Center for Adolescent Research in Schools (CARS)

Background Informationg• Students are in special education due to emotional and behavior problems that impair academicand behavior problems that impair academic performance

• Poor outcomes among students with emotional andPoor outcomes among students with emotional and behavioral problems– High dropout rate– Poor academic achievement– Poor post‐school outcomes

• Very few evidence based interventions targeting high• Very few evidence based interventions targeting high school age students and none are integrated across education and mental health

Intervention Development for Schools

Behavioral Health Researchers Special Education Researchers

Intervention Development for Schools

Research TeamResearch Team• Lee Kern, Ph.D., Principal Investigator, Lehigh University

• Steven Evans Ph D Co Principal Investigator Ohio University• Steven Evans, Ph.D., Co‐Principal Investigator, Ohio University

• Tim Lewis, Ph.D., Co‐Principal Investigator, University of Missouri

• Deborah Kamps, Ph.D., Juniper Gardens Children’s Project, University of Kansas

l i h i i i i f hi• Carl Paternite, Ph.D., Miami University of Ohio

• Terry Scott, Ph.D., University of Louisville

• Mark Weist Ph D University of Maryland• Mark Weist, Ph.D., University of Maryland

Goals of ProjectGoals of Project

• Identify/develop effective education and mental y/ phealth interventions for students in special education due to emotional or behavior problemsproblems– Maximize feasibility of interventions– Maintain evidence based best practices approach– Interventions should be widely applicable and culturally appropriate

• Develop interventions for delivery by specialDevelop interventions for delivery by special education teachers and school mental health professionals

Goals of ProjectGoals of Project

• Identify/develop effective education and mental y/ phealth interventions for students in special education due to emotional or behavior problemsproblems– Maximize feasibility of interventions– Maintain evidence based best practices approach– Interventions should be widely applicable and culturally appropriate

• Develop interventions for delivery by specialDevelop interventions for delivery by special education teachers and school mental health professionals

Characteristics of InterventionsCharacteristics of Interventions

• Develop set of interventionsDevelop set of interventions– Training procedures– Evidence‐based– Address most common problems of population

• System for assessment and prescription ofSystem for assessment and prescription of selected interventions

• CARS consultant helps staff throughCARS consultant helps staff through assessment and prescription

• Measure use and intervention integrityeasu e use a d te e t o teg ty

INSTRUCTIONAL/CLASSROOMINSTRUCTIONAL/CLASSROOM STRATEGIES

Enhancing Teacher and Classroom Capacity

Background InformationBackground Information

• Lack of effective behavioral management

k f d i• Lack of structure and routines

• Lack of effective instructional procedures

• Negative student‐teacher interactions

• Low engagement with schoolLow engagement with school

Specific Strategies

• Check & Connect• Classroom Structure

• Rules and routines

• Improving Teacher‐Student Interactions• Improving Teacher Student Interactions• Responding to problem behaviorE id B d A d i I t ti• Evidence‐Based Academic Instruction• Opportunities to Respond (OTR)I i d ’ h i d i• Incorporating students’ choice and interests

• Accommodations

Check & Connect• Developed for high‐risk urban students at the secondary level (Anderson, Christenson, Sinclair, Lehr, 2004; Evelo, Sinclair, Hurley, Christenson, Th l 1996)Thurlow, 1996)

• Utilizes a monitoring system with two components– CheckCheck

– Systematically assess the extent to which students are engaged in school. 

Connect– Connect– Respond on a regular basis to students’ educational needs according to their type and level of risk for disengagement f h lfrom school. 

• Establish an adult mentor at school to enhance school engagementschool engagement

Check & Connect: Implementation Steps

• Meet with student regularly (daily or at least weekly)y)

• Give students regular feedback about their• Give students regular feedback about their overall progress and in relation to specific risk factorsfactors

CHECK M Tu W Th F M Tu W Th F M Tu W Th F M Tu W Th F M Tu W Th F

Tardy

Skip

AbsentAbsent

Behavior referral

Detention

In‐school suspension

Out‐of‐school suspensionOut‐of‐school suspension

Failing classes/Behind in credits_____ D’s      _____ F’s      _____ Classes passed out of _____ total     ____Credits earned out of _____ total < H

igh risk

CONNECT  

BASIC k for month

BASIC 

Shared general information

Provided regular feedback

Discussed staying in school

Problem‐solved about riskProblem solved about risk

INTENSIVE

Arranged for alternative to suspension

Contracted for behavior orContracted for behavior or grades

Communicated with parents

Made special accommodations

Participated in community iservice

Participated in social skills group

Worked with tutor or mentor

Other_____________________

Rules & Routines

• Provide structure and increase predictability of classroom environment.

• Same instructional procedures used to teach academics:– Present the rule or routine.  Post in prominent positions in the 

classroom at student eye levelclassroom at student eye level.  

– Discuss why the rule or routine is important.  

– Elicit and demonstrate examples and non‐examples of the desired b h ibehavior.   

– Provide opportunities for practice with feedback.

– Explain what will happen when the rule or routine is followed and what will happen if not followed.  

– Once taught, provide frequent and consistent acknowledgement for compliance.  

Teacher‐Student InteractionsTeacher Student Interactions

• Increase ratio of positive to negativeIncrease ratio of positive to negative interactions (4:1)

• Provide instruction that involves frequentProvide instruction that involves frequent opportunities to actively respond to academic requests (OTR):– Response Cards (RC)– Computer Assisted Instruction (CAI)– Class‐wide Peer Tutoring  (CWPT)– Guided Notes 

Responding to Problem BehaviorsResponding to Problem Behaviors

1. Identify triggers and intervene early in the chain.

2. Set up environment to reduce “triggers” and teach students skills to handle those that cannot be controlled.

3. Create “new chains” and reinforce student use.

5. Peak

4. Acceleration

6. De‐escalation

3. Agitation

2. Trigger

1. Calm

. Trigger

7. Recovery

Time

Curriculum‐based Interventions• Incorporate choice and preference in classroom activities

• Design relevant activities that will incorporate the students’ interests:– Assess the content for importance or relevance.

– Point out to students the importance and worth of information.

– Select topics that reflect students’ interests.p

– Relate content to local issues or problems that are important or familiar to students.

– Begin and conclude classes with statements such as “This is anBegin and conclude classes with statements such as  This is an important topic/skill because…,” and “Why was this important for us to learn about?”

– Allow students to select from a list of optionsAllow students to select from a list of options.

Examples of Implementing ChoiceExamples of Implementing ChoiceExamples

Area of Choice Elementary Students Secondary Students

Choice of task/activity Drawing letters on colored paper v. tracing letters on 

Interviewing ornithologist v writing a paper on birds

personal boards

Choice of task sequence Order to complete spelling words

Order to complete science, literature, math homework

Choice of materials Colored crayons v. pencil Handwriting v typing

Choice of whom to workwith

Peers, teachers, older peers Peers, teachers, study hall supervisor

Choice of place of work Floor, reading mat, individual desk

Individual desk, hallway, library

Choice of time to complete  During current period, next  During current period, next work period, next day period, next day

Choosing Instructional/Classroom Strategies

Given the Information gathered… 7

Identify Needed 

Intervention

8Implement 

the Intervention

1Assess Classroom Environment 

2 – 6 Interpretation

3Does the class need routines?

2Does the class need rules? 

7.1 Determine practical constraints 

and feasibility

1.1 Gather teacher report of  classroom 

management 

5Does 

student disrupt 

class, argue, or display other

8.1 Proceed with 

interventions in 

chronological

6Does 

student need 

curriculum based 

4Do teacher‐student 

interactions need to be improved?

YES YES

1.2 Conduct direct observations of the teacher and target student behaviors  

(MOOSES)

7.2 Determine teacher willingness to engage in the interventions

YESYES

other difficult to manage 

behaviors?

chronological order until 

implemented with high 

fidelity (80%)

intervention

8 2Measure

YES YESYES

2.1 Implement  rules intervention

3.1 Implement routines intervention

6.1 Choice

6.2. Preferred activities

6.3. Relevance

5.1Responding to problem behaviors

5.2. Problem‐solving

5.3. De‐escalation 

8.2 Measure outcomes and use data to inform 

modifications to 

interventions

4.1 OTR

4.2. Praise

6.4. Student interest 

6.5. OTR

techniques

Check and Connect

School Mental Health Interventions

Challenges and StrategiesChallenges and Strategies• School mental health trained professionals in schools vary considerably between schools andschools vary considerably between schools and districts– Quantity– Training– Willingness

• Collect descriptive data on staff within eachCollect descriptive data on staff within each building, offer training and procedures, and measure implementation and outcomes– How many with what training?– How do they spend their time?– What is their accountability?What is their accountability?

Choosing Mental Health Interventions

Given the Information Gathered… 6

PrioritizeIntervention 7

Implement 

1What is the Problem?

2 – 5 Interpretation

3Does 

student show signs 

of withdrawal, 

2Does 

student show signs of 

anxiety or worry?

6.1 PRIORITY: Rank problems based on how much they are impairing school & 

academic functioning

the Intervention1.1 Gather teacher, 

parent and self report of difficulties 

related to impairment at 

school

5Does 

student disrupt 

class, argue, or display other

7.1 Begin with the   feasible intervention

4Does 

student show signs of poor 

social skills, frequent

YES YES

irritability, negativity or sad mood?

1.2 Obtain relevant school records to assess impairment 

(e.g., office referrals)

worry?

6.2 FEASIBILITY: Indicate whether each of the interventions can be feasibly provided

6.3 ACCEPTABILITY:  

YESYES

other difficult to manage 

behaviors?

intervention with the 

highest clinical priority and proceed 

through entire intervention

frequent conflict or 

poor problem solving skills?

2.1 The C.A.T. Project

16 Session Program

3.1 Coping with Stress program

15 Session Program

4.1 Interpersonal Skills Group

28 thirty minute Session 

5.1 Referral to Special Education Teacher for 

classroom management or Teacher‐Student communication 

Indicate whether the student, teachers and/or parents are willing to participate

1.3 Conduct Observations

6.4 Record list of interventions that are 

1.4 Consult with CARS MH consultant

7.2 Measure outcomes and use data to inform 

modifications to 

Group or Individual Group or 

Individual 

Program

Group

concerns, and/or the development of an 

FBA/BIP

5.2 De‐Escalation Techniques

feasible and acceptable in order or priority 

ranking

CARS MH consultantinterventions

Family Interventions  

DocumentationDocumentation

• Explanations of each step in figureExplanations of each step in figure

• Assessment table providing information about measuresmeasures

• Table for documenting choice of areas of i iimpairment

Rationale for Selecting Areas of Impairment

Area of ImpairmentProblem for the 

Student? Relevant Interview Results

Relevant Scores from Assessments Other information that contributed to 

decisionAssessments Score

Anxiety or WorryYesNo

Withdrawal, Irritability, Negativity or Sad Mood

YesNo

Poor Peer RelationsYesNo

Disruptive BehaviorYesNo

DocumentationDocumentation

• Explanations of each step in figureExplanations of each step in figure

• Assessment table providing information about measuresmeasures

• Table for documenting choice of areas of i iimpairment

• Selecting interventions for use based on identified areas of impairment

Instructions: Record all of the interventions indicated by steps one through five on the Choosing Mental Health Interventions diagram. Then rank the interventions in the second column (1,2,3…) according to directions 6.1. Next record either a √ or X in the Feasibility column according to the directions in 6.2. Then record either a√ or X in the Acceptability column according to the instructions in 6 3 All interventions should have a number in the

Intervention Ranking (no fractions, decimals or ties) Feasibility (if you record an X, then record explanation on back)

Acceptability (if you record an X, then record explanation on back)

X in the Acceptability column according to the instructions in 6.3. All interventions should have a number in the ranking column and either a √ or an X in the Feasibility and Acceptability columns. No other marks should be in any of these columns. There should be an explanation on the back of this form for all Xs in the Feasibility or Acceptability columns.

1. 1R. 1F. 1A.

2. 2R. 2F. 2A.

3. 3R. 3F. 3A.

4. 4R. 4F. 4A.

5. 5R. 5F. 5A.

6. 6R. 6F. 6A.

7. 7R. 7F. 7A.

8. 8R. 8F. 8A.

9. 9R. 9F. 9A.

Brief Descriptions of InterventionsBrief Descriptions of Interventions

• CBT for anxiety and worryCBT for anxiety and worry

• CBT for depressed mood

l Skill G f i l• Interpersonal Skills Group for social impairment

• De‐Escalation training for anger control

• Family Interventionsy

2.1 C.A.T. Project2.1 C.A.T. Project• CBT is an effective treatment for anxiety in 

hild d d lchildren and adolescents• Coping Cat and C.A.T. were developed by Phil Kendall and are the most studiedPhil Kendall and are the most studied protocols for treating child & adolescents with anxiety.

• CBT and medication are effective in treating anxiety and a combination of the two has the highest response rate (Walkup et al 2008)(Walkup et al., 2008).

• Manuals and interactive computer training materials are availableare available

• 14 individual child sessions plus 2 parent sessions

3.1 Coping with Stress Program3.1 Coping with Stress Program

• CBT is a moderately effective treatment for adolescents ywith depression (mean ES = 0.34; Weisz, McCarty & Valeri, 2006). Recommendations include:

Increasing dosage– Increasing dosage– Providing booster sessions or other long‐term follow‐up

• Coping with Stress is a manualized CBT intervention forCoping with Stress is a manualized CBT intervention for adolescents with depression, is available free of charge, and has been used in many trials (Clarke & Lewinsohn, 1995).1995).

• 16 individual or group sessions plus 3 parent and adolescent sessions

4.1 Interpersonal Skills Group4.1 Interpersonal Skills Group

• There is no empirically supported treatmentThere is no empirically supported treatment for impaired social functioning

• Interpersonal Skills Group (ISG) was developedInterpersonal Skills Group (ISG) was developed over last ten years working with middle and high school students with ADHD

• As part of comprehensive program, we do not have outcome data specific to ISG

• Measures of social functioning have indicated improvement in response to programs

5.2 De‐escalation Techniques5.2 De escalation Techniques

• There is no empirically supported treatmentThere is no empirically supported treatment for anger control

• Our procedures integrate:• Our procedures integrate:– Collaborative Problem Solving (Greene, 2006)

Ad l A C l– Adolescent Anger Control (Feindler & Ecton, 1994)

• Target student and includes some teachers as coaches and treatment extenders

Family InterventionsFamily Interventions• Family Interventions

l l h– Functional Family Therapy (Alexander & Sexton, 2002)• Has been disseminated in community clinics in NY (Zazzali et al., 2008)and school‐community clinic partnerships (Mease & Sexton, 2004)

“ l l l l l l• Requires “multi‐year clinical training, clinical consultation, and quality assurance monitoring…” in order to implement

– Family Check‐Up (Dishion & Kavanagh, 2003)• Part of Adolescent Transitions Program (secondary school based treatment program)

• Limited evidence for ATP and FCUd l fl– Negotiating Parent Adolescent Conflict (Robin & Foster, 1989)

• Modest benefits in two trials with families with adolescents with ADHD (Barkley et al., 1992, 2001)

Family InterventionsFamily Interventions

• Our family intervention is based on elementsOur family intervention is based on elements of all three of these and trial and error with families of adolescents with ADHD over lastfamilies of adolescents with ADHD over last ten years.

• Some of the specific procedures have been• Some of the specific procedures have been evaluated in pilot studies (Raggi et al., 2009) and have been part of comprehensive programsbeen part of comprehensive programs evaluated with positive outcomes (Evans et al., 2009).

Measures of Intervention l dImplementation and Outcomes

• Intervention Integrity • FeasibilityIntervention Integrity– Audio recordings coded for adherence and 

Feasibility– Are the interventions used by SMH clinicians 

competence

– Accuracy of data recording on

at most/all sites?

– Feasibility ratings by all SMH clinicianrecording on 

implementation formsSMH clinician participants including those who use and those h d twho do not.

Measures of Intervention l dImplementation and Outcomes

• Proximal • Distal– Attendance– CBT homework tasks

l d d f

Distal– Parent & Self BASC‐2– Reynolds Adolescent Adj S i• Completed outside of 

session• Quality of task completion

Adjustment Screening Inventory (RAASI)

– Reynolds Adolescent completion

– Self‐ratings of anxiety/depression outside of session

Depression Scale (RADS) – Multi‐Dimensional Anxiety Scale foroutside of session Anxiety Scale for Children (MASC)

– Classroom Performance SurveySurvey

– Impairment Rating Scale