Early intervention with children at risk of emotional/behavioral disorders: a critical examination of research methodology and practices.

Early intervention with children at risk of emotional/behavioral disorders: a critical examination of research methodology and practices. Abstract Children's behavior problems pose challenges to families,schools, and society. The research literature argues that earlydetection/intervention is the most powerful course of action inameliorating a��mel��io��rate?tr. & intr.v. a��me��lio��rat��ed, a��me��lio��rat��ing, a��me��lio��ratesTo make or become better; improve. See Synonyms at improve.[Alteration of meliorate. these problems in children at risk of emotional/behavioraldisorders. However, specifying precisely what constitutes a qualityprogram of early intervention ear��ly interventionn. Abbr. EIA process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. is not a simple task. Currentconceptualizations suggest that successful early intervention cannot beunidimensional in nature, but must consist of a complex series ofinteractions and transactions that synergistically syn��er��gis��tic?adj.1. Of or relating to synergy: a synergistic effect.2. Producing or capable of producing synergy: synergistic drugs.3. serve to nurture NURTURE. The act of taking care of children and educating them: the right to the nurture of children generally belongs to the father till the child shall arrive at the age of fourteen years, and not longer. Till then, he is guardian by nurture. Co. Litt. 38 b. andenhance both the development of the child and family. In this paper, wereviewed the accumulated research to learn more about the criticalelements of early intervention. Specifically, we examined three majorareas addressed in the literature. First, we describe literature searchprocedures and criteria for study inclusion, along with methods foranalyzing these early intervention studies. Second, we examine theconduct of the intervention, including characteristics of studyparticipants, types of interventions, types of measures, age of onset The age of onset is a medical term referring to the age at which an individual acquires, develops, or first experiences a condition or symptoms of a disease or disorder.Diseases are often categorized by their ages of onset as congenital, infantile, juvenile, or adult. and length of intervention, treatment fidelity, and social validitymeasures. Finally, we draw upon that review to offer recommendations forfuture research. ********** Children's behavior problems can pose tremendous challenges tofamilies, schools, and society. Once established, problem behavior tendsto persist (e.g., Campbell & Ewing, 1990; Loeber & Dishion,1983; Patterson, Capaldi, & Bank, 1989; Webster-Stratton, 2000).Left untreated, children's behavior problems typically multiply,intensify, and diversify over time (Campbell & Ewing, 1990), thusputting the child at increased risk for academic failure, socialisolation, and peer rejection. These, in turn, accelerate the likelihoodof school avoidance, alcoholism alcoholism,disease characterized by impaired control over the consumption of alcoholic beverages. Alcoholism is a serious problem worldwide; in the United States the wide availability of alcoholic beverages makes alcohol the most accessible drug, and alcoholism is and drug abuse, and lifespan antisocial antisocial/an��ti��so��cial/ (-so��sh'l)1. denoting behavior that violates the rights of others, societal mores, or the law.2. denoting the specific personality traits seen in antisocial personality disorder. behavior (Asher & Coie, 1990; Dodge, 1993; Kazdin, 1993; Loeber& Dishion, 1983; Walker & Severson, 1990). Given the pernicious pernicious/per��ni��cious/ (per-nish��us) tending toward a fatal issue. per��ni��ciousadj.Tending to cause death or serious injury; deadly. effects of children's behavior disorders, early intervention toprevent the development of such disorders is a judicious ju��di��cious?adj.Having or exhibiting sound judgment; prudent.[From French judicieux, from Latin i alternative tointervening after the behavior is well entrenched en��trench? also in��trenchv. en��trenched, en��trench��ing, en��trench��esv.tr.1. To provide with a trench, especially for the purpose of fortifying or defending.2. (e.g., Dodge, 1993;Kaiser & Hester, 1997; Kauffman, 1999; Kazdin, 1993;Webster-Stratton, 2000). By most accounts, early detection/intervention is the most powerfulcourse of action in ameliorating life long problems associated withchildren at risk for emotional/behavioral disorders (cf. Hester &Kaiser, 1998; Kauffman, 1999; Serna, Nielsen, Lambros, & Forness,2002). Indeed, a growing body of empirical research Noun 1. empirical research - an empirical search for knowledgeinquiry, research, enquiry - a search for knowledge; "their pottery deserves more research than it has received" supports thepositive impact of early intervention (e.g., Del'Homme, Kasari,Forness, & Bagley, 1996: Forness et al., 1998; Kaiser & Hester,1997; Kamps & Tankersley, 1996; McEvoy, Davis, & Reichle, 1993).Moreover, recent legislation, such as the No Child Left Behind Act The No Child Left Behind Act of 2001 (Public Law 107-110), commonly known as NCLB (IPA: /ˈnɪkəlbiː/), is a United States federal law that was passed in the House of Representatives on May 23, 2001 , TheGood Start, and the Grow Smart initiatives, has reemphasized thecritical role that early intervention plays in promoting the social/emotional development of young children. Notwithstanding the unanimity UNANIMITY. The agreement of all the persons concerned in a thing in design and opinion. 2. Generally a simple majority (q.v.) of any number of persons is sufficient to do such acts as the whole number can do; for example, a majority of the legislature can pass of support for early intervention,specifying precisely what constitutes a quality program of earlyintervention is not a simple task (Bailey, Aytch, Odom, Symons, &Wolery, 1999). Most experts agree that prevention of children'semotional/behavioral disorders requires intervention in multipleenvironments, by multiple agents over time, with continued intervention,support, and transition services as children move from setting tosetting (Hamblin-Wilson, & Thurman, 1990; Hester & Kaiser, 1998;Rule, Fietchtl, & Innocenti, 1990; Rous, Hemmeter, & Schuster,1994). For example, effective intervention might include intervention inthe home environment, as well as the school and community, with a focusnot only on child behavior, but intervention with parents, teachers, andpeers. Child characteristics, parent characteristics, the dynamics ofthe interaction between the parent and child, and how that relationshipis influenced by economic, cultural, and social circumstances (ConductProblems Prevention Research Group, CPPRG CPPRG Conduct Problems Prevention Research Group , 1992), all impinge im��pinge?v. im��pinged, im��ping��ing, im��ping��esv.intr.1. To collide or strike: Sound waves impinge on the eardrum.2. on thedevelopment of children. The long-term efficacy of that interventionprocess is dependent largely on its continuity and consistency acrosspersons, across settings, and over time. Various authorities assert itis the complex interplay between child and child-partner(parent/teacher/peer), along with variables within the context of thesetting that shape the quality of behavior. The complexity of thesevariables is depicted in Figure 1. Moreover, collaboration betweenprevious and future teachers, along with in put from parents couldfacilitate a successful transition for a child. This conceptualization con��cep��tu��al��ize?v. con��cep��tu��al��ized, con��cep��tu��al��iz��ing, con��cep��tu��al��iz��esv.tr.To form a concept or concepts of, and especially to interpret in a conceptual way: highlights the need for teachers, researchers, and other professionalsto look beyond the child for effective intervention strategies. [FIGURE 1 OMMITTED] Given the broad support for early intervention for children withemotional/behavioral disorders, we examined the methodology and resultsof the accumulated research to learn more about the critical elements ofthese early interventions and how these elements are implemented. Ourintent was threefold: (1) to examine the selection criteria foridentifying participants; (2) to compare the research methodologieswithin and across preventive intervention studies intervention studies,n.pl the epidemiologic investigations designed to test a hypothesized cause and effect relation by modifying the supposed causal factor(s) in the study population. ; and (3) to documentthe assessment of prevention/intervention efforts. Our discussion isdivided into three parts. First, we describe literature searchprocedures and criteria for study inclusion, along with methods foranalyzing these early intervention studies. Second, we examine theconduct of the intervention, including characteristics of studyparticipants, types of interventions, types of measures, age of onsetand length of intervention, treatment fidelity, and social validitymeasures. Finally, we draw upon that review to offer recommendations forfuture research. Procedures for the Review and Analysis of Early InterventionResearch Selection Procedures This review focused on research on early intervention for theprevention of emotional/behavioral disorders. We relied on a number ofstrategies to locate potential studies for inclusion in the analysis.First, we identified studies through computerized bibliographic searchesfrom abstract and citation archives (PsycINFO and EducationAbstracts-ERIC) and reference lists from literature reviews. Thesesearches were based on the following keywords and various combinationsof these words: problem behavior; young children; risk/at-risk; earlyintervention; conduct disorder Conduct DisorderDefinitionConduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of ; prevention; longitudinal studies longitudinal studies,n.pl the epidemiologic studies that record data from a respresentative sample at repeated intervals over an extended span of time rather than at a single or limited number over a short period. ;resiliency; consumer satisfaction; parent/ mother-child; teacher-child;treatment fidelity; treatment efficacy; attachment; outcome studies;parents; and emotional and/or behavioral disorders. These keywords wordswere selected because they are prevalent in the literature, they havebeen established as critical factors in successful interventions, andthey represent the evolving terminology in education legislation. Initially, over 500 articles were screened. Because of the currentlegislative focus on early intervention and outcomes measurement throughevidence based research, and to limit biases (Glass, 1976) andmethodological flaws, we conducted our review according to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. preselectedcriteria and a standard coding protocol that reflected the legislativeagenda. These criteria included: 1) studies published between 1990-2002to focus on more current investigations; 2) evidence based research onearly intervention; 3) interventions directed primarily atmanifestations of child behavior and social functioning social functioning,n the ability of the individual to interact in the normal or usual way in society; can be used as a measure of quality of care. ; 4) targetedparticipants who ranged in age from birth through elementary school elementary school:see school. ageat the onset of intervention; and 5) studies published in peer-reviewedjournals. Using these parameters we identified 21 core studies forinclusion in our review. These studies, are identified with an asterisk (1) See Asterisk PBX.(2) In programming, the asterisk or "star" symbol (*) means multiplication. For example, 10 * 7 means 10 multiplied by 7. The * is also a key on computer keypads for entering expressions using multiplication. in the References. To insure accuracy of selection, two investigators independentlyidentified the selected articles. Ideally, our review would include allsignificant empirical research reported during the time-period1990-2002. We acknowledge that it may not be complete due to thereliance on journal articles (i.e., the omission of books, chapters, anddissertations), as well as oversight and error on our part. Studies thatmet our inclusion criteria For Wikipedia's inclusion criteria, see: What Wikipedia is not.Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. were coded systematically according tospecific characteristics that authorities have suggested focus onempirical support for early intervention for the prevention ofemotional/behavioral disorders and the characteristics of thepopulations for whom these interventions were most efficacious ef��fi��ca��cious?adj.Producing or capable of producing a desired effect. See Synonyms at effective.[From Latin effic (e.g.child's age at onset of intervention, intervention components)(Kaiser & Hester, 1997). Analysis of Research Studies on Early Intervention Analysis of the selected articles focused on three domains: 1)characteristics and selection criteria of the participants; 2)intervention implementation with regard to type and length ofintervention, types of measures used, treatment efficacy, treatmentfidelity, and social validity measures; and 3) longitudinal assessment.Each of these domains is addressed in the following discussion. Characteristics and Selection Criteria The way in which study participants are selected has criticalimplications on outcomes. If intervention results are to be informative,researchers need clearly to define the populations for which thetreatment was designed (Chambless & Hollon, 1998). Interventioneffectiveness may be applicable only to those participants who meet thestringent selection criteria for inclusion in a particular intervention.Unfortunately, there often is arbitrary use of diagnostic labels (e.g.,emotionally disturbed, conduct disorder, behaviorally disordered),without strict adherence to diagnostic definitions. In other instances,there may be reluctance to affix affixv. 1) to attach something to real estate in a permanent way, including planting trees and shrubs, constructing a building, or adding to existing improvements. a label(s) to young children and/or anabsence of objective measures to support a particular classification.Upon review, four major areas of concern emerged with regard toparticipant selection: 1) variability in terminology used to describeparticipants and inconsistency in��con��sis��ten��cy?n. pl. in��con��sis��ten��cies1. The state or quality of being inconsistent.2. Something inconsistent: many inconsistencies in your proposal. in operational definitions; 2)variability among primary informants; 3) variability in assessmentmeasures; and 4) researcher subjectivity. The 21 studies that we reviewed contained a significant amount ofvariability regarding the terminology and/or operational definition usedto identify participants. The discordance discordance/dis��cor��dance/ (dis-kord��ans) the occurrence of a given trait in only one member of a twin pair.discor��dant dis��cor��dancen. in selection criteria acrossstudies poses a problem both in terms of comprehensively reviewing andaccurately synthesizing early intervention/prevention efforts. Theterminology used to identify the participants included, but was notlimited to: at-risk, high-risk, conduct disorder, emotional disturbance,problem behavior, disruptive behavior, and emotional/behavioraldisorder. The heterogeneity het��er��o��ge��ne��i��tyn.The quality or state of being heterogeneous.heterogeneitythe state of being heterogeneous. among participants also confounds efforts toreplicate existing interventions, as intervention efficacy only appliesto those studies using identical selection criteria (Sidman, 1960). A common method to determine the presence/absence and the severityof specific problem behaviors in young children is the use of adultinformant informantHistorian Medtalk A person who provides a medical history (s) (e.g., parent, teacher, childcare provider). Studies thatrelied on these types of measures contained considerable variabilityregarding individual child behavior, largely due to the subjectivenature of these accounts. For example, Kaiser et al. (2002) found a linkbetween level of teacher experience and reports of child behaviorproblems; that is, teachers with less than seven years of teaching ratedchildren higher on total behavior problems than more experiencedteachers. Further compounding this problem is the use of single versusmultiple informants. In addition, the wide variety of assessmentmeasures raises questions about the reliability and validity ofassumptions regarding important attributes of the target population. Wefound little consistency in the measures applied (see Table 1). Measuresincluded standardized and nonstandardized instruments, adaptations andsubscales of standardized measures, and weighted/averaged standardizedmeasures. In addition, a number of studies relied on variousenvironmental characteristics, such as socioeconomic status and crimestatistics, to determine at risk or high risk status of children. A final concern that stemmed from our review related to researcherbias and subjectivity, both of which can be highly influential indetermining treatment outcomes. Foremost was that the selection of"cut" scores on various instruments to determine inclusion orexclusion of children from the various studies may result in Type I andType 2 errors (Campbell, 1994). When either interpreting extant ex��tant?adj.1. Still in existence; not destroyed, lost, or extinct: extant manuscripts.2. Archaic Standing out; projecting. data orreplicating an intervention, one must keep in mind the ideographiccharacteristics of study participants. Studies that appear to target thesame population in fact, may not do so. Intervention Implementation: Critical Variables Experimental designs of early intervention. In a controlledinvestigation, researchers must demonstrate treatment efficacy toconclude that benefits observed are due to the effects of the treatmentand not to chance or confounding confoundingwhen the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies.confounding factor factors (e.g., time, measurevariations, participant variability, treatment fidelity) (Campbell &Stanley, 1963; Chambless & Hollon, 1998). Efficacy is bestdemonstrated in group design studies in which participants are randomlyassigned to treatment/comparison/control conditions or to carefullycontrolled single subject designs (Chambless & Hollon, 1998).Replication by an independent research team also helps to protectagainst investigator bias or aberrant findings (Chambless & Hollon,1998). Finally, Cohen cohenor kohen(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. (1988) and others argue that controlledinvestigations need a sufficient number of participants to detectpossible differences among treatments by means of a statistical test ofsignificance. Typically, research designs are divided into two broadcategories--group and single-subject designs. Ninety-five percent (n=20)of the studies we reviewed relied on group design, whereas, 5% (n=1)used single subject methodology (Musser, Bray, Kehlr, & Jensen,2001). Of the studies utilizing a group design, 24% (n=5) comparedtreatment effects to a normative nor��ma��tive?adj.Of, relating to, or prescribing a norm or standard: normative grammar.nor sample of children (August, Realmuto,Hektner, & Bloomquist, 2001; Braswell et al., 1997; Kamps,Tankersley, & Ellis, 2000; Shelton et al., 2000; Tremblay,Pagani-Kurtz, Masse, Vitaro, & Pihl, 1995) (see Table 1). Age of child participants at preintervention assessment. Theearlier intervention begins the more effective it will be (Kamps &Tankersley, 1996; Kauffman, 1999) and the less likely that secondarycomplications will arise (e.g., Guralnick & Bennett, 1987). In thestudies reviewed, the initial age of preintervention assessment rangedfrom birth through elementary school. However, only 24% (n=5) of thestudies identified children prior to kindergarten kindergarten[Ger.,=garden of children], system of preschool education. Friedrich Froebel designed (1837) the kindergarten to provide an educational situation less formal than that of the elementary school but one in which children's creative play instincts would be (Barkley et al., 2000;Eckenrode et al., 2001; Sanders, MarkieDadds, Tully, & Bor, 2000;Serna, Nielsen, & Forness, 2000; WebsterStratton, 1998) (see Table1). Type of intervention. As indicated previously, there is growingsentiment that multidimensional intervention is essential for success inearly intervention/prevention (Dodge, 1993; Kaiser & Hester, 1997;CPPRG, 2000). Our review indicated that 38% (n=8) of the availablestudies included a single component. By comparison, 43% (n=9) includedtwo intervention components, while only 19% (n=4) included threeintervention components (see Table 1). Length of intervention. The persistence of early behavioralproblems suggests that longer term interventions are likely to be moreeffective than brief or episodic episodicsporadic; occurring in episodes. e. falling a paroxymal disorder described in Cavalier King Charles spaniels in which affected dogs, starting at an early age, experience episodes of extensor rigidity, possibly brought on by stress. e. treatment (McConaughy, Kay, &Fitzgerald, 2000). In the studies reviewed, the intervention periodvaried widely, ranging from less than one month to 36 months.Forty-three percent (n=9) of the interventions fell within the one tofour month range (see Table 1). However, due to inconsistent reportingregarding the frequency and duration of intervention, we were unable tocapture a more complete picture of the duration of intervention efforts. Types of measures. In order to demonstrate that a treatment isefficacious for a particular problem, assessment needs to consist ofrigorously applied, reliable, and valid methods. That assessment mustfocus specifically on the presence of intervention components and laterchild outcomes. According to Bennett, Lipman, Racine, and Offord (1998),it should include assessment of 80% or more of the original subjectpopulation and rely on sound statistical analysis, as appropriate.Furthermore, multiple methods of assessment are preferable to singlemeasures, particularly if investigators use self-report (Bailey et al.,1998). Of the studies reviewed, 90% (n=19) used two or more data sourcesto assess treatment outcomes, with 43% (n=9) relying on three sources.Of the studies we reviewed, CPPRG (2002) reported data from fivesources, which exceeds the number of data sources reported by otherstudies included in this review. Although this study included data fromthe child, parent, teacher, peer, and official records, the researchersreported they were unable to collect direct observational data due totime and resource constraints (see Table 1). Treatment implementation. The actual implementation of theintervention plan poses challenges to researchers working in appliedsettings. Implementing multicomponent interventions further exacerbatesthe situation when it comes to recruitment and retention of participants(Hester & Kaiser, 1998; Ikeda, Simon, & Swahn, 2001), as well asmonitoring and maintaining treatment fidelity (Ikeda et al., 2001; Prinz& Miller, 1991). Not surprisingly, the majority of studies wereviewed contained problems in one or more of these areas. Fidelity refers to the demonstration that an experimentalmanipulation is conducted as planned, thereby insuring that each of itsintervention components is delivered in a comparable manner to allparticipants over time (Dumas, Lynch, Laughlin, Smith, & Prinz,2001). There is mounting recognition that fidelity of intervention isfundamental to the evaluation, comparison, and dissemination disseminationMedtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there ofeffective treatment (Dumas et al., 2001; Moncher & Prinz, 1991). Inlooking at the research results, readers seek assurance that the effectsof treatment (regardless of directionality) stem from the interventionrather than failure to deliver all components of an interventionaccording to the intervention protocol (content fidelity) or failure todeliver the intervention as designed throughout the intervention period(process fidelity). To assess treatment fidelity, investigators mightwrite intervention protocols, introduce content fidelity checklists thatalign with intervention components, and assure that intervention agentsare trained, supervised, and monitored to promote consistentimplementation of the intervention over time (Dumas et al., 2001). Ingroup design studies, outcomes of statistical analysis may becompromised by lack of adherence to protocol content and process (Dumaset al., 2001; Kazdin, 1986). Accordingly, it is incumbent on researchersto demonstrate to readers that their interventions were implemented withsatisfactory levels of fidelity. Unfortunately, we did not find this tobe the case. Of the studies reviewed, only 38% (n=8) reported content andprocess fidelity. The absence of treatment fidelity reports makes itextremely difficult to judge whether standardization in content orimplementation of an intervention was assessed or if this informationwas simply not reported. On the other hand, studies that do not addressadequately the fidelity with which the intervention was conducted cannotdetermine if a nonsignificant non��sig��nif��i��cant?adj.1. Not significant.2. Having, producing, or being a value obtained from a statistical test that lies within the limits for being of random occurrence. outcome is the result of an ineffectiveintervention or the result the failure to implement the intervention asit was intended. Social Validity. Parent satisfaction with child services is anessential component of program evaluation Program evaluation is a formalized approach to studying and assessing projects, policies and program and determining if they 'work'. Program evaluation is used in government and the private sector and it's taught in numerous universities. because parents typically rateservices for the child as their highest priority (Bailey et al., 1998).This information can provide insight into issues of participantattrition/retention, strategies for recruiting future participants,developing programs that more effectively meet participant needs(McNaughton, 1994), as well as informing policy makers and fundingagencies about the relationship between program effectiveness andconsumer satisfaction (Wolery, 1987). Nonetheless, only six (29%) of thestudies in our review mentioned assessment of social validity. Moreover,there are a number of methodological challenges in measuring parentsatisfaction. For example, little is known about the reliability andvalidity of the various instruments used to assess parent satisfaction,the manner in which participants are recruited to completequestionnaires, or the time frame in which the evaluations werecompleted (McNaughton, 1994). Longitudinal Assessment of Early Intervention In prevention/intervention research it is important to know whethervarious treatment effects differ over time and whether treatment has anenduring effect (Chambless & Hollon, 1998). By assessing childoutcomes longitudinally, we are able to contribute more substantially tothe prevention/intervention literature. In that long term assessment oftreatment effects pose special challenges to researchers (Tremblay etal., 1995), it is not surprising that the majority of studies with youngchildren had no follow up data (Kazdin, 1993). Available follow up dataare difficult to interpret in that researchers are unable to account forall intervening variables. Lack of participant retention over time alsolimits the validity of treatment effects. However, if participant lossis not random and those children at highest risk for behavior problemsare lost to follow up, any researcher estimates of predicative pred��i��cate?v. pred��i��cat��ed, pred��i��cat��ing, pred��i��catesv.tr.1. To base or establish (a statement or action, for example): I predicated my argument on the facts. accuracywill be biased (Bennett et al., 1998). Although studies have begun to incorporate follow up assessments,the majority (62%) of studies in this review contained only limitedfollow up data (less than one year). Nineteen percent of the studies hadno longitudinal assessment (n=4). Of those studies that included alongitudinal assessment, two reported on child outcomes five years postintervention (Ialongo, Poduska, Werthamer, & Kellam, 2001; Tremblayet al., 1995) and one 10 years post intervention (Eckenrode et al.,2001) (see Table 1). Discussion In the current review, we identified a number of issues critical tounderstanding the variation found within early intervention researchmethodology. The degree of variability in the methodology across studiesand the absence of detailed descriptions of procedures were particularlyevident in three domains: 1) participant selection criteria, 2)implementation issues In the Business world, companies frequently set-up a connection between which they transfer data. When the connection is being set-up, it is referred to as implementation. When issues occur during this phase, they are known as implementation issues. , and 3) treatment effects. Accordingly, we willfocus on those areas, as well as possible ways to strengthen ourcollective understanding of early intervention for the prevention ofemotional/behavioral disorders. Participant Selection Criteria As evidenced in our review, there is no standard definition and/orcriteria for identifying emotional/behavioral disorders, compounding thedifficulty in identifying children for inclusion in research studies.Further complicating com��pli��cate?tr. & intr.v. com��pli��cat��ed, com��pli��cat��ing, com��pli��cates1. To make or become complex or perplexing.2. To twist or become twisted together.adj.1. the situation is the wide variability in the typesof measures used by researchers to identify children in both theclinical and sub clinical range. Researchers used standardized measures(e.g. CBCL CBCL Child Behavior Checklist (psychology)CBCL Center for Biological and Computational Learning (Massachusetts Institute of Technology)CBCL Canadian Bonded Credits Limited (Toronto, Ontario), BASC BAScabbr.1. Bachelor of Agricultural Science2. Bachelor of Applied Science , SSRS SSRS SQL Server Reporting Services (Microsoft SQL Server 2005)SSRS Single State Registration SystemSSRS Social Skills Rating SystemSSRS SQL Server Resolution Service (Microsoft SQL Server 2000), and TOCA), subscales of standardized measures,and modified scales of standardized measures. Items included in theadaptations of standardized measures are seldom reported, resulting inreliability and validity issues which often are ignored but pose asignificant barrier to replicating research findings. To achievereliable, effective interventions, it is essential that we developstandardized terminology and measures in order to identify the targetpopulation precisely (August, Realmuto, Crosby, & MacDonald, 1995;Ayoub & Jacewitz, 1982). Along with importance of consistent terminology in establishing areliable target population, the issue of consistency regarding thesource of information used to identify the target population also is acritical factor in conducting high quality research. Even thoughresearch suggests strongly that parents and teachers do not identify thesame children as high risk (Kaiser, Cai, & Hancock, 2002; Offord etal., 1996), in our review studies continue to rely on informant accountsrather than direct observations to make these identifications. However,four studies in this review used direct observational measures inaddition to behavior reports from the parent, child, and teacher(Barkley et al., 2000; Braswell et al., 1997; Shelton et al., 2000;Webster-Stratton, 1997). While use of indirect assessment is moreefficient and cost effective, direct observation yields far morereliable information (Bailey et al., 1998) and should probably be themainstay of early intervention research. Another issue regarding early intervention research is apossibility of false positives among the pool of participants (August etal., 1995). Research suggests that behavior problems manifest in thepreschool years often persist over time (e.g., Campbell & Ewing,1990, Lober & Dishion, 1985), but this is not the case for allchildren with early problem behaviors. For example, Van Acker (2003)identifies two categories of aggressive children, those that manifestaggressive behavior in childhood and those that manifest aggressivebehavior in adolescence. It is those children with early onsetaggression that are likely to engage in aggressive behavior throughoutthe lifecourse. One might argue that prevention intervention effortsshould begin when early warning signs arise and target those childrenwho are more likely to display more aggressive behaviors throughouttheir lives. At the same time, we would seek to avoid inappropriatelyintervening with children who display a developmentally appropriatebehavior that is likely to diminish with time (Campbell, 1994; Walker,Colvin, & Ramsey, 1995). Despite the focus on early identification,the majority of studies (76%) in this review identified children onlyafter they entered elementary school. Implementation Issues Our review and the work of others support the proposition thatthere is increasing emphasis on multi dimensionalinterventions--interventions in multiple domains over time, as indicatedby the variation in intervention components included in this review:child/parent; child/teacher; teacher/parent; child/peer; as well ascombinations of three or even four of these partners. For example, fiveof the studies in this review intervened in two or more domains for twoor more years (August et al., 1995; Braswell et al., 1997; CPPRG, 2002;Kamps, Tankersley, & Ellis, 2000; Tremblay et al., 1995). On theother hand, it is the complexity of these interventions that makes itdifficult to identify the most salient aspects of a particularintervention. As interventions become increasingly complex and multidimensional,it becomes even more important to address the issue of treatmentfidelity. It is essential that all participants receive all componentsof the intervention protocol and that the protocol is delivered asprescribed in order to evaluate intervention efficacy appropriately.Readers often assume that interventions are implemented according toresearch protocols, but our review indicates that some researchersoffered reports of treatment fidelity, while others made no mention ofeither process or content fidelity. We acknowledge that spacelimitations in many journals often impact the length and complexity ofmanuscripts. It is possible that some authors were unable to provide thedetail needed to describe all aspects of an investigation due to issuesof space. On the other hand, it is possible that the absence oftreatment fidelity discussions reflects a deficiency in the researchdesigns to adhere to adhere toverb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful2. content and process protocols. Despite spacelimitations in journals, it is imperative that researchers report bothprocess and content fidelity as well as the procedures necessary foreffective and consistent implementation of treatment components (Dumaset al., 2001). Treatment Effects In that early intervention does not occur in a vacuum (Bailey etal., 1999), researchers have begun to focus on interactions of childbehavior with others (parents, teachers, peers) and the quality of theseinteractions across time. However, few studies have addressed thesupportive aspects of others in the maintenance and generalization gen��er��al��i��za��tionn.1. The act or an instance of generalizing.2. A principle, a statement, or an idea having general application. ofchild behavior (Bailey et al., 1999). The burden of interventioneffectiveness usually rests with the child; that is, the child behavioris the major focus of post intervention assessment. Absent are data onthe environmental context(s) and the individuals with whom the childinteracts and the intensity and quality of those interactions whenfollow up data are collected. Because of the multiple factors thatcontribute to emotional/behavioral disorders, if a child has support inone or more domains, he/she may be protected from some of that risk(Cole et al., 1993). Accumulated research indicates that responsiveness (Kaiser &Goetz, 1993), engagement (Hart, 2000), stability, and predictabilityprovide the foundation for a positive relationship between the child andothers (Bronfenbrenner & Morris, 1998). If teachers in preschoolsand childcare centers were trained to support child learning in theseways, a corridor for prevention intervention would be available for allchildren during their earliest school experiences. As Kauffman (1999)suggests, if early intervention is to be successful, it is imperativethat we provide young children at risk with environments that bothdirectly teach and actively support adaptive behaviors. Our reviewunderscores the need for multidimensional interventions, interventionswhich incorporate all characteristics of children at risk and themultiple settings in which they live and learn. Although directly teaching adaptive behaviors increases short termintervention efficacy, behavior rarely maintains without trainingparticipants for generalization across time and setting. Mostindividuals do not change their behavior without consistent feedback andsupport, yet it appears that researchers expect children withemotional/behavioral disorders to maintain treatment effects over timewithout continued, systematic support. Research suggests that treatmenteffects are more likely to be maintained if intervention is scheduled atregular intervals over time. These booster Booster - A data-parallel language."The Booster Language", E. Paalvast, TR PL 89-ITI-B-18, Inst voor Toegepaste Informatica TNO, Delft, 1989. sessions should be morefrequent immediately post intervention with a plan for systematicallyfading them as targeted behaviors are maintained at criterion levels forspecified periods of time. The booster sessions should be an integralpart of the post intervention protocol for all study participants-notjust the child participants (Gable gableTriangular section formed by a roof with two slopes, extending from the eaves to the ridge where the two slopes meet. It may be miniaturized over a dormer window or entranceway. , Hendrickson, & Van Acker, 2001;Kaiser & Hester, 1997). Our review raises questions regarding treatment effects and theirclinical or functional significance. While statistical significanceindicates a change or difference in groups that is mathematicallymeaningful, it may have little relevance unless the treatment effectsresult in a discernable reduction in problem behavior to an acceptablelevel (Chambless & Hollon, 1998). Assessing such clinicalsignificance also can be accomplished by establishing a normativecomparison group as a part of the research design. As we discussed, fewstudies have utilized both a normative comparison group and a controlgroup. The inclusion of the three groups would allow researchers tocompare the effects of the intervention to a similar population that didnot receive the intervention, as well as provide researchers with theability to compare the treatment progress to that of a normative group. Another factor that influences outcome data has little to do withthe effects of treatment, but rather with the source and continuity ofresearch funds. For example, obtaining grants for research requiresresearchers to develop innovative approaches to old problems, ratherthan conducting a replication of previous interventions, which wouldserve to strengthen our knowledge of effective intervention. Fundingagencies often have to make decisions that hinder the very research thatis needed to address the efficacy of early intervention for theprevention of emotional/behavioral disorders. Moreover, the length offollow up assessments (or lack thereof) usually is based on thelongevity of funding, rather than a researcher's commitment toassessing treatment effectiveness over time. Funding cycles range fromone to five years--limiting longitudinal assessments. If we are to makeadvances in the field, we need to examine carefully the effectiveness ofparticular intervention components and rigorously adhere to the slowmeticulous me��tic��u��lous?adj.1. Extremely careful and precise.2. Extremely or excessively concerned with details.[From Latin met method of systematic research (Sidman, 1960). That commitmentwill require slowly building a research base and identifying significantintervention components, careful adherence to content and processprotocol, precise measurement, direct/systematic replication of results,and discussion of results that were not significant, for it is oftenthrough our mistakes and failures that we can make the most advances.Funding agencies also must consider funding research over longer periodsof time, providing funding for replication studies and other researchthat addresses issues of standardization of criteria for researchparticipants, measures, fidelity, and longitudinal assessments. Limitations It is reasonable to indicate limitations of our research in orderto improve upon reviews of this nature in the future. First, inreviewing the terms used to identify studies in the initial literature,we acknowledge that the term "aggression" was not included asone of our keywords in the computerized bibliographic search. Asdiscussed previously, the issue of variability with regard toterminology is critical to identifying a target population. While thisis a limitation, it underscores the wide ranging criteria by whichparticipants are being identified. Additionally, our focus on journalarticles served to narrow the scope of our review, but reduced thecomprehensiveness perhaps necessary for a complete understanding.Finally, while we did explore the variation in assessment procedures andsources of information, we did not explore the variations with regard tothe type of measurements utilized. Conclusion While we acknowledge the aforementioned limitations, we alsorecognize the importance of this review. Much of the research onprevention/ intervention focuses on the efficacy and outcome ofintervention. However, as discussed in our review, it is extremelydifficult to compare intervention effects across studies without firstaddressing the variation found in research designs. Given the lack ofconsistency across these interventions, it is impossible to determinewhat variables, either singularly or in combination, will result in theamelioration a��me��lio��ra��tion?n.1. The act or an instance of ameliorating.2. The state of being ameliorated; improvement.Noun 1. of problem behavior in young, at risk children. In all, we feel that this review raises a number of questionsregarding research on early intervention. It causes us to reflect onthose aspects of empirical inquiry that tend to hinder the very work weseek to accomplish. In particular, benefits likely would accrue fromstandardization of participant selection criteria and measurement tools,use of protocols to assure fidelity, the direct assessment ofsignificant others with whom the child interacts over time, and a moreprecise explication ex��pli��cate?tr.v. ex��pli��cat��ed, ex��pli��cat��ing, ex��pli��catesTo make clear the meaning of; explain. See Synonyms at explain.[Latin explic of the research limitations. We trust that futureresearch will allow us to more precisely identify issues associated witheffective intervention and to determine which variables work bestsingularly or in a synergistic synergistic/syn��er��gis��tic/ (sin?er-jis��tik)1. acting together.2. enhancing the effect of another force or agent.syn��er��gis��ticadj.1. fashion to ameliorate a��mel��io��rate?tr. & intr.v. a��me��lio��rat��ed, a��me��lio��rat��ing, a��me��lio��ratesTo make or become better; improve. See Synonyms at improve.[Alteration of meliorate. risk factors inchildren.Table 1 Frequency and Percentage of Study CharacteristicsCharacteristic f(N=21) PExperimental Design Group Randomized 15 71 Nonrandomized 1 5 Universal 4 19 Single Subject 1 5Group Assignment Treatment vs. Control 12 57 Treatment vs. Normative 1 5 Both Normative and Control 4 19 Treatment Only 4 19Age of Child at Onset of Intervention Birth 1 5 1-4 years old 4 19 Kindergarten 5 24 Elementary School 7 33 Multiple Categories 4 19Length of Intervention 1 month 1 5 1-4 months 8 38 5-11 months 2 10 12-23 months 2 10 24-35 months 5 24 36 months 2 10 Unknown 1 5Intervention Components Child 3 14 Parent 5 24 Teacher 0 0 Child/ Parent 7 33 Child/ Teacher 1 5 Parent/ Teacher 1 5 Child/ Parent/ Teacher 4 19Data Source Direct Observation 2 10 Parent Report/ Teacher Report 1 5 Parent Report/ Direct Observation 2 10 Teacher Reports/ Direct Observation 2 10 Child Report/ Parent Report/ Teacher Report 2 10 Child Report/ Parent Report/ Direct Observation 1 5 Child Report/ Parent Report/ Official Record 1 5 Child Report/ Teacher Report/ Official Record 1 5 Parent Report/ Teacher Report/Direct Observation 4 19 Child Report/ Parent Report/ Teacher Report/ 4 19 Direct Observation Child Report/ Parent Report/ Teacher Report/ 1 1 Peer Rating/ Official RecordLength of Longitudinal Assessment No Post-treatment assessment 4 19 < 1 month 1 5 1-6 months 4 19 7-12 months 4 19 13-24 months 3 14 25-60 months 2 10 61-120 months 0 0 120 months 1 5 Ongoing 2 10Fidelity Assessment None 9 43 Content Only 3 14 Process Only 1 5 Both Content and Process 8 38Social Validity Assessment Consumer Satisfaction 6 29Clinical Significance 7 33 References Asher, S. 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Hendrickson University of Iowa Not to be confused with Iowa State University.The first faculty offered instruction at the University in March 1855 to students in the Old Mechanics Building, situated where Seashore Hall is now. In September 1855, the student body numbered 124, of which, 41 were women. Please address all correspondence to Peggy P. Hester, PhD.,Associate Professor, Child Study Center, Old Dominion University,Norfolk, VA 23529, phester@odu.edu.