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The utility of the Child and Adolescent Functional Assessment Scale (CAFAS) in identifying outcomes of students with emotional disturbance served in a day treatment program

ProQuest Dissertations and Theses, 2009
Dissertation
Author: Mitchell D Moisio
Abstract:
This study investigated student outcomes by analyzing archival PEP client data from the Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 2000). Participants were students with severe emotional and behavioral problems, being served by the Positive Education Program's (PEP) Day Treatment Centers in a midwestern urban center. The CAFAS is a multidimensional rating scale that measures degree of behavioral and emotional impairment across domains in children and adolescents. In addition to subscale and total score analysis, the CAFAS permits analysis of subscale score results in terms of CAFAS Tiers that represent different client types (Hodges, 2004). Hodges (2004) indicated that CAFAS Tiers are a research-based way of assigning clients to diagnostic groups based on the level of impairment in their functioning. CAFAS Tiers have multiple potential utilities which include screening clients for serious problems (i.e., self-harm potential), linking research-based treatments to specific client needs, and assisting agencies with staff training needs and cost allocation decisions (Hodges, 2003a, 2004). This study investigated the utility of the CAFAS in identifying outcomes for PEP students (aka: children, clients, youths) as a function of their CAFAS Tier type. PEP clients' CAFAS Tier type and change in CAFAS scores were compared over a one year period. Results showed that four out of five Tier types demonstrated significant score reduction between first and last CAFAS. Tier groups with highest impairment (i.e., highest overall CAFAS scores at intake) showed the greatest amount of score reduction from first to last CAFAS. The Thought Problems and Delinquency Tiers remained significantly impaired on the Thinking and Community subscales. Lastly, the membership in the severe Tiers' groups at intake decreased by last CAFAS--except for the Thought Problems Tier. Potential benefits of this study include (a) a means to more closely analyze PEP students' outcomes, (b) a basis to modify treatment protocols, and (c) a way in which staff training needs can be assessed.

TABLE OF CONTENTS ABSTRACT…………………………………………………………………..………………………………… v LIST OF TABLES……………………………………………………………………………………………. xi LIST OF FIGURES……………………………………………………………………………………………

xii CHAPTERS

CHAPTER I: INTRODUCTION………………………………………………………………

1 Research Questions…………………………………………………………………

5 Definition of Terms………………………………………………………………..

5 Clinical Implications……………………………………………………………….

7 Limitations………………………………………………………………………………

8 Conclusion……………………………………………………………………………….

8 CHAPTER II: LITERATURE REVIEW……………………………………………………..

9 The History of Children and Emotional and Behavior

Problems………………………………………………………………………………….

9

In the Beginning……………………………………………………………

9 The Nineteenth Century………………………………………………

11

The Twentieth Century……………………………………………….

12 Landmark Legal Cases and Legislation…………………………

15 Origins of the Definition of ED…………………………………….

17 Characteristics of Students with Emotional Disturbance………

18 Prevalence…………………………………………………………………… 18

Characteristics…………………………………………………………….

19

viii

Special Education Services for Students with Emotional

Disturbance…………………………………………………………………………….

20

The Positive Education Program………………………………….

21

The Population of Students with Emotional Disturbance and

Diagnostic Instruments……………………………………………………………

23

CAFAS……………………………………………………………………………

23

CAFAS Tiers……………………………………………………….

26

CAFAS Tiers and Intervention……………………………

28 Empirically Supported Treatments for

Disorders Commonly Found in CAFAS Tier

Types…………………………………………………………………

29 CAFAS Tier Type Outcome Studies……………………

PEP CAFAS Outcome Studies……………………………. 36

40

Summary………………………………………………………………………………….

41 CHAPTER III: METHODOLOGY……………………………………………………………. 44

Ethical and Legal Considerations…………………………………………… 44

Institutional Review Board……………………………………………

44

Rights and Informed Consent……………………………………….

44

Participants and Procedures……………………………………………………

45

Data……………………………………………………………………………… 45

Measures…………………………………………………………………………………. 45

The Child and Adolescent Functional

Assessment Scale…………….……………………………………………

45

ix

Research Questions…………..…………………………………………………… 50

Data Collection Procedures…………………………………………………….

Data Analysis…………………….…………………………………………………….

50

51

CHAPTER IV: RESULTS……………………………………………………………………….

52

Statistical Analyses………………………………………………………………..

54

Assumptions for Statistical Models………………………………

55

Research Question #1: What is The Magnitude of

CAFAS Score Change Across all Tier Types

(i.e., total score) Between First and Last CAFAS?......

56

Research Question #2: What is the Magnitude

of CAFAS Score Change Relative to each

Individual Tier Type Between First and Last CAFAS?...

57 Research Question #3: What is the Magnitude

of the Difference in CAFAS Tier Score

Change when Individual Tiers are Compared?..........

58 Research Question #4: What is the Pattern

of Differences in Subscale Scores for Each

Tier at the Last CAFAS Administration?...................

60 CHAPTER V: DISCUSSION…………………………………………………………………….

66 Research Questions…………………………………………………………………

66 Discussion of Findings…………………………………………………………….

67 Research Question #1: What is The Magnitude of

CAFAS Score Change across all Tier Types

x

(i.e., total score) Between First and Last

CAFAS?.........................................................

Research Question #2: What is the Magnitude of

CAFAS Score Change Relative to Each Individual Tier

Type Between First and Last CAFAS?......................

67

68

Research Question #3: What is the Magnitude of the

Difference in CAFAS Tier Score Change when

Individual Tiers are Compared?............................

70 Research Question #4: What is the Pattern of

Differences in Subscale Scores for Each Tier at Last

CAFAS Administration?......................................

71 Synthesis………………………………………………………………………………….

73 Limitations………………………………………………………………………………

75 Program Implications………………………………………………………………

76 Future Research………………………………………………………………………

77 Conclusion……………………………………………………………………………….

78 REFERENCES……………………………………………………………………………………….

79 APPENDICES……………………………………………………………………………………….

93 A. Cleveland State University Institutional Review Board

Approval………………………………………………………………………………….

94

B. Positive Education Program Institutional Review Board

Approval…………………………………………………………………………………

96

C. The CAFAS……………………………………………………………………………….

98

xi

LIST OF TABLES

Table

Page 1. CAFAS Tiers: Hierarchical Client Types………………………………..……

2. Summary Statistics………………………………………………………………………

49

53

3. Research Question #2: Paired T-Test Results…………………………….

57

4. Research Question# 3: ANOVA Post Hoc Results…………………………

60 5. Research Question #4: MANOVA Results………………………………….….

62

xii

LIST OF FIGURES

Figure Page

1. Bar graph showing percent of sample Tier type at first

CAFAS and last CAFAS……………………………………………………………………..

54 2. Bar graph for first total CAFAS versus last total CAFAS…………………. 56

3. Bar graph showing first total CAFAS versus last total CAFAS according to individual Tier type……………………………………….

58

4. Last CAFAS Home Role Performance Subscale for Behavior Problems Without Moderate Mood Disturbance (BPR) and Delinquent Behavior (DEL) Tiers ……………………………………………………

63 5. Last CAFAS Community Role Performance Subscale for Behavior Problems without Moderate Mood Disturbance (BPR), Behavior Problems with Moderate Mood Disturbance (BPM), Delinquent Behavior (DEL), Self-Harmful Potential (SHP), and Thought Problems (THP) Tiers ……………………………………………………………………………..…….

63

6. Last CAFAS Moods/Emotions subscale for Behavior Problems without Moderate Mood Disturbance (BPR), Behavior Problems with Moderate Mood Disturbance (BPM), Delinquent Behavior (DEL), Self-Harmful Potential (SHP), and Thought Problems (THP) Tiers…………………………………….

64

7. Last CAFAS Thinking subscale for Behavior Problems

xiii

without Moderate Mood Disturbance (BPR), Behavior Problems with Moderate Mood Disturbance (BPM), Delinquent Behavior (DEL), Self-Harmful Potential (SHP), and Thought Problems (THP) Tiers……………………………………

64

1

CHAPTER I INTRODUCTION Before federal regulations were established to facilitate services for children with disabilities, only one in five disabled students received public education (Lee, 2003). As a result of the implementation of the Individuals with Disabilities Education Act (IDEA) over the past three decades, approximately 6.5 million students with disabilities have been served, and 97% of those youth attended regular schools (Lee, 2003). Today, students with disabilities are not only entitled to a free appropriate public education (FAPE), but it is a legal requirement that every public school district seeks out, identify, and serve children with disabilities (Federal Register, 2006; IDEA, 2004). Of the several different special education disabilities currently defined under IDEA, children identified with emotional disturbance (ED) account for approximately 1% of the school-aged population (Hallahan, Keller, & Ball, 1986; Kauffman, 2005). Compared to other types of disabilities, students with ED are most at risk for failing to complete school with a dropout rate of about 40% (Wagner, 1995). Further, the National Agenda for Achieving Better Results for Children and Youth with Serious Emotional Disturbance (1994) found that students

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with ED miss more school, are retained more often, and receive more failing grades than any other disability group. Students with ED experience longer delays in finding employment after graduation from school, and are more likely to hold several part-time jobs as opposed to a single job over time. They are also less likely to complete a post-secondary program. Obviously, longitudinal data suggest a poor prognosis (Malmgren, Edgar & Neel, 1998; Wagner, D’Amico, Marder, Newman, & Blackorby, 1992). Recognizing the scope of the problems related to students with ED, the U.S. Department of Education published the National Agenda for Achieving Better Results for Children and Youth with Serious Emotional Disturbance in 1994. This agenda focused on seven targets: -Positive learning opportunities and results, -School and community capacity, -Diversity, -Collaboration with families, -Appropriate assessment, -Ongoing skill development and support, and -Comprehensive and collaborative systems. Based on the findings of the National Agenda, Osher and Hanley (2001) identified programs across the nation that exemplified the National Agenda in their practice. One such program is the Positive Education Program (PEP) in Cleveland, Ohio. PEP is a 35-year-old agency co-founded by Drs. Rico Pollotta and Lee Maxwell in 1971. It currently operates as a non-profit mental health agency under

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both the Cuyahoga County Community Mental Health Board and the Educational Service Center of Cuyahoga County. It consists of ten day treatment centers, two early intervention centers, and provides a variety of other services including, but not limited to, PEP Assist, Day Care Plus, Early Start, Connections, Diagnostic Assessment Service, and Group Homes (Maxwell, 2003; Osher & Hanley, 2001; Positive Education Program [PEP], 2006a). PEP is one of many agencies dealing with an overall trend in education and mental health for increased accountability—especially for programs receiving state and local mental health funding. In fact, programs such as PEP have increasingly stringent requirements to collect evaluative data for identifying clients, measuring performance and outcomes, and making funding decisions (Bates, 2001; Garland, Kruse & Aarons, 2003). To meet these demands, many agencies, including PEP, use multidimensional assessment tools such as the Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 2000). The CAFAS is a multidimensional rating scale that measures degree of impairment across domains in children and adolescents (Hodges, 2003a). The CAFAS is widely used and has been adopted in more than 20 states and at local levels (Bates, 2001; Hodges, Wong & Latessa, 1998). The CAFAS is particularly useful for mental health agencies because it can monitor and track behavioral change among students through regular administration. In addition, the overall total score can be interpreted through descriptive levels of dysfunction in impairment. For example, a total score of 100- 130 indicates that a “Youth likely needs care which is more intensive than

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outpatient and/or which includes multiple sources of supportive care” (Hodges, 2000, p.1; also see Appendix C). The CAFAS can also be used to categorize youths into client types or CAFAS Tiers (Hodges, 2004). CAFAS Tiers are a research-based way of assigning clients to diagnostic groups based on the severity of their impairment in functioning. Hodges (2004) listed some potential advantages of screening youth this way. For example, the CAFAS Tiers screening process can quickly identify clients who may need to be more closely monitored (e.g., those with thought problems and/or self-harm risk); or to develop more specialized treatment protocols. CAFAS Tiers can also serve as a means to look at client progress and outcomes over time as a function of Tier type. CAFAS Tiers are arranged by type and severity—making changes in Tier type clinically meaningful. Fortunately, PEP has been collecting CAFAS data on many of its clients for several years; and results of the 2005 and 2006 outcomes generally show favorable overall gains across the entire client population (PEP, 2005b, 2006b). While these data are meaningful, a next logical step is to more closely analyze outcomes for PEP clients as a function of CAFAS Tiers or client types. In doing so, this research has the potential to (a) identify which client types make the most improvement as measured by the CAFAS, (b) assist with developing specific treatment protocols for different kinds of clients, (c) help with cost allocation and planning, (d) provide program evaluation data, and (e) potentially assist with identifying staff training needs. In order to conduct this study the following research questions will be addressed.

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Research Questions 1. What is the magnitude of CAFAS score change across all Tier types (i.e., total score) between first and last CAFAS? 2. What is the magnitude of CAFAS score change relative to each individual Tier type between first and last CAFAS? 3. What is the magnitude of the difference in CAFAS Tier score change when individual Tiers are compared? 4. What is the pattern of differences in subscale scores for each Tier at the last CAFAS administration? Definition of Terms The following definitions clarify the meaning of important terms in the current research: Child and Adolescent Functional Assessment Scale (CAFAS) The CAFAS is a multidimensional rating scale that measures degree of impairment across domains in children and adolescents. Impairment is the extent to which the child’s problems interfere with his functioning across eight different subscales including: School/Work, Home, Community, Behavior Towards Others, Moods/Emotions, Moods/Self-Harm, Substance Use, and Thinking. A rater familiar with the child; and who has been trained in its use, completes the scale resulting in eight subscale scores and a total score (Hodges, 2003a). CAFAS Tiers A way of categorizing client types based on individual client scores on the CAFAS subscales. Hodges and Wotring (2000) used cluster analysis to generate

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client-type clusters based on mean total and subscale scores. The original five clusters were further expanded to eight Tier types (Hodges, 2003a, 2004). The CAFAS Tiers in order of severity from most to least are Thought Problems, Maladaptive Substance Use, Self-Harmful Behavior, Delinquent Behavior, Behavior Problems with Moderate Mood Disturbance, Behavior Problems Without Moderate Mood Disturbance, Moderate Mood Disturbance, and Mild Mood and/or Mild Behavioral Problems (Hodges, 2004). Membership in each Tier is determined by subscale score analysis. Each Tier has its own algorithm for membership (see Table 1). Emotional Disturbance

Emotional disturbance (ED) is a term from the Individuals with Disabilities

Education Act (IDEA, 2004). ED is an educational disability that includes students with emotional and behavior problems. The IDEA definition of ED is the following: A condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance: (A). An inability to learn which cannot be explained by intellectual, sensory, or health factors; (B). An inability to build or maintain satisfactory interpersonal relationships with peers and teachers; (C). Inappropriate types of behavior or feelings under normal circumstances; (D). A general pervasive mood of unhappiness or depression; or (E). A tendency to develop physical symptoms or fears associated with personal or school problems. (ii) Emotional disturbance includes children who are schizophrenic, but does not include children who are socially maladjusted, unless it is determined that they have an emotional disturbance (Federal Register, 2006, ss300.8, [4][i], p. 46756)

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Individuals with Disabilities Education Act (IDEA) IDEA is a federal law that was first enacted in 1975 (i.e., The Education for All Handicapped Children Act, PL 94-142). It requires that all public schools provide special education services for children with disabilities. The law also requires school districts to provide necessary accommodations, modifications and supplemental aides and services sufficient for a child to make progress in school. It was most recently amended in 2004 and renamed the Individuals with Disabilities Education Improvement Act (Federal Register, 2006; IDEA, 2004). Positive Education Program (PEP) The Positive Education Program is a combined mental health and special education program serving children in northeast Ohio. It is comprised of several day treatment centers and other programs that provide services for students with emotional and behavior problems ages preschool through 21. A more in-depth description is provided in Chapter II (PEP, 2001, 2003, 2004, 2005a). Clinical Implications Hodges and Wotring (2004) wrote “The consistently poor outcomes for some types of clients have generated a genuine interest among clinical staff in learning and implementing evidence-based treatments” (p. 396). The primary clinical implications of this study arise from the potential interpretation of outcome data. Interpretations of client outcomes serve to assist in formulating or modifying treatment programming decisions, making funding decisions, and monitoring care at the systems level across agencies and programs (Garland, et al., 2003; Hodges, 2004).

8

The research questions that this study poses center around which students’ CAFAS scores—according to CAFAS Tier type—change most over time in PEP’s day treatment program. Having statistical data to address this question could potentially help PEP and other service providers customize treatment programs and resources to existing and future students’ needs based on their CAFAS profiles. Limitations Since this study is archival, the limitations to this research are primarily related to the sample size and inability to control for rater bias. However, the CAFAS requires that the rater be well-informed about the child, and have achieved a level of reliability as a rater (Hodges, 2003). These factors should offer some control over these limitations. Conclusion The purpose of this chapter was to provide a brief description of the research topic, and the importance of the research. The questions intended for examination, significance, and limitations of this study have been identified. The following chapter will provide a review of literature that is relevant to the topic of investigation.

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CHAPTER II LITERATURE REVIEW The primary purpose of this chapter is to review relevant research related to this study. The chapter is divided into four sections. The first section outlines the history of public interest and education as they relate to students with emotional and behavior problems. Historical and current perspectives of children with emotional and behavior problems and treatments are reviewed here. In the second section, the characteristics of students with emotional disturbance are explored—including descriptions of the problematic types of behaviors they tend to exhibit. The third section reviews the types of services that are currently available for this population—including special education in public schools to more restrictive settings—such as day treatment programs. In the next section, the importance of assessing outcomes for this population is discussed. Finally, the summary concludes this chapter with the proposed research questions. The History of Children and Emotional and Behavior Problems In The Beginning

For a long time, children were described and viewed as “miniature” adults

10

and therefore a separate stream of research on children was virtually nonexistent. Neither doctors nor teachers realized that children may be different from adults—they just grew up and that was that (Kanner, 1967; 1973). The earliest inkling of interest in child development may be attributed to Johann Amos Komensky (or Comenius). Komensky was a Moravian Church educator who wrote several books during the Thirty Years’ War (1618-1648). In his writings, he advocated for gradual instruction of “habits, diction, and grasp of the environment” (Kanner, 1967, p. 117-118). Also in the 1600s, John Locke suggested that children’s education should be based on “native instincts and capabilities,” and therefore it was important to study children (Kanner, 1973, p. 189). In 1762, Jean Jacques Rousseau published his book, “Emile” which actually makes a direct plea for the study of children and illustrates developmental observations of his own child. This work led others such as Stanley Hall and German educator, Bartholomäi (1870) to chart development of children in similar ways in the second half of the Nineteenth Century. They began to gather survey information about differences in children. Stanley Hall had thousands of parents fill out questionnaires about their children’s development; and Bartolomäi surveyed what he referred to as “the contents of children’s minds” upon entering school (Bartholomäi, 1870; as cited in Kanner, 1967, p. 118). The findings were presented in terms of percentages (Kanner, 1967). As the beginnings of identifying and describing deviations in children emerged, so did the terminology for the individuals who were deviant. Some of the most primitive descriptions included terms like “insane” or “idiots” (Kanner,

11

1967; 1973; Kauffman, 1989, p. 47). Distinctions were made between the two terms, however a legal separation was not made until 1886 in England (Hayman, 1939; as cited in Kauffman, 1985). Of course no historical account of child study, disorders, and treatments in the 1700s would be complete without mentioning the work of Jean Marc Gaspard Itard. Itard worked with the “Wild Boy of Aveyron.” As the story goes, the boy was found in the forest where he had been abandoned for quite a while. Itard thought him to be severely retarded, but was convinced that the boy could be taught skills, and indeed he could. This remarkable accomplishment provided a basis for some of the principles still used in today’s educational methods for the disabled (Kanner, 1967; Kauffman, 1985; Lane, 1976). The Nineteenth Century The beginning of the Nineteenth Century brought improved and kinder treatments for those considered insane and idiots. This was largely due to new emphases on individual rights and freedoms after the American and French Revolutions (Kauffman, 2005). Private and public efforts to cure the problems of idiocy and insanity were evident in the first half of the century. Education was the preferred treatment and humanistic teaching methods were employed—which are strikingly similar to modern techniques used today (i.e., methods were based on individual assessment, were very structured, and emphasized the teaching of self-help skills) (Brigham, 1848; as cited in Kauffman, 1985). By the middle of the Nineteenth Century, new institutions for children who were delinquent and/or

12

“intellectually limited” flourished (Brigham, 1845 as cited in Kauffman, 1985 p. 46; Kauffman, 1985). However, with a changed economic and social climate after the Civil War, pessimism regarding the treatment of the mentally ill was more common (Kauffman, 2005). The causes of their disorders were thought to be irreversible and were generally attributed to masturbation, heredity, overwork, religion or disease (Kauffman, 2005). In fact, masturbation was so intolerable during the Nineteenth Century extreme attempts like castration and ovariotomy were made to stop it (Bremner, 1971). At the end of the Nineteenth Century, despite some regression after the Civil War, there were notable advances too. For example, several textbooks were published that began to deal with etiology and classification of psychiatric disorders (Kanner, 1960 as cited in Kaffman, 1985). A psychoeducational clinic was established by Lightner Witmer at the University of Pennsylvania in 1896; and Chicago and Denver established the first juvenile courts in the country in 1899. It is likely that many of these events in the latter part of the Nineteenth Century set the stage for significant growth in the Twentieth Century (Kauffman, 1985). The Twentieth Century In the first half of the Twentieth Century several positive accomplishments were made related to the mental and physical well-being of children (Ollendick & Hersen, 1983; as cited in Kaufman, 2005). The first teacher training programs in special education began in Michigan in 1914. All states had compulsory education laws by 1918 (Kaufman, 1985, 2005). While the field of children’s emotional and

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behavior disorders was clearly emerging in first part of Twentieth Century, the field of “child psychiatry” was not presented until 1937 by the French pioneer named Heuyer at the First International Congress in Paris (Kanner, 1973). While child psychiatry was developing, so were professional organizations related to children with emotional and behavior problems. In 1922, the Council for Exceptional Children was founded. It included mostly educators along with some parents and other professionals. Then, in 1924, the Orthopsychiatric Association was established and was mostly made up of psychiatrists and psychologists (Kaufman, 2005). Concern for the physical and mental health of children was becoming more of a priority in the early 1900s. In 1919, Ohio enacted a law for the care of children with handicaps; and by 1930, 16 states had laws allowing school districts to recover some of the costs of educating students with handicaps (Kauffman, 1985, 2005). In the 1930s, child guidance clinics were becoming fairly common even though child psychiatry was a relatively new discipline (Kanner, 1973). In fact, their existence helped to promote treatment for not only severe childhood problems, but also more mild issues. They also promoted collaboration among agencies and helped to draw attention toward exceptional children (Kanner, 1973; Kauffman, 1985). During World War II and the Great Depression, funds and attention were diverted from education. Most of the special programs were for the mild mentally retarded with few programs for children with severe behavior problems—except in

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larger cities (Henry, 1950 as cited in Kauffman, 1985). Even though specialized programs were few, work and progress on defining characteristics of childhood disorders were flourishing. Dr. Laura Bender wrote on the topic of childhood Schizophrenia and started the children’s ward at Bellevue Psychiatric Hospital in New York City. In 1934 Leo Kanner was beginning to study Autism at Johns Hopkins University Medical School (Kauffman, 1985, 2005). Towards the middle of the Twentieth Century, the first book describing teaching techniques for children with behavior problems was published by Kornberg (1955) (as cited in Kaufman, 1985); and scholars saw that specific techniques were needed to assess and identify children with emotional and behavior problems in school. In the 1960s and 1970s, interventions for children with severe emotional and behavior disorders were gaining interest and several treatment approaches emerged (Kauffman, 2005). Behavior modification had the widest acceptance—today known as applied behavior analysis (Kauffman, 2005). It is no doubt that B. F. Skinner’s classic work, Science and Human Behavior (Skinner, 1953), played a vital role in gaining acceptance for a behavioral approach. Labrador (2004) wrote the following: Skinner is, without a doubt, one of the most predominant figures in the development of Behavior Modification and Behavior Therapy. Skinner’s work is essential to the development of Behavior Modification and Behavior Therapy. Beginning with the social need for efficient psychotherapy, and after having generated a solid theoretical body of behavioral laws, Skinner indicated and also developed the appropriate path towards efficient interventions for unadaptive behavior. He developed a new theory regarding abnormal behavior (psychopathology), as well as a procedural model for evaluation (diagnosis) and intervention: “The functional analysis of behavior”. His applications for this kind of work are pioneering and at the same time, he is the agglutinant figure of what we today call “Behavior Modification and/or Therapy” (p. 178).

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Eventually Skinner’s work found its way to schools and classes for children with behavior problems. One of the first pilot programs was implemented in 1968 by Frank Hewitt and colleagues at the University of California at Los Angeles and in the Santa Monica School System. They created what would become one of the most replicated classroom programs for children with behavior problems, the Engineered Classroom. Its structure relied heavily on behavior modification and behavior analysis (Hewett & Taylor, 1980). Behavior modification techniques were clearly the predominant therapeutic approach for students with behavior problems, but not the only approach. In the 1960s Nicholas Hobbs, a professor and very well-accomplished child advocate, started Project Re-ED—a new approach for treating troubled children. His Re- Education method focused on building positive relationships with children. Instead of conceptualizing emotional and behavior problems as a symptom of the individual, he thought they were more closely related to failing ecosystems. As a result, his method focused on therapeutic camping to remove children from problematic environments in order to “re-educate” them. He published his model in 1982 in the Troubling and Troubled Child. His approach has become widely accepted in programs across the country, and is known as Re-Ed (re-education). Many of those programs only serve children with emotional and behavior problems on an outpatient or residential basis (Wrightschool.org [n.d.]; Zigler, 1985). Landmark Legal Cases and Legislation Along with the growing interest in this population and appropriate services for them, a number of landmark legal cases in education were unfolding that

16

dealt with access to public education for all children. Two of these high profile cases were Mills v. Board of Education of the District of Columbia and Pennsylvania Association for Retarded Children v. Commonwealth of Pennsylvania (PARC). The PARC case found that every mentally retarded child in Pennsylvania had the right to a public education. The Mills case found that public schools in Washington, DC could not exclude any exceptional children from a public education—regardless of cost (National Center on Education Finance, [n.d.]; Tucker, Goldstein, & Sorenson, 1993). Finally in 1975, The Education for All Handicapped Children Act (EHA, PL 94-142) was passed into law. It was fueled by litigation (e.g., Mills and PARC) and states’ failures to meet the needs of exceptional learners (Tucker, Goldstein, & Sorenson, 1993). The law mandated local education agencies (LEAs) to provide a free appropriate education (FAPE) to all students with disabilities including students with emotional and behavior problems (i.e., emotional disturbance). Since the original EHA, there have been several reauthorizations including 1983 (P.L. 98-1999), 1986 (P.L. 99-457), 1990 (P.L. 101-476) when the EHA was renamed to Individuals with Disabilities Education Act, 1997 (P.L. 105-17), and most recently in 2004 with the passage of the Individuals with Disabilities Education Improvement Act (P.L. 108-446) (ED.gov, 2005; Nelson, Rutherford, Center & Walker, 1991). Despite the many reauthorizations over the course of the last 33 years, the contents of the definition of emotional disturbance has largely remained unchanged. The current definition is the following:

Full document contains 127 pages
Abstract: This study investigated student outcomes by analyzing archival PEP client data from the Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 2000). Participants were students with severe emotional and behavioral problems, being served by the Positive Education Program's (PEP) Day Treatment Centers in a midwestern urban center. The CAFAS is a multidimensional rating scale that measures degree of behavioral and emotional impairment across domains in children and adolescents. In addition to subscale and total score analysis, the CAFAS permits analysis of subscale score results in terms of CAFAS Tiers that represent different client types (Hodges, 2004). Hodges (2004) indicated that CAFAS Tiers are a research-based way of assigning clients to diagnostic groups based on the level of impairment in their functioning. CAFAS Tiers have multiple potential utilities which include screening clients for serious problems (i.e., self-harm potential), linking research-based treatments to specific client needs, and assisting agencies with staff training needs and cost allocation decisions (Hodges, 2003a, 2004). This study investigated the utility of the CAFAS in identifying outcomes for PEP students (aka: children, clients, youths) as a function of their CAFAS Tier type. PEP clients' CAFAS Tier type and change in CAFAS scores were compared over a one year period. Results showed that four out of five Tier types demonstrated significant score reduction between first and last CAFAS. Tier groups with highest impairment (i.e., highest overall CAFAS scores at intake) showed the greatest amount of score reduction from first to last CAFAS. The Thought Problems and Delinquency Tiers remained significantly impaired on the Thinking and Community subscales. Lastly, the membership in the severe Tiers' groups at intake decreased by last CAFAS--except for the Thought Problems Tier. Potential benefits of this study include (a) a means to more closely analyze PEP students' outcomes, (b) a basis to modify treatment protocols, and (c) a way in which staff training needs can be assessed.