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Carole Upshur, EdD., ProfessorDepartment of Family Medicine and Community Health
Melodie Wenz Gross, PhD, Assistant Research Professor
Department of PsychiatryUniversity of Massachusetts Medical School
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
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
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-1st 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 Meet children where they are (e.g., give out small paper
plates to draw happy and sad faces on, create personalized mats for children to sit on for the lesson
Reward children frequently during the session for paying attention; added durable wooden heart rewards to be used all day
4-6 parent group sessions were offered each year, adapted from Second Step parent training; parent take home letters were adapted/simplified; additional parent handouts provided
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? Year 1 (n =12)
Year 2 (n =13)
How much time did it take to learn the lessons? % Very Little Time % Some Time % A lot of Time % Too Much Time
33.3 50.0 16.7 0.0
30.8 46.2 23.0 0.0
How hard was it to incorporate Second Step into your daily curriculum? % Not At All Hard % A Little Bit Hard % Somewhat Hard % Very Hard
33.3 50.0 16.7 0.0
38.5 23.0 38.5 0.0
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
60.0 71.4 77.8 85.7 66.7
23.1 30.8 76.9 46.2 30.8
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
What was Related to Greater Implementation Success?
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
DisciplineGeneral supervisionStaff-child interaction
Observed ratings of classroom disruptive behavior by children
Classroom Characteristic
Year 1 Year 2
Intervention
(n=8)
Control
(n=7)
Intervention
(n=7)
Control
(n=4)
Average Child Age 47.79 49.41 44.99 48.25
Mean Observer Rated Behavior Problems 1.95 1.59 5.19** 2.38
Mean Teacher Rated Prosocial Skills 55.67 53.21 57.89 53.64
% of Children Meeting Clinical Cut-off for Teacher Rated Behavior Problems
26.61 22.34 22.31 6.48
% of Children Receiving TFK Services 12.13 10.57 23.29 20.50
% of Low Income Children 48.11 37.47 44.07 55.65
Mean ECERS Environment Items 5.21 5.01 -- --
Mean ECERS Interaction Items 22.00 19.62 22.11 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
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 for Second Step materials and training
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.
