A comprehensive program conducted in public school classrooms in Salt Lake City in collaboration with a mental health agency was shown to be effective for children and adolescents with severe emotional and behavioral problems. Researchers report that providing mental health services within public school settings makes them more accessible and normalizes the lives of children and their families. Compared with more restrictive environments, day treatment is both effective and cost-efficient, and more families complete treatment.
Few high-quality studies have examined the results of day treatment programs, report researchers Kristen E. Robinson, Valley Mental Health, Salt Lake City, and Lisa J. Rapport, Wayne State University. They sought to overcome the methodological problems of previous research. The study included 145 children (79 percent boys) 5 to 17 years of age whose behavior had failed to improve in previous treatment. Half were elementary students and the other half were in junior or senior high school. All the children exhibited emotional problems beyond the scope of outpatient services and 97 percent had been classified as having a severe emotional disorder by both school district and mental health professionals. Three-quarters were referred with disruptive behavior disorders (Attention Deficit Disorder, Oppositional Defiant Disorder, Conduct Disorder) and 21 percent were diagnosed with mood and anxiety disorders.
The treatment program consisted of academic instruction and mental health treatment in self-contained classrooms for a full academic year. Instruction was given by certified teachers employed by the school districts. The program took place in public-school classrooms that differed from regular classrooms only in their mental-health components. Each class was staffed by a special-education teacher and an academic aide. Mental-health treatment was guided by a multidisciplinary team of child psychiatrists, psychologists and social workers. Treatment staff consisted of one clinical social worker and a bachelor-level behavior specialist per 24-child classroom.
The program philosophy was based on the belief that all behavior is learned and can be changed. Treatment focused on teaching and reinforcing desirable behaviors while reducing undesirable ones. It emphasized teaching of specific problem-solving skills. The program stressed generalization of improved behaviors to other settings. One hour of individual child therapy per week, weekly family therapy, and medication management were provided. Wraparound services were available for parents through community resources such as recreation and health centers, advocacy groups and housing assistance.
The central component of the behavioral program was a five-level system. Every child began each day with 100 points. Two points were deducted for each inappropriate behavior. Points were deducted for poor behavior at home as well as school. The number of points left at the end of the day determined the student’s behavioral level and what privileges he earned. Sixty points or less placed the student at the lowest level. He received verbal praise for good behavior but was not eligible for tangible rewards or activities. As the child’s behavior improved he earned small toys, free time, and opportunities to play video and board games with staff. If a child had 80 points or higher for three weeks, he attended regular classes part time. As point levels increased, the child had both more freedom and more responsibility. A child’s level was dropped immediately for serious infractions such as physical aggression.
Constant feedback was provided to reinforce appropriate behavior. Inappropriate behavior was ignored the first time it occurred. Students were taught cooperative skills by a “precision request format”. If a child did not comply with a direct request, the behavior was explicitly labeled and the child then had three to five seconds to comply. If the child failed to comply the second time, the child was asked to sit by himself for three minutes. Students were also given “positive practice”; they were asked to repeat appropriate behavior several times.
Social skills were taught daily using the Skillstreaming curriculum. Skills included listening, following directions, recognizing and expressing feelings, using relaxation techniques and resisting peer pressure. Generalization of skills to other settings was encouraged through modeling, role-play practice and brief homework assignments. Specific skills were practiced in individual therapy as well. The Mystery Motivator was one technique that proved to be particularly effective in developing positive behavior and skills. It paired a specific behavioral goal, such as following directions, with an intermittent schedule of backup rewards so the child did not know when he would receive a reward.
Parents were encouraged to attend weekly family therapy to identify and reduce factors that maintain negative behaviors in the home. Parents were taught to recognize patterns of preceding events and consequences of behaviors that perpetuate undesirable behaviors. They were also taught techniques to improve relationships in the home. Families were referred to outpatient services including respite/crisis care and recreational programs to increase support in their community.
Generalizing positive behaviors and social skills to all settings was a specific goal of the treatment program. Daily notes from home communicating behavioral and academic information improved academic performance, social skills and home behavior. Students were involved in regular education classes and community activities as their behavior improved. Family therapy and parenting classes provided a way for parents to learn and practice new skills with their children. Generalization is necessary in order to attain long-term improvement of behavior.
The Youth Outcome Questionnaire is a 64-item parent-completed checklist that measures parent perceptions of behavioral progress for children 4 to 17 years of age. In the Utah program, it was readministered every three months during treatment. It has been shown to be statistically adequate and highly useful in describing changes in behavior. The questionnaire measures internal emotional distress the child is experiencing, including anxiety, depression and fearfulness; physical symptoms such as headaches, stomach aches and nausea; problems with interpersonal relationships; social problems such as aggressiveness, delinquency, truancy, sexual problems, running away and substance abuse; and behavioral dysfunction, including disorganization, failure to complete school assignments, and inability to concentrate, to handle frustration and manage impulses. Other critical items such as paranoia, obsessive-compulsive behaviors, hallucinations, suicide, mania and eating disorders are also identified. The need for intensive treatment is indicated with a
score of 46 or more. Children in the present study scored between 67 and 88 before treatment. Normally behaving children score between 20 and 27.
Children attending this school-based program demonstrated significant improvement in their behavior over a nine-month period of time. Over half of the children showed overall symptom reduction, and more than one quarter scored within the normal range. This positive response was equally likely for boys and girls, across diagnostic categories including both internalizing (depression, anxiety) and acting-out behavior problems. Only physical complaints such as headaches and nausea were unchanged by the treatment.
One marked difference was noted between symptom reduction in elementary and secondary groups. Although both younger and older students improved by the end of the full school year, the younger students in this sample responded more quickly to treatment. Although many students showed significant improvement from the program, a majority of these youngsters continue to struggle with severe problems. However, since children with serious behavior disorders tend to get worse over time, the success of this treatment program is significant.
This program includes a wide variety of well-established behavioral interventions within a natural setting. The school setting offers benefits of increased access for families, convenience and decreased stigma associated with mental-health services. Providing comprehensive academic, health, and mental-health services in one central location is cost-efficient to families, agencies and funding sources. Schools alone can not provide such a wide range of professional services. The success of this program is remarkable because it includes a heterogeneous sample of children with severe problems and improves their behavior significantly in a natural and least restrictive environment.
The comprehensive nature of this program makes it difficult for researchers to determine which components contribute the most to its success. Follow-up studies are necessary to determine the durability of treatment over time and across settings. Future research should examine the long-term outcomes of the school-based model in terms of symptom reduction, academic progress and vocational success. This school-based treatment is an innovative service that offers wide benefits. Collaboration between school districts and community mental health centers appears to result in cost savings and more comprehensive and effective services than either can achieve alone.
“Outcomes of a Mental Health Program for Youth With Serious Emotional Disorders”, Psychology in the Schools, Volume 39, Number 6, November 2002, pp. 661-675.
Published in ERN March 2003 Volume 16 Number 3