Interventions for Externalizing and Internalizing behaviors at Tier 2 and Tier 3

1. Interventions for Externalizing and Internalizing behaviors at Tier 2 and Tier 3 Kimberly J. Vannest, PhD

2. Overview • Evidence based interventions are critical at all levels of a response to intervention model. Best practices in a general education classroom can prevent learning and behavior problems while serving as a protective and resiliency factor for children who have characteristics of risk.   For students demonstrating learning or behavior problems that place them at risk, evidence based interventions serve to ameliorate and potentially mediate further exacerbation of problems.

3. This presentation will: • Provide a description of a multi tier model for context with suggested timelines and procedures • Present a list of applicable interventions at each of the three levels in RTI (for behavior). • Provide the essential steps for highlighted interventions so that participants may leave the session with methods for application.

4. Vannest, K.J. (2009) kvannest@tamu.edu

5. Provide a description of a multi tier model for context with suggested timelines and procedures

6. Three tier preventive intervention classification system

7. First, lets all get on the same page. There are multiple names for a 3-tier model Medical Model Positive Behavioral Supports Universal Targeted Individual • Primary • Secondary • Tertiary

8. September & OctoberUniversal Best Practices Teach explicit school wide expectations Reinforce new pro-social skills 1:1 Reinforce pro-social behaviors on a fixed or intermittent schedule Use data to evaluate practices Conduct universal screening to determine elevated levels of risk Killer academic programming

9. November & DecemberTargeted Interventions • Target the problem • Consider externalizing vs. internalizing types of risk • Consider specific differences ex. attention problems or aggression problems (i.e. one is neurological, the other is not likely) • Identify resources & Train for needs • Implement • Measure teacher fidelity, Measure student progress

10. January & February Individual Interventions Making Progress ? Monitor ongoing progress yes no New intervention or individualized programming

11. Suggested timeline Review Vannest, K.J. (2009) • August – September • Prep teachers and parents, send notices, review school rules for consensus • Teach school rules to students, use school rules to guide universal programs • October • Screen school population @ week 6 (Behavior Emotional Screening System) • Review risk list • Determine number of students to serve • October-November • Notify & consent parents • Conduct assessments to identify problem type (BASC-2) • Consider coordinating reading or academic screening and behavioral risk notification • November-December • Use targeted interventions (Intervention Guide & Classroom Guides) • Use resource mapped interventions • January-February, March-May as appropriate • Use targeted interventions (Intervention Guide & Classroom Guides) • Use resource mapped interventions • Consider specialized services based on diagnostic assessment, structured background interview, direct observation and FBA

12. Screening & Resource allocation • We have an inefficient reactive rather than proactive approach. • The community costs for treatment of chronic conditions, juvenile justice, adult incarceration, restorative justice, loss to family and work force contributions far exceeds the cost of screening and early intervention. • Our current system of service identification depends on parent and teacher referral • Idiosyncratic, externalizing behavior problem-focused method of either unknown or poor validity. • Schools screen for other types of problems including vision, hearing, speech, academic problems associated with specific learning disabilities, and developmental delay but not for emotional and behavior problems.

13. Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Student Classroom Snapshot

14. Things I hear: • “ we are too busy with academic RTI to worry about behavior”

15. If 20% of our student population is struggling with social emotional, behavioral issues – academics will be affected. • A reciprocal relationship exists between achievement and behavior. • Academic performance is inversely related to problem behavior that begins early in a child’s development (Brier, 1995; McEvoy & Welker, 2000).

16. What's the significance of students with problem behaviors? Vannest, K.J. (2009) kvannest@tamu.edu • There is evidence to show that young children with challenging behavior are more likely to experience: • expulsion from preschool programs at 3.2 times the rate of K-12 students (Gilliam, 2005) • early and persistent peer rejection (Coie & Dodge, 1998); • mostly punitive contacts with teachers (Strain et al., 1983); • family interaction patterns that are unpleasant for all participants (Patterson & Fleishman, 1979); • school failure & negative achievement trajectory (Kazdin, 1993; Lipsey & Derzon, 1998; Patterson & Fleishman, 1979; Tremblay, 2000; Wahler & Dumas, 1986), • high risk of fatal accidents, substance abuse, divorce, unemployment, psychiatric illness, and early death (Coie & Dodge, 1998; Kazdin, 1985). • Adult lives characterized by violence, abuse loneliness & anxiety (McCord, 1978; Olweus, 1991)

17. What are the positive outcomes expected from early intervention? Vannest, K.J. (2009) kvannest@tamu.edu Decreased risk of withdrawal, aggression, non-compliance, and disruption (Strain & Timm, 2001). Treatment impact on fears, phobias, depression, anxiety, hyperactivity, conduct, and obsessive-compulsive disorders. Positive peer relationships including understanding of friendship, cooperation, and sharing (Denham & Burton, 1996). Increased self-control, self-monitoring, and self-correction and improved social-emotional health (Webster-Stratton, 1990). Academic success (Walker et al., 1998). Reduced risk for teen pregnancy, juvenile delinquency, and special education placement (Strain & Timm, 2001). www.challengingbehavior.org

18. System for Managing Behavioral and Emotional Problems

19. Group: Roster Report Classification Key that lists elevation levels In a Roster report, students are listed according to whatever level is chosen; in this case, the district level was chosen, and results are sorted within each school in the district Results can be sorted alphabetically (student name), or by classification level (either ascending or descending)

20. Methodology A multi-year research review study by Vannest, Reynolds & Kamphaus, 2008 Inclusion criteria -Any research articles that were experimental or quasi-experimental in design and demonstrated positive effects which could be attributed to the intervention. Studies sorted by the type of problem behavior for which the intervention was designed. Of the thousands of studies reviewed, 40 distinct interventions are listed here today.

21. Example annotation Vannest, K.J. (2009) kvannest@tamu.edu • Robinson, P. W., Newby, T. J., & Ganzell, S. L. (1981). A token system for a class of underachieving hyperactive children. Journal of Applied Behavior Analysis, 14(3), 307–315. • This study investigated the efficacy of a token economy reinforcement system on the reading achievement of a large group of children with hyperactivity and low reading ability. Eighteen third-grade males identified as hyperactive and performing below grade reading level participated. Tokens were awarded for learning a reading unit or teaching a unit to another student and were redeemed for time spent playing a video game or pinball. Students completed nine times as many reading assignments during the token-economy condition as during the reversal period, when the tokens were removed (p < .05). Students also passed more standardized level tests required by district during the token-economy condition.

22. Present a list of applicable interventions at each of the three levels in RTI (for behavior).

23. Interventions with Evidence • Advance organizers • Anger Management Skills Training • Behavioral Interventions • Choice • Class Wide Peer Tutoring • Cognitive organizers • Cognitive Restructuring • Cognitive-Behavioral Therapy • Computer-Assisted Instruction • Contingency Management • Daily Behavior Report Cards • Exposure-Based Techniques • Family Therapy • Functional Assessment • Functional Communication Training • Integrated Cognitive-Behavioral Therapy • Interdependent Group-Oriented Contingency Management • Interpersonal Therapy for Adolescents • Milieu Language Teaching • Mnemonics • Modeling • Modified Task Presentation Strategies • Moral Motivation Training • Multimodal Interventions • Multisystemic Therapy • Opportunities to respond • Pacing • Parent Training • Peer Mediated Interventions • Peer tutoring • Peer-Mediated Conflict Resolution and Negotiation • Picture Exchange Communication System • Pivotal Response Training • Precorrection • Presentation Strategies • Problem Solving • Procedural prompts and behavioral momentum • Replacement Behavior Training • Self instruction • Self mediated strategies • Self monitoring • Self-Management • Social Skills Training • Task Modification • Task Selection Strategies • Token Economy System • Verbal Mediation • Video Modeling

24. Using intervention across tiers is partially about resources and skills

25. Provide the essential steps for highlighted interventions so that participants may leave the session with methods for application.

26. Intervention categorization • Interventions are organized according to the most common behavior problem clusters found in a nationally represented sample of nearly 4000 teachers and parents across the United States. • Students, schools, teachers and parents were matched for all demographic variables.

27. Intervention categorization • Behavior and emotional categories include: • Academic Problems • Adaptability • Aggression • Anxiety • Attention Problems • Conduct Problems • Depression • Functional Communication • Hyperactivity • Leadership/Social Skills

28. Interventions for Aggressive Behaviors Problem Solving Training Cognitive Restructuring Verbal Mediation Social Skills Training Peer Mediated Conflict Resolution and Negotiation Replacement Behavior Training

29. Interventions for Conduct Problems Token Economy Systems Interdependent Group-Oriented Contingency Management Anger Management Skills Training Problem-Solving Training Social Skills Training Moral Motivation Training Parent Training Multimodal Interventions Multisystematic Therapy

30. Interventions for Hyperactive Behaviors Functional Assessment Contingency Management Parent Training Self- Management Task Modification Multimodal Interventions

31. Interventions for Attention Problems Contingency Management Daily Behavior Report Cards Modified Task-Presentation Strategies Self-Management Classwide Peer Tutoring Computer Assisted Instruction Multimodal Interventions

32. Academic Problem Interventions Mediated Interventions •Focus on effective teaching 2. Peer Mediated Interventions •Focus on peers helping peers 3. Self-Mediated Interventions •Focus on student regulating learning

33. Interventions for Anxiety Disorders Exposure-Based Techniques Contingency Management Modeling Family Therapy Integrated Cognitive-Behavioral Therapy

34. Interventions for Depression Cognitive- Behavioral Therapy A. Psychoeducation B. Problem-Solving Skills Training C. Cognitive Restructuring D. Pleasant Activity Planning E. Relaxation Training F. Self- Management Training G. Family Involvement II. Interpersonal Therapy for Adolescents

35. Interventions for Somatization Disorders Behavioral Interventions Multimodal Cognitive-Behavioral Therapy

36. Interventions for Problems with Adaptability Functional Behavior Assessment Precorrection Procedural Prompts and Behavioral Momentum Self Management Training Cognitive Behavior Management

37. Interventions for Problems Functional Communication Functional Communication Training Picture Exchange Communication System Video Modeling Milieu Language Teaching Pivotal Response Training

38. Social Skills Defined Definition: Children who exhibit strong social and interpersonal skills and demonstrates positive relationships with others without significant maladaptive behaviors (Bierman, Miller, & Stabb, 1987). Etiology: Children who demonstrate characteristics of emotional and behavior disorders, autism spectrum disorders, and ADHD demonstrate deficits in social skills (Bellini et. al., 2007, Forness & Knitzer, 1992). Prevalence: 18-20% of teachers report deficits in social skills in the classroom setting (Reynolds, Kamphaus, 2004). Outcomes: Positive, everyday experiences with their parents are fundamental to children’s developing social skills. Children whose parents frequently play with them have more advanced social skills and get along better with peers. Children who have a hard time getting along with others in the preschool years are more likely to experience later academic difficulties.

39. Social Skills Training Teaching prosocial concepts to children to function successfully in social environments across all settings. Basic Elements of Social Skills Training Teaching the skill and talking about the problem area or weakness Modeling the skill through active demonstration Practicing the skill in a controlled environment while receiving feedback Generalizing the skill by practicing it in new environment

40. Context of our current research • Universal Screening • Brief assessment to determine problem type • The “10 minute” meeting • Discuss intervention selection NOT problem admiration • ½ day School wide training in most common interventions • Follow up coaching in classrooms • Electronic daily behavior report cards

41. Example problem assessment report

42. Case Example of Elmer • Elmer’s scores on Hyperactivity, Anxiety, and Attention Problems fall in the clinically significant range, and probably should be considered among the first behavioral issues to resolve. • Note that Elmer also had scores on Aggression and Conduct Problems that are areas of concern. Interventions for these areas are not provided in this report. However, these areas may require additional follow up • Example: Hyperactivity • Functional Assessment • Contingency Management • Parent Training • Self-Management • Task Modification • Mulitmodal Interventions

43. Assistance for expert decision making Our current models involve resource mapping, but we may consider the match between problem type and intervention rather than a generic intervention or an overly engineered or prescribed one • Look at supports available to Elmer at home or in the community • Look at capacity and resources of the school. • Also consider the barriers in the related settings. For example: • A functional assessment to determine specific antecedent and consequence manipulations may be beyond the scope of the available time and resources of the school and classroom. • Contingency management may not seem like the type of intervention suggestion that would work with a particular teacher personality. • Parent training likewise may not be a “best fit”. • However self-management works well for Elmer’s age, the school, the classroom and your time use. So you might then engage in a treatment plan that includes or starts with self-management.

44. Parent Tip Sheets

45. Tools for Partnership

46. Multiple steps and examples

47. Communication with Caregivers

48. Teacher Training - • If leadership teams decide to use an intervention as a tier two support. The school should be trained. • Small teacher groups • Use conference or prep time • Train in a 30 minute block with a competency check • Use scenarios appropriate for your school i.e. your own student examples.

49. Effective Training • What do we know about getting teacher training content to “stick” • Requires modeling • Requires performance feedback • Requires praise for change • For any new behavior consider… • Praise for attempting something new • Coaching and contingencies

50. Improving practice • Step by step instructions for all the interventions listed here are excerpted from the Intervention Guide which lists the evidence-base for each intervention and provides procedures, directions and consideration for use in schools. (Vannest, Reynolds & Kamphaus)