Carole Upshur, EdD., Professor Department of Family Medicine and Community Health [email protected]

Melodie Wenz Gross, PhD, Assistant Research Professor Department of Psychiatry University of Massachusetts Medical School [email protected]

Addressing Behavior Problems in Preschool Settings

National Institute of Mental Health R34 MH073830

         Together for Kids Coalition Health Foundation of Central Mass United Way of Central Mass University of Massachusetts Zuckerberg Leadership Fund Lynn Hennigan, Director of Services for the Young Child, Community Healthlink Rainbow Child Development Center Worcester Comprehensive Child Care Services-Great Brook Valley YMCA of Central Mass, Worcester Commons YWCA of Central Mass, Salem Square

       Carole Upshur, EdD, Professor, Department of Family Medicine and Community Health, UMMS, PI Melodie Wenz Gross, PhD, Assistant Research Professor, Department of Psychiatry, UMMS, Co-Investigator George Reed, PhD, Associate Professor, Biostatistics Unit, Division of Preventive and Behavioral Medicine, UMMS Judy Davis, MPH, and Gail Sawosik, Project Coordinators Rachel D’Angelo, Data Entry Katelyn Allen, Katie Bateman, Courtney Carpenter, Alicia Derry, Rachel Friendly, Jenny Hazelton, Karen Nideur, and Laura Seekamp, Observational staff Esteban Cardemil, PhD, Clark University, Stephanie M Jones, PhD, Harvard University, Daniel Shaw, PhD, University of Pittsburgh, Scientific Advisory Committee

  ◦

2001-current: work of TFK coalition to develop and provide mental health consultation services to child care centers This work found:

Great interest in child care sites in receiving help to work with young children’s disruptive behavior ◦ Ability of centers to conduct regular screening for behavior problems and work collaboratively with TFK to deliver teacher mental health consultation and parent and child services ◦ Successful outcomes in reducing behavior problems and increasing developmental and school readiness skills among children and families provided services

10 5 0 40

Figure 1. Changes in maladaptive behavior and aggression for matched groups.

35 Maladaptive 30 25 Aggression 20 15 Maladaptive intervention Maladaptive control Aggression intervention Aggression control T1 T2

Time

Percent of TFK individual services children with IEPs, services or requested IEPs or services

100 90 80 70 20 10 0 60 50 40 30 IEP IEP requested Any services Services requested Total

200 180 160 140 120 Pre-TFK Post-TFK Kindergarten K 1 K2

    Many teachers want to leave the problem to the ‘expert’; we found some teachers did not embrace new learning about behavioral management but thought consultant would ‘fix’ the child Over several years of mental health consultation we did not find significant changes in teacher self-reported confidence in knowing how to handle challenging behaviors Some teachers with children with challenging behaviors did not refer children because parents were reluctant to participate in MH consultation Consultants could not provide individual services to all children identified in the course of the year

10 0 30 20 60 50 40 46,6 51,3 at risk 26,5 43,3 4,5 suspensions 2,6 terminations baseline 5 years later

  ◦ ◦ ◦ ◦ Review and select/adapt from several already developed models (3P, Incredible Years) a primary prevention approach Goal: supplement mental health consultation to: ◦ Teach all children social skills and emotional regulation Serve as early intervention and prevention of high rates of problem behavior Reduce the numbers of children that require referral for mental health consultation Improve teacher skills in managing behavior Not require stigmatization of child/family for children to receive some needed intervention

      Group social skills curriculum for preK-1 st grade Taught by teachers (not counseling or outside staff) Picture cards, stories, puppets, CD with songs, supplemental story books Teaches recognizing feelings in self and others and labeling them Learning to calm down when upset Learning how to problem solve: ◦ Share toys, join a group, wait politely, avoid distraction etc.

    Feasible cost to implement ◦ Kits cost $289 per classroom ◦ Training of trainers 2-day session per person costs $525 ◦ ◦ Level of overall training required modest compared to some other programs Accessible train the trainer workshops around the country Only a 2-4 hours required to get teachers started ◦ ◦ Teacher requirements and time modest Only a few minutes needed to prepare a lesson Lessons can be broken down and delivered in short periods of time that can fit with other curriculum requirements Pictures in the materials were very representative of the multicultural background of urban preschool children

     Curriculum adapted from 1x per week and 45 minute lessons to 4x per week and 15 minute lessons=89 lesson days Sessions repeated as needed

   4 programs with 15 classrooms randomly assigned to intervention (2) or control group (2) All sites (intervention and control) continued to receive Mental Health Consultation through TFK Teachers were trained in an initial 2 hour dinner meeting and then monthly 90 minute dinner meetings the first year; alternate months the second year   Mental health consultants received individual training on the curriculum, attended some teacher sessions, and periodically consulted with the research staff about matching curriculum topics to individual treatment plans for identified/referred children Mental health consultants co-led the parent sessions in Year 2

      Activities and language in curriculum too advanced for younger children/those with developmental delay/ESL Children could not sit quietly for any length of time and had never been asked to raise their hand in a group circle activity During implementation, teacher turn over was 25% and 37.5% in the two centers in Year 1 and 75% and 25% in Year 2 Children coming and going all year; less than 50% received most of the curriculum All centers had new state curriculum requirements and accreditation visits during Year 1 Few parents attended parent sessions designed to link classroom activities to home activities

   Of 25 total lessons (broken into the 89 delivery days), teachers completed: ◦ a mean of 22 lessons in Year 1 (range=17 to 25) and ◦ a mean of 23 lessons in Year 2 (range=11 to 25); (only 1 classroom completed less than 24) Teachers reported: ◦ 85% completion of main curriculum points in Year 1 (range = 62% to 99%) and ◦ ◦ ◦ 87% (range = 49% to 99%) in Year 2 Mean observed fidelity ratings on a five point scale (1= ‘not at all’ to 5 = ‘very much’) were: 3.6 in Year 1 (range 3.11 to 4.25) and 3.5 in Year 2 (range 2.90 to 3.93)

How hard was it to learn and implement Second Step? How much time did it take to learn the lessons? % Very Little Time % Some Time % A lot of Time % Too Much Time How hard was it to incorporate Second Step into your daily curriculum? % Not At All Hard % A Little Bit Hard % Somewhat Hard % Very Hard What were the most difficult things to implementing the curriculum? % Learning How to Give the Lessons % Filling Out Daily Reports % Getting Children to Sit for Circle % Thinking Up Different Activities to Make Sure Children Understood % Time for Monthly Meetings Year 1 (

n

=12) 33.3 50.0 16.7 0.0 Year 2 (

n

=13) 30.8 46.2 23.0 0.0 33.3 50.0 16.7 0.0 60.0 71.4 77.8 85.7 66.7 38.5 23.0 38.5 0.0 23.1 30.8 76.9 46.2 30.8

2 1 4 3 Teacher ratings of helpfulness of curriculum 0 Helpful to children Helpful to teacher Improved classroom Yr 1 Yr 2

Percent of teachers reporting they would implement Second Step 'next year' after study ended 70 60 50 40 30 20 10 0 Not at all Unsure Probably Yes, definitely Yr 1 Yr 2

100 90 80 70 60 50 79 82 88 74 40 30 20 10 0 Received Letters From Teachers Tried Activities At Home 35 39 Attended Parent Sessions Year 1 Year 2

What was Related to Greater Implementation Success?

       Teacher Characteristics: Higher baseline teacher personal accomplishment self-rating Less teaching experience; Greater teacher education Greater baseline teacher observed skills Greater attendance at Second Step trainings  Higher self-efficacy in delivering the lessons Classroom characteristics: Having more children with behavioral or other problems in the classroom related to completing fewer lessons, but with greater fidelity Lower child and teacher turnover Higher quality baseline classroom environment and interactions



Was Second Step effective in changing the classroom environment?



Did it help to improve…

 teacher skills?

 teacher and child interactions?

 child behavior?

 child social skills?



Observed quality of classroom interactions

(ECERS Interaction scale: teacher discipline, supervision, teacher child interactions, child-child interactions) 

Observed individual teacher skills

(Caregiver Interaction Scale summary score) 

Observed child behavior

(classroom level behavioral counts of disruptive behavior, verbal aggression and physical aggression) 

Teacher ratings of child behavior problems

(Sutter-Eyberg) 

Teacher ratings of child adaptive/prosocial skills

(Adaptive Behavior Scale)

  

Teacher skills ECERS Interaction Quality

Discipline General supervision Staff-child interaction

Observed ratings of classroom disruptive behavior by children

Year 1 Year 2 Classroom Characteristic Average Child Age Mean Observer Rated Behavior Problems Mean Teacher Rated Prosocial Skills % of Children Meeting Clinical Cut-off for Teacher Rated Behavior Problems % of Children Receiving TFK Services % of Low Income Children Mean ECERS Environment Items Mean ECERS Interaction Items Intervention (n=8) Control (n=7) 47.79 1.95 55.67 26.61 12.13 48.11 5.21 22.00 49.41 1.59 53.21 22.34 10.57 37.47 5.01 19.62 Intervention (n=7) 44.99

5.19**

57.89 22.31 23.29 44.07 -- 22.11 Control (n=4) 48.25

2.38

53.64 6.48 20.50 55.65 -- 18.69



No significant differences between intervention and control in any outcomes in Year 1



In Year 2, Intervention Centers improved whereas Control Centers got worse in:

▪ ▪ Observed teacher skills Observed ECERS Interaction scale (including discipline, general supervision and staff-child interaction) ▪ Observed overall child behavior problems

Year 1 Year 2

Year 1 Year 2

Year 1 Year 2

Year 1 Year 2

Year 1 Year 2

Year 1 Year 2

10 0 60 30 20 50 40 11 8 No 36 34 53 55 Sometimes Frequently 3 0 Don't Know Year 1 Year 2

30 20 10 0 70 60 50 40 59 42 35 33 21 8 3 0 Got Worse Same-Already Difficult Same-Already Positive Improved Year 1 Year 2

  High implementation: 88% lessons in Year 1& 92% in Year 2 No teachers rated that it “Takes too much time” or “Was too hard”  Positive teacher ratings on helpfulness to children, themselves and classroom  Evidence for sustainability: 62% said they would “definitely” and another23% would “probably” use the curriculum after the project ended  Teacher experience, skills, attitudes, classroom quality, teacher and child turnover, and number of children with behavioral problems and delays affect implementation  Mental health consultants felt the curriculum was helpful to reinforce individual child work  The majority of parents reported that they received letters about Second Step and tried the suggested activities at home

 Teacher observed skills, and classroom interactions seems to improve in intervention versus control classrooms, more strongly so in the second year of implementation  Mental health consultants felt the curriculum helped their work with individual children  In Year 2 mental health consultants were able to open more consultation only case (as opposed to individual therapy) and caught up with the number of referred children; some indication that the curriculum allowed them to be more effective with cases and handle more cases  Observed child behavior got worse in all classrooms in Year 1, but seemed to show improvement for the intervention sites in Year 2, while child behavior in control classrooms got worse  The majority of parents reported that their child talked about feelings frequently and in Year 2, a majority of parents reported that their child’s ability to cooperate had improved

     www.cfchildren.org

training for Second Step materials and http://www.americanwoodcrafterssupply.com

For wooden hearts-1 ¾” http://www.hfcm.org/?id=288 Reports of the results of the TFK mental health consultation development project http://www.sciencedirect.com/science For copies of the article: Upshur, Wenz Gross & Reed (2009). A pilot study of early childhood mental health consultation for children with behavior problems in preschool.

Early Childhood Research Quarterly, 24

: 29-45.