Blyly-Strauss Drafttwo

Table of Contents
Abstract
Introduction
Literature Review
Early Childhood Mental Health
Prevalence Rates
Individual and Environmental Correlates
The First Year of Life
The Second Year of Life
The Third Year of Life
Individual and Environmental Interactions
Comorbidity
Short-Term Trajectories
Early Childhood Program Expulsion
Family Perspectives on Impact of Behavior-Related Childcare Problems
Early Intervention and Early Childhood Special Education
Prevalence of Developmental Delays
Factors Impacting Referral and Service Provision
Critique of the Literature
Intervention Models
Childrens Curricula
Teacher Consultation and Training
Parent Education
Multi-Modal Interventions
Trajectories and Impact of Challenging Behavior into the K-12 Years
Recommendations for Application
Discussion of Findings
Externalizing Behaviors
Internalizing Behaviors
Language, Self-Regulation, and Social-Emotional Development
Comorbidity
Intervention Models
Incredible Years and Dinosaur School
Programs Designed to Develop Childrens Self-Regulation Skills
Early Childhood Mental Health Consultation
Other Single-Mode Interventions
Multi-Modal Interventions
Trajectories and Impact of Challenging Behaviors into the K-12 Years
Recommendations
Interagency Collaborations
Dealing with Cultural Change
Fostering Trust and Stakeholder Buy-In
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Creating Alignment
Screening and Referral as a Community Affair
Expanding Access to Parenting Education and Supports
Providing Training and Support to Early Childhood Providers
Implementing Individualized Interventions
Program Assessment
Tier One
Important Questions
Evaluation Methodology
Tier Two
Important Questions
Tier Three
Important Questions
Tiers Four and Five
Conclusions
Suggested Areas for Future Research
Intervention Models
Trajectories and Impact of Challenging Behaviors into the K-12 Years
Potential for Cross-Thematic Research
References
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Running Head: EARLY CHILDHOOD MENTAL HEALTH OUTCOMES
Supporting Early Childhood Mental Health Outcomes:

Improving Behavioral Trajectories and Preventing Early Childhood Program Expulsion
Mina Blyly-Strauss
University of Minnesota
Abstract
This paper uses an interdisciplinary approach to explore the early roots, trajectories, and
impact of challenging behaviors in the early childhood period. It explores issues of identification
and intervention to promote healthy social-emotional and more broad developmental outcomes.
Studies were identified through use of key-word searches of internet databases. Selected studies
were presented as empirical research, primarily published in professional journals with a widerange of focichild development, early childhood education, special education, speech-language
science, childrens mental health, pediatric medicine, family studies, and public health. Study
samples were generally young children (birth through five years of age) and/or parents, teachers,
or other professionals working with young children. The racial and economic characteristics of
samples varied depending on the research questions and recruitment methods used.
Findings indicated a variety of individual and environmental characteristics present in the
first three years of life as influential in development of behavioral trajectories. Young children
with challenging behaviors have likely been under-identified for early intervention and early
childhood special education services, have been expelled from early childhood programming at
rates substantially higher than K-12 peers, and childcare-related employment problems have
adversely impacted their families. Although poor social-emotional and academic outcomes may
reach into the elementary school years, they need not do so. Multiple intervention models
targeting young childrens social-emotional and self-regulation skills have shown promise in
reducing challenging behaviors and increasing adaptive skills. Stacking interventions, especially
parent- and teacher-focused interventions, may bring the most significant degree of outcomes
benefit due to their broad impact on the ecological context young children live in.

The author recommends creation of an interagency collaborative across the city of
Minneapolis, Minnesota, to promote young childrens good mental health through prevention
and early intervention efforts at the onset of developmental trajectories. Universal
developmental screening, starting in infancy, is recommended along with universal access to
parenting education and professional development and early childhood mental health
consultation for early childhood providers. A shared resource library and coordinated referral
system for meeting additional family resource needs is also proposed to address the individual
nature of child, family, and professional contexts.

Introduction
This paper emerged as a follow-up to the authors earlier graduate work, Using Arts in
the Schools to Reach Students with Social/Emotional/Behavioral Concerns (Blyly-Strauss,
2008). This earlier work proposed arts content integration and arts therapy techniques be
incorporated into students K-12 school experience in a tiered manner, noting comorbidity
between social/emotional/behavioral problems and severe academic underachievement and
learning disabilities. K-12 students with social/emotional/behavioral problems were found to
have lower high school graduation rates than both the general education student population and
the special education student population as a whole and the arts were found to be one promising
method to engage struggling learners and help them constructively address underlying
social/emotional/behavioral concerns.
In retrospect and in consideration of more recent anecdotal experiences and training in
early childhood programs and development, the author noted that this previously proposed
intervention approach may often act in a reactionary manner because it fails to address the early
developmental roots of many social-emotional challenges as well as the earliest forms of school
failure that some young children and their families experience. The current paper sought to
improve on the prior work by examining these early roots and experiences of challenging
behaviors and proposing preventative and early intervention strategies to work on addressing
potential social-emotional problems and developmental delays at their initial stages in
development. It is hoped that with this approach adverse trajectories may be healthily altered
long before they pose a significant threat to formal academic achievement, high school
graduation, and related life-course outcomes.
This paper begins with a literature review that seeks to answer the following questions:
Where do challenging behaviors in early childhood populations come from and what are their
trajectories? How many children are being expelled from early childhood programming due to
challenging behaviors and what do these children (and their behaviors) look like? What impact
do these early removals from preschool and daycare programs have on the children and their
families? What role may early intervention and early childhood special education programming
currently play in addressing the developmental concerns that precede expulsion? And, what
types of interventions have been used to improve the social-emotional development of young
children?
The second part of the paper addresses application of research findings. First, a synthesis
of research findings is discussed, pulling out implications for work with young children, their
families, and early care providers in the authors home city of Minneapolis, Minnesota. Then,
recommendations are outlined for improving access to prevention and early intervention
programming for young children through use of citywide interagency collaborations to provide
universal early childhood screening and parent education programs, as well as improvements in
professional development and support for early childhood care providers. The paper concludes
with brief summative remarks and recommended directions for future research to build on the
existing professional literature base.
Literature Review
This literature review covers a broad base of research relating to the care of young
children with challenging behaviors with an eye towards factors that hold potential for
prevention and early intervention in the development of such behaviors. It begins with
exploration of early childhood mental healththe prevalence rates of disorders, factors
associated with their emergence over the first three years of life, and short-term trajectories for
early behavioral challenges. Next, an overview of the research base on young children with
challenging behaviors expulsion from early childhood care settings is presented. Third, it
considers parents perspectives on the interactions between their children with challenging
behaviors and the childcare and education systems and how these interactions impact their
families. Then it turns to a broader look at prevalence rates of developmental delays in young
children and service rates through formal early intervention and early childhood special
education programs. Fifth is an overview of curricular models that have been used to promote
self-regulation and social-emotional skills development in young children. The literature review
concludes with a look at trajectories of challenging behaviors into the elementary school years
and their impact on K-12 education.
The research base relating to young childrens mental health is very broad owing to
numerous decades of established history and multiple theoretical models of development. For
purposes of this paper, this research base has been broken down into four conceptual themes:
prevalence rates, individual and environmental correlates, comorbidity between disorders, and
short-term trajectories.
Prevalence rates. Studies have primarily considered prevalence rates of emotional and
behavioral disorders among preschool children. Such studies generally break down results in
terms of externalizing and internalizing disorders, as outlined below. It is important to note,
however, that investigation of infant and toddler samples (approximately birth through 36
months) have also revealed significant behavioral problems in this extremely young population.
Prevalence rates have been found to be 20.3% (Briggs-Gowan, Carter, Bosson-Heenan, Guyer,
& Horwitz, 2006) to 26% (Rose, Rose, & Feldman, 1989) for overall behavioral problems in
general populations under three-years-old. Although some may assume these high rates
represent normative toddler behavioral development that is transient, the relatively high rates of
persistence obtained in longitudinal study follow-up indicate otherwise (Briggs-Gowan et al.,
2006; Rose et al., 1989).
Prevalence rates for externalizing behavior disorders among young children in
community samples have ranged from 2.2% (Larson, Pless, & Miettinen, 1988) when
representative of the general population to 26.4% (Keenan, Shaw, Dellliquadri, Giovannelli, &
Walsh, 1998) for those considered at-risk (e.g., low-income inner-city contexts). This range
represents the extremes, with prevalence rates of 9.3% noted for community samples of infants
and toddlers (Briggs-Gowan, Carter, Skuban, & Horwitz, 2001) and approximately 20% for
toddlers and preschoolers attending childcare (Crowther, Bond, & Rolf, 1981). Substantially
higher ratesclose to 80% were found in a clinic-referred sample (Keenan & Wakschlag,
2000).
Prevalence rates for internalizing behavioral disorders among young children in
community samples have ranged from 2.5% (Larson et al., 1988) when representative of the
general population to 14.9% (Keenan et al., 1998) for those considered at-risk (e.g., low-income
inner-city contexts). These rates represent extremes, with rates for clinical levels of internalizing
behaviors in infants and toddlers at 6.7% (Briggs-Gowan et al., 2001) and toddlers and
preschoolers in daycares at approximately 6% (Crowther et al., 1981).
Subthreshold rateswhere preschool children exhibit many behavioral symptoms but fall
just short of meeting clinical diagnostic criteriaranged from 17.7% in a clinic-referred sample
(Keenan & Wakschlag, 2000) to 29.9% in a low-income community sample (Keenan et al.,
1998). Subthreshold rates for infant and toddler behavioral symptoms were found to be higher
(11.8%) than for those meeting clinical criteria (Briggs-Gowan et al., 2001).
Most studies used a combination of questionnaire, interview, and observation data
collection methods in laboratory (Keenan et al., 1998; Keenan & Wakschlag, 2000) and home
(Larson et al., 1988) settings, while others relied on record reviews and parent (Briggs-Gowan et
al., 2001; Briggs-Gowan et al., 2006) or teacher report measures (Crowther et al., 1981). Sample
sizes were 46 (Rose et al., 1989), 79 (Keenan & Wakschlag, 2000), 104 (Keenan et al., 1998),
558 (Crowther et al., 1981), 1280 (Briggs-Gowan et al., 2006), 1548 (Larson et al., 1988), and
1,788 (Briggs-Gowan et al., 2001). While some studies (Briggs-Gowan et al., 2001; BriggsGowan et al., 2006; Crowther et al., 1981; Larson et al., 1988) used relatively gender- and
income-balanced samples representative of the populations of focus, others used convenience
samples that were more heavily male and low-income (Keenan et al., 1998; Keenan and
Wakschlag, 2000). Keenan and Wakschlags (2000) sample was heavily African American
(80%+) with smaller percentages of Caucasian, Hispanic, and bi-racial participants. Rose et al.s
(1989) sample was 53% African American, 38% Hispanic, with the balance Caucasian or other
ethnicity. Three studies had samples that were approximately 60% Caucasian with the remainder
of participants being African American or other minority racial groups (Briggs-Gowan et al.,
2001; Briggs-Gowan et al., 2006; Keenan et al., 1998). Two of the studies (Keenan et al., 1998;
Larson et al., 1988) prospectively tracked participants from infancy.
Although these studies used a variety of both indirect and direct methodologies, the nonrepresentativeness of a few of the studies and smaller sample sizes make generalization difficult.
The wide spread in prevalence rates and fact that the studies are primarily over a decade old call
into question the validity and relevance to contemporary conditions without further replication of
findings. It appears that this topic of study is currently out of fashion as more recent research
tends to focus on general prevalence rates for early childhood delays, on specific factors related
to etiology of behavior disorders, and on longitudinal academic outcomes.
Individual and environmental correlates. Although the average age of onset for
clinically-significant behavioral disorders in children from low-income backgrounds has been
found to be between twenty-six and twenty-eight months of age (Keenan & Wakschlag, 2000),
there is strong indication that markers of risk are evident far earlier in a childs life.
The first year of life. Prospective longitudinal research has found neonatal correlates for
behavioral disorders present in preschool-age children. Internalizing disorders were correlated
with very early measures of home environment (Larson et al., 1988), Family SES (Robinson et
al., 2008), maternal behaviors (Larson et al., 1988), maternal reports of baby blues symptoms
(Robinson et al., 2008), maternal lack of social support and help (Larson et al., 1988), maternal
ill health (Larson et al., 1988), and the childs fathers presence at the delivery (Larson et al.,
1988). Externalizing disorders were correlated with low gestational age (Robinson et al., 2008),
very early measures of home environment (Larson et al., 1988), maternal behaviors (Larson et
al., 1988), maternal reports of baby blues symptoms (Robinson et al., 2008), maternal lack of
social support and help (Larson et al., 1988), maternal ill health (Larson et al., 1988), the fathers
limited caretaking role (Larson et al., 1988), and family SES (Larson et al., 1988; Robinson et
al., 2008). It is interesting to note that Robinson et al. (2008) found increased duration of breastfeeding acted as a protective factor against preschool mental health problems, while Larson et al.
(1988) looked at the same variable and found no such relationship.
Infant characteristics at three- to six-months have also been connected to development of
preschool internalizing and externalizing behavior problems (Garstein, Putnam, & Rotherbart,
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2012). Early measures of infant anger, sadness, fear, frustration, low reactivity, and poor
regulatory control were correlated with development of preschool internalizing behaviors. Early
measures of frustration, motor activation, low reactivity, and sadness were correlated with
development of preschool externalizing behaviors. Parental report of difficult temperament in
infancy predicted externalizing and internalizing symptoms in children up into the elementary
years (Campbell & Ewing, 1990).
Longitudinal research tracking children identified as regulatory disordered as eight- to
11-month-old infants has noted developmental differences at follow-up when the children were
four to four-and-a-half years old (Degangi, Porges, Sickel, & Greenspan, 1993; Dale, OHara,
Schein, Inserra, Keen, Flores, & Porges, 2011). In addition to being identified with regulatory
disorders, those infants who later developed the most severe behavioral problems also exhibited
elevated levels of cardiac vagal tone (Dale et al., 2011; Degangi et al., 1993). In comparison to
peers who did not exhibit early regulatory disorders, these preschoolers exhibited greater levels
of hyperactivity (Dale et al., 2011; Degangi et al., 1993), more attention-related problems (Dale
et al., 2011; Degangi et al., 1993), and a higher incidence of severe emotional and behavioral
difficulties (Dale et al., 2011; Degangi et al., 1993).
Of note, while Degangi et al. (1993) had an extremely high number of boys (8/9) in the
regulatory-disordered sample, Dale et al. (2011) had a far more gender-balanced (12 males, 11
females) sample of children with regulatory-disorders and found equitable gender balance in
those with the highest behavioral ratings. Dale et al. (2011) noted additional environmental
correlates to those preschoolers with the most severe behavioral problemsparents reported
significantly lower levels of family cohesion and participation in recreational activities. Degangi
et al. (1993) found that while high measures of difficult temperament was associated with better
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developmental outcomes for the control group, for those children identified as regulatory
disordered who also had high measures of difficult temperament the developmental outcomes
were much poorer than averageshowing a decreasing trend in cognitive abilities over time.
Studies with low-income samples have found strong correlations between insecure
attachments in infancy and preschool behavioral disorders (Erickson, Sroufe, & Egeland, 1985;
Shaw & Vondra, 1995). While Erickson et al. (1985) found distinct patterns of behavioral
problems at age-three depending on the sub-type of insecure attachment, Shaw and Vondra
(1995) found no such distinction. While infants who had insecure attachments to their mothers
were found to be significantly more likely than infants with secure attachments to develop
behavioral disorders by their preschool years, both studies identified environmental and maternal
mediators in intervening years that appeared to account for exceptions to this pattern which will
be discussed more thoroughly later in this literature review.
Study participants included representative birth cohorts (Larson et al., 1988; Robinson et
al., 2008) and community samples identified from newspaper birth announcements (Garstein et
al., 2012), recruited through advertisements (Dale et al., 2011; Degangi et al., 1993), and
recruited from local service provider offices (Erickson et al., 1985; Shaw & Vondra, 1995). All
studies took a prospective longitudinal approach, with measures collected in infancy and at
various intervals through the preschool years. A number of the community samples were largely
(Dale et al., 2011; Garstein et al., 2012; Robinson et al., 2008)and at times entirely (Degangi et
al., 1993)Caucasian and primarily middle class (Degangi et al., 1993; Garstein et al., 2012).
Others community samples were primarily low-income (Erickson et al., 1985; Shaw & Vondra,
1995) and 60-80% Caucasian with the balance being African American (Shaw & Vondra, 1995)
or a multi-racial mix of African American, Hispanic, Native American, and multi-racial
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(Erickson et al., 1985). Sample sizes were 22 (Degangi et al., 1993), 23 (Dale et al., 2011), 82
(Shaw & Vondra, 1995), 96 (Erickson et al., 1985), 317 (Garstein et al., 2012), 1548 (Larson et
al., 1988), and 2868 (Robinson et al., 2008). A majority of studies (Dale et al., 2011; Degangi et
al., 1993; Erickson et al., 1985; Larson et al., 1988; Shaw & Vondra, 1995) used multiple
methods of data collection that included interview, questionnaires, and direct infant testing
and/or observation. Robinson et al. (2008) relied on record reviews and parent-report measures
including questionnaires and interviews. Garstein et al. (2012) relied solely on parent-report
through a series of questionnaires.
Although the sample sizes are small, the convergence in some areas of Dale et al.s
(2011) and Degangi et al.s (2012) research across a decades time suggest that there may be
some stability and generalizability to middle-class Caucasian populations possible. Further
research with larger and more racially and economically diverse samples would be desirable to
further validate and extend findings in this area. Garstein et al.s (2012) study used a larger
sample size and though it considered a wider degree of early variables and different terminology
than Dale et al.s (2011) and Degangi et al.s (2012) research, some variables appeared to relate
to regulation and further support a case for a link between poor regulation in the first year of life
and later behavioral problems in young children. Replication of the research with larger and
more diverse samples could add generalizability potential to the findings on variables most
impactful on later social-emotional development.
The second year of life. Prospective longitudinal studies have found correlates to
significant externalizing behavioral challenges as early as fourteen to eighteen months of age,
including having a difficult temperament (Keenan et al., 1998), high levels of reactivity (Garstein
et al., 2012), negative emotionality (Garstein et al., 2012; Gillion & Shaw, 2004; Mathiesen,
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Sanson, Stoolmiller, & Karevold, 2009), low levels of effortful control (Garstein et al., 2012;
Willoughby, Kupersmidt, Voegler-Lee, & Bryant, 2011), high levels of aggressiveness (Keenan
et al., 1998), high levels of non-compliance (Keenan et al., 1998), high caregiver stress levels
(Larson et al., 1988), a parental sense of lack of support (Larson et al., 1988; Mathiesen et al.,
2009), and lack of father involvement (Keenan & Wakschlag, 2000; Larson et al., 1988).
Another environmental factor that some studies found significantly correlated to increased levels
of externalizing behaviors of preschoolers was young maternal age (Gillion & Shaw, 2004;
Keenan & Wakschlag, 2000), though this factor was not always found to have significant
correlation (Mathiesen et al., 2009). These early indicators appear to act as risk factors, with
studies often citing different combinations of factors in relation to preschoolers externalizing
behavior problems.
Internalizing disorders were found to have similarly early roots, with fourteen- to
eighteen-month correlates that included difficult temperament (Keenan et al., 1998), elevated
levels of non-compliance (Keenan et al., 1998), high levels of behavioral inhibition (Garstein et
al., 2012; Mathiesen et al., 2009; Williams et al., 2009), high parental stress level (Mathiesen et
al., 2009), and maternal depression (Mathiesen et al., 2009). Persistence of infants behavioral
problems into the preschool years has been associated with high measures of parental anxiety,
parental distress, and family life disruption during the second year of life (Briggs-Gowan et al.,
2006). These early indicators also appear to act as risk factors, with studies often citing a variety
of combinations of factors in relation to preschoolers internalizing behavior problems.
Recruitment methods for these studies included stratified random sampling (Willoughby
et al., 2011), targeted recruitment at specific places (e.g., WIC offices, clinics; Gilliom & Shaw,
2004; Keenan et al., 1998; Keenan & Wakschlag, 2000; Mathiesen et al., 2009), mailed
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recruitment from published birth announcements (Garstein et al., 2012; Williams et al., 2009),
and recruitment of a birth cohort (Briggs-Gowan et al., 2006; Larson et al., 1988). A majority of
studies used multiple methods of data collection, such as questionnaires, interviews, direct child
assessment, and/or coding from direct observation (Gilliom & Shaw, 2004; Keenan et al., 1998;
Keenan & Wakschlag, 2000; Larson et al., 1988; Williams et al., 2009; Willoughby et al., 2011).
Three studies relied on parent-report data obtained from multiple questionnaires (Briggs-Gowan
et al., 2006; Garstein et al., 2012; Mathiesen et al., 2009). Sample sizes were 79 (Keenan &
Wakschlag, 2000), 113 (Williams et al., 2009), 129 (Keenan et al., 1998), 303 (Gilliom & Shaw,
2004), 317 (Garstein et al., 2012), 926 (Willoughby et al., 2011), 939 (Mathiesen et al., 2009),
1280 (Briggs-Gowan et al., 2006zc), and 1548 (Larson et al., 1988).
While some samples were 80-100% Caucasian (Garstein et al., 2012; Mathiesen et al.,
2009; Williams et al., 2009), others had a more racially diverse sample including African
American (Briggs-Gowan et al., 2006; Gilliom & Shaw, 2004; Keenan et al., 1998; Keenan &
Wakschlag, 2000; Willoughby et al., 2011), Hispanic (Briggs-Gowan et al., 2006; Gilliom &
Shaw, 2004; Keenan & Wakschlag, 2000; Willoughby et al., 2011), Asian (Briggs-Gowan et al.,
2006), multi-racial (Briggs-Gowan et al., 2006; Gilliom & Shaw, 2004; Keenan & Wakschlag,
2000), and/or other (Willoughby et al., 2011) participants. One study reported using a
representative birth cohort sample from Montreal, though did not break down the specific racial
composition (Larson et al., 1988). While some studies had samples from a range of socioeconomic backgrounds (Briggs-Gowan et al., 2006; Larson et al., 1988; Mathiesen et al., 2009),
many had participants who were either primarily middle- to upper-class (Garstein et al., 2012;
Williams et al., 2009) or low-income (Gilliom & Shaw, 2004; Keenan et al., 1998; Keenan &
Wakschlag, 2000; Willoughby et al., 2011).
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That many studies used a combination of methods of data collection to corroborate

findings, had moderately-sized samples, and had some areas of convergence lends credence to
their findings. Because the studies tended to have samples that were either largely Caucasian
and middle- to upper-class or predominantly ethnic minority and lower-income and addressed
somewhat differentthough often relatedresearch questions while tracking differentlyconstructed variables, it would be desirable for future research to replicate findings using larger
and more broadly-representative samples.
The third year of life. There is indication that speech and language plays an important
role in the development of self-regulation in early childhood (Valloton & Ayoub, 2011; Winsler,
de Leon, Wallace, Carlton, & Willson-Quayle, 2003). Winsler et al. (2003) found that preschool
children whose private speech during problem solving tasks was largely unrelated to the task at
hand were rated by teachers as having poorer social skills and more behavior problems than their
peers with more task-relevant and/or internalized private speech. These children were also
observed to have a greater degree of negative affect and spend significantly less time engaging in
goal-directed activities than their peers. Children whose private speech was task-relevant,
though full-volume, were rated by parents as having lower social skills than children with more
internalized speech but they were also observed to display more positive affect.
Vallotton and Ayoub (2011) found that vocabulary level at twenty-four months had
significant effects on the trajectories of young childrens self-regulation development. For girls,
a larger vocabulary at twenty-four months predicted a higher degree of self-regulation at thirtysix months of age. For boys, a larger vocabulary at twenty-four months predicted a higher
growth rate of self-regulation skills through thirty-six months of age. Vocabularys impact on
self-regulation was noted to be more important for boys, as high vocabulary levels allowed boys
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levels of self-regulation to catch up with that of girls, while boys with low vocabulary levels had
self-regulation skills that remained substantially lower than both girls with low vocabularies and
male peers with higher vocabularies. This research is interesting to consider in relation to
research that investigates vocabulary exposure young children get at home. For example, Hart
and Risley (1992) found a five-fold difference in the number of vocabulary words parents
exposed infants and toddlers toranging from one-hundred to five-hundred unique words per
hour.
These studies used a combination of data collection methods that included observation
(Hart & Risley, 1992; Vallotton & Ayoub, 2011; Winsler et al., 2003), structured tasks
(Vallotton & Ayoub, 2011; Winsler et al., 2003), and completion of parent (Vallotton & Ayoub,
2011; Winsler et al., 2003) and teacher (Winsler et al., 2003) questionnaires. Sample sizes were
32 (Winsler et al., 2003), 40 (Hart & Risley, 1992), and 146 (Vallotton & Ayoub, 2011).
Caucasian children constituted sixty (Hart & Risley, 1992) to seventy-seven (Vallotton &
Ayoub, 2011) percent of the samples, with the remainder categorized as African American (Hart
& Risley, 1992; Vallotton & Ayoub, 2011; Winsler et al., 2003), Hispanic (Vallotton & Ayoub,
2011), Asian American (Winsler et al., 2003), and other (Vallotton & Ayoub, 2011).
Economically, the samples of two of the studies were relatively diverse (Hart & Risley, 1992;
Winsler et al., 2003) while one of the studies was focused on a low-income population (Vallotton
& Ayoub, 2011).
The use of multiple measures and relatively culturally- and economically-diverse samples
is promising. Direct consideration of the impact of different factors on young childrens selfregulation appears to be a relatively new field for research and this author would like to see
findings replicated with larger sample sizes in the future.
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Individual and environmental interactions. Interactions have been noted between

specific parenting actions, child characteristics, and development of challenging behaviors. For
example, Williams et al. (2009) found that permissive parenting of a child with high levels of
behavioral inhibition was strongly correlated with development of increased internalizing
behaviors and that authoritarian parenting of a child with an average score on behavioral
inhibition was correlated with a steeper decline in externalizing behaviors. Gilliom and Shaw
(2004) found that high levels of both child negative emotionality and fear, when combined with
high levels of negative maternal control, were associated with more severe behavioral
problemsthis impact of negative maternal control was not found with children who lacked
either of the two variables. These are notably correlational results to be considered within the
bidirectional context of parent-child relationships (Gillion & Shaw, 2004). Anthony, Anthony,
Glanville, Waanders, and Shaffer (2005) found that if parental stress is high and parents have
high expectations for their children, high levels of externalizing behaviors are seen in preschool
classroom settings.
Environmental risk factors have been found to further impact interactions between
parents actions and young childrens behaviors. OBrien Caughy, OCampo, and Muntaner
(2004) found that African American preschoolers whose parents denied racisms affect on those
close to them or on African Americans in general experienced significantly higher levels of
internalizing behavioral problems. Parents who actively responded to racism appeared to offer
their children protection from anxiety and depression when living in areas with high levels of
fear of victimization. Whitaker, Phillips, and Orzol (2006) found that three-year-old children
whose families were food-insecure were significantly more likely to have internalizing and
externalizing behavioral problems than their peers whose families were food secure. In this
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same study, food insecurity resulted in a more than doubling of the risk for severe internalizing
symptoms in mothers. There is also indication that preschool environments with high levels of
underactive behaviors (e.g., withdrawal, social reticence) are correlated with less growth in
school readiness and some developmental domains in comparison to classrooms with typical
levels of behaviors and those with high levels of overactive behaviors (e.g., aggression, defiance,
inattention; Bulotsky-Shearer et al., 2011).
Data collection methods included interviews (Gilliom & Shaw, 2004), parent (Anthony et
al., 2005; Gilliom & Shaw, 2004; OBrien et al., 2004; Whitaker et al., 2006; Williams et al.,
2009) and teacher (Anthony et al., 2005; Bulotsky-Shearer et al., 2011) questionnaires,
structured activities with the children (Gilliom & Shaw, 2004; Williams et al., 2009), observation
(Bulotsky-Shearer et al., 2011; Gilliom & Shaw, 2004), parent interview (Whitaker et al., 2006),
and review of existing records (e.g., crime report data, census data; OBrien et al., 2004).
Sample sizes ranged from 113 (Williams et al., 2009) to 3861 (Bulotsky-Shearer et al., 2011),
with the middle size ranges all falling between 200 and 303. Two of the studies (Anthony et al.,
2005; Bulotsky-Shearer et al., 2011) used predominantly African American samples from Head
Start centersone of these also included sample members from heavily Caucasian private
preschool settings (Anthony et al., 2005). Two of the other studies had samples that were
primarily African American of low-income (Gilliom & Shaw, 2004) or mixed-income (OBrien
et al., 2004) backgrounds, one had a sample that was predominantly middle- to upper-class
Caucasian (Williams et al., 2009), and another had a sample that was multi-racial and
economically diverse (Whitaker et al., 2006).
The racial split in these samples was striking to this author. With moderate to large
sample sizes currently showing significant effects, it would be interesting to see if findings
19
would be replicable with random community samples or whether the findings are more strongly
tied to unique variables present in the current sample populations.
Comorbidity. Comorbidity between Conduct Disorder (CD), Oppositional Defiance
Disorder (ODD), and Attention Deficit/Hyperactivity Disorder (AD/HD) was high in a clinicreferred sample (Keenan & Wakschlag, 2000). An early onset of approximately twenty-seven
months was noted for these disorders. Children with early emotional disorders appear at
increased risk of developing other comorbid disorders through the preschool and early school
years (Lavigne et al., 1998), with comorbid association between internalizing and externalizing
disorders noted from toddlerhood through the preschool years (Rose et al., 1989). Additionally,
at least Young children with comorbidity of significant internalizing, externalizing, and/or
regulation-related behavioral symptoms tended to have a higher rate of persistence of significant
behavioral challenges (Briggs-Gowan et al., 2006).
Young children with challenging behaviors have also been found to have comorbid
delays in play skills (Montes, Lotyczewski, Halterman, & Hightower, 2012), social relations
(Bulotsky-Shearer, Dominguez, & Bell, 2011), cognitive skills (Baker et al., 2003; BulotskyShearer et al., 2011; Montes et al., 2012), motor skills (Bulotsky-Shearer et al., 2011; Montes et
al., 2012), and speech/language development (Montes et al., 2012). Baker et al. (2003) found
that approximately 24% of 36-month-olds with developmental delays scored in the clinical range
on the Child Behavior Check List (CBCL), with high stability (70-73%) over a one-year period
and approximately 26% of the sample with developmental delays showing scoring in the clinical
range at 48-months of age. These rates of challenging behavior were significantly higher than
those of children in the sample who did not have developmental delays. In this study, a
seemingly bidirectional relationship between child behavioral problems and parental stress was
20
notedbehavior problems at 36-months and increases in preschool behavioral problems were

associated with increases in parental stress levels and parenting stress when a child was 36months-old and increases in parenting stress were associated with increases in child behavioral
problems at 48-months of age.
Developmental delays and challenging behaviors put these young children at risk for poor
classroom outcomes in preschool and kindergarten settings (Bulotsky-Shearer et al., 2011;
Montes et al., 2012). In one kindergarten-readiness study (Montes et al., 2012), children with
challenging behaviors were found to be fourteen times more likely to have an ADD or ADHD
diagnosis than their peers without behavioral problems. Nearly thirty percent of children with
challenging behaviors had received some form of early intervention, in comparison to
approximately six percent of the pre-kindergarten population without behavioral problems.
Researchers have also noted comorbidity between known communication delays and
disorders and social-emotional problems in toddlers (Baker & Cantwell, 1982; Carson, Klee,
Perry, Donaghy, & Muskina, 1997; Tervo, 2007), preschoolers (Baker & Cantwell, 1982; Cohen,
Davine, Horodezky, Lipsett, & Isaacson, 1993; Stevenson & Richman, 1978; Willinger et al.,
2003), older children (Baker & Cantwell, 1982; Cohen et al., 1993; Cohen et al., 1998), and
young adults (Beitchman et al., 2001). Social-emotional problems were noted for children with
expressive language disorders (e.g., Beitchman et al., 2001; Cohen et al., 1998; Willinger et al.,
2003), receptive language disorders (Cohen et al., 1993; Tervo, 2007), mixed expressivereceptive language disorders (Cohen et al., 1993; Tervo, 2007; Willinger et al., 2003), and mixed
speech-language disorders (Baker & Cantwell, 1982). Notably, only Baker and Cantwell (1982)
found serious social-emotional problems in children with solely speech disorders, though they
21
found incidence of psychiatric disorders in this population to be significantly lower than that
found in children with language disorders or speech-language disorders.
Individuals with communications delays and disorders had comorbid social skill deficits
(e.g., Cohen et al., 1998; Stevenson & Richman, 1978; Tervo, 2007), anxiety disorders (e.g.,
Baker & Cantwell, 1982; Beitchman et al., 2001; Carson et al., 1997), and social withdrawl (e.g.,
Baker & Cantwell, 1982; Cohen et al., 1993; Willinger et al., 2003). Attention problems (e.g.,
Cohen et al., 1998; Stevenson & Richman, 1978; Willinger et al., 2003), hyperactivity (Cohen et
al., 1993; Cohen et al., 1998, Stevenson & Richman, 1978), and thought problems (Willinger et
al., 2003) were also noted in a number of studies. Although sometimes reported in those with
solely expressive language disorders (Willinger et al., 2003), aggression and oppositional
behaviors were most notably present in those with receptive or mixed expressive-receptive
language disorders (Cohen et al., 1993; Tervo, 2007). Beitchman et al. (2001) also noted an
increased incidence of Antisocial Personality Disorder in males with language impairments. In
general, children with mixed expressive-receptive language disorders (Cohen et al., 1998; Tervo,
2007) and those with mixed speech-language disorders (Baker & Cantwell, 1982) faired the
worst developmentallyexhibiting elevated rates of both severe behavioral disorders and
developmental delays.
Sometimes social-emotional problems came to clinical attention more readily than
communication disorders (Cohen et al., 1993; Cohen et al., 1998). Cohen et al. (1993) found that
34.4% (99/228) of a psychiatric clinic-referred sample of four- to twelve-year-old children with
no previously identified language disorders met criteria for a language disorder by scoring 2 SD
below the mean on one area or 1SD below the mean on two areas using standardized language
tests. Children with unsuspected language disorders were more likely to have been referred for
22
externalizing behavior problems and to come from single-parent households than their peers with
known language disorders or with no language disorders. Cohen et al. (1998) found that 40.3%
(87/216) of a psychiatric clinic-referred sample of seven- to fourteen-year-old children with no
previously identified language disorders met criteria for a language disorder by scoring 2
standard deviations (SD) below the mean on one area or 1SD below the mean on two areas using
standardized language tests. Children with unsuspected language disorders were more likely to
have mothers with low educational levels than their peers with known language disorders or with
no language disorders.
Children with unsuspected language disorders showed similar deficit levels on measures
of social problem-solving and global developmental levels when compared to clinic-referred
peers without language disorders (Cohen et al., 1998). Measures of social competence (Cohen et
al., 1998), attention problems (Cohen et al., 1998), social withdrawl (Cohen et al., 1998), and
verbal IQ score (Cohen et al., 1993) placed children with unsuspected language impairments in
between children with known language impairmentswho generally had the most severe
symptomsand those with no language disorder.
These studies drew samples using random sampling (Beitchman et al., 2001; BriggsGowan et al., 2006; Montes et al., 2012; Stevenson & Richman, 1978), targeted recruitment at
local venues (e.g., community service agencies, daycares, WIC offices; Baker et al., 2003;
Keenen et al., 1998), recruitment from birth records (Carson et al., 1997), and convenience
samples (e.g., Head Start, clinics; Baker & Cantwell, 1982; Bulotsky-Shearer et al., 2011; Cohen
et al., 1998; Cohen et al., 1993; Lavigne et al., 1998; Tervo, 2007; Willinger et al., 2003).
Sample sizes fell into the following categories: 46-118 (Carson et al., 1997; Keenen et al., 1998;
Rose et al., 1989; Tervo, 2007; Willinger et al., 2003), 205-510 (Baker & Cantwell, 1982; Baker
23
et al., 2003; Beitchman et al., 2001; Cohen et al., 1998; Cohen et al., 1993; Lavigne et al., 1998),
and 705-3861 (Briggs-Gowan et al., 2006; Bulotsky-Shearer et al., 2011; Montes et al., 2012;
Stevenson & Richman, 1978). Racial data, when provided, indicated samples that included
Caucasian (Briggs-Gowan et al., 2006; Bulotsky-Shearer et al., 2011; Keenen et al., 1998;
Lavigne et al., 1998; Montes et al., 2012; Rose et al., 1989; Tervo, 2007), African American
(Briggs-Gowan et al., 2006; Bulotsky-Shearer et al., 2011; Keenen et al., 1998; Lavigne et al.,
1998; Montes et al., 2012; Rose et al., 1989), Latino or Hispanic (Briggs-Gowan et al., 2006;
Bulotsky-Shearer et al., 2011; Lavigne et al., 1998; Montes et al., 2012; Rose et al., 1989), Asian
(Briggs-Gowan et al., 2006; Bulotsky-Shearer et al., 2011), multiethnic (Briggs-Gowan et al.,
2006), and/or other (Bulotsky-Shearer et al., 2011; Montes et al., 2012; Rose et al., 1989;
Tervo, 2007). One study noted that 61% of the sample was Caucasian, but gave no racial
breakdown of the other 39% (Baker et al., 2003). One study noted a small percentage of
bilingual children in the sample (Baker & Cantwell, 1982). Many samples represented a mix of
income levels (Baker & Cantwell, 1982; Baker et al., 2003; Beitchman et al., 2001; BriggsGowan et al., 2006; Cohen et al., 1998; Cohen et al., 1993; Montes et al., 2012; Stevenson &
Richman, 1978), while others drew from primarily low-income (Bulotsky-Shearer et al., 2011;
Keenen et al., 1998; Lavigne et al., 1998; Rose et al., 1989) or middle-income populations
(Carson et al., 1997; Tervo, 2007).
There appear to be a number of areas of convergence relating to what types of
communication disorders and social-emotional problems are most likely to be found together and
areas of likely impact from their comorbidity. The use of moderate to large sample sizes,
representing a variety of racial and economic backgrounds, lends credence to these studies
findings.
24
Short-term trajectories. The behavioral trajectory a majority of young children follow

is for externalizing behaviors (e.g., aggression, defiance, hyperactivity) to decrease from
toddlerhood through the preschool years while internalizing behaviors (e.g., anxiousness,
depression) become more common (Gilliom & Shaw, 2004; Mathiesen et al., 2009; Williams et
al., 2009). Not all young children, however, follow this trajectory so researchers have sought to
define less common social-emotional trajectories and the correlates associated with them.
Children with significant challenging behaviors early on often experience persisting
emotional and/or behavioral disorders throughout the early childhood years. Young children
with externalizing behavioral disorders (Campbell & Ewing, 1990; Fischer, Rolf, Hasazi, &
Cummings, 1984; Rose et al., 1989) and those with comorbid disorders (Briggs-Gowan et al.,
2006) are especially likely to have significant behavioral symptoms that persist. Persistence
rates were similar across genders (Briggs-Gowan et al., 2006; Fischer et al., 1984), and older
children (4- or 5-years-old initially) had higher rates of persistence than their younger peers (ages
2- or 3-years old initially; Lavigne et al., 1998). There was a trend towards young children with
externalizing disorders later developing internalizing disorders (Lavigne et al., 1998; Rose et al.,
1989), although this was not a universal finding (Fischer et al., 1984). Persistence of serious
behavioral challenges was greatest for those preschoolers whose parents experienced distress,
anxiety, and disruption of family life (Briggs-Gowan et al., 2006; Rose et al., 1989).
Gilliom and Shaw (2004) found that at-risk boys who were both low in fearfulness and
high in negative emotionality, when combined with high levels of negative maternal control,
started out with high levels of externalizing behaviors and did not decrease in the number and
intensity of externalizing behaviors from ages two- to six-years. Children who were both low in
fearfulness and low in negative emotionality, when combined with high levels of negative
25
maternal control, also exhibited a high stable pattern of externalizing behaviors from ages twoto six-years. Children who scored high in both negative emotionality and fearfulness, when
combined with high levels of negative maternal control, started out with the highest levels of
internalizing behaviors at age two and maintained the highest levels of internalizing behaviors
through age six. Children who scored high in negative emotionality and high in fearfulness,
when combined with low levels of negative maternal control, started out with moderate levels of
internalizing behaviors at age two but then had a much steeper increase in internalizing behaviors
through age six.
Mathiesen et al. (2009) found that high levels of negative emotionality in a child, when
paired with low levels of partner support for the parent, predicted a higher slope for externalizing
behaviors between the age of eighteen-months through four-and-a-half years. Increasing levels
of family stress, emotionality, and shyness from age eighteen-months through four-and-a-half
years predicted increases in internalizing behaviors above and beyond the typical increases in
these behaviors over that time-span. Increased levels of maternal depression during the toddler
period (from eighteen-months to two-and-a-half years) also predicted increases in internalizing
behaviors at four-and-a-half years that were beyond the typical increases for that time period. Of
interest to note, while Gilliom and Shaw (2004) found high initial levels of externalizing
behaviors associated with sharp increases in internalizing behaviors over time, Mathiesen et al.
(2009) found no such relationship.
While there has been a significant correlation found between attachment status in infancy
and social-emotional adjustment in the preschool years, environmental mediators across time
have been indicated in divergence from expected trajectories (Erickson et al., 1985; Shaw &
Vondra, 1995). Children who had secure attachments in infancy but demonstrated significant
26
problem behaviors in preschool had mothers who were less warm and encouraging of their
childrens engagement in problem-solving tasks at 24 months, did not provide age-appropriate
play materials at home at 30 months, were less structured and encouraging of their childrens
engagement in educational tasks at 42 months, and did not set firm and consistent limits when
their preschooler deviated from the assigned task (Erickson et al., 1985). Children who had
insecure attachments in infancy but typical behavioral patterns in preschool had mothers who
provided age-appropriate play materials at home at 30 months and were more warm and
supportive of their childrens engagement in educational tasks at 42 months. These mothers also
reported having higher levels of emotional support from family and friends and living with the
same man from the time their child was 18-months old through their fourth birthday.
Shaw and Vondra (1995) found gender differences in the impact of environmental
mediators and correlations with changes in attachment status and behavioral problems. Rating of
maternal depression at twelve months was significantly related to girls attachment status at 18
months, with a similar (though non-significant) trend for boys. From infancy through threeyears of age, ratings of maternal depression were significantly correlated with boys level of
externalizing behavioral problems. For girls, on the other hand, ratings of child temperament at
one- and two-years of age were more predictive of internalizing and externalizing behavioral
problems at age three.
Many of the studies used a combination of data collection methods (e.g., structured
interviews, questionnaires, structured activities in the laboratory; Campbell & Ewing, 1990;
Erickson et al., 1985; Gilliom & Shaw, 2004; Lavigne et al., 1998; Rose et al., 1989; Shaw &
Vondra, 1995; Williams et al., 2009) while others relied on an assortment of questionnaires alone
(Briggs-Gowan et al., 2006; Fischer et al., 1984; Mathiesen et al., 2009). Sample sizes fell into
27
the following categories: 46 to 113 (Campbell & Ewing, 1990; Rose et al., 1989; Shaw &
Vondra, 1995; Williams et al., 2009), 267 to 310 (Erickson et al., 1985; Gilliom & Shaw, 2004),
510 to 541 (Fischer et al., 1984; Lavigne et al., 1998), and 939 to 1280 (Briggs-Gowan et al.,
2006; Mathiesen et al., 2009). Two of the studies had 95+% Caucasian samples (Mathiesen et
al., 2009; Williams et al., 2009) while others (Briggs-Gowan et al., 2006; Erickson et al., 1985;
Gilliom & Shaw, 2004; Lavigne et al., 1998; Rose et al., 1989; Shaw & Vondra, 1995) had more
racially-diverse samples. While some samples represented diverse socio-economic backgrounds
(Briggs-Gowan et al., 2006; Mathiesen et al, 2009), other studies had samples comprised of those
who were primarily middle- to upper-class (Williams et al., 2009) or low-income (Erickson et
al., 1985; Gilliom & Shaw, 2004; Lavigne et al., 1998; Rose et al., 1989; Shaw & Vondra, 1995).
While these trends and accompanying correlates are interesting to note, the differences in
research questions and variables assessed make them difficult to compare. Additionally, the
division of most studies across racial and economic lines calls into question the generalizability
of findings across a broad population. Further research to replicate findings with more diverse
samples would be desirable.
Survey studies have provided insights on preschool and daycare expulsion at county
(Greenberg & Ash, 2011), state (Buck & Ambrosino, 2004; Gilliam & Shahar, 2006; Hoover,
Kubicek, Rosenberg, Zundel, & Rosenberg, 2012) and national (Gilliam, 2005) levels within the
United States. These studies have all limited their focus to the preceding 12-month periods and
to expulsions reported by providers to be directly related to young childrens challenging
behaviors. This is important to note because parent report (Montes & Halterman, 2011) has
placed behavior problems as second to serious chronic health conditions in reasons given for
28
child care expulsionsthese studies, therefore, may underestimate the number of early
childhood program expulsions taking place in the United States.
All studies found expulsion rates that were substantially higher than comparable K-12
expulsion rates in the same geographical areas. On local and state levels, preschool and daycare
expulsion rates were found to range from 4.5 per 1000 young children (Greenberg & Ash, 2011)
to 27.42 per 1000 young children (Gilliam & Shahar, 2006), in comparison to K-12 expulsion
rates that all fell between 1.0 and 2.9 per 1000 pupils. Gilliam (2005) found the national average
for state-funded preschool programs to be 6.67 per 1000 young children, in comparison to a
national K-12 expulsion rate of 2.09 per 1000 pupils. In this national study, individual states
expulsion rates ranged from 0 per 1000 young children (Kentucky) to 24.31 per 1000 young
children (New Mexico), with Minnesotas Head Start programs at 4.16 per 1000 young children
and school readiness programs at 2.92 per 1000 young children (in comparison to a state-wide K12 expulsion rate of 0.76 per 1000 pupils).
Studies found higher levels of expulsions from home daycares (Greenberg & Ash, 2011;
Hoover et al., 2012) and private/for-profit preschool programs (Gilliam, 2005; Greenberg & Ash,
2011) when compared to publicly-funded programs, and there was indication that individual
providers who had considered expelling or expelled a child in the past were more likely to do so
again in the future (Gilliam & Shahar, 2006; Greenberg & Ash, 2011). Boys were significantly
more likely to be expelled than girls and children of color were more likely to be expelled than
their non-Hispanic Caucasian peers (Gilliam, 2005; Greenberg & Ash, 2011). On a more upbeat
note, researchers also found that lower levels of expulsions occurred when access to mental
health consultation was available (Gilliam, 2005; Greenberg & Ash, 2011; Hoover et al., 2012)
and that early care providers were interested in information and/or training opportunities for how
29
to better work with children with challenging behaviors (Buck & Ambrosino, 2004; Hoover et
al., 2012).
Some areas of inconsistency between study findings also emerged. For example, Gilliam
and Shahar (2006) found no significant difference in expulsion rates between providers with
differing levels of education, Greenberg and Ash (2011) found that providers with associates or
masters degrees had significantly higher expulsion rates than those with high school education or
bachelors degrees, and Hoover et al. (2012) found that home daycare providers with masters
degrees were significantly less likely to expel than other home daycare providers but when
looking at center-based care situations there was no significant difference in expulsion rates
linked to provider education levels. The impact of a providers years of experience also had
differential findings among the studiesGreenberg and Ash (2011) found no correlation between
years of experience and likelihood to expel while Hoover et al. (2012) found that home daycare
providers with fewer than six years of experience were significantly more likely to expel than
those with six or more years of experience.
Challenging behaviors noted of most concern to early childhood providers included
hurting self or others (Buck & Ambrosino, 2004; Greenberg & Ash, 2011; Hoover et al., 2012),
disrespectful/defiant (Buck & Ambrosino, 2004; Hoover et al., 2012), yelling/screaming
(Greenberg & Ash, 2011), destroying or damaging property (Greenberg & Ash, 2011; Hoover et
al., 2012), sad/unhappy/depressed (Hoover et al., 2012), inhibited/withdrawn (Hoover et al.,
2012), and acting out in non-aggressive ways (Buck & Ambrosino, 2004). Such behaviors
were reported to occur at a much higher frequency than expulsions, with these behaviors most
commonly reported in center-contexts with a high percentage of children receiving childcare
subsidies (Buck & Ambrosino, 2004) and in home daycare settings (Greenberg & Ash, 2011;
30
Hoover et al., 2012). On average, providers reported that approximately 11% of young children
in their care exhibited challenging behaviors over the past twelve months (Greenberg & Ash,
2011; Hoover et al., 2012). Researchers noted that the strategies reported for addressing these
challenging behaviors were generally reactionary (Buck & Ambrosino, 2004; Greenberg & Ash,
2011; Hoover et al., 2012)e.g., talking to the child, redirecting, giving a time-out, and
talking to the parent(s).
Response rates and sample sizes for these surveys varied17% (1,075) for Hoover et al.
(2012), 36% (60) for Buck and Ambrosino (2004), 42.2% (114) for Greenberg and Ash (2011),
64.32% (119) for Gilliam and Shahar (2006), and 81% (3,898) for Gilliam (2005). Gilliam
(2005) utilized telephone survey methodology; the other studies all used mail-in surveys and
noted that for that method their response rates fell within a range considered acceptable.
Common practice was to either mail surveys to all licensed programs meeting inclusion criteria
or to construct a random sample generated from all licensed programs meeting inclusion criteria
(e.g., home day care, Head Start, for-profit child care center, etc.). It was also noted that while
some surveys (Gilliam, 2005; Gilliam & Shahar, 2006) were expressly targeted to lead
teachers, others (Buck & Ambrosino, 2004; Greenberg & Ash, 2011; Hoover et al., 2012) were
mailed out to administrators or lead contacts listed in the records so may have been filled out by
people who did not have full direct knowledge of the level and types of challenging behaviors
that present themselves in daily classroom settings.
Gilliam (2005)owing to its large sample size, high response rates, broad national
sampling, and responses that came directly from lead teachersis the best guidepost to look at
when considering the state of preschool and daycare expulsion in the United States. That this
study has some findings that correlate with other studies indicates that there are some factors that
31
may increase or decrease the likelihood for preschool or daycare expulsions to take place. The
high level of convergence among studies that indicate substantially higher rates of expulsion in
these settings when compared to local K-12 systems indicates that there may be a mismatch
between some young childrens social-emotional needs and the resources of their care providers
which is not as evident in educational settings for older children.
Family Perspectives on Impact of Behavior-Related Child Care Problems
Many family impact studies related to childcare problems and children with challenging
behaviors and/or developmental disabilities consider a broad span from the early childhood
period through the K-12 years (Freedman, Litchfield, & Erickson Warfield, 1995; Montes &
Halterman, 2008; Montes & Halterman, 2011; Rosenzweig, Brennan, & Ogilvie, 2002), while
others focus more exclusively on the early childhood period (Rosenzweig, Brennan, Huffstutter,
& Bradley, 2008; Worcester, Nesman, Mendez, & Keller, 2008). Primary caregivers of children
with challenging behaviors report childcare-related employment problems at a rate two to three
times higher than primary caregivers of children without challenging behaviors (Montes &
Halterman, 2008; Montes & Halterman, 2011). There was indication that a majority of children
with challenging behaviors were not currently being cared for in childcare settings (Rosenzweig
et al., 2002; Rosenzweig et al., 2008). While some primary caregivers reported that their child
was asked to leave their childcare setting (Worcester et al., 2008), others reported withdrawing
their child from a childcare setting because they were afraid that their child would be asked to
leave (Rosenzweig et al., 2002).
Primary sources of preschool- and school-age care for these families were public special
education programs (Freedman et al., 1995; Montes & Halterman, 2008; Rosenzweig et al.,
2002) and Head Start (Montes & Halterman, 2008). While school-based programs provided a
32
substantial amount of care to children, some primary caregivers reported a great deal of stress
from this carefor example, feeling that they needed to fight for appropriate services, that
school personnel did not know how to deal with their childs behavior, and that the school called
them about every little incidentwhich increased employment challenges (Rosenzweig et al.,
2002; Worcester et al., 2008). Other primary caregivers reported more positive experiences with
their early intervention and school-based providers (Worcester et al., 2008). Outside of school,
primary caregivers relied on a variety of childcare options such as home-based care (e.g., nanny,
PCA; Freedman et al., 1995; Rosenzweig et al., 2002; Rosenzweig et al., 2008), family or
neighbor care (Freedman et al., 1995; Montes & Halterman, 2008), sibling care (Rosenzweig et
al., 2002; Rosenzweig et al., 2008), after-school programs (Freedman et al., 1995), and/or
primary caregiver care (Rosenzweig et al., 2002; Rosenzweig et al., 2008).
Childcare-related employment challenges included inhibited career advancement
(Freedman et al., 1995; Rosenzweig et al. 2002; Worcester et al., 2008), need for a flexible work
schedule (Rosenzweig et al., 2002), missed time at work (Montes & Halterman, 2011; Worcester
et al., 2008), diminished work performance (Montes & Halterman, 2011; Rosenzweig et al.,
2002), needing to cut down hours at work (Freedman et al., 1995; Rosenzweig et al., 2002;
Rosenzweig et al., 2008), and needing to quit their job to care for their child (Freedman et al.,
1995; Montes & Halterman, 2008). Minority ethnicity and low-income status appeared to
increase the likelihood of childcare-related employment challenges (Montes & Halterman, 2008).
Primary caregivers of children with challenging behaviors and/or developmental
disabilities reported financial strain due to their daycare-related employment challenges (Montes
& Halterman, 2008; Rosenzweig et al., 2002; Worcester et al., 2008), a sense of social isolation
(Worcester et al., 2008), and high stress levels (Freedman et al., 1995; Rosenzweig et al., 2002;
33
Worcester et al., 2008). Many primary caregivers experienced frustration trying to get
pediatricians or others to take their initial concerns seriously, resulting in reported delays of up to
two years between initial primary caregiver concern and later diagnosis and support (Rosenzweig
et al., 2002; Worcester et al., 2008); others reported more positive partnership experiences with
the process of identification and service delivery (Worcester et al., 2008).
Studies used face-to-face interviews (Rosenzweig et al., 2008; Worcester et al., 2008), inperson focus groups (Freedman et al., 1995; Rosenzweig et al., 2002), and data from larger
telephone surveys including the National Survey of Childrens Health (Montes & Halterman,
2008) and the random-digit Gallup panel (Montes & Halterman, 2011). In most cases,
participants that met established criteria were recruited from the community through local
programs and/or waiting lists (Freedman et al., 1995; Rosenzweig et al., 2002; Rosenzweig et al.,
2008; Worcester et al, 2008), though random sampling occurred in a couple of the studies
(Montes & Halterman, 2008; Montes & Halterman, 2011). Sample sizes ranged from 8
(Worcester et al, 2008) to 60 (Rosenzweig et al., 2008) in interview contexts, from 26 (Freedman
et al., 1995) to 41 (Rosenzweig et al., 2002) in focus groups, and from 1431 (Montes &
Halterman, 2011) to 14,993 (Montes & Halterman, 2008) in the telephone surveys. While some
studies focused on a single local community or county (Rosenzweig et al., 2002; Worcester et al,
2008), others made an effort to get representation from across the United States (Montes &
Halterman, 2008; Montes & Halterman, 2011).
Primary caregivers in the samples included mothers (Freedman et al., 1995; Montes &
Halterman, 2008; Montes & Halterman, 2011; Rosenzweig et al., 2002; Rosenzweig et al., 2008;
Worcester et al, 2008), fathers (Freedman et al., 1995; Montes & Halterman, 2011; Rosenzweig
et al., 2002; Rosenzweig et al., 2008; Worcester et al, 2008), and grandmothers (Worcester et al,
34
2008). A majority of the studies had 2/3 or more of the caregivers reporting middle-level income
or higher (Freedman et al., 1995; Montes & Halterman, 2011; Rosenzweig et al., 2002;
Rosenzweig et al., 2008), though in others over a 1/3 of families reported low-income or poverty
backgrounds (Montes & Halterman, 2008). All studies reported parents as predominantly (2/3 or
more) married and/or living in a two-parent household. Races represented in the samples
included Caucasian (Freedman et al., 1995; Montes & Halterman, 2008; Montes & Halterman,
2011; Rosenzweig et al., 2002; Rosenzweig et al., 2008; Worcester et al, 2008), African
American (Montes & Halterman, 2011; Rosenzweig et al., 2002; Worcester et al, 2008), Asian
(Rosenzweig et al., 2002), Hispanic/Latino (Montes & Halterman, 2011), and other race or
minority (Montes & Halterman, 2008; Rosenzweig et al., 2002).
Limitations to the current studies include relatively small sample sizes in those using
interview and focus group methodologies, lack of random sampling in these same studies, as
well as lack of control groups. Although these are significant limitations, the fact that there are a
number of areas of convergence among these studies, as well as with the larger studies with
national samples, indicates that some degree of generalizability may be possible to similar
demographics. It is important to note that all of the studies had samples of primarily families
living in married and/or two-parent households and most reported a high percentage of the
sample being in middle-level or higher income bracketsindicators often associated with family
stability. It is possible, therefore, that families with a sole primary caregiver and those with lowincome or poverty status would face greater degrees of challenge when faced with daycare
problems related to a childs challenging behavior. These studies had samples that were
predominantly Caucasian and English-speaking, so findings may not be generalizable to those
35
from other ethnic backgroundsespecially Asian, Hispanic/Latino, or Native Americanor

recent immigrant populations.
The research base on early intervention (EI) and early childhood special education
(ECSE) addresses prevalence rates of developmental delays, factors that impact identification of
delays and referrals to evaluation, and rates of participation in EI and ECSE services. Because of
overlap between topics addressed in the studies, a combined critique of the research is presented
at the end of this section.
Prevalence of developmental delays. Much of the research on incidence of
developmental delay addresses the birth-to-three population (Chan & Obnsorg, 1999; Derrington
& Lippitt, 2008; Rosenberg & Smith, 2008; Rosenberg, Zhang, & Robinson, 2008; Smith, Akai,
Kerman, & Keltner, 2010), though some studies considered preschool-age children (Delgado &
Scott, 2006) or the wider range from birth-to-five years of age (Blanchard, Gurka & Blackman,
2006). Prevalence rates for developmental delays ranged from 12% (Rosenberg et al., 2008) to
23% (Smith et al., 2010) for infants twelve-months of age or younger and from 13.8%
(Rosenberg et al., 2008) to 30% (Smith et al., 2010) for toddlers twenty-four-months of age.
Rates as developmental delay were as high as 47% (Rosenberg & Smith, 2008) in a population
investigated by the child welfare system. Between nine- and twenty-four-months of age, a
statistically-significant relationship emerged between developmental delay and poverty status,
with children coming from families living below the poverty level showing more delays by twoyears of age (Rosenberg et al., 2008). No statistically significant gender differences were noted
in distribution of developmental delays.
36
Factors impacting referral and service provision. While up to twenty-percent of

parents in a national sample reported developmental concerns about their young children (18months to 5-years of age; Blanchard et al., 2006), less than ten-percent of mothers in a high-risk
sample reported developmental concerns about their young children (12- to 24-months of age)
who were subsequently identified by researchers as having developmental delays (Smith et al.,
2010). Accurate maternal knowledge of child development increased the likelihood of mothers
reporting concerns about their childrens development. Despite regular contact with medical
offices, this high-risk sample reported doctors expressing few concerns about their childrens
development2% for those twelve-month-olds exhibiting developmental delays and 9% for
those twenty-four-month-olds exhibiting developmental delays. Although the American
Academy of Pediatrics issued a policy statement in 2001 calling for its members to do universal
developmental screening with standardized screening tools as part of routine well-child care,
follow up research found that only twenty-three percent of pediatricians reported using
standardized instruments a majority of the time (Sand et al., 2005). If young childrens delays
are not recognized by caregivers than these children are unlikely to be appropriately referred for
further evaluation and possible services (Sand et al., 2005; Smith et al., 2010).
Noting low rates of formal developmental screening in pediatric practice, researchers
encouraged efforts to incorporate standardized screening instruments and referral practices into
well-child clinic visits (King et al., 2010; Schonwald, Huntington, Chan, Risko, & Bridgemohan,
2006). While (Schonwald et al., 2009) one study implemented a single standardized survey
instrument, the Parents Evaluation of Developmental Skills (PEDS), the other (King et al.,
2010) allowed clinics to self-select screening instruments which resulted in a wider variety of
standardized tools being used (the PEDS, the Ages & Stages Questionnaire (ASQ), the
37
Prescreening Developmental Questionnaire (PDQ), and the Bayley Infant Neuro-developmental

Screener (BINS)).
Chart review found that after training had been provided on the use of the PEDS and
clinics had agreed to use the screening instrument, the PEDS was used for screening
approximately 60% of two- and three-year-old children (Schonwald et al., 2009). Providers
generally reported a favorable response to the PEDSstating that it was easy to use, saved time
during clinic visits, and that it provided structure to discussion of parental concerns. Reported
challenges included some parents needing an interpreter to assist in filling out the form and that
some parents did not fill out the form in the waiting room (e.g., they forgot or needed to watch
small children). Although there was a significant increase of identification of developmental and
behavioral concerns from use of the PEDS, the referral rate for two-year-olds remained similar to
before implementation of the PEDS while the referral rate for three-year-olds increased
resulting in an overall referral rate of 33.6% for children with new developmental concerns.
King et al. (2010) focused on implementation of screening for younger childrenat 918- and 24-30-month check-ups. They found dramatic differences in screening rates (33%100%), failed-screen rates (5%-53%), and referral rates (27%-100%) between clinics. In this
study, the average screening rate was 80% and the average referral rate was 61%. Clinics
created their own systems to make the screenings happen during well-child visitsoften
dividing responsibilities among multiple staff members and adjusting their implementation
systems as they reviewed data on rates of screening distribution and completion. Challenges
noted by clinics were difficulty consistently screening during busy times (such as flu season) and
when short-staffed and/or training new staff members in on procedures. Though not required by
the study, some clinics took the extra step of tracking the outcomes of referrals they madethey
38
found that families often did not understand the reason for the referral, that many families did not
follow through on the referral, and that their efforts resulted in better communication with local
referral resources. Three of the six clinics that implemented referral-tracking efforts found that a
larger number of children were being identified and gaining access to services through their
developmental screening and surveillance efforts.
Identification rates for EI (McManus, McCormich, Acevedo-Garcia, Ganz, & HauserCram, 2009; Rosenberg et al., 2008) and ECSE (McManus, Carle, Acevedo-Garcia, Ganz, &
McCormich, 2011) services fell significantly below prevalence rates for developmental delay
with a range of 10.1% (Rosenberg et al., 2008) to 46% (McManus et al., 2009) of children
exhibiting developmental delays receiving services. One factor suggested for this discrepancy
was variation in state criteria across the country (McManus et al., 2009; Rosenberg et al., 2008;
Smith et al., 2010), though it was also noted that even within the state of Minnesota participation
rates varied from county to county (Chan & Obnsorg, 1999). In general, young children
participating in special education services were most likely to be boys (Blanchard et al., 2006;
Delgado & Scott, 2006; McManus et al., 2011) and to demonstrate more severe delays or
disabilities (McManus et al., 2009; McManus et al., 2011). African American children tended to
be under-represented among those receiving services (Chan & Obnsorg, 1999; Delgado & Scott,
2006; McManus et al., 2011; Rosenberg et al., 2008). While some studies found higher rates of
service for those living above the poverty line (McManus et al., 2009; McManus et al., 2011),
this was not a universal finding (Rosenberg et al., 2008).
When considering findings of under-identification, a capacity limitation of the current
intervention system was brought upthat current funding and staffing would not be sufficient to
evaluate and provide service to all children meeting states current evaluation criteria
39
(Derrington & Lippitt, 2008; Rosenberg & Smith, 2008). Passage of the Keeping Children and
Families Safe Act (P.L. 108-36) in 2003 and the Individuals with Disabilities Education Act
(P.L. 108-446) in 2004 mandated referrals of all infants and toddlers who experienced
substantiated cases of abuse and neglect (Derrington & Lippitt, 2008). If fully implemented, this
legislative mandate was estimated to bring an additional 96,000 referrals into the countrys EI
system, with 1,201 of those referrals coming in to Minnesotaan estimated increase of 30.85%.
Considering that children involved with the child welfare system who had unsubstantiated
reports of abuse and neglect had similarly high prevalence rates of developmental delay
(Rosenberg & Smith, 2008) and that, conservatively, only 46% of infants and toddlers exhibiting
delays are currently in service (McManus et al., 2009) a significantly larger gap between need
and capacity is evident.
Looking to 2010 census data (US Census, 2010), the population of young children birth
to five-years of age in Minnesota was 355,363. That same year, child count data (Minnesota
Department of Education, 2011) noted that 13,743 young children birth to five-years of age were
being served by special education systems in Minnesota. That translates into an overall service
rate of 3.87% for the birth to five-year-old population in the state. In the preschool years (ages
3-5), boys were over twice as likely to be receiving special education services as girls
(Individuals with Disabilities Education Act Data, 2010).
Critique of the literature. A majority of these studies used large representative samples
obtained through methods such as random-digit phone surveys (Blanchard et al., 2006;
McManus et al., 2009; McManus et al., 2011), review of existing records such as birth certificate
and service databases (Chan & Obnsorg, 1990; Delgado & Scott, 2006; Derrington & Lippitt,
2008; Rosenberg & Smith, 2008), and mailed surveys to randomly selected professional
40
organization members (Sand et al., 2005). Other data sources included the Early Childhood
Longitudinal Program-Birth Cohort (Rosenberg et al., 2008), a longitudinal study tracking firsttime mothers and their children (Smith et al., 2010), and studies tracking well-child visit clinic
practices (King et al., 2010; Schonwald et al., 2009). Sample sizes fell within the following
categories: 450-1000 (Smith et al., 2010; McManus et al., 2009; Sand et al., 2005), 1900-2200
(McManus et al., 2011; Rosenberg & Smith, 2008), 9000-12,000 (Rosenberg et al., 2008), and
24,000+ (Blanchard et al., 2006; Chan & Obnsorg, 1999; Delgado & Scott, 2006). One study
followed two urban clinics serving large numbers of children (Schonwald et al., 2009), while a
second followed seventeen clinics spread across fifteen states (King et al., 2010).
While some studies used extensive record reviews (Chan & Obnsorg, 1999; Delgado &
Scott, 2006; Derrington & Lippitt, 2008; King et al., 2010; Schonwald et al., 2009), others relied
on self-reported information obtained through surveys (Blanchard et al., 2006; McManus et al.,
2009; McManus et al., 2011; Sand et al., 2005), focus groups (Schonwald et al., 2009), or
structured interviews (King et al., 2010). Response rates for surveys ranged from 55% (Sand et
al., 2005) to nearly 69% (Blanchard et al., 2006). When child-testing data was reviewed
(Rosenberg & Smith, 2008; Rosenberg et al., 2008; Smith et al., 2010) it came from use of
standardized instruments common to the field (e.g., the Bayley Scales, Battelle Developmental
Inventory, Preschool Language Scale, Vineland Adaptive Behavior Scale) and used qualifying
criteria to align with moderate states criteria (Minnesota is considered a moderate state)
reflecting either 1.5 SD below the mean in one area or 1 SD below the mean in two areas (or,
alternatively, 25% delay in one area or 20% delay in two areas). Not all studies that collected
data on the children accounted for all five developmental domains included in federal guidelines,
41
so a noted limitation was that the prevalence findings may under-represent the true number of
children with significant delays (Rosenberg et al., 2008; Rosenberg & Smith, 2008).
Based on the large representative sample sizes and frequent convergences of findings,
these studies appear to offer accurate representation of the field at their times of origin. It should
be noted that special education provision for young children is still a relatively young initiative
continually being shaped by changes to federal and state legislation and local practices related to
child find and service provision. It is this authors opinion, therefore, that there is an ongoing
need to build on this research base to be able to accurately track the impact of current social and
legal contexts on the incidence and service rates of young children with developmental delays.
Interventions Models
Research has examined the effectiveness of intervention models from a variety of
different perspectives. The literature reviewed below focuses on childrens curricula for socialemotional competence and self-regulation, training and consultation models for teachers, parent
education approaches, and the efficacy of multi-modal intervention approaches targeting child,
teacher, and/or parent educational approaches.
Childrens curricula. A number of curricular models have been implemented to
promote the development of social-emotional and self-regulation skills in young children,
including the Incredible Years: Dinosaur Curriculum (Dinosaur School; Webster-Stratton, Reid,
& Hammond, 2001b; Webster-Stratton, Reid, & Stoolmiller, 2008), Tools of the Mind (Tools;
Barnett et al., 2008; Diamond, Barnett, Thomas, & Munro, 2007), Promoting Alternative
Thinking Strategies (PATHS; Domitrovich, Cortes, & Greenberg, 2007), Strong Start Pre-K
(Gunter, Caldarella, Korth, & Young, 2012), and You Can Do It! (YCDI; Ashdown & Bernard,
2012). While most of these curricula were implemented in regular preschool classrooms
42
(Ashdown & Bernard, 2012; Barnett et al., 2008; Diamond et al., 2007; Domitrovich et al., 2007;
Gunter et al., 2012; Webster-Stratton et al., 2008), one was implemented in a clinical setting
(Webster-Stratton et al., 2001). Music and dance programming have also been studied for their
potential to develop young childrens self-regulation and social skills (Lobo & Winsler, 2006;
Winsler, Ducenne, & Koury, 2011).
Common curricula elements included a group lesson with explicit discussion of topics
related to social skills (Ashdown & Bernard, 2012; Domitrovich et al., 2007; Gunter et al., 2012;
Webster-Stratton et al., 2001b; Webster-Stratton et al., 2008), modeling of social and/or problem
solving skills (Ashdown & Bernard, 2012; Webster-Stratton et al., 2001b; Webster-Stratton et
al., 2008), use of childrens literature related to the lessons theme (Gunter et al., 2012; WebsterStratton et al., 2001b), use of puppets or stuffed animals as participants and to help with
modeling (Ashdown & Bernard, 2012; Gunter et al., 2012; Webster-Stratton et al., 2001b;
Webster-Stratton et al., 2008), and role-play practice of the discussed social and/or problem
solving skills (Ashdown & Bernard, 2012; Webster-Stratton et al., 2001b). These lessons took
place once (Domitrovich et al., 2007; Webster-Stratton et al., 2001b), twice (Gunter et al., 2012;
Webster-Stratton et al., 2008), or three times (Ashdown & Bernard, 2012) a week and were
sometimes followed by extension activities (e.g., art activities, games; Domitrovich et al., 2007;
Webster-Stratton et al., 2008) and letters home explaining about the key concepts from the
lessons and how to support them in other settings (Gunter et al., 2012; Webster-Stratton et al.,
2001b). While the Tools curriculum (Barnett et al., 2008; Diamond et al., 2007) was explicitly
designed to be integrated throughout the classroom (e.g., enhancing dramatic play time, reading
time, etc.), some other curricula provided some level of training or guidance to teachers for how
43
to reinforce lesson concepts throughout the day in natural learning opportunities (Ashdown &
Bernard, 2012; Domitrovich et al., 2007; Webster-Stratton et al., 2008).
Dinosaur School was implemented in a group clinical setting with four- to eight-year-old
children with diagnoses of CD, ODD, and AD/HD comorbid with ODD (Webster-Stratton et al.,
2001b). Children attended weekly group sessions of five to six children for approximately six
months. Group sessions focused on topics such as conflict resolution, understanding others
perspectives, feelings language, and dealing with loneliness and negative attributions. Puppets,
video modeling, role-playing, coloring books and other art activities, books with children stating
feelings and solving social problems, and weekly homework to be signed off on by parents were
included in the intervention. Parents and teachers were also provided with weekly good
behavior charts that the children were rewarded for bringing back to the weekly sessions.
In comparison to wait-list controls, children participating in Dinosaur School showed
larger reductions in conduct problems and their behavioral improvement was still evident at a
one-year follow-up (Webster-Stratton et al., 2001b). Approximately eighty percent of children
in the treatment condition improved in one or more criteria for conduct problems (compared to
approximately 47% of controls), approximately sixty-seven percent of the children in the
treatment condition fell below the cut-off for ODD (compared to approximately 28% of
controls), and approximately sixty-three percent of teachers reported that children in the
treatment condition showed reduced aggression towards peers at school (in comparison to
approximately 29% of teachers of controls). Of interest, all of the children in the treatment
condition who had no parenting risk factors showed improvement in one or more conduct
problem while approximately seventy-two percent of their peers who had parental risk factors
showed such improvement. At one-year follow up, approximately ninety percent of children in
44
the treatment condition who had no family stress risk factors demonstrated clinically-significant
behavioral improvements while approximately sixty-three percent of children in the treatment
condition who had family stress risk factors showed such improvements.
Dinosaur School was also implemented in preschool and early elementary school
classrooms twice a week (Webster-Stratton et al., 2008). Large group instructional strategies
were similar to those used in the clinical setting, being implemented during classrooms circle
time. These direct instruction and modeling times were followed by small group skill practice
sessions. Teachers were also encouraged to promote the skills at other times throughout the class
day. Although Dinosaur School was discussed as a child-centered curricular intervention, it is
important to note that teacher training in appropriate curriculum administration was provided.
Children participating in the classroom-based Dinosaur School showed more
improvement in school readiness measures than controls, with those with the lowest initial skills
in these areas showing the most substantial gains (Webster-Stratton et al., 2008). Conduct
problems were also differentially impacted by Dinosaur School participation, with those with the
highest initial levels of conduct problems having the steepest decline with intervention. When
compared to peers in control-condition classrooms, children in classrooms implementing
Dinosaur School also showed significantly greater increases in the number of positive feelings
that they could identify and positive strategies they could generate.
The Tools curriculum integrates forty Vygotsky-inspired activities throughout the
preschool day (Barnett et al., 2008; Diamond et al., 2007). Primary elements of the curriculum
include use of planning and other scaffolding techniques to help develop mature dramatic play
and use of external mediators (e.g., pictures, modeling and using explicit private speech) to help
children regulate their behavior. Studies report on children who participated in the program for
45
one school year (Barnett et al., 2008) and for one to two school years (Diamond et al., 2007).
Although Tools was discussed as a child-centered curricular intervention, it is important to note
that teacher training in appropriate curriculum administration was provided.
When compared to peer controls in classrooms using the districts standard preschool
curriculum, children participating in Tools classrooms performed a half-deviation lower on
measures of internalizing and externalizing behavioral problems (Barnett et al., 2008).
Moderate-sized effects were found on English and Spanish language development in children
participating in Tools classrooms. Additionally, there was indication that teachers in Tools
classrooms were demonstrating a greater degree of responsiveness to childrens academic and
emotional needs and better management of instructional time and routines. While children
participating in Tools classrooms performed comparably to peers in control-condition classrooms
on a task with minimal executive functioning demands, they performed significantly better on
tasks that required use of more extensive executive functioning skills (Diamond et al., 2007).
The PATHS curriculum contains weekly thematic circle times on topics such as feelings,
compliments, problem solving, and self-control strategies (Domitrovich et al., 2007). Extension
activities including books, games, and art projects continue the themes into the rest of the
classroom days. Additionally, teachers were provided with guidance on how to take advantage
of teachable moments as they occurred throughout the day to reinforce the curriculums
concepts. Although PATHS was discussed as a child-centered curricular intervention, it is
important to note that teacher training in appropriate curriculum administration was provided.
In comparison to control classrooms, after thirty weekly lessons children in classrooms
using the PATHS curriculum were better able than control-condition peers to identify feelings
and demonstrated a wider receptive vocabulary related to emotions (Domitrovich et al., 2007).
46
Children in classrooms implementing PATHS also experienced a significant reduction in anger

attribution bias and teachers rated them lower in measures of internalizing behaviors. Follow-up
analysis showed that the intervention effect was most significant for children with higher verbal
abilities, while children in the intervention group with low verbal abilities performed similarly to
children in the control condition.
Strong Start Pre-K is a highly-structured, partially scripted, curriculum designed to
develop childrens feelings vocabulary and prevent emotional and mental health problems from
occurring (Gunter et al., 2012). It contains childrens literature as part of each lesson and uses a
stuffed animal to help deliver content and act as a mascot. Additionally, a pamphlet was sent
home after each lesson discussing the lesson and how to reinforce the concepts at homein the
case of this study, both English and Spanish versions were made available due to the schools
demographics. Two optional booster lessons are also available. Although Strong Start Pre-K
was discussed as a child-centered curricular intervention, it is important to note that teacher
training in appropriate curriculum administration was provided.
After ten lessons over a six-week period, children in classrooms implementing the Strong
Start Pre-K curriculum showed statistically-significant decreases in internalizing behaviors in
comparison to peers in control classroomswith those receiving the two booster lessons
showing the greatest level of decrease overall (Gunter et al., 2012). Classrooms implementing
the Strong Start Pre-K curriculum also experienced a statistically-significant decrease in conflict
(with the largest decrease in the classroom implementing the booster sessions), while those in the
control condition showed an increase in this measure. Of note, children in the two treatment
conditions and control condition all were rated by teachers to have increased levels of emotional
regulation and teachers across all conditions noted improved relationships between teacher and
47
students. Also of interest, the Strong Start Pre-K condition without booster lessons showed an
increase in teacher report of childrens dependency, while the controls and classroom that
implemented the booster sessions reported a decrease in this measure.
The YCDI curriculum consists of a series of structured lessons designed to promote
confidence, emotional resilience, persistence, and organization (Ashdown & Bernard, 2012).
Social emotional skills are described, modeled, and then acted out in role-play during lessons.
Puppets, songs, and colorful posters are used to support childrens understanding of the skills and
concepts. After three lessons a week for two weeks, children in classrooms using the YCDI
curriculum were reported by teachers to have higher levels of social skills and social-emotional
wellbeing when compared to children in control condition classrooms. There was no
intervention impact noted on the Total Problem Behaviors measure, however, indicating that
there was not an overall decrease in problem behaviors with this brief intervention. Although
YCDI was discussed as a child-centered curricular intervention, it is important to note that
teacher training in appropriate curriculum administration was provided.
Lobo and Winsler (2006) designed and tested a dance and creative movement curriculum
to see what impact it may have on childrens social skills and behavior problems. The dance and
creative movement curriculum centered around the concepts of body (e.g., parts, shapes,
balance), movement (i.e., locomotion), space (e.g., place, size, direction), time (i.e., speed, flow),
force (e.g., weight, combinations, staying in place), and form (e.g., abstract, narrative, recurring
themes). Children participated in the curriculum for thirty-five minutes, twice a week, for eight
weeks. When compared to peers in control classmates, children participating in the dance and
creative movement curriculum showed larger increases in social competence and decreases in
internalizing and externalizing behavioral problems as reported by teachers and parents.
48
Winsler et al. (2011) investigated whether past and/or present participation in the
Kindermusik music and movement program was correlated with better self-regulation skills than
controls with no prior music experience and those with non-Kindermusik music experiences.
They found that there appeared to be a dosage effect, where preschool children who had been in
the Kindermusik program longer and for a more substantial portion of their lives performed
better on the laboratory tasks. Children who had participated in the Kindermusik program
engaged in more private speech in comparison to those who had not participated in the program
(95% vs. 71%) and attempted less social engagement with the experimenter (5% vs. 18%)both
factors associated with better performance on self-regulation tasks. Current participation in
Kindermusik was also associated with better self-regulation. Children currently enrolled in the
Kindermusik program were found to engage in more relevant private speech than those who
were not currently enrolled in the program. The impact on relevance of private speech had a
differential impact based on gender, where a wide gap (25% vs. 8%) was found in the percentage
of irrelevant private speech by boys and girls who were not currently enrolled in the program and
the gap narrowed significantly (14% vs. 9%) between genders for those currently enrolled in the
Kindermusik program. This gender finding is notable because, as with Winsler et al. (2003),
children with irrelevant private speech performed more poorly on tasks requiring self-regulation.
All studies used some kind of control and/or comparison group when analyzing and
reporting on intervention findings. Studies primarily drew from convenience samples, including
Head Start (Domitrovich et al., 2007; Lobo & Winsler, 2006; Webster-Stratton et al., 2008),
public school preschool (Barnett et al., 2008; Diamond et al., 2007; Gunter et al., 2012), early
elementary schools (Ashdown & Bernard, 2012; Webster-Stratton et al., 2008), and clinical
(Webster-Stratton et al., 2001b) settingsalthough one study did draw its sample from a broader
49
array of places (Winsler et al., 2011). Sample sizes ranged from 40 (Lobo & Winsler, 2006) to
1,768 (Webster-Stratton et al., 2008), with a majority ranging from 84 to 147 (Ashdown &
Bernard, 2012; Diamond et al., 2007; Gunter et al., 2012; Webster-Stratton et al., 2001b; Winsler
et al., 2011).
When identified by race, samples included Caucasian (Domitrovich et al., 2007; Gunter
et al., 2012; Lobo & Winsler, 2006; Webster-Stratton et al., 2001b; Webster-Stratton et al., 2008;
Winsler et al., 2011), African American (Barnett et al., 2008; Domitrovich et al., 2007; Gunter et
al., 2012; Lobo & Winsler, 2006; Webster-Stratton et al., 2008; Winsler et al., 2011),
Hispanic/Latino (Barnett et al., 2008; Domitrovich et al., 2007; Gunter et al., 2012; Lobo &
Winsler, 2006; Webster-Stratton et al., 2008), Asian (Barnett et al., 2008; Gunter et al., 2012;
Lobo & Winsler, 2006; Webster-Stratton et al., 2008), Arabic (Lobo & Winsler, 2006), Native
American (Gunter et al., 2012), and other/mixed race (Barnett et al., 2008; Domitrovich et al.,
2007; Lobo & Winsler, 2006; Webster-Stratton et al., 2008; Winsler et al., 2011) demographics.
While many samples came from primarily low-income environments (Ashdown & Bernard,
2012; Barnett et al., 2008; Diamond et al., 2007; Domitrovich et al., 2007; Gunter et al., 2012;
Lobo & Winsler, 2006; Webster-Stratton et al., 2008), others drew primarily from those that
were more middle- and/or upper-income (Webster-Stratton, 2001b; Winsler et al., 2011).
From an implementation standpoint, it is important to consider that a majority of studies
(with exception of Webster-Stratton et al., 2001b) focused on general classroom settings instead
of clinical or self-contained special education settings. It is interesting to note, considering the
findings of Winsler et al. (2011) that the impact of participation was greatest for those children
currently enrolled in the program, that only Webster-Stratton et al. (2001b) reported on a oneyear follow-up to see if treatment effects were maintained, while other researchers reported
50
simple pre- and immediately-post measures. It is also important to note that while there was
some racial diversity in many of the samples and some similar curricular methods or
characteristics that were found in multiple curricula, the sample sizes were generally moderate
and often only one study addressed the treatment effects of each curriculum and so broad
generalization on any specific curriculum may not be warranted. Further verification of
treatment effects for individual curricula would be desirable.
Teacher consultation and training. Early childhood mental health consultation
programs have been implemented in preschool and daycare contexts to improve the behavioral
outcomes of young children with challenging behaviors and to reduce the incidence of
expulsions (Perry, Dunne, McFadden, & Campbell, 2008; Upshur, Wenz-Gross, & Reed, 2009).
Although focused around a similar theme of promotion of early childhood mental health, these
programs have been structured differently. While one program used universal screening with a
standardized instrument as part of the deciding factor for which children to refer (Upshur et al.,
2009), other children were referred by a variety of sources and did not receive scoring on
standardized measures until the intake process was underway (Perry et al., 2008). One program
model focused on a variety of services delivered over four- to six-months, that included
assessment, working directly with the individual children, parent consultation and therapy,
teacher consultation, and parent-teacher team meetings (Upshur et al., 2009). The other program
model took place over approximately three-months and included assessment, consultation and
modeling of strategies for working with individual children, a written report of recommended
strategies to use with the child, and a more general onsite educational component to teach child
care providers how to work with young childrens challenging behaviors (Perry et al., 2008).
51
A majority of children were referred to mental health consultation programs for concerns
about externalizing behaviors (Perry et al., 2008; Upshur et al., 2009), and nearly half of parents
reported a significant life change (e.g., birth of a sibling, divorce) had recently occurred for
referred children (Perry et al., 2008). Children participating in these early childhood mental
health consultation programs experienced a number of positive behavioral benefits, including
decreases in maladaptive behaviors and increases in adaptive behaviors (Upshur et al., 2009),
decreased levels of internalizing behaviors (Perry et al., 2008), decreased levels of externalizing
behaviors (Perry et al., 2008; Upshur et al., 2009), and increased proficiency in social skills
(Perry et al., 2008). It appeared that children most at riskwith the highest initial levels of
aggression and developmental delayshowed the largest improvements from the mental health
consultation program intervention (Upshur et al., 2009). Improvements in individual childrens
developmental skills were also found to independently be associated with improvement in
behavioral scores from pre- to post-intervention (Upshur et al., 2009).
Although a majority of teachers surveyed reported that the program was very useful and
that the mental health consultant was a trusted ally, some expulsions continued to take place
(Perry et al., 2008). Factors associated with these removals included high rates of externalizing
behavior problems, younger children in the first year of the mental health program
implementation, and a low level of maternal education. Interestingly, even when teacher report
measures showed no growth in teacher knowledge over the three year implementation period and
less than half of teachers reported that in-class modeling by consultants was helpful, about twothirds reported that the consultation process was helpful and there was a significant drop in the
number of suspensions and expulsions (from 43.3 per 1000 to 2.6 per 1000; Upshur et al., 2009).
52
Teacher training has also taken place as a stand-alone initiative (Webster-Stratton et al.,
2008) and in combination with other program elements such as early childhood mental health
consultation (Raver et al., 2009). Webster-Stratton et al. (2008) provided approximately twentyeight hours of training, spread out over four monthly sessions, to Head Start and primary grades
classroom teachers on the implementation of the Dinosaur School curriculum [discussed more
thoroughly under child-centered interventions] and general classroom management and parent
involvement strategies. When compared to controls, teachers who had received the training
demonstrated more emphasis on social/emotional teaching and were more warm and affectionate
toward children and less harsh and inconsistent. A significant effect was found, where
intervention teachers who were initially the harshest improved the most. In comparison to peers
in the control condition, children in the intervention condition also showed benefits including
improved school readiness skills, lower levels of conduct problems, and an improved ability to
generate positive strategies and identify positive emotions. Additionally, eighty percent of the
Head Start teachers (in comparison to less than 45% of primary grade teachers) asked for
ongoing training to take place.
The Chicago School Readiness Project (CSRP) brought classroom teachers thirty-hours
of training in classroom management based on the Incredible Years Teacher Training Program,
stress-reduction workshops, weekly mental health consultation to coach on implementation of
strategies learned in training, and child-specific mental health consultation (Raver et al., 2009).
When compared to controls, children in the intervention group were found to have significantly
fewer internalizing (e.g., sadness, withdrawal) and externalizing (e.g., aggression, defiance)
behavior problems by the end of the school year. Girls and Hispanic children showed the
greatest degree of behavioral improvement with the intervention. Although the sample was
53
comprised of low-income children, those with one or fewer additional risk factors tended to
show benefit while children with two or more additional risk factors did not show statisticallysignificant behavioral improvement. A majority of teachers (80+%) reported that the training
and mental health consultation was helpful for their work with children whose behavior was
difficult and that it allowed them to devote time to individual children needing extra help.
The study samples came from trainings implemented in existing daycare, preschool, and
primary school programs in the United States. Sample sizes ranged from 136 (Upshur et al.,
2009) to 1,768 (Webster-Stratton et al., 2008) and were comprised of predominantly low-income
(Raver et al., 2009; Webster-Stratton et al., 2008) or mixed-income (Perry et al., 2008; Upshur et
al., 2009) populations. Racial categories represented in the samples included Caucasian (Perry et
al., 2008; Upshur et al., 2009; Webster-Stratton et al., 2008), African American (Perry et al.,
2008; Raver et al., 2009; Upshur et al., 2009; Webster-Stratton et al., 2008), Hispanic (Perry et
al., 2008; Raver et al., 2009; Upshur et al., 2009; Webster-Stratton et al., 2008), and mixed or
other race (Perry et al., 2008; Raver et al., 2009; Upshur et al., 2009; Webster-Stratton et al.,
2008). Two studies noted inclusion of non-English speaking families in their samples (Raver et
al., 2009; Webster-Stratton et al., 2008).
All studies were published within the past four years and seem to indicate that a
percentage of children have had their behaviors successfully modified in a desired direction by
consultation and training directed at their daycare and preschool teachers. While the samples
appear to be relatively ethnically diverse, replication with larger sample sizes and long-term
follow-up would be desirable to further verify and extend knowledge of child behavioral
outcomes.
54
Parent education. Parent education programming has been designed to work in clinical
(Cunningham, Bremmer, & Boyle, 1995; Kardy & Rosenthal, 1977; Nixon, Sweeney, Erickson,
& Touyz, 2004; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005), home (Dishion et al.,
2008; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006), and community (Cunningham et al.,
1995; deGraaf, Speetjens, Smit, de Wolff, & Tavecchio, 2008; Fletcher, Freeman, & Matthey,
2011) settings. It has taken place on an individual level (Cunningham et al., 1995; deGraaf et al.,
2008; Dishion et al., 2008; Fletcher et al., 2011; Nixon et al., 2004; Shaw et al., 2006), in small
groups (Kardy & Rosenthal, 1977; Rapee et al., 2005), as well as within large-group contexts
(Cunningham et al., 1995; deGraaf et al., 2008; Fletcher et al., 2011; Kardy & Rosenthal, 1977).
An area of noted difficulty in this field is recruiting and maintaining parent participation in this
type of intervention (Gross, Julion, & Fogg, 2001; Mendez, Carpenter, LaForett, & Cohen,
2009).
The Family Check-Up (FCU) is a brief family-centered intervention implemented with
families whose toddlers are at risk for development of serious conduct problems (Dishion et al.,
2008; Shaw et al., 2006). The intervention consists of approximately three home-visit sessions
a getting to know you session, a comprehensive assessment that includes videotaping parentchild interactions, and one of more structured feedback/intervention sessions to discuss family
strengths and suggested areas of change.
In comparison to children in the control condition, children whose families participated in
FCU displayed lower levels of problem behavior growth by age four (Dishion et al., 2008).
Parents in the intervention condition displayed an increased usage of positive behavior support
strategies between the time the FCU when their children were two-years-old and the follow-up
when their children were three-years-old, with study authors hypothesizing that use of improved
55
behavior support strategies had lead to the reduction in growth of problem behaviors. Similarly,
maternal involvement levels increased in intervention families between the FCU when children
were two-years-old and the follow-up when children were three-years-old and then remained
stable at the age four follow-up (Shaw et al., 2006). This is in contrast to mothers in the control
condition who displayed decreasing levels of involvement with their children from two- through
four-years of age. Children whose families participated in FCU showed significant decreases in
destructive behavior, including for those children with initially high levels of inhibition who had
mothers with a depressed mood.
Rapee et al. (2005) also took a preventative/early intervention approach to early
childhood mental health problems. The preschool intervention involved six small group parent
sessions that lasted approximately ninety minutes each and were facilitated by a clinical
psychologist with experience in anxiety treatment for children. The first session outlined the
nature of anxiety and its developmental pathways. The second session addressed management
techniques and the role of overprotection in maintaining anxiety. The third, fourth, and fifth
sessions looked at cognitive restructuring and exposure hierarchies. The final session addressed
the importance of high-risk periods (such as transition to school) along with strategy application.
In comparison to those in the control condition, children whose parents participated in the
educational intervention experienced fewer anxiety disorders at one-year follow-up. The more
intervention sessions that mothers attended, the more significantly the drop in anxiety disorders
in their children. Although childrens rate of anxiety disorder decreased with their parents
participation in the intervention, the level of inhibition in these children were not significantly
changed.
56
The Triple P-Positive Parenting Program (Triple P) has five levels of parenting education
that utilizes group as well as individual-direction and telephone support (deGraaf et al., 2008;
Fletcher et al., 2011). Level 1 of Triple P works at a universal level to provide information
related to common parenting challenges through the media. Level 2 provides tip sheets to
individual parents relating to specific parenting concerns and provides seminars open to large
audiences. Level 3 of Triple P provides four brief counseling sessions to address specific
parenting problems. Level 4 provides a broader array of optionsa series of ten group sessions
for parents in general (Standard Triple P) as well as specialized for parents of children with
disabilities (Stepping Stones), Group Triple P with five sessions and follow-up telephone
support, and Self-Directed Triple P that uses a self-help model with weekly telephone support.
Level 5 of Triple P contains the same type of activities as Level 4 with addition of specialized
supports like home-based skills training for dealing with stress, emotions, marital
communication, and anger management.
Meta-analysis of studies documenting effects of Level 4 Triple P programming found
moderate to large effects on childrens behavior, both immediately post-intervention and at 6-12
month follow-up (deGraaf et al., 2008). Level 4 Triple P programming had the largest long-term
effects when samples were less than 60% boys and when initial behavior problem scores were in
the clinical range. Few moderators were found, so the study authors concluded that the
intervention was effective with a broad range of families, using different formats, and with
different behavioral problems. A second meta-analysis (Fletcher et al., 2011) found Triple P
programming to significantly improve parenting practices. The impact on parenting practice was
largest for participating mothers, though fathers still showed moderate levels of improvement
from program participation. While mothers showed equitable improvement from all formats of
57
Triple P, fathers showed the most substantial benefit from participation in the Stepping Stones
format and showed no benefit from the self-directed format.
Parents were trained in behavior modification principles in order to reduce the occurrence
of externalizing behavioral problems (e.g., defiance, aggression, temper tantrums) of their
children (Kardy & Rosenthal, 1977). Ten weekly sessions were held that included whole group
instruction in behavioral principles, role-play, small groups where questions were answered and
individual programs were worked on, and large-group processing. Parents were taught about
defining problem behaviors and to record baseline and treatment records of those behaviors. In
comparison to wait-list controls, parents who participated in the parent education program
reported greater family cohesion and a seven- to sixty-percent decrease in problem behaviors in
their target children, while wait-list controls experiencedon averagea seventeen-percent
increase in problem behaviors. Trained observers blind to treatment and control status
corroborated significant decreases in target behaviors by children whose parent(s) participated in
the educational program.
Parent-child interaction therapy (PCIT) is an individualized clinical intervention to
address childrens externalizing behaviors (Nixon et al., 2004). The standard version of PCIT
takes place over twelve weekly one- to two-hour long sessions, divided into two phases. The
first phase focuses on improving the parent-child relationship through practice of effective skills
within play time. The second phase is focused on teaching additional parenting skills and
behavior management strategies. The abbreviated version of PCIT has only five face-to-face
sessions (instead of twelve) and delivers the rest of the content through video and five 30-minute
phone consultations. Both the standard and abbreviated versions of PCIT include an hour-long
face-to-face booster session a month after treatment has ended. At one-year follow-up, parent
58
report and independent observation indicated a number of benefits to those who participated in
the standard and abbreviated versions of PCIT, including that the children were less oppositional
and causing their mothers less stress and that the mothers had maintained reduced levels of
coercive discipline. Mothers who had participated in the abbreviated intervention were observed
to praise their children significantly more often than those who had participated in the standard
intervention. At two-year follow-up an interesting finding emergedwhile 56% of children in
the standard PCIT condition and 68% of children in the abbreviated PCIT condition still met
criteria for ODD, maternal report indicated that 70% of the children in the standard PCIT
condition and 67% of the children in the abbreviated PCIT condition had made significant,
reliable, decreases in oppositional behavior.
Cunningham et al. (1995) compared enrollment patterns and outcomes of parent
education programs taking place in a large-group community context with an individual clinical
parent education program, both of which met for eleven to twelve sessions and had similar
curriculum. Topics such as reinforcement of prosocial behavior, problem solving, transitional
strategies, encouraging compliance, and ignoring minor disruptions were addressed in the
curriculum. Instructional strategies such as group discussion, coping modeling problem solving,
role-play, and homework were used. Both the individual clinical intervention and the group
community context offered concurrent social skills programming for children that parents could
opt-in to use.
Although parents were randomly assigned to the two intervention and control conditions
and were invited to participate using a standard phone protocol, acceptance patterns differed for
the two intervention formats (Cunningham et al., 1995). Immigrant parents, parents with
relatively low English skills, and parents with children considered at higher risk were more likely
59
to enroll in the group community intervention than the individual clinical one. Two-parent
families were also significantly more likely to enroll in the group community intervention than
the individual clinical one. Families declining to enroll in the offered condition most quickly
declined offers of individual clinical intervention. While over 15% of families declining
participation in the individual clinical intervention stated that their child was not a problem, this
reason was given by just 2.5% of families declining to participate in the group community
intervention.
The community group format was both more cost-effective and showed greater results at
follow-up than the individual clinical format (Cunningham et al., 1995). At follow-up, parents
who participated in the group community format were able to come up with more solutions to
child management problems, reported a greater reduction in child management problems, a
greater sense of competence, and maintenance of behavioral improvement over time.
Additionally, parents often connected outside of the community group intervention and were
likely to maintain these contacts after the intervention ended.
Although many studies of parent education programs noted substantial attrition rates, few
followed-up to find out what parental attributes or barriers were behind these parents program
non-completion. Two exceptions were Mendez et al. (2009) who looked into factors impacting
parent participation in a Head Start-based parent education program and Gross et al. (2001) who
investigated motivations for participation in parent education programs located at childcare
centers. Mendez et al. (2009) identified three adaptive profiles of parents who were involved in
their childs education and maintained average or above average levels of locus of control and
two maladaptive profiles of parents demonstrating distress and low educational involvement. In
60
general, this study found that school involvement was positively correlated with participation in
parent education workshops and use of home interventions.
Gross et al. (2001) found that parents cited factors such as having parent groups located
at their childs daycare center, the personability and trustworthiness of program representatives,
the availability of free childcare during the groups, and receiving a free videotape of their parentchild play as significantly more motivating than more traditional motivators such as financial
compensation. The most frequently cited reasons that parents said they participated in the
groups were that they wanted to learn about children their childs age, that they wanted to share
experiences with other parents, and that they wanted help addressing their childrens challenging
behaviors. Parents who stated initially that they were enrolling in the parent program to share
experiences and learn better discipline techniques to use with their children were more likely to
stay in the program than parents who did not cite these reasons for participation. Reported
barriers cited for dropping out of the parent education program included a lack of time, change in
job and school schedule, and too much stress to take on the added commitment of parent group.
Researchers used a combination of interview (Cunningham et al., 1995; Gross et al.,
2001; Mendez et al., 2009; Nixon et al., 2004), questionnaire (Cunningham et al., 1995; Dishion
et al., 2008; Karoly & Rosenthal, 1977; Mendez et al., 2009; Nixon et al., 2004; Shaw et al.,
2006), independent observation (Cunningham et al., 1995; Dishion et al., 2008; Karoly &
Rosenthal, 1977; Nixon et al., 2004; Shaw et al., 2006), and structured activities or clinical
testing (Cunningham et al., 1995; Dishion et al., 2008; Shaw et al., 2006) when determining
intervention effects. Sample sizes fell into the following ranges: 17 to 54 (Karoly & Rosenthal,
1977; Nixon et al., 2004), 120 to 201 (Gross et al., 2001; Mendez et al., 2009; Shaw et al., 2006),
and 659 to 3564 (Cunningham et al., 1995; Dishion et al., 2008). While one study (Karoly &
61
Rosenthal, 1977) had a sample that was entirely Caucasian, another study had a sample that was
primarily Caucasian (96+%; Rapee et al., 2005), and a third study had a sample that was heavily
African American (81%; Mendez et al., 2009) other studies had samples that were a mix of
Caucasian (Dishion et al., 2008; Shaw et al., 2006), African American (Dishion et al., 2008;
Gross et al., 2001; Shaw et al., 2006), Hispanic (Dishion et al., 2008; Gross et al., 2001), multiracial (Dishion et al., 2008; Gross et al., 2001; Shaw et al., 2006), and other (Dishion et al.,
2008) populations. One study (Cunningham et al., 1995) noted participation by families with
low English proficiency levels. When noted, many of the studies had samples from primarily
low-income backgrounds (Dishion et al., 2008; Gross et al., 2001; Mendez et al., 2009; Shaw et
al., 2006), while one had a sample that represented a broader economic spectrum (Cunningham
et al., 1995).
Although many of the sample sizes are not large and the sample demographics tend to be
relatively homogenous, the use of multiple measures bodes well for the findings as applied to the
specific samples. Further research to validate findings with larger and more economically and
ethnically diverse samples would allow for greater generalization of results.
Multi-modal interventions. Researchers have considered the effectiveness of stacking
various combinations of interventions, including child and parent interventions (Drugli &
Larsson, 2006; Foster, Olchowski, & Webster-Stratton, 2007; Niles, Reynolds, & Roe-Sepowitz,
2008), teacher and parent interventions (Foster et al., 2007; Webster-Stratton, Reid, &
Hammond, 2001a), child and teacher interventions (Foster et al., 2007), and child and teacher
and parent interventions (Foster et al., 2007). Results focused on impact on childrens behavior
problems in home (Drugli & Larsson, 2006; Foster et al., 2007; Webster-Stratton et al., 2001a)
and school (Drugli & Larsson, 2006; Foster et al., 2007; Webster-Stratton et al., 2001a) settings,
62
and increases in childrens social skills (Drugli & Larsson, 2006; Niles et al., 2008). A number
of the studies reported long-term follow-ups (Drugli & Larsson, 2006; Niles et al., 2008;
Webster-Stratton et al., 2001a).
Combining implementation of the Incredible Years Parent Programme and the Dinosaur
School curriculum in a clinical setting produced different results for young children, ages fourto eight-years-old, than implementation of the parenting component alone (Drugli & Larsson,
2006). Families receiving the combined treatment saw more significant reductions in child
aggression than those families receiving parent-only treatment or in the wait-list control group.
Post-treatment, children receiving the combined interventions showed a drop in clinical-level
conduct problems displayed in daycare and preschool settings and experienced a greater increase
in social problem solving skills than other comparison groups. These results were not fully
maintained at one-year follow-up: children in the combined treatment experienced rebound in
aggression scores and the number of children with behaviors falling within the clinical range,
though the levels remained lower than pre-intervention levels. Interestingly, while children in
the combined-treatment condition showed stable levels of social problem-solving from
intervention end to follow-up, children in the parent-treatment-only condition experienced
increases in positive social problem-solving during this time period.
The Chicago Child-Parent Center (CPC) program included preschool and primary grade
classrooms with relatively low child-to-staff ratios, a focus on development of language and
math skills, and multiple formats of childrens instruction (Niles et al., 2008). It also included an
intensive parent involvement component with parent education, classroom volunteering,
attendance at special events, support for further educational attainment, home visits, and a health
and nutrition component. At follow-up, a significant gender impact was notedwith boys
63
showing greater benefit than girls from program participation. Early adolescent boys who had
participated in the program as preschoolers showed significantly lower levels of acting out
behavior and lower levels of total problem behaviors than boys in a comparison group who had
not participated in the program. Additionally, families identified as high-risk and children who
attended the program for more than a year showed a greater degree of benefit than families of
lower-risk status and children who attended the program for one year or less.
When combining implementation of twelve weekly sessions of the Incredible Years
Parent Program with implementation of six monthly day-long training sessions for Head Start
teachers, behavioral improvements were evident in preschool children, parents, and teachers
(Webster-Stratton et al., 2001a). When compared to peers in the control condition, children
whose parents and teachers received training showed fewer behavioral problems at home and
school, a greater percentage moved from high to low range for negative behaviors, and
observations indicated that 95.5% (in comparison to 55.6%) experienced at least a thirty-percent
reduction in non-compliance and negative behaviors in their preschool classroom. Over twice as
many parents participating in the parent education piece displayed a thirty-percent drop in
critical statements when compared to peers not participating in the parent education piecein
general these parents showed lower levels of negative parenting and higher levels of positive
parenting than controls. Additionally, teachers participating in trainings showed more positive
and less harsh classroom management techniques.
At one-year follow-up during childrens kindergarten year, families who continued with
booster sessions of parent training appeared to be at higher-risk initially when compared to
controls (e.g., higher percentage of past alcohol/drug abuse, higher baseline of negative life
events, higher baseline for childrens behavior problems at home; Webster-Stratton et al.,
64
2001a). These mothers who attended the booster sessions continued to show significantlyincreased levels of positive parenting and decreased levels of negative parenting. Additionally,
eighty-percent of their children (in comparison to 58% of controls) fell below the at-risk cutoff for conduct problems at home. When comparing results from various combinations of
interventions, Foster et al. (2007) determined that a combination of parent and teacher
intervention was the most cost-effective approach to prevention, noting that at start-up it would
cost roughly $3000 per child (with lower costs for subsequent cohorts once materials were
purchased and staff trained).
The cost of intervention falls substantially below the estimated financial and societal
costs of not providing appropriate programming to support the needs of children who are at
riskincluding factors such as child abuse, decreased earnings potential from high school dropout, crime-and substance-abuse related costs, and cost of care for chronic medical conditions
(Cohen, Piquero, & Jennings, 2010; Temple & Reynolds, 2007). For example, the lifetime cost
of abuse or neglect of a child was estimated to be between $250,000 and $285,000 and the
lifetime costs of an individuals drug abuse and alcohol dependence were about $700,000 each
(Cohen, Piquero, & Jennings, 2010). Loss of earnings potential from high school drop-out was
estimated to cost between $211,062 (Temple & Reynolds, 2007) and $450,000 (Cohen, Piquero,
& Jennings, 2010).
The sample sizes ranged from 127 (Drugli & Larsson, 2006) to 1387 (Niles et al., 2008).
Two of the study samples were predominantly Caucasian (Drugli & Larsson, 2006; Foster et al.,
2007), one sample was predominantly African American (Niles et al., 2008), and one sample was
more racially diverse (Webster-Stratton et al., 2001a). Two of the study samples were lowincome, drawing from programs with entrance criteria related to this demographic variable
65
(Niles et al., 2008; Webster-Stratton et al., 2001a). It appears from these studies that combining
interventions may be an effective and cost-effective way to design early intervention programs
for young children at risk for later emotional-behavioral difficulties. Interventions may be most
effective when accompanied by some form of follow-up or booster programming to help
maintain behavioral changes. Further research with more diverse samples is warranted to
replicate findings and enhance generalizability.
Trajectories and Impact of Challenging Behavior into the K-12 Years
For some children, early challenging behaviors follow a trajectory of continued socialemotional difficulties and academic challenges in classroom contexts. Longitudinal studies have
sought to track the patterns and impacts of early internalizing (Fischer et al., 1984; Egeland,
Kalkoske, Gottesman, & Erickson, 1990; Williams et al., 2009), externalizing (Campbell &
Ewing, 1990; Campbell, Spieker, Burchnial, Poe, & NICHD Early Child Care Research
Network, 2006; Egeland et al., 1990; Fischer et al., 1984; Lavigne et al., 2001), and regulatory
disordered (Bron, Van Rijen, Van Abeelen, and Landbregste-Van Den Berg, 2012) behavior.
Egeland et al. (1990) found that preschool children with behavioral problems developed
into first and second grade students whose academic achievement fell significantly below their
control peers who had not demonstrated preschool behavioral problems. Generally, the students
who had initially demonstrated externalizing behavior demonstrated the worst social-emotional
and academic performance, the children who had initially demonstrated no pattern of behavior
problem had the best performance on social-emotional and academic measures, and those who
had initially demonstrated internalizing behavior had social-emotional and academic
performance that fell somewhere in between the two extremes. In third grade, over 70% of the
66
preschool children who had challenging externalizing behavior continued to demonstrate

significant behavioral problems.
Egeland et al. (1990) found elementary students who defied the trendsthose whose
behaviors had improved since preschool as well as those who did not have behavioral problems
in preschool but later developed them during their primary school years. Children who had
demonstrated behavioral problems in preschool and were doing well in elementary school came
from homes that were organized, predictable, provided access to stimulating and age-appropriate
toys and books, and where there was a warmer emotional climate than there peers who continued
to demonstrate significant behavioral problems. These children had mothers who showed
decreasing levels of depression from preschool into the elementary school years. Children who
did not have behavioral problems in preschool but later developed them came from homes that
offered a poorer-quality emotional climate, less developmental stimulation, a poorer language
environment, and higher levels of family stress than their peers who continued to display no
significant behavioral problems. Mothers from these homes had significantly higher depression
scores when their children were in third grade.
Campbell and Ewing (1990) found that forty-seven percent of children who continued to
demonstrate challenging behavior from preschool to age nine were receiving some form of
remedial or special education services. The families of children who continued to have
significant challenging behavior were also significantly more likely to seek outside support from
mental health and/or pediatric professionals than families whose children demonstrated declines
in behavioral problems or those in the control group whose children did not have challenging
behavior in preschool. Although all children (controls as well as those who had challenging
preschool behavior) showed an equitable likelihood to have internalizing behavior at age nine,
67
children who had demonstrated externalizing behavioral problems at ages three and six were
significantly more likely to continue to meet DSM criteria for an externalizing disorder at age
nine. Externalizing symptoms relating to AD/HD, conduct disorder, and oppositional defiance
were the most persistent. This finding echoes that of an earlier study (Fischer et al., 1984) that
found on follow-up at ages 9-15 that preschool externalizing behavioral problems were much
more predictive of non-normative similar behaviors for both boys and girls than early
internalizing behaviors were. Maternal report of infant temperament, negative maternal control
when the child was three-years-old, consistent parent-report of challenging behavioral
symptoms, and higher levels of family stress when the child was three-years-old were associated
with ratings of significant externalizing behavior problems at age nine (Campbell & Ewing,
1990). Maternal report of infant temperament, negative child behavior and non-compliance at
age three, and ongoing family stress were associated with internalizing behavior problems at age
nine.
Williams et al. (2009) found that children with high levels of behavioral inhibition at
fourteen-months of age had a steeper increase of internalizing behaviors through the time they
were four-years-old and then maintained that higher level of internalizing behavior through age
seven. Children with high initial scores in behavioral inhibition also decreased more quickly
than average in the number of externalizing problems over time, while their peers who had low
scores initially in behavioral inhibition had a slower-than-average decrease in externalizing
problems over time.
Campbell et al. (2006) found that stable levels of physical aggression from toddlerhood
through twelve years of ageeven if those stable levels are lowpredicted poorer social and
academic outcomes than those exhibiting very low levels of aggression or following a decreasing
68
trajectory. Children maintaining high-stable levels of aggression constituted the smallest group
of children but also faired the worst in later childhood. These children were five-times as likely
as children who initially had very low levels of aggression to meet diagnostic criteria for AD/HD
and three-times as likely to meet criteria for Oppositional Defiance Disorder. Teachers rated
these children with high-stable levels of aggression as low in social skills and high in
internalizing and externalizing behaviors and they scored lower on the Woodcock-Johnson
achievement tests than any other group. Self-reports from the children indicated a higher level of
depression than their very low-aggression peers and a decreasing friendship quality from ages
nine to twelve, a period when most children reported increases in friendship quality. Children
with low- and moderate-stable trajectories also were reported to have poorer social skills, more
externalizing behaviors, and scored lower on the Woodcock-Johnson than children with very low
levels of aggression. They were more likely to meet criteria for AD/HD and more likely to selfreport risky behaviors and bullying other children.
When tracking children from preschool through approximately age eight, Lavigne et al.
(2001) found that early diagnosis of ODD was associated with later singular diagnosis of ODD
and with comorbid diagnosis of ODD with AD/HD, an anxiety disorder, or a mood disorder.
Having an early diagnosis of ODD tripled the chances of a child having a later diagnosis of
ODD, with or without comorbidity. At each of the five waves of the study, between 50% and
60% of the children initially screening above the 90th percentile for Total Problems on the Child
Behavior Checklist met criteria for a diagnosis. It was noted that some of the shift from wave to
wave took place because children had moved between the subthreshold and threshold categories.
Bron et al. (2012) found that children identified with regulatory disorders during their
infancy through preschool years exhibited significantly more internalizing, externalizing, and
69
total behavioral problems in middle childhood and into adolescence when compared to norm
groups. Parents and teachers reported that half of the girls who had been identified as regulatory
disordered demonstrated significant externalizing behavioral problems and that close to 40% of
the boys demonstrated significant internalizing behavioral problems. Both boys and girls were
significantly more likely to be identified as having internalizing problems (e.g., affective
problems, anxiety problems) and externalizing problems (e.g., AD/HD, oppositional defiance
problems, and conduct problems) than were peer norms. The only environmental factor that was
a significant predictor was low maternal SES, which was correlated with externalizing and total
problem scores.
Children and youth receiving special education services for a primary disability of
emotional or behavioral disturbance/disorderwere largely male and demonstrated an overrepresentation of African American students. These students were reported to have had
approximately a three-year delay between parent report of initial difficulty (average age of 4.6
years) and receipt of special education services (average age of 7.8 years; Wagner, Kutash,
Duchnowski, Epstein, & Sumi, 2005). Approximately one-third of elementary and middle
school students and thirty percent of high school students with a primary disability of emotional
or behavioral disturbance received preschool ECSE services. According to parent report, over
one-quarter of these students had leaning disabilities, approximately one-third had difficulty with
conversational skills, and 30-44% had difficulty understanding what others said. Although less
than eleven percent were noted to have low cognitive skills, widespread academic
underachievement in reading and math was common (Nelson, Benner, Lane, & Smith, 2004;
Wagner et al, 2005). Students with externalizing behavioral problems more most likely to
demonstrate significant academic underachievement (Nelson et al., 2004).
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Students receiving special education services for a primary disability of emotional or

behavioral disturbance had parents who are significantly more likely than peers with other
disabilities or the general student population to come from families living in poverty, to come
from single-parent households, to have a head of household who was unemployed, and to have
the added stress of at least one other family member with a disability (Wagner et al, 2005).
These students were significantly more likely than their peers with other disabilities to be
reassigned to different schools by their school districts and to be suspended or expelled from
school. Parents of these students were significantly more likely than parents of children with
other disabilities to report spending a lot of effort to obtain the services their children need and
they were almost twice as likely to have been involved in mediation and due process hearings to
get the services they felt their children needed.
Study samples were identified in a number of ways: random sampling (Wagner et al.,
2005), follow-up of clinical or screening samples (Bron et al., 2012; Lavigne et al., 2001),
convenience samples (e.g., maternity ward, daycare; Campbell et al., 2006; Fischer et al., 1984;
Nelson et al., 2004), and recruitment via the mail or public call for study participants (Campbell
& Ewing, 1990; Williams et al., 2009). Final sample sizes fell into the following ranges 32 to 46
(Bron et al., 2012; Campbell & Ewing, 1990), 96 to 155 (Egeland et al., 1990; Nelson et al.,
2004; Williams et al., 2009), 391 to 541 (Fischer et al., 1984; Lavigne et al., 2001), and 1364 to
2158 (Campbell et al., 2006; Wagner et al., 2005). When noted, a few of the studies reported a
sample mix of Caucasian and minority ethnicities (Campbell et al., 2006; Lavigne et al., 2001;
Wagner et al., 2005), two studies reported primarily Caucasian samples (85+%; Nelson et al.,
2004; Williams et al., 2009) and another (Bron et al., 2012) took place in the Netherlands so is
likely to be heavily Caucasian although no mention of racial breakdown was made.
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Due to the relatively small number of studies with different research foci and resultant
lack of significant findings convergence, this author cautions against making interpretations
beyond that some behavioral trajectories begun in the early childhood years continue to have
impact on children as they move through the K-12 school system. The recruitment methods,
sample sizes, and sample mix for these studies is not randomly representative enough for this
author to feel that the findings can be generalized without further verification from additional
studies showing areas of convergence.
Recommendations for Application
This recommendations for application section is divided into two subsections
discussion of findings and recommendations. The first section presents a discussion of the
literature review, integrating findings from the research and drawing out implications for
creation of a program model to actively work to promote young childrens social-emotional
wellbeing, thereby reducing risk for preschool and daycare expulsion. The second section
contains outline of a program model and related rationale for ways to approach prevention and
early intervention efforts. Although there is a precedent for statewide implementation of
prevention programs focused on early childhood mental health in both Michigan (Carlson et al.,
2012) and Colorado (Hoover et al., 2012), this paper focuses on a significantly smaller
geographical and systems scale. This author has grown up and spent much of her career working
with children and adolescents in the city of Minneapolis, Minnesota; for this reason this
geographical area is the focus of the application recommendations presented.
According to the 2010 Census, the city of Minneapolis saw a slight increase in the
percentage (from 6.6% to 6.9%, or from 25,187 to 26,453 individuals) of population under fiveyears-old since 2000 (City of Minneapolis 2000 and 2010 demographic profile, 2011), with an
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estimated 33,131 families in the city having children under the age of six-years-old (2010
American Community Survey 1-year estimates, 2010). During the same period, the number of
children served by Minneapolis Public Schools EI/ECSE program increased from 656 children to
849 students (Planning for changing enrollment, 2010). This translates into a 2010 EI/ECSE
service rate of roughly 3.21% of the citys population, birth to five-years of agesomewhat
below an estimated service rate of 3.87% for the state as a whole that year (13,743/355,363;
Minnesota Department of Education, 2011; US Census, 2010).
The citys population increase coincided with a small decrease in the percentage of
people identifying as whitefrom 65.1% to 63.8%and a moderate increase in the Hispanic or
Latino populationfrom 7.6% to 10.5% (City of Minneapolis 2000 and 2010 demographic
profile, 2011). Other demographics in the city included Black (18.6%), Asian (5.6%), American
Indian and Alaska Native (2%), Hawaiian or Other Pacific Islander (greater than zero), and two
or more races (4.4%). According to the 2010 American Community Survey one-year estimates
(2010), the fertility rates of these racial demographics in the city vary greatly, with African
American (90 per 1000 live births) and Hispanic/Latino (95 per 1000 live births) birth rates
significantly higher than the birth rates of the white population (47 per 1000 live births).
Although information on the racial breakdown for different age categories is not available on the
Census or American Community Survey websites, the higher birth rates for minority populations
indicates to this author that the early childhood population is likely to be more racially diverse
than the citys population as a whole.
This demographic picture is complicated by the fact that racial populations are not evenly
distributed throughout the city, resulting in many neighborhood pockets that are primarily white
(e.g., Bryn-Mawr with 89.4% white, Fulton with 90.56% white, and Kenwood with 90.81%
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white) and primarily non-white (e.g., Central with 78.95% non-white and most heavily
Hispanic/Latino and African American, East Phillips with 83.4% non-white and most heavily
Hispanic/Latino and African American and Native American, and Near-North with 86.43% nonwhite and most heavily African American and Asian and Hispanic/Latino) (Census 2010
redistricting file summary data, 2011). The home languages spoken in Minneapolis is also
important to attend to as 45.6% of the population whose home language was not English were
estimated to speak English less than very well (Language spoken at home, 2010). These
demographic and housing patterns are important to take into account when considering the
applicability of research findings and design of prevention efforts, as different strategies and
resources may be best directed in different ways in different parts of the city.
According to the 2010 American Community Survey one-year estimates (2010), 10.8%
of the citys population 25-years-old and older had less than a high school diploma, 18.4% had a
high school diploma or equivalency as their highest level of education, 19.3% had some college
but no degree, 7% had an associates degree, 28.1% had a bachelors degree, and 16.5% had a
graduate or professional degree. The poverty rate for those 25-years-old and over was correlated
with the level of educational attainment: 47% those with less than a high school diploma lived in
poverty, with the greatest impact being on women (59.5% vs. 35.9%); 26.4% of those with a
high school diploma were living in poverty, again with a greater share of those in poverty being
women (27.3% vs. 25.6%); 16.9% of those with some college or an associates degree lived in
poverty, once again repeating the higher percentage of women in the poverty category (19.5%
vs. 14.3%); lastly, 6% of those with a bachelors degree or higher were living in poverty, though
in this case men had the higher poverty rate (6.5% vs. 5.5%) though overall the poverty rate was
still vastly lower than those with less formal education.
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This information on the correlation of educational levels and poverty rates is important
when considering the correlations between the racial breakdowns of neighborhood outlined
above and the poverty levels of those same neighborhoods historically. For example: in Bryn
Mawr, whose population was 89.4% white, the poverty level was 2% (Poverty: Bryn
Mawr/Minneapolis, 1999); in Fulton, whose population was 90.56% white, the poverty level was
2% (Poverty: Fulton/Minneapolis, 1999); in Kenwood, whose population was 90.81% white, the
poverty level was 3% (Poverty: Kenwood/Minneapolis, 1999); in Central, whose population was
78.95% non-white, the poverty level was 29% (Poverty: Central/Minneapolis, 1999); in Phillips,
whose combined population was 79.06% non-white (the neighborhood was split into East
Phillips and Phillips West between the time the poverty rates and the 2000 census occurred), the
poverty level was 34% (Poverty: Phillips/Minneapolis, 1999); and, in Near-North, whose
population was 86.43% non-white, the poverty level was 38% (Poverty: Near
North/Minneapolis, 1999).
These patterns of higher racial diversity being paired with higher poverty levels (and,
presumably, lower levels of educational attainment) may have an unusually large impact on the
citys early childhood population due to the higher birth-rates in a number of non-white
populations and the risk that poverty and related stresses appear to play on young childrens
development. Because of this, attention to these demographic characteristics of Minneapolis
population will play an important role in discussion of implications of research findings.
Discussion of Findings
This discussion of findings is broken into the same six subheadings that were used in the
literature review. It takes an integrative approach to synthesizing the research base and drawing
75
out considerations for the development of programmatic efforts to prevent and early intervene in
young childrens trajectories of challenging behaviors.
Early childhood mental health. There is a broad research base relating to the
development of young childrens challenging behaviors, representing a variety of theoretical
models and research approaches. Areas of exploration include prevalence rates, early correlates
to internalizing and externalizing behaviors, comorbidity between disorders and delays, and
unfolding of developmental trajectories. Two broad themes that emerge from this research base
include a set of environmental risk factors that interact in unique ways with specific child
characteristics to manifest significant internalizing and externalizing behaviors and an
interconnection of language development, self-regulation, and social-emotional development.
When considering the longitudinal findings noted in this research base, it may be worthwhile to
consider that parents of children with challenging behaviors have reported frustration at delays of
up to two- (Rosenzweig et al., 2002; Worcester et al., 2008) to three- (Wagner et al., 2005) years
between statement of their initial concerns and having medical and/or school personnel take their
concerns seriously enough to begin delivery of supportive services.
In general, the pathways of internalizing and externalizing disorders are traced separately
in terms of correlates and trajectories within the research base and so this is how they will be
presented in this discussion sectionexamination of externalizing behaviors (which have the
strongest correlation with early childhood expulsion) is first and internalizing behaviors second.
Discussion will then turn to the connection between language development, self-regulation, and
social-emotional development. Lastly, comorbidity between behavioral disorders and other
domains will be touched on.
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Externalizing behaviors. Prevalence rates for clinically-significant externalizing

disorders in young children ranged from 2.2% (Larson et al., 1988) to 26.4% (Keenan et al.,
1998) in community sampleswith higher percentages noted for young children falling in a
subthreshold category just short of diagnostic criteria, as well as for clinic-referred samples. The
first years of life appear to hold critical correlates to the development of externalizing disorders,
with the average age of onset of serious disturbance (e.g., ODD, CD) among clinic-referred
samples being between twenty-six and twenty-eight-months (Keenan & Wakschlag, 2000).
As early as birth to six-weeks post-partum, longitudinal studies have found factors such
as low gestational age (Robinson et al., 2008), measures of home environment (Larson et al.,
1988), maternal report of baby blues symptoms (Robinson et al., 2008), maternal sense of lack
of social support and help (Larson et al., 1988), and family SES (Larson et al., 1988; Robinson et
al., 2008) linked to the later development of preschool externalizing disorders. Three- to sixmonth old infants scoring high in frustration, sadness, motor activation, and with low reactivity
were found to develop externalizing behavior problems in the preschool years (Garstein et al.,
2012). Eight- to eleven-month-old infants identified as regulatory disordered were found to have
higher levels of hyperactivity, attention problems, and severe emotional or behavioral difficulties
as preschoolers when compared to peers who were not identified with early regulatory disorders
(Dale et al., 2011; Degangi et al., 1993). When compared to other regulatory disordered
children, those who developed the most severe behavioral problems in the preschool years had
exhibited higher levels of cardiac vagal tone in infancy. Parental report of difficult temperament
in infancy has also been found to predict externalizing symptoms up into the elementary school
years (Campbell & Ewing, 1990).
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Externalizing behavioral problems in preschoolers were correlated with factors present at

fourteen- to eighteen-months of age, including difficult temperament (Keenan et al., 1998), high
levels of reactivity (Garstein et al., 2012), negative emotionality (Garstein et al., 2012; Gilliom &
Shaw, 2004; Mathiesen et al., 2009), low levels of effortful control (Garstein et al., 2012;
Willoughby et al., 2011), high levels of aggression and non-compliance (Keenan et al., 1998),
high caregiver stress level (Larson et al., 1988), a parental sense of lack of support (Larson et al.,
1988; Mathiesen et al., 2009), and lack of father involvement (Keenan & Wakschlag, 2000;
Larson et al., 1988). These early indicators appeared to act as risk factors, with studies often
citing different combinations of factors in relation to preschoolers externalizing behavioral
problems. As young children move from toddlerhood into the preschool years, some similar risk
factors continued to be correlated with externalizing behaviors. For example, Anthony et al.
(2005) found that high parental stress level paired with high expectations for their children was
correlated with severe externalizing behaviors manifested in preschool classroom settings.
Another environmental factor that appears correlated with preschool externalizing behaviors in
family food insecurity (Whitaker et al., 2006).
While externalizing behaviors typically follow a decreasing trajectory from toddlerhood
through the preschool years, this is not always the case. For example, Gilliom and Shaw (2004)
noted two combinations of child and parent factors that were correlated with high-stable levels of
externalizing behaviors from two- to six-years of age: at-risk boys who were both low in
fearfulness and high in negative emotionality, paired with high levels of negative maternal
control; and, at-risk boys who were both low in fearfulness and low in negative emotionality,
paired with high levels of negative maternal control. Mathiesen et al. (2009) found that high
levels of negative emotionality in a child, when paired with low levels of partner support for the
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parent, predicted a higher-than-typical slope for externalizing behaviors between eighteen

months and four-and-a-half years. Shaw and Vondra (1995) found that high ratings of maternal
depression across the infant and toddler years was associated with high levels of externalizing
behaviors in three-year-old boys.
When considering this research base in relation to the diverse populations of Minneapolis
it is worth noting thatwith exception of the research on regulation, which draws from largely
middle class samplesa majority of the studies drew from primarily low-income populations.
The most frequently represented racial demographics were Caucasian and African American,
with limited inclusion of some Hispanic/Latino and multi-racial population within the samples.
Although Minneapolis does have some neighborhoods that are primarily lower or upper income,
as well as heavily Caucasian or African American, these findings would not be able to be totally
generalizable across the city without further research with more diverse samples to further
validate findings. Instead, they would best be used to identify some risk factors that may be
well-attended to when initially designing prevention efforts, with flexibility to adjust as
experiences with the local demographics indicates need for.
When considering design of prevention efforts in Minneapolis it seems that it would be
important to target efforts aimed to prevent or early intervene in the trajectories of externalizing
behaviors in the first years of lifefrom birth even. When looking for infants and toddlers that
may be at increased risk, aspects of temperament and regulation would likely be good factors to
screen for. Additionally, environmental factors relating to maternal wellbeing, family stress
level, and sense of support appear to play a role in development and/or maintenance of high
levels externalizing behavioral problems in some children. It would, therefore, be useful to
account for some level of intervention at the family levelperhaps through interagency
79
partnerships that provided for physical and mental healthcare services and/or assistance with the
development of family support systems within the community. An additional component that
may be beneficial is consideration of the goodness of fit between young childrens temperament
and the parenting style of their caregivers, with possible coaching/educational opportunities to
help caregivers adjust their styles to better match their young childs needs.
Internalizing behaviors. Prevalence rates for clinically-significant internalizing
disorders in young children ranged from 2.5% (Larson et al., 1988) to 14.9% (Keenan et al.,
1998) in community sampleswith higher percentages noted for young children falling in a
subthreshold category just short of diagnostic criteria. As with externalizing disorders, the first
years of life appear to hold important implications for the internalizing trajectories that
ultimately unfold. Post-partum measures of factors such as home environment (Larson et al.,
1988), family SES (Robinson et al., 2008), maternal behaviors (Larson et al., 1988), maternal
reports of baby blues symptoms (Robinson et al., 2008), and a maternal sense of lack of social
support and help (Larson et al., 1988) have been linked to the later development of preschool
emotional disorders (Larson et al., 1988). Three- to six-month old infants scoring high in anger,
sadness, fear, frustration, low reactivity, and poor regulatory control were found to develop
internalizing behavior problems in the preschool years (Garstein et al., 2012). Parental report of
difficult temperament in infancy also predicted internalizing behavioral symptoms into the
elementary school years (Campbell & Ewing, 1990).
Internalizing behavioral problems in preschoolers have been correlated with a variety of
factors present at fourteen- to eighteen-months of age, including difficult temperament and
elevated levels of non-compliance (Keenan et al., 1998), high levels of behavioral inhibition
(Garstein et al., 2012; Mathiesen et al., 2009; Williams et al., 2009), and high parental stress
80
level and maternal depression (Mathiesen et al., 2009). Individual and environmental indicators
appear to act as risk factors, with studies often citing specific combinations of factors in relation
to preschoolers internalizing behavioral problems. Williams et al. (2009), for example, found
that permissive parenting of a young child with high levels of behavioral inhibition was strongly
correlated with development of increased internalizing behaviors. In some studies,
environmental factors alone appeared to have a great deal of influence on the development of
internalizing disorders. For example, OBrien et al. (2004) found that African American
preschoolers whose parents denied effects of racism experienced higher levels of behavioral
problems such as depression and anxiety. This connection between race and internalizing
behavior was also found by Robinson et al. (2008), who noted increased likelihood of
internalizing behaviors for preschool children whose mothers were not Caucasian. Another
environmental variable tied to significant internalizing behaviorsin both children and their
motherswas family food insecurity (Whitaker et al., 2006).
While internalizing behaviors typically follow a slowly increasing trajectory from
toddlerhood through the preschool years, this is not always the case. For example, Gilliom and
Shaw (2004) found that children who scored high in both negative emotionality and fearfulness,
when combined with high levels of negative maternal control, began with and maintained high
levels of internalizing behaviors from two- through six-years of age. In this same study, children
who scored high in both negative emotionality and fearfulness, when combined with low levels
of negative maternal control, experienced a much steeper increase in internalizing behaviors
from ages two- through six-years. Mathiesen et al. (2009) found that increasing levels of family
stress, emotionality, and shyness starting at eighteen-months of age predicted steeper increases of
internalizing behaviors through four-and-a-half years of age. In this same study, increasing
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levels of maternal depression during the toddler period (18-30 months) predicted steeper
increases of internalizing behaviors through four-and-a-half years of age. Shaw and Vondra
(1995) found that measures of temperament at one- and two-years of age predicted internalizing
behaviors in three-year-old girls.
When considering this research base in relation to the diverse populations of
Minneapolis, as a whole these studies represent a relatively wide range of family income levels.
A majority of the studies were conducted with largely Caucasian samples, with the next largest
representation being African American populations. Only one study included any Hispanic or
multi-racial populations in its sample. Although the economic ranges of Minneapolis
population may be well-represented in this research base, caution should be taken not to overgeneralize findings to culturally-diverse populations without further evidence to its applicability.
That being said, there are some general themes that may be useful in the planning of prevention
programming, with acknowledgement that adjustments may be necessary to meet the specific
needs of different demographics.
When considering design of prevention efforts in Minneapolis it seems important to
target efforts aimed to prevent or intervene early in the trajectories of internalizing behaviors in
the first years of lifefrom birth even. Many of the early risk factors for internalizing disorders
appear similar to those discussed above for externalizing disorders, so the basic intervention
methods would likely be able to be quite similarscreening for temperamental and regulatory
disorder characteristics in infants and toddlers, collaborating in provision of physical and mental
healthcare services for families, and working to develop a sense of social support for caregivers.
For internalizing disorders, it does appear that caregiver mental health may play a larger role
than it does for externalizing disorders, so it would be important that access to services in a
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relatively non-stigmatizing setting was available. Fear, inhibition, and shyness in young children
also seem to play a fairly significant role in development of internalizing disorders so it may be
beneficial to build in some opportunities for infants and toddlers to practice interacting with
other youngsters in a safe environment with their primary caregivers present.
Language, self-regulation, and social-emotional development. As speech and language
develop rapidly into the third year of life, there is indication that this domain becomes
increasingly intertwined with social-emotional development. As discussed earlier, children with
regulatory disorders in infancy have been found to be at increased risk for development of
externalizing behavioral problems (Dale et al., 2011; Degangi et al., 1993). Once children begin
talking, strong correlations have been found between self-regulation abilities and language
development and usage (Valloton & Ayoub, 2011; Winsler et al., 2003).
Winsler et al. (2003) found that preschool children whose private speech during problemsolving tasks was largely unrelated to the task at hand were rated by teachers as having poorer
social skills and more behavioral problems than peers with more task-relevant and/or internalized
private speech. These children were also observed to have a greater degree of negative affect
and spend significantly less time engaging in goal-directed activities than their peers. Vallotton
and Ayoub (2011) found that vocabulary level at twenty-four-months of age predicted the degree
of self-regulation for girls at thirty-six-months and the growth rate of self-regulation skills for
boys through thirty-six-months of age. The impact of vocabulary level on self-regulation
development was greatest for boys: boys with low vocabulary levels had self-regulation skills
that remained substantially lower than both girls with low vocabulary levels and boys with
higher vocabulary levels. This is an interesting finding considering that boys were found to be
significantly more likely to be expelled from early childhood programs than girls (Gilliam, 2005;
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Greenberg & Ash, 2011), and that a majority of expulsions were reportedly due to externalizing
behaviors (e.g., Buck & Ambrosino, 2004; Hoover et al., 2012; Upshur et al., 2009) which have
been tied to poor self-regulation (Dale et al., 2011; Degangi et al., 1993).
Beyond research focusing specifically on the connections between language and selfregulation, others have noted connections between known communication delays and disorders
and social-emotional problems in toddlers (Baker & Cantwell, 1982; Carson et al., 1997; Tervo,
2007), preschoolers (Baker & Cantwell, 1982; Cohen et al., 1993; Tevenson & Richman, 1978;
Willinger et al., 2003), older children (Baker & Cantwell, 1982; Cohen et al., 1993; Cohen et al.,
1998), and young adults (Beitchman et al., 2001). This apparent cormorbidity of communication
and behavioral symptoms across age demographics is interesting to consider in the context of
research on K-12 students being served for a primary disability of emotional or behavioral
disturbanceapproximately one third of whom were reported to have difficulty with
conversational skills and 30-44% of whom were reported to have difficulty with receptive
communication (Wagner et al., 2005).
Social-emotional problems were found for some children with expressive language
disorders (e.g., Beitchman et al., 2001; Cohen et al., 1998; Willinger et al., 2003), receptive
language disorders (Cohen et al., 1993; Tervo, 2007), mixed expressive-receptive language
disorders (Cohen et al., 1993; Tervo, 2007; Willinger et al., 2003), and mixed speech-language
disorders (Baker & Cantwell, 1982)though generally not for speech disorders alone. The most
common behavior problems for children with communication delays and disorders included
social skill deficits (e.g., Cohen et al., 1998; Stevenson & Richman, 1978; Tervo, 2007), anxiety
disorders (e.g., Baker & Cantwell, 1982; Beitchman et al., 2001; Carson et al., 1997), and social
withdrawal (e.g., Baker & Cantwell, 1982; Cohen et al., 1993; Willinger et al., 2003). Attention
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problems (e.g., Cohen et al., 1998; Stevenson & Richman, 1978; Willinger et al., 2003),
hyperactivity (Cohen et al., 1993; Cohen et al., 1998; Stevenson & Richman, 1978), and thought
problems (Willinger et al., 2003) were also noted in a number of studies. Although sometimes
reported in those with solely expressive language disorders (Willinger et al., 2003), aggression
and oppositional behaviors were most notably present in those with receptive or mixed
expressive-receptive language disorders (Cohen et al., 1993; Tervo, 2007).
Studies of children in psychiatric clinic samples found unsuspected language impairments
in 34.4% (Cohen et al., 1993) to 40.3% (Cohen et al., 1998) of those without previously
identified language impairments. The criteria used to identify these unsuspected language
impairments was 2 SD below the mean in one area or 1 SD below the mean in two areas, as
measured by standardized language tests. Children with previously unsuspected language
impairments were more likely to have mothers with low education levels (Cohen et al., 1998)
and come from single-parent homes (Cohen et al., 1993) than their peers with known language
impairments and with no language impairments. This is interesting to consider in light of
research that found that less than ten percent of mothers in a high-risk sample reported
developmental concerns about their young children who were subsequently identified as
developmentally delayed (Smith et al., 2010)in this study, accurate knowledge of child
development was found to increase the likelihood that mothers would report concerns about their
childs development.
Children with previously unsuspected language impairments were most likely to have
been referred for externalizing behaviors (e.g., oppositional behaviors, aggression, hyperactivity;
Cohen et al., 1993). It is important to note, though, that in general the most common reason for
any psychiatric clinic referral was externalizing behaviors (Cohen et al., 1998). Children with
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previously unsuspected language impairments had scores that fell between those with known
language impairments (who generally had the most severe symptoms) and those with no
language impairment on measures of social competence (Cohen et al., 1998), attention problems
(Cohen et al., 1998), social withdrawal (Cohen et al., 1998), and verbal IQ scores (Cohen et al.,
1993).
Identifying children with previously unsuspected language impairments brought the
percentage of children with language impairments up to approximately 67.7% (270/399) of the
clinic-referred sample of four- to twelve-year-old children in one study (Cohen et al., 1993) and
66.1% (251/380) of the clinic-referred sample of seven- to fourteen-year-old children in another
study (Cohen et al., 1998)a high rate of correlation for those with potentially-clinicallysignificant psychiatric concerns. Children with language impairments came from families with
lower SES backgrounds and had mothers with lower educational levels than their peers without
language impairments (Cohen et al., 1993). As a whole, children with language impairments
were most likely to have combined expressive-receptive impairments, with a smaller percentage
having receptive impairments alone, and very few having expressive impairments alone.
As may be expected with receptive language impairments, children with unsuspected
language impairments and those with previously identified language impairments made
significantly more errors than their non-language impaired peers on tasks requiring listening to
stories and then pointing to the correct picture of the emotion represented in it (Cohen et al.,
1998). Children with language impairments also demonstrated more difficulty than their nonlanguage impaired peers in defining problems in hypothetical situations, identifying the feelings
of participants in the situation, identifying obstacles that may prevent a social problem from
being resolved, and identifying when the problem was completely resolved.
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As a whole, these studies do not accurately represent the population characteristics found
in many Minneapolis neighborhoodsparticularly those that are composed primarily of lowincome and non-Caucasian populations. A majority of studies used primarily middle-income
populations in their samples, though there were others that used samples with more dispersed
income levels. Not all studies listed racial or ethnic composition, but those that did were
primarily Caucasian. Very limited numbers of African American, Hispanic, Asian, or other
racial demographics were noted. Findings are, therefore, only used tentatively as an indication
of some areas to consider in planning for prevention efforts with full acknowledgement that
additional research will be needed to determine the specific needs and applications more
apparent for specific cultures, language-groups, and communities.
When considering design of prevention efforts in Minneapolis it would seem that, due to
the possibility of high comorbidity, it would be wise to screen for language delays in children
who have been noted to have behavioral challenges. It also seems prudent to provide caregiver
training and support in the creation of language-rich environments for all young children starting
from infancy, perhaps working collaboratively with pediatric staff, parent educators, and early
childhood mental health consultation specialists to develop instructional materials and/or a media
awareness campaign. Lastly, when implementing behavioral interventions for children most at
risk for expulsion, it seems important to make the most out of possibilities for communication
skills developmentsuch as building vocabulary, communicative turn-taking, and interpreting
non-verbal communication.
Comorbidity. Comorbidity was found between externalizing disorders (CD, ODD, and
AD/HD) in a clinic-referred preschool sample (Keenan & Wakshlag, 2000). Young children
with challenging behaviors have also been found to have comorbid delays in a variety of other
87
areas including play skills (Montes et al., 2012), social relations (Bulotsky-Shearer et al., 2011),
cognitive skills (Bulotsky-Shearer et al., 2011; Montes et al., 2012), motor skills (BulotskyShearer et al., 2011; Montes et al., 2012), and speech/language development (Cohen et al., 1993;
Montes et al., 2012)placing them at risk for poor classroom outcomes in early childhood
settings (Bulotsky-Shearer et al., 2011; Montes et al., 2012) and beyond through the K-12 years
(Nelson et al., 2004; Wagner et al., 2005). The finding of developmental delays in multiple
domains, especially in the heavily low-income preschool sample used by Bulotsky-Shearer et al.
(2011) is reminiscent of other research that found a statistically-significant relationship between
poverty and developmental delays emerge by two-years of age (Rosenberg et al., 2008). This
finding is also reminiscent of research by Baker et al. (2003) that found increased levels of
clinically-significant and persistent externalizing and internalizing behaviors in preschool
children ages three- to four-years-old. The presence of behavioral problems in this sample
predicted subsequent parental stress level, which in-turn predicted subsequent child behavioral
problem levels after accounting for earlier child behavioral problems.
Minneapolis, the samples were primarily low income and from Caucasian, African American,
and Hispanic/Latino background. This does not represent the economic diversity or full range of
cultural diversity across the city, so caution should be taken not to over-generalize findings
without further confirmation with the groups and individuals being worked with. When
considering design of prevention efforts in Minneapolis, it appears that children manifesting
challenging behaviors may be at risk for co-morbid delays in other areas. It would, therefore, be
well-advised to do comprehensive early childhood screenings to become aware of all areas of
development that may be able to benefit from early intervention so as to not just treat behavioral
88
symptoms, but better prepare children as whole-beings for success in social, academic, and other
lifelong endeavors.
Early childhood program expulsion. Despite the limited nature of this research base,
there are some definite themes and areas of convergence that should be attended to when
considering the design and delivery of preventative program approaches. All studies found
expulsion rates from early childhood programs to be substantially higher than the comparable
local expulsion rates for K-12 public school populations. Home daycares (Greenberg & Ash,
2011; Hoover et al., 2012) and private/for-profit preschool programs (Gilliam, 2005; Greenberg
& Ash, 2011) had higher levels of expulsion rates than publicly-funded early childhood
programs. When considering the reports of parents of children in the early childhood through K12 years, a majority of children with challenging behaviors were not currently being served in
childcare settingseither because their child was asked to leave or because they withdrew their
child out of fear that the child would be asked to leave (Rosenzweig et al., 2002; Rosenzweig et
al., 2008). This may indicate a continuing pattern of exclusion (forced and/or felt) from nonpublic school care settings continuing into the K-12 years. This is not particularly surprising, as
longitudinal studies have found that persistence rates of challenging behaviors tend to be fairly
high (e.g., Campbell & Ewing, 1990; Egeland et al., 1990; Lavigne et al., 2001).
Here in Minnesota, Gilliam (2005) found expulsion rates from Head Start programs to be
4.16 per 1000 young children and expulsions from public school readiness programs to be 2.92
per 1000 young childrenboth rates substantially higher than the statewide K-12 expulsion rate
of 0.76 per 1000 students. In this study, state-level analysis for expulsions from private
preschool programs was not reported and no data was collected relating to daycare programs, so
it is quite possible that these state-level figures underestimate the number of expulsions from
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early childhood programs happening in Minnesota. It is unclear from the parent-report literature
whether parents of children with challenging behaviors in Minnesota continue to experience
exclusion from non-public school care settings as their children growno state-specific data was
reported.
Boys were significantly more likely to be expelled than their female counterparts
(Gilliam, 2005; Greenberg & Ash, 2011). This may be a reflection of gender differences in
development that appear to place boys in a higher-risk category for slower development of selfregulation capacity (Vallotton & Ayoub, 2011; Winsler et al., 2011). Children of color were also
more likely to be expelled than their non-Hispanic Caucasian peers (Gilliam, 2005; Greenberg &
Ash, 2011). Analysis of parent report data indicated that minority ethnicity appeared to increase
the likelihood of childcare-related employment problems occurring (Montes & Halterman,
2008), which may be in part a reflection of this increased level of expulsion and difficulty
finding suitable back-up childcare.
Externalizing behaviorssuch as hurting self or others (Buck & Ambrosino, 2004;
Greenberg & Ash, 2011; Hoover et al., 2012), being disrespectful/defiant (Buck & Ambrosino,
2004; Hoover et al., 2012), and destroying or damaging property (Buck & Ambrosino, 2004;
Hoover et al., 2012)were most often reported by providers as those of concern. This is
consistent with findings from intervention literature that noted that externalizing behaviors were
the most common reason for referral (Perry et al., 2008; Upshur et al., 2009). There were also
some internalizing behaviors noted by providers as being of concern, primarily signs of
depression and withdrawn behaviors (Hoover et al., 2012). In all, providers reported that
approximately 11% of young children in their care had exhibited these types of significant
challenging behaviors over the past year (Greenberg & Ash, 2011; Hoover et al., 2012). This
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figure appears to be realistic, as it falls in the middle of prevalence rates of clinically-significant

behavioral disorders found in young children drawn from community samples.
While strategies reported for addressing these challenging behaviors were predominately
reactionary (e.g., talking to the child, giving a time-out, and talking to the parents; Buck &
Ambrosino, 2004; Greenberg & Ash, 2011; Hoover et al., 2012), early care providers did report
interest in receiving further information and/or training on how to better work with children with
challenging behaviors (Buck & Ambrosino, 2004; Hoover et al., 2012). This is an important
finding given that intervention studies noted improved child outcomes from training and support
provided to early childhood providers (e.g., Raver et al., 2009; Webster-Stratton et al., 2008).
Additionally, there was a correlation between reported access to mental health consultation and
lower levels of expulsion for early childhood programs (Gilliam, 2005; Greenberg & Ash, 2011;
Hoover et al., 2012). Intervention literature further supports the idea that access to mental health
consultation services reduces the number of expulsions from early childhood programs (Perry et
al., 2008; Upshur et al., 2009).
Taken together, these findings indicate that there is likely to be a mismatch between some
young childrens social-emotional needs and the resources of their early care providers. While
publically-funded early care programs have been found to have lower rates of expulsion than
their private and/or for-profit counterparts, the expulsion rates in these settings have consistently
been higher than local rates of expulsion from public K-12 school programs. It appears that
children exhibiting externalizing behaviors and boys are most likely to be expelled from early
care programs. Additionally, children of minority ethnicities may be at increased risk for
expulsion when compared to their non-Hispanic Caucasian peers. Although many early care
providers may currently lack sufficient resources to meet the needs of young children with
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challenging behaviors, there is indication of a willingness to learn new techniques and evidence
that mental health consultation can lower the rates of early childhood program expulsion.
Minneapolis, the samples are likely acceptably comparable to the populations enrolled in early
childhood programs as studies all used either random sampling or blanket surveys to licensed
early care facilities in their geographical regions. When considering the context of Minneapolis,
it would be important for prevention efforts to be implemented through inter-agency
collaboration that includes both publically-funded early childhood programs and private
preschool and daycare programs spread throughout the city. Although it may be beneficial to
have a core area of focus on strategies to effectively support the development of boys, there may
be a need for more specialized types of training or caregiver supportaround topics related to
culturally-appropriate practice, for exampleto be provided in different neighborhoods,
depending on whether a majority of children attend early care programs close to home or close to
where their parent(s) may work.
Family perspectives on impact of behavior-related child care problems. Family
studies involved parent and grandmother report of the impact of childcare problems for young
children and youth with challenging behaviors. Young children and youth with challenging
behaviors were generally not cared for in typical childcare settings. Instead, they received care
in a variety of settings such as public special education programs (Freedman et al., 1995; Montes
& Halterman, 2008; Rosenzeig et al., 2002), home-based care (e.g., nannies, PCAs; Freedman et
al., 1995; Rosenzeig et al., 2002; Rosenzeig et al., 2008), neighbor care (Freedman et al., 1995;
Montes & Halterman, 2008), sibling care (Rosenzeig et al., 2002; Rosenzeig et al., 2008), and
primary caregiver care (Rosenzeig et al., 2002; Rosenzeig et al., 2008). Some primary
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caregivers reported a high-level of stress associated with special education participationfor

example, feeling that they needed to fight to get appropriate services for their child, that school
personnel did not know how to deal with their childs behavior, and that the school called them
at work about every little behavior incident (Rosenzeig et al., 2002; Wagner et al., 2005;
Worcester et al., 2008). Other primary caregivers reported more positive interactions with early
intervention and school-based service providers (Worcester et al., 2008).
Primary caregivers reported a number of employment-related challenges due to difficulty
finding sufficient and reliable childcare for their young children and youth with challenging
behaviors. Missed time at work (Montes & Halterman, 2011; Worcester et al., 2008),
diminished work performance (Montes & Halterman, 2011; Rosenzweig et al., 2002), needing to
cut down hours at work (Freedman et al., 1995; Rosenzweig et al., 2002; Worcester et al., 2008),
inhibited career advancement (Freedman et al., 1995; Rosenzweig et al., 2002; Worcester et al.,
2008), and needing to quit their job to care for their child (Freedman et al., 1995; Montes &
Halterman, 2011) were some of the most frequently cited challenges. These employment-related
challenges are important to consider when looking at research on K-12 student populations
served under the category of emotional or behavioral disturbance which finds that the head of
household of these students are more likely than parents of children with other disabilities to be
unemployed and living in poverty (Wagner et al., 2005).
Childcare-related employment challenges contributed to financial strain (Montes &
Halterman, 2011; Rosenzweig et al., 2002; Worcester et al., 2008), a sense of social isolation
(Worcester et al., 2008), and high stress levels (Freedman et al., 1995; Rosenzweig et al., 2002;
Worcester et al., 2008). Although a causal link cannot be made, correlations have been found
between parental stress levels (Anthony et al., 2005; Larson et al., 1988; Mathiesen, 2009) and
93
sense of lack of social support (Larson et al., 1988; Mathiesen, 2009) and development of severe
challenging behaviors in young children. It is possible, therefore, that adding in childcare-related
employment strains on top of existing challenges of parenting a child with challenging behaviors
may serve to exacerbate childrens existing behavioral challenges. In fact, research by Hart and
Kelley (2006) found that maternal work-family conflict and parenting stress was associated with
parent report of internalizing and externalizing symptoms in a community daycare sample of
young children ages one- to four-years.
Minneapolis, it is important to note that the samples used were primarily Caucasian or African
American, living in married and/or two-parent households, and middle-income or higher in
Socio-Economic Status. While these demographic characteristics represent a percentage of
Minneapolis population, it is possible that families in the city who have a sole-primary caregiver
and those already sitting in a lower-income bracket may face a greater degree of challenge
resulting from inability to find reliable care for a child with challenging behaviors. Additionally,
it is unclear how representative the experiences related in these studies may be to those
experienced by other demographics in the city, including the increasing Latino population and
more established Native American and Asian populations, as well as more recent immigrants
such as those from East Africa.
When considering design of prevention efforts in Minneapolis, it appears important to
create systems that support stability of care for young children so as to help families maintain
employment stability. It would also likely be beneficial to help primary caregivers maintain or
further develop support systems to cope with their childrens challenging behaviors and the
added family strain that they are likely to contribute to.
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Early intervention and early childhood special education. Prevalence rates of

developmental delays have been found to range from 12% (Rosenberg et al., 2008) to 23%
(Smith et al., 2010) for infants twelve-months of age or younger and from 13.8% (Rosenberg et
al., 2008) to 30% (Smith et al., 2010) for toddlers twenty-four months of agewith substantially
higher rates (47%; Rosenberg & Smith, 2008) found in a population investigated by the child
welfare system. Criteria for determining delays in these studies was aligned with criteria in the
moderate states, of which Minnesota is one, translating into 1.5 SD below the mean in one
domain or 1 SD below the mean in two domains (Rosenberg et al., 2008; Rosenberg & Smith,
2008) or, alternatively, a 25% delay in one domain or 20% delay in two domains (Smith et al.,
2010). It was noted that these prevalence rates were likely to be underestimates because none of
the studies considered all five domains which can be used to qualify children for services as
developmentally delayed. This possibility of underestimate is not difficult to imagine when
considering that significant social-emotional problems have been found in excess of 20% of the
general population under three-years-old and that these behavioral problems tend to be persistent
(Briggs-Gowan et al., 2006; Rose et al., 1989). No significant gender differences were noted in
prevalence rates for developmental delay. As noted earlier in discussion, by two years of age,
children coming from families living below the poverty level were showing an increased rate of
developmental delay (Rosenberg et al., 2008).
Service rates have fallen significantly below prevalence rates for young children with
developmental delays, with 10.1% (Rosenberg et al., 2008) to 46% (McManus et al., 2009) of
children with developmental delays receiving services. Young children receiving services were
most likely to be boys (Blanchard et al., 2006; Delgado & Scott, 2006; McManus et al., 2011)
with preschool-age boys over twice as likely to be receiving services as similarly-aged girls
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(Individuals with Disabilities Education Act Data, 2010). This is a striking finding given that no
significant gender differences were noted for general prevalence rates of developmental delay.
Young children receiving special education services were likely to demonstrate relatively severe
delays or disabilities (McManus et al., 2009; McManus et al., 2011). In general, young African
American children were found to be under-represented among those receiving services (Chan &
Obnsorg, 1999; Delgado & Scott, 2006; McManus et al., 2011; Rosenberg et al., 2008). While
some studies found higher rates of service for children living above the poverty line (McManus
et al., 2009; McManus et al., 2011), this was not a universal finding (Rosenberg et al., 2008).
The exact reasons for the gap between prevalence rates and service rates is not clear,
although studies have given some clues as to what may contribute to this difference. While up to
20% of parents in a nationally-representative sample reported developmental concerns about
their young children under five-years-old (Blanchard et al., 2006), evidence has been found that
high-risk samples who lack accurate knowledge of child development are far less likely to
express concerns about their childrens development. Less than ten-percent of mothers in a highrisk sample expressed developmental concerns about their twelve- to twenty-four-month-old
children who were subsequently identified by researchers as having developmental delays (Smith
et al., 2010). This is a notable finding with implications for the future, as low maternal education
level alone has been found to account for up to 19% of special education placements for tenyear-old children (Hollomon, Dobbins, & Scott, 1998).
Sadly, mothers reported that even more infrequent concerns over development had been
expressed by their childrens doctors (Smith et al., 2010). Despite the American Academy of
Pediatrics (AAP) issuing a 2001 policy statement calling for members to do universal
developmental screening with standardized screening tools as part of routine well-child care, in
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follow-up research only 23% of pediatricians reported doing so a majority of the time (Sand et
al., 2005). This is interesting to consider given that many primary caregivers reported frustration
about pediatricians and others not taking their behavioral concern seriously, resulting in reported
delays of up to two- to three-years between initial caregiver concern and later diagnosis and
support (Rosenzweig et al., 2002; Wagner et al., 2005; Worcester et al., 2008). If young
childrens delays are not recognized by caregiversas well as by pediatriciansthan it is
unlikely that appropriate referral for further evaluation and possible services would be made
(Sand et al., 2005; Smith et al., 2010).
Noting the low-rates of adherence with the AAPs policy statement, efforts have been
made to implement universal screening in early childhood well-child visits (King et al., 2010;
Schonwald et al., 2009). Record reviews found that these efforts increased screening rates,
though the level of increase varied depending on specific clinics. Medical providers reported
that the PEDS (a brief parent report instrument) was easy to use, saved time during clinic visits,
and provided structure to discussion of parental concerns (Schonwald et al., 2009). Clinics that
tracked the results of referrals found that families often did not understand the reason for the
referral, that many families did not follow through on the referral, that their efforts resulted in
better communication with local referral resources, and that a larger number of children were
being identified and gaining access to services through their developmental screening and
surveillance efforts (King et al., 2010). Noted areas of challenge with implementation included
needing to have an interpreter to assist some parents in filling out the form and parents that failed
to fill out the form in the waiting room (e.g., they forgot or needed to watch small children;
Schonwald et al., 2009) and difficulty consistently screening during busy times (such as flu
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season) and when short-staffed and/or training new staff members in on procedures (King et al.,
2010).
Another factor cited for variation in identification and service rates was different stateby-state eligibility criteria (McManus et al., 2009; Rosenberg et al., 2008; Smith et al., 2010).
Even within the state of Minnesota, however, there was a fairly wide-range of participation rates
for birth-to-three populations from county to county (Chan & Obnsorg, 1999). Some correlates,
such as lower identification rates in counties that had higher percentages of African American
populations, were noted to possibly reflect a lack of access or acceptance for EI.
Because the Chan and Obnsnorg (1999) study was over a decade old, this author turned
to the 2010 state census (US Census, 2010) and special education child-count (Minnesota
Department of Education, 2011) data to gain insight on current service patterns. It is important
to note that, unlike Chan and Obnsnorg (1999), the present method includes the entire population
birth through age 5 so may not account for difference in service patterns for birth-3 and 3-5
populations. In 2010, Minnesota children birth through age five appeared to be underrepresented in EI/ECSE programs if they were white (75.76% of the population, comprising
70.44% of those served), Asian (5.55% of the population, comprising 3.65% of those served), or
Multi-Racial (3.57% of the population, comprising 3.48% of those served) and over-represented
in EI/ECSE programs if they were Native American (1.47% of the population, comprising 2.18%
of those served), Black (8.28% of the population, comprising 9.83% of those served), or
Hispanic (9.27% of the population, comprising 10.22% of those served).
Federal legislation has tried to increase access to EI for children in high-risk categories.
The Keeping Children and Families Safe Act (P.L. 108-36) of 2003 and the Individuals with
Disabilities Education Act (P.L. 108-446) of 2004 mandated referrals of all infants and toddlers
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who experienced substantiated cases of abuse or neglect (Derrington & Lippitt, 2008). This
federal mandate was expected to bring an additional 96,000 referrals into the countrys EI
systems, with 1,201 of those referrals coming into Minnesota (an estimated increase of 30.85%).
Considering that children involved with the child welfare system who had unsubstantiated
reports of abuse and neglect had rates of delay similar to those with substantiated cases
(Rosenberg & Smith, 2008) and that, conservatively, only 46% of infants and toddlers exhibiting
delays in the general population were currently receiving services (McManus et al., 2009), a
large gap between likely incidence and service rates is evident.
Minneapolis, it holds up well. The samples were generally rather large and representative of the
general population, either drawn through random selection methods or over-all review of
existing records such as birth certificates and service records for broad geographical areas of
interest. There was more research focused specifically on the birth-to-three period than that for
the preschool years, but given that a majority of the early indicators and correlates for later
behavioral challenges stem from this early period this weight on the early prevalence and
identification rates is not concerning to this author. When considering design of prevention
efforts in Minneapolis, themes that readily emerge are a need for better early screening
procedures, a need for community education on typical development so that more consistent
referrals to screening and/or assessment will be made, and a need to increase evaluation and
service capacity within Early Intervention and Early Childhood Special Education programs.
Interventions models. Many intervention models have been used to address young
childrens challenging behaviors through direct instruction in social skills and self-regulation
techniques, teacher training and support, and parent educationas well as a variety of
99
combinations of the aforementioned. These interventions have primarily been implemented in

community and classroom settings (Ashdown & Bernard, 2012; Barnett et al., 2008; Diamond et
al., 2007; Domitrovich et al., 2007; Gunter et al., 2012; Lobo & Winsler, 2006; Niles et al., 2008;
Perry et al., 2008; Raver et al., 2009; Upshur et al., 2009; Webster-Stratton et al., 2001a;
Webster-Stratton et al., 2008; Winsler, Ducenne, & Koury, 2011), although some have taken
place in clinical settings (Drugli & Larsson, 2006; Karoly & Rosenthal, 1977; Webster-Stratton
et al., 2001b). The exact skills and topics focused on in training varied among the different
intervention models depending on their underlying philosophies and overall goals for the types
of change they were designed to enact.
Common elements to direct interventions with children included explicit discussion of
topics related to social skills (Ashdown & Bernard, 2012; Domitrovich et al., 2007; Gunter et al.,
2012; Webster-Stratton et al., 2001b; Webster-Stratton et al., 2008), modeling of social and/or
problem-solving skills (Ashdown & Bernard, 2012; Webster-Stratton et al., 2001b; WebsterStratton et al., 2008), use of childrens literature related to the lessons theme (Gunter et al.,
2012; Webster-Stratton et al., 2001b), use of puppets or stuffed animals as participants and to
help with modeling (Ashdown & Bernard, 2012; Gunter et al., 2012; Webster-Stratton et al.,
2001b; Webster-Stratton et al., 2008), role-play practice of the discussed social and/or problemsolving skills (Ashdown & Bernard, 2012; Webster-Stratton et al., 2001b), extension activities
beyond whole-group lessons (e.g., art activities, games; Domitrovich et al., 2007; WebsterStratton et al., 2008), and letters to parents and/or teachers explaining key concepts from the
lessons and how to support them in other settings (Gunter et al., 2012; Webster-Stratton et al.,
2001b). In general, interventions of longer duration, as well as those with components integrated
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throughout childrens classroom experience instead of isolated to specific lessons, appeared to

produce the greatest degree of benefit.
Incredible Years and Dinosaur School. The Incredible Years training program for
teachers (Raver et al., 2009; Webster-Stratton et al., 2001a; Webster-Stratton et al., 2008) and
parents (Drugli & Larsson, 2006; Webster-Stratton et al., 2001a), as well as its child-focused
instructional component called the Dinosaur School Curriculum (Drugli & Larsson, 2006;
Webster-Stratton et al., 2001b; Webster-Stratton et al., 2008), were the most heavily represented
intervention model in this literature revieweither implemented alone or in combination with
additional intervention elements. This intervention was implemented in both clinical settings as
well as community classroom settings (most often Head Start classrooms).
Noted benefits of Dinosaur School implementation included reduction in conduct
problems (Webster-Stratton et al., 2001b; Webster-Stratton et al., 2008), improved school
readiness (Webster-Stratton et al., 2008), larger gains in the number of positive feelings children
could identify (Webster-Stratton et al., 2008), and larger gains in the number of positive
strategies children could generate (Webster-Stratton et al., 2008) when compared to peers in
control conditions. Differential effects were noted, with children with one or more family stress
risk factors showing lower levels of improvement both initially and at one-year follow-up than
their peers with no family stress risk factors (Webster-Stratton et al., 2001b), children with the
lowest levels of school readiness skills showing the greatest increases in school readiness skills
(Webster-Stratton et al., 2008), and children with the highest level of conduct problems showing
the steepest decline in the number of conduct problems (Webster-Stratton et al., 2008).
Noted benefits to teachers receiving Incredible Years training included demonstrating
more emphasis on social/emotional teaching in the classroom (Webster-Stratton et al., 2008),
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more warmth and affection towards children (Webster-Stratton et al., 2001a; Webster-Stratton et
al., 2008), and a less harsh and inconsistent management style (Webster-Stratton et al., 2001a;
Webster-Stratton et al., 2008). As with the impact on children, impact on teachers showed
differential effects with teachers who were initially the most harsh showing the greatest degree of
improvement (Webster-Stratton et al., 2008). Children whose teachers received training based
on the Incredible Years demonstrated significantly fewer internalizing and externalizing behavior
problems by the end of the year (Raver et al., 2009). A differential effect on the children, similar
to that found by Webster-Stratton et al. (2001b), was noted where children with two or more risk
factors beyond poverty did not show statistically significant behavioral improvement. In general,
girls and Hispanic children showed the greatest degree of behavioral improvement in Raver et
al.s (2009) study.
When the Incredible Years Parent program was implemented with parents in combination
with either Incredible Years for teachers (Webster-Stratton et al., 2001a) or Dinosaur School
(Drugli & Larsson, 2006), improvements were noted in the behaviors of children, parents, and
teachers. When both children and parents received the intervention, there was a greater
reduction in childrens aggression and larger increase in problem-solving skills in comparison to
the other two conditions (parent-only training and wait-list control; Drugli & Larsson, 2006). At
one-year follow-up, children in families receiving the combined intervention experienced a
rebound in aggression levels, though levels remained lower than before the interventions, and
they showed stability in social problem-solving abilitywhile those whose parents only received
Incredible Years training showed an increase in social problem-solving skills during this time.
When parents and teachers received Incredible Years training, children experienced a drop in
non-compliance and negative behavioral problems in home and classroom settings (Webster-
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Stratton et al., 2001a). Participating parents showed a large drop in critical statements, lower
levels of negative parenting, and higher levels of positive parenting. Mothers who attended
voluntary booster sessions during their childs kindergarten year continued to show decreased
levels of negative parenting and increased levels of positive parenting. Teachers showed similar
effect, with decrease in harsh classroom management and increase in more positive techniques.
Minneapolis, it is important to note that three of the five studies had samples that were primarily
(or entirely) low-income and multi-racial. The other two studies were on interventions
implemented in clinical settings with primarily Caucasian samples from middle- and upper-class
backgrounds. When looking at the city as a whole, these studies over-represent low-income and
ethnic minority populations. When matching individual studies to demographics of specific
neighborhoods, more ready comparison may be able to be made based on the racial and
economic stratification present.
When considering design of prevention efforts in Minneapolis, it appears that Incredible
Years and Dinosaur School is one approach that may hold promise for use with teachers, parents,
and/or children. This intervention may not be as effective for children facing multiple family
risk factors, so either those other risk factors should be addressed simultaneously or perhaps a
different intervention model altogether considered for families facing multiple risk factors.
Attention should also be paid to providing some kind of ongoing support or booster sessions to
help prevent drop-off effects noted at one-year follow-up. It is also worth noting that WebsterStratton et al. (2001a) found more consistent parent participation rates when implementing the
intervention in a Head Start setting than when implemented in a clinical setting, speculating that
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this was because the universal intervention in the community had less stigma attached than
attending small-group sessions in a clinical setting.
Programs designed to develop childrens self-regulation skills. Community-based
direct child-intervention models have been explored for their impact on young childrens selfregulation skills. While one of these models (the Tools curriculum; Barnett et al., 2008;
Diamond et al., 2007) is integrated throughout a childs classroom day, the other involved more
infrequent special lessons of shorter duration (Winsler et al., 2011). Both intervention models
demonstrated positive effects on childrens self-regulation skills under some conditions and had
some noted benefit and/or manifested effect in language.
The Tools curriculum integrates elements such as play planning and other scaffolding
techniques to help develop mature socio-dramatic play and use of external mediators (e.g.,
pictures, modeling and using explicit private speech) to aid children in behavioral regulation
(Barnett et al., 2008; Diamond et al., 2007). When compared to control peers in classrooms
using standard district preschool curriculum, children participating in classrooms using the Tools
curriculum performed a half-deviation lower on measures of internalizing and externalizing
behaviors (Barnett et al., 2008) and performed significantly better on tasks that required use of
executive functioning skills (Diamond et al., 2007). Moderate-sized effects on English and
Spanish language development in these children was found (Barnett et al., 2008). Additionally,
there was indication that teachers in Tools classrooms were demonstrating a greater degree of
responsiveness to childrens academic and emotional needs and better management of
instructional time and routines.
Winsler et al. (2011) found a dosage effect for Kindermusik program participation
children who had been in the music and movement program longer and for a more substantial
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portion of their lives performed better on laboratory tasks requiring self-regulation skills.
Children who had participated in the program engaged in more private speech (95% vs. 71%)
and attempted less social engagement with the experimenter (5% vs. 18%) than those who had
not participated in the programboth factors associated with better performance on selfregulation tasks. Current enrollment in Kindermusik programming was also associated with
better self-regulation skills and these children engaged in more relevant private speech. This is
notable because Winsler et al. (2003) had found that children with largely task-relevant private
speech had better social skills and fewer behavioral problems than children with more taskirrelevant private speech. Winsler et al. (2011) also found a differential impact on irrelevant
private speech based on gender, with a wide gap (25% vs. 8%) noted between boys and girls who
were not currently enrolled in the Kindermusik program and a much narrower gap (14% vs. 9%)
for boys and girls currently enrolled in the program. This differential gender impact is
reminiscent of Vallotton and Ayoubs (2011) finding that vocabulary level was more critical to
self-regulation development of boys than for that of girls andtaken togethermay indicate a
particular need for prioritizing boys for early self-regulatory and language intervention in light of
limited programmatic resources.
Minneapolis, it is important to note that three of the five studies had samples that were primarily
(or entirely) from low-income backgrounds, one drew from a mixed-income sample, and one
drew its sample from primarily middle- and upper-income populations. Although the samples
were racially diverse and even included Spanish-language measures (a rarity in studies
reviewed), this economic skew indicates that caution should be taken in generalization of
findings to middle- and upper-income populations. When considering design of prevention
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efforts in Minneapolis, the most ready implication is that trajectories for young childrens selfregulation development are not fixedtherefore, early intervention aimed at self-regulation
skills can be effective. Additionally, there is indication that young boys may be impacted most
significantly by interventions in this domain.
Early childhood mental health consultation. Different structures have been used to
provide early childhood mental health consultation to preschool and daycare providers. These
efforts have sought to reduce the severity of young childrens challenging behaviors and
decrease the incidence of early childhood expulsion. One program used universal screening with
a standardized instrument as part of the deciding factor for which children to refer and provided
an average of four- to six-months of services (assessment, direct work with children, parent
consultation and therapy, teacher consultation, and parent-teacher team meetings; Upshur et al.,
2009). The other program had children referred by teachers or others and did not involve formal
screening until the intake process for services was underway and the entire assessment and
intervention process lasted approximately three months (assessment, teacher consultation and
modeling of strategies, drafting a written report of recommendations, and providing general
teacher training in working with children with challenging behaviors; Perry et al., 2008).
Both studies found children were most likely to be referred for concerns about
externalizing behaviors and reported that referred children received benefits from program
participation, including decreased levels of externalizing behaviors. Upshur et al. (2009) also
reported decreased levels of maladaptive behaviors and increased levels of adaptive behaviors.
Differential effects were noted in this studychildren with the highest initial levels of
aggression and developmental delay showed the largest improvements from program
participation. Perry et al. (2008) also noted decreased levels of internalizing behaviors and
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increased proficiency in social skills. Both Perry et al. (2008) and Upshur et al. (2009) found
significant reductions in the number of program expulsions following program implementation.
The Chicago School Readiness Project also included mental health consultation as part of
its multi-component teacher intervention (Raver et al., 2009). A majority (80+%) of teachers
reported that the training and mental health consultation was helpful in their work with children
whose behavior was difficult and allowed them to devote time to individual children needing
extra help. Overall, children in the program showed significant reductions in internalizing and
externalizing behavior problems by the end of the school year, though a differential effect was
noted with children who experienced two or more risk factors in addition to poverty not showing
statistically significant behavioral improvement.
Minneapolis, two of the three studies had ethnically and economically diverse samples while the
third study drew its sample from an ethnically diverse low-income population. Overall, the
studies appear reasonably-well representative of the citys racial demographics though none
discussed home-language, which could limit generalization of findings to some populations
within the city. When considering design of prevention efforts in Minneapolis, it appears that
early childhood mental health consultation is an intervention model that has demonstrated
effectiveness in decreasing many young childrens challenging behaviors and reducing early
childhood expulsion rates in some contexts.
Other single-mode interventions. A variety of approaches have been taken in the
education of children (Domitrovich et al., 2007; Gunter et al., 2012; Ashdown & Bernard, 2012;
Lobo & Winsler, 2006) and parents (Cunningham et al., 1995; deGraaf et al., 2008; Dishion et
al., 2008; Fletcher et al., 2011; Kardy & Rosenthal, 1977; Nixon et al., 2004; Rapee et al., 2005;
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Shaw et al., 2006) to promote better social-emotional adjustment and behaviors of young
children. PATHS (Domitrovich et al., 2007), Strong Start Pre-K (Gunter et al., 2012), and YCDI
(Ashdown & Bernard, 2012) are all structured child-oriented curricula with a series of topical
lessons centered around social-emotional themes. Lobo & Winsler (2006) took a different
approachdesigning a dance and creative movement intervention where children practiced skills
such as control of their bodies and responding to movement directions that they speculated
would carry over into the regular preschool classroom setting as improved behavior and social
skills. FCU (Dishion et al., 2008; Shaw et al., 2006) and Triple P (deGraaf et al., 2008; Fletcher
et al., 2011) were two of the more widely-reviewed parent education interventions to address
externalizing behaviors, though researchers investigated the benefits of a variety of other clinical
and community interventions designed to address internalizing (Rapee et al., 2005) and
externalizing (Cunningham et al., 1995; Kardy & Rosenthal, 1977; Nixon et al., 2004) behaviors
in young children.
In comparison to control peers, children in classrooms implementing the PATHS
curriculum showed improved ability to identify feelings, demonstrated a wider receptive
vocabulary related to emotions, reduced anger attribution bias, and lowered ratings of
internalizing behaviors (Domitrovich et al., 2007). On further analysis it was found that children
with higher verbal abilities appeared to benefit the most from the intervention, with those with
lower verbal abilities performing similarly to peers in the control classrooms. Given that many
studies found comorbidity between language disorders and social emotional problems
(Beitchman et al., 2001; Cohen et al., 1998; Tervo, 2007; Willinger et al., 2003), this seeming
failure to achieve equitable social-emotional gains from the intervention begs the question of
whether additional communication-focused intervention delivered prior toor concurrently
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withthe social-emotional curriculum may result in more substantial social-emotional gains for
this subset of children.
In comparison to control peers, children in classrooms implementing the Strong Start PreK curriculum showed statistically-significant decreases in internalizing behaviors and classroom
conflict (Gunter et al., 2012). The greatest impact was found for children when booster sessions
were implemented. In comparison to control peers, children in classrooms implementing the
YCDI curriculum were reported to have higher levels of social skills and social-emotional
wellbeing (Ashdown & Bernard, 2012). There was no statistical decrease in Total Behavior
Problems, but this intervention was also the shortest of those reviewed in the literature (three
lessons a week for two weeks), so this fits with the general trend that longer and more
comprehensive interventions brought about more significant behavioral changes.
Lobo and Winsler (2006) created a dance and creative movement curriculum around the
concepts of body (e.g., parts, shapes, balance), movement (i.e., locomotion), space (e.g., place,
size, direction), time (i.e., speed, flow), force (i.e., weight, combinations, staying in place), and
form (e.g., abstract, narrative). In comparison to control peers, children participating in this
intervention showed larger decreases in internalizing and externalizing behaviors and increases
in social competence. Although this intervention was not presented as a self-regulation booster,
one has to wonder whether some of the behavioral improvements manifested may be related to
development of increased levels of relevant private speech (as found with the Kindermusik
program; Winsler et al., 2011) and/or an increase in vocabulary that has been related to the
amount and speed of self-regulation development (Vallotton & Ayoub, 2011).
Brief home-based intervention using the FCU prevention/intervention model was found
to increase parent interaction (Shaw et al., 2006) and use of positive behavioral support strategies
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(Dishion et al., 2008), as well as lower the level of problem behavior growth as toddlers moved
through the preschool years (Dishion et al., 2008; Shaw et al., 2006). Rapee et al. (2005) used a
clinical approach to intervention of preschool internalizing behaviors. They found that the more
parent education sessions mothers attended, the more significant the drop in their childrens
anxiety disorders at one-year follow-up.
The Triple P program has five levels of parent involvement (deGraaf et al., 2008;
Fletcher et al., 2011). Level 4 Triple P programming had moderate to large effects on childrens
behavior, both immediately post-intervention and at 6-12 month follow-up, with the largest longterm effects in samples that were less than 60% boys and where the initial behavior problem
scores were highest (deGraaf et al., 2008). While mothers showed equitable improvement in
parenting practice from all formats of Triple P, fathers showed the most substantial benefit from
participation in the Stepping Stones format and showed no benefit from the self-directed format
(Fletcher et al., 2011).
Educating parents on behavior modification principles was found to enhance parental
reports of family cohesion and to significantly decrease the occurrence of target behaviors in
children (Kardy & Rosenthal, 1977). Trained observers blind to treatment and control conditions
corroborated reports of significant decreases in problematic behaviors targeted by parents. PCIT
was a more recent clinical intervention found to reduce mothers use of coercive discipline,
reduce oppositional behaviors in children, and reduce the amount of stress children caused for
their mothers (Nixon et al., 2004).
Minneapolis, it is important to note that a majority of the studies were conducted with samples
that were primarily low-income. Although the childrens curriculum studies had samples that
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were ethnically diverse, this lack of economic diversity makes it unrealistic to try to generalize
findings to a majority of the citys population. The samples used for parent education studies
were generally more ethnically homogenous than those used in studies of childrens programs.
Additionally, unlike some of the other interventions discussed previously, these were single
studies on specific models without additional studies to corroborate findingsmaking attempts
at generalization, in general, a risky feat. When it comes to implications for prevention efforts in
Minneapolis, the best that can be tentatively said is that child-directed interventions of longer
duration appear to be most likely to bring benefit, that language may be a mediating factor in the
effectiveness of some interventions, and that parent training can improve both parenting practice
and childrens behavioral patterns.
Multi-modal interventions. Many multi-model interventions were comprised of varying
combinations of Incredible Years training for parents (Drugli & Larsson, 2006; Webster-Stratton
et al., 2001a) and teachers (Webster-Stratton et al., 2001a), as well as Dinosaur School
curriculum with young children (Drugli & Larsson, 2006). Because these interventions and their
outcomes were discussed above, they will not be revisited at any length in this section.
The Chicago Child-Parent Center (CPC) program combined specialized preschool and
primary school classroom settings with an intensive parent-involvement component (Niles et al.,
2008). Upon follow-up in early adolescence, a significant gender differential was found. Boys
appeared to benefit the mostdemonstrating significantly lower levels of acting out behaviors
and lower levels of Total Problem Behaviors than boys in the comparison group. Families who
were identified as high-risk and children who had participated in the program for more than
one year showed more benefit than families of lower risk status and children who participated for
one year or less. The finding that boys derived greater benefit from intervention is consistent
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with findings from another model (Winsler et al., 2011), as is the finding that longer-term
participation in intervention offers greater benefit (Gunter et al., 2012; Webster-Stratton et al.,
2001b; Winsler et al., 2011). The finding that those at most risk or with most significant needs
derived greater benefit from intervention is similar to findings from some other interventions
(Upshur et al., 2009; Webster-Stratton et al., 2008), but contradictory to the findings of others
(Raver et al., 2009; Webster-Stratton et al., 2001b).
When comparing costs and benefits of implementation of Incredible Years and Dinosaur
School curricula to multiple audiences (i.e., teachers, parents, and children), Foster et al. (2007)
determined that the most cost-effective combination was to provide training to teachers and
parents. The start-up cost was pegged at approximately $3000 per child, with decreasing costs
for each subsequent cohort of teachers and parents trained. This cost falls far below the
estimated economic and social costs of not providing programs addressing the needs of children
who are at risk (e.g., the lifetime cost of abuse or neglect of a child was estimated to be between
$250,000 and $285,000; Cohen et al., 2010).
Minneapolis, it does not well-represent the citys diversity as one study had a sample that was
primarily low-income African American while the other had a primarily Caucasian sample.
Findings can therefore not be generalized to the citys population as a whole, though some
tentative implications may be made based on convergence with other studiesprimarily that
more long-term interventions may offer a greater degree of benefit to children and that
depending on details of the interventionthose with the most risk-factors may or may not draw
benefit from it so attention should be paid to addressing the multiple risk-factors present in
attempt to reach maximal benefit. Additionally, though it may seem expensive at the front-end,
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design and implementation of effective interventions to address young childrens socialemotional needs is likely to be less costly than addressing those needs if they persist into
adolescence.
Trajectories and impact of challenging behavior into the K-12 years. Longitudinal
studies have tracked the patterns and impacts of early externalizing (Campbell & Ewing, 1990;
Campbell et al., 2006; Egeland et al., 1990; Fischer et al., 1984; Lavigne et al., 2001),
internalizing (Fischer et al., 1984; Egeland et al., 1990; Williams et al., 2009), and regulatory
disordered (Bron et al., 2012) behaviors. They have found that early problems tend to persist
and at times have spill-over effects into domains besides behavior. For example, Campbell et al.
(2006) found that having stable levels of physical aggression from toddlerhood through twelveyears of age predicted poor social and academic outcomes. Children with high-stable levels of
aggression were the smallest demographic but were found to be at substantially increased risk for
AD/HD and ODD diagnosis, were rated by teachers as having low social skill levels and high
levels of externalizing behaviors, scored lowest on the Woodcock-Johnson achievement tests,
and self-reported higher levels of depression and decreasing friendship quality at an age when
most children reported increases in the quality of their friendships. Children with low- and
moderate-stable levels of aggression also were at increased risk for AD/HD diagnosis, were
reported by teachers to have poorer social skills and more externalizing behaviors, scored lower
on the Woodcock-Johnson tests than peers with very low levels of aggression, and were more
likely to self-report engaging in bullying and risky behaviors.
Having a diagnosis of ODD in early childhood tripled the chances of a child having a
diagnosis of ODD, with or without comorbidity, in their elementary-school years (Lavigne et al.,
2001). At each of the five waves of the study, between 50% and 60% of the children initially
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screening above the 90th percentile for Total Problems on the Child Behavior Checklist met
criteria for a diagnosis, with some of the shift being accounted for by movement between
subthreshold and threshold levels of behavioral symptoms. Children with high levels of
behavioral inhibition at fourteen-months of age were found to have a steeper-than-average
increase in internalizing symptoms through age four-years and then maintained a high level of
internalizing behaviors through age seven (Williams et al., 2009). Having low levels of
behavioral inhibition at fourteen-months was also found to relate to a slower-than-average
decrease in externalizing behaviors through the duration of the study.
Children who were identified with regulatory disorders during their infancy through
preschool years had significantly higher levels of internalizing (e.g., affective problems, anxiety),
externalizing (e.g., AD/HD, oppositional defiance problems, and conduct problems), and total
problem behaviors in middle childhood and adolescence than their peers without early regulatory
disorders (Bron et al., 2012). Parents and teachers reported that half of the girls who had
received early identification for a regulatory disorder demonstrated significant externalizing
behavior problems and that forty-percent of the boys who had received early identification for a
regulatory disorder demonstrated significant internalizing behavioral problems. Maternal SES
was correlated with externalizing and total behavior problem scores.
Students with emotional and/or behavioral disorders pose greater disciplinary and
parental challenges to school systems than both the general student population and other students
with disabilities (Wagner et al., 2005). These students are suspended and expelled from school
and moved to alternate placements within school districts more often than other students. Their
parents are often unhappy with the services being provided to their children in the schools and
are almost twice as likely to be involved in mediation and due process hearings as parents of
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students with other disabilities. These students are also prone to significant academic
underachievement (Nelson et al., 2004; Wagner et al. 2005).
Trajectories between early childhood and the K-12 years are not necessarily locked in.
For example, Egeland et al. (1990) found that children who defied the persistence trends noted in
their longitudinal study had environmental factors that set them apart from other children.
Children who had severe behavioral problems in preschool but were doing well in elementary
school came from homes that were organized, predictable, provided access to stimulating and
age-appropriate materials, and had a warmer emotional climate than their peers who continued to
demonstrate significant behavioral problems. These apparently resilient children also had
mothers who demonstrated decreasing levels of depression from preschool into the elementary
school years. Children who did not have behavioral problems in preschool but later developed
them in the elementary school years came from homes with higher levels of family stress, a
poorer-quality emotional climate, a poorer language environment, and less developmentallystimulating materials than their peers who continued to be free of challenging behaviors. These
environmental factors with seeming influence to change behavioral trajectories are quite similar
to the focus of many parent education program (e.g., deGraaf et al., 2008; Dishion et al., 2008;
Nixon et al., 2004), offering hope that helping parents to create a high-quality home environment
with positive social interactions can help prevent adverse social-emotional and academic
outcomes.
Minneapolis, it is important to note that half of the studies had samples that were primarily
Caucasian, while the other half used more racially-diverse samples. When considering design of
prevention efforts in Minneapolis it appears that early challenging behaviors have a tendency to
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persist into the elementary years and it would, therefore, be wise to work on development of
effective early intervention methods to minimize later social-emotional and academic
difficulties.
Recommendations
The implications for prevention efforts that emerged in the discussion above fits within a
number of themes, as outlined below:
1. The current systems are not adequately meeting the needs of young children with challenging
behaviors, their family systems, and their early childhood teachers and childcare providers.
Young children with challenging behaviors are being expelled from early childhood
programs at a significantly higher rate than their K-12 peers attending public schools. This
instability of childcare often contributes to a lack of stability in parental employment, which
may increase family stress levels and exacerbate existing behavioral problems in young
children. Additionally, there appears to be a breakdown in the screening and referral system,
where many medical professionals are not adequately screening for developmental delays in
young children and parents do not always recognize the signs of developmental delay to seek
further assessment. There are also noted concerns about capacity limitations in the current
Early Intervention and Early Childhood Special Education systems that are not allowing
them to evaluate and service all children who may meet criteria for Developmental Delay.
Since these are large systemic issues crossing multiples systems, interagency collaborations
will be necessary in order to enact prevention and early intervention efforts that provide for
continuity of care.
2. A combination of biological and environmental risk factors impact the development of
challenging behaviors in young children and should be screened for and addressed.
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Presence of specific temperamental factors and regulatory disorders in the first three years of
life have been linked to development of externalizing behavior problems. Environmental
factors such as maternal wellbeing, family stress level, and sense of support also appear to
play a role in the development and/or maintenance of severe externalizing behaviors in some
young children. Similar factors have been implicated in the development of internalizing
behavior problemsthough there is indication that caregiver mental health may play a more
substantial role in the development of internalizing disorders than it does for externalizing
disorders. Comorbidity between young childrens challenging behaviors and delays in other
domains (e.g., language, cognition, motor), sometimes unsuspected, have often been found so
it would be wise to complete comprehensive developmental screening on young children to
identify all areas of development that may benefit from intervention instead of solely treating
behavioral symptoms.
3. There are multiple areas for parent education and support that hold promise. Because some
trajectories of challenging behavior appear to have a link between specific child temperament
and parenting styles, parent education could help parents to adjust their styles to be more
sensitive and responsive to their childrens needthereby improving the goodness of fit
between childrens predispositions and parents responses. Additionally, since early
language development appears to play an important role in young childrens development of
self-regulation, modeling and instruction in ways to create language-rich home environments
may be beneficial. To improve parents ability to support their childrens development and
identify early signs of delay, education on the typical sequence and timing of early childhood
development is important. While parents have demonstrated the ability to apply training
presented from clinical settings at home, there is indication that having parent education
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presented in an open community group setting may reduce stigma and improve participation
rates. An additional area of need appears to be development of parents sense of social
support through development of community support systems, as lack of such felt support has
been indicated as an important risk factor for adverse early childhood behavioral outcomes.
4. Early childhood providers are often open to and can benefit from additional training and
support. Strategies for classroom management and working with children with challenging
behaviors are two areas reported as of interest by early childhood providers that have proven
beneficial in the literature base. Additionally, since children of minority ethnic backgrounds
often appear over-represented in the expulsion rates, training around culturally appropriate
practice and working with families from diverse backgrounds may be appropriate. Early
childhood mental health consultation is a model that has demonstrated effectiveness in
decreasing many young childrens levels of challenging behaviors and significantly reducing
early childhood expulsion rates.
5. Interventions delivered directly to young children can be a beneficial supplement to parent
and teacher education. Trajectories of young childrens behavioral and self-regulation
development have shown amenability to intervention. Because of a relatively high
comorbidity between social-emotional and self-regulation difficulties and language delays
and disorders, and because language development has shown the possibility of mediating
effectiveness of social-emotional interventions, it would likely be beneficial to implement
interventions that develop communication skills alongside more discretely behavioral skills.
In designing interventions with children, attention should be paid to ongoing development
and maintenance of skills through either booster sessions or extended-length programming
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as both methods have shown greater improvement in behavioral outcomes than implementing
more short-term interventions.
6. Investing in multi-component early intervention and prevention efforts when children are
young may save financial resources in the long-run. Some young childrens challenging
behaviors persist into the elementary years and beyond, bringing with increased likelihood of
comorbidity among mental health disorders and other social and academic difficulties.
Although more intensive to coordinate due to the current divisions between social service
systems, attending to multiple child and family risk factors is important since there is
indication that focusing on one risk factor while not addressing others may undermine
intervention effectiveness. Though it may seem expensive at the front-end, design and
implementation of effective prevention and early intervention methods to address young
childrens social emotional needs in context is likely to be less costly than addressing those
needs if they persist into adolescence and adulthood.
What follows is discussion of how this author proposes to address the research findings
and implications outlined above. It is beyond the scope of this paper to create a fullycomprehensive plan inclusive of all possible partners, funding sources, policies, etc. Instead,
what the reader will find below is a rough framework for comprehensive programming designed
for the prevention and early intervention of challenging behaviors in Minneapolis young
children. A collaborative approach to enhancement of community and caregiver capacities is
proposed for fostering young childrens healthy social-emotional development, ultimately laying
a strong foundation for social and academic success.
In broad practical application, the proposed citywide interagency collaboration may be
considered one of community educationacross the boardfor all stakeholders with interest in
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the social-emotional health and academic wellbeing of upcoming generations. Community

education holds the following ten principles at its core: lifelong learning, self-determination, selfhelp, leadership development, institutional responsiveness, maximum use of resources,
integrated delivery of services, decentralization, inclusiveness, and access to public information
(Decker, Decker, & Brown, 2007). These principles are evident as individuals and agencies
learn about each other, create new organizational cultures to work together towards a shared
vision from their individual programmatic strengths, and support the skills education of multiple
constituencies (e.g., pediatric staff, early childhood providers, parents, young children, etc.).
This prevention and early intervention framework starts with a discussion of interagency
collaborations. Given that the prevention and early intervention undertakings proposed are likely
to require more than any one program or agency could accomplish alone across the city of
Minneapolis, attention is paid to the need for trust-building, culture change, and alignment of
purpose to increase capacity for successful collaboration. Next, a picture is painted of what a
more aligned referral and screening process may look like. Following is a call for universal
access to culturally-sensitive parent education to address the support needs of both those families
that are at high-risk as well as families who are in need for a little boost in informational and/or
interpersonal support resources. Implementation of early care provider professional
development program and citywide early childhood mental health consultation is outlined next,
followed by a brief discussion of considerations to be made in child-centered interventions. This
section concludes with a brief overview of program assessment to help shape, monitor, and
assess the effectiveness of prevention and early intervention programming as it develops.
Interagency collaborations. Developing interagency collaboration across the city is
important for creating seamless systems of prevention and early intervention targeting young
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childrens social-emotional wellbeing. Although smaller in scale, the benefits of a communitywide collaborative approach to early childhood mental health was noted by Maggi, Roberts,
MacLennan, & Amedeo (2011) in their comparison of childcare centers in a resilient community
to those communities with typical rates of early childhood mental health problems and those with
elevated levels of early childhood mental health problems. Collaboration is a relational form far
more intense, potent, and durable than cooperation or coordination (Winer & Ray, 2008). In
collaborations, each organization or entity maintains a separate function and provides their own
set of services or products to the community, but they do so in a context of shared vision. As
defined by Winer and Ray (2008), Collaboration is a mutually beneficial and well-defined
relationship entered into by two or more organizations to achieve results they are more likely to
achieve together than alone (p. 24).
Some of the most obvious collaborations are necessary between the school districts EI
and ECSE and district Early Childhood Family Education (ECFE) and Hi-5 programs, local
Head Start centers, community preschools, daycare centers, and home daycare programs. Such
collaborations make possible early referral of young children at risk of expulsion so that
consideration of comprehensive evaluations and special service plans can be made. Another
community agency that is important to engage in collaborative relationship with is county child
welfare services to make sure that young children they have contact with, through substantiated
or unsubstantiated claims of abuse and/or neglect, go through developmental screening as this
population appears to be at high risk for developmental delays and may or may not be enrolled in
regular early childhood programming outside the home. Since not all young children are
involved in early childhood programs or the child welfare system, working with local
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pediatricians, hospitals, WIC offices, etc. is also important to make sure that universal screening
is taking place for all young children.
When it comes to the support and education of parents and other primary caregivers so
that they can best meet the social-emotional and regulatory needs of young children, some
collaborationssuch as between the school districts EI, ECSE, and ECFE programsmay be
similar to what is in place already while additional collaborative efforts may be necessary as
well. Organizations such as the Washburn Center for Children already have family therapy
programming which is servicing some families with significant needs, but connections to other
county and private mental and physical healthcare programs is also desirable to be informed of
available resources and able to work through a central referral process to address families
mental and physical health care needs. Additionally, attention should be paid to connecting with
programs such as WIC as well as food pantries and other sources that may be able to help
families achieve a sense of food security. It is also beneficial to have relationships developed
with local libraries, parks, mutual aid societies, non-profit agencies, public housing authorities,
etc. which may provide free or low-cost meeting spaces for parent education classes to take place
within the hearts of the many geographical and ethnic communities that call Minneapolis home.
These places outside school district buildings may feel safer for some parents to gather and learn
than the more traditional ECFE sites. Some of these collaborationssuch as with mutual aid
societies and ethnic-specific non-profitsmay also be able to bring valuable and cost-effective
promotional and interpretive services to family education programming.
A third category of collaboration involves providing for training and support for early
care providers. Likely collaborators include community preschool and daycare centers, home
childcare providers, early childhood mental health practitioners (e.g., school psychologists from
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the district, specialists from Washburn or other social service agencies), local colleges and
universities with early childhood studies departments, as well as Hennepin countys child
welfare and public health and human services departments. The University of Minnesota may be
a particularly useful collaborator as it houses the Center for Early Education and Development
and the Child, Youth, and Family Consortium along with many other programs and have
graduate students who may also be interested in completing internship and practicum hours, as
well as research studies, within the collaborative.
Three key considerations for the creation of interagency collaborations are elaborated on
belowthe need for cultural change, the need to build trust and buy-in among individuals and
agencies, and the need to align visions to promote early childhood mental health.
Dealing with cultural change. This sort of large interagency collaborative project is
likely to require cultural change as there is movement from relative isolation of programs and
agencies to hands-on work in creating and pursuing a shared vision for early childhood mental
health across the citys diverse communities. To bring about such large-scale systems change, it
may be helpful to start out slowacknowledging that cultural shift generally takes time and
occurs through relationship building and buy-in one person at a time. When taking it slow at the
beginning, it is important to engage in conversation with stakeholders and to remember that a
grief process may be evident (Hall & Hord, 2006) as new collaborators give up some of their
accustomed processes to join in a more aligned vision with other agencies. Required shifts
include moving from competition to consensus building, from working alone on a specific
program mission to being more inclusive of different fields, from thinking mostly of discrete
programs and services to envisioning larger strategies and results, and from focus on immediate
results to more long-term collaborative aims (Winer & Ray, 2008).
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At times mandates can help get the momentum going even if buy-in is not all therewith
acceptance, cultural shifts, and refinement of details taking place as an initiative is underway
(Hall & Hord, 2006). This type of more immediate and drastic change is most likely only if a
large grant or legislative appropriation for the recommended collaborative is obtained early on.
Regardless of how this particular collaborative starts, it is important to remember that successful
change efforts do not fully occur over night; they require ongoing support and nurturance over an
extended period of three to five years (Tallerico, 2007; Hall & Hord, 2006).
Fostering trust and stakeholder buy-in. In order for interagency collaborations to work
well, individuals within those organizations have to develop trusting relationships with each
other. Research has found that high levels of trust in a group leads to more cooperation, a greater
acceptance of interdependence of group members, and increased motivation to contribute
(Kouzes & Posner, 2010). When initiating interagency meetings it would be beneficial to allow
time in the beginning for groundingto think and share about the stakes each agency and
individual has in the mental health and wellbeing of the citys children. Ground rules for respect
should be established so that no group member is interrupted and everyone feels heard.
Other factors that promote trust in a collaborative effort include disclosure of selfinterests, effective use of the groups time during meetings, acknowledging individuals
contributions to the efforts, keeping stakeholders informed of essential information, and building
shared routines and language among collaborators (Winer & Ray, 2008). Trust begins to build
from a place where each individual feels heard and there is a sense of commonality of purpose
within the group and its aims. If trust is not present, healthy conversation and creative idea
generation will be stunted and individuals are unlikely to commit their time or energy to new
initiatives (Fleming & Thompson, 2004). Because of this, it is important from the outset to take
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time to build trust andif issues such as competition for resources or conflicts between members
emerge during the processto continue to take the time necessary to address things within the
group as they begin to surface instead of allowing them to fester and corrode trust within the
collaborative (Winer & Ray, 2008).
Along with building trust, it is critical to foster stakeholder buy-in for each of the
agencies and individuals representing them. One benefit of active stakeholder involvement is
that it can make the groups work more sustainable by creating an infrastructure that could
continue if any one person (or agency) left (Levin, 2000). Another benefit to stakeholder buy-in
is that it helps cultural change within the collaborative take root as individuals and agencies
begin to hold each other accountable to the shared mission.
Without fostering stakeholder buy-
in, it is unlikely that any attempt at collaboration would last the three to five years likely needed
to complete a cultural transformation called for to bring about a holistic community focus on the
prevention and early intervention of mental health challenges for young children.
Creating alignment. On an organizational level, aligning conversations around children
and what we (collectively) want for children to carry away with themselves for the rest of their
lives is a powerful way to begin leveraging change in an educational system (Beaton, 2007;
Pankake & Moller, 2007). Such alignment can begin with trust-building grounding exercises as
outlined above but then should carry over into the development of a collaborative vision.
Development of a vision statement can begin with a session where agency representatives
brainstorming important words and phrases that describe their vision, then begin to discuss these
initial thoughts in more depth to agree on the most important concepts (Winer & Ray, 2008). A
subgroup may draft a vision statement from this brainstorming and discussion, bringing it back
(sometimes multiple times) to the whole group for further refinement and revision.
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Once a vision has been adopted, it is important for the collaboration to begin identifying
short- and long-term indicators that they are making progress towards reaching their vision.
These indicators can be used to create a well-defined strategic action plan and will an important
influence on the development collaborative assessment [as outlined further later on]. An action
plan should be specific, establish responsibilities and accountability standards for stakeholders,
produce a budget of anticipated expenses and revenue sources, and include a communication
plan (Winer & Ray, 2008). Once designed and agreed upon by the collaborative, the action plan
would be put into motion.
Screening and referral as a community affair. This author would like to see creation
of a significant public awareness campaign addressing major developmental milestones for early
childhood development and providing information on the importance of early screening and how
to make a referral. This media campaign should be widespread throughout the city, including
advertisements in the many neighborhood and ethnic newspapers as well as community access
cable and the usual bus stop and billboard signage. Images should be representative of the
diversity within the city, with the written and/or auditory messages presented in multiple
languages (e.g., English, Spanish, Somali, Arabic, Hmong, etc.). Outreach efforts should be
brought into the different ethnic communities through personal and educational presence at local
street festivals, powwows, health fairs, and other community events.
Through inter-agency collaborative efforts, standardized screening instruments should be
selected for use across the city for infant/toddler and preschool populations and a standardized
results reporting format adopted. If possible, screening instruments should be normed on a
culturally and linguistically diverse sample. Screening instruments should address the five
developmental domains (social-emotional, communication, motor, cognition, self-help/adaptive).
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This author assumes that measures of self-regulation (e.g., attention span, ability to self-sooth,
activity level, etc.) are likely to be embedded within the screening items for the five core
developmental domainsif they are not, an additional screening tool for young childrens ability
to self-regulate should also be adopted. While some may have concern that such broad screening
would produce a vast number of unneeded over-referrals, research into this issue found that 70%
of children receiving false-positive results on developmental screeners fell below the 25th
percentile on at least one diagnostic measure so were at risk for delay and would benefit from
follow-along services (Glascoe, 2001).
Medical personnel, preschool and daycare providers, mental health practitioners working
with children, child welfare workers, as well as school district early childhood personnel should
be thoroughly trained in use of these screening instruments and reporting format. A citywide
computerized database should be established for entering in screening results, with security
measures that allow practitioners access only to the screening status of children they are
currently working with. Processes for obtaining informed parental consent for screening and
discussing results with parents (including translation of any formal report into their home
language, if needed) should also be developed.
Prior to well-child visits for all young children (infancy through the preschool years),
medical personnel should check the computerized database to determine whether or not the child
has been screened within the past six monthsif the child has not then the standardized
screening instrument should be administered (with translation services, as necessary) as part of
the well-child check-up. Child welfare workers should also check the database as new children
enter their caseloads, administering the screening instrument to those who have not been
screened within the past six months. Preschool and childcare staff who have concerns about the
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behavior and/or developmental status of a child in their care should also check to see whether the
child has been screened in the past six months andif notadminister the screening instrument.
When entering in screening results, a pop-up window with electronic referral form should be
triggered by results that fall into pre-defined criteria of at-risk status in one or more
developmental domain. These electronic referrals should then automatically be directed to the
childs home school district (based on parents address on file) to follow up with the families.
This author acknowledges that implementing such universal screening methodology is
likely to place a strain on existing EI and ECSE resources as they face the prospect of meeting
increasing evaluation and service requirements. Because special education in Minnesota
functions on a reimbursement system, a percentage of initial expenses outlaid by the district
would be returned. Additionally, with implementation of expanded parent and early childhood
provider education, it is thought that such high resource demands would level off over time as
caregivers possess more tools and supports to mitigate development of environmentallymediated delays. It should also be noted that through the inter-agency collaborative process the
weight of some current service-provider tasks (such as researching and connecting families to
resources and advising childcare providers and preschool teachers on more effective
management techniques) may begin to shift to others, which may lesson the burden on EI and
ECSE personnel in such a way to allow some evolution of role and shift of resources from
service to evaluation teams.
Another factor to note, although its full analysis extends beyond the scope of this paper,
is that neighboring school districts (e.g., Columbia Heights, Richfield, Saint Paul, Saint Louis
Park, Osseo, etc.) may also experience an increase in referrals and related resource demands
from implementation of universal screening in Minneapolis. This is because the districts where
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parents reside are the ones where responsibility falls for EI and ECSE services. Therefore, if a
parent living outside of Minneapolis takes his or her young child to a pediatrician, daycare
provider, or preschool program within Minneapolis (for example, if they want a place close to
where they work) then their child would be screened as part of the collaborative effort and if
their scores fell within the at-risk criteria it would be their home district that would need to
complete a timely evaluation and provide services if the child met eligibility criteria. Because of
this possible spillover effect, it would be well advised to notify neighboring districts early on
about the universal screening effort so that they are not caught off-guard by an unexpected
increase in referrals.
Expanding access to parenting education and supports. This author recommends
collaboration between PICA Head Start, ECFE, and any other entities within the city that offer
parent education programming to share strategies that they have found successful with the citys
diverse populations and to identify challenges and gaps in parent education services. Slidingscale fee parent education classes should be available in convenient locations within all
neighborhoods throughout the citynot just in school buildings but also in settings that may feel
more comfortable to demographics that have traditionally been under-represented in
participation, such as in culturally-specific organizations and mutual aid societies. Ensuring that
sites are located near parents home and/or early childhood care settings and in places that are
likely to feel safe is likely to minimize transportation-related barriers and stigma, therefore
increase participation rates. Providing high-quality sliding-scale fee childcare (including sibling
care) on-site is also likely to make classes accessible to a larger percentage of parents while
providing valuable opportunities for development of childrens peer socialization skills.
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Curriculum in parent education classes should address topics such as early childhood
development, temperament (child and parent), parenting styles and behavior management,
creating a language-rich home environment, and general strategies for helping young children
through times of family life transition (e.g., birth of a younger sibling, moving, parental
separation). Parent education classrooms should offer parents an environment that feels safe and
supportive, with room for respectful expression of varying experiences and opinions. Working
in partnership with the University of Minnesota and/or other institutions of higher learning, it
may ultimately be beneficial to create an internship-style approach to helping members within
the different neighborhoods and cultural communities get the training needed to become licensed
parent educatorsas this may ultimately further the sense of safety and normalcy of parent
education classes within these communities as well as expand the possibility of having classes
presented directly in parents predominant home languages. Provision for online access to
culturally-relevant, multi-lingual, parent education opportunities may also be beneficial for
expanding participation rates across the city.
A comprehensive list of support service providers in the city, as well as those serving
Hennepin County more broadly, should be constructed and distributed to all parent educators for
use in making referrals for families in need of support beyond what is appropriate in general
parent education classes. Support services include those who provide for physical and mental
health care for adults and children, family therapy, food and housing assistance programs,
daycare and employment assistance, and related programs. The list of support services should
include key contacts, specialties of each provider, cost and/or insurance information, and a brief
overview of intake procedures so that parent educators can help prepare parents for what to
expect when referrals are made.
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As with screeningperhaps in conjunction with itshould be publicity about parent

education opportunities and how to get involved in them, to aid in normalization of participation.
As with community outreach for screening purposes, diversity should be evident in the languages
and images useddepicting different cultures, single parents, heterosexual parents, homosexual
parents, grandparents, adoptive parents, etc. Print materials should also be produced in multiple
languages that list some of the common parenting challenges that primary caregivers face when
raising young children and that speak to the power of peer parenting support in addressing the
challenges and celebrating the joys of primary caregiver roles. Such print materials should be
provided to pediatric clinics, libraries, early childhood programs, social service agencies, and
other places where parents may seek responses to parenting questions and dilemmas. Rather
than being mailed to these locations, it may be beneficial for parent educators to schedule times
to bring the materials in in-person (perhaps with some current or past participants in their
classes) to speak with the staff about the parent education programming to build awareness of
and confidence inthe programming.
Providing training and support to early childhood providers. High-quality
professional development for K-12 educators has been noted to be intensive, ongoing, and jobembedded (Darling-Hammond, Chung Wei, Andree, Richardson, & Orphanos, 2009). Many of
these same characteristics appear to be echoed in the research relating to teacher-focused
interventionswhere ongoing trainings throughout the school year and context-specific
mentorship within early childhood mental health consultation contexts appeared to produce the
greatest results for young children. It is, therefore, this authors belief that provision of both
ongoing monthly group professional development as well as tiered, potentially more intensive
and job-embedded, early childhood mental health consultation be provided for.
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Although monthly trainings focused on topics such as child development, classroom

management, and teacher stress reduction show benefit to teacher practice and child outcomes in
the reviewed literature, this author posits thatas in K-12 (Darling-Hammond et al., 2009)
these types of brief topical in-services alone may not provide the most significant gains possible
in child outcomes. While this author admits that these trainings, either centered around a
published curriculum such as the Incredible Years Teacher Training, culturally-sensitive
practice, or other short-term training opportunities through collaborating entities (e.g., University
of Minnesota, Washburn Child Guidance Center, Hennepin County Child Welfare), may be the
most straight-forward way to start it may be more impactful in the long-run to also adapt some of
the tenets of Professional Learning Communities (PLC) used in the K-12 school system. A PLC
approach would be likely to further encourage the collaboratives cultural shifts towards mutual
support of young childrens healthy social-emotional development and provide for more
personally meaningful learning for early childhood professionals. While Minneapolis school
district personnel do currently have PLC groupings, this author believes that it may be beneficial
to engage in the PLC process year-round on a citywide level inclusive of the broad range of early
childhood providers working in preschool and childcare settings.
One of the main ideas of PLCs is a shift from focus on teaching to a focus on childrens
learning (DuFour, 2005). In the early childhood context, this could be seen by shifting the focus
away from basic implementation of a curricular model (such as CreativeCurriculum) or having
general activities available in a classroom that address the different developmental domains into
a greater focus on what early childhood providers can do to scaffold each young childs
development across domains. When a child exhibits a challenging behavior in such a learning
culture, then, it may become automatic for early childhood providers to re-examine the context
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and what they can do to support development of more adaptive social-emotional and
communication skills rather than to become frustrated and feel a tinge of helplessness that the
child was in conflict with another or did not follow a direction.
A second main idea of PLCs is to create a culture of collaboration among teachers in
which they work together to improve classroom practice (DuFour, 2005). Implemented in an
early childhood context, this could look like groups of eight to ten early childhood providers
from the same neighborhoods and/or servicing similar demographics getting together for an hour
or two on a monthly basis to review developmental instructional strategies that have been shown
successful with demographics similar to their own, sharing successful strategies from their own
instructional experiences, and problem-solving around specific challenges that they are facing in
their classrooms or daycare settings to gain new perspectives on situations and additional
strategies to try to improve young childrens learning across domains. It would be important that
early childhood providers working in home daycare settings be included in collaborative PLC
settings as they are likely to face a greater degree of isolation in practice than those working in
school or center settings who may spend a majority of time in their own classrooms but at least
have potential for lunch- or break-time chatter with other early childhood staff.
The third and final main idea for PLCs is a focus on results as measured and tracked by
data (DuFour, 2005). In this early childhood context, the results tracked could comeat least in
partfrom the collaboratives aligned vision and action plan so that it could be used as part of
the formative assessment data collection process. Results to be tracked in the short-term could
include measures of young childrens attainment of developmental milestones, increases in
social-emotional and communication skills, decreases in challenging behaviors exhibited in
classroom settings, increases in proactive communication and strategy alignment between
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families and early childhood providers, and decreases in early childhood suspension and
expulsion rates.
In addition to widely implementing PLCs among early childhood providers, this author
recommends implementation of a citywide early childhood mental health consultation program
to offer tiered levels of support for early childhood providers. Statewide initiatives have
implemented early childhood mental health consultation through their public health systems
(Carlson et al., 2012; Hoover et al., 2012) and it is this authors recommendation that Hennepin
County Public Health may also be an appropriate center point for this effort within the
Minneapolis collaborative. Having this programmatic aspect run through public health, as
opposed to the school district, would maintain this service as separate from special education
(similar to tiered interventions utilized in K-12, such as Response to Intervention and Positive
Behavioral Support models) and could make staffing more cost-efficient since non-licensed
personnel with psychology, counseling, and/or early childhood education backgrounds may be
recruited and trained to deliver early childhood mental health consultation services.
It would be important that all early childhood providersincluding, and perhaps
especially, home childcare providersare aware of early childhood mental health consultation
services and how to gain access to them. Although not discussed in the literature base, it may
also be beneficial to allow access to this program component to Personal Care Attendants and
nannieswhile these early care providers do not have the power to expel children, per se, it may
be suspected that working intensively with young children who have challenging behaviors could
result in relatively high turn-over rates that could exacerbate child and family stress. As with
other early childhood mental health consultation programs (e.g., Carlson et al., 2012; Perry et al.,
2008; Upshur et al., 2009), early childhood providers should have a process for making
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behavior-specific requests to receive mental health consultation services for a specific child or
small group of children. An intake process needs to include a parent-consent piece for any
consultation directed at a specific child, and also should include collection of demographic and
perceived needs data to determine if additional referrals for family services or supports may be
beneficial.
Early childhood mental health consultation services should utilize a tiered approach,
which could range from relatively indirect classroom observation and strategy recommendation
for challenges with small groups of children to more intensive assessment, modeling, and
therapeutic work with an individual child. If an early childhood provider has a high number of
young children in his or her care with significant mental health needs, more intensive mentorship
may be provided to the provider on work with high-needs population and topics such as making
adaptations or delivery of a specific social skills curriculum. When mental health consultation is
requested for a specific child who is receiving early intervention or early childhood special
education services, the childs special education team should be invited and encouraged to
participate in team meetings and behavioral planning sessions so that considerations of
developmental levels in other domains will be made along with alignment between the childs
services to promote consistent reinforcement of important social-emotional skills and concepts.
Implementing individualized interventions. Although many young children with
challenging behaviors may meet criteria for service under EI or ECSE programs, in which case
individualized interventions would be developed through those programs, there may be some
children in early childhood programs whose only area of significant need is in the socialemotional domain. For these children, the design of individualized interventions is likely to
come through the early childhood mental health consultation program described above. There
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may be times, however, when an early childhood provider does not feel like they can wait to do
something until the referral and assessment process through early childhood mental health
consultation takes place. For this reason, it is advisable to create resource libraries with
information specific to behavioral intervention as well as published curricular models such as
Incredible Years and Tools of the Mind that can be checked out for consultation. This author
suggests having these resource libraries co-located with print and video resources aimed at
parents (possibly within a special section of the citys local libraries or in sites where parent
education and/or professional learning sessions are held), with an online resource catalog so that
specific titles can easily be located and reserved.
Program assessment. This author believes that program assessment should be
integrated within the collaborative planning and implementation processes to ensure that the
effort is established and operates in a manner that corresponds with existing and anticipated
contexts in Minneapolis communitieskeeping in mind the young children, families, early
chilhood providers, and others intricately connected in webs of social interdependence. A
utilization-focused approach to evaluation appears relevant, as it is done for and with specific
intended primary users for specific, intended uses (Patton, 2008, p. 37). In this case, the
primary users would include many of the collaboratives stakeholders (school district programs,
preschool and childcare programs, medical and social-service agencies, county child-welfare and
public health programs, families with young children, etc.) and intended uses would include
matching collaborative programming to community strengths and needs and documenting
efficacy in order to maintain and/or obtain any needed increases in resources.
Jacobs (2003) presents a five-tiered model for program evaluation that accounts for
assessment activities from initial program conceptualization through impact studies. The first
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three tiersneeds assessment, monitoring and accountability, and quality review and program
clarification fall into the category of formative evaluation methods. Formative evaluation is very
important for helping interagency collaborative staff and other immediate stakeholders keep
abreast of the current functioning of the initiative as well as to alert them to ongoing strengths
and areas in need of improvement. Although this evaluation model was designed for family life
education programs, this author feels that it holds potential for the proposed prevention and early
intervention efforts engaged in through interagency collaboration. By starting out with
assessment procedures from the beginningand maintaining them throughout the duration of the
collaborative endeavorsinformation will be in-flowing to help the initiative adjust as needed to
best align with current community strengths, needs, and resources. What follows are some
examples of possible applications of Jacobs model within the context of this prevention and
early intervention collaborative initiative; it should be noted that the exact research questions and
methodologies used (especially for tiers two and three evaluation) would align with an agreed
upon vision and action plan as developed through interagency collaborative processes.
Tier one. Tier one of Jacobs (2003) five-tier model is a needs assessment. The purpose
of this tier is to determine the scope of unmet problem and service needs in a community, to
propose programming to address the unmet needs, to establish baseline data on needs that the
proposed programming seeks to address, and to build interest and support for the proposed
program. Due to the geographical focus on Minneapolis, the nature of the inter-agency
collaborative proposed, and the limitations of the current research base in regards to direct
application to Minneapolis culturally, linguistically, and economically diverse population it will
be important to lay the groundwork for preventative and early intervention efforts targeting
young childrens social-emotional development by taking the time to understand the contexts of
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the citys neighborhoods and communities. At this tier, there are specific questions and methods
for evaluation that may be appropriate for this prevention and early intervention collaborative
initiative, as outlined below.
Important questions. Questions to be included in a needs assessment for this
collaborative initiative fall into four primary themes:
Existing community resourceswhat programs, departments, and agencies are currently

working with young children, their families, and/or early childhood providers? What
services do they provide? How do constituents gain access to those services? Who are
primary users of these services? Are there constituencies that these programs, departments,
and agencies have tried unsuccessfully to reach out to in the pastif so what were the
barriers they experienced? What roles, if any, do these constituencies currently play in
screening and referring for possible developmental difficulties in young children? What
unmet needs do these constituencies currently see for young children and their families in the
communities they work in? Etc.
Early childhood providershow many licensed preschool and daycare providers are there in
the city? Where are they located and who do they serve? What types of challenging
behaviors do these early childhood providers see most often? What types of challenging
behaviors do these early childhood providers find most difficult to handle in their current
settings and why? How many children are currently being expelled from the citys early
childhood programs? What types of professional development opportunities do these early
childhood providers currently access? What current supports and/or barriers do early
childhood providers face when it comes to professional development? Etc.
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Parents and other primary caregivers of young childrenhow many families send their
young children to preschool, daycare, or other early childhood programs? What are their
experiences with these early childhood programs? Who is most likely to participate in parent
education classes? Why do they participate and what supports or resources make this
participation possible? What are barriers (social, economic, cultural, logistic, etc.) to
participation in parent education classes? What other resources do families feel would help
them to be more successful in their care-giving roles? Etc.
Potential un-tapped resourceswhat grants, corporate sponsorships, or other private funding

sources may be available to support educational programs for early childhood providers and
families? What state or federal grants may be available to promote educational and health
outcomes for young children and/or their families? How much reimbursement and/or
supplemental aid may follow EI and ECSE evaluation and service rate increases? What
possible human resourcessuch as research assistants, interns, volunteers, etc.may have
interest in the topics of public health, early childhood education, mental health promotion,
parent education, teacher education, and related topics? Etc.
Evaluation methodology. Evaluation at the needs assessment tier may take the form of
reviewing existing records as well as gathering new information. For example, existing
agency/program/departmental records could be reviewed to analyze present resources, foci,
usage, and characteristics of the demographics served. Internet searches could be conducted to
look for governmental and private foundation Requests For Proposals (RFPs). Existing parent
survey data from ECFE, PICA, or other programs may contain information on parents
experiences and perceived needs. A brief survey could be mailed or conducted on the phone,
contacting likely providers of services to the families of young children to identify existing
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programs, demographics served, and sources ofand barriers toprofessional development.

Focus groups could be held with professionals from different social service fields to examine
what unmet or under-met needs they find with the families they work with. Focus groups could
also be held with parents of young children to examine factors that may motivate or dissuade
them from participating in parent and family education programs with their young children.
Surveys or focus groups could also be conducted with early childhood providers to explore their
perceptions and responses to young childrens challenging behaviors.
Once the specifics of a need are defined, additional information reviews will be required
to begin building a foundation for the program. For example, Minnesota law should be
consulted to determine the appropriate qualifications for staff of a district program and any other
legal guidelines (such as liability, staff-participant ratios, physical space, amenities, etc.).
Community facilities should also be looked into to identify possible locations throughout the city
that would be able to meet the needs of the collaborativeboth for holding professional planning
meetings as well as hosting parent education classes and other educational endeavors such as
professional development and resource libraries. Although such initial undertakings may appear
burdensome, they need not necessarily be taken on entirely by one personthere is potential for
involving multiple researchers interested in and/or with expertise in the different fields to
efficiently investigating specific questions and then compile results for usage.
Tier two. Tier two of Jacobs (2003) five-tier model is monitoring and accountability.
The purpose of this tier is to monitor the initiatives performance, to demonstrate accountability
to funders, to build constituency base, and to provide information useful for current planning and
decision-making as well as for higher-tier evaluation efforts. In the context of the collaborative,
it appears reasonable that some monitoring data would be collected on an ongoing basis by
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individual agencies within the collaborative, while other measures relating specifically to the
collaboration process and areas of shared responsibility (such as the flow from screening through
referral and assessment) would require monitoring at a broader scale. At the monitoring and
accountability tier, there are specific questions and methods for evaluation that may be
appropriate for this prevention and early intervention collaborative initiative, as outlined below.
Important questions. Because this initiative serves a broad stakeholder base in a multifaceted manner, it would be important to keep track of a variety of types of information for basic
monitoring and accountability purposes. Questions that would get at this monitoring and
accountability information can be explored through the same themes outlined in this papers
recommendations section:
Interagency collaborationwhat programs, departments, and agencies are collaborating?

Who are the key-contacts or representatives for collaborating programs, departments, and
agencies? How frequentlyand for what length of timeare meetings being held to work
on collaborative visioning and planning? How many people, on average, attend visioning
and planning meetings? What resources are brought into the initiative by each collaborator?
What new resources are available to the collaborative that would not be available for
individual agencies/programs/departments working alone? How many families and early
childhood providers are directly serviced by the collaboratives efforts? How many young
children are being asked to leave their early childhood settings by care providers? Etc.
Universal screeninghow many children are being screened? Who, within

programs/departments/agencies, are primarily administering the standardized screening
instruments? What language(s) are screening instruments being implemented with? How
many conferences with parents are being held to go over the results of standardized
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screenings? What language(s) are screening results being delivered to parents in? On
average, what is the cost for each screening (e.g., staff time, purchase of reporting form,
maintenance of web-database, etc.)? What percentage of young children who are screened
meet the at-risk criteria for referral? What programs and/or agencies generate the most
referrals? How many referrals are generated for children whose parents reside in the
Minneapolis school district? How many referrals are generated for children whose parents
reside in school districts outside of Minneapolis? Of young children referred, how many are
receiving follow-up evaluations? Of young children evaluated, how many meet eligibility
criteria for early intervention or early childhood special education services? Etc.
Universal parent education and specialized supportshow many parent education classes are
being offered across the city? What programs/departments/agencies are delivering parent
education classes? How many staff are involved in delivering parent education classes?
What are the class sizes (both for parents as well as in any early childhood and/or daycare
provided)? How many primary caregivers are participating across the city? What are the
demographics of primary caregivers participating in the classes (e.g., age, ethnicity, home
language, neighborhood of residence, number of children in household)? How many
participants leave the program after participation in three or fewer sessions? On average,
how much does it cost for each primary caregiver to participate in parent education classes?
How much revenue is brought in by sliding-scale fees? What percentage of the overall
program budgets do fees cover? What state allocations and/or grants are being used to make
up the difference? How many referrals to outside resources are being made? Etc.
Training and support for early childhood providershow many early childhood providers
are participating in professional development opportunities promoted through the
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collaborative? What types of settings (e.g., public preschool, private preschool, daycare
center, home daycare) are participating early childhood providers coming from? How many
PLC groups are meeting across the city? How often and for what length of time are PLC
groups meeting? How many requests are being made for early childhood mental health
consultation? What are the demographic characteristics of the early care settings that are
making requests for early childhood mental health consultation? Are requests most likely to
be made for a single child or multiple children within an early care group setting? How
many early childhood mental health consultants are on staff? How many hours of
consultation, on average, are being made for each request? Where does funding for the
professional development and mental health consultation programming come from? Etc.
Individualized interventions for young childrenhow many young children are receiving
individualized interventions through EI or ECSE programming? How many resources are
available to early childhood providers in the resource library? How often are resources being
checked out of the library? How many individualized intervention plans are being developed
by early childhood providers on their own? Etc.
Program assessmentwho is collecting assessment informationare all collaborative

members involved? What types of data are being collected? What assessment methods are
being used most often? Etc.
Evaluation methodology. Evaluation at the monitoring and accountability tier may be
accomplished through careful planning of the forms and procedures put in place during the
action-plan development and implementation processesthen reviewing the collected
information at regular intervals to monitor any changes that may occur. For example, care
should be taken when designing participant registration and referral forms to include relevant
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demographic information in addition to contact information. Copies of parent education and

professional learning schedules should be retained and compiled. There should be a sign-in
procedure in place to track the number of participants attending professional learning and parent
education sessions. Formal contracts or agreements should be put together for inter-program and
inter-agency partnerships. There should be a process for logging staff referrals that were made,
noting (minimally) the date of referral, the referring staff, and the agency referred to. An exit
survey may be designed and mailed (or emailed or administered over the phone by an
interpreter) to those individuals who do not return to ongoing parent education or professional
learning sessions. Also, programs, departments, agencies, and the collaborative as a whole
should ensure oversight of budgets, maintaining accurate records of accounts receivable and
accounts payable. By building monitoring systems into the initiative from the beginningas
well as carefully training staff in on these systems so that they are implementedthe interagency
collaborative should be able to meet its program monitoring and accountability needs.
Tier three. Tier three of Jacobs (2003) five-tier model is quality review and program
clarification. The purpose of this tier is to develop a more accurate and holistic picture of how
the initiative is being implemented, to determine the consistency and quality of implementation,
and to provide useful information for improvement. In the collaborative context, this would be
the tier to begin examining whether the collaboratives stated vision is becoming a reality in the
day-to-day culture of operations. At the quality review and clarification tier, there are specific
questions and methods for evaluation that may be appropriate for this prevention and early
intervention collaborative initiative, as outlined below.
Important questions. Because this collaborative initiative involves a wide variety of
constituents (e.g., medical and social service personnel, early childhood providers, parents and
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other primary caregivers, young children) and has a broad stakeholder base, it would be
important to keep track of a variety of information for understanding the collaboratives day-today functioning, degree of fidelity in implementation, and overall quality. Some questions that
would get at information important in quality review and program clarification include:
Interagency Collaborationare representatives from all relevant fields in the community at

the table? Are ground rules being abided to in meetings and in relation to communication
between meetings? Are programs/departments/agencies following through on action items
they agreed to? How do individuals from programs/departments/agencies describe their
work with others in the collaborative and their level of commitment to the vision of the
collaborative? Etc.
Universal screeningare the demographics being screened representative of the cultural,

linguistic, and economic mix in the city? Are pediatric personnel incorporating standardized
screening into all well-child visits for young children who have not been recently screened?
Are child welfare personnel incorporating standardized screening into their practice for all
young children who have not been recently screened? Are early childhood providers
utilizing standardized screening with all young children that they have behavioral and/or
developmental concerns about who have not recently been screened? How long is it taking
between administration of standardized screening instruments, reporting results to parents,
entering them into the computer database, and making formal referrals? How are due
process timelines being followed from initial referral to completion of evaluation? Etc.
Universal parent education and specialized supportsare the demographics being served in
parent education classes representative of the cultural, linguistic, and economic mix in the
city? Are there specific sites that appear to attract higher percentages of some demographics
145
and, if so, what unique characteristics may they have? Are there class sites in all
neighborhoods? For parents who are not currently participating in parent education classes,
what real or perceived barriers to participation are they experiencing? How does using space
outside school district buildings work? What role may parents home language and access to
interpretive services be playing in class attendance and participation? What does the content
of the curriculum look like? How are opportunities for young childrens learning and
development fostered while their parents are attending class? How is culturally-sensitive
practice being implemented? At the end of the day, are the budgets balancing? Etc.
Training and support for early childhood providerswhat types of topics, research bases,
and classroom challenges are being discussed in PLCs? What barriers and/or supports
appear to influence early childhood provider participation in professional learning
opportunities? Are early childhood providers taking advantage of early childhood mental
health consultation andif sowhat are these consultation sessions looking like? What
does parent involvement in early childhood mental health consultation look like? What sort
of training/preparation is being provided to individuals working in the mental health
consultant roles and is this education preparing them to address the types of questions and
concerns that early childhood providers express in the field? What factors appear relevant in
whether or not an early care provider expels a young child from their care setting? Etc.
Individualized interventions for young childrenwhat are individualized interventions for

young children looking like in practice? What types of resources are in the resource
libraries? Are there some resources that are being checked out more than others? Are there
topics of concern to early childhood providers that are not addressed in the present library
146
resources? Is the online resource catalog user-friendly and being used (as opposed to people
just heading into the library in-person)? Etc.
Program assessmentwith what degree of consistency are assessment procedures being

implemented? What factors appear to act as barriers and/or supports to assessment plan
implementation? How do constituents understand the purpose and relative value of ongoing
program evaluation? Are there areas that would benefit from further training and/or
streamlining of procedures? Etc.
Evaluation methodology. One major source of information for this third tier of
evaluation comes from review of the data gathered in an ongoing manner through the monitoring
system described above. Additionally, formative evaluation instruments such as surveys and
structured interviews may be generally formed around questions such as those described above,
or in more detail by incorporating specific indicators from professional guidelines relevant to
specific stakeholder groupssuch as the one the Minnesota Department of Education has for
ECFE programs or one that the National Association for the Education of Young Children
(NAEYC) puts out. It may also prove beneficial to revisit the focus group format utilized in the
needs assessment tier to gather input from parents and early childhood providers, finding out
their perceptions of the programming and any blocks (logistical and/or mental) they may have in
relation to full participation. Other methods that may be helpful at this tier of evaluation include
gathering observation data (either in person or using video tape) to facilitate reflection and
critique of meeting procedures, classroom practices, and screening procedures. Review of
ground rules, meeting notes, lesson plans, handouts, publicity materials, etc. can also be valuable
to check for alignment with the collaboratives vision and action plan goals, as well as the
quality and accuracy of source content.
147
Tiers four and five. The final two tiers of Jacobs (2003) evaluation framework are
summative in nature. Tier four outcomes evaluation is concerned with determining what
progress toward program outcomes has been made, if any, that can be linked to program
participation and to suggest information for program improvement. Tier five addresses program
impact through formalized research methodology. Summative evaluation measures and methods
should center around specific measurable outcomes outlined in the collaboratives action plan.
In general, outcomes that may be looked at in these tiers relate: to decreases in early childhood
expulsion rates; increases in young childrens social, self-regulation and communication skills;
increased reported levels of parent and early childhood provider knowledge and sense of support;
and decreased incidence of behavioral and academic difficulties when young children reach the
K-12 system.
Conclusions
This paper sought to answer five core research questions and to make recommendations
to address the realities documented in the research base. This section of the paper will re-explore
each of the original research questions, the related findings and implications, and how the
recommendations proposed would address the implications within the context of the city of
Minneapolis. For ease of readership, the exact questions will be reviewed in the order initially
presented in the introduction.
Where do challenging behaviors in early childhood populations come from and what are
their trajectories? Challenging behaviors in early childhood populations have been
longitudinally traced to a variety of risk factors in the first three years of life involving both
young child (e.g., regulatory disorders, negative and/or difficult temperament; aggressiveness)
and environmental context (e.g., parental lack of social support; high parent stress level). Risk
148
factors associated with externalizing and internalizing behaviors in young children were often
similar, though early signs of infant inhibition and poor parental mental health appeared to play a
more significant role in the development of internalizing behaviors in young children.
Comorbidity was noted between multiple externalizing behavioral disorders (e.g., ODD, CD,
AD/HD) as well as between challenging behaviors and delays in other developmental domains
(e.g., cognitive, motor). Significant comorbidity was also noted between language development
and social-emotional development in young childrenwith children with low vocabulary levels
(especially boys) and with language disorders more likely to have delays and/or disorders in selfregulation and the social-emotional domain. Average behavioral trajectories in young children
show significant decreases in externalizing behaviors and increases in internalizing behaviors
from toddlerhood through the preschool years. Subsets of the population with specific
combinations of early behavioral and environmental risk factors show quite different behavioral
trajectories, with continuing and often increasing social-emotional as well as academic
difficulties going into the K-12 school years.
The recommendations proposed are designed to address early risk factors for challenging
behaviors from preventative and early intervention lenses in hopes of altering destructive
behavioral trajectories early in their development. Universal screening of young children on a
regular basis is intended to pick up on early signs of delay and/or disorder so that more thorough
evaluation and intervention can take place to mediate long-term outcomes. Universal parent
education is designed to address some of the environmental risk factors including lack of a sense
of social support and poor goodness-of-fit between childrens needs and parental response.
Collaboration for a smooth referral process to additional supports and services (e.g., physical and
mental health services, food and housing assistance) needed by young childrens families is
149
another avenue of recommended practice for helping to ameliorate environmental risk factors for
adverse behavioral development.
How many children are being expelled from early childhood programming due to
challenging behaviors and what do these children (and their behaviors) look like? Children
were found to be expelled from early childhood programs at a significantly higher rate than
expulsions from public K-12 programs in the same geographical areas. For Minnesota, the
expulsion rates from Head Start programs (4.16 per 1000 children) and public school readiness
programs (2.92 per 1000 children) were found to be significantly higher than the statewide K-12
expulsion rate (0.76 per 1000 students). When considering these rates, it is important to note that
this may be an underestimate of the severity of discrepancy in Minnesota because studies of
other areas in the country found significantly higher expulsion rates from private preschool and
daycare programs than from their public counterparts.
Boys and children of color appeared at greater risk for expulsion from early childhood
programs than their female and non-Hispanic Caucasian peers. Although not always resulting in
expulsion, both externalizing (e.g., hurting self or others, disrespectful/defiant, destroying or
damaging property) and internalizing (e.g., inhibited/withdrawn, sad/unhappy/depressed)
behavioral problems were noted of concern by early childhood providers. Early childhood
provider reports of approximately 11% of young children in their care displaying such
challenging behaviors over the past twelve months fell well within the prevalence ranges for
young childrens clinically-significant behavioral disorders found in community samples. Early
childhood providers with access to mental health consultation services had lower rates of
expulsion than those without access to such services.
150
The proposed recommendations address these findings through programming aimed at

ameliorating early risk factors for the developmental trajectories of challenging behaviors, as
described above. Additionally, provision for early childhood mental health consultation is
provided for along with other professional training and peer supports to help early childhood
providers meet the developmental needs of young children. While the emerging research base
on preschool and daycare expulsion did not seek out early childhood providers knowledge of
developmentally appropriate practice or perceptions of the overall developmental status of
children about whom they had behavioral concerns, this author implied from the research base
on developmental trajectories that there are likely to be multiple areas of development that are
correlated with some of the challenging behaviors resulting in expulsion and that if early care
providers had increased knowledge and practical strategies to work holistically with young
children than they may feel more success and, consequently, be less likely to expel young
children from their care.
What impact do these early removals from preschool and daycare programs have on the
children and their families? Primary caregivers reported a variety of employment-related
problems (e.g., missed time at work, diminished work performance, and needing to quit their job
to care for their child) stemming from difficulty with finding affordable, stable, care for their
children with challenging behaviors. Minority ethnicity and low-income status appeared to
increase the likelihood of such childcare-related employment problems. Childcare-related
employment problems were linked to increased financial strain, a sense of social isolation, and
high stress levels in primary caregivers. Frustration was expressed by many primary caregivers
over trying to get pediatricians or other professionals to take their initial behavioral concerns
seriously, resulting in reported delays of up to two years before diagnosis and support were
151
provided. Although no research was found directly addressing the impact of early childhood
expulsion on young children, given the role parental stress and sense of lack of support appear to
play in development of challenging behaviors, this author implies that early childhood expulsion
may contribute to environmental variables that maintain and/or increase challenging behaviors in
young children.
The recommendations proposed address these research findings primarily through
prevention and early intervention efforts to keep challenging behaviors from developing fully.
Universal standardized screening on a regular basis is intended to prevent long delays between
young childrens initial manifestations of developmental difficulty and provision of appropriate
supports. Additionally, through universal parent education classes parents may find a ready
social support network outside of work to talk through parenting challenges with, as well as
sources for referral to additional community supports if needs expressed extend beyond the
scope of their general classes. Training and support are also provided to early childhood
providers to expand their repertoire of strategies and hopefully minimize their feeling of need to
expel young children from their care.
What role may early intervention and early childhood special education programming
currently be playing in addressing developmental concerns that precede expulsion? While no
studies specifically addressing participation rates of children with challenging behaviors in early
intervention or early childhood special education were located, it is clear that Minnesotas 2010
service rate of 3.87% fell significantly below prevalence rates of both developmental delays and
behavioral disorders. By two years of age, children coming from families living below the
poverty level were found to have increased incidence of developmental delays. Additionally,
children involved in the child welfare system were found to be at a significantly increased rate of
152
developmental delay. While some of the gap between incidence and service rates may be due to
families declining services, it appears likely that much of the difference is accounted for by
under-referralwith pediatricians not following American Academy of Pediatrics
recommendation to use standardized screening instruments as part of well-child visits and
parents not always recognizing when their child has delays.
The two areas of recommendation stemming from these research findings are universal
screening and universal parent education. Although it may be argued a better use of funds to
closely target those at greatest risk for developmental delay, this author believes that doing so
may increase the existing stigma associated with these programs, which could ultimately result in
less participation by those in the greatest need of services. By working to build trust in a
citywide collaborative it is hoped that buy-in for use of standardized screening instruments will
be more forthcoming than it has been for a professional organizations written recommendation.
By adding in parent education, as well, than parents knowledge of child development should
increase so that they may be more likely to recognize delays in development and, therefore, be
able to push for early childhood screening for their children if they have not recently been
screened.
What types of interventions have been used to improve social-emotional development in
young children? A variety of intervention models targeting children, early childhood providers,
and parents have been created and tested. Two models of particular note are Incredible Years
(which has child-, parent-, and teacher-focused elements) and early childhood mental health
consultation (which, as noted earlier, has been linked to lower levels of early childhood
expulsion). In general, interventions that were longer in duration and more intensive, as well as
those with booster-session follow-ups, appeared to have the greatest impact on behaviors. There
153
was indication that combining interventions may have a greater degree of impact on young
childrens challenging behaviors than a single intervention alone.
These research findings are evident in the recommendations for prevention and early
intervention programming. Although no particular brand of intervention (e.g., Incredible Years,
Tools of the Mind, You Can Do It!) is endorsed, the recommendation is to create universal
access to parent and early childhood provider education and support opportunities so that
participants can choose to engage for a duration and intensity level that will meet their needs in
an environment that does not stigmatize participation. Because early childhood mental health
consultation, as a model, has been shown to significantly decrease incidence of early childhood
expulsion, this model is incorporated into the recommendations for early childhood provider
support and training.
Suggested Areas for Future Research
The suggested areas for future research section corresponds to same themes presented in
the literature review. A separate section at the end addresses potential cross-thematic research.
Early childhood mental health. In general, the field would benefit from having a
greater number of studies using more economically, racially, and linguistically diverse samples
to make findings more readily generalizable. Of particular note is the seeming absence of Native
American populations, very little inclusion of Asian or Pacific Islander populations, and no
specific mention of recent immigrant or refugee populations. It may be of particular interest to
extend longitudinal research to recent immigrant and refugee populations as it may be suspected
that if the impact of stress and lack of social support that appears to be a risk factor in other
populations holds true, rates of challenging behavior may be expected to spike due to the strains
of acculturation in an unfamiliar place likely far from extended family and other natural
154
supports. Beneficial coping mechanisms may also be identified in these populations that could
be adapted for use with native-born populations as, anecdotally, this author has seen very few
recent immigrants or refugees ending up in non-Autism K-12 programs for children with
behavioral disorders.
Research relating to development of young childrens self-regulation and to comorbidity
between language impairments and challenging behaviors would benefit from replication with
low-income and ethnically and linguistically diverse populations. A number of these studies
specifically screened out children with sensory impairments, so another direction for research
would be to see if language plays the same role in regulation and has the same types of
comorbidity with behavioral disorders in populations who are Deaf, hard-of-hearing, and/or
blind.
Early childhood program expulsion. A primary area suggested for future research is
conduct more in-depth study of the rates and correlates of preschool and daycare expulsion in
Minnesota. In particular, a state-wide survey of expulsion rates and perceived needs from public
and private early childhood programs could be used as a needs-assessment tool to help secure
legislative policy support and funding for a state-wide prevention program, as was done in
Colorado (Hoover et al., 2012). In Colorado, in addition to identifying how many children were
being expelled attention was also paid to the types of challenging behaviors early childhood
providers were seeing, their typical responses, and background characteristics (such as years of
experience and formal education levels) of the early childhood providersall of which would be
useful in a state-wide study focused on Minnesota.
Studies focused at local city- or county-level analysis could shed additional light on what
demographic, programmatic, or other contextual factors may influence rates of expulsion for
155
different types of publically- and privately-funded early childhood programs. This approach
could also make possible comparisons between neighboring localitiessimilar to what Chan and
Obnsorg (1999) did looking at EI participation rates in Minnesotawhich could allow deeper
investigation of what impact, if any, conditions noted at birth and participation in EI and ECSE
programs may have on expulsion rates.
Family perspectives on impact of behavior-related child care problems. Two major
limitations of the existing research base include mostly small sample sizes and a lack of
economic, racial, and linguistic diversity among sample participants. It is therefore
recommended that similar studies be conducted with larger and more diverse sampleseither
through targeted selection within specific populations or use of randomized sampling techniques.
An additional recommendation is to conduct research using a comparison group to explore
themes such as reported stress levels, employment experiences, and childcare experience
between primary caregivers with and without children with severe challenging behaviors to
determine the magnitude and possible qualitative differences in family experience.
Early intervention and early childhood special education. Due to the changing legal
and social nature of EI and ECSE programming, it is important that studies continue to be
conducted to assess the fidelity of screening, referral, and service procedures. Special attention
may be warranted to the prevalence rates of developmental delay in different cultural and
economic communities, as well as the awareness and usage levels of EI and ECSE services.
Additionally, research on parents and service providers experiences interacting with EI and
ECSE programming could add further depth of understanding of these systems beyond raw
demographics and service rates.
156
Interventions models. Since a majority of studies reported only immediate results, it

would be good to conduct further follow-up studies to assess the durability of results and what
factorsif anymay be associated with differences in long-term outcomes. A second area of
research expansion would be to use larger and more economically, ethnically, and linguistically
diverse samples. While Head Start does provide a nice convenience sample, it would be good to
see findings replicated with young children, early care providers, and parents of a variety of
backgrounds. Additionally, there are some racial/ethnic demographics which were rarely noted
as included in samplesNative American, Asian American, and those whose home language
was neither English nor Spanishwhich would be important to include in future research to
make findings more readily generalizable.
Trajectories and impact of challenging behavior into the K-12 years. As early
intervention efforts are put in place, it is important that longitudinal studies to track children who
have participated to determine which methods bring the most beneficial outcomes to children
and their families.
Potential for cross-thematic research. Many areas of cross-thematic areas may be
worth exploration through future research. One area would be the perceptions of immigrant
parents on their young childrens social-emotional development and experiences with early care
and/or intervention settings. Another area for research is how children with challenging
behaviors may view classroom experiences from preschool on up through the entrance into the
K-12 system and/or childrens experiences of participation in a variety of intervention programs.
An additional area for research could be to track the trajectories of children who entered early
intervention and/or early childhood special education programs with behavioral challenges, in
157
comparison to those who may have qualified for services but did not participate, to detect what
the impact and potential cost-savings may be over the subsequent years.
158
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Table of Contents

Running Head: EARLY CHILDHOOD MENTAL HEALTH OUTCOMES

Supporting Early Childhood Mental Health Outcomes:

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That many studies used a combination of methods of data collection to corroborate

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Individual and environmental interactions. Interactions have been noted between

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notedbehavior problems at 36-months and increases in preschool behavioral problems were

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Short-term trajectories. The behavioral trajectory a majority of young children follow

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from other ethnic backgroundsespecially Asian, Hispanic/Latino, or Native Americanor

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Factors impacting referral and service provision. While up to twenty-percent of

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Prescreening Developmental Questionnaire (PDQ), and the Bayley Infant Neuro-developmental

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Children in classrooms implementing PATHS also experienced a significant reduction in anger

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