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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

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3.2: Problem Solving Approaches and Interventions

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• Vera Kennedy
• West Hills College Lemoore

There are six problem solving approaches and interventions most commonly used among practitioners. Each approach examines a different aspect of a social problem. The nature of the problem and people involved determines the most appropriate intervention to apply.

A social systems approach examines the social structure surrounding the problem or issue. This approach requires macro, meso, and micro levels of analysis (see pages 12-13) to help understand the structure of the problem and the arrangement of individuals and social groups involved. Analysis requires comprehension of the entire issue and parts associated, as well as, which components and protocols of the structure are independent or dependent of each other. Application of this approach requires grasp of the complete problem including the hierarchy, order, patterns, and boundaries of individuals and social groups including their interactions, relationships, and processes as a body or structure surrounding the issue (Bruhn and Rebach 2007).

The interventions deployed using a social systems approach focus on establishing and maintaining stability for all parties even while change is occurring. Social system interventions require change agents or leaders such as sociological practitioners to help control and guide inputs (what is put in or taken into the problem) and outputs (what is produced, delivered, or supplied resulting from change) used in problem solving (Bruhn and Rebach 2007). This approach requires the involvement of everyone in the social structure to design or re-design the system and processes around the issue.

The human ecology approach examines the “web of life” or the ecosystem of a social problem or issue. This approach is often visually represented by a spider web to demonstrate how lives are interlinked and interdependent. A human ecology approach focuses on macro and meso levels of analysis to develop knowledge about the social bonds, personal needs, and environmental conditions that impede or support life challenges and opportunities for individuals. Practitioners evaluate and analyze where individuals and groups fit in the social structure or ecosystem and their roles. The purpose of this approach is to identify cognitive and emotional boundaries people experience living in social systems to help confront and remove the obstacles they face.

Interventions applied in a human ecological approach target changes in families, institutions, and small communities. The goal is to confront the stressors and strain created by social situations and settings. Interventions from a human ecology approach help people determine acceptable behaviors within different social environments (Bruhn and Rebach 2007). Practitioners work with social groups to remove collaborative challenges between groups in a social ecosystem and the individuals working and living within them. Change is concentrated on developing a new system and process to support and remove obstacles for individuals effected by a social problem.

• Describe the social systems approach and explain what type of social problems or issues this approach is the most valid method to use.
• Describe the human ecology approach and explain what type of social problem or issues this approach is the most valid method to use.
• A county mental health court
• Gender neutral bathrooms on a college campus
• Anti-bullying campaign in local K-12 schools

A life cycle approach examines the developmental stages and experiences of individuals facing issues or various life crises. Meso and micro levels of analysis are required with this method. Data gathered assists practitioners in understanding the adaption of individuals or groups to change, challenges, and demands at each developmental stage of life (Bruhn and Rebach 2007). Analysis incorporates evaluation of interpersonal connections between a person and the environment, life transitions, and patterns. This approach if applicable when working with individuals, groups, and organizations, which all have and go through a life cycle and stages of development.

Interventions using this approach target changes in social norms and expectations of individuals or groups facing difficulties. Practitioners help identify the context and issues creating anxiety among individuals or groups and facilitate coping strategies to attack their issues. This approach builds on positive personal and social resources and networks to mend, retrain, or enable development and growth.

The clinical approach evaluates disease, illness, and distress. Both meso and micro levels of analysis are required for this method. Practitioners assess biological, personal, and environmental connections by surveying the patient or client’s background, and current and recent conditions (Bruhn and Rebach 2007). A Patient Evaluation Grid (PEG) is the most commonly used tool for data collection. This approach requires in-depth interactions with the patient or client to identify themes associated with their condition and the structure of the social system related to their illness and support. When applying this approach in medical practice, the evaluation and analysis leads to a diagnosis.

• Describe the life cycle approach and explain what type of social problems or issues this approach is the most valid method to use.
• Describe the clinical approach and explain what type of social problem or issues this approach is the most valid method to use.
• Policing strategies to reduce crime and improve community relationships
• Reductions in self-injury or cutting among teens
• A community college social work education degree program

Intervention in a clinical approach concentrates on removal of symptoms, condition, or changes in the individual to solve the problem. The overarching goal of this method is to prevent the problem from reoccurring and the solution from interfering with the individual’s functioning. Problem management must minimally disrupt the social system of the patient or client.

A social norms approach focuses on peer influences to provide individuals with accurate information and role models to induce change (Bruhn and Rebach 2007). This approach observes macro, meso, and micro levels of analysis. Intervention centers on providing correct perceptions about thinking and behavior to induce change in one’s thoughts and actions. This technique is a proactive prevention model aimed at addressing something from happening or arising.

There are three levels of intervention when applying a social norms approach (Bruhn and Rebach 2007). Practitioners use interventions independently or together for a comprehensive solution. At the universal level of intervention , all members of a population receive the intervention without identifying which individuals are at risk. A selective level of intervention directs assistance or services to an entire group of at risk individuals. When specific individuals are beyond risk and already show signs of the problem, they receive an indicated level of intervention . A comprehensive intervention requires an integration of all three levels.

Practitioners assist communities in problem solving by applying a community based approach . All three levels of analysis (macro, meso, and micro) are required for this method. The aim of this approach is to plan, develop, and implement community based interventions whereby local institutions and residents participate in problem solving and work towards preventing future issues. Practitioners work with communities on three outcomes, individual empowerment, connecting people, and improving social interactions and cooperation (Bruhn and Rebach 2007). Concentrating on these outcomes builds on community assets while tailoring solutions to local political, economic, and social conditions. By building bridges among individuals and groups in the community, practitioners facilitate connections between services, programs, and policies while attacking the problem from multiple vantage points.

A community based approach helps ensure problem analysis, evaluation, and interventions are culturally and geographically appropriate for local residents, groups, and organizations. To operate effectively, this intervention requires practitioners to help facilitate face-to-face interactions among community members and develop a communication pattern for solving community problems. To build an appropriate intervention, practitioners must develop knowledge and understanding about the purpose, structure, and process of each group, organization, and collaboration within the community (Bruhn and Rebach 2007). Upon implementation, a community based approach endows local residents and organizations to observe and monitor their own progress and solutions directly.

• Describe the social norms approach and explain what type of social problems or issues this approach is the most valid method to use.
• Describe the community based approach and explain what type of social problem or issues this approach is the most valid method to use.
• Human trafficking prevention program
• Reductions in electronic cigarette, vaping, and new tobacco product usage

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The Six-Step Crisis Intervention Model Explained

When an individual experiences a crisis, the proper response can make a life-saving difference. Mental health professionals must understand these nuanced situations and enact steps to bring the patient back to a healthy place. One model that can guide these responses is Gilliland's six-step crisis intervention strategy. By moving through the steps with care and concern for the individual, mental health professionals can help guide the person in crisis away from dangerous actions and toward their pre-crisis state.

We'll take a closer look at this crisis intervention model and how crisis workers can use it to assist their clients.

Table of Contents

Step 1: Define the Problem

Step 2: Ensure the Individual's Safety

Step 3: Provide Support

Step 4: Explore Alternatives

Step 5: Make Plans

Step 6: Obtain Commitment

The Benefits of the Six-Step Crisis Intervention Model

Tips for Using the Six-Step Crisis Intervention Model

When to Use the Six-Step Crisis Intervention Model

Implementing the Six-Step Crisis Intervention Model

What is the Six-Step Crisis Intervention Model?

According to the creators of the six-step model , a crisis occurs when someone perceives or experiences an event or situation as intolerable, with demands that exceed their current resources and coping mechanisms. When this happens, they need assistance to regain control and stabilize. The six-step model enlists a systematic process of listening and responding to empower the individual and help them return to their pre-crisis psychological state. Assessments occur at every step, and the crisis worker listens attentively to make their evaluations.

The six steps involved in this method include three listening-oriented steps and three action-oriented steps. The first three focus on listening.

Step number one asks the crisis worker to define the problem. This first stage establishes a connection between the crisis worker and the client as they begin discussing the issue. To fully understand the situation and form a bond with the client, the crisis worker implements:

• Active listening:  Active listening requires placing your full attention on the client, demonstrating acceptance and removing biases. The crisis worker must understand the client's perspective without allowing their feelings to get in the way. This type of listening also helps improve the relationship between the two parties.
• Empathy:  Practicing empathy is about taking someone else's point of view and showing them that you understand them. It asks you to remove any judgment or biases and accept the patient as a whole person, not define them by their current situation. It also requires being in the present and putting the other person and their feelings first. Empathy is essential throughout the six-step process, especially when establishing the relationship.
• Genuineness: People can often tell when you aren't being genuine. In a crisis, this can quickly paint you as untrustworthy and break down the relationship between crisis worker and client. Speak genuinely but carefully and solidify your position as a trustworthy partner in their mental health.
• Understanding: You also need to show the client that you understand their situation. You may use language that confirms you understand the problem or relate to their issue somehow.

The crisis worker should look at the problem from the client's point of view. They should try to understand where the client is coming from and their available resources, such as coping skills or caring friends and family.

A vital part of any crisis intervention plan is ensuring the individual cannot harm themselves or others. At this stage, the crisis worker conducts suicide risk assessments and homicide risk assessments. You may evaluate factors like agitation or the client's potential for causing harm.

Another important step here is controlling the individual's access to dangerous items. These can be as clear-cut as firearms or as subtle as office supplies, like staplers and paper cutters. The client's location and the resources of the mental health crisis system will make a big difference in this step.

For example, an inpatient psychiatric client likely has far less access to harmful items than a client being treated through a mobile care unit. That client might be able to use a variety of dangerous instruments and lack supervision when the crisis worker leaves.

The crisis worker must help transition the client into a safe environment before they can work on the next steps.

In the third step, the crisis worker shows the client that they accept and care for them. They'll discuss the problem and offer support for meeting basic needs. These might come in the form of:

• Emotional support: The crisis worker must express emotional support through statements that illustrate empathy, trust, and care. Emotional support can also come from trusted friends and family.
• Instrumental support: Instrumental support refers to services and aid, like shelter and food. Fulfilling basic needs is a necessary prerequisite for the problem-solving that occurs in the next three action steps.
• Informational support: By providing informational support, the crisis worker offers advice and suggestions. You might teach the individual about healthy coping strategies or reassure them that many resources are available.

The goal of these supports is to set the person up so they can understand the options available for dealing with the situation.

As we switch gears into the action steps, step four is about finding new solutions and navigating possibilities. The crisis worker collaborates with the person in crisis to explore these options. If their coping skills are weaker, the crisis worker may need to offer more assistance at this step, but it's important to draw on assessments first to understand the client's capabilities.

Other elements that the crisis workers might draw on during this step include situational supports, like people in the individual's life who care about them or coping mechanisms that can help them through the situation so they can move into the problem-solving stage.

During this step, it's necessary to use and cultivate positive, constructive thinking patterns. The crisis worker may need to spend some time helping the client reframe their thoughts in more positive ways.

With trust established and options explored, it's time to make a plan. During step five, the individual and the crisis worker continue to collaborate, building a plan with clear, concrete steps that will help the client regain control. These plans must be realistic and achievable.

They should empower the client, making them feel like they can accomplish the tasks and take ownership of the recovery process. This step relies heavily on collaboration with the client because it helps them take control, using their existing resources and capabilities.

The individual's plan should be detailed and straightforward. It might involve referrals and resources like people or groups that can help the client, such as support groups, medical providers, or food banks.

The last step is to obtain commitment. Getting commitment might be as simple as asking the client to verbalize the plan or as complex as writing up a document and having both parties sign it. In either case, the crisis worker needs to confirm that the client fully understands the plan and feels capable of following through.

The crisis worker should also make plans to follow up with the client. You can create a sense of accountability and, of course, help ensure the client's well-being. If the client needs further care, the crisis worker can also make referrals.

Crisis intervention is a powerful tool. An unmanaged crisis can lead to significant psychological stress, which can link to major depressive disorder or other mental health conditions. Crisis intervention has proven efficacy in preventing mental illness from developing and helping to treat patients currently suffering from one.

Studies have even shown that emergency departments with crisis intervention teams saw reduced return visits and shorter durations of stay. They reduced the number of repeat admissions and found that the interventions were more effective than standard care in improving the patient's mental health.

We know that crisis intervention can be a critical part of improving psychiatric case outcomes. The six-step model emphasizes two distinct components of helping someone with a problem — listening and taking action. It covers vital steps of crisis intervention, like creating a bond with the client, identifying resources, and guiding them toward a healthy solution. It also offers a clear, systematic approach that helps ensure the crisis worker accomplishes the tasks that can help the client.

Although the six-step crisis model is fairly straightforward, it still requires the nuance demanded of crisis intervention. Some things to keep in mind when using the six-step crisis model include:

• Accurate assessments: This strategy is based on the results of your assessments. They must be accurate. Crisis workers must remember that every person and situation is unique. Generalizations can lead to dangerous errors that divert the treatment plan. Robust assessment tools can be particularly useful in the six-step strategy.
• Empowerment: Crises occur when a person loses control and feels unsafe. The six-step model focuses on restoring that power through collaboration. The crisis worker should maintain an open mind when problem-solving and look for routes that help the person regain control. A heavy-handed approach might be necessary for some patients, but they should contribute to the best of their ability.
• Action-oriented strategizing: Crisis intervention is focused on action and the situation at hand. Crisis workers should recognize the impacts of the situation, anticipate its effects and help the client create a plan. Each step in the process should be geared toward that end goal.
• Focus on the present: Similarly, crisis intervention offers immediate support. Unlike long-term solutions like psychotherapy, the crisis worker must provide immediate support, like coping skills that the patient can use right away or access to resources that they can use to quickly return to the pre-crisis state.
• A holistic view of the client: The crisis worker needs to maintain their holistic view of the client, considering the whole person instead of separating them from their cognitive and emotional function.

Crisis intervention is an immediate, short-term response to mental, physical, emotional and behavioral distress. It is not a long-term option like psychotherapy or similar treatments. The goal is to restore the person's functioning to before the crisis and reduce the opportunity for long-term trauma. It aims to help the client get access to assistance, support and resources that help them become stable.

The six-step model can be used in many situations, but some common triggers for crises include:

• Family situations: Some family situations — like child or spousal abuse, unplanned pregnancy or serious or chronic illness — can cause stress and lead to a crisis.
• Economic situations: Financial strain from the loss of a job, eviction, theft, medical expenses, gambling or poverty can trigger many crises based on the sudden or chronic financial strain they create.
• Community situations: An individual's community can also contribute to their mental state. For example, someone facing violence in their neighborhood, poor housing or inadequate community resources might experience a crisis.
• Significant life events: Some events often viewed as happy situations can paradoxically trigger crises. These might include marriage, the birth of a child or a promotion at work. Other significant events, like raising a rebellious adolescent, losing a loved one or seeing a grown child leave the nest can also cause a crisis.
• Natural elements: Plenty of natural disasters can trigger crises, such as floods, hurricanes and fires. They might involve harm to a loved one or the destruction of possessions, creating states of distress. Even seemingly minor events, like a bout of gloomy or hot weather, can put someone into a crisis state.

Some signs that someone is in crisis and may need the help of an intervention strategy include:

• Feelings of hopelessness.
• Difficulty eating or sleeping.
• Depression.
• Neglected personal hygiene.

Symptoms can vary widely, but remember that a crisis intervention plan is generally warranted when the situation exceeds the patient's resources and coping skills.

Implementing the six-step crisis intervention model will look different for various providers, such as inpatient crisis teams or mobile crisis response units. Still, completing the six steps typically requires robust documentation to ensure appropriate billing procedures , patient assessment, and follow-up care. Without the proper documentation solution, you might be spending too much time on paperwork and not enough time on the client. Or you might completely neglect your notes. To make the process easier, use a documentation platform that allows for quick, intuitive note-taking.

ICANotes is that platform, offering a cloud-based solution for mobile, inpatient, or outpatient crisis intervention. It eliminates the busy work, allowing you to focus on your patient and their acute problems without ignoring necessary documentation procedures. ICANotes mental health EHR software also supports a range of other tasks, like billing, reporting, referrals, e-prescribing and scheduling . From initial suicide risk assessments to referrals to other mental health professionals, ICANotes simplifies the entire process.

If the six-step crisis intervention model is part of your practice, ICANotes can help. With intuitive note-taking features and an array of assessment tools, you can successfully follow the patient-centered approach of this model. Collect all the information you need to make an accurate evaluation and help the patient move forward. To learn more about ICANotes and how it can help you with the 6-step model, explore its features or reach out to us today for more information!

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• https://www.counseling.org/resources/library/Selected%20Topics/Disaster/vistas06.03.pdf
• https://positivepsychology.com/active-listening/
• https://www.mentalhealthfirstaid.org/2021/08/practicing-empathy-as-a-mental-health-first-aider/
• https://www.med.upenn.edu/hbhe4/part3-ch9-key-constructs-social-support.shtml
• https://www.ncbi.nlm.nih.gov/books/NBK559081/
• https://www.dshs.wa.gov/esa/social-services-manual/crisis-intervention
• https://www.samhsa.gov/find-help/disaster-distress-helpline/warning-signs-risk-factors
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29 Response to Intervention: Conceptual Foundations and Evidence-Based Practices

Frank M. Gresham, Department of Psychology, Louisiana State University, Baton Rouge, LA

• Published: 21 November 2012
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Response to intervention (RTI) is based on the notion of determining whether an adequate or inadequate change in academic or behavioral performance has been accomplished by an intervention. In an RTI approach, decisions regarding changing or intensifying an intervention are based on how well or how poorly a student responds to an evidence-based intervention that is implemented with integrity. RTI is used to make important educational decisions about services for children in schools, including (but not exclusively) special education and related services. RTI has three defining features: (a) delivery of high-quality interventions that are evidence-based, (b) assessment of the rate and level performance using data-based practices, and (c) making important educational decisions about children and youth. RTI typically takes place in a three-tier model that includes universal, selected, and intensive interventions. Two basic approaches to RTI practice are problem solving approaches and standard protocol approaches, with the former approach being emphasized in this chapter. This chapter concludes with a discussion of treatment strengths and how it might be operationalized in the delivery of RTI-based approaches in schools.

Students’ academic and behavioral difficulties are addressed in school settings using a predictable three-stage process of referral, testing, and placement. Historically, school psychologists have engaged in a process whereby they receive referrals from teachers, conduct comprehensive assessments, and make special education eligibility recommendations based on established criteria (Bocian, Beebe, MacMillan, & Gresham, 1999 ). Teacher referrals are based primarily on a student’s performance relative to the modal performance of a given classroom, and thus the guiding principle is one of relativity . The testing stage of this process is based primarily on norm-referenced tests, and the guiding principle is one of acceptability —is the performance acceptable relative to normative standards? Placement recommendations are based on the principle of profitability , which reflects the collective perception that special education services at a given school site will benefit the child.

More often than not, the assessment data used to make these placement recommendations have little, if anything, to do with recommended intervention strategies (Gresham & Witt, 1997 ; Reschly, 2008 ). Despite a longstanding tradition, the “refer–test–place” approach to the identification of students with disabilities has several drawbacks. The procedures used by schools to identify students with learning and/or behavioral difficulties are often confusing, logically inconsistent, and fraught with much “diagnostic error” (Gresham, 2002 ; 2008 ; MacMillan & Siperstein, 2002 ; Ysseldyke & Marston, 1999 ).

There are two different routes whereby children become qualified as being eligible for special education (MacMillan, Gresham, Bocian, & Siperstein, 1997 ). Children qualified via route 1 include children with sensory (deaf or blind), physical (orthopedic), medical (chronic illnesses), or mental (moderate-severe-profound mental retardation) disabilities. The overwhelming majority of these cases are diagnosed by physicians employing medical histories, physical examinations, and laboratory tests to determine the correct diagnosis. Most children with these disabilities are identified prior to school entry (often shortly after birth), and there is little disagreement among medical or educational professionals concerning the validity of the diagnosis. The reason for this high level of agreement is that these children display highly visible or salient characteristics, about which there is little room for disagreement.

Children deemed eligible for special education via route 2 create much consternation and disagreement among educational, psychological, and medical professionals. These children may be identified as having a specific learning disability, mild mental retardation, emotional disturbance, or attention-deficit/hyperactivity disorder. Unlike children with sensory or physical impairments, children with these so-called “mild” or high-incidence disabilities are deemed eligible using procedures that are plagued with much diagnostic error (Gresham, 2008 ). Children functioning around the margin of a disability group create special problems in assessment, measurement, and special education eligibility determination. It is difficult to know the precise point where low academic achievement becomes a “specific learning disability,” or when a behavior problem becomes an “emotional disturbance.” This is because these disabilities are measurement bound, and hence are identified based on the degree of impairment rather than the kind of impairment (e.g., deaf, blind, or orthopedic impairment).

There are two basic types of diagnostic error for high-incidence disabilities: false positive errors and false negative errors . False positive errors (“false alarms”) occur when children are identified as having a disability (e.g., specific learning disability) when in fact they do not have a disability. False negative errors (“misses”) occur when children are not identified as having a disability when in fact they do have a disability. False positive and false negative errors may also occur among various disability categories. For example, children meeting well-established criteria for mild mental retardation may be incorrectly identified as having a specific learning disability. In these cases, two diagnostic errors occur. Failure to identify a child with mental retardation is a false negative error (a “miss”), and instead classifying the child as having a specific learning disability is a false positive error (a “false alarm”).

A typical error in this process occurs when school psychologists attempt to differentiate children with learning disabilities (discrepant low achievers) from students who are “garden-variety” low achievers (nondiscrepant low achievers). In fact, attempts to differentiate learning disabled from discrepant and nondiscrepant low achiever populations are futile, based on a large body of research showing that these children share salient characteristics making them part of the same population (Fletcher, Francis, Shaywitz, Lyon, Foorman, Steubing, et al., 1998 ; Gresham, 2002 ; Gresham, MacMillan, & Bocian, 1996 ; Steubing, Fletcher, LeDoux, Lyon, Shaywitz, & Shaywitz, 2002 ).

Research by Gresham and colleagues suggested that schools frequently do not base their classification and placement decisions on state or district guidelines for high-incidence disabilities of mild mental retardation or specific learning disabilities (Gresham, MacMillan, & Bocian, 1998 ). Numerous interviews of these schools’ placement committees indicated that they were basing their eligibility decisions based on their perceptions of what is best for a given child in terms of educational needs and supports, and not based on some equivocal and arbitrary authoritative definition of a mild disability. Based on these problems with the traditional “refer–test–place” approach, an alternative approach based on response to intervention is recommended.

Response to Intervention: An Alternative Approach

The notion of response to intervention, or RTI, is based on the concept of determining whether an adequate or inadequate change in academic or behavioral performance has been achieved by an intervention (Gresham, 2002 ). In an RTI approach, decisions regarding changing or intensifying an intervention are made based on how well or how poorly a student responds to an evidence-based intervention that is implemented with integrity. RTI logic is used to select and/or modify interventions, based on how the child responds to that intervention. RTI assumes that if a child shows an inadequate or weak response to the best intervention available and feasible within a given setting, then that child can and should be eligible for additional assistance, including special education and related services. RTI is not used exclusively to make special education entitlement decisions, although it can be used for that purpose. RTI is a philosophy of behavior change based on treatment response, rather than diagnostic assessment of unobservable and highly inferential psychological or emotional processes.

RTI logic is not a new concept in other fields. The field of medicine provides a useful example of how physicians use RTI principles in their everyday practice to treat physical problems. Physicians assess weight, blood pressure, and heart rate every time they see a patient, because these three factors are important indicators of general physical health, and have scientifically established benchmarks for typical and atypical functioning. If these weight and blood pressure measurements exceed benchmark criteria, then a physician may recommend that the patient diet, exercise, and quit smoking. The next time the patient sees the physician, these same indicators are measured; if the indicators show no change, then the physician may place the patient on a special diet and exercise regimen, and tell the patient to stop smoking. The next time the patient sees the physician, these same indicators are measured, and if they still show nochange, the physician may put the patient on medication, refer to a dietician, and send the patient to a smoking cessation clinic. Finally, the next time the physician sees the patient, and the same indicator data are in the atypical range, then upon further assessment the patient may require surgery to prevent mortality.

Several important points should be recognized in considering the above example. First, intervention intensity was increased only after the data suggested that the patient showed an inadequate response to intervention. Second, treatment decisions were based on objective data collected continuously over time (data-based decision making). Third, the data that were collected were well-established indicators of general physical health. Finally, decisions about treatment intensity were based on the collection of more and more data, as the patient moved through each stage of treatment intensification. RTI can and should be used in schools in a parallel manner, to make important educational decisions for children and youth.

The concept of RTI can also be found in the experimental analysis of behavior literature that has studied the conditions under which behavior shows “resistance to extinction” (Nevin, 1988 ). Gresham ( 1991 ) applied this literature to the field of behavior disorders in describing how and why certain behaviors are highly resistant to change (i.e., they do not respond to intervention efforts). Using an analogy to Newtonian physics, Nevin ( 1988 ) used the term behavioral momentum to explain a behavior’s resistance to change. That is, a moving body possesses both mass and velocity, and will maintain constant velocity under constant conditions. The velocity of an object will change only in proportion to an external force, and in inverse proportion to its mass. Considering the momentum metaphor, an effective intervention (“force”) will result in a high level of momentum (“responsiveness”) for the behavior in question.

For example, an intervention designed to decrease rates of disruptive and oppositional behavior in a classroom would be considered successful if it rapidly decreased these problem behaviors, and reliably, during intervention, and if these behavioral decreases persisted after the intervention was withdrawn. In contrast, if disruptive and oppositional behaviors returned to baseline levels after the intervention was withdrawn, teachers would not be satisfied with the intervention no matter how well the student behaved during intervention. Many behaviors are highly resistant to intervention efforts, and therefore require strong and consistent applications of powerful interventions (i.e., those with a large amount of “force”).

Evolution of the RTI Concept

The historical basis of RTI, at least in special education, can be traced to the National Research Council (NRC) report (Heller, Holtzman, & Messick, 1982 ) in which the validity of the special education classification system was evaluated on the basis of three criteria: (a) the quality of the general education program, (b) the value of the special education program in producing important outcomes for students, and (c) the accuracy and meaningfulness of the assessment process in the identification of disability. Vaughn and Fuchs ( 2003 ) suggested that the first two criteria emphasized the quality of instruction, whereas the third criterion involved judgments of the quality of instructional environments, and the student’s response to instruction delivered in those environments. The third criterion described in the NRC Report is consistent with Messick’s ( 1995 ) notion of evidential and consequential bases of test use and interpretation . That is, there must be evidential and consequential bases for using and interpreting tests in a certain way. If these bases do not exist, then we may conclude that there is insufficient evidence for the validity of a given assessment procedure.

An important aspect in the evolution of the RTI concept is the notion of treatment validity (sometimes called treatment utility of assessment ). Treatment validity can be defined as the extent to which any assessment procedure contributes to beneficial outcomes for individuals (Cone, 1989 ; Fuchs & Fuchs, 1998 ; Hayes, Nelson, & Jarrett, 1987 ). A central feature of treatment validity is that there must be a clear and unambiguous relationship between the assessment data collected and the recommended intervention.

For any assessment procedure to have treatment validity, it must lead to the identification of relevant areas of concern (academic or behavioral), inform treatment planning, and be useful in evaluating treatment outcomes. Traditionally, many assessment procedures in school psychology have failed to demonstrate treatment validity because they do not inform instructional or behavioral intervention practices (Cronbach, 1975 ; Gresham, 2002 ; Gresham & Witt, 1997 ; Reschly, 2008 ). The concept of RTI depends largely on the treatment validity of measures used to determine adequate or inadequate treatment response. In short, assessment procedures having treatment validity not only inform the selection of intervention procedures, they also are used to evaluate treatment outcomes.

The RTI concept further evolved as a viable alternative to the IQ–achievement discrepancy approach to identifying learning disabilities from the LD Initiative, which was a working group meeting held in Washington, D.C. and sponsored by the Office of Special Education Programs in May, 1999. Based on the LD Initiative, a national conference was held in Washington, D.C. in August, 2001, entitled the LD Summit . Nine white papers were written and presented over a 2-day period to a group of LD professionals and stakeholders from all over the United States. One paper (Gresham, 2002 ) specifically addressed the literature on responsiveness to intervention that was responded to by four well-known professionals in the field of LD (Fuchs, 2002 ; Grimes, 2002 ; Vaughn, 2002 ; Vellutino, 2002 ). Gresham’s paper argued that a student’s inadequate response to an empirically validated intervention, implemented with integrity, can and should be used as evidence of the presence of LD, and should be used in eligibility decisions. RTI was viewed as a viable and superior alternative to defining LD on the basis of IQ–achievement discrepancy approaches, which have a myriad of conceptual and measurement difficulties.

Subsequent to the LD Summit, the President’s Commission on Excellence in Special Education (2002) emphasized RTI as a viable alternative to IQ–achievement discrepancy in the identification of LD. In December, 2004, President Bush signed into law the reauthorization of the Individuals with Disabilities Education Improvement Act (IDEIA, 2004 ). The law states that a child may be determined to have a specific learning disability based on how that child responds to a scientific, research based intervention or RTI.

Features of RTI

RTI involves the provision of high quality interventions matched to student need, frequent progress monitoring to guide decisions about changes in interventions, and using student data to guide important educational decisions. RTI models have three defining characteristics: (a) delivery of high quality interventions that are evidence based, (b) rate and level of performance, and (c) important educational decisions. High quality interventions are those that are matched to student need, scientifically based, and individually based. Rate and level of student performance involves the assessment of the rate of change in behavior over time, the relative standing of student behavior on important academic or behavioral dimensions, and data-based decision making on student response to interventions. Important educational decisions are those that are based on student response to intervention across multiple tiers of intervention, differing in intensity. These decisions might be made about changes in the intensity of intervention, special education eligibility, and/or exiting special education (Gresham, 2002 , 2006 ).

The effectiveness of schoolbased interventions is based on several interrelated factors that must be considered in the design, implementation, and evaluation process. It is unfortunate that some school based professionals engage in a fruitless search for “silver bullet” interventions that will be universally effective with all students, will work every time, will be easy to implement, and will maintain their effectiveness over a long period of time. Such interventions do not exist. Interventions implemented in schools often do not enjoy empirical support, and are chosen for reasons such as personal appeal, popularity, acceptability, and/or ease of implementation rather than research supporting their use.

The following medical analogy illustrates the above logic. If surgeons adopted a procedure that has a 20% mortality rate over one that has a 10% mortality rate because: (a) it is easier to do, (b) the surgeon was trained in it, and (c) the surgeon just likes it better, such a practice would not be tolerated. However, intervention strategies in schools are often driven by a similar logic. Intervention practices in schools are based, in part, on the fact that many educators have not been trained in empirically supported intervention methods, and/or they simply may be invested in philosophical or theoretical approaches that are at odds with more effective intervention strategies (Gresham, 2004 ).

RTI and the Three-Tier Model

Perhaps the most important concept in a RTI approach to service delivery in schools is the notion of matching the intensity of the intervention to the intensity and severity of the presenting problem behavior. One approach adopted by the U.S. Public Health Service describes three levels of “prevention” outcomes: primary prevention, secondary prevention, and tertiary prevention. This approach considers prevention as an outcome, rather than simply a means to an end. Primary prevention efforts seek to prevent harm, whereas secondary prevention efforts seek to reverse harm. Tertiary prevention efforts target the most severe academic and/or behavior difficulties and attempt to reduce harm (Walker, Ramsay, & Gresham, 2004 ).

This prevention model has subsequently been recast in terms of types of interventions that differ in the nature, comprehensiveness, and intensity of the interventions, as well as the degree of unresponsiveness of an individual’s behavior to a given intervention. This model of intervention typically is composed of three tiers of intervention intensity: universal interventions, selected interventions, and targeted/intensive interventions.

Universal Interventions

These interventions are designed to target and affect all students, and are delivered in the same manner and under the same conditions. These interventions are delivered in a classwide, schoolwide, or districtwide level, with each student receiving the same “dosage” of the intervention. Some examples of universal interventions are vaccinations, schoolwide discipline plans, districtwide bully prevention programs, and districtwide adopted reading, mathematics, and language arts curricula.

Universal interventions accomplish two major goals of education: the academic and social development of students. Implementing best practice, evidence-based interventions focuses on reducing or eliminating academic or behavioral difficulties before they become more severe. Estimates suggest that universal interventions will be effective with 80%–90% of any given school population. This figure may be higher or lower depending on the severity level of academic and behavioral challenges in any given school or school district, as well as on the quality of the particular universal intervention that is implemented.

Selected Interventions

These interventions focus on the weak or nonresponders to universal interventions. It is estimated that approximately 5%–10% of the school population may require some form of selected interventions. These students are at risk for severe academic or behavioral difficulties if more intense interventions are not implemented. Many of these students will respond to relatively simple, individually focused academic and behavioral interventions. These interventions are delivered in general education classrooms, and are typically developed in a consultation framework between general education teachers and support personnel (e.g., school psychologists or school counselors).

The goal of selected interventions is to provide more intense, individually prescribed intervention strategies to remediate academic and/or behavioral difficulties. These strategies are not complicated or comprehensive, but should be evidence based. Numerous examples of these types of interventions can be found in the area of academics (see Daly, Chafouleas, & Skinner, 2005 ) and social behavior (see DuPaul& Stoner, 2003 ; Miltenberger, 2004 ).

Targeted/Intensive Interventions

The most intense level of intervention focuses on students that are the most resistant to change, and who exhibit chronic academic or behavioral difficulties. It is estimated that this group of students constitutes about 1%–5% of any given school population. In terms of behavioral difficulties, these students are responsible for 40%–50% of behavioral disruptions in schools, and they drain 50%–60% of school building and classroom resources (Walker et al., 2004 ). In the area of reading, these students are weak responders to universal and selected intervention efforts, and will require very intensive phonics-based reading instruction (Vaughn, Linan-Thompson, & Hickman, 2003 ; Vellutino, 1987 ).

For behavioral difficulties, these interventions usually are based on a functional behavioral assessment (FBA) to determine the consequent events maintaining problem behaviors. FBA is defined as a collection of methods for collecting information regarding antecedents, behaviors, and consequences, to determine the function (purpose or “cause”) of problem behavior (Gresham, Watson, & Skinner, 2001 ). Once behavioral function is determined, this information is used to design interventions to reduce competing problem behaviors, and to increase positive replacement behaviors that serve the same behavioral function.

For academic difficulties, intense remedial efforts are typically delivered in a small group pull-out setting, and involve a relatively large number of hours of instruction. For example, intensive reading interventions by Vellutino and colleagues (Vellutino, Scanlon, Sipay, Small, Pratt, Chen et al., 1996 ), Torgesen and colleagues (Torgesen, Alexander, Wagner, Rashotte, Voeller, & Conway, 2001 ), and Vaughn et al. ( 2003 ) require anywhere from 35 to 68 hours of intense, phonics-based reading instruction. Even despite these intense intervention efforts, approximately 25% of the poor reader population will show an inadequate or weak response to intervention (Torgesen, Wagner, Rashotte, Rose, Lindamood, Conway, et al., 1999).

Response to Intervention Models

Two basic approaches are used to deliver interventions in a RTI approach: (a) problem-solving approaches, and (b) standard protocol approaches (Fuchs, Mock, Morgan, & Young, 2003 ). Some RTI models combine these two approaches, particularly within a multi-tier model of service delivery described earlier (see Barnett, Daly, Jones, & Lentz, 2004 ; Duhon, Noell, Witt, Freeland, Dufrene, & Gilbertson, 2004 ; VanDerHeyden, Witt, & Naquin, 2003 ). These particular models are best described as multi-tier RTI approaches to intervention. Despite these two basic RTI approaches, this chapter will concentrate on problem-solving RTI, because this approach is the most commonly used by school psychologists.

Problem Solving Approaches

Problem solving can be traced back to the behavioral consultation model first described by Bergan ( 1977 ), and later revised and updated by Bergan and Kratochwill ( 1990 ). Behavioral consultation takes place in a sequence of four phases: (a) problem identification, (b) problem analysis, (c) plan implementation, and (d) plan evaluation. The goal in behavioral consultation is to define the problem in clear, unambiguous, and operational terms, to identify environmental conditions related to the referral problem, to design and implement an intervention plan with integrity, and to evaluate the effectiveness of the intervention (Bergan & Kratochwill, 1990 ). More recently, the behavioral consultation model was described by Tilly ( 2002 ) in the form of four fundamental questions governing the identification and intervention of school based academic and behavioral problems: (a) What is the problem? (b) Why is the problem happening? (c) What should be done about it?, and (d) Did it work? Each of these steps is described briefly in the following sections.

Problem Identification

Problems are defined, in a problem solving approach, as a discrepancy between current and desired levels of performance. As such, the larger this discrepancy, the larger the problem. For example, if a student’s current rate of oral reading fluency is 50 words correct per minute, and the desired rate is 100 words correct per minute (based on a benchmark standard), then there is a 50%, or 50-word discrepancy between current and desired levels of performance. This same logic can be applied to any type of referral problem (academic or behavioral) as the first step in a problem solving approach.

A critical aspect of problem identification is the operational definition of the referral problem into specific, measurable terms that permit direct, objective assessment of the behavior or skill in question. Operational definitions are objective, clear, and complete. These definitions are objective if they can be read, repeated, and paraphrased by others. Operational definitions are clear if two or more observers of a behavior or skill are able to read the definition and use it to record and measure the behavior or skill. Operational definitions are complete if they specify the boundary conditions for inclusion of behaviors that are not part of the definition. For example, an operational definition of noncompliance might be as follows: Noncompliance is defined as the student not complying with a verbal request or directive from the teacher within 5 seconds after the request or directive has been given. Examples of verbal requests or directives are being told to sit down, begin work, copy from the board, come to the teacher’s desk, and so forth. Any other behaviors that do not meet this operational definition are not considered to be part of the response class of noncompliance.

Problem Analysis

Another important aspect of problem solving is to determine why the problem is occurring. At this stage, the distinction between “can’t do” (acquisition or skill deficits) and “won’t do” (motivational or performance deficits) is critical (Gresham, 1981 ; VanDerHeyden & Witt, 2008 ). “Can’t do” problems are considered to be acquisition deficits, meaning that the child does not have the skill or behavior in his or her repertoire. For example, if the child does not engage in appropriate social interactions with peers on the playground, then it may be because the child lacks appropriate peer group entry strategies. In this case, the acquisition deficit should be remediated by directly teaching the child appropriate peer group entry strategies.

“Won’t do” problems are considered to be performance or motivational deficits, meaning that the child knows how to perform the skill or behavior, but does not do so. Reasons for not performing the behavior or skill may be due to the lack of opportunities to perform the skill or behavior, or the lack of or low rate of reinforcement for performing the behavior or skill. In cases like these, remedial interventions would involve providing multiple opportunities to perform the behavior or skill, and increasing the rate of reinforcement for skill or behavioral performance.

Plan Implementation

The implementation of an intervention plan, designed in the problem analysis state of problem solving, is a critical aspect of the RTI enterprise. All RTI approaches argue for the implementation of scientific, evidence-based interventions; however, this is only part of the task in plan implementation. A fundamental principle of any intervention in a problem solving approach, particularly interventions delivered by third parties such as teachers or parents, is that the intervention will be delivered as intended or planned (Gresham, 1989 ). This is known as treatment integrity or treatment fidelity . From a research perspective, it must be demonstrated that changes in a dependent variable (behavior or skill) can be attributed to systematic, manipulated changes in the independent variable (i.e., the treatment). From a practice perspective, consultants collaboratively designing and assisting in the implementation of interventions must take steps to ensure that the intervention is implemented as intended. Poorly implemented interventions are likely to be ineffective in changing behavior. Treatment integrity, therefore, becomes a cornerstone of any RTI model.

Treatment integrity focuses on the accuracy and consistency with which interventions are delivered in schools or classrooms. Accuracy refers to the degree to which an intervention is implemented according to an established set of procedures. Consistency refers to the degree to which the intervention is implementedwhen it is supposed to be implemented (each subject period, on the half hour, daily). The ineffectiveness of many interventions designed in a problem solving approach may be due to the poor integrity with which these interventions are implemented, and poor integrity can result from inaccuracy, inconsistency, or both (Gresham, 1997 ). Deviations from an agreed-upon intervention plan or protocol explain why many interventions delivered in schools are not used, and are rendered ineffective. Without assessment of treatment integrity in an RTI approach, one cannot know if a given treatment was simply ineffective, or if the treatment would have been effective had it been implemented with good integrity.

Plan Evaluation

An essential component of the RTI approach is the determination of what constitutes an adequate or inadequate response to intervention. This determination is somewhat easier for academic performance than it is for social behavior. For academic performance, curriculum based measurement (CBM) typically is used to index response to intervention. CBM has the most well-established empirical history, and close connection to problem solving based assessment practices (Deno, 2005 ; Shinn, 2008 ). CBM measures are considered to be among the most highly regarded assessment tools for continuous progress monitoring to quantify student performances in reading, mathematics, and written language in short-term interventions. To be useful in formative evaluations, progress monitoring tools must meet technical adequacy standards (reliability and validity), must be sensitive to short-term changes in academic performance, and must be time-efficient so that teachers can monitor student performance frequently (1–2 times per week). CBM indices are ideal in an RTI approach because there are well-established benchmarks for both level and trend (growth) in the basic areas of academic performance (see Shinn, 2008 ).

Unfortunately, there is no CBM analogue for dependably measuring students’ response to short-term interventions in the area of social behavior. Progress monitoring for students’ social behavior is important, because educators need to determine whether a student’s rate of progress in a social-behavioral intervention is adequate to reach an acceptable criterion of proficiency in a reasonable period of time. The purpose of progress monitoring of social behavior is to establish students’ rates of improvement, to identify students who are not responding to an intervention, and to use these data to make decisions about continuing, altering, or terminating intervention based on how students are responding.

For students’ social behavior, several methods have been proposed and used, to determine whether a student is showing an adequate or acceptable response to intervention. These methods include: (a) absolute change in behavior, (b) percent change from baseline, (c) reliable change index, (d) effect size estimates, and (e) social validation of behavior change (see Gresham, 2005). Each of these methods has advantages and disadvantages, and will be described briefly in the following section.

Absolute change in behavior is the degree or amount of change an individual makes that does not involve comparison to other groups. Absolute change can be calculated in one of three ways: (a) the amount of change from baseline to post-intervention levels of performance; (b) an individual no longer meeting established criteria for a diagnosis (e.g., classification of emotionally disturbed or DSM-IV diagnoses); and (c) the total elimination of behavior problems. Absolute change is straightforward, intuitively logical, and easy to calculate. It is also consistent with a problem solving approach to defining problems as the discrepancy between expected and desired levels of performance described earlier. Using this approach, a problem is considered “solved” if the degree of absolute change is large relative to the three criteria described above.

There are some problems with using metrics of absolute change. For instance, an individual might show a relative large amount of absolute change from baseline to post-intervention levels of performance, but this change may not be large enough to allow that individual to function successfully within a general education setting. Absolute change also interacts with tolerance levels for problem behavior at the classroom and school levels. That is, even though a change in behavior is large, the behavior pattern still might not be tolerated by significant others in the school environment. Also, an individual may no longer meet the diagnostic criteria for an emotional disturbance, but this may be due to biases operating in the diagnostic and eligibility decision-making process.

Percent change from baseline is another metric that can be used to index response to intervention. This metric involves comparing the median level of performance in baseline to the median level of performance in intervention. For example, if the median frequency of a behavior in baseline is 8, and the median frequency of behavior after intervention is 2, then the percent change from baseline would be 75% (8–2/8=75%). The advantage of this metric is that outliers or aberrant data points, or floor and ceiling effects, do not greatly affect this metric, mainly because the median rather than the mean is used in its calculation. Percent change is commonly used in medicine to evaluate the effects of medical treatments, such as drugs to reduce cholesterol or blood pressure.

There are well established medical benchmarks for desirable levels of blood cholesterol (<200 dl ) and blood pressure (120/80) indexed to important medical outcomes (e.g., cardiovascular disease or mortality rates). Unfortunately, there are no such benchmarks for many behaviors targeted for intervention. There are no clear guidelines for determining the magnitude of behavior change that is sufficient to indicate an individual has demonstrated an adequate response to intervention. As such, this metric should be supplemented by other measures or indicators or response to intervention.

The reliable change index (RCI) is based on the notion that an individual’s behavior during intervention is sufficiently large to have surpassed the margin of measurement error. RCI is calculated by subtracting an individual’s mean score after baseline (posttest score) from the pretest score, and dividing this difference by the standard error of difference between posttest and pretest scores (Jacobson, Follette, & Revenstorf, 1988 ). The standard error of difference represents the variability in the distribution of change scores if no change had occurred, and is based on the standard deviation of pretest scores and the test/retest reliability of the measure used to index behavior change. An RCI of 1.96 ( p <.05) would be considered a statistically reliable change in behavior.

RCI has the advantage of quantifying reliable changes from baseline to post-intervention levels of performance, and confidence intervals can be placed around change scores to avoid overinterpretation of results. The RCI is affected by the reliability (stability) of outcome measures used. If a measure is highly reliable (stable), then small changes in behavior might be considered statistically reliable, but not educationally significant or important. In contrast, if a measure has relatively low reliability (stability), then large changes in behavior may be educationally important but statistically unreliable.

Perhaps the most serious drawback of RCI is that it cannot be used to estimate reliable changes in behavior using direct observations of behavior. No “test-retest” reliability coefficient is calculated in using direct observations of behavior. “Reliability” in direct observations is typically calculated by interobserver agreement indices. This is not the same as stability of behavior over time, in the traditional use of that term, and thus cannot be used to calculate RCI.

Two types of effect size estimates for the individual case are typically used to gauge response to intervention. The first estimate is a modification of Cohen’s d that is used in meta-analytic research. This effect size is calculated by subtracting the intervention mean from the baseline mean, and dividing by the standard deviation of baseline data points (Busk & Serlin, 1992 ). A drawback of this effect size estimate is that it can yield large effect size estimates that cannot be interpreted in the same way as effect sizes calculated in meta-analytic research.

A second effect size metric is the percent of nonoverlapping data points (PND) computed by calculating the percentage of nonoverlapping data points between baseline and intervention phases (Mastropieri & Scruggs, 1985–1986). If the goal of an intervention is to decrease behavior, one computes PND by counting the number of intervention data points exceeding the highest data point in baseline, and dividing by the total number of data points in the intervention phase. For example, if 8 of 10 data points in intervention exceeded the highest baseline data point, the PND would be 80%. Alternatively, if the goal of intervention is to increase behavior, then one calculates PND by counting the number of intervention data points that are below the lowest baseline data point, and dividing by the total number of data points in the intervention phase.

PND was proposed to provide a quantitative index to document the effects of an intervention that is easy to calculate. There are, however, some drawbacks of using this method that should be noted. One, PND often does not reflect the magnitude of behavior change in an intervention. That is, one can have 100% nonoverlapping data points in the treatment phase, yet have an extremely weak treatment effect. Two, unusual baseline trends (high and low data points) can skew the interpretation of PND. Three, PND is greatly affected by floor and ceiling effects. Four, aberrant or outlier data points can make interpretation of PND difficult (see Strain, Kohler, & Gresham, 1998 for a discussion). Five, there are no well-established guidelines for what constitutes a large, medium, or small effect using PND.

Perhaps the most essential and relevant means of determining adequate response to intervention is social validation . Social validity addresses three fundamental questions with respect to intervention: What should we change? How should we change it? How will we know it was effective? There are often disagreements among professionals and treatment consumers on these three fundamental questions (see Hawkins, 1991 ; Schwartz & Baer, 1991 ). Wolf ( 1978 ) described the social validation process as involving the social significance of intervention goals, the social acceptability of intervention procedures, and the social importance of intervention outcomes. This last aspect of the social validation process is the most relevant in quantifying and evaluating treatment effectiveness in a RTI approach.

Establishing the social importance of the effects of intervention attests to the practical or educational significance of behavior change. Do the quantity and quality of the changes in behavior make a difference in the student’s behavioral functioning and adjustment? In short, do the changes in behavior have habilitative validity (Hawkins, 1991 )? Is the student’s behavior now in the functional range, subsequent to the intervention? These questions capture the essence of establishing the social importance of intervention effects.

A way of establishing the social importance of intervention effects is to view behavioral functioning (academic or social) as belonging to either a functional or dysfunctional distribution. An example might be socially validating a behavioral intervention by showing the student’s behavior moved from a dysfunctional to a functional range of performance. Using teacher and/or parent ratings on nationally normed behavior rating scales is one means of quantifying the social importance of intervention outcomes (Gresham & Lopez, 1996 ). Moving a student’s problem behavior ratings from the 95th percentile to the 50th percentile would represent a socially important change. Similarly, changing a target behavior problem measured by direct observations into the range of nonreferred peers would also corroborate the behavior ratings, and therefore could be considered socially important.

Social importance can also be conceptualized and evaluated on several levels: proximal effects, intermediate effects, and distal effects (Fawcett, 1991 ). Proximal effects are changes in target behaviors produced by the intervention such as increases in social skills, decreases in aggressive behavior, or increases in oral reading fluency. Proximal effects can be evaluated by visual inspection of graphed data, percent change from baseline, and/or the reliable change index. Intermediate effects can be evaluated by more molar assessments, such as substantial changes in ratings on normed behavior rating scales, teacher ratings of academic performance, or standardized tests of academic achievement. Distal effects can be evaluated by changes on social impact measures such as office discipline referrals, suspension/expulsion rates, school attendance, promotion/retention status, or incarceration rates.

It should be noted that social impact measures are not particularly sensitive in detecting short-term changes in behavior produced by interventions. Many treatment consumers may consider these social impact measures to be the most important metrics in gauging successful intervention outcomes; however, exclusive reliance on these measures might ignore or mask a great deal of behavior change (see Kazdin, 2003 ).

It is often the case that rather large and sustained changes in behavior are required before these changes are reflected on social impact measures. A method based on just noticeable differences (JNDs) has been recommended to index intervention outcomes (Sechrest, McKnight, & McKnight, 1996 ). A JND approach answers the question: How much of a difference in behavior is required before it is “noticed” by significant others (teachers, parents, school personnel), or reflected on other social impact measures? For example, how much of a decrease in aggressive/disruptive behavior in the classroom and on the playground is required, before it is reflected in a decrease and subsequent elimination of office discipline referrals? Similarly, how much of an increase in oral reading fluency is necessary before it is reflected in a student’s performance on a high-stakes achievement test?

Conclusion and Future Directions

RTI is a process of providing high quality interventions that are matched to student need, and uses frequent progress monitoring of student response to interventions to assist in making important educational decisions. At the most basic level, all RTI approaches share three common features: (a) use of evidence-based interventions, (b) assessing the rate and level of student performance in those interventions, and (c) use of individual student responsiveness data to make educational decisions. The key concept in any RTI approach is that the intensity of an intervention is matched to the intensity and severity of academic or behavioral difficulties. RTI is typically conceptualized in a three-tier model that describes three levels of prevention: primary prevention, secondary prevention, and tertiary prevention. These three levels of prevention seek to prevent, reverse, and reduce harm, respectively.

An important and unresolved concept in RTI is treatment strength (see Yeaton & Sechrest, 1981 ). What makes a given intervention or treatment strong? In pharmacological interventions, more of a drug necessarily makes it stronger (e.g., 100 milligrams is twice as strong as 50 milligrams—assuming no drug tolerance effects). However, in education or psychology, administering more of a treatment does not necessarily make it stronger. For example, doubling the amount of an ineffective treatment would have nothing to do with its strength in changing behavior, because the treatment does not have the active ingredients necessary to change behavior.

Another dimension of treatment strength is duration of the treatment. Are longer treatments stronger than thosedelivered with shorter durations? This depends on the inherent properties of the treatment that constitutes its ability to change behavior. For example, is a 3-month treatment stronger than a 1-month treatment? Again, administering a longer duration of treatment would not necessarily result in larger changes in behavior if the treatment contains few or no active ingredients to promote behavior change. In fact, there are cases in which longer treatments may lose their effectiveness over time. A good example is the concept of reinforcer satiation in which a reinforcer loses its effectiveness over time (i.e., children get tired of the reinforcer).

A third dimension of treatment strength is the intensity of the treatment. Treatment intensity can refer to how many times the treatment is delivered (e.g., twice a day, once per day, once per week). Treatment intensity can also be conceptualized as the consistency with which a treatment is delivered. This concept captures the notion of treatment integrity, or the degree to which a treatment is implemented as planned or intended.

In an RTI approach to intervention service delivery, the strength of educational or psychological interventions cannot be reliably defined a priori, because there is not a one-to-one correspondence between the “dosage” of a treatment and subsequent response to a treatment. Several assumptions may be helpful in considering the notion of treatment strength. One, stronger treatments often result in greater behavior change than weaker treatments. It is unclear, however, what makes a treatment “strong.” A defensible approach to determining treatment strength can be found in the meta-analytic literature on academic and behavioral interventions. That is, treatments producing larger effect sizes can legitimately be considered stronger than treatments producing smaller effect sizes. In other words, evidence-based treatments are de facto stronger than treatments having little or no empirical evidence to support their use. For example, a treatment that produces an effect size of d =.80 will be much stronger than another treatment that produces an effect size of d =.20.

Another assumption in treatment strength is the effect of treatment integrity. That is, treatment strength may be diluted or enhanced by the level of treatment integrity. For example, an evidence-based treatment delivered with 100% integrity should be stronger than that same treatment delivered with only 50% integrity. However, treatment integrity does not necessarily result in stronger treatments (i.e., 100% of a weak treatment may not equal 50% of a strong treatment). Moreover, each component of a treatment may not be equally strong in producing behavior change (Gresham, 1989 ).

This chapter discussed RTI from the perspective of a three-tier approach to service delivery in schools. Instead of diagnosing within-child conditions (e.g., specific learning disabilities or emotional disturbance), the RTI approach focused on four stages of a problem solving process: problem identification, problem analysis, plan implementation, and plan evaluation. Each of these steps in the problem solving process takes place at each of three levels of intervention: universal, selected, and intensive. This chapter concluded with a discussion of how strength of treatments can moderate treatment outcomes, and discussed unresolved issues in conceptualizing and operationalizing treatment strength.

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Article • 7 min read

Heron’s Six Categories of Intervention

Understanding how to help people more effectively.

By the Mind Tools Content Team

At work, in whatever role or industry, most people deal daily with others who need their help, support, advice or expertise. Precisely how they deliver that "help" determines its success and also has an impact on the relationship they build with the person they are helping.

John Heron's framework provides a model for analyzing how you deliver help. His model identifies six primary categories or styles of helping intervention.

Based on studies in counseling, his categories became widely used to study and train health and education professionals. However, more recently, business professionals – managers, supervisors, coaches, consultants, sales people – have used the model to learn and improve how they interact when helping their employees, team members, clients, and customers.

This article helps you understand Heron's model, so that you can use it to improve your business and management communication skills and so improve the outcome of the help you offer.

Understanding the Model

Heron's model has two basic categories or styles – "authoritative" and "facilitative." Those two categories further break down into a total of six categories to describe how people intervene when helping.

There are some technical words used to describe the categories. Don't be put off by them – they are necessary to describe this model and we define them fully below.

If a helping intervention is "authoritative," it means that the person "helping" (often a manager or supervisor) is giving information, challenging the other person, or suggesting what the other person should do.

If a helping intervention is "facilitative," it means that the person "helping" is drawing out ideas, solutions, self-confidence, and so on, from the other person, helping him or her to reach his or her own solutions or decisions.

• Prescriptive
• Informative
• Confronting

Authoritative Interventions

• Prescriptive – You explicitly direct the person you are helping by giving advice and direction.
• Informative – You provide information to instruct and guide the other person.
• Confronting – You challenge the other person's behavior or attitude. Not to be confused with aggressive confrontation, "confronting" is positive and constructive. It helps the other person consider behavior and attitudes of which they would otherwise be unaware.

Facilitative Interventions

• Cathartic – You help the other person to express and overcome thoughts or emotions that they have not previously confronted.
• Catalytic – You help the other person reflect, discover and learn for him or herself. This helps him or her become more self-directed in making decisions, solving problems and so on.
• Supportive – You build up the confidence of the other person by focusing on their competences, qualities and achievements.

Heron, John. Helping the Client: A Creative Practical Guide , 5th Ed. pp. 5-6. Copyright © 2001 by John Heron. Reprinted by permission of SAGE Publications, Ltd.

How to Use the Model

You can use the model to look at the way you communicate in different "help" settings at work. If you habitually use one or two styles, the model will help you learn and use more of the styles, and so improve your impact and the outcome of the help you give. Use figure 1 below to analyze the styles you use in given work settings.

If you are helping someone to solve a specific problem or issue, use the model to plan your intervention so that you help your team member or client in the best possible way. Use figure 1 to select appropriate styles and plan what to say and ask the other person.

A great way to understand your helping styles is to ask your colleagues and team members directly for feedback.

The examples below show how, by changing or varying the style of help offered, you can achieve a better outcome.

Example 1: Production line supervisor Bob is naturally "prescriptive" with his supervisees. He has found that some team members are bringing more and more problems to him. He realizes that his natural communication style may be partly to blame.

Using Heron's categories as a framework, he concludes that a more "supportive" style may help the team members gain confidence and so solve more of the problems for themselves. He schedules a meeting and plans what he will say and questions he will ask to be more "supportive", using the example "what to say or ask" below.

Example 2: HR consultant John has a long-term business client who is the HR director of a large national organization. He meets with his client monthly and helps her as a "sounding board" for strategic planning and decision-making. John is usually "facilitative" and uses a "catalytic" style of helping his client.

However, he currently is concerned that his client, in one policy-related area, may be making uninformed decisions. He provides some information and tries to help his client understand the issue ("informative" help), in the hope she will change her plans. She fails to act on the new information. Frustrated, and with the Heron model in mind, John concludes that a "confronting" style is now appropriate to achieve a better outcome for his client, and help her avoid making a big mistake. He sets up another meeting with her, and prepares what to say and ask, to "confront" the issues.

The following table helps you analyze or plan your communication skills for helping by indicating what you say and what you ask when using each one of the six categories of the Heron model.

Figure 1: Heron Model: What to Say and Ask

Heron's Six Categories of Intervention can be used as a framework to help you understand and improve your business communication skills.

Whether you are helping a team member, employee, client or customer, the model can help you develop greater awareness of your own "helping" style and its impact, and can help you adapt the way you help to improve the outcome and your "helping" relationships.

Heron, J. (2001). 'Helping the Client: A Creative Practical Guide,' 5th Ed. SAGE Publications, Ltd. pp. 5-6.

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Evidence-Based Interventions for Children with Challenging Behavior pp 31–40 Cite as

The Prevention Model and Problem Solving

• Kathleen Hague Armstrong 5 ,
• Julia A. Ogg 6 ,
• Ashley N. Sundman-Wheat 7 &
• Audra St. John Walsh 5  
• First Online: 01 January 2013

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With growing numbers of developmental needs expressed in communities, the way services are delivered to families must change to assist children. A prevention model which provides multiple levels of support from prevention efforts to extensive, individualized interventions can assist practitioners in meeting the needs of children efficiently and effectively. In addition, prevention and intervention efforts are more effective when problems are clearly identified and tied to specific interventions which are evidence-based. The use of a problem-solving process gives practitioners a specific way to think about child concerns and develop and track progress of interventions matched to the child or children’s needs.

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A need for children’s services and support in communities across the United States is prominent. Approximately 1 in 5 children in the United States have a diagnosable behavioral health disorder and current statistics indicate that only 20 % of children with severe behavioral health concerns will receive any kind of assistance (Society for Research in Child Development, 2009 ; U.S. Public Health Service, 2001 ). These problems when left unaddressed can negatively affect their functioning and development (Brauner & Stephens, 2006 ). With such a large need present and a limited number of qualified professionals to meet the need, communities must adopt an efficient model of service delivery. By matching the intensity of a service with the needs of a family, more children can be helped to reach developmental milestones on time. In the next section, a tiered service delivery model, identified as the prevention model, is described. This model focuses on prevention and early intervention to promote positive outcomes.

Primary Prevention

Primary prevention, also referred to as Universal, efforts consist of enhancing protective factors in families and community settings and are designed to prevent the future development of more negative child and family outcomes. An example of primary prevention is the Back to Sleep campaign, which is a public service campaign that is designed to educate all parents and caregivers about the importance of putting babies to sleep on their backs to prevent sudden infant death syndrome (SIDS). Prevention efforts can consist of general support and information provided through handouts or public service announcements. A key idea within primary prevention is to provide educational information to people who care for and/or work with children, so that they will be better informed about how to best promote healthy development. The guidelines presented in Chap. 1 for common behavior problems are examples of primary prevention efforts because all young children will benefit when those guidelines are followed. In the case of older children, school-wide social skills programs are considered to be primary prevention efforts because all children will benefit from social skills instruction. Primary prevention requires relatively little time and cost relative to individual intervention efforts, and is accessible to everyone in the community. Although some children and families will need more intensive interventions as well, the needs of 80–90 % of children and families are expected to be met with these low cost efforts. High quality, primary prevention efforts are also important as they can reserve resources to develop and provide services and supports to children and families in significant need.

Secondary Prevention/Intervention

Secondary prevention, also referred to as Targeted, involves activities slated for children who may develop problem behaviors as a result of certain risk factors, and as such need programs tailored to promote their success. Children growing up in poverty are an example of individuals for whom secondary prevention efforts such as developmentally appropriate preschool experiences can result in positive outcomes such as improved readiness for school. Secondary prevention activities are provided in groups and are often implemented through educational, health care, or social services. Head Start is an example of a federally funded secondary prevention endeavor that promotes school readiness and cognitive gains through the provision of educational, health, nutritional, social, and other services. Children and families are eligible for Head Start based upon income status and/or disability, thus targeting the needs of approximately 5–15 % of children. The Nurse–Family Partnership is another secondary prevention approach, in that it targets low income, first-time mothers and provides them with healthcare and development guidance. Group parent training programs are yet another example of secondary prevention efforts, as they provide caregivers with information and support to improve parent–child relationships and proactive discipline skills.

Tertiary Prevention/Intervention

Lastly, tertiary prevention, or Clinical/treatment, includes more intensive and individualized supports for children with chronic issues and their families. As healthy development in young children includes both physical and mental health, these services are generally delivered by an interdisciplinary team and often across systems of care. Ideally, tertiary prevention/intervention will only be required by 5 % of families if quality primary and secondary prevention strategies are in place and accessible to families. Tertiary strategies should be aimed to maximize development and improve functioning, and as such, may prevent a problem from becoming worse or a related problem from developing. An example of tertiary prevention/intervention efforts would be Part C of The Individuals with Disabilities Education Act ( IDEA ) a federal law ensuring services to children birth to three with delays and/or disabilities. Over 6.5 million eligible infants, toddlers, children, and youth with disabilities are covered under this legislation (Retrieved December 10, 2012 from http://www2.ed.gov/policy/speced/reg/idea/part-c/index.html ). Each child and family eligible for Part C services will receive an Individual Family Support Plan (IFSP) which documents developmental goals, objectives and outcomes, as well as age-appropriate services and supports for the child and family. Another example of tertiary efforts would be individual behavioral health services needed for children with significant disruptive behaviors that resulted in their suspension from daycare or preschool, and are designed to help them thrive in such environments. Children who have experienced trauma or chronic illness are another group who might need extensive evaluation and support from a mental health professional to improve coping strategies.

Matching the Level of Care to the Child and Family’s Needs

The prevention model is often depicted as a pyramid, in which one thinks about how to prevent and intervene with developmental problems:

Tertiary prevention / intervention : Smallest number of children/families who require more extensive support and therapeutic services.

Secondary prevention / intervention : Higher risk children and families need increased support and guidance to strengthen their coping skills.

Primary prevention : Most children and families benefit from general information and support.

Problem-Solving Process Embedded in the Prevention Model

Four-step problem-solving process:

Problem identification — Is there a problem ? What is it ?

Sub-step 1: Define the problem in specific behavioral terms

What does the behavior look like?

When did the behavior occur?

What was the child doing?

Who else was present and what were they doing?

Sub-step 2: Define the desired behavior in specific behavioral terms

What is the desired or replacement behavior?

What skills are needed to reach desired behavior goal?

Sub-step 3: Determine where the child’s behavior falls in comparison to age expectations (this is also called Gap Analysis)

How does the child’s present behavior compare to expectations for her age?

These expectations are also referred to as benchmarks or milestones.

There are several methods one might use to help identify the problem, including structured interviews, screening tools, standardized rating scales, observations, and/or other assessments.

The problem-solving process is embedded in the prevention model

Problem analysis — Why is the problem happening ?

The purpose of this step is to develop multiple hypotheses to explain why the child is not exhibiting the desired behavior.

Hypothesis Format: (Child) does (problem behavior) because…

It is important to think about the environment in which the child lives, family relationships and support systems, and health factors that may be contributing to the problem.

Intervention implementation — What will be done about the problem ? Who will do it ? How often and for how long will they do it ? How will we know if the intervention is working ?

Using the information gathered through problem analysis, interventions are selected/developed and implemented.

The interventions should be closely aligned with the hypothesis for why the problem is occurring. For example, two children who exhibit tantrum behavior may have different reasons for doing this (Anthony: to get attention, Sarah: because she does not have the language to express her needs), and the interventions that would be most likely to be successful should match to the specific hypotheses. An intervention to address Anthony’s tantrums may focus on strategies to seek attention appropriately and his parents may need to ignore tantrums. For Sarah, an intervention to increase her ability to express her needs (e.g., teaching her words or sign) would be more likely to be effective.

The following information must be specified in the plan:

Who will do what ?

When it will be done?

How long will it be tried?

Also included in this step is determining the data collection method, which will be needed to monitor the response to the intervention.

How will we know if the intervention is working?

When will the intervention be evaluated?

Intervention evaluation — Is the intervention working ?

This step involves revisiting the problem originally identified and examining data to determine if the intervention is working.

A determination is made (based on the data) whether the intervention needs to continue, be modified, or be discontinued.

If the problem persists, the problem-solving process must be repeated in order to redesign a more effective intervention. New information is gleaned throughout the problem-solving process which can be used to better understand the problem and informing more effective future iterations of the intervention.

The problem-solving process appears in Fig.  3.2 . and is applied in a case study in Table  3.1 .

The four-step problem-solving process

Collaborative Problem Solving

The problem-solving process works best when developed with a team of individuals who are familiar with the child and her family. Members of the team might include providers from preschool, child protective services, primary care, and mental health, with each one helping to develop the plan that builds on the child and family’s strengths to establish effective services and supports. Including a collaborative team in the problem-solving process has the potential to improve outcomes in a number of ways. For instance, through collaboration a child’s providers may be able to more accurately define the presenting problem and generate hypotheses about why the problem is occurring. Through their coordinated efforts, this team will be more able to develop interventions that are linked to validated hypotheses as well as tailor them to the individual child and family.

As part of collaborative problem-solving process, establishing and maintaining rapport is essential. Initially building rapport may require a considerable amount of time and energy; however, the effectiveness and efficiency of the problem-solving process will improve as time goes on. For example, a caregiver must feel comfortable sharing sensitive information with the team such as whether or not they think they will be able to carry out the intervention as intended. If rapport has not been established, then the caregiver may agree to implement an intervention that they cannot carry out, and therefore, the benefit is lost. Developing and maintaining rapport involves active listening to the caregiver’s perspective, developing shared goals, determining whether or not an intervention is acceptable and feasible to a caregiver, and sharing the importance of conducting the intervention as it is intended.

Conclusions

The prevention model is a notion which matches the level of care to a child’s and family’s needs. This model is frequently visually depicted by a pyramid, which outlines levels of support from least intensive to most intensive as based upon the needs of children and their families, and includes general education at the primary level which is expected to benefit most children and families, more focused guidance and support at the secondary level, aimed at children and families at higher risk, and extensive supports at the tertiary level, intended for those needing the most extensive support and intervention. The prevention model helps to guide the provision and funding of services and supports which are ultimately aimed to improve health and well-being of all children and their families. Within each level, the problem-solving process is used to pinpoint goals and objectives, and ensure that prevention and intervention efforts are appropriate and feasible. Lastly, data collection determines how well the intervention is working.

Assess Your Knowledge

Sandy enrolled in a group parent training class because her daughter Jenny has been throwing tantrums. Jenny has never been diagnosed with a disability, but recently has been engaging in more frequent tantrums. The group parent training class in which Sandy is enrolled fits best with which level of prevention?

Problem solving

You have determined that the behavior of greatest concern with Kelly is hitting other children. You have determined that she does this three times more than her peers do. You have determined that the most likely reason for her behavior is that she does not have the skills to communicate her wants and need, which in turn leads to her hitting others. Using the problem-solving model, what would be your next step?

Monitor the effects of your intervention

Implement an intervention to teach Kelly communication skills

Implement an intervention where you punish Kelly for hitting

Identify the problem

Sophia’s mother states that her daughter is behind in her motor skills. If you are following the problem-solving process what is your next step?

Enroll Sophia in physical therapy

Observe Sophia on the playground

Gather information about Sophia’s motor skills and compare this to established norms

Send Sophia for evaluation by a specialist

Spencer was born 9 weeks premature and has experienced multiple developmental delays and difficulties in his early years (i.e., heart problems, feeding difficulties). Since Spencer has a number of needs, he receives an IFSP to promote his growth and development. This type of prevention strategy falls into what category?

During what step of the problem-solving process should a team determine how they will measure the intervention’s effects?

Problem Identification

Problem Analysis

Intervention Implementation

Intervention Evaluation

Effective prevention strategies at the secondary level should only be required by what percent of families?

Jessica is driving when she hears an ad for the “Let’s Move” which provides information about improving nutrition and increasing activity so that individuals maintain a healthy weight. This campaign falls into what prevention tier?

In the Intervention Implementation step, it is important to:

Gather more information about the problem

Evaluate the validity of each possible cause for the problem

Examine the gap in skills between the children and their peers

Determine who will implement the intervention and how long it will be tried

As the level of tiered services increases, what changes occur to progress monitoring?

The frequency of progress monitoring increases

Progress monitoring tools cost more

The frequency of progress monitoring stays the same

The frequency of progress monitoring decreases

If Ethan was not responding to the intervention conducted at home with his mother, what should the practitioner’s next steps be?

Continue the intervention

Enroll Ethan’s mother in a parenting class

Implement a brand new intervention

Recycle back through the problem-solving steps to generate a new intervention

Assess Your Knowledge Answers

1) b 2) b 3) c 4) c 5) c 6) d 7) a 8) d 9) a 10) d

Brauner, C., & Stephens, C. (2006). Estimating prevalence of serious emotional and behavioral disorders: Challenges and recommendations. Public Health Reports, 121 , 303–310.

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Department of Pediatrics College of Medicine, University of South Florida, Tampa, FL, USA

Kathleen Hague Armstrong & Audra St. John Walsh

Department of Psychological & Social Foundations, University of South Florida, Tampa, FL, USA

Julia A. Ogg

School Psychology District School Board of Pasco County, Land O’Lakes, FL, USA

Ashley N. Sundman-Wheat

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Armstrong, K.H., Ogg, J.A., Sundman-Wheat, A.N., Walsh, A.S. (2014). The Prevention Model and Problem Solving. In: Evidence-Based Interventions for Children with Challenging Behavior. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-7807-2_3

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DOI : https://doi.org/10.1007/978-1-4614-7807-2_3

Published : 20 May 2013

Publisher Name : Springer, New York, NY

Print ISBN : 978-1-4614-7806-5

Online ISBN : 978-1-4614-7807-2

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