RTI: An Intervention-Based Approach toIdentification and Treatment of EBD

Frank M. Gresham, Ph.D.

Louisiana State University

gresham@lsu.edu

Some Issues in ED Determination

Students with emotional/behavioral challenges unserved/underserved Students often create chaotic classroom or school environments Prevalence rate for ED projected @ 2% but always has been <1% ED shows greatest state variability than any of 13 disability groups ED definition:

Vague Confusing Contradictory (bordering on the oxymoronic)*

Estimates suggest that 20% of kids in schools need mental health services Schools often believe they are not responsible for mental health services Schools often see conduct problems as responsibility other agencies

“The term does not include children who are socially maladjusted, unless it is determined that they are seriously emotionally disturbed.”

Let’s Play the Logic Game

Frank is socially maladjusted. Frank therefore cannot be emotionally disturbed. Frank is determined to be emotionally disturbed. Frank is both socially maladjusted & emotionally disturbed.

???????

Some Numbers27th Annual Report to Congress (2005)

4.4% 8.0%

54.4% 47.4%

5.2% 9.6%

CA (6-21 yrs.) US (6-21 yrs.)

ED

SLD

MR

CA under-identifies (under-serves???) ED and MR and overserves SLD relative to US average

Prevalence Rate Relative to Population

0.29% 0.72%

4.11% 4.33%

0.44% 0.90%

CA US

ED

SLD

MR

The Real CulpritIDEIA Definition

Chronicity (“Long period of time”) Severity (“To a marked degree”) Outcome (“Adversely affects educational performance”) Characteristics

Inability to learn Inability to build or maintain satisfactory interpersonal relationships Inappropriate types of behavior under normal circumstances General pervasive mood of unhappiness or depression Tendency to develop physical symptoms or fears associated with

personal or school problems Does not include social maladjustment, unless student is ED (???)

Social Maladjustment Exclusion Clause

Conceptually illogical Over 20 published articles question and refute its existence IDEIA statute provides no definition of SM IDEIA regulations provide not guidelines for distinguishing SM

from ED About ½ of the states ignore social maladjustment exclusion Many psychological disorders are co-morbid

Conduct Disorder + Depression Oppositional Defiant Disorder + ADHD Conduct Disorder + ADHD

“A youngster cannot be socially maladjusted by any credible interpretation of the term without exhibiting one or more of the five characteristics to a marked degree and over a long period of time.” (Kauffman, 1997, p. 28)

RTI: Provision of high-quality interventions matched to student need, frequent progress monitoring to guide decisions about changes in interventions, and using student data to guide important educational decisions.*

High-Quality Instruction/Intervention Matched to student need Scientifically-based Individually-based

Learning Rate and Level of Performance Rate=Growth over time compared to peers Level=Relative standing on dimension of achievement/behavior Data-based decision making (decisions based on student data)

Important Educational Decisions Based on individual response Across multiple tiers of intervention Decisions made about

Intensity of intervention Special education eligibility Exiting special education

* National Association of State Directors of Special Education (2005)

NASP Position Statement on ED

“ED is more than a transient, expected response to stressors in the child’s or youth’s environment and would persist even with individualized interventions.”

“No single diagnosis should be used to deny services to students. The impact of the behavior on the student’s educational progress must be the guiding principle for identification.”*

“Persistence: The extent to which difficulties have continued despite the use of well-planned, empirically-based and individualized intervention strategies provided within the least restrictive environment.

*Social Maladjustment Exclusion Clause

What is Scientifically-Based Knowledge?

Scientifically-based knowledge involves the application of rigorous, systematic, and objective procedures to obtain reliable and valid knowledge relevant to educational activities and programs

Scientifically-based knowledge is: Objective Involves direct measurement Reliable and valid Based on high quality experimental design Rules out alternative explanations High sensitivity (high true positive rates) High specificity (high true negative rates)

Pseudoscience (4 out of 5 dentists recommend Crest)

Nonscience (My kid learned to read with Whole Language)

Nonsense (A child cannot be ED if he/she is socially maladjusted)

What Are Some Evidence-BasedBehavioral Interventions?

Group Contingencies (Good Behavior Game) Token/Point Systems (with response cost component) Replacement Behavior Training (teaching functionally equivalent behaviors)

Differential Reinforcement (DRO/DRA/DRI/DRL) Antecedent-Based

Choice (preferred activities) Task interspersal Modification of task difficulty Precorrection

Classroom-Based Behavioral Consultation Performance Feedback (teachers’ integrity) Self-Monitoring

Evidence-Based Treatments for DSM Categories(Journal of Clinical Child and Adolescent Psychology (2008), 37, pp. 1-301)

Disruptive Behavior Disorders (CD/ODD) Anger Control Training (CBM-based intervention) Behavioral Parent Training First Steps to Success (classroom-based behavioral intervention) Multisystemic Therapy (family/community-based treatment)

ADHD Behavioral Parent Training Behavioral Classroom Management

Anxiety Disorders Individual Cognitive Behavior Therapy Group Cognitive Behavior Therapy Exposure-Based Therapies (specific fears/phobias)

Depression Cognitive Behavior Therapy (Individual) Cognitive Behavior Therapy (Group)

Fundamental Principles of RTI

Intensity of intervention matched to degree of unresponsiveness Movement through tiers based on inadequate response Decisions regarding movement based data from multiple sources Increasing body of data collected to inform decision-making Change in intervention considered only after inadequate response Intervention delivery approaches

Problem solving (consultation) Standard protocol

Advantages of RTI

Early identification of learning/behavior problems Conceptualizes learning/behavior problems from risk rather than deficit model Reduction of identification biases (overrepresentation) Strong focus on student outcomes

Measures & domains based on relationships to child outcomes Documents relationships to positive child outcomes Emphasizes direct measurement of achievement, behavior, & the

instructional environment Focuses on measurable and changeable aspects of instructional

environment Identifies ABT students (Ain’t Been Taught)

Comparison of Traditional & RTI Assumptions

Indirect measurement Within-child focus Nomothetic (groups) Moderate-high inference Behavioral stability Static, 1-shot

assessment Lack of treatment validity

Direct measurement Environmental focus Idiographic (individual) Low inference Behavioral variability Continuous progress

monitoring Treatment validity

Traditional RTI

What You Won’t See in a RTI Assessment

“Draw-a-Something” Measures Apperception Tests Rorschach Test MMPI

WHY? Because none of the above are directly related to child outcomes and

are not useful in either planning interventions or progress monitoring the effects of interventions.

This type of information is superfluous to data-based decision making in RTI

Almost all are technically inadequate based on the Test Standards

Problem-Solving Logic in RTI

What is the problem? Discrepancy between expected & current levels of performance 100% homework completion expected but only 20% completed Problems can be defined differently by different individuals

Why is the problem happening? Can’ do Won’t do Low inference

What should be done about it? Antecedent strategies Consequent strategies Instructional strategies

Did it work? Data-based decision making Benchmarks Social validation

Assessment Principles in RTI Purposes of Assessment

Referral Screening Classification Intervention planning Continuous progress monitoring Program evaluation

Types of Assessment Data Direct observations of behavior Permanent products Behavior ratings Daily Behavior Reports

Assessment Principles Problem Solving Low Inference Functional Assessment Multiple Operationalism Assessment Quality Social Validity

Basic Principles of Screening for EBD in Schools

Similar logic to other fields (e.g., medicine) PSA tests PAP smears Mammograms

Instruments must be technically sound Low false negative rates Low false positive rates (willing to tolerate higher) Stable prediction over time Cost beneficial (benefits outweigh costs)

Brief Research based Easily understood & applied

A Useful Behavior Screening Tool:Systematic Screening for Behavior Disorders

Walker & Severson (1990)

Multiple Gating Procedure Grades 1-6 Combination of 3 Assessment Procedures

Teacher nominations-Gate 1 Teacher rating scales –Gate 2 Direct observations (classroom & playground)-Gate 3

Nationally standardized (n=4500) Normative data Extensive reliability & validity data Early Screening Project (ages 3-5 years)

Published by Sopris West, Longmont, CO

SSBD(continued)

Gate 1 Teachers rank order class on internalizing & externalizing behavior Teacher select top 3 ranks for internalizing & externalizing behavior

Internalizing: Defined as overcontrolled behavior pattern characterized by social withdrawal, anxiety, and lacking self-confidence

Externalizing: Defined as an undercontrolled behavior pattern characterized by aggression, bullying, noncompliance, and impulsivity

Gate 2 Teachers ratings & CEI checklist Exceed normative criteria; move to next gate

Gate 3 Direct observation in classroom & playground Exceed normative criteria; move to intervention phase

Decision Rules for SSBD Screening

A

Accurate Prediction

SENSITIVITY

B

False Positive

C

False Negative

D

Accurate Prediction

SPECIFICITY

At Risk Not At Risk

Risk IndicatorPresent

Risk IndicatorAbsent

Accuracy=Correct Decisions/All Decisions A+D/A+B+C+D

Another Useful Screening Tool:Student Risk Screening Scale (Drummond, 1993)

Frank 1 1 3 2 3 3 3 16

Clay 1 1 0 1 2 1 0 6

Jill 0 0 1 1 1 0 1 4

Luke 2 2 2 2 3 2 3 16

Matt 1 1 0 1 1 1 1 6

Steals

Lie,Cheat

BxProb.

PeerReject

LowAch

Neg.Att.

AggBeh. Total

O-Never; 1-Occasionally; 2-Sometimes; 3-Frequently9-21 High Risk4-8 Moderate Risk0-3 Low Risk

3-Tier Model of RTI Intervention

Universal Intervention All students Schoolwide or classwide Examples (reading curriculum, school discipline procedures) 80-85% will respond

Selected Interventions Classroom strategies Small group strategies Consultation-based interventions About 7-10% of students

Intensive Interventions Individualized interventions Intense & powerful (FBA-based interventions) 3-5% of students

Types of RTI

Preventive RTI Universal prevention (“primary prevention”) Universal screening (2-3 times per year)

Reactive RTI Selected interventions (“secondary prevention”) Replaces refer-test-place model for ED

SPED Eligibility RTI Intensive interventions (“tertiary prevention”) “Disability” versus “Need” decisions

Multi-Tier Social Skills InterventionsSocial Skills Improvement System (Gresham & Elliott, 2008)

Classwide Intervention Program (CIP) Tier 1 Universal Intervention Provides general education teachers with a structured efficient way to

integrate opportunities 10 most important social skills for school success CIP has 3 levels

Preschool/Kindergarten Early Elementary (Grades 1-3) Late Elementary/Middle (Grades 4-6)

Top 10 Social Skills (based on responses of over 800 teachers rating over 100 social skills: 0-Not important, 1-Important, 2-Critical)

Listens to others Follows directions Follows classroom rules Ignores peer distractions Asks for help Takes turns in conversations Cooperates with others Controls temper in conflict situations Acts responsibly with others Shows kindness to others

Classwide Intervention Program(continued)

6-Step Instructional Sequence Tell (Coaching) Show (Modeling) Do (Behavioral Rehearsal) Practice Monitor Progress Generalize

3 lesson per week, 25 minutes per lesson X 10 weeks Progress Monitoring Tools Treatment Integrity Checks

SSIS Intervention GuideTier 2 Selected Intervention

Designed for weak responders to CIP Teaches social skills across 6 domains

Communication Cooperation Assertion Responsibility Empathy Self-Control

Delivered in small pullout group setting (4-6 children) 2 sessions per week, 45 minutes per session X 15 weeks Teaches 20 social skills

Top 10 retaught 10 “keystone behaviors” also taught

Distinguishes acquisition from performance deficits

FBA Replacement Behavior TrainingTier 3 Intensive Intervention

Designed for weak responders to Tier 2 Intervention Guide Identifies competing problem behaviors using SSIS-Rating Scales Behaviors receiving rating of 2 (Very Often) or 3 (Almost Always)

targeted to replacement Descriptive FBA conducted to identify function of competing

problem behaviors Social skills replacement behaviors serving same function selected

as target of intervention FBA process

Records review FBA interviews (teacher, student, parent) Systematic direct observations Behavior ratings Daily behavior reports

FBA Replacement Behavior Training(continued)

Intervention Strategies Antecedent Strategies

Precorrection Prompts Check and connect Altering schedule of activities Choice Task modification Task interspersal Providing frequent breaks

Consequent Strategies Differential reinforcement (DRO, DRI, DRA) Response cost Noncontingent reinforcement (NCR) Behavioral contracting School-home notes

Responsiveness to Intervention Model

 

 

Degree of Unresponsiveness to Intervention

LOW HIGH

HIGH

Inte

nsit

y o

f tr

eatm

en

t

Level IUniversal

Interventions

Level IISelected

Interventions

Level IIIIntensive

Interventions

Level IVSpecial

Education IEP Determination

Classification of RTI Outcomes

Requires

More Intense Services

A

True Positive

SENSITIVITY

B

False Positive

Does Not Require

More Intense Services

C

False Negative

D

True Negative

SPECIFICITY

Outcome Status Inadequate Responder

AdequateResponder

Accuracy=Correct Decisions Relative to All DecisionsA+D/A+B+C+D

Measurement of ResponsivenessStandards & Procedures

Academics (CBM) Norms Benchmark criteria Growth criteria

Behavior Direct observations Behavior ratings scales Daily behavior reports Brief, focused behavior rating scales (weekly) Permanent products & progress monitoring

Solutions Social validation (peer comparisons & subjective judgments) Visual analysis of graphed data Effect size estimates

Brief Behavior Rating Scale(Weekly)

Difficulty paying attention Never Sometimes Often Almost AlwaysDifficulty organizing tasks Never Sometimes Often Almost AlwaysFidgets with hands or feet Never Sometimes Often Almost AlwaysBlurts out answers Never Sometimes Often Almost AlwaysInterrupts/intrudes on others Never Sometimes Often Almost Always

Treatment IntegrityAn Essential Component of RTI

Extent to which intervention is implemented as planned Deviations from integrity compromises effectiveness Teacher-implemented interventions high-risk for integrity lapses Integrity can be measured by:

Direct observations of implementation Permanent products Self-reports (not recommended)

Treatment integrity can be improved by: Specific performance feedback on implementation Contingency management Modeling of intervention implementation

Treatment Integrity & Behavior Change

High IntegrityExpected

High IntegrityWrong Treatment

Poor Functional Analysis

Low IntegrityChanged treatment

Other unknown variables

Low IntegrityExpected

Adequate Behavior Change Inadequate Behavior Change

ImplementedAs Planned

Not ImplementedAs Planned

Ways of Expressing Integrity

Percentage of intervention steps implemented Intervention manual Rating of intervention implementation Permanent products of intervention Task analysis of intervention

Some RTI References

Gresham, F.M. (2002). Responsiveness to intervention: An alternative approach to the identification of learning disabilities. In R. Bradley, L. Danielson, & D. Hallahan (Eds.), Learning disabilities: Research to practice (pp. 467-519). Mahwah, NJ: Lawrence Erlbaum.

Gresham, F.M. (2006). Response to intervention. In G. Bear & K. Minke (Eds.), Children’s needs-III (pp. 439-451). Bethesda, MD: National Association of School Psychologists.

Gresham, F.M. Response to intervention: An alternative means of identifying students as emotionally disturbed. Education and Treatment of Children, 28, 328-344.

Gresham, F.M. (2004). Current status and future directions of school-based behavioral interventions. School Psychology Review, 33, 326-343.

Gresham, F.M. (2005). Response to intervention (RTI): An alternative means of identifying students as emotionally disturbed. Education and Treatment of Children, 28, 328-344.

Gresham, F.M. (2007). Best practices in diagnosis. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology-V. Bethesda, MD: National Association of School Psychologists.

Brown-Chidsey, R., & Steege, M. (2005). Response to intervention: Principles for effective practice. New York: Guilford Press.

National Association of State Directors of Special Education (2005). Response to intervention: Policy considerations and implementation. Alexandria, VA: Author.

Jimmerson, S., Burns, M., & VanDerHeyden, A. (Eds.) (2007). Handbook of response to intervention. New York: Springer.

Glover, T., DiPerma, J., & Vaughn, S. (Eds.) (2007). Special series on service delivery systems for response to intervention: Considerations for research and practice. School Psychology Review, 36 (4), 526-646.

Silverman, W., & Hinshaw, S. (Eds.) (2008). The second special issue on evidence-based psychosocial treatments for children and adolescents: A 10-year update. Journal of Clinical Child and Adolescent Psychology, 37, 1-301.

THANK YOU

Questions?

Laizzez le bon temps rouler!