Carole Upshur, EdD., Professor
Department of Family Medicine and Community Health
Carole.upshur@umassmed.edu
Melodie Wenz Gross, PhD, Assistant Research Professor
Department of Psychiatry
University of Massachusetts Medical School
Melodie.wenzgross@umassmed.edu
Addressing Behavior
Problems in Preschool
Settings
National Institute of Mental Health R34
MH073830
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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
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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
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Judy Davis, MPH, and Gail Sawosik, Project Coordinators
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Rachel D’Angelo, Data Entry
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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
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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
Figure 1. Changes in maladaptive behavior and aggression for
matched groups.
40
35
Maladaptive
30
ESP Raw Scores
Aggression
25
Maladaptive intervention
Maladaptive control
20
Aggression intervention
Aggression control
15
10
5
0
T1
T2
Time
100
Percent of TFK individual services children with IEPs, services
or requested IEPs or services
90
80
70
60
50
40
30
20
10
0
IEP
IEP requested
Any services
Services requested
Total
200
180
K1
160
K2
140
120
Pre-TFK
Post-TFK
Kindergarten
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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
60
51.3
50
46.6
43.3
40
30
baseline
5 years later
26.5
20
10
4.5
2.6
0
at risk
suspensions
terminations
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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
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Group social skills curriculum for preK-1st grade
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Taught by teachers (not counseling or outside staff)
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Picture cards, stories, puppets, CD with songs,
supplemental story books
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Teaches recognizing feelings in self and others and
labeling them
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Learning to calm down when upset
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Learning how to problem solve:
◦ Share toys, join a group, wait politely, avoid distraction etc.
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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
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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
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Pictures in the materials were very representative of the
multicultural background of urban preschool children
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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
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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
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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
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Children coming and going all year; less than 50%
received most of the curriculum
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All centers had new state curriculum requirements and
accreditation visits during Year 1
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Few parents attended parent sessions designed to link
classroom activities to home activities
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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)
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Teachers reported:
◦ 85% completion of main curriculum points in Year 1 (range = 62% to
99%) and
◦ 87% (range = 49% to 99%) in Year 2
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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)
Year 2
(n =13)
33.3
50.0
16.7
0.0
30.8
46.2
23.0
0.0
33.3
50.0
16.7
0.0
38.5
23.0
38.5
0.0
60.0
71.4
77.8
85.7
66.7
23.1
30.8
76.9
46.2
30.8
4
Teacher ratings of helpfulness of curriculum
3
2
Yr 1
Yr 2
1
0
Helpful to children Helpful to teacher
Improved
classroom
Percent of teachers reporting they would
implement Second Step 'next year' after
study ended
70
60
50
40
Yr 1
30
Yr 2
20
10
0
Not at all
Unsure
Probably
Yes, definitely
100
88
90
80
79
82
74
70
60
Year 1
50
40
35
39
30
20
10
0
Received Letters From Teachers
Tried Activities At Home
Attended Parent Sessions
Year 2
What was Related to Greater Implementation
Success?
Teacher Characteristics:
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Higher baseline teacher personal accomplishment self-rating
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Less teaching experience; Greater teacher education
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Greater baseline teacher observed skills
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Greater attendance at Second Step trainings
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Higher self-efficacy in delivering the lessons
Classroom characteristics:
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Having more children with behavioral or other problems in the
classroom related to completing fewer lessons, but with greater
fidelity
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Lower child and teacher turnover
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Higher quality baseline classroom environment and interactions
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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?
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Observed quality of classroom interactions
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Observed individual teacher skills
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Observed child behavior
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Teacher ratings of child behavior problems
(ECERS Interaction scale: teacher discipline, supervision, teacherchild interactions, child-child interactions)
(Caregiver Interaction Scale summary score)
(classroom level behavioral counts of disruptive behavior, verbal
aggression and physical aggression)
(Sutter-Eyberg)
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Teacher ratings of child adaptive/prosocial
skills (Adaptive Behavior Scale)
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Teacher skills
ECERS Interaction Quality
Discipline
General supervision
Staff-child interaction
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Observed ratings of classroom disruptive
behavior by children
Year 1
Classroom Characteristic
Year 2
Intervention
Control
Intervention
Control
(n=8)
(n=7)
(n=7)
(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
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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
60
53
55
50
40
36
34
Year 1
30
Year 2
20
11
8
10
3
0
0
No
Sometimes
Frequently
Don't Know
70
59
60
50
42
40
35
Year 1
33
Year 2
30
21
20
8
10
3
0
0
Got Worse
Same-Already Difficult
Same-Already Positive
Improved
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High implementation: 88% lessons in Year 1& 92% in Year 2
No teachers rated that it “Takes too much time” or “Was too hard”
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Positive teacher ratings on helpfulness to children, themselves and
classroom
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Evidence for sustainability: 62% said they would “definitely” and
another23% would “probably” use the curriculum after the project ended
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Teacher experience, skills, attitudes, classroom quality, teacher and child
turnover, and number of children with behavioral problems and delays
affect implementation
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Mental health consultants felt the curriculum was helpful to reinforce
individual child work
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The majority of parents reported that they received letters about Second
Step and tried the suggested activities at home
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Teacher observed skills, and classroom interactions seems to improve in
intervention versus control classrooms, more strongly so in the second
year of implementation
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Mental health consultants felt the curriculum helped their work with
individual children
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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
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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
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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
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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.