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

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Abstract

Background

The Good Behavior Game (GBG) is a classroom behavior management strategy focused on socializing children to the role of student and aimed at reducing early aggressive, disruptive behavior, a confirmed antecedent to service use. The GBG was tested in a randomized field trial in 19 elementary schools with two cohorts of children as they attended first and second grades. This article reports on the impact of the GBG on service use through young adulthood.

Methods

Three or four schools in each of five urban areas were matched and randomly assigned to one of three conditions: (1) GBG, (2) an intervention aimed at academic achievement, or (3) the standard program of the school system. Children were assigned to classrooms to ensure balance, and teachers and classrooms were randomly assigned to intervention conditions.

Results

This study provides evidence of a positive impact of a universal preventive intervention on later service use by males, although not by females, for problems with emotions, behavior, or drugs or alcohol. For both cohorts, males in GBG classrooms who had been rated as highly aggressive, disruptive by their teachers in the fall of first grade had a lower rate of school-based service use than their counterparts in control classrooms.

Replication

The design employed two cohorts of students. Although both first- and second-grade teachers received less training and support with the second cohorts of students than with the first cohort, the impact of GBG was similar across both cohorts.

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)

  • D.J. Rickwood et al.

    Social-psychological factors affecting help-seeking for emotional problems

    Soc. Sci. Med.

    (1994)
  • A.R. Stiffman et al.

    The Service Assessment for Children and Adolescents (SACA): adult and child reports

    J. Am. Acad. Child Adolesc. Psychiatry

    (2000)
  • F.C. Verhulst et al.

    Factors associated with child mental health services use in the community

    J. Am. Acad. Child Adolesc. Psychiatry

    (1997)
  • H.J. Walter et al.

    Teachers’ beliefs about mental health needs in inner city elementary schools

    J. Am. Acad. Child Adolesc. Psychiatry

    (2006)
  • H.C. Wilcox et al.

    The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts

    Drug Alcohol Depend.

    (2008)
  • American Federation of Teachers, 2000. Building on the best, learning from what works: five promising discipline and...
  • S. Aos et al.

    Benefits and Costs of Prevention and Early Intervention Programs for Youth

    (2004)
  • H. Barrish et al.

    Good behavior game: effects of individual contingencies for group consequences on disruptive behavior in a classroom

    J. Appl. Behav. Anal.

    (1969)
  • P. Berman et al.

    Federal Programs Supporting Educational Change, Vol. IV: The Findings in Review

    (1975)
  • P. Berman et al.

    Federal Programs Supporting Educational Change, Vol. VIII: Implementing and Sustaining Innovations

    (1978)
  • J. Block et al.

    Mastery Learning

  • C.H. Brown

    Analyzing preventive trials with generalized additive models

    Am. J. Community Psychol.

    (1993)
  • C.H. Brown et al.

    Principles for designing randomized preventive trials in mental health: an emerging developmental epidemiology paradigm

    Am. J. Community Psychol.

    (1999)
  • B.J. Burns et al.

    Children's mental health service use across service sectors

    Health Aff.

    (1995)
  • D. Cicchetti et al.

    Toward a transactional model of childhood depression

  • E.J. Costello et al.

    Who gets treated? Factors associated with referral in children with psychiatric disorders

    Acta Psychiatr. Scand.

    (1990)
  • P.J. Curran et al.

    The application of latent curve analysis to testing developmental theories in intervention research

    Am. J. Community Psychol.

    (1999)
  • A. Datnow et al.

    Teachers’ responses to success for all: how beliefs, experiences, and adaptations shape implementation

    Am. Educ. Res. J.

    (2000)
  • Department of Health and Human Services, 2001. Youth violence: A report of the Surgeon General. Rockville,...
  • F. Dominici et al.

    On the use of generalized additive models in time-series studies of air pollution and health

    Am. J. Epidemiol.

    (2002)
  • D.S. Elliott et al.

    Issues in disseminating and replicating effective prevention programs

    Prev. Sci.

    (2004)
  • M.E. Ensminger et al.

    School and family origins of delinquency: comparisons by sex

  • M.E. Ensminger et al.

    Paths to high school graduation or dropout: a longitudinal study of first grade cohort

    Sociol. Educ.

    (1992)
  • E.M.Z. Farmer et al.

    Pathways into and through mental health services for children and adolescents

    Psychiatr. Serv.

    (2003)
  • D.P. Farrington et al.

    Are there any successful men from criminogenic backgrounds?

    Psychiatry

    (1988)
  • M.E. Garralda et al.

    Child and family factors associated with referral to child psychiatrists

    Br. J. Psychiatry

    (1988)
  • M.M. Gerber et al.

    Teacher as imperfect test: reconceptualizing the referral process

    Educ. Psychol.

    (1984)
  • R.S. Gordon

    An operational classification of disease prevention

    Public Health Rep.

    (1983)
  • 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.

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