Impact of the Good Behavior Game, a universal classroom-based behavior intervention, on young adult service use for problems with emotions, behavior, or drugs or alcohol☆
Introduction
Over the past decade, the public health concept of an integrated system of interventions and services for mental health has entered the parlance of practitioners and policymakers in many fields, including education. This concept is based on an epidemiological understanding of population risk in which preventive interventions followed by treatment and maintenance are delivered to distinct populations and sub-populations on the basis of levels of risk (Gordon, 1983, Mrazek and Haggerty, 1994). Mrazek and Haggerty (1994) defined five levels of intervention in public mental health: three levels of preventive interventions, treatment intervention, and maintenance intervention. Universal preventive interventions are delivered to an entire population without focusing on any specific group in the population and often aim at strengthening some aspect of the environment. An example in education would be training teachers in an effective classroom behavior management strategy thereby strengthening the classroom environment and socializing students to behave in a positive manner. In a truly integrated service system, selective interventions backed up by indicated interventions are delivered to the segment of the population that is at increased risk relative to the population average and does not respond to interventions earlier in the continuum. It follows that in a population served by an integrated system of interventions, we would expect that influencing a risk factor or a set of risk factors through a preventive intervention would lower the proportion of the population needing to be served through more intensive levels of interventions and services for problems attributable to that risk factor. This paper contributes to our understanding of the interplay between levels of the system by studying the impact of the Good Behavior Game (GBG), a universal preventive intervention delivered in first and second grades and aimed at reducing aggressive, disruptive behavior on later service use for problems with emotions, behavior, or drugs, or alcohol from elementary school to young adulthood.
Developmental epidemiology is the prevention science strategy that has guided three generations of preventive intervention trials carried out in partnership with the Baltimore City Public School System (Kellam and Rebok, 1992, Kellam et al., 1999). It draws on three perspectives: community epidemiology, life course development, and theory testing through randomized field trials. Community epidemiology is concerned with the non-random distribution of health problems or related factors in a fairly small population in the context of its environment, such as a neighborhood or a school catchment area. Service use can be conceptualized as a response to these problems. With selection bias controlled, the second perspective of studying variation in developmental antecedents and pathways within the defined population, coupled with the third perspective of directing preventive interventions at hypothesized causal risk factors, allows the study not only of main effects but also of variation in the impact of the preventive intervention on outcomes, including service use. Developmental epidemiology is critical to services research because understanding what interventions work for whom and under which conditions is essential information for providing services in an integrated fashion.
Life course/social field theory (Kellam et al., 1975) has guided the hypotheses of three generations of Baltimore-based field trials and provides a useful framework as we consider use of services throughout childhood and adolescence. A basic tenet of the theory is that individuals move through different social fields across the lifespan. For example, the main social fields for first graders are the classroom and the family. Within each social field, natural raters, such as teachers in the classroom, parents in the family, peers in the peer group, supervisors in the workplace, and spouses in the marital social field, define social task demands specific to that social field. The interactive process of demand—as defined by the natural rater—and response—by the individual—is termed social adaptation. The judgment of an individual's performance by a natural rater is social adaptational status (SAS; Kellam et al., 1975). In contrast to SAS, psychological well-being (PWB) reflects an individual's internal state, as indicated through symptoms and diagnoses. There are two key hypotheses in life course/social field theory. First, in keeping with Cicchetti and Schneider-Rosen (1984), we hypothesize that success in mastering social task demands specific to one stage of development and social field will lead to an increase in later successes both across development and across social fields. Additionally, we hypothesize a potential reciprocal relationship between SAS and PWB.
Aggressive, disruptive behavior, as early as first grade, is a well-established predictor of deleterious outcomes such as later aggressive, disruptive behavior, conduct disorder, antisocial personality disorder, and illicit drug use (Dishion et al., 1996, Ensminger and Slusarcick, 1992, Ensminger et al., 1983, Farrington and Gunn, 1985, Farrington et al., 1988, Ialongo et al., 2001, Kellam and Ensminger, 1980, Kellam and Rebok, 1992, Kellam et al., 1975, Kellam et al., 1983, Kellam et al., 1991, Kellam et al., 1994b, McCord, 1988, Patterson et al., 1992, Robins, 1978). Children often begin to exhibit aggressive, disruptive behavior at an early age in their interactions with family, including parents and siblings, and with peers. An early risk factor for the development of conduct problems, including aggressive, disruptive behavior, throughout childhood is ineffective and coercive parenting practices in response to challenging child behavior, which escalates and reifies the oppositional behavior (Patterson et al., 1992, Reid, 1993, Reid and Eddy, 1997). When these children enter school, they often engage in the same aversive behaviors with the teacher as they did with the parents. Teachers who lack training in classroom behavior management may find themselves engaging in ineffective and coercive interactions with these students, further intensifying the negative behaviors rather than extinguishing them.
The interactive process captured in the ratings of SAS is particularly relevant to child and adolescent services research because by and large, children and adolescents receive services through the intercession of adults who perceive them to need those services. In fact, during the school years, the determination of need for services, followed by referral and use, quite often occurs as a result of poor social adaptation of children to the teacher's behavioral task demands (Gerber and Semmel, 1984, Hocutt, 1996, Lloyd et al., 1991, Mattison et al., 1986, Poduska, 2000, Shinn et al., 1987). Hocutt (1996) refers to the “teachability” of students when discussing factors that teachers consider when thinking about children's need for services. She defines teachability as the “extent to which the student is alert, sustains attention in the classroom, and begins and completes [tasks] on time,” a concise description of classroom SAS.
Further, although both SAS and PWB have been found to be associated with the use of mental health services (Burns et al., 1995, Costello and Janiszewski, 1990, Feehan et al., 1990, Garralda and Bailey, 1988, John et al., 1995, Laitinen-Krispijn et al., 1999, Rickwood and Braithwaite, 1994, Staghezza-Jaramillo et al., 1995, Verhulst and der Ende, 1997), there is evidence that children with aggressive, disruptive behavior and diagnoses are more likely to receive services than children with depressive symptoms or a diagnosis of depression alone (Cohen et al., 1991, Wu et al., 1999). In a recent study, elementary school teachers cited disruptive classroom behavior as the largest mental health problem in their schools and a lack of information/training as the greatest barrier to addressing these problems, with a lack of time as a close second (Walter et al., 2006).
Results published to date on the GBG as it was tested alone in the first generation of trials in Baltimore have shown a positive impact of the intervention on aggressive, disruptive behavior at the end of first grade (Brown, 1993, Dolan et al., 1993), through middle school (Kellam et al., 1994a, Kellam et al., 1998), and to the transition into young adulthood (Kellam et al., 2008, Petras et al., 2008), particularly for the most aggressive, disruptive males. In addition, results from the second generation of trials conducted in Baltimore in which the GBG was combined with an instructional intervention showed at sixth-grade follow-up that children in this combined classroom-based intervention were rated by teachers as having fewer conduct problems and were less likely to have a diagnosis of conduct disorder, to have been suspended from school, or to have been in need of, or to have received, mental health services (Ialongo et al., 2001).
The overarching hypothesis for this paper is that to the extent that service use for problems with behavior, feelings, or drugs and alcohol is associated with aggressive, disruptive behavior, the GBG, a universal intervention aimed at aggressive, disruptive behavior, will reduce the use of services over the course of childhood to young adulthood. In keeping with prior results, we further hypothesize that the impact will be greatest for those youth who exhibited the highest levels of aggressive, disruptive behavior on entrance to first grade. We will examine GBG impact on service use across several specific service sectors in addition to school because children and adolescents receive services for problems with behavior, feelings, and drugs and alcohol through a variety of additional service sectors, including the mental health, medical health, welfare, and justice systems (Burns et al., 1995, Leaf et al., 1996).
Section snippets
The GBG intervention
The GBG is directed at the entire class and targets aggressive, disruptive behavior (Barrish et al., 1969). The GBG has been cited as an effective program by the American Federation of Teachers (AFT) in its Building on the Best, Learning from What Works series (AFT, 2000) and by the Surgeon General in his report on youth violence (Department of Health and Human Services, 2001). It has been replicated by at least a dozen independent research groups, in the United States and abroad, since its
Results
The results are organized by service sector, beginning with (1) use of services for problems with behavior, emotions, or drugs or alcohol from any provider, followed by use of services from the specific providers: (2) mental or medical health provider, (3) school-based services, (4) drug treatment services, (5) juvenile or adult justice system, and (6) social services. For each service sector, we present the results for Cohort 1 followed by the results for Cohort 2. Because there are
Discussion
This study provides evidence of a positive impact of a universal preventive intervention on later service use by males, though not by females, for problems with emotions, behavior, or drugs or alcohol. Impact was seen across both cohorts with regard to the use of school-based services by highly aggressive, disruptive males. The primacy of the education sector in the delivery of mental health services is well established in the services literature; it is the most common sector for service use
Conflict of interest
The author and all of the co-authors declare that they have no conflict of interest.
Acknowledgements
During the last 22 years this research has been supported by the following grants: NIMH: R01MH42968, P50MH38725, T32MH018834 with supplements from NIDA to each of these grants; and NIMH/NIDA: R01MH40859. The NIMH or NIDA had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
We acknowledge our partners—the students, parents, teachers, and administrators of the Baltimore
References (79)
- et al.
Methods for testing theory and evaluating impact in randomized filed trials: intent-to-treat analysis for integrating the perspective of person, place, and time
Drug Alcohol Depend.
(2008) - et al.
Diagnostic predictors of treatment patterns in a cohort of adolescents
J. Am. Acad. Child Adolesc. Psychiatry
(1991) - et al.
Deviancy training in male adolescent friendships
Behav. Ther.
(1996) - et al.
The short-term impact of two classroom-based preventive interventions on aggressive and shy behaviors and poor achievement
J. Appl. Dev. Psychol.
(1993) - et al.
Parental help-seeking for behavioural and emotional problems in childhood and adolescence
Community Health Stud.
(1990) - et al.
Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes
Drug Alcohol Depend.
(2008) - et al.
Predicting adolescent mental health service use in a prospective record-linkage study
J. Am. Acad. Child Adolesc. Psychiatry
(1999) - et al.
Mental health service use in the community and schools: results from the four-community MECA study
J. Am. Acad. Child Adolesc. Psychiatry
(1996) - et al.
Developmental epidemiological courses leading to antisocial personality disorder and violent and criminal behavior: effects by young adulthood of a universal preventive intervention in first- and second-grade classrooms
Drug Alcohol Depend.
(2008) Parents’ perceptions of their first graders’ need for mental health and educational services
J. Am. Acad. Child Adolesc. Psychiatry
(2000)
Social-psychological factors affecting help-seeking for emotional problems
Soc. Sci. Med.
The Service Assessment for Children and Adolescents (SACA): adult and child reports
J. Am. Acad. Child Adolesc. Psychiatry
Factors associated with child mental health services use in the community
J. Am. Acad. Child Adolesc. Psychiatry
Teachers’ beliefs about mental health needs in inner city elementary schools
J. Am. Acad. Child Adolesc. Psychiatry
The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts
Drug Alcohol Depend.
Benefits and Costs of Prevention and Early Intervention Programs for Youth
Good behavior game: effects of individual contingencies for group consequences on disruptive behavior in a classroom
J. Appl. Behav. Anal.
Federal Programs Supporting Educational Change, Vol. IV: The Findings in Review
Federal Programs Supporting Educational Change, Vol. VIII: Implementing and Sustaining Innovations
Mastery Learning
Analyzing preventive trials with generalized additive models
Am. J. Community Psychol.
Principles for designing randomized preventive trials in mental health: an emerging developmental epidemiology paradigm
Am. J. Community Psychol.
Children's mental health service use across service sectors
Health Aff.
Toward a transactional model of childhood depression
Who gets treated? Factors associated with referral in children with psychiatric disorders
Acta Psychiatr. Scand.
The application of latent curve analysis to testing developmental theories in intervention research
Am. J. Community Psychol.
Teachers’ responses to success for all: how beliefs, experiences, and adaptations shape implementation
Am. Educ. Res. J.
On the use of generalized additive models in time-series studies of air pollution and health
Am. J. Epidemiol.
Issues in disseminating and replicating effective prevention programs
Prev. Sci.
School and family origins of delinquency: comparisons by sex
Paths to high school graduation or dropout: a longitudinal study of first grade cohort
Sociol. Educ.
Pathways into and through mental health services for children and adolescents
Psychiatr. Serv.
Are there any successful men from criminogenic backgrounds?
Psychiatry
Child and family factors associated with referral to child psychiatrists
Br. J. Psychiatry
Teacher as imperfect test: reconceptualizing the referral process
Educ. Psychol.
An operational classification of disease prevention
Public Health Rep.
Cited by (0)
- ☆
Supplementary material of the descriptive epidemiology of cumulative services can be viewed by accessing the online version of this paper at http://dx.doi.org/10.1016/j.drugalcdep.2007.10.009.