Tier two interventions implemented within the context of a tiered prevention framework

Tier Two Interventions Implemented within the Context of a Tiered Prevention Framework Barbara S Mitchell, Melissa Stormont, and Nicholas A Gage University of Missouri ABSTRACT: Despite a growing body of evidence demonstrating the value of Tier and Tier interventions, significantly less is known about Tier level treatments when they are added within the context of a tiered continuum of support The purpose of this article is to systematically review the existing research base for Tier small group intervention studies conducted within a tiered prevention framework Results indicated that few studies documented fidelity of Tier I implementation prior to the addition of Tier interventions Methods for identifying students to receive Tier supports varied across investigations, but included teacher nomination, use of student data, and/or screening score results More than half of the reviewed studies demonstrated use of the Behavior Intervention Program: Check-in/Check-out (BEP/CICO), although social skill instructional groups and academic instructional groups were also employed as Tier interventions Overall, positive results for reducing problem behavior were reported In addition, school-based personnel implemented the Tier intervention in nearly half of the investigations Among studies that reported measures of social validity teacher and student perceptions of the treatments were largely positive Implications for future research are evaluated using criteria from the Society for Prevention Research (Flay et al., 2005) A substantial number of children and adolescents have or are at risk for developing emotional and behavioral disorders (EBD) (National Research Council and Institute of Medicine [NRC & IOM|, 2009; Van Landeghem & Hess, 2005) Outcomes for students experiencing EBD are very poor and include drop out, incarceration, homelessness, psychopathology, diminished functioning, inability to find and maintain employment, and problems developing healthy interpersonal relationships (Lehr, Johnson, Bremer, Cosiú, & Thompson, 2004; NRC & lOM, 2009) Unfortunately, although signs of EBD can be detected at an early age, many children and youth who experience symptoms and disorder are often inadequately supported, delayed in accessing services, or receive no treatment at all (NRC & lOM, 2009) In response to the growing concern for students who experience EBD, a number of practices have shown evidence for preventing, treating, and/or reducing symptoms Use of a tiered intervention framework such as SchoolWide Positive Behavior Support (SWPBS) is one promising avenue for delivering schoolbased prevention efforts Derived from a public health disease prevention model (Gordon, 1983), SWPBS is the application of a three-tiered continuum of supports for students in school settings (Lewis & Sugai, 1999; Sugai Behavioral Disorders, 36 (4), 241-261 et al., 2000; Walker et al., 1996) SWPBS is a systematic approach to plan, develop, and provide primary prevention to all students (Tier 1); specialized group or targeted support to some students who may be at risk for academic and/or behavioral problems (Tier 2); and intensive, individualized support for a small percentage of students who already exhibit patterns of chronic and persistent failure (Tier 3) (Sugai & Horner, 2008) The purpose for delivering Tier supports to all students is to reduce new cases of problem behavior and/or academic failure (Lewis & Sugai, 1999; Sugai et al., 2000; Sugai & Horner, 2008) Specific to behavioral outcomes Tier prevention components include clearly identified expectations and rules that are specifically taught to students, a systematic process for acknowledging appropriate behavior, and consistent reteaching and response for inappropriate behavior (Lewis & Sugai, 1999; Sugai et al., 2000) These practices are embedded throughout instruction across classroom and nonclassroom settings The vast majority of students, approximately 80%, respond to this level of support A large body of evidence shows that these features can be implemented by school personnel (Colvin, Kameenui, & Sugai, 1993; Lewis, Sugai, & Colvin, 1998); these practices are effective in reducing office discipline referrals, school August 2011 / 241 suspensions, and problem behaviors (Colvin, Sugai, Good, & Lee, 1997; Lewis, Colvin, & Sugai, 2000; Lewis et al., 1998); and improvements in student behavior and perceptions of school safety are associated with increased academic outcomes (Bradshaw, Koth, Bevans, lalongo, & Leaf, 2008; Bradshaw, Mitchell, & Leaf, 2010; Horner et al., 2009) In addition to the research outcomes for Tier supports, a number of studies also demonstrate the effectiveness of functionbased, individualized planning that is characteristic of Tier interventions (Fairbanks, Sugai, Guardino, & Lathrop, 2007; Ingram, LewisPalmer, & Sugai, 2005; March & Horner, 2002; Todd, Horner, & Sugai, 1999) Tier support typically involves the use of functional behavioral assessment (FBA) and/or functional analysis results to determine patterns across setting event, antecedent, and maintaining consequence conditions of problem behavior Information from a FBA is then used to develop individualized intervention plans for students School, family, and community agencies may also collaborate to coordinate intervention planning and efforts At the Tier level, the goal is to reduce the severity and intensity of existing cases of chronic behavior and/or academic failure (Sugai et al., 2010) Due to the high level of technical expertise and the extensive amount of resources required Tier support is generally reserved for a small number of children, approximately 5%, who demonstrate persistent failure or serious, violent, and dangerous types of behavior, and/or when Tier and Tier interventions are determined to be inadequate (Sugai et al., 2010) Tier is identified as specialized group or targeted systems designed for students considered at risk The goal at this level is to reduce current cases of problem behavior and/or academic failure to prevent student problems from escalating to an intensity that requires individualized planning (Sugai et al., 2010) Hallmark characteristics of Tier include rapid access to intervention that is continuously available, low-effort teacher implementation facilitated by a team-based approach, and frequent monitoring of progress to determine the effectiveness of the intervention and/ or need for further support (Mclntosh, Campbell, Carter, & Dickey, 2009; Sugai et al., 2010) An estimated 10-15% of a school's population may potentially be identified as atrisk, so the need for interventions that are both effective and efficient is pressing 242 / August 2011 Specific to students with EBD, it is estimated that currently only 25% of children who have these disorders are actually identified and served in schools, and this typically occurs after the opportunity for Tier and Tier prevention has long passed (Kauffman, 2005) The systematic use of tiered models for intervention is a way to serve these individuals before their problems are exacerbated Although extensive research has been conducted for both Tier and Tier supports, less is known about the level of Tier implementation prior to adding supplemental supports, the feasibility of Tier implementation by typical school personnel, and the perceived value in relation to time and effort when Tier supports are provided as part of a prevention framework (Mclntosh et al., 2009) A wide range of interventions is highlighted as potentially beneficial for at-risk children and youth Recommended Tier interventions have included: The Behavior Education Program, which includes a daily check-in/check-out with an adult at school (BEP/CICO); First Step to Success, which is a school- and home-based intervention for primary level children; Check and Connect, a drop-out prevention and mentoring program; social skill instructional groups; and academic supports (Sugai et al., 2010) Although many evidence-based interventions are available to support individuals who have behavior problems, the details and logistics of providing Tier intervention within a tiered framework have not been clearly articulated in the literature (Campbell & Anderson, 2008; Mclntosh et al., 2009; Sugai & Horner, 2008) A number of issues remain in question The purpose of this review is to explore the existing research base for Tier group intervention studies conducted within the framework of a tiered continuum of supports Group interventions are specifically selected as an area of interest because they hold potential for effectively serving a number of students in the same fashion, and may demonstrate efficient use of limited resources Emphasis on studies conducted within a tiered model is also an important distinction A number of investigations already demonstrate positive outcomes for use of small group supports provided in isolation, but less is known about how these interventions can be used within a framework of tiered intervention (Campbell & Anderson, 2008; Mclntosh et al., 2009; Sugai & Horner, 2008) Specific research questions for this review include: Behavioral Disorders, 36 (4), 241-261 To what extent has integrity of Tier implementation been assessed prior to the addition of Tier interventions among studies in the existing research base? What are the characteristics of students who have participated in Tier group interventions and how was identification for these additional supports determined? What outcomes are most often targeted, which types of group interventions have been implemented, and what effects they show within a tiered framework? Have school-based teams demonstrated capacity to implement and sustain Tier interventions, or have these efforts largely been conducted by research personnel? Have Tier interventions rated by schoolbased personnel as socially valid (i.e., important, effective, and feasible)? Method The following strategies were used to complete a comprehensive search for published studies of interventions provided as Tier level supports within a tiered prevention framework: (1) database search, (2) journal review, (3) application of inclusion criteria, and (4) ancestral review Use of these techniques led to an initial pool of 67 possible studies These steps and processes are described in detail in the following sections Database Search First, a search was conducted using two databases, the Education Resources Information Center (ERIC) and PsyclNFO with the following terms: check-in/check-out, effective behavior support, positive behavior support, school-wide positive behavior support, and the behavior education program Because the phrase "positive behavior support" located the greatest number of entries in both databases it was then used as a key word combined with each of the following additional terms: at-risk students, behavior change, behavior problems, behavior modification, benchmarking, check-in/check-out, early intervention, high-risk students, identification, intervention, outcomes of education, outcomes of treatment, prediction, prevention, program effectiveness, referral, response to intervention, screening instruments, screening tests, secondary intervention, small group intervention, targeted intervention, teacher nomination, the behavior Behavioral Disorders, 36 (4), 241-261 education program, and tier two intervention Using these procedures, 41 potential articles from the ERIC database and 11 additional articles from the PsyclNFO search were located Journal Review Second, an examination of ten peerreviewed journals that frequently publish articles about SWPBS, prevention, and special education was conducted In most cases, each journal was reviewed from 1984 or the earliest published volume through the most current edition This year was identified because a three-tiered support continuum was first established as a disease prevention model in the early eighties (Gordon, 1983) and shortly after, the tiered prevention model was applied to social behavior in school settings (Walker et al., 1996) Five experts in the area of EBD and/or SWPBS nominated journals that were likely to publish work in the subject of Tier intervention Each of the selected experts has worked and published in the area of special education and positive behavior supports for a number of years within a research university Based on expert recommendations the following journals were included in this search: Behavioral Disorders, Education and Treatment of Children, Exceptional Children, Journal of Behavioral Education, Journal of Emotional and Behavioral Disorders, Journal of Positive Behavior Interventions, Psychology in the Schools, Remedial and Special Education, School Psychology Quarterly, and School Psychology Review For two of the selected journals the search years were modified based on the availability of volumes School Psychology Quarterly was reviewed from 2001-2009 and Education and Treatment of Children was examined from 1989-2009 Using this procedure, another 15 articles were identified Application of Inclusion Criteria Each of the initial 67 articles located were then reviewed according to the following inclusionary criteria: (a) an intervention study published in a peer-reviewed journal; (b) explicit statement within text of the article that the study was conducted in a setting implementing one of the following: SWPBS, a tiered prevention model that includes social behavior, a continuum of supports, or a systemsbased response to intervention approach; (c) August 2011 / 243 the independent variable described in the study was a supplemental (i.e Tier 2) group intervention applied to a selected set of students, in which two or more students received the same intervention rather than individualized planning; (d) participants were determined to be at risk by one or more criteria, such as teacher nomination, results of a screening instrument, office discipline referral data, and/or direct observation data; and (e) results of the study examined a social or behavioral outcome such as change in disruptive behavior, office discipline referral rates (ODR), peer relationships, and/or social skill competency Studies that primarily examined academic outcomes such as increased writing performance, phonological awareness, or college entrance exam scores were included if they met the first four criteria and adhered to the fifth criteria by also reporting some type of social or behavioral outcome Studies that reported academic outcomes alone, even if conducted within SWPBS, a three-tiered model of support, or a Response to Intervention (Rtl) approach, were not considered for this review (e.g., Kamps & Greenwood, 2005; Lane et al., 2008; Lane, Robertson-Kalberg, Mofield, Wehby, & Parks, 2009) In addition, articles reporting outcomes of a class-wide or grade level intervention were also excluded (e.g., Mclntosh, Chard, Boland, & Horner, 2006; Nelson, Martella, & Marchand-Martel la, 2002; Todd, Haugen, Anderson, & Spriggs, 2002) To ensure that inclusion criteria were well defined and studies were accurately accepted or disqualified, a second reviewer was used To complete this process, each of the studies located by the previously described methods were given to a second reviewer with specific experience and expertise in SWPBS who completed an independent review of potential studies After independent review, the two reviewers developed a comprehensive list of studies that met all inclusion criteria In the case of disagreement, the publication was reexamined and discussed until consensus was reached or communication with an author verified a decision Ancestral Review Einally, two reviewers also conducted a search of references listed in each of the accepted studies No additional studies were located using this technique 244 / August 2011 Excluded Studies A number of studies considered for acceptance were disqualified and warrant specific mention to provide additional clarity about the nature and type of work that is included Eor example First Step to Success is a targeted intervention program for young children exhibiting antisocial or aberrant behavior with a robust evidence base of single-subject, quasiexperimental, and random-clinical trial research (Walker et al., 1998; Walker et al., 2009) First Step to Success consists of three modules (screening, school intervention, and parent intervention) designed to be used together to identify students with emerging behavioral and social concerns, and to improve social adjustment and academic performance through coordinated support from parents, teachers, and peers (Sprague & Perkins, 2009; Walker et al., 1997) However, the program utilizes its own screening module for student identification; therefore, to date, the literature base has not investigated implementation within a tiered model, such as SWPBS, which was an inclusion criterion for this study Second, literature supporting Check and Connect, a mentoring and dropout prevention program was also examined and considered for acceptance but is not included in this review Studies of Check and Connect have been completed among students with disabilities at both the elementary and secondary levels and show outcomes for improving attendance rates and engagement in school Although many investigations of Check and Connect met one or more of the inclusion criteria, there were no reports that indicated or described this intervention as provided within a tiered prevention framework; thus these studies were excluded Finally, two studies of BFP/CICO were also determined ineligible for this review (March & Horner, 2002; Hawken & Horner, 2003) March and Horner (2002) designed a two part investigation to examine the effects of BEP/CICO for 24 middle school students and then used FBA results to modify the intervention for three students who did not demonstrate initial success Later, Hawken and Horner (2003) examined the effects of BEP/CICO on problem behavior and academic engagement among four students (Hawken & Horner, 2003) Although both studies showed positive outcomes for use of the BEP/CICO intervention, neither included an Behavioral Disorders, 36 (4), 241-261 explicit statement that these supports were provided within a SWPBS continuum or a tiered prevention framework, thus they were not included for review Results From the multi-method search, a total of 13 studies met all inclusion criteria and are reported in this review The studies range in date of publication from the earliest in 2002 to the most recent in 2009 Among the 13 studies reviewed, a total of three different research methods were utilized: seven studies incorporated exclusive use of single subject designs, five studies were quasi-experimental, and one was a descriptive case study (see Table /) Tier Level of Implementation To date, a number of published studies speak to the effectiveness of Tier behavioral supports and provide details for how to employ these techniques In addition, specifically within the context of SWPBS, a number of research-validated instruments and tools are available to help assess integrity of implementation, monitor progress toward school-wide goals, and evaluate outcomes of Tier prevention efforts Examples of such instruments include The Team Implementation Checklist (TIC; Sugai, Horner, & LewisPalmer, 2009), The School Safety Survey (SSS; Sprague, Colvin, & Irvin, 2002), The Effective Behavior Support/Self Assessment Survey (EBS/SAS; Sugai, Horner, & Todd, 2000), and The Benchmarks of Quality (BoQ; Cohen, Kinkaid, & Childs, 2007) However, The School-wide Evaluation Tool (SET; Horner et al., 2004) is perhaps the most well known metric for assessing Tier implementation and was developed specifically as a research tool Among the studies included for review, only a disappointing few gave documentation of their Tier efforts, either by describing specific features in place or by a measure of implementation fidelity such as the numerous instruments listed above In the four studies that did provide SET results, overall implementation of Tier prior to the addition of Tier was high, ranging from a mean of 80-100% of features in place (Fairbanks et al., 2007; Hawken et al., 2007; Mclntosh et al., 2009; Todd et al., 2008; see Table 1) Behavioral Disorders, 36 (4), 241-261 Identification of Tier Participants Table provides a brief description of participant demographic characteristics Use of a systematic process to identify students who require additional intervention is of vital importance within a tiered continuum of support As such, it is imperative to know how these students were identified Methods for identifying student participants varied across the 13 studies reviewed In general, student identification for participation was based on one or a combination of the following: (a) nomination process in which a classroom teacher, a parent, or a problem solving team identified the student as at-risk; (b) use of student datatypically office discipline referral informationto indicate that the student was unresponsive to the Tier prevention efforts or to a Tier intervention; or (c) use of behavioral screening score results Nomination Process Among studies that identified students through a nomination process, the referral was based on perception of need in most examples For example, Campbell and Anderson (2008) reported on two students who were referred to the school's problem solving team by a classroom teacher because of disruptive and noncompliant behavior Similarly, McCurdy, Kunsch, and Reibstein (2007) documented use of a prereferral intervention team nomination process Participants were included based on demonstration of behavioral difficulties in the classroom and/or existence of a behavior plan Mclntosh and colleagues (2009) accepted students nominated by teachers because of classroom problem behavior and perceived lack of responsiveness to the Tier prevention efforts Fairbanks and colleagues (2007) also incorporated a teacher nomination process to identify students Participants in this study were referred based on increasing office referrals and problem behavior in the classroom, but neither the number of referrals nor the level of classroom problem were defined Finally, the investigation completed by Todd, Campbell, Meyer, and Horner (2008) identified student candidates through a multi-informant process, which included administrator nomination, teacher verification of problem behavior, parental consent, and student willingness to participate in the intervention August 2011 / 245 (/) ằ- H & flj O) l !U - O O ^ -C *"' QJ ii^ ^ " o Đ E S Eg g c "- Ê -D * -9 p ro d E O iợ a a XI '5 u l strict beha 0) o g > Q j Q ^ -z: ^ ^ c " '" c I > S "I 'ụ ẻ; 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