Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior.

OBJECTIVE: To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period. STUDY DESIGN: In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors. RESULTS: Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall. CONCLUSIONS: Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior.

BACKGROUND: People with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior. METHODS: Three data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places. RESULTS: Patients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one's own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient's biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low. CONCLUSION: Highly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

[Validation for people with dementia: innovation without evidence? : Systematic review]. / Validation bei Menschen mit Demenz: Innovation ohne Evidenz? : Systematischer Review.

BACKGROUND: Validation was an innovative approach to dealing with people with dementia that was supposed to reduce the incidence of challenging behavior. This effect, however, remains unclear to this day. OBJECTIVE: Does validation reduce challenging behaviour in people with dementia? MATERIAL AND METHOD: Systematic review according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Literature search in PubMed, CINAHL, PsycInfo and Web of Science. Description and critical appraisal of identified studies by two reviewers using the revised Cochrane risk of bias tool for randomized controlled trials. RESULTS: A total of five studies were identified. Only one showed a significant reduction in challenging behavior compared to the control group. All studies had a moderate to high risk of bias. CONCLUSION: Despite the negative results, a positive effect of validation cannot be ruled out as the trials tested validation as an isolated treatment and not as an integrated part of daily care. In addition, blinding, which is common in clinical trials, is not an appropriate criterion for evaluating trials investigating interventions where the effects result exclusively from interpersonal interaction.

Consultations for refractory cases in mental health services: a descriptive study.

BACKGROUND: Yearly, almost six percent, which is more than 1,000.000 people, in the Netherlands receive mental health treatment, which usually improves their quality of life. Concurrently, mental healthcare professionals recognize clinically refractory cases in which improvement fails to occur, with severe ongoing burdens for patients. The Dutch Centre for Consultation and Expertise (CCE) is available to support such refractory cases. The Dutch government's (financial) facilitation of consultation through the CCE is unique in the world. CCE consultations provide therefore unique insight into and an overview of refractory cases in mental health services. The objective of this study was to gain insight into the commonalities underlying the reasons for CCE consultations and the solutions proposed that play roles in (the reduction of) refractory cases for which consultation has been requested. METHODS: This descriptive study was conducted with quantitative and qualitative data from 472 CCE consultations in the Netherlands. Using descriptive statistics and thematic content analysis, four exemplary situations were distilled from the qualitative data. RESULTS: Most (83%) cases in the sample could be explained with four exemplary situations involving self-harm (24.2%), aggression (21.8%), self-neglect (24.4%), and socially unacceptable behavior (12.5%), respectively. Each situation could be characterized by a specific interaction pattern that unintentionally maintained or aggravated the situation. At the time of closure of the consultation applicants' questions had been answered and their situations had improved in 60.4% of cases. CONCLUSIONS: This study offers an overview of approaches that provided new perspectives for patients and professionals in many refractory cases in the Dutch mental health services.

Well-being, multidisciplinary work and a skillful team: essential elements of successful treatment in severe challenging behavior in dementia.

OBJECTIVE: Conceptualize successful treatment of persons with dementia and severe challenging behavior as perceived by professionals. METHODS: In this concept mapping study 82 experts in dementia care participated. The study followed two phases of data collection: (1) an online brainstorm where participants completed the focus prompt: 'I consider the treatment of people with severe challenging behavior in dementia successful if.'; (2) individual sorting and rating of the collected statements followed by data analysis using multidimensional scaling and hierarchical cluster analysis, resulting in a concept map. RESULTS: Three clusters were identified, the first addressing treatment outcomes and the latter two addressing treatment processes, each divided into sub-clusters: (1) well-being, comprising well-being of the person with dementia and all people directly involved; (2) multidisciplinary analysis and treatment, comprising multidisciplinary analysis, process conditions, reduction in psychotropic drugs, and person-centered treatment; and (3) attitudes and skills of those involved, comprising consistent approach by the team, understanding behavior, knowing how to respond to behavior, and open attitudes. CONCLUSIONS: Successful treatment in people with dementia and severe challenging behavior focuses on well-being of all people involved wherein attention to treatment processes including process conditions is essential to achieve this.

Transferring people with dementia to severe challenging behavior specialized units, an in-depth exploration.

OBJECTIVES: One of the main reasons for people with dementia to move to a dementia special care unit of a nursing home is challenging behavior. This behavior is often difficult to manage, and in the Netherlands, residents are sometimes relocated to a severe challenging behavior specialized unit. However, relocation often comes with trauma and should be prevented if possible. This study aimed to investigate the patient- and context-related reasons for these relocations. METHODS: Qualitative multiple case study using individual (n = 15) and focus group interviews (n = 4 with n = 20 participants) were held with elderly care physicians, physician assistants, psychologists, nursing staff members, and relatives involved with people with dementia and severe challenging behavior who had been transferred to a severe challenging behavior specialized unit. Audio recordings were transcribed and analyzed with thematic analysis, including directed content analysis. RESULTS: After five cases, data-saturation occurred. The thematic analysis identified three main processes: increasing severity of challenging behavior, increasing realization that the clients' needs cannot be met, and an increasing burden of nursing staff. The interaction between these processes, triggered mainly by a life-threatening situation, led to nursing staff reaching their limits, resulting in relocation of the client. CONCLUSION: Our study resulted in a conceptual framework providing insight into reasons for relocation in cases of severe challenging behavior. To prevent relocation, the increasing severity of challenging behavior, increasing burden on nursing staff, and increasing realization that the clients' needs cannot be met need attention.

Well-being in long-term care: an ode to vulnerability.

In health care, well-being is considered to be composed of multiple interacting dimensions and to regard the subjective (affective and cognitive) evaluation of these dimensions. These dimensions are often referred to as physical, psychological, and social domains of life. Although there are various disease-specific and group-specific conceptual approaches, starting from a universal perspective provides a more inclusive approach to well-being. Indeed, universal approaches to well-being have striking overlaps with dementia-specific approaches. Although many initiatives have been launched to promote person-centered care and attention for well-being in recent decades, the current COVID pandemic showed that the primary focus in (Dutch) long-term care was still on physical health. However, a well-being perspective can be a central base of care: it is a means to include positive aspects, and it can be applied when addressing problems such as challenging behavior in the sense that both are about needs. Furthermore, providing care from this perspective is not only about the well-being of frail people and their loved ones but also about the well-being and needs of the involved professionals. Increasingly, research shows the importance of the quality of the resident-carer relationship, the carer's behavior, and their well-being for improving the well-being of residents. Applying the care approaches 'attentiveness in care' and relationship-centered care can contribute to the well-being of all involved stakeholders as these uphold the reciprocity of care relationships and take the values and attitudes, but also the vulnerability of those involved, into account.

Systematic review: emotion dysregulation and challenging behavior interventions for children and adolescents on the autism spectrum with graded key evidence-based strategy recommendations.

Challenging behavior, such as aggression, is highly prevalent in children and adolescents on the autism spectrum and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behavior measures, while few included emotion dysregulation measures. This review highlights the importance of teaching emotion regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously designed studies and for including emotion dysregulation as an outcome/mediator in future trials.

Losing hope or keep searching for a golden solution: an in-depth exploration of experiences with extreme challenging behavior in nursing home residents with dementia.

BACKGROUND: Situations of extreme challenging behavior such as very frequent and/or severe agitation or physical aggression in nursing home residents with dementia can be experienced as an impasse by nursing home staff and relatives. In this distinct part of our WAALBED (WAAL-Behavior-in-Dementia)-III study, we aimed to explore these situations by obtaining the experiences and perspectives of nursing home staff and relatives involved. This can provide a direction in providing tools for handling extreme challenging behavior of nursing home residents with dementia and may improve their quality of life. METHODS: Qualitative multiple case study with individual interviews and focus group discussions. Interviewees were elderly care physicians, psychologists, care staff members, unit managers and relatives (n = 42). They were involved with nursing home residents with dementia and extreme challenging behavior living on dementia special care units in the Netherlands. For these residents, external consultation by the Centre for Consultation and Expertise was requested. Audio-recordings of the interviews were transcribed verbatim and analyzed with thematic analysis, including conventional content analysis. RESULTS: Seven cases were included. Forty-one individual interviews and seven focus group discussions were held. For six stakeholder groups (resident, relative, care staff, treatment staff, nursing home staff, and the organization), three main factors could be identified that contributed to experiencing a situation of extreme challenging behavior as an impasse: 1) characteristics and attitudes of a stakeholder group, 2) interaction issues within a stakeholder group and 3) interaction issues among (groups of) stakeholders. The experienced difficulties with the resident's characteristics, as well as suboptimal interdisciplinary collaboration and communication among the nursing home staff are remarkable. Nursing home staff kept searching for a golden solution or lost hope. CONCLUSIONS: This study offers important insights into situations of extreme challenging behavior in nursing home residents with dementia and offers caregivers targets for improving care, treatment and interdisciplinary collaboration, such as working uniformly and methodically.

Stimuli changes and challenging behavior in nursing homes during the COVID-19 pandemic.

BACKGROUND: COVID-19 restrictions in nursing homes resulted in a reduction in stimuli for residents. This study aimed to explore observed effects of changes in stimuli, both targeted (e.g., planned recreational activities) and untargeted (e.g., spontaneous noise), on challenging behavior in nursing home residents during COVID-19 anti-pandemic measures. METHODS: In an online survey, nursing home healthcare professionals in the Netherlands provided their perspectives on the effects of the reduction in untargeted stimuli on residents with mild, advanced, or no dementia, and on different types of challenging behavior (i.e., psychotic, depressed, anxious, agitated, or apathetic behavior). Additionally, we asked participants' opinions about strategies for limiting untargeted stimuli and for adjusting targeted stimuli for optimal management of challenging behaviors. RESULTS: In total, 199 professionals completed the survey. Residents with advanced dementia and those with psychotic and agitated behavior seemed to benefit from the reductions in stimuli not specifically targeted at the resident. In contrast, residents without dementia and those with depressive and apathetic behavior seemed to be negatively affected by reductions in untargeted stimuli. Participants would like to continue reducing untargeted stimuli in the future (e.g., limiting the use of corridors adjacent to residents' rooms) and to adapt existing or introduce new initiatives involving targeted stimuli (e.g., small-scale, individually tailored activities). Responses to open-ended questions revealed additional initiatives that could be useful in nursing home care. CONCLUSIONS: This study provided lessons to learn from the COVID-19 measures in nursing homes. While many residents may have been negatively affected by the restrictions imposed during the pandemic, specific resident groups may have benefitted from the reduction in untargeted stimuli and from the adjustments made to daily activities. Various strategies and initiatives used in nursing homes during the pandemic seem promising for meeting individual needs in managing challenging behavior. These findings suggest that certain stimuli may affect specific resident groups differently. This underlines the importance of finding the right balance between stimuli and tranquility, tailored to the needs of individual residents. It is important to consider the stimuli present in nursing homes, whether targeted or untargeted, when analyzing and treating challenging behavior.

Program evaluation of in-patient treatment units for adults with acquired brain injury and challenging behavior.

RATIONALE: As acquired brain injury rates continue to increase, the ongoing need for efficient and effective treatment within neurobehavioral rehabilitation settings is clear. Some evidence suggests certain treatment components may be very important to incorporate into service delivery models (e.g., multidisciplinary). However, program evaluation literature and the uptake of complementary intervention strategies, like applied behavior analysis (ABA), in existing neurobehavioral settings remains largely unexplored. PRIMARY OBJECTIVE: The purpose of this project was to: (1) develop and implement a simple, systematic program evaluation informed by best-practices (i.e., research) to assess service delivery models of several neurobehavioral rehabilitation settings, and (2) survey the current use of ABA by participating neurobehavioral agencies. METHODOLOGY: The program evaluation tool was applied to the charts of randomly selected past and current clients (referred to as participants). A secondary research assistant independently reviewed 29% of the charts to conduct interobserver agreement, which s. was 80% (range, 53%-100%). RESULTS: Average program evaluation total percentage score was 33% (range, 4% - 63%), and program evaluation items describing ABA-uptake suggested the incorporation of ABA was low. DISCUSSION: We discuss service model areas of strengths and areas for improvement as specified by tool outcomes, as well as in relation to quality improvement implications.

Behavioral changes in migrants with dementia : Experiences of professional caregivers.

BACKGROUND: Professional caregivers take care of an increasing number of migrants with dementia who may show behavioral changes. OBJECTIVE: Insight into the experiences of professional caregivers concerning the care for people with a migration background who suffer from dementia and behavioral changes. MATERIAL AND METHODS: Semi-structured interviews with 20 professional caregivers providing community and residential care. RESULTS: The caregivers' experiences focus on behavioral changes itself and on their efforts to offer person-centered care. Caregivers are aware of the mismatch between the cultural background of the client and their relatives and the professional care context. The different care perspectives of relatives and professionals sometimes result in conflict and poor collaboration. Over time, the reflections on experiences result in an awareness that more expertise and support is needed. CONCLUSION: Professional caregivers deserve support in their aim to provide high quality care for migrants with dementia and behavioral changes.

Building high-quality interpersonal staff-client relationships with people with severe to profound intellectual disabilities and challenging behavior: Insights of professionals and relatives.

Background: Staff-client relationships impact the quality of support and life of people with severe to profound intellectual disabilities and challenging behavior, but are challenging to build due to clients' intense, complex and varying support needs. The present study explores the perspectives of professionals and relatives on what affects these interpersonal relationships. Method: 17 professionals and 11 relatives participated in focus groups and interviews. Data collection and analysis was performed in collaboration with a co-researcher. Data were synthesized thematically. Results: Interpersonal relationships constituted equivalence, striving for mutual understanding, trust and exploring clients' potential. The combination of staff characteristics (enthusiasm/passion, patience, resilience, creativity/humor, flexibility) and expertise (knowledge, vulnerability/sincerity, self-reflection) enabled staff to build these relationships. The importance of involving relatives was addressed. Contextual influences included the team (cooperation, flexibility, culture), organization (cooperation, boundary conditions) and setting (predictability, interior/atmosphere). Conclusions: The findings make practical knowledge explicit and scientifically underpinned for this specific population.

Parent-Implemented Behavior Interventions via Telehealth for Older Children and Adolescents.

Children and adolescents with intellectual and developmental disabilities (IDD) are more likely to engage in challenging and interfering behavior than their typically developing peers, which has been linked to many negative outcomes. The most effective interventions to address challenging and interfering behavior incorporate function-based assessments, which are used to develop individualized behavior interventions. Functional communication training (FCT) is an evidence-based practice to decrease challenging and interfering behavior that can be taught to parents using behavioral parent training (BPT); however, there are limited skilled professionals who can develop interventions and train parents. Telehealth can enable greater access to these professionals. This study used withdrawal designs to determine whether high parent treatment fidelity resulted in decreased challenging and interfering behavior and increased appropriate replacement behavior. Three participants (8-17 years) were included in the study, and their parents served as interventionists during mealtime, toothbrushing, and room cleaning. Data were analyzed using visual analysis. Each parent achieved high treatment fidelity with one session of BPT and bug-in-ear coaching. All participants had a decrease in challenging and interfering behavior and an increase in functional communication responses (FCRs) upon the introduction of the intervention with reliable reversals. All parents reported high social validity. Results and implications for practice and future research are discussed.

Utilizing Telehealth to Coach Parents to Implement Trial-Based Functional Analysis and Treatment.

The trial-based functional analysis (TBFA) offers several advantages in natural settings, such as time efficiency and ecological validity. Previous studies have successfully trained or coached a variety of professionals and parents to conduct a TBFA utilizing in-person training procedures; however, no study has evaluated the effectiveness of telehealth coach or train others to implement a TBFA. Utilizing telehealth coaching, we coached three mothers of children with autism to conduct a TBFA in their home. The TBFA identified consequences maintaining challenging behavior for all three participants. Based on the results of the TBFA, we developed a functional communication training (FCT) intervention. Experimenters coached the mothers to implement the FCT intervention in their home. All interventions resulted in decreased challenging behavior and increased communication. The results suggest parents are capable of conducting a valid TBFA with telehealth coaching and support.

The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings.

INTRODUCTION: Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises. AIMS: We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs. METHOD: Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees. RESULTS: Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time. CONCLUSION: The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.

Intoxicated persons showing challenging behavior demand complexity interventions: a pilot study at the interface of the ER and the complexity intervention unit.

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation-liaison-psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P < 0.001). Field-relevant stakeholders strongly supported the interdisciplinary approach and ER-facility for IPCBs and acknowledged their unmet health needs. A biopsychosocial assessment at the ER, followed by a short admission if necessary, is effective in IPCBs. This approach helps to merge separated healthcare systems and may reduce stigmatization of IPCBs needing help.

Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands.

OBJECTIVES: From the perspective of the nursing home (NH) practitioners, to gain understanding of (1) whether challenging behavior in NH residents changed during the COVID-19 measures, (2) whether the practitioners' involvement in the treatment of challenging behavior changed, (3) what can be learned from the experience of NH staff. METHODS: A mixed methods study with a survey in 323 NH practitioners (psychologists, elderly care physicians, nurse practitioners) in the Netherlands, and in-depth interviews in 16 NH practitioners. Nonparametric analyses were used to compare estimated proportions of residents with increased and with decreased challenging behavior. Content analyses were conducted for open-ended questions and in-depth interviews. RESULTS: Participants reported changes in challenging behavior with slightly higher proportions for increased (Q1/Mdn/Q3: 12.5%, 21.7%, 30.8%) than for decreased (8.7%, 14.8%, 27.8%, Z = -2.35, p = .019) challenging behavior. Half of the participants reported that their work load increased and work satisfaction worsened during the measures. Different strategies were described to respond to the effects of COVID-19 measures, such as video calls, providing special areas for residents to meet their loved ones, adjusting activities, and reducing the exposure to negative news. CONCLUSIONS: Because COVID-19 measures resulted in both increased and decreased challenging behavior in NH residents, it is important to monitor for their potential long lasting effects. Increased work load and worsened work satisfaction of the NH staff, together with the changes in type of challenging behavior, indicate that the harmful effects of the anti-pandemic measures should be taken seriously.

Evaluation of a statewide initiative to reduce expulsion of young children.

This program evaluation study describes 3 years of implementation of Arkansas's BehaviorHelp (BH) system, a statewide expulsion prevention support system for early care and education (ECE). BH coordinates three tiers of supports to ECE professionals, including phone support, on-site technical assistance (TA), and infant and early childhood mental health consultation (IECMHC). We examine differences in characteristics of those served across BH service tiers, describe short-term case outcomes, and explore factors associated with expulsions. BH accepted referrals for 1,195 children in 488 ECE programs. The majority of referrals involved male children over the age of three, and most cases were assigned to the TA tier (68.5%). Cases assigned to receive IECMHC (28.4%) were more likely to involve children in foster care, receiving developmental therapies, and with higher rates of exposure to potentially traumatic events. The expulsion rate among referred children was 2.9%, and reported teacher engagement with the support process was high. Teachers receiving IECMHC services reported significant improvements in children's symptoms of emotional and behavioral problems. Exploratory analyses revealed that risk factors for expulsion included being a male, in foster care, in a lower quality ECE environment, and having a teacher with less training in social-emotional development.

Este estudio de evaluación de programa describe tres años de implementación de (BH), un sistema de todo el estado de apoyo de prevención a la expulsión en el caso del cuidado temprano y la educación (ECE). BH coordina tres niveles de apoyo a los profesionales ECE, incluyendo apoyo por teléfono, asistencia técnica en el lugar de trabajo, (TA) y consulta de salud mental del infante y en la temprana niñez (IECMHC). Examinamos las diferencias en cuanto a características de aquellos que recibieron servicios a lo largo de los niveles de BH, describimos los resultados de un caso a corto plazo y exploramos los factores asociados con las expulsiones. BH aceptó referencias en el caso de 1195 niños en 488 programas ECE. La mayoría de las referencias tenían que ver con niños varones de más de tres años, y la mayoría de los casos fueron asignados al nivel TA (68.5%). Los casos asignados para recibir IECMHC (28.4%) estaban más propensos a tratarse de niños bajo cuidados adoptivos temporales, que recibían terapias de desarrollo, y con altos puntajes de haber estado expuestos potencialmente a eventos traumáticos. El porcentaje de expulsión entre niños referidos fue de 2.9% y la participación del maestro, tal como fue reportada, en el proceso de apoyo, fue alta. Los maestros que reciben servicios IECMHC reportaron mejoras significativas en los síntomas de problemas emocionales y de conducta de los niños. Análisis exploratorios revelan que los factores de riesgo de expulsión incluían un varón, bajo cuidado adoptivo temporal, dentro de un ambiente ECE de baja calidad y con un maestro con menos entrenamiento en el desarrollo socio-emocional.

Cette étude d'évaluation de programme décrit trois années de mise en place du programme ComportementAide de l'état américain de l'Arkansas (abrégé ici BH pour BehaviorHelp), un système de soutien pour prévenir l'expulsion au niveau de l'état, pour les crèches et l'éducation (abrégé ECE ici suivant l'anglais). Le BH coordonne trois niveaux de soutien aux professionnels de l'ECE, y compris du soutien avec le téléphone, une assistante technique sur place (ATG) et la consultation de santé mentale du nourrisson et de la petite enfance (IECMHC). Nous avons examiné les différences dans les caractéristiques de ceux servis par les niveaux de service du BH, nous décrivons des résultats de cas à court-terme, et nous explorons les facteurs liés aux expulsions. Le BH a accepté des recommandations pour 1195 enfants de 488 programmes ECE. La majorité des recommandations a consisté en petits garçons de plus de trois ans, et la plupart des cas ont été référés au groupe TA (68,5%). Les cas référés afin qu'ils reçoivent la IECMHC (28,4%) étaient plus à même d'impliquer des enfants placés en famille, recevant des thérapies développementales, et avec des taux d'exposition à des faits traumatiques bien plus élevés. Le taux d'expulsion au sein des enfants recommandés était de 2,9%, et l'engagement rapporté des enseignants avec le processus de soutien était élevé. Les enseignants recevant les services IECMHC ont fait état d'améliorations importantes dans les symptômes de problèmes émotionnels et comportementaux des enfants. Des analyses exploratoires ont révélé que les facteurs de risque d'expulsion incluaient être un garçon, placé en famille, dans un environnement ECE de moindre qualité, et le fait d'avoir un enseignant avec moins de formation en développement socio-émotionnel.

Suspension and expulsion in Colorado early care and education settings: Child, program, and community-level predictors.

Expulsion presents a significant risk in Early Care and Education (ECE) settings due to its association with early disadvantage and frequency of use. A statewide survey was conducted to characterize ECE suspension and expulsion (S/E) in Colorado. Child, program, and community-level factors were examined as predictors of S/E, alongside preventative intervention supports capable of reducing S/E. Six hundred and sixty three licensed child care programs participated in the survey, providing information on 19,848 enrolled children, 312 suspensions, and 74 expulsions. A series of multilevel hierarchical regressions were conducted, examining predictors for S/E. Children with IEPs/IFSPs were disproportionately suspended; 2-3-year-olds were disproportionately expelled; and boys, 5-6-year-olds, and children with disabilities were disproportionately suspended and expelled. Center-based programs, lower quality ratings, and "zero tolerance" policies predicted greater use of suspension. In contrast, school-district affiliation and knowledge of how to access infant and early childhood mental health consultation (IECMHC) decreased suspension. Lower levels of regional child poverty predicted higher use of expulsion. Affiliation with a school-district, IECMH consultant-led training, and use of quality coaches predicted decreased expulsion. This study identifies the need for ongoing protection for children with IEPs/ IFSPs and the preventative interventions that mitigate risk for S/E.

Introducción. La expulsión presenta un riesgo significativo en el marco del Temprano Cuidado y Educación (ECE) debido a su asociación con tempranas desventajas y la frecuencia de uso. Una encuesta a nivel estatal se llevó a cabo para caracterizar la suspensión y expulsión de ECE (S/E) en Colorado. Asuntos relacionados con el niño, el programa y de nivel comunitario se examinaron como factores de predicción de (S/E), junto con apoyos de intervención para prevenir, capaces de reducir S/E. Métodos. Participaron en la encuesta 663 programas de cuidado infantil autorizados, lo cual aportó información sobre 19,848 niños matriculados, 312 suspensiones y 74 expulsiones. Se llevó a cabo una serie de regresiones jerárquicas de niveles múltiples, examinando así los factores de predicción de S/E. Resultados. A los niños con participación en programas o planes IEP/IFSP se les suspendió de manera desproporcionada; niños entre los dos y tres años fueron desproporcionalmente expulsados; y varones de cinco a seis años, y niños con discapacidades fueron desproporcionalmente suspendidos y expulsados. Los programas con base en un centro, los más bajos puntajes de evaluación de la calidad y las políticas de 'tolerancia cero' predijeron el mayor uso de la suspensión. En contraste, la afiliación a un distrito escolar y el conocimiento de cómo tener acceso a la consulta de salud mental infantil y la temprana niñez (IECMHC) redujo las suspensiones. Los más bajos niveles de pobreza regional de niños predijeron el más alto uso de la expulsión. La afiliación a un distrito escolar, el entrenamiento de consultores de IECMH, así como el uso de entrenadores calificados predijeron una reducción de las expulsiones. Conclusiones. Este estudio identifica la necesidad de una continuada protección para niños en programas o planes IEP/IFSP y las intervenciones de prevención que mitigan el riesgo de S/E.

INTRODUCTION: L'expulsion présente un risque important pour les contextes de Soins Précoces et Education (en anglais Early Care and Education, abrégé ici ECE) du fait de son lien à un désavantage précoce et la fréquence de l'utilisation. Un sondage au niveau de l'état a été fait afin de caractériser la suspension ECE et l'expulsion (S/E) dans l'état du Colorado aux Etats-Unis. L'enfant, le programme et les facteurs aux niveau de la communauté ont été examinés en tant que facteurs de prédiction de la (S/E), en parallèle avec des soutiens d'une intervention préventive capable de réduire la S/E. Méthodes. 663 programmes de crèches accréditées ont participé au questionnaire, offrant des renseignements sur 19848 enfants inscrits, 312 suspensions et 74 expulsions. Une série de régressions hiérarchiques à niveaux multiples a été faite, examinant les facteurs de prédiction pour la S/E. Résultats. Les enfants avec des plans IEP/IFSP (Plan d'Enseignement Individualisé/Plan Individualisé de Service à la Famille) ont été suspendus de manière disproportionnée ; les enfants de deux à trois ans ont été expulsés de manière disproportionnée, et les enfants avec des handicaps ont été suspendus et expulsée de manière disproportionnée. Les programmes centres (centrés sur une condition), les cotes de qualité inférieure et les politiques de « zéro tolérance ¼ ont prédit une plus grande utilisation de la suspension. Par contre, l'affiliation à un district académique et des connaissances sur la manière d'accéder à la consultation de santé mentale du nourrisson et de la petite enfance (IECMHC) ont fait décroître le taux de suspension. Des niveaux plus bas de pauvreté de l'enfant régionale ont prédit une utilisation plus élevée de la suspension. L'affiliation à un district académique, la formation faite par un consultant IECMH et l'utilisation de formateurs de qualité ont prédit une expulsion moins élevée. Cette étude identifie le besoin de protection continue des enfants avec des plans IEP/IFSP et d'interventions préventives qui mitigent le risque de S/E.