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DOI: 10.1177/1534650109349293 2010 9: 28 originally published online 14 October 2009Clinical Case Studies

Raymond V. Burke, Brett R. Kuhn, Jane L. Peterson, Roger W. Peterson and Amy S. Badura BrackBehavior Problems

''Don't Kick Me Out!'': Day Treatment for Two Preschool Children With Severe

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“Don’t Kick Me Out!”: DayTreatment for Two PreschoolChildren With Severe Behavior

Problems

Raymond V. Burke,1,2 Brett R. Kuhn,3 Jane L. Peterson,1

Roger W. Peterson,1 and Amy S. Badura Brack 4

Abstract

Parents of young children with severe emotional and behavior problems have few services from

which to choose if their child is expelled from preschool for aggressive and disruptive behavior.Two case studies provide an overview of a multicomponent, intensive, day-treatment programfor children with moderate to severe behavior disorders. Proximal and distal program goals are

to eliminate presenting problem behaviors and increase social competencies and to reintegratechildren back to their school, preschool, or daycare, respectively. The cases presented in thisstudy provide preliminary evidence that day treatment can be a viable option for young children

with disruptive behavior disorders.

Keywordsbehavior disorders, day treatment, young children, behavior therapy

1 Theoretical and Research Basis

Recent estimates suggest that 10% to 20% of preschool children exhibit severe behavior prob-

lems that place them at risk for social and academic difficulty throughout their school years

(National Scientific Council on the Developing Child, 2008; Powell, Fixsen, & Dunlap, 2003).

These rates are consistent with previous reports that between 16% and 22% of children and ado-

lescents have mental disorders and emotional and behavioral problems (Costello et al., 1996;

Roberts, Attkisson, & Rosenblatt, 1998). Early onset behavior problems have resulted in anincreasing number of young children being “kicked out” of preschools. Nationally, the preschool

expulsion rate is more than three times the rate found among K-12 students (Gilliam, 2005) with

some individual states reporting preschool expulsion rates that are more than 13 times K-12 rates

(Gilliam & Shahar, 2006).

Without intervention, children’s behavior problems remain fairly stable over time or escalate

and increase the likelihood that as older students, they will require alternative educational place-

ment, special education services, or drop out of school altogether (Koertering & Braziel, 1999;

1Behave’n, Omaha, NE2University of Nebraska, Lincoln

3University of Nebraska Medical Center, Omaha, NE4Creighton University, Omaha, NE

Corresponding Author:

Raymond V. Burke, 8922 Cuming Street, Omaha, NE 68114

Email: [email protected]


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Burke et al. 29

Olsen & Hoza, 1993; Raver & Knitzer, 2002; Snyder, 2001). Children who receive special edu-

cation services, that is, identified as learning disabled or seriously emotionally disturbed, are

overrepresented among those expelled from school (Morrison & D’Incau, 1997).

To reduce expulsions and dropouts, prevention and intervention efforts must effectively

address children’s social behavior and academic deficits. Despite a number of well-documentedstudies of primary prevention school-based programs (see Berryhill & Prinz, 2003; Brock, Laza-

rus, & Jimerson, 2002), there are few published studies and no randomized controlled trials with

day treatment programs for young children with disruptive behavior disorders (Tse, 2006). How-

ever, a meta-analysis of published primary prevention programs for young children found that

behavioral and cognitive behavioral interventions were twice as effective as nonbehavioral inter-

ventions (Durlak & Wells, 1997).

Behavioral treatment program. Well-researched theories provide the basis for the program

described in this article. Traditional behavioral theories including operant conditioning (Skinner,

1953) and social learning theory (Bandura, 1969) are employed through the use of reinforcement

and a discipline hierarchy. The program focuses on building social competencies through a

combination of verbal reinforcement (Maag, 2001), modeling (Bandura & McDonald, 1963), problem solving and social skill instruction (Gresham, Sugai, & Horner, 2001), and a contin-

gency based point system (Axelrod, 1971; Christophersen, Arnold, Hill, & Quilitch, 1972; Wolf,

Giles, & Hall, 1968).

Positive reinforcement includes the use of tokens paired with verbal praise and social rein-

forcement (e.g., signs of affection such as a hug or high-five). Verbal praise is provided contingent

on children’s demonstration of prosocial behaviors and when they practice social skills related to

individualized treatment plan (ITP) goals. Initially, staff members use a fixed continuous rein-

forcement schedule for children’s newly developing skills and behavior. After skill competency

is demonstrated, reinforcement is faded using an intermittent schedule to enhance resistance to

extinction. Staff provides children with tokens throughout the day. The frequency with whichthis exchange occurs varies by child and is based on ITP goals, developmental level, and sched-

ule of reinforcement. Once a child earns the predetermined number of tokens, they can be

exchanged for activities (e.g., play with toys, a piggy back ride, special time with staff) and

prizes (e.g., stickers, Kazdin, 1977). Throughout the day, children also may exchange tokens to

purchase special trinkets (e.g., stickers, pencils, small toys, tops, hats).

Another theoretical foundation is social interactional theory (Patterson, Reid, & Dishion,

1992), emphasizing the influence of adult and peer interactions on children’s socialization and

establishing the basis for changing adults’ social interactions to influence children’s social

behavior. Social skill instruction for all children is a critical program component and begins with

skills of accepting negative and positive consequences and continues with teaching of adaptivereplacement skills. Additional skill instruction is based on skill deficits specified by the parent in

each child’s ITP. For example, a child with problems spitting and screaming when frustrated may

be taught how to calm herself, ask adults for help, or walk away from the problem. A child who

is aggressive and frequently hits children and staff may be taught how to ask other children for

toys, how to wait patiently (e.g., for toys or staff attention), and how to find toys with which no

one else is playing.

Negative consequences target problem behaviors and are integrated into the contingent use of

a four-level disciplinary response hierarchy (Larzelere & Kuhn, 2005) beginning with (a) a

verbal request to stop the inappropriate behavior, (b) use of a brief time-out (approximately 10

seconds where the child sits on floor and counts to 10), (c) use of a time-out chair at a distance

of 2′ to 5′ from the desired activity for approximately 10 seconds, and (d) use of a backup time-

out room with an open door for a maximum of 30 seconds (Peterson & Peterson, 2006). Time-out


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30 Clinical Case Studies 9(1)

procedures involve restricting access to positive reinforcement to reduce the likelihood that the

target behavior will be strengthened (Wolery, Bailey, & Sugai, 1988).

The purpose of this case study is to provide an overview of a multicomponent, intensive

day treatment program (Behave’n Day Center; BDC) for two children with moderate to

severe behavior disorders. We present two children’s cases and describe components of the program including staff training, treatment strategies, participant characteristics, parent

involvement, and outcome assessment. We chose a case study design because this report rep-

resents an initial evaluation of a previously untested intervention (Drotar, La Greca, Lemanek,

& Kazak, 1995).

2 Case Presentation

Liam (all names are pseudonyms). Liam is a 4-year-old Caucasian male who lived with his bio-

logical mother, an 8-year-old brother, a 6-year-old brother, and 15-month-old step-sister. Liam’s

biological father lives in another state; his involvement in Liam’s life is limited to sending a box

of clothes at unpredictable times once each year. Liam’s mother had a boyfriend who is father ofLiam’s step-sister. The boyfriend lived with the family until 2 months prior to Liam’s enrollment

in the day treatment program. The boyfriend was abusive to Liam’s mother on several occasions

before she decided to move the family back to her parents’ home.

Keisha. Keisha is a 4-year-old African American female who resided with her parents, new-

born sister, and grandmother. At admission, her father was unemployed and her mother was on

maternity leave. They had been living with the grandmother for approximately one year because

of financial strain.

3 Presenting complaintsLiam. Liam was described by his mother as aggressive, having language and developmental

delays, and unwilling to share with others. Liam’s mother reported that Liam’s 15-month-old

sister had language and compliance skills that surpassed Liam’s abilities. During the admission

interview Liam’s mother indicated that he kicked, hit, and bit his siblings on a daily basis and

aggressively spit food and drink “all day.” Liam’s mother unsuccessfully attempted to teach

Liam how to use sign language and the Picture Exchange Communication System (Bondy &

Frost, 2004) to communicate. Liam was not toilet trained prior to BDC enrollment.

Keisha. At admission, Keisha’s mother reported that Keisha consistently demonstrated

“aggressive and hyperactive behavior” such as hitting, biting, spitting, throwing objects, and

pinching her mother and peers in day care. The aggressive episodes occurred two to three timesdaily at day care and 6 to 10 times per evening at home. In addition, Keisha had one to three

tantrums per evening during which she threw herself face first on the floor or onto toys, and

kicked, screamed, and banged her head on the floor.

4 History

Liam. Prior to enrollment in BDC, Liam attended a local public school’s preschool for children

with developmental disabilities. His mother withdrew Liam from the preschool program after 6

months, citing a lack of improvement in behavior and vocabulary. Liam’s limited communica-

tion strategies included nonverbal (primarily waving and pointing) and verbal (one-word

utterances) attempts to get his needs met by those in his environment. When faced with unwanted

requests or correction, Liam intensely resisted complying by shouting and shaking his head “no,”

crossing his arms, stamping his feet, hitting, kicking, and biting those in his vicinity.




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Burke et al. 31

Keisha. Keisha had been expelled from five daycares for aggressive behavior toward class-

mates and staff prior to coming to the day treatment program. At home, Keisha’s mother reported

that Keisha yelled at her, refused to sit still, and hit other children in the neighborhood. During a

recent tantrum at home, Keisha broke the kitchen table by jumping from the kitchen counter onto

the table. Shortly after that tantrum, Keisha’s mother saw a television news report about the BDC program, contacted BDC, and enrolled Keisha in the program.

5 Assessment

Measurement of Progress

Data from parent-completed measures and staff observations of target behaviors are used to

evaluate interventions and monitor children’s progress on ITPs. BDC staff and parents also par-

ticipate in monthly reviews of children’s ITP goals, progress at home and at BDC, and the need

for additional target areas when specific ITP goals are met.

Parent-completed measures. Parents complete the Child Behavior Checklist (CBCL; Achen- bach, 1991a) prior to admission and at departure from BDC. The CBCL, the most widely used

measure of children and adolescents’ behavior problems, is available for children 1.5 to 5 years

(Achenbach & Rescorla, 2000). Two broadband scales related to internalizing and externalizing

behavior problems are included in an overall Total Problem score. T -scores of 60 to 63 for Inter-

nalizing, Externalizing, and Total Problem scales place a child in the borderline clinical range

while T -scores greater than 63 place the child in the clinical range (Achenbach, 1991a). The

CBCL has strong psychometric properties that have been well-established during more than 20

years of use in published studies (Achenbach, 1991b).

Staff observations. Children attending BDC work to improve one or two target behaviors at a

time. Baseline data are collected during the first day at BDC. Target behaviors and goals areoperationally defined, for example, when given an instruction, Edward will say “Okay” and

perform the task within 5 seconds 80% of the time. A primary staff person is assigned to each

child at enrollment. Once each week, each child’s primary staff records the estimated percentage

of time that the target behavior occurred based on the overall number of opportunities for occur-

rence of the target behavior during that week. The clinical therapist and supervisor meet weekly

to review the child’s progress.

Individualized treatment plan reviews. A review of children’s behavior and related goals occurs

during monthly 1-hour ITP meetings with a BDC therapist, a BDC supervisor, and a child’s

parent(s) or legal guardian. Participants discuss whether goals are met at home and at BDC, are

in need of revision, or require more time for treatment effects to occur.

6 Case Conceptualization

The individualized treatment plan. Within the first week after BDC enrollment, the BDC thera-

pist and parents meet to develop an ITP for each child. During the ITP meeting, the parent

identifies approximately five target areas for the child. Current behavior patterns related to each

target area are discussed, interventions for each target area are proposed, goal behaviors are

specified, and individuals responsible for implementing each intervention are identified. Center-

based interventions are implemented with one or two target behaviors at a time. Once the ITP is

established, BDC staff work with the parent(s) to develop competency with home-based inter-

vention strategies.

Liam. Liam’s speech and language patterns were consistent with those of a 16-month-old.

Liam’s admission mental status exam indicated a diagnosis of Mild Mental Retardation and




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Mixed Receptive-Expressive Language Disorder and an Axis I diagnosis of Oppositional Defi-

ant Disorder. His T -scores on the CBCL placed him in the borderline clinical range for the Total

and Internalizing broadband scales, as well as on the Withdrawn and Attention Problem sub-

scales. His CBCL T -score of 70 placed him in the clinical range on the Pervasive Developmental

Problems subscale (Table 1).

On the preadmission questionnaire, Liam’s mother identified his strengths as “fine motor

skills” and “likes to draw.” Liam’s weakness was “speech” and her target behavioral issues were

“compliance, spiting [sic].” During the initial ITP meeting, the BDC team, including Liam’smother, identified compliance with adult instructions and successfully completing time-outs as

primary target areas for Liam. Four additional target areas were identified at that meeting: “not

asking to go into the kitchen,” “temper tantrums,” “spitting food and drink,” and “taking things

from his sister.” While the focus was on encouraging prosocial behaviors, staff used the time-out

continuum to address misbehaviors related to the additional target areas.

Reinforcement of positive replacement behaviors included use of verbal praise, tokens, stars,

and high-fives for socially appropriate behaviors. Redirection included the use of brief time-outs

and full time-outs in an identified chair at BDC and in an identified time-out room at home. In

addition, BDC staff used positive practice to give Liam multiple opportunities to complete brief

and full time-outs. During practice, staff used sign language paired with verbal instructions toindicate that they were going to practice how to complete time-outs. Then, staff verbally reminded

Liam to sit quietly on the floor with his legs crossed and his hands in his lap for 3 seconds. Verbal

praise and stars were provided when Liam completed the practice to criteria. Additional practice

followed unsuccessful attempts.

Keisha. Keisha came to treatment with a diagnosis of Attention Deficit Hyperactivity Disor-

der (ADHD) for which she was prescribed Adderall. CBCL broadband scores for Internalizing,

Externalizing, and Total Problems were all in the clinical range at admission despite medication.

Aggressive Behavior, Attention Problems, Emotionally Reactive, and Anxious/Depressed syn-

drome scales on the CBCL also were in the clinical range at admission (Table 1).

Keisha’s services included 4 months of day treatment, 1 hour of family therapy per week, and

15 hours of parent education per month. Keisha’s mother and BDC staff initially identified three

ITP target areas of (a) listening (e.g., compliance with adult instructions), (b) attending the day

treatment center without complaining on the way, and (c) playing without hitting other children.

Table 1. Significant Changes in Child Behavior Checklist T -Scores

Liam Keisha

Pre Post Pre Post

Internalizing 63a 37 66b 45Emotionally reactive 67a 51

Anxious/depressed 69a 51

Withdrawn 67a 51

Externalizing 59 40 82b 52Attention problems 67a 50 73b 57Aggressive behavior 84b 51

Total 60a 41 77b 47Pervasive developmental problems 70b 51

a. Borderline clinical range.

b. Clinical range.




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Burke et al. 33

As Keisha made improvements in her initial target areas, her mother added two additional ITP

target areas (“following directions in public places” and “staying in bed all night”).The mother was encouraged to use the time-out hierarchy for misbehavior related to the target

areas (i.e., a verbal request to stop the behavior, a brief 10-second time-out, a brief 10-second

time-out in a chair, and time-out in a chair up to a maximum of 30 seconds). BDC staff encour-

aged the mother to use brief, one- to four-word corrective responses (up to one word per year of

life; Peterson & Peterson, 2006) when Keisha misbehaved to avoid lecturing and inadvertent

reinforcement of inappropriate behavior.

Day treatment center staff primarily focused on teaching Keisha to follow instructions. Base-

line data indicated that Keisha said “Okay” following an instruction on 10% of the occasions

while compliance with the instruction occurred 50% of the time. The treatment goal was for

Keisha to say “Okay” and follow the instruction 80% of the time. Contingent verbal praise, highfives, and stars that could be exchanged for desired activities and tangible rewards were used to

reinforce Keisha when she complied with instructions. Stars were provided for each behavior

rehearsal that Keisha completed, with up to 15 opportunities to practice each day. When instruc-

tions were not followed, staff used the continuum of time-out responses followed by the

opportunity to respond appropriately to the original instruction.

7 Course of Treatment and Assessment of Progress

Liam. During the 3 months that Liam was enrolled at BDC, he improved substantially in his two

primary target areas. During the first 4 weeks post-baseline, Liam completed time-outs and fol-lowed adult instructions, on average, 74% and 59% of the time, respectively. The average

percentage of completed time-outs and instructions increased to 100% and 74% during the final

4 weeks of his stay at BDC (Figure 1).

At program graduation, Liam’s Internalizing and Total Problem T -scores were in the normal

range as was his T -score for the Pervasive Developmental Problems (Table 1). His vocabulary

score had increased 34 points. At the conclusion of Liam’s treatment, his mother reported that he

was toilet trained, had only infrequent temper tantrums that were developmentally appropriate,

was eating and drinking without spitting, and played for extended periods without aggressive

behavior toward his siblings. Liam’s mother reported that he had increased his vocabulary and

his spontaneous use of sign language at home.

Keisha. Keisha’s mother indicated that Keisha met her goals for the target areas of not attend-

ing without complaining and playing without hitting peers by the end of the first month in the

BDC program. Compliance with instructions remained a target area while a target area of

0

25

50

75

100

Baseline 1 2 3 4 5 6 7 8 9 10 11 12 13

Week

P e

r c e n t

Completes T. O.

Follows instructions

Figure 1. Liam: Weekly progress with two target areas




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“following directions in public places” was added during the 1-month ITP meeting. After 2

months of attending the day treatment center, Keisha had met the “following directions in public places” goal; compliance with instructions remained a target area; and the goal of staying in bed

all night was added. While noting improvements with compliance during the third month of

treatment, this target area remained on the list during Keisha’s ITP review. Her mother indicated

that Keisha met the goal of “staying in bed all night” during that third month. No additional target

area was identified. By the end of the fourth month of treatment, Keisha’s mother indicated that

Keisha had reached all home ITP goals.

Keisha steadily improved on her primary treatment goal of following instructions. By the end

of the second month of treatment, Keisha was verbally responding with “Okay” and completion

of the instruction on 80% of the occasions at BDC. She maintained or exceeded that level

throughout the remaining 5 weeks for all but 1 week, when compliance dipped to 70% (Figure2). During the second month at BDC, Keisha’s parents, with approval of the physician, decided

to discontinue the Adderall. She continued her BDC placement medication-free until program

graduation.

Keisha’s post-CBCL T -scores on subscales and syndrome scales were in the normal range

(Table 1). At the start of the school year, Keisha was enrolled in a general education kindergarten

class at a neighborhood school.

8 Complicating Factors

In many communities, parents of young children with severe emotional and behavior problemshave few services from which to choose once their child is expelled from preschool for aggres-

sive and disruptive behavior (Powell et al., 2003). It is estimated that only one-third to one-half

of children identified with emotional and behavior disorders receive services (Kazdin, 1990;

U.S. Public Health Service, 2000) and those who do, receive low rates of service or only part of

their recommended level of service (Powell et al., 2003). Lack of services can result in a loss of

parent employment and increased financial stress, social and emotional isolation for parents and

children, and an increased risk for child physical abuse and neglect (Taylor-Richardson,

Heflinger, & Brown, 2006). Interventions are needed that help behaviorally challenged children

improve their social and academic skills in preparation for a successful transition to elementary

school (Eckert, McGoey, & DuPaul, 1996).

During the 2-years surrounding Liam and Keisha’s treatment, Behave’n’s central city pro-

gram served 174 children, ages 2 to 7 years, 73% of whom had a mental health diagnosis.

Thirty-four percent of referred children had prenatal exposure to alcohol, tobacco, or drugs; 76%

0

20

40

60

80

100

Baseline 1 2 3 4 5 6 7 8 9 10 11 12 13

Week

P e

r c e n t

Comply 2 secSay "Okay"

Figure 2. Keisha: Weekly progress with two target areas




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Burke et al. 35

of parents reported a family history of substance abuse. Thirty-five percent of children had a his-

tory of one or more types of maltreatment. Prior to BDC referral, more than half of the children

had participated in treatment with a psychiatrist (25%) or therapist (26%), 12% had multiple

home placements, and 9% had been prescribed psychotropic medication.

Despite complicating factors for Liam (i.e., unsuccessful history of interventions for com-munication and other developmental delays) and Keisha (i.e., inconsistency in living and school

arrangements, financial stress within the family, consistent history of previously uncontrolled

aggressive behaviors), their cases strongly suggest that day treatment is beneficial for young

children with disruptive behavior disorders.

9 Managed Care Considerations

Funding for BDC is provided by federal, state, local, and private sources. Seventy-seven percent

of referred children are funded from Medicaid (45%) or some combination of Medicaid and

Child Welfare (30%) or Medicaid and public school (2%) sources. The remaining children are

funded from sole sources such as a private payee (16%), Child Welfare (6%), and schools (1%).Although treatment is costly, especially for private payees, there are several factors that con-

tribute to the assessment of program costs and benefits including reduced costs for the treatment

of children in the educational or juvenile justice systems, reduced costs for social and mental

health services for the child and family, and increased parent earnings due, for example, to

improved workplace attendance (Small, Reynolds, O’Connor, & Cooney, 2005). Assessment of

long term benefits for the BDC program is difficult because we lack multiple years of follow-up

data on BDC participants. However, the large percentage of children whose parents reported reli-

able, meaningful improvements after placement and the follow-up reports from parents in the

two case studies suggest that immediate and long-term benefits may be expected. For the pur-

poses of this brief cost-benefits analysis, we compared program costs with locally availablealternative placements for children who have been expelled from preschool, school, and child

care programs.

The BDC day treatment and family therapy programs cost US$112.00 per child per day. The

majority of parents considering BDC enrollment has exhausted typical community resources for child

care and preschool. If their children were not enrolled in BDC, they would likely be placed with a

one-to-one para-educator in a preschool or elementary school classroom (an estimated US$143.00

per day) or enrolled in one of the local alternative schools (US$130.00 to US$230.00 per day).

The average length of treatment at BDC is slightly less than 57 days for an average cost of

US$6,384.00. The school-based alternatives to BDC involve services for the entire school year

with costs that range from US$23,400.00 (US$130.00 per day×

180 school days) to US$41,400.00(US$230.00 per day × 180 school days). The BDC program represents a potential annual savings

of US$17,016.00 to US$35,016 per child per school year or a return on every US$1.00 invested

of US$3.67 to US$6.48 per child (Small et al., 2005). While we do not have long-term results for

program graduates, if the current results are maintained over time, then the savings and return on

investment have the potential of increasing for each year that the child continues in school with-

out the need for additional services. This return on investment is conservative and does not

include a host of other possible benefits such as reductions in the need for social and mental

health services, juvenile justice services, and other remedial educational services.

10 Follow-UpLiam. Two years post departure, Liam was attending second grade in a general education public

school and, according to his mother, continued to make impressive gains in his ability to speak.




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He reportedly was using full sentences, asking questions, and playing well with his peers and

siblings.

Keisha. After 4.5 months at BDC, Keisha graduated and returned to a community day care

near her home. At one-year post-graduation, Keisha remained medication-free. Keisha’s mother

described her as “a typical child” and indicated that she was doing well in public school. Sheattended a general education classroom with no student support services in the classroom.

11 Treatment Implications of the Case

Students are expelled from school due to repeated or serious verbally or physically aggressive

behavior (Gilliam, 2005). These behavior problems are evident early in children’s lives. Without

effective intervention, these children are likely to experience academic deficits throughout their

school years (Reid, Gonzalez, Nordness, Trout, & Epstein, 2004) and are at risk for developing

antisocial patterns that persist into adulthood (Patterson et al., 1992). However, in most commu-

nities, there is limited access to and availability of these services (Powell et al., 2003). The BDC

program holds promise for addressing this shortage of community-based services.The Behave’n Day Center is an independently owned, for-profit, multicomponent day treat-

ment program designed to reduce childhood behavior problems and improve mental health and

academic success. The Behave’n Day Center is accredited by the Commission on Accreditation

of Rehabilitative Facilities—Day Treatment: Family Services (Children and Adolescents) and is

a state-licensed child care program for children, ages 2 to 13 years; however, services are pro-

vided for children ages 2 to 7 years. The BDC service components include family therapy and a

day treatment center with emphasis on three key program components: (a) behaviorally focused

interventions, (b) staff training and data driven implementation of the intervention, and (c) direct

training of parents in the intervention with the opportunity to practice learned skills in the child

care setting. Proximal and distal program goals are to eliminate presenting problem behaviorsand increase social competencies, and to reintegrate children back to their school, preschool, or

daycare, respectively.

Liam’s and Keisha’s cases, representative of typical improvements seen at BDC, suggest that

these goals are being met. An examination of program-wide results on the (CBCL; Achenbach,

1991a, 1991b) support results from the two case studies. Pre-post CBCL scores were available

for 105 of the 174 (60%) children enrolled in the BDC program during the 2 year period sur-

rounding Liam and Keisha’s time in treatment. BDC population mean scores at admission

indicated that enrolled children had T -scores in the borderline clinical range for Internalizing,

and in the clinical range for Externalizing and Total Problem scales (Table 2). Mean T -scores at

departure from the BDC program were in the normal range ( p<

. 01; Table 2). We used the Reli-able Change Index (RCI; Jacobson & Truax, 1991) as an indicator of clinically significant change

within the population. A change of 8 T -score points on the CBCL was used to indicate a meaning-

ful, reliable change on the CBCL (Thompson, Ruma, Brewster, Besetsney, & Burke, 1997) from

BDC program enrollment to departure. Approximately two-thirds of children had reliable change

on CBCL Internalizing (62%), Externalizing (70%), and Total Problem (69%) scales during their

stay at BDC (Table 2). This compares favorably with other studies that have used the RCI to

assess improvements. For example, 19% to 31% of parents who completed a parent training

program reported reliable improvements in child behavior and parents’ potential for child physi-

cal abuse (Thompson et al., 1997). Consistent with the majority of children completing BDC,

Liam and Keisha demonstrated reliable change on all CBCL broadband and subscale scores

(Table 1).

A limitation of the current BDC assessments is that no BDC assessors of intervention out-

come (e.g., staff and parents) are blind to the intervention. Findings would be stronger if some




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Burke et al. 37

outcome measures were completed by an informant not aware of treatment status, or greater

attention were paid to the reliability and training of staff observers of the child’s behavior while

at BDC, school, or home. In addition, results should be interpreted with caution given limited

long-term follow-up data.

12 Recommendations to Clinicians and Students

The current article summarizes two case studies and provides an initial description of a multi-

component, intensive day treatment program (Behave’n Day Center) for children with moderate

to severe behavior disorders. The pieces of the BDC puzzle are comprised primarily of widely

disseminated, validated intervention components (Powell, Dunlap, & Fox, 2006). However, the

entire puzzle paints a unique picture of a novel day treatment center that serves “at risk” children

and families by infusing behaviorally focused interventions, staff training and a data-driven

approach to implementing those interventions, and parent training in the use of interventions sothat the child can be reintegrated back into the home, school, or community daycare. Preliminary

outcome data suggest that the treatment center has been successful and highly sought after by

parents and referring professionals in the community.

While follow-up reports from parents indicated that both Liam and Keisha were successfully

enrolled in public elementary school or a neighborhood child care center, more rigorous evalua-

tion of those outcomes is necessary to assess the durability of BDC effects with all children

enrolled at BDC. A recent review of early intervention programs for preschool children with

ADHD found few published studies with this population (McGoey, Eckert, & DuPaul, 2002),

most of which were conducted in clinical settings and lacked assessment of generalizability in

preschool or day treatment programs. Our experiences support Tse’s (2006) recommendations to(a) increase utilization of evidence-based interventions in day treatment programs, (b) prevent

elementary school problems by improving access to services for young children with disruptive

behavior disorders, (c) emphasize social skills training to provide socialization opportunities that

many children are missing with their current experiences, and (d) engage parents and caretakers

when children enroll in day treatment programs so that treatment is optimized and benefits main-

tain at home and school over time.

The challenge for day treatment programs and similar services is to demonstrate program

fidelity and effectiveness within a service-oriented organization. Key aspects of the program

include behaviorally focused interventions offered through well-trained staff, data-driven imple-

mentation of interventions, and the direct training of parents in the interventions with an

opportunity to practice in the child care setting. A well-articulated program and close attention to

staff development and intervention implementation with parents and children appears to contrib-

ute to positive outcomes for children.

Table 2. Pre-post CBCL Subscale T -Scores and Percent Making Reliable Changea

Enrollment Departure Percent w/ Reliable Change

Internalizing 59.64b 50.40* 62%Externalizing 70.94c 57.40* 70%

Total problem 66.68c 54.57* 69%

CBCL = child behavior checklist.a. n = 105.b. Borderline clinical range.c. Clinical range.*p


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Declaration of Conflicting Interests

The first, third, and fourth authors are directly involved in the day treatment services described in this

manuscript. This could be perceived as a conflict of interest. The second and fifth authors are employed

full-time by universities not affiliated with the day treatment program.

Funding

The authors received no financial support for the research and/or authorship of this article.

Note

1. DSM-IV, 312.9 Disruptive Behavior Disorder-NOS, Disruptive Behavior Disorder NOS (not otherwise

specified) is utilized when there are conduct or oppositional-defiant behaviors that do not meet diag-

nostic criteria for conduct disorder or oppositional defiant disorder, but in which there is clinically sig-

nificant impairment. ( Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-IV;

American Psychiatric Association, 1994, p.103).

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Bios

Ray Burke, Ph.D., is Director of Community Services and Program Evaluation for Behave'n (a day treat-

ment and mental health clinic for young children with behavior disorders) and an adjunct faculty member

in the Department of Education and Human Sciences at the University of Nebraska, Lincoln with research

interests in behavior disorders, treatment fidelity, and resistance to behavior change.

Brett R. Kuhn, Ph.D. is a licensed psychologist and Associate Professor of Pediatrics at the University of

Nebraska Medical Center (UNMC). He has served as the Supervising Practitioner at Behave'n Day Center

since its inception. His clinical and research interests fall in the areas of children's behavioral health prob-

lems including sleep disorders, elimination problems, and challenging behavior.

Jane L. Peterson, Nebraska Licensed Mental Health Practitioner, is co-founder of Behave'n and has co-

authored children's books and books on parenting and family therapy. Her clinical interests include

replication of programs for young children with mental health disorders.

Roger W. Peterson, is co-founder of Behave'n, a Licensed Mental Health Practitioner, co-author of chil-

dren's and parenting books, and has worked with children and families for over 30 years. He is actively

involved in legislation and practices to improve access to mental health services for Nebraska's children and

families.

Amy Badura Brack, Ph.D., is an associate professor of psychology at Creighton University with clinical

research interests in stress reactions and behavioral disorders.

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