Chapter 4:
Providing Intensive Interventions to Troubled Students

Chapter 2 described schoolwide interventions that are intended to reduce and prevent most behavior problems in schools. Chapter 3 discussed the use of early intervention strategies for the approximately 10 to 15 percent of students who continue to experience behavioral problems even when schoolwide interventions are in place. These students also may be exhibiting early warning signs and, if so, will require the Student Support Team to develop individualized early interventions to meet their needs.

In this chapter, the focus turns to the remaining 3 to 10 percent of children who experience significant emotional and behavioral problems. Specific interventions and their intensity will depend on the nature, severity, and frequency of each child's emotional and behavioral problems.

Frequently, students who require intensive interventions, services, and supports are experiencing moderate to severe emotional and behavioral disorders that significantly impair their functioning and quality of life across the domains of family, school, peers, and community. In many situations, these students are often eligible for special education services or have a mental health diagnosis.

Safe schools implement intensive interventions that include a full array of services and supports and that coordinate the resources of the school and other community agencies. This array of services and supports should be individualized to meet the unique needs of each child and family. Rather than plugging children and families into interventions based on categories or levels of symptoms, the Student Support Teams should work with other community agencies to tailor services and supports to the needs of each child and family. The following are examples of intervention approaches and practices that are being used successfully to provide intensive interventions to children and their families.

Comprehensive School-Based Mental Health Programs

Many schools have access to mental health professionals, such as school psychologists, counselors, and school social workers. Many of these staff can provide support for prevention, early intervention, and intensive intervention services. Effective school-based mental health programs are located in school buildings using these and other mental health professionals.(Adelman, 1996; Center for Mental Health in the Schools, 1996, 1999; Nastasi, Varjas, & Bernstein, 1998) Together, they provide a comprehensive range of mental health services to children and their families, and often have strong collaborative ties with multiple community agencies.

The success of comprehensive school-based mental health programs depends on the ability of administrators, teachers, school-based mental health professionals, and other school staff to integrate mental health priorities and educational priorities into one vision that affects the everyday practices and decision-making of school professionals. Successful school-based mental health programs are woven into the fabric of the school including its classroom and instructional priorities. To accomplish this integration successfully, schools must combine the development of their comprehensive school-based mental health program with systematic schoolwide reform efforts. By joining schoolwide reform efforts, school-based mental health professionals can emphasize the benefits of building collaborative efforts within and between schools and community mental health providers, social services, juvenile justice agencies, and families.

Special Education and Related Services

Special education eligibility under IDEA includes the designation of emotional disturbance. In general, under the federal definition, this designation includes children and youth demonstrating unsatisfactory personal relationships with peers and teachers and who have inappropriate types of behaviors or feelings under normal circumstances.

For children who are eligible under IDEA, and whose behavior interferes with their learning or the learning of others, the IEP Team must consider, if appropriate, "positive behavioral interventions, strategies, and supports to address that behavior." These interventions, strategies, and supports must be incorporated into the student's IEP. It is also important to point out that the positive behavioral interventions, strategies, and supports available under IDEA are not limited to students with emotional disturbance. Such interventions can help any student whose behavior interferes with his or her social and emotional development and learning.

The 1997 reauthorization of IDEA emphasized in both spirit and letter that special education is an array of services and supports rather than a place. Under its Least Restrictive Environment (LRE) requirements, IDEA specifies that special classes, separate schooling, or other removal of children with disabilities from the regular educational environment should occur only if the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily. It is important to note that positive behavioral interventions and supports, like other services provided to students with disabilities, can be implemented in the regular education classroom.

Alternative Programs and Schools

Schools have sometimes been unsuccessful in addressing the complex needs of significantly troubled children and youths who have intensely challenging behaviors. Some districts have established alternative programs to continue educating students who previously would have dropped out or been suspended or expelled (Quinn, Osher, & Valore, 1997). These programs have increased dramatically, with three out of four school districts reporting some form of alternative program. Some school districts locate alternative programs in neighborhood schools, while others operate their programs in separate facilities. Some alternative programs are behavioral in focus. Others emphasize a day treatment model, which provides students and families with intensive mental health and special education services. Effective alternative programs are not custodial; rather, they collaborate with regular schools to facilitate reintegration (Tobin & Sprague, 1999). Characteristics of effective alternative programs include the following:

• Intensive individualized instruction in credit-earning coursework.

• Continuation of special education services for students with IEPs.

• Positive behavioral supports--including social skills and anger management/abatement--within a structured school environment.

• Psychological and mental health consultation and counseling.

• Active family involvement.

• Transition services that support the return to regular school.

• Community agency involvement (e.g., mental health programs, social services, law enforcement, juvenile justice).

• Caring staff committed to building relationships with students.

• Effective, engaging instructional techniques with curriculum demands that match each student's academic skills.

Systems of Care(Lourie, Stroul, & Friedman, 1998)

A system of care has been defined by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U. S. Department of Health and Human Services as a coordinated continuum of mental health and related services and supports designed to work with families to help children and adolescents with serious emotional disturbances get the services they need, in or near their home and community.

In systems of care, local public and private organizations work in teams with families to plan and implement a tailored set of services for each child's physical, emotional, social, educational, and family needs. Teams include family advocates and representatives from mental health, health, education, child welfare, juvenile justice, vocational rehabilitation, recreation, substance abuse, and other services. In effective systems of care, teams include the child and family and build upon the child's and family's strengths rather than focusing solely on problems.

The range of services that may be included in a system of care are as follows:

• Career counseling.

• Case management (service coordination).

• Community-based inpatient psychiatric care.

• Counseling (individual and group).

• Crisis outreach teams.

• Crisis residential care.

• Day treatment.

• Education/special education services.

• Family support.

• Health services.

• Independent living supports.

• Intensive family-based counseling.

• Legal services.

• Protection and advocacy.

• Psychiatric consultation.

• Recreational therapy.

• Residential treatment.

• Respite care.

• Self-help or support groups.

• Small therapeutic group care.

• Therapeutic foster care.

• Transportation.

• Tutoring.

For greatest effectiveness, the Student Support Team and the local system of care should develop established interagency agreements that facilitate the integration and coordination of services. When these services seem necessary for a child and family in need, agency staff competent in such intensive services can become part of the Student Support Team. The expanded team works together with the family and student to develop a plan. Together, they determine roles and responsibilities (e.g., case management); develop methods for coordination and communication; and provide for ongoing evaluation.

Individualized Mental Health Services and Supports

Effective systems of care tailor interventions to address the strengths and needs of individual youth who may require different interventions at different developmental stages (Santarcangelo, Bruns, & Yoe, 1998). Over the past decade, powerful and intensive interventions have been developed to address the multiple factors contributing to serious emotional and behavioral problems. To be effective, an intervention should address all of these factors and support the entire social ecology of the youth in trouble. These programs provide intensive therapy and support that is available 24 hours a day, seven days a week. There is daily contact, either face-to-face or by phone, with families. These services usually last for a minimum of three to five months, depending on the seriousness of the problem and the success of the intervention. Three models that have demonstrated impressive results are highlighted below.

Multisystemic Therapy

One intervention that has proven its effectiveness is Multisystemic Therapy (MST; Schoenwald, Borduin, & Henggler, 1998). It has been effective with youth with issues ranging from substance abuse and crime to suicidal and homicidal impulses. Multisystemic Therapy is built upon the following nine essential principles:

• The primary purpose of assessment is to understand the fit between the identified problems and their broader systemic context.

• Therapeutic contacts emphasize the positive and use systemic strengths as levers for change.

• Interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members.

• Interventions are present-focused and action-oriented, targeting specific and well-defined problems.

• Interventions target sequences of behavior within and between multiple systems that maintain the identified problems.

• Interventions are developmentally appropriate and fit the developmental needs of the youth.

• Interventions are designed to require daily or weekly effort by family members.

• Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.

• Interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members' needs across multiple systemic contexts.

Treatment Foster Care

Multisystemic Therapy is an example of an effective strategy for addressing the needs of youths whose behaviors or needs have not worsened to the point where out-of-home placement is mandated. Treatment Foster Care extends the model of intensive, family-focused intervention to youth whose delinquency has been so serious and so chronic that they are no longer permitted to live at home. Like multisystemic therapy, it works because it includes every major aspect of a youth's life in the intervention: the individual, family, peers, and school. Indeed, Treatment Foster Care has been rigorously evaluated, and, compared with ordinary group care, has been shown to reduce repeat offenses and to increase the number of successful youths who return to living with relatives. (Chamberlain,1990; Chamberlain & Moore, 1998; Chamberlain& Reid, 1998; Moore & Chamberlain,1994).

The model on which treatment foster care is based recognizes the challenges of living with a youth exhibiting serious antisocial behavior. Parents can be worn down by escalating conflict to a point where their normal parenting resources are seriously diminished. It is precisely these normal resources--the ability to provide meaningful adult supervision, to implement discipline consistently, to minimize association with delinquent peers, and to support academic achievement--that keep delinquency at bay. What treatment foster care does is provide these powerful socialization forces of family life for youngsters at a point when the youths' behaviors have become so dangerous to society that they are removed from their homes.

Treatment Foster Care families are recruited for their ability to share the basis of their experience with adolescents, their willingness to act as treatment agents, and their ability to provide a nurturing family environment. Foster families apply formally and participate in 20 hours of pre-service training, which emphasizes the use of behavior management methods. These methods, which provide youths with a structured daily living environment, include close supervision, clear rules, and enforcement of limits. Treatment Foster Care parents are taught how to implement individualized plans that take into account youths' needs and the treatment foster care family's schedule and values. A three-level system is used in which the youth's privileges and level of supervision are based on their compliance with program rules, adjustment in school, and general progress. Treatment Foster Care parents participate in weekly foster parent group meetings. Here they review youths' progress, identify problems, and discuss potential solutions.

Each youth in Treatment Foster Care participates in individual behavior therapy focused on skill-building in problem-solving, social perspective taking, and non-aggressive methods of self-expression. Birth families and other concerned individuals involved with the youth's care participate in weekly family therapy focused on parent management training with an emphasis on supervision, encouragement, discipline, and problem-solving. Schools are an important part of the intervention; each youth carries a card to class and teachers sign off on attendance, homework completion, and attitude. Youths who are suspended are required to do schoolwork or chores during school hours.

Wraparound Planning and Services

Another approach to providing intensive interventions that has spread throughout the country is the Wraparound process. Wraparound is not a therapy or a program, but rather it is an approach to providing services and supports to children with serious emotional and behavioral problems and their families. The Wraparound approach involves 10 essential elements and values that guide the process of providing intensive services to children and their families (Burns & Goldman, 1999; Kendziora, Bruns, Pacchiano, and Mejia, in press).

The Wraparound approach includes a definable planning process involving the child and family, community agencies, and school staff that results in a unique set of school and community services and supports tailored to meet the needs of the child and family. This Wraparound team includes the child and family, professional service providers (e.g., mental health workers, educators, child welfare workers, law enforcement and juvenile justice personnel), and natural supports from the community, including extended family members, friends, clergy--anyone the family may call upon to help their child. The team develops goals and identifies the individualized set of services and supports necessary to achieve those goals. The plan employs a strengths-based assessment, is coordinated by a Wraparound facilitator or case manager, specifies a crisis/safety plan, and identifies measurable outcomes that can be monitored regularly.

Since a critical element of the Wraparound approach is that services and supports are provided in the child's and family's community, the involvement of school professionals from the child's neighborhood school can be extensive. School-based Wraparound planning builds upon the individualized nature of special education planning and includes the teacher and other relevant school personnel as part of the planning team. Given that Wraparound services and supports are usually paid for through flexible, noncategorical funding, the Wraparound team can often provide additional supports for the child that are implemented during the school day to aid teachers and other school staff.

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