Development and testing of a stepped-care schoobased intervention trial for children with behavior problems

This randomized clinical trial will evaluate the efficacy and implementation in schools of a multi-modal stepped-care program targeting childhood behavior problems. An evidence based intervention for childhood behavior problems is not yet available for implementation at schools (Inventgroep, 2005) whereas schools offer a first choice environment with unique possibilities for intervention. Interventions applied at schools offer the possibility to directly address the context in which behavior problems are manifested. Furthermore, schools enlarge the accessibility to mental help for those children who would otherwise, due to cultural or social-economical factors, not be reached.

Children at risk for developing severe behavior problems are selected and invited to participate in a school-based group CBT training of which the efficacy will be evaluated. The teachers in 50% of the schools, based on random selection, will be offered additional teacher training. Parental informed consent will be obtained and parents will be regularly informed on the progress of their children. Parents of children who did not benefit sufficiently from the training are invited to participate in a supplementary parent-training.
Therapists will visit parents at home in order to enhance participation and treatment motivation as much as possible and in order to remove any possible treatment participation barriers for a difficult-to-reach population. Pre- post- and follow-up assessments will be conducted in order to evaluate the treatment efficacy of this multimodal stepped care intervention trajectory. All participants involved will be asked to participate in a study on treatment satisfaction.

Addittional training of teachers will result in greater effect-sizes for a school-based child intervention program for childhood behavior problems.
Assessment of stepped-care child, teacher and parent intervention.

The first assessment (T1) will take place at the start of the school year, the last assessment (T7) will take place one year after T1. The second assessment will be obtained approximate 2 to 4 weeks after T1. After T2 the treatment will start.

The child intervention includes 10 weekly sessions as well as 5 teacher sessions. Teacher sessions will run simultaneously with the child training.
Post-treatment assessment (T3) will be conducted to evaluate the outcome of the child intervention and the waitlist condition. Children in the waitlist condition will be offered the intervention after the waitlist period, the intervention will be followed by T4 assessment. After the post-treatment assessments (T3 and T4) it will be decided which children are in need of a second treatment step (parent-training). Pre- and posttreatment assessments (T5 and T6) will be conducted with those children in need of additional parent-training.

The social cognitive intervention program (T.G. Van Manen, 2001; T. G. Van Manen, Prins, & Emmelkamp, 2004) is a cognitive behavioral treatment and consists of four major components (a) social information processing, (b) problem solving abilities, (c) social cognitive skills, and (d) self-control skills (for a detailed description see Van Manen, 2001).

The treatment sessions follow the sequence of six steps in Dodge’s model on information processing (Dodge, 1993). The problem-solving skills and the social cognitive skills were integrated into the sequence of these six steps. For the behavioral enactment and evaluation steps of the model, three self-control components, i.e., self-observation, self-evaluation, and self-reinforcement, were then integrated. The therapists will use prompts, cognitive modeling (verbalizing the problem solving steps), roleplay, positive reinforcement, time-out procedure, and coaching using video feedback.



The active condition includes an additional teacher training program. The teacher training program will be developed according to cognitive behavioral intervention principles. In five individual sessions teachers will be trained to support their students with generalization of newly learned behavior to situations with class-room peers. For that purpose psycho-education on the child intervention program will be included as well as participation enhancement techniques (Nock, 2005).



Children who did not benefit sufficiently from the child or child + teacher training program will be offered a second treatment ‘step’; parent-training. Childhood behavior problems have been effectively treated with parent-training programs (Nock, 2003). Parent-training will furthermore include psycho-education on the child program and participation enhancement techniques (Nock, 2005).