Identifying and Selecting Evidence-Based Early Intervention Programs for Elementary Students Displaying Physical Aggression.

Author:Klumpner, Susan

Social workers in schools are often the first service providers to assess and address psychosocial-behavioral struggles in children and youth. In order to effectively address those struggles, school social workers must develop a standard of practice that is theory driven and evidenced based. That standard should include procedures to search for and identify proven intervention and prevention services appropriate for delivery in schools, followed by a systematic process to choose which of those interventions--based on the cumulative evidence, the school setting, population of concern, and available resources--is the optimum combination of fit and efficacy.

We will offer such a set of skills and procedures in the context of identifying and selecting group-delivered manualized preventive interventions for elementary grade students displaying aggressive behaviors. Children who display such early start physical aggression in the elementary grades are one of the highest risk populations of children in need of early mental health services. Their higher likelihood of manifesting a trajectory of violent and antisocial behaviors as youth may lead to diagnoses such as oppositional defiant disorder (ODD) and conduct disorder (CD; Tremblay, McCord, & Boileau, 1992; Wang & Fredricks, 2014), often resulting in early sexual behavior, drug use, and depression into adulthood (Freudenberg & Ruglis, 2007; Park et al., 2014; Solberg & Olweus, 2003). In the shorter term, such early aggressive students experience lower math and reading achievement continuing through high school (Breslau et al., 2009; Polderman et al., 2010).

Why take a systematic and evidenced-based approach to address these disruptive behavior disorders in schools? Research illustrates that ODD and CD are two of the most common diagnoses in childhood and adolescence and are associated with significant impairment to functioning. In a longitudinal study examining the three-month prevalence of mental disorders in a national representative sample of children ages nine to thirteen, who were then followed to age sixteen, rates of CD ranged from 2.7 percent at ages nine to ten to 1.6 percent at age sixteen; however, there was slight curve to the trajectory with the peak years being age thirteen at 3.3 percent and age fourteen at 2.8 percent (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). In the same study, the rates of ODD were 2.7 percent at ages nine to ten and 2.2 percent at age sixteen, again with a peak in the middle of 3.1 percent at age fourteen and 4.1 percent at age fifteen. This study places CD and ODD as the second and third most common diagnoses in three-month periods from ages nine to sixteen, with enuresis ranking first (from 7.0% at ages nine to ten and trending down to zero at age sixteen). Interestingly, CD and ODD were considerably more common than attention deficit/hyperactivity disorder (ADHD), which ranged from 0.03 percent at ages fourteen and sixteen to 2.2 percent at ages nine to ten. Not surprisingly, boys had higher overall rates across ages at 4.2 percent for CD and 3.1 percent for ODD, with girls at 1.2 percent and 2.1 percent, respectively. Note that a study such as this reduces the known bias in diagnostic outcomes in the field as each child was assessed by the research team with regard to the diagnostic criteria for each disorder and each age. In another study of lifetime rates examining field diagnoses, behavior disorders, such as ODD and CD, were the second most common lifetime diagnoses (19.1%) among thirteen- to eighteen-year-old youth in the United States following anxiety disorders (31.9%), with substance abuse disorders ranking third (11.4%; Merkangas et al., 2010). In terms of diagnoses with severe impairment or distress, behavior disorders were also second (9.6%), with mood disorders ranking first (11.2%) and anxiety disorders third (8.3%).

For clarity, ODD is often initially diagnosed in childhood and includes a pattern of aggressive behaviors lasting at least six months (involving at least one individual who is not a sibling) across three categories: (1) angry or irritable mood, (2) argumentative or defiant behavior, or (3) vindictiveness (American Psychiatric Association [APA], 2013). Conduct disorder, usually diagnosed in adolescence, is a pattern in which the basic rights of others or major age-appropriate societal norms or rules are violated and at least three of the following four symptoms are displayed: (1) aggression toward people and animals, (2) destruction of property, (3) deceitfulness or theft, or (4) serious violations of rules (APA, 2013). Given the rate of students displaying early aggressive behaviors, conducting a school-based needs assessment of such behaviors may be warranted and may result in a more universal approach to intervention implementation.

The Intersection of Education, Mental Health, and Social Work

Levels of Prevention, a model based on individual risk, is a classification system that emerged from a public health perspective. It has been widely applied to inform social work services (Bowen, Powers, Woolley, & Bowen, 2004) and is used to categorize prevention initiatives into three levels: primary, secondary, or tertiary (Caplan, 1964). As defined by Offord (2000), primary prevention programs seek to reduce the incidence of a disorder and are delivered to an entire population; secondary prevention seeks to reduce the prevalence of a disorder by focusing on individuals with high risk for or early signs of a disorder whereas tertiary prevention seeks to reduce the severity of a disorder among those who already meet diagnostic criteria. Thus, primary or universal programs benefit all students; for example, some students may exhibit problematic behaviors, but all students can benefit from learning and practicing prosocial behaviors. Secondary or level two programs are implemented only with students already showing initial disruptive or acting out behaviors. Finally, tertiary or level 3 programs are more intensive, often involve more resources, and are implemented with students with significant aggressive or violent behaviors.

This clinical conceptualization parallels a now widespread approach to organize prevention practices in schools--response to intervention (RTI)--and can potentially be used as a way for clinicians to frame school-based pro-social behavioral programming. (For a full discussion of the role of school social workers in RTI, see Avant, 2014.) Response to intervention is an educational model to identify, evaluate, and serve students with diverse learning and behavioral needs. It also has three levels most commonly referred to in schools as universal or level 1, targeted or level 2, and intensive or level 3. All students receive the core curriculum and behavioral interventions at the universal level. As the school year progresses, at-risk students are identified and receive targeted-level interventions, in which academic and behavioral interventions become more intense and are often delivered to groups. The intensive tier--characterized by more individual intervention, longer duration and higher frequency, and often more specialized staff--includes family interventions (Fuchs & Fuchs, 2006; Hughes & Dexter, 2011). Through progress monitoring, school administrative and support staff collaboratively make placement or programming decisions based on student needs. In the following we will provide overviews of manualized prevention intervention programs that fit within the first two tiers in this system, can be implemented in schools, and have been shown by research to effectively prevent or treat elementary grades children for disruptive or aggressive behaviors.

Identifying Evidenced-Based Interventions for Early Onset Aggression

In addition to (or in lieu of) academic journal databases, the following websites should be consulted when searching for evidence-based programs for educational and/or behavioral health interventions:

* What Works Clearinghouse (

* Cochrane Collaborative (

* Substance Abuse and Mental Health Services Administration (SAMHSA;

* National Registry of Evidence-based Programs and Practices (NRPP) at SAMHSA (

* U.S. Department of Education (

* National Center for Education Statistics (

* Education Resources Information Center (

* University of California Los Angeles (UCLA) School Mental Health Project (

* Office of Juvenile Justice and Delinquency Prevention Programs (

For this particular search, we were interested in the following inclusion criteria: (1) at least one program component implemented in schools, (2) target population of prekindergarten to middle school students, (3) universal or targeted intervention, and (4) focus on children at risk for or diagnosed with ODD or CD.

We excluded the Seattle Social Development Project because it is...

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