 2001; President's New Freedom
Commission, 2003). As indicated in the Surgeon General's report on
mental health (U.S. Department of Health and Human Services, 2000), one
in five children display a diagnosable mental disorder each year and
approximately 5% have an ED that significantly impacts their daily
functioning at home and school. Similarly, children with ED represent
about 5% of youth diagnosed with mental disorders and about 1% of those
children diagnosed with ED are treated (Oswald & Coutinho, 1995;
Walwarth, Nickerson, Crowel, & Leaf, 1998). Research has found that
the number of students classified as ED varies by state and school
district. For example, in a study representing over 14,000 school
districts, Coutinho and Oswald (2005) found that state and local
variations in ED classification are due, in part, to the child's
gender with males overrepresented as ED (e.g., male: female odds ratios
ranged from approximately 2 to 6 for ED in comparison to 1.7 to 2.7 for
LD students). It is unknown whether gender differences are due to a
higher prevalence rate of ED among males and/or under diagnosis of ED
The identification of children with ED is hindered by vague
diagnostic/eligibility criteria which impacts access to effective
school-based interventions (Forness & Kavale, 2001; Reddy, 2001).
Scholars have attributed the identification problem, in part, to the
Individual Disability Education Act definition (IDEA, 1997, 2005).
According to IDEA, ED is one of 12 disability categories that is defined
as "a condition exhibiting one or more of the following
characteristics over a long period of time and to a marked degree which
adversely affects school performance: (a) an inability to learn which
cannot be explained by intellectual, sensory, or health factors, (b) an
inability to build or maintain satisfactory interpersonal relationships
with peers and teachers, (c) inappropriate types of behavior or feelings
under normal circumstances, (d) a general pervasive mood of unhappiness
or depression, (e) a tendency to develop physical symptoms or fears
associated with personal or school problems" (IDEA, 1997, 2005).
The five ED criteria in IDEA are not supported by research on the
subtypes of children with emotional and behavioral disorders (Schroeder
& Gordon, 2002). In addition, there is a clause requiring
"adverse educational performance" (e.g., poor grades) which
may be interpreted by some professionals to exclude children who have
marginal grades (e.g., D's), but who exhibit social and behavioral
difficulties at school. Also, IDEA includes an exclusionary criterion of
"social maladjustment" which is not fully defined and thus may
misled some professionals to exclude children diagnosed with conduct
disorder. Research has found that conduct disorders often co-occur with
attention deficit hyperactivity disorder (ADHD), reading disabilities,
depressive disorders, and anxiety disorders (Hinshaw, Lahey, & Hart,
1993; Reddy & DeThomas, in press). Nelson (1992) asserted that the
field does not have evidence to differentiate between conduct disorders
and other emotional and behavioral disorders. In fact, students with ED
who exhibit disruptive behavior or symptoms of conduct disorder
constitute the largest subgroup of youth placed in ED classrooms
(Greenbaum et al., 1996; U.S. Department of Health and Human Services,
2000; Wagner, 1995).
Historically, there has been a reliance on restrictive educational
and out-of-home placements (e.g., residential care) for children with
ED. However, with the advent of managed care, the use of restrictive
placements has decreased, and as a result, schools and community
agencies have increasingly become the "system of care" for
children with ED (Reddy & Savin, 2000; Weist, Evans, & Lever,
2003). Treatment outcomes (e.g., reduced aggressive and disruptive
behaviors) acquired in restrictive placements are often temporary and
limited in scope (e.g., behavioral control and containment). Many
restrictive placements also do not successfully transition children back
into their homes, schools, and neighborhoods (Epstein, Kutash, &
Duchnowski, 1998; Hansen, Litzelman, March, & Milspaw, 2004).
Despite national initiatives (e.g., President's New Freedom
Commission, 2003; Surgeon General Report, 2000), parents and schools
struggle to educate and treat children with ED (U.S. OSEP, 2001).
Described by some as "mad, bad, sad, and can't add"
(Friedman & Kutash, 1986), these children are prone to academic
failure, family/peer rejection, restricted educational placements, and
in some cases out-of-home placements and hospitalizations. As Osher,
Osher, and Smith (1994) stated, educating children with ED "is one
of the most stressful, complex, and difficult challenges facing public
education today, and perhaps one of our greatest failures" (p. 7).
Research has shown that children with ED have lower grades than other
disability groups, significant academic and language deficits, and high
grade retention and absenteeism rates (Armstrong, Derick, &
Greenbaum, 2003). Research has also shown that children with ED are more
likely to drop out of school, receive school suspensions and expulsions,
fail one or more courses, not graduate, and have difficulties socially
integrating at school than other disability groups (Duchnowski, 1994;
U.S. OSEP, 2001; Wagner, 1995).
Numerous personal, diagnostic, and organizational barriers
interfere with treatment success for children with ED in school and home
(Reddy, 2001). For example, youngsters with ED represent a complex mix
of emotional, behavior, educational, and medical/neurological
difficulties that make the diagnostic, teaching, and learning process
difficult. School and family treatments are further complicated by high
rates of family psychopathology, inadequate parenting skills, and
limited support systems and resources. In addition, lack of knowledge of
services and programs offered by other agencies (e.g., schools, social
service, juvenile justice), differential use of terminology between
agencies, and ineffective interagency collaboration often interfere with
treatments. Limited or poor school preservice and inservice training on
internalizing and externalizing symptoms in the classroom and behavioral
techniques (e.g., use of aversive techniques, physical restraints,
positive behavioral techniques) are also found. Other barriers may
include limited placement options (e.g., access to intermediate levels
of care) and support services (e.g., respite for parents and teachers)
(Reddy, 2001). Despite these barriers, innovations in school-based
programming continue. In the past decade, new school prevention and
intervention programs have emerged from school, agency, and/or
university partnerships and offer promising new approaches for educating
and treating children with ED.
The purpose of this paper is to present exemplary school prevention
and intervention programs for children and adolescents at risk for and
with ED. Three school prevention and intervention programs are described
for their mission and objectives, treatment components, required
material and training, and outcome findings. Considerations for future
school prevention and intervention programs are offered. Finally,
priorities for training school personnel are proposed.
School Prevention and Intervention Programs
To enhance the reader's appreciation of the variety of school
prevention and intervention programs for children with ED, a descriptive
overview of three model programs are provided. A comprehensive
literature review of over 26 published outcome studies from 1998 to 2005
in over 12 peer reviewed journals (1) was completed. Each study was
reviewed on several variables (e.g., sample characteristics, treatment
components, and outcome findings). As a result of the review, three
programs were selected based on five criteria: (a) each program was
designed specifically for children at-risk for or with ED, (b) each
program focused on academic and behavior outcomes, (c) outcome data for
each program was available, (d) each program had at least three
published outcome studies (including follow-up data), and (e) each
program was nominated by experts in the field of school psychology and
child mental health as an excellent program. Based on the five criteria,
two prevention (2) programs, First Step to Success (Walker et al., 1998)
and Parent Teacher Action Teams (PTAR; Kay & Fitzgerald, 1997) and
one intervention (3) program Integrated Mental Health Program (IMHP;
Roberts, Jacobs, Puddy, Nyre, & Vernberg, 2003) were selected. The
choice of these programs does not represent a special status, but rather
were selected to illustrate examples of well-designed data-driven school
prevention and intervention programs for children at risk for and with
ED. Following the summary and critique of the programs, we offer
considerations for future school prevention and intervention programs
for this population.
First Step to Success
First Step to Success is a home and school prevention program for
at-risk kindergartners with early signs of antisocial behavior such as
difficulties with peer and teacher relationships, aggressive and
disruptive behavior, and internalizing behaviors such as anxiety,
inattention, and withdrawn behavior in the classroom (Walker et al.,
1998). The primary objective is to train at-risk children (preschool
through third grade) to interact appropriately with peers and adults at
school to prevent the development of long-term and more serious
anti-social behavior patterns. First Step includes three modules: a
proactive universal screening process; consultation-based school
intervention with the child, peers, and teacher (CLASS); and intensive
parent training focused on improving academic performance and adjustment
The centerpiece of First Step is proactive universal screening, a
multi-stage process that evaluates at-risk kindergarteners for emerging
antisocial behavior patterns and identifies children who would most
benefit from the program. During Stage one, each teacher is asked to
list five children in their classroom who match a standardized
description of the targeted externalizing behaviors and five children
who matched standardized description of the targeted internalizing
behaviors. A child cannot be placed on both lists. Teachers are asked to
rank-order students in terms of the level of severity of their behavior.
During Stage two, teachers evaluate the three highest ranked
children on each of the externalizing and internalizing lists using the
Early Screening Project (ESP) procedure (Walker, Severson, & Feil,
1994), an extension of The Systematic Screening for Behavior Disorders
(SSBD) procedure (Walker & Severson, 1990). (4) The ESP is a
multi-method, -agent, and -setting screening procedure that includes
teacher rankings, ratings, and behavioral observations across the
screening stages for children three to five years (Walker et al., 1998).
Measures included in this procedure are the ESP Adaptive Behavior Rating
Scale (Walker et al., 1998), the ESP Maladaptive Behavior Scale (Walker
et al., 1998), and the Aggression Subscale of the Teacher Report Form
(TRF, Achenbach, 1991a). The goal of Stage two is to assess the
children's adaptive and maladaptive behaviors compared to normative
behaviors by having the teachers complete the ESP Adaptive Behavior
Rating Scale, ESP Maladaptive Behavior Rating Scale, and the TRF.
Students who met criteria (i.e., exceed ESP normative criteria) move to
Stage three. The ESP's psychometric validity is well established
and includes a national standardization sample of 2,853 children from
three to six years (Walker, et. al., 1998).
During Stage three, the children are observed in their classrooms
by an independent group of observers from the Oregon Research Institute
(ORI), who implement the Academic Engaged Time (AET) measure (Rich &
Ross, 1989). AET assesses the time the child attends to the teacher,
follows directions, and/or asks for help. ORI members conduct the
post-intervention and follow-up observations. The AET results are used
for screening and baseline data for those enrolled in the program.
Inclusion criteria are an AET of 65% or lower and/or T-score of one or
more standard deviations above the mean on the TRF Aggression scale.
School Intervention: CLASS. First Step uses a modified version of
the CLASS Program (Hops & Walker, 1998). The program runs for 30
days with daily performance criteria each child must meet. The program
consultant monitors the program in the regular classroom. Appropriate
behaviors (e.g., attending to the teacher and remaining in seat) are
rewarded, while inappropriate behaviors (e.g., calling out, being
out-of-seat, and other disruptive behaviors) are given negative
feedback. Children repeat a program day if they do not meet the
criteria. On average, students take about two months to complete the
program. Each day involves two 20 to 30 minute sessions where the
consultant (e.g., a trained school counselor, school psychologist,
resource teacher, or behavioral specialist), works one-on-one with the
child and provides continuous feedback (i.e., use of red or green cards)
on the appropriateness of the child's behavior. The child earns
points for displaying behaviors such as following directions, completing
work, and appropriate self-control. For children with less-than-average
intelligence, pictorial aids and consumable rewards are substituted into
the program. If the child meets the criteria for the two 20 minute
sessions, a home-privilege is given to the child that day. Home
privileges are negotiated with parents and may include extra play time
or another reinforcing activity for that child. By day 15, the use of
the red/green cards is discontinued, and the time period that the child
must be appropriate to earn the rewards is gradually increased from 30
seconds to 10 minutes. Criteria are met if the child displays
appropriate behavior (e.g., follow directions, complete assigned work)
for multiple days (i.e., more than 3 days) in a row. During the
maintenance phase of the program (i.e., days 21 through 30), the child
is rewarded primarily with verbal praise from both his/her teacher and
parents. Tangible awards are given to a child for behaviors that
consistently improve over three or more days (e.g., following directions
The consultant starts the program, trains teachers, negotiates with
parents about appropriate rewards, and works directly with the child
through day five of the program. The consultant also explains the
program to the teacher, parents, child, and the child's peers and
serves as a model for the teacher and parents (Walker et al., 1998). On
day six, the classroom teacher then assumes responsibility for program
implementation (i.e., providing awards and points, supervising group
activities, and collaborating with parents).
Home Intervention: homeBase. The home intervention is a six week
curriculum that includes six one-hour lessons that enhance
children's competencies and skills in the following areas:
communication and sharing in school, cooperation, limit setting, problem
solving, friendship making, and the development of confidence (Walker et
al. 1998). Consultants teach homeBase lessons to parents in their homes,
and parents are encouraged to practice skills with their children 10 to
15 minutes daily. The homeBase program begins after the child has
finished day ten of the school program.
Training/Implementation. First Step uses a trainer-of-trainers
model in which "program consultants" (e.g., graduate students,
teachers, school counselors, and teacher aides) receive intensive
training and on-going supervision from project coordinators. Training
consists of standardized lectures, videotaped demonstrations and role
playing, group discussion and detailed feedback by the program
coordinators. Staff and consultant training is one and one half days and
teacher training is one day. On average, each consultant is assigned two
to three cases over a three-month period. The consultants work with
parents to help them implement home interventions for their children.
The parent training is one session (one hour) per week, for six weeks to
allow them to understand the basic behavioral principles involved in the
program and to review specific content that they must implement with
their child. After each training session, the parent is given a handbook
and set of skill-based games and activities to teach their child (Golly,
Stiller, & Walker, 1998).
Several outcome studies support the efficacy of First Step. Results
from a four-year randomized, experimental, wait-list control study found
that First Step yielded statistically significant improvements in
adaptive and maladaptive behaviors and sustained treatment outcomes
across grade levels and home and school settings in a sample of 46
kindergarteners (Walker et al., 1998). In comparison to the wait-list,
significant group differences (favoring First Step) were found on the:
Adaptive Teacher Rating Scale, Maladaptive Teacher Rating Scale, TRF
Aggression Scale, and AET. However, no group differences were found for
A replication study of 20 kindergarteners, using the same
procedures as Walker et al. (1998), found similar findings on the
Adaptive Teacher Rating Scale, Maladaptive Teacher Rating Scale, AET,
and CBCL Aggression Scale (Golly, Stiller, & Walker, 1998).
Participants reported high levels of satisfaction with the training and
program. However, a control group was not used. Similar to Walker et al.
(1998), improvements in internalizing behaviors (e.g., social
withdrawal) were not found.
Golly, Spraque, Hill, Beard, and Gorham (2000) investigated the
efficacy of First Step with a multiple-baseline design with two sets of
identical Caucasian male twins (age 5 years). Both sets of twins
attended regular education classrooms. The intention of this
investigation was to eliminate genetic differences by assigning one twin
from each pair to the whole-class social-skills training only and then
to the First Step program (i.e., CLASS, homeBase). Unfortunately, twin
pair number one moved before the study could be completed and only
received the teacher portion of the program (i.e., did not receive the
homeBase intervention) and twin pair number two did not receive homeBase
due to parents refusal to participate. Thus, this study only included
the whole-class social-skills training and teacher intervention. Results
revealed significant improvements in appropriate classroom behavior
(e.g., talking out, out of seat, touching others) for all four
participants and significant improvements in AET for those participants
who received the teacher intervention.
Overton, McKenzie, King, and Osborne (2002) conducted a replication
study of Walker et al. (1998) involving 22 kindergartners (16 males,
five to six years old) from five school districts. The ethic breakdown
was five Caucasians, seven African Americans, five African American and
Caucasian, one Hispanic, three Native Americans and one Native American
and Caucasian. Results were somewhat comparable to the Walker et al.
(1998) study. For example, positive improvements in AET at post-test and
one-year follow-up were found. Reductions in externalizing behavior as
measured by the CBCL and TRF Externalizing Scales at program completion
were found, but were not maintained at one-year follow-up. Differences
in outcome findings may be attributed to population differences. For
example, this study included families from communities with high rates
of poverty and Walker et al. (1998) included families from communities
with high rates of middle-class incomes.
Beard and Sugai (2004) compared the effectiveness of First
Step's teacher-directed versus teacher and parent-directed
components on reducing antisocial behavior in the classroom. A total of
six Caucasian kindergartners (four males) in two kindergarten classes
were randomly assigned to two interventions. Four of the children lived
in low income and two lived in middle income neighborhoods. Results
revealed that child problem behaviors (i.e., talking out, touching
others and property, being out of seat, and non-compliance) reduced to
almost zero and AET increased to 90 % on average. Improvements in
behavior problems and AET were maintained at five month follow-up for
four of the six students. Results suggested that the First Step
components were equally effective in improving AET and problem behaviors
in the classroom.
First Step is a promising empirically supported program for young
children at-risk for antisocial behavior patterns used in 12 states,
three Canadian provinces, Australia and New Zealand. The integration of
comprehensive screening, school, and home training and interventions are
distinguishing features of First Step. School success is promoted
through teaching children adaptive behavior such as attending to tasks,
getting along with teachers, and developing positive peer relations.
Parent participation is a critical element of this program. Parents are
trained to reinforce children's school behavioral improvements at
home, forging a collaborative partnership between parents and school
First Step is described as a prevention program, but more
accurately fits into the category of an indicated prevention
intervention in that an at-risk group is targeted as having minimal but
detectable symptoms that foreshadow a behavioral and/or emotional
disorder, but do not presently meet the criteria of a diagnostic
disorder (Pfeiffer & Reddy, 1997). This program does not target the
entire school population and thus does not constitute a universal
prevention program. As part of the universal screening process, teachers
are asked to nominate and rate children who represent externalizing and
internalizing behavior patterns, complete five checklists, and conduct
behavioral observations. Although the screening process is noteworthy,
it may be difficult for some school districts to implement.
Some program limitations are also noted. For example, the program
does not reduce internalizing distress often associated with
externalizing problems. In the outcome investigations reviewed, teacher
raters were not blind to the children's assignment to treatment.
First Step is not designed for children with autism, severe language
problems, and families who require intensive interventions and support
services. Since this program uses a combined treatment approach, it
remains unclear which component of the program contributes to outcomes.
Finally, replication studies that include wait-listed control groups are
Parent Teacher Action Research (PTAR)
Like First Step, the PTAR Team approach is a prevention program for
children at-risk for antisocial behavior patterns in elementary school.
However, PTAR is a primary (5) prevention program that provides
whole-class social skills instruction and universal screening to all
students. Based on 50 years of educational action research, PTAR offers
a structure for parents and regular education teachers to work as
collaborative partners in identifying goals and designing and
implementing action plans (Kay & Fitzgerald, 1997). Participatory
action research, a collaborative problem solving process, fosters equal
partnerships between parents, teachers, and other professionals. Action
research involves defining a problem, gathering and organizing data
related to the problem, taking action to address the problem, evaluating
data, and then beginning the cycle again as needed (Kay &
Fitzgerald, 1997). Action research teams work flexibly together and use
understandable language to define goals and action plans.
PTAR allows teachers' choice of social skills curricula and
the PTAR team's choice of interventions for an individual child.
This flexible approach permits the PTAR team to customize a program
around the child's needs. The team includes individuals involved in
the child's life at home and school (e.g., regular education
teacher, parent(s), parent liaison, and a PTAR staff member).
Similar to First Step, PTAR includes a multi-step screening
procedure, the Systematic Screening for Behavior Disorders (SSBD; Walker
& Severson, 1990; Severson & Walker, 2002) that includes parents
and teachers as informants. For Step One, teachers are given a list of
externalizing behaviors (e.g., calls out in class, does not follow
directions) and internalizing behaviors (e.g., withdraws, does not talk
to peers). Teachers are asked to select children who represent the top
five externalizers and five internalizers in their class. Teachers are
then asked to rate the children on the SSBD Critical Events Index (CEI)
and Combined Frequency Index of Adaptive and Maladaptive Behaviors.
For Step Two, children are matched on whether they are
internalizers or externalizers (based on SSBD ratings) and matched by
gender (i.e., for research purposes only). In Step Three, parents are
invited to participate and asked to complete the Teachers Report Form
(TRF: Achenbach, 1991a). In Step Four, TRF Total Problems Scale scores
are added to the matching criteria and the children are re-matched on
the basis of all three criteria: (a) internalizer vs. externalizer, (b)
gender, (c) TRF Total Problem Scale. Rematching is conducted to yield
comparable levels of problems among children. For research purposes,
children are then randomly assigned to a PTAR team or control group.
Parent consent is required before a referral is made to the team. Parent
participation is critical for effective team functioning.
Each PTAR team consists of the child's regular education
teacher, parent(s), a parent liaison who is recruited from the local
community to assist low-income families and a facilitator from the
Achieving, Behaving, Caring (ABC) project staff (credentials are not
specified by authors). Other professionals (e.g., school psychologists,
speech/language specialists) are invited to participate in the team as
needed. Making Action Plans, an adaptation of the McGill Action Planning
System (MAPS: Forest & Pearpoint, 1992), identifies children's
strengths, parents' hopes for their children, mutual parent-teacher
goals, and observable indicators for goals. MAPS helps parents and
teachers focus on children's strengths and adheres to the following
rules: (a) parents are encouraged to speak first, (b) individuals can
stop speaking at anytime, (c) minutes are taken that represent
individual's own words, and (d) ideas are expressed in positive
language. MAPS focuses on the progress of the child, program
effectiveness, and program modifications needed for child outcomes.
Using this process, the team develops positive academic, social and/or
behavioral goals for each child and encourages parent participation.
The facilitator's role in the first two meetings is to
implement MAPS to develop mutual goals, establish objectives of
observable indicators for goals, and assist team members in planning
their behavioral observations. During subsequent meetings, the PTAR team
identifies and agrees on academic, social, and/or behavioral goals for
the school year, observable indicators of progress at home and school,
and action plans. PTAR teams consult with other professionals (e.g.,
school psychologists, learning disability specialists) as needed. The
role of the facilitator is to create an agenda based on established
goals, summarize previous meetings, encourage parents and teachers to
share observations, link observations to goals, assist members to
formulate hypotheses about behavior, help members generate action plans
for the home and school, summarize actions plans, set meetings, and take
and distribute notes. The role of the parent liaison between team
meetings is to contact parents about observations and action plans,
conduct home visits as needed, provide community resources, meet with
facilitators biweekly, and maintain and distribute detailed notes. The
PTAR team meets once a week (e.g., one hour) for six weeks.
Whole-class social skills instruction is provided approximately 15
to 20 minutes, twice a week from October through May (McConaughy, Kay,
& Fitzgerald, 1998). Available social skills programs include:
Lion's Quest (Quest International, 1990), Responsive Classroom
(Charney, 1992), Second Step (Beland, 1998), Skillstreaming the
Elementary School Child (McGinnis & Goldstein, 1984), and Taking
Part (Cartledge & Kleefeld, 1991). These social skills programs are
theoretically rich and data driven. As outlined by The Social Skills
Planning Guide (Alberg, Petry, & Eller, 1994), the social skills
curricula target communication, interpersonal, personal, and response
skills. Detailed information on each program can be found in the above
Several investigations provide evidence of PTAR's
effectiveness. McConaughy, Kay, and Fitzgerald (1998) compared the
effectiveness of PTAR versus whole-class social skills training with 36
first-grade children (28 males) at-risk for ED who lived in rural and
semi-rural communities. Using an experimental design with a matched
control group, results revealed PTAR yielded significant reductions in
both externalizing and internalizing problems (i.e., social problems,
delinquent behavior, and aggressive behavior) compared to controls.
Independent observers rated PTAR children as having reduced
hyperactivity in class and reduced aggressive behavior during recess
than controls. PTAR teachers reported greater improvements in on-task
behavior, social skills, cooperation, assertion and self-control than
In a replication study conducted by McConaughy, Kay, and Fitzgerald
(1999), 82 first and second graders at-risk for ED were randomly
assigned to PTAR or a control group (i.e., received social skills
training by teachers). At the end of two-years, PTAR children exhibited
significant reductions in teacher reported internalizing problems and
delinquent behavior (i.e., the TRF's Withdrawn, Internalizing, and
Delinquent Behavior Scales) and parent reported externalizing,
internalizing, and delinquent behavior (i.e., CBCL's Total
Problems, Internalizing, Externalizing, Thought Problems, Withdrawn,
Delinquent Behavior and Aggressive Behavior Scales) than the controls.
Independent observers rated PTAR children with fewer internalizing
problems in the classroom than controls. PTAR parents also reported
improvements in children's cooperation, self-control, competence,
and ability to access school-based services. The authors attributed
their findings to the universal screening process (i.e., SSBD) and
active involvement of parents in intervention selection.
McConaughy, Kay, and Fitzgerald (2000) reanalyzed two separate
cohorts of PTAR participants (i.e., one-year versus two-year outcome
data) to compare the long-term benefits of PTAR. Matched pairs of 82
first and second grade children were randomly assigned to PTAR teams or
a control group. Results revealed more main and interaction effects at
the end of Year 2 versus Year 1 supporting the overall effectiveness of
PTAR and the long-term implementation of PTAR for producing lasting
change in children's problems and competencies. For example,
results at year one showed reductions in teacher reported internalizing
and externalizing behaviors and greater reductions at year two. The
authors concluded that PTAR produced greater gains when implemented over
the course of two years.
PTAR is an effective model for fostering home and school
collaboration. Similar to First Step, PTAR can be best described as an
indicated prevention program (Pfeiffer & Reddy, 1997). A key feature
of both First Step and PTAR is the use of a comprehensive multi-step
screening process. However, some schools may find it challenging to
implement. PTAR emphasizes and mandates parent involvement. Thus,
program implementation is not possible for parents who cannot or will
not actively participate in the program. For non-English speaking
parents, outreach services (e.g., translators for collaboration and
completing questionnaires) are obtained to facilitate the process.
Conclusions drawn from outcome results should be tenuously made
because teachers were not blind to the assignment of treatment for
children and child samples included a range of problems such as
behavior, speech, and social skills issues. Since all children received
social skills training, it remains unclear whether outcomes in social
skills were attributed to PTAR or other factors (e.g., maturation).
Additionally, replication studies that include wait-listed control
groups are needed.
Intensive Mental Health Program
In contrast to First Step and PTAR, the Intensive Mental Health
Program (IMHP) is an intervention program for elementary school-aged
children with ED (Roberts, Jacobs, Puddy, Nyre, & Vernberg, 2003;
Vernberg, Roberts, & Nyre, 2002). IMHP is a half-day self-contained
classroom program that provides comprehensive school-based
psychological, educational, and family services. Services are
coordinated and implemented across the self-contained classroom, regular
education classroom (i.e., neighborhood school), and home setting.
IMHP is designed to improve the psychological functioning,
behavioral control, and academic performance for children with ED. An
innovative feature of IMHP is that behavior management strategies are
implemented in the self-contained classroom, regular education
classroom, and home (Vernberg et al., 2002). Like PTAR, IMHP is tailored
to the individual child and includes psychosocial interventions, group
and individual therapy, social skills and relaxation training, behavior
management programs and the use of medication in the classroom and home.
IMHP is designed to increase access to mental health services,
promote interdisciplinary training of psychologists, and evaluate the
effectiveness of programs. Other important features of IMHP are the
emphasis on placement permanency in the child's home and regular
education classroom; use of empirically supported interventions;
development of cognitive and behavior skills; collaboration among
professionals, agencies/settings (e.g., school, after-school programs,
neighborhood), and stakeholders; generalization and maintenance of
behavioral outcomes; child-centered, family-focused, community-based,
developmental, and culturally competent services; on-going assessment
and diagnosis; and the development of effective parenting strategies
(Vernberg, Jacobs, Nyre, Puddy, & Roberts, 2004).
When children with ED are referred to the program, they are
screened on their current psychological functioning, behavior, academic
performance, family environment, and prior treatment history.
Information is gathered from the school, regular and special education
teachers, as well as parents and community providers involved in the
children's care. The Child and Adolescent Functioning Assessment
Scale (CAFAS) (Hodges 2000; Hodges, Wong, & Latessa, 1998) is used
for the initial intake and discharge from the program. The CAFAS
includes a Total Scale, a global measure of the child's adaptive
functioning, three Role Performance Scales that measure the child's
ability to act age-appropriately in important settings (i.e., School,
Home, and Community Scales), and five Psychological Functioning Scales
that measure the child's severity of psychological impairment
(i.e., Behavior Toward Others, Moods/Emotions, Self-Harmful Behaviors,
Substance Use, and Thinking Scales). The CAFAS also includes two
Childrearing Environment Scales (i.e., Maternal Needs, Family/Social
Support Scales). CAFAS ratings are made after all clinical case
materials (e.g., school and home reports, grades, peer relations) are
reviewed. The CAFAS has strong reliability and validity indices as an
outcome measure in clinical settings (see Hodges, Wong, & Latessa,
1998 for details). All children screened for the program met the federal
educational standards outlined in the Individuals with Disabilities
Education Act (1997) for ED, exhibited a program-specific standard for
critical need (i.e., risk of hospitalization or other out-home care,
threat to self, classmates, teachers, or family members, and/or exhibit
disorganized and bizarre behaviors), and received less restrictive
services prior to IMHP (Vernberg et al., 2004). Approximately, 90% of
the children in IMHP received one or more DSM-IV-TR diagnoses such as
Learning Disabled, Attention-Deficit/Hyperactivity Disorder (ADHD) or
another disruptive behavior disorder such as Oppositional Defiant
Disorder and/or Conduct Disorder. Furthermore, these children typically
had low Global Assessment of Functioning (GAF) Scale scores ranging from
20 to 50.
Decisions regarding placement and/or services in IMHP are made by a
multidisciplinary team. Screening information (e.g., current academic
and behavioral functioning, prior experience in school and treatment)
plays an integral role in designing each child's Individualized
Education Plan (IEP). The service-delivery team includes special
education teachers, paraprofessional teachers, licensed
master's-level therapists, licensed doctoral-level clinical
psychologists, certified school psychologists, school social workers,
research staff, and a child psychiatrist (Vernberg et al., 2002, 2003).
IMHP emphases a team model that embraces the contributions of all
members involved (e.g., parents, psychologists, professional teacher,
special education teachers, social workers, and community providers).
The program focuses on the involvement and consistent implementation of
interventions and services among parents, school staff, medical and
psychiatric personnel, community agencies, and therapists.
IMHP children receive: (a) daily specialized academic instruction
from a special education teacher, (b) a positive behavioral management
system (i.e., token economy system with response cost) in the IMHP
school, home, and neighborhood school, (c) individual therapy (twice
weekly), (d) group therapy (four 30 minute sessions per week) plus daily
group check-in sessions, and (e) crisis management (Roberts et al.,
2003). The program goal is that each child obtains 80% of his/her daily
points in the IMHP classroom, home, and neighborhood school.
IMHP is implemented by a multi-disciplinary team. The
child-to-staff ratio includes three professionals (e.g., special
education teacher, paraprofessional teacher, master's level
therapist) for every six children with support personnel for a half day
(i.e., three-hour) self-contained classroom. Two therapists work on
alternating days in the classroom in order to participate in
supervision, parent and/or consultation meetings, and service
coordination. The teaching staff meets weekly to review children's
academic and behavioral progress, problems, treatment planning,
discharge planning and new admissions. Master's-level therapists
and social workers are responsible for coordinating interventions and
services across agencies, overseeing the behavioral management system
and implementing individual and group treatments and crisis management.
Therapists are provided two-hours of weekly supervision (Roberts et al.,
2003). On average, children are enrolled in IMHP for approximately two
years with the majority of children transitioned to their neighborhood
school for half of the school day within the first month.
During program implementation, data are gathered continuously on
each child. Data collection includes: (a) daily behavior point sheets
completed in the home, neighborhood school, bus, and IMHP classroom; (b)
daily symptom rating scales of psychological and behavioral symptoms;
(c) the CAFAS (Hodges 2000; Hodges, Wong, & Latessa, 1998) three
times a year; (d) the Behavioral Assessment Scale for Children (BASC;
Reynolds & Kamphaus, 1992) twice a year; (e) the Diagnostic
Interview for Children and Adolescents (DICA; Welner, Reich, Herjanic,
Jung & Amado, 1987) annually; (f) the Parenting Stress Index--III
(PSI; Abidin, 1995) annually; (g) the Hope Scales (Snyder et al., 1996,
1997) for adults and children twice per year; and (h) the HOME Scale
(Caldwell & Bradley, 1994) twice per year (Vern-berg et al., 2004).
Outcome studies provide support for the efficacy of IMHP. For
example, Roberts et al. (2003) conducted a single subject design study
with three Caucasian children (two males, mean age 10 years). Two out of
three children demonstrated clinical improvements in overall adaptive
functioning and severity of Role Performance and Psychological
Symptomology as measured by the CAFAS Scales. Additionally,
generalizability of cognitive and behavioral coping strategies learned
in therapy was found in two of the three subjects.
Since IMHP's inception, Vernberg et al. (2002) found 41 out of
43 (i.e., 95%) IMHP children attended their neighborhood schools for
half of a day within one month of starting the program and the majority
met or exceeded their treatment goal (i.e., earn 80% of their points).
Results indicated that IMHP is effective in helping children with ED to
function in their neighborhood school during treatment. Also, 74% of
children discharged from IMHP were enrolled full-time in their
neighborhood schools and lived with their biological or adoptive
In a study of 50 children (42 boys, age five to 13 years), results
indicated that 84% of the children showed clinically and statistically
significant improvements in overall adaptive functioning across settings
from intake to discharge as measured by the CAFAS (Vernberg et al.,
2004). The sample included 70% Caucasian, 16% African American, 8%
Native American, 2% Hispanic, and 4% biracial children. Also, clinically
and statistically significant improvements in overall school performance
and home behavior, as well as behavior towards others, regulation of
moods and emotions, self-harm, and problem solving were found. IMHP
children were successfully transitioned to a full day regular education
classroom in approximately one year (Nyre, Roberts, Jacobs, Puddy, &
Vernberg, 2002). Additionally, IMHP was found to be a cost effective
intervention (i.e., $9,000 annually per child) in comparison to other
IMHP, an innovative self-contained program for children with ED,
developed out of a collaborative partnership between Lawrence, Kansas
Public Schools and the Clinical Child Psychology Program at the
University of Kansas. IMHP's success rests on the careful planning
and implementation of targeted behavioral interventions across
IMHP's self-contained program, neighborhood schools, and homes.
IMHP's promotion of mental health services, interagency
collaboration, and placement permanency (i.e., home, neighborhood
school) offer unique contributions to the field. Although IMHP offers
noteworthy findings, the efficacy of IMHP in comparison to treatment
alternative or wait-list control groups are needed. Thus, definitive
conclusions about the short-term and long-term efficacy of IMHP are
premature. Nevertheless, IMHP offers a promising treatment alternative
to more restrictive care (i.e., residential treatment, group home) for
children with ED.
In the next section, considerations for future school prevention
and intervention programs for children with ED are presented and
priorities for training school personnel are proposed.
Future School Prevention and Intervention Programs
The three programs described illustrate the range of prevention and
intervention programs for children at risk for and with ED. Each program
has a strong theoretical basis, empirical support, and use of innovative
school prevention and intervention approaches. Collectively, these
programs offer a glimpse of some of the key treatment ingredients for
developing and measuring future school prevention and intervention
Based on the three programs, we recommend that future school
prevention and intervention models include: (a) comprehensive outcome
assessment approaches that includes multiple domains (i.e., academic,
behavior, and social competencies), (b) psychometrically sound and
clinically sensitive outcome assessment instruments, (c) the assessment
of quantifiable behavioral goals, (d) empirically supported academic and
behavioral interventions, (e) well-defined treatment components, (f)
intensive skill-based parent and teacher training, (g) home and school
contingency management plans, (h) interventions tailored to the
developmental level of the child, (i) culturally appropriate
interventions that target functional behaviors and competencies in
children, parents, and/or teachers, (j) parents and teachers as agents
of therapeutic change, (k) varied treatment agents (e.g., regular and
special education teachers, teacher aides, parents, school
psychologists, social workers), (1) different treatment settings (e.g.,
regular education classrooms, self-contained classrooms, lunch/recess,
after school programs, home, neighborhood, and community agencies), and
(m) outcome success defined by statistically and clinically meaningful
methods (e.g., effect sizes, Jacobsen and Truax method) (Reddy, 2001;
Reddy & Savin, 2000). Additionally, other important program
components include intensive case management and the assessment of
treatment acceptability and treatment adherence among parents, teachers,
and/or other school personnel (Springer & Reddy, 2004).
The efficacy of prevention and intervention programs is based, in
part, on the screening and selection of children for the program. In the
programs reviewed, the screening process was critically important for
ensuring that children at-risk for receiving an ED classification or
children with an ED classification obtain appropriate intervention
services (e.g., specialized instruction, medication, social skills
training, child/parent therapy) tailored to the unique strengths and
challenges of the individual child.
The three programs also suggest that the future success of school
prevention and intervention programs for children at risk for and with
ED lies in the integration of assessment and treatment methods and
collaboration among professionals (e.g., teachers, teacher aides, school
psychologists, clinical psychologists, psychiatrists) and agencies
(e.g., education, social services, mental health, juvenile justice)
(Pfeiffer & Reddy, 1998; President's New Freedom Commission,
2003). Advancements in school-based programming can offer significant
contributions, however school personnel will not serve as the sole
providers in educating and treating children with ED. Thus, a paradigm
shift is needed so that school personnel adhere to a
collaborative/participatory approach in educating and treating this
population with other professionals (e.g., clinical psychologists,
psychiatrists). This approach embraces a commitment to flexibility and
collaboration across disciplines, creating an atmosphere of mutual
respect for the knowledge and contribution of each team member
regardless of their background. Soliciting the input and participation
of all stakeholders (e.g., parents, teachers, other school personnel,
agency providers) is critical for designing and evaluating future
prevention and intervention models. The use of surveys (e.g., mail and
e-mail distributed), focus groups, and community meetings are examples
of ways to solicit stakeholders' input and participation.
Future models of school prevention and intervention programs will
benefit from broadening the scope of treatments in the school, home, and
community. We recommend that future models adopt an integrated continuum
of services that encompass prevention, intervention, maintenance, and
health promotion/wellness programs and services across settings (Reddy,
2001; Pfeiffer & Reddy, 1997; Weist et al., 2003). Health
promotion/wellness interventions are designed to enhance overall
well-being, resilience, enjoyment, and efficacy in children with ED and
their families (Cowen, 1991). The three programs highlighted do not
incorporate maintenance and health promotion/wellness interventions.
Maintenance interventions and health promotion/wellness interventions
are potent yet often overlooked modes of intervention for children with
ED (Reddy, 2001). Maintenance interventions, frequently called aftercare
services, are designed to sustain educational and behavioral gains
achieved during prevention and/or treatment interventions. Moreover,
maintenance interventions are designed to prevent relapse for children
during stress periods (e.g., new school, change in teachers, relocation
to another town/community, parent separation/divorce, death, birth of a
Finally, developers of new prevention and intervention programs
should attend to ecological factors that influence children's
learning and behavior (Bronfenbrenner, 1979; Hansen et al., 2004). As
previously noted, children's level of social integration in their
school, home, and community significantly impact academic and behavioral
outcomes in this population (e.g., Armstrong et al., 2003; Duchnowski,
1994; Wagner, 1995). Thus, feelings of belonging, connection, and sense
of safety at home and school can profoundly influence the short-term and
long-term success among children with ED.
Priorities for Training
School personnel (i.e., school psychologists, social workers,
teachers, and administers) who design, implement, and evaluate new
prevention and intervention programs for children at-risk for and with
ED require a broad range of competencies and skills. Priorities for
school inservice training may include knowledge of developmental
psychology (emphasizing normal and atypical developmental factors),
neurocognitive processes and pathways of childhood disorders,
psychopharmacology interventions, special education and mental health
policy and regulations, and empirically supported prevention, treatment,
maintenance, and wellness/health promotion interventions for childhood
disorders and problems. Also, school personnel warrant intensive parent
and teacher training (e.g., behavior management, social
skills/self-control, academic skills), skills for effective
collaboration with agencies (e.g., school, social service, juvenile
justice, and/or primary health care) and professionals (e.g.,
physicians, nurses, occupational therapists, physical therapists), and
skills for child advocacy. It is recommended that teaching staff and
child study team members be separately surveyed on their inservice
Prevention and intervention programs for children at-risk for and
with ED offer an effective approach for promoting children's
academic, behavioral, and social competencies in the schools. A
comprehensive integrated cross-disciplinary approach is advocated for
educating and treating this population. Three exemplary school
prevention and intervention programs were described that are effective,
theoretically driven, and flexible for application in school and
community settings. Based on "what works" in the three model
programs, considerations for future school prevention and intervention
programs were offered. Additionally, priorities for training school
personnel were outlined.
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Linda A. Reddy and Laura Richardson
Fairleigh Dickinson University
Correspondences to Linda A. Reddy at Fairleigh Dickinson
University, Child/Adolescent ADHD Clinic, 1000 River Road, Teaneck, NJ.
07666; E-mail: LReddy2271@aol.com or Reddy@FDU.edu.
1 Studies were most frequently cited in the Journal of Emotional
and Behavior Disorders.
2 A prevention program is defined as one that targets children that
may be at-risk for a problem, but have not developed the problem itself.
3 An intervention program is defined as one that targets children
who already have developed the problem.
4 For a more detailed description of ESP and SSBD see Severson and
5 A primary prevention program is defined as one that provides
services to all children, not just those who are at-risk for a problem
or have a problem.