Effectiveness of Behavioral Preschool Teacher Training for Externalizing
Condition: Attention Deficit and Disruptive Behavior Disorders; Problem Behavior; Attention Deficit Disorder With Hyperactivity
MeSH terms: Attention Deficit Disorder with Hyperactivity; Mental Disorders; Problem Behavior; Attention Deficit and Disruptive Behavior Disorders
Study type: Interventional

Summary: 
      A cluster randomized controlled pre-post effectiveness trial of behavioral preschool teacher
      training (BPTT) delivered in a practitioner assisted group format for children with
      externalizing behavior problems. Preschools were randomized to either intervention in 25
      preschools or as 22 waiting list control preschools, where teachers in preschool classes with
      the target child or children were program receivers. Participants were 100 target children
      3-5 years old together with 72 enrolled preschool teachers and 83 parents as informants of
      behavioral outcomes after a five months period of implementation (at six months). The
      intervention was part of the Swedish evidence-based parent and teacher training programs
      (Comet) for children and youth with elevated externalizing behavior, and here an adapted
      version was tried in preschool for the first time. Also investigated was eventual generalized
      effects to the children's homes and improved social competence as an intermediate mechanism
      for reduced problem behavior. Effects of implementation fidelity in addition to social
      acceptability and relevance, such as reliable change, was investigated as well.
    

Detailed description: 
      Study:

      A cluster randomized controlled pre-post effectiveness trial of behavioral preschool teacher
      training (BPTT) delivered in a practitioner assisted group format for children with
      externalizing behavior problems. Preschools were randomized to either intervention in 25
      preschools or to 22 waiting list control preschools, where preschool classes with the target
      child or children were program receivers. Informed preschools could apply for participation
      in the study, then, target children were screened for eligibility. Participants were 100
      target children 3-5 years old together with 72 enrolled preschool teachers and 83 parents as
      informants of behavioral outcomes after a five months period of implementation (at six
      months).

      Intervention:

      The intervention was part of the Swedish evidence-based parent and teacher training programs
      (COmmunication METhod - Comet) for children and youths aged 3-12 and 12-18 years with
      moderate or elevated externalizing behavior, usually delivered in practitioner assisted group
      formats but previously evaluated as delivered via internet, single workshops followed by
      self-administered training, and universal prevention as well. Program implementations and
      evaluations are executed as collaboration projects between university researchers and the
      social services administration at place. Intervention content is influenced by operant
      conditioning, social learning theories, applied behavior analysis, and coercion theory. The
      focus is to establish a positive and effective interaction and communication style primarily
      through different reinforcement techniques (e.g., selective attention, more to positive
      behaviors and less to negative behaviors) and modeling. Parents or teachers meet in
      psychoeducational group sessions (often 9 to 11 sessions à 2.5 to 3 hours) led by one or two
      practitioner supervisors. They each follow a comprehensive manual and a highly structured
      curriculum. Training occurs at sessions (role-plays) and between sessions together with the
      children, followed-up with feedback in the next session.

      Here an adapted version was tried in the preschool setting for the first time. The program
      corresponded in much to the parent training supplemented with techniques from the school
      teacher training and a group level administrated glove-puppet play technique to foster
      children's prosocial skills. (Results from the universal part of the program are not
      reported.) The nine sessions curriculum consisted of 2.5-hour biweekly meetings and two
      optional visits from supervisors with coaching on the spot. Practitioner supervisors (n = 27)
      were educated by a cognitive-behavior oriented psychologist during five days term one and two
      days term two.

      Investigation issues:

      The primary aim was to investigate behavioral outcome effects of the preschool teacher
      program. Would effects (Cohen's d) be in the medium-large range as found for Comet parent
      training (i.e., d = .50-.90) or in the small-medium range as often found for preventive
      developmental preschool programs (i.e., d = .20-.40)? With effects of about .40, a sample
      size restricted to 100 subjects, and an alpha at .05, power would be close to sufficient
      (i.e., .70). Of interest was to compare the effects of this program with effects found for
      other preschool program investigations of externalizing behavior problems.

      Also investigated was eventual generalized effects to the children's homes. Of what magnitude
      would such effects be, if any, and would the parents' ratings validate the teachers' ratings,
      and thus, support the intervention? Such effects may have implications for future
      implementations, for example if the program is sufficiently efficient as a stand-alone
      intervention in reducing externalizing behavior problems or not sufficiently efficient. There
      was also a question of degree of informants agreement/discrepancy. Furthermore, would
      improved prosocial and regulatory skills function as a predictive and an intermediate
      mechanism for reduced problem behavior, and/or would there be room for other intervention
      features to contribute as well? In addition, as a trial in the real world, effects of
      implementation fidelity as well as social acceptability and relevance, such as proportions of
      children with reliable change, were investigated.
    

Intervention name(s): Comet
Intervention type(s): Behavioral
Other intervention name(s): Comet in group format
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Preschools randomized to either behavioral teacher training or as waiting list control preschools.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Externalizing behavior problems; Social competence; School readiness; Teacher management training; Cluster randomized effectiveness trial