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Accountability Steps for Highly Reluctant Speech: Tiered-Services Consultation in a Head Start Classroom

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Title: Accountability Steps for Highly Reluctant Speech: Tiered-Services Consultation in a Head Start Classroom
Language: English
Authors: Howe, Heather, Barnett, David
Source: Journal of Educational & Psychological Consultation. 2013 23(3):165-184.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 20
Publication Date: 2013
Document Type: Journal Articles
Reports - Research
Education Level: Early Childhood Education
Preschool Education
Descriptors: Preschool Education, Consultation Programs, Preschool Children, Communication Problems, Speech Communication, Behavior Modification, Response to Intervention, Disadvantaged Youth, Accountability, Problem Solving, Progress Monitoring, Parents, Preschool Teachers, Intervention
DOI: 10.1080/10474412.2013.813805
ISSN: 1047-4412
Abstract: This consultation description reports parent and teacher problem solving for a preschool child with no typical speech directed to teachers or peers, and, by parent report, normal speech at home. This child's initial pattern of speech was similar to selective mutism, a low-incidence disorder often first detected during the preschool years, but the parent and teachers were concerned about making a referral for diagnosis and treatment due to the child's age. Also the agency had accepted tiered services where Tier 1 included classroom interventions, including those that were teacher developed. The intervention was based on building practice opportunities and positive attention to establish typical patterns of classroom language. A single case accountability design with peer norms was used for progress monitoring. Results were positive for social interactions, multiword use, and opportunities to respond. Child approaches peer and child approaches teacher showed more variability but patterns were similar to typical peers. The consultation illustrates the distinctions between highly reluctant speech and selective mutism using Tier 1 and relatively low-intensity teacher-managed interventions.
Abstractor: As Provided
Number of References: 41
Entry Date: 2014
Accession Number: EJ1030307
Database: ERIC
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  Value: <anid>AN0089770604;7ma01jul.13;2019Feb12.18:31;v2.2.500</anid> <title id="AN0089770604-1">Accountability Steps for Highly Reluctant Speech: Tiered-Services Consultation in a Head Start Classroom. </title> <sbt id="AN0089770604-2">Introduction</sbt> <p>This consultation description reports parent and teacher problem solving for a preschool child with no typical speech directed to teachers or peers, and, by parent report, normal speech at home. This child's initial pattern of speech was similar to selective mutism, a low-incidence disorder often first detected during the preschool years, but the parent and teachers were concerned about making a referral for diagnosis and treatment due to the child's age. Also the agency had accepted tiered services where Tier 1 included classroom interventions, including those that were teacher developed. The intervention was based on building practice opportunities and positive attention to establish typical patterns of classroom language. A single case accountability design with peer norms was used for progress monitoring. Results were positive for social interactions, multiword use, and opportunities to respond. Child approaches peer and child approaches teacher showed more variability but patterns were similar to typical peers. The consultation illustrates the distinctions between highly reluctant speech and selective mutism using Tier 1 and relatively low-intensity teacher-managed interventions.</p> <p>Preschools are among the first settings that enable appropriate social and communication assessments to occur because the social demands that impact early learning experiences are often first experienced in preschool settings. Furthermore, it is not uncommon for preschool children to speak at home with family members but avoid speaking in class, especially early in the school experience. This "reluctant speech" may occur due to significant events such as adjusting to new settings, separating from parents, learning new routines, or demonstrating fear and anxiety about making new friends (e.g., [<reflink idref="bib19" id="ref1">19</reflink>]; [<reflink idref="bib20" id="ref2">20</reflink>]). Most children begin feeling comfortable speaking with teachers and other students relatively soon after entering a new classroom. However, when a student's silence with new peers and adults extends further than 1 month, and the absence of speech cannot be accounted for in other ways (e.g., a communication disorder), the student may be exhibiting characteristics of an anxiety-based disturbance in typical verbal functioning referred to as selective mutism (SM; American Psychiatric Association [APA], 2000). A key feature of SM is the failure to speak in environments outside of the home. The child has the skills required for age-appropriate speech; however, these skills are not displayed in specific settings like school. Research has found that children with SM tend to avoid situations that have a high expectation for verbal behavior ([<reflink idref="bib19" id="ref3">19</reflink>]). When faced with a perceived "high pressure" situation, a child described as selectively mute is likely to exhibit behaviors such as blushing, avoiding eye contact, and becoming fidgety or rigid ([<reflink idref="bib19" id="ref4">19</reflink>]). Efforts to force children to talk can result in irritability or tantrums.</p> <p>Classroom teachers, school psychologists, and other support personnel play critical roles in the identification of SM because the affected children speak regularly at home ([<reflink idref="bib20" id="ref5">20</reflink>]; [<reflink idref="bib22" id="ref6">22</reflink>]). Early identification and intervention are important to prevent the further progression of avoidance-related behaviors. Accurate developmental skill assessment of young students with SM is difficult or not possible because the children do not respond verbally ([<reflink idref="bib20" id="ref7">20</reflink>]). Furthermore, literacy and social skill progression are highly dependent on verbal communication (e.g., [<reflink idref="bib36" id="ref8">36</reflink>]).</p> <hd id="AN0089770604-3">RELUCTANT SPEECH AND BEHAVIORAL INTERVENTIONS FOR SELECTIVE MUTISM</hd> <p>The relationship between reluctant speech, SM, and other closely related anxiety constructs may not always be clear (e.g., [<reflink idref="bib39" id="ref9">39</reflink>]). Children's expressions of stress and anxiety are diverse and may include recurrent fears, sleep problems and nightmares, difficulties separating from parents and school attendance, crying and tantrums, discomfort or clinginess, irritability, withdrawal in social situations, and persistent reactions to trauma. In contrast, selective mutism and reluctant speech both involve communication problems in social situations such as school but not at home with parents or siblings although anxiety may be hypothesized as a factor ([<reflink idref="bib4" id="ref10">4</reflink>]).</p> <p>There is relatively little research on reluctant speech ([<reflink idref="bib31" id="ref11">31</reflink>]; [<reflink idref="bib32" id="ref12">32</reflink>]). Reluctant speech has been described as minimal speech outside the home environment ([<reflink idref="bib4" id="ref13">4</reflink>]). Characteristics include very low rates of speech or speech with very low audibility, nonverbal communication, and avoidance or escape ([<reflink idref="bib32" id="ref14">32</reflink>]). Alternatively, SM is described as a rare disorder characterized by children having verbal communication competencies but selectivity in speech. The behaviors associated with SM may include shyness and withdrawal or other similar responses possibly related to anxiety in addition to highly reluctant speech in some social situations such as school.</p> <p>A stringent diagnostic determination of SM based on comprehensive procedures is difficult for younger children due to its close association with other social anxiety constructs and the lack of suitable diagnostic measures ([<reflink idref="bib9" id="ref15">9</reflink>]). Furthermore, young children may be described as SM when responses to situations and persons have been insufficiently sampled or relatively low-intensity interventions have not been tried.</p> <p>Many interventions for selective mutism have appeared in the literature. Reviews generally support the efficacy of behavioral interventions (e.g., [<reflink idref="bib19" id="ref16">19</reflink>]; [<reflink idref="bib26" id="ref17">26</reflink>]; [<reflink idref="bib40" id="ref18">40</reflink>]). [<reflink idref="bib19" id="ref19">19</reflink>] propose that characteristic SM behaviors are learned and that they serve one of two functions: to escape feelings of anxiety or to obtain attention. Similarly, reluctant speech is likely to have been reinforced ([<reflink idref="bib32" id="ref20">32</reflink>]). However, most research reviews show support for behavioral interventions involving an independent therapist and multistep and often intensive procedures ([<reflink idref="bib19" id="ref21">19</reflink>]; [<reflink idref="bib33" id="ref22">33</reflink>]; [<reflink idref="bib40" id="ref23">40</reflink>]). Interventions for SM typically incorporate components of contingency management, shaping, stimulus fading, desensitization, social skills training, and modeling ([<reflink idref="bib19" id="ref24">19</reflink>]; [<reflink idref="bib21" id="ref25">21</reflink>]; [<reflink idref="bib37" id="ref26">37</reflink>]). For example, a contingency management technique could reinforce increasingly closer approximations of a target verbal behavior such as mouthing words or whispering followed by typical verbal speech ([<reflink idref="bib19" id="ref27">19</reflink>]). Stimulus fading gradually increases the number of people and settings that make reinforcement available for verbal behavior ([<reflink idref="bib2" id="ref28">2</reflink>]; [<reflink idref="bib19" id="ref29">19</reflink>]). The addition of a stimulus-fading component to a traditional positive reinforcement contingency management plan increases the intensity of the intervention. Other more intrusive interventions such as psychopharmacological treatment are described although rarely as an initial treatment for selective mutism (e.g., [<reflink idref="bib17" id="ref30">17</reflink>]). Thus, although many interventions with some evidence of efficacy are available, decisions for any individual case are required concerning differences in intensity, naturalness, and intrusiveness of intervention methods ([<reflink idref="bib4" id="ref31">4</reflink>]; [<reflink idref="bib6" id="ref32">6</reflink>]).</p> <hd id="AN0089770604-4">PRESCHOOL POSITIVE BEHAVIORAL SUPPORT (PBS) AND RESPONSE-TO-INTERVENTION (RtI)</hd> <p>PBS and RtI have been integrated into multitiered preschool models for organizing school services (e.g., [<reflink idref="bib10" id="ref33">10</reflink>]). In an integrated approach, PBS provides a system of schoolwide prevention and service delivery for school social environments for all children ([<reflink idref="bib12" id="ref34">12</reflink>]) and adds a framework of prevention and intervention activities organized as tiers by sequencing and combining valid interventions by intensity variables based on students' responses. Tier 1 includes agencywide PBS programs, classwide core curriculum (this would include social problem solving in many preschool curricula), and low-intensity individualized efforts commonly used by effective teachers (i.e., differentiated positive attention; increased and differentiated practice opportunities). Universal screening occurs at Tier 1 by measuring child engagement, positive classroom management practices, instruction opportunities, and curriculum-based measurement (e.g., [<reflink idref="bib10" id="ref35">10</reflink>]; [<reflink idref="bib24" id="ref36">24</reflink>]) including children's communication with peers and adults. Tier 2 provides supplemental intervention for children who need more comprehensive programming. Tier 3 adds more frequent progress monitoring and structured problem solving by applying functional assessment methods for children not responding to Tier 2 interventions or who need more immediate comprehensive programming. In tiered services, prevention and intervention history can be used as evaluation data for disability questions ([<reflink idref="bib7" id="ref37">7</reflink>]; [<reflink idref="bib25" id="ref38">25</reflink>]).</p> <hd id="AN0089770604-5">CONSULTATION AND TIERED SUPPORTS</hd> <p>Multitiered models determine how consultation and problem solving are carried out ([<reflink idref="bib10" id="ref39">10</reflink>]; [<reflink idref="bib23" id="ref40">23</reflink>]). Preschool multitiered services at Tier 1, the focus of this report, include use of feedback and consultation on instructional and classroom management variables ([<reflink idref="bib12" id="ref41">12</reflink>]; [<reflink idref="bib15" id="ref42">15</reflink>]; [<reflink idref="bib29" id="ref43">29</reflink>]). In addition, consultation occurs for specific child behaviors of concern through problem solving based on low-intensity (teacher-managed) Tier 1 methods. [<reflink idref="bib30" id="ref44">30</reflink>] noted that consultation may also need to address longer range goals of behavioral change with repeated cycles of problem solving and interventions for individual children with developmental concerns. Problem solving and interventions may be applied to questions of reluctant speech and selective mutism and fit the tiered format of sequencing interventions by levels of needed intervention intensity in school services ([<reflink idref="bib6" id="ref45">6</reflink>]). In summary, as applied to preschool Tier 1, consultation and problem solving are focused on teacher and parent support for low-intensity teacher-managed interventions ([<reflink idref="bib7" id="ref46">7</reflink>]; [<reflink idref="bib15" id="ref47">15</reflink>]).</p> <hd id="AN0089770604-6">PRESCHOOL TIER 1: CONSULTATION SUPPORT AND NATURAL AND EMPIRICAL INTERVENTIONS</hd> <p>This case description involved the use of a consultation-based problem-solving approach ([<reflink idref="bib4" id="ref48">4</reflink>]; [<reflink idref="bib28" id="ref49">28</reflink>]; [<reflink idref="bib29" id="ref50">29</reflink>]) to address response classes represented by reluctant speech and selective mutism as reported by two preschool teachers teaming with a parent and school psychology consultant-in-training. Teachers and the child's parent were concerned about the individual child but also were apprehensive about the potential negative effects of making a referral. To alleviate concerns about a referral for mental health services ([<reflink idref="bib7" id="ref51">7</reflink>]; [<reflink idref="bib25" id="ref52">25</reflink>]), a classroom intervention was implemented guided by natural intervention design principles and procedures. The consultation procedures are based on environmental interventions (e.g., milieu language; positive attention) from applied behavioral analysis (e.g., [<reflink idref="bib27" id="ref53">27</reflink>]) and include several guiding premises ([<reflink idref="bib4" id="ref54">4</reflink>]):</p> <p></p> <ulist> <item> 1. The least intrusive intervention that will accomplish the goals of change is generally preferred.</item> <p></p> <item> 2. Assessments stress natural environments, activities, and routines.</item> <p></p> <item> 3. Naturalistic interventions occur within salient settings using caregivers who have the greatest opportunity to interact with the child.</item> <p></p> <item> 4. Intervention selection and development are guided by consultation and data-based problem solving (i.e., problem identification, analysis, intervention design, goal setting, implementation, fidelity checks, feedback, and evaluation; e.g., [<reflink idref="bib29" id="ref55">29</reflink>]).</item> <p></p> <item> 5. Data-based evaluation methods are used based on components from single case experimental designs ([<reflink idref="bib4" id="ref56">4</reflink>]; [<reflink idref="bib16" id="ref57">16</reflink>]).</item> <p></p> <item> 6. Starting with effective instruction and classroom management ([<reflink idref="bib41" id="ref58">41</reflink>]), interventions sequentially progress in intensity and individualization as needed.</item> <p></p> <item> 7. Intervention evaluation can result in sufficient descriptive and functional information for a valid diagnostic evaluation if needed ([<reflink idref="bib10" id="ref59">10</reflink>]; [<reflink idref="bib25" id="ref60">25</reflink>]).</item> </ulist> <hd id="AN0089770604-7">METHOD</hd> <p></p> <hd id="AN0089770604-8">Participants</hd> <p></p> <hd id="AN0089770604-9">Child</hd> <p>Christopher was a 4-year-old Caucasian student who attended Head Start, a federally funded program for parents meeting poverty guidelines. His teachers were concerned at the beginning of the year that he was not speaking in class. When either teacher prompted Christopher to speak he would avoid eye contact, become noticeably distressed, rock back and forth, and remain silent. This nonverbal behavior occurred throughout the day. Head Start screens comprehensively for health and other areas of child and family need, but because this was a Tier 1 consultation, further functional and developmental child assessment typically would occur in Tier 3.</p> <p>Although the behavior was evident early in the year, Christopher's teachers wanted to give him sufficient time to become comfortable in their classroom before making a decision about making a referral for services. Christopher's mother also was surprised to hear that he was not speaking in class and was also highly concerned about a referral. She reported that he spoke fluently at home. Consequently the referral for Tier 1 support services was initiated in January.</p> <p>Key decision-making factors throughout the consultation, as expressed by the teachers and parent, included (a) Christopher's pattern of responses continuing to be dissimilar to typical classroom peers, (b) concern with kindergarten transition risk and increasing social anxiety due to possibly significant difficulty with the preschool classroom and teacher-child relationships, and (c) teachers' and parent's preference for an initial trial using natural and environmental interventions over referring to an outside agency.</p> <p>All of the criteria for SM (APA, 2000) were met by this child except that in January, Christopher began to use inaudible speech (i.e., mouthing letters and words) and began whispering in the context of a one-on-one interaction with a single teacher in response to specific prompts. The teacher would prompt Christopher to name a letter, identify a color, and so on, and he would provide a correct response "under his breath." Christopher began to consistently mouth letters and words in response to specific classroom prompts. This was reassuring to his teachers because it confirmed that he was learning developmentally appropriate material and supported the teachers' and parent's preference to give Christopher more time to feel comfortable practicing speech in the classroom before making a referral for outside services.</p> <hd id="AN0089770604-10">Typical peers</hd> <p>Two male children selected by the teachers were used for peer micronorms ([<reflink idref="bib11" id="ref61">11</reflink>]) to help set goals and evaluate progress. Children were similar in age, ethnicity, and did not demonstrate challenging behaviors. Permission was obtained from each student's parent to serve as a comparison for Christopher's verbal and social behavior.</p> <hd id="AN0089770604-11">Support team and roles</hd> <p>The problem-solving team for this consultation consisted of a school psychology student assigned to a classroom for support in a RtI practicum ([<reflink idref="bib28" id="ref62">28</reflink>]), two classroom teachers, a Head Start family advocate, the practicum student's university supervisor, and the referred child's mother. The practicum student was responsible for researching potential intervention strategies, developing an observation code, collecting direct observation data, consulting with teachers and parent using problem-solving steps appropriate for tiered services ([<reflink idref="bib29" id="ref63">29</reflink>]), and facilitating team meetings. The teachers also completed observations and implemented the intervention. The parent attended all team meetings and provided reports of the student's behavior at home.</p> <p>Tier 1 consultation contacts and problem-solving efforts were primarily directed toward providing support for teacher-managed intervention strategies. Consultation with the problem-solving team occurred through weekly classroom observations of Christopher's interactions with teachers and peers (expanded later); consultations with Christopher's classroom teachers; individual/group supervision with university practicum supervisor; and team meetings that included Christopher's mother, classroom teachers, university supervisor, and practicum student (1/16/2008, 1/23/2008, and 3/5/2008). Individual/group supervision and team meetings were used to examine graphed data (e.g., a feedback condition; [<reflink idref="bib18" id="ref64">18</reflink>]) related to Christopher's progress toward intervention goals.</p> <hd id="AN0089770604-12">Setting</hd> <p>The Head Start was located in the metropolitan area with a mix of ethnicities from low-income families. The Head Start was committed to carrying out multitiered services (RtI & PBS) as described earlier. A strong classroom level of support (Tier 1) was in place in this preschool classroom from the start of the year, which included high levels of teacher-directed and incidental instruction as well as opportunities to respond, positive classroom management techniques, and high levels of student engagement ([<reflink idref="bib7" id="ref65">7</reflink>]). These instructional and child variables were measured through direct observation of the classroom through agency-wide classroom screening procedures ([<reflink idref="bib15" id="ref66">15</reflink>]; [<reflink idref="bib34" id="ref67">34</reflink>]).</p> <hd id="AN0089770604-13">Target Variables</hd> <p></p> <hd id="AN0089770604-14">Preliminary observations</hd> <p>Target variables were selected based on information collected through Narrative Real Time (NRT) observations (not graphed; <emph>N</emph> = 3), teacher interviews, and team meetings. NRTs are used for preliminary observations by descriptively recording setting, behaviors, and interactions along with time markers (e.g., [<reflink idref="bib4" id="ref68">4</reflink>]; [<reflink idref="bib13" id="ref69">13</reflink>]). NRTs revealed that Christopher did not answer questions when prompted by the teacher during circle time and would play alone, without interacting with or speaking to peers, during center time. Christopher avoided eye contact and became anxious when his teachers focused on his speech.</p> <hd id="AN0089770604-15">Teacher report</hd> <p>A structured teacher daily report (TDR) was developed to record the times of the day that Christopher's teachers heard him speak. The classroom teachers also provided descriptions of these behaviors. The TDR was used as a data source for times when the observer was not present.</p> <hd id="AN0089770604-16">Code definitions</hd> <p>Based on preliminary observations and teacher interviews, an observation code (see Appendix) was developed to measure instances of Christopher's social interaction, approaching the teacher, approaching a peer, opportunities to respond, mouthing words, single-word use, and multiword use. Thirty-second partial interval recording was used to estimate the occurrence of social interactions, child-teacher interactions, child-peer interactions, and opportunities to respond. Mouthing words, single-word, and multiword use were recorded as frequencies and converted into rates. Code definitions are as follows; however, mouthing words and single-word use did not yield usable data. Data collected were collected weekly from January through April.</p> <p> <emph>Social Interaction</emph>: Interacting or playing with peers—mutual interest in an activity, joining a group, or approaching another student; engaging in an activity following a request from another student; sharing toys; playing games.</p> <p> <emph>Child Approaches Teacher</emph>: Verbally initiating conversation with a teacher—requesting permission to perform some action, offering a response to prompt, and sharing information without a request.</p> <p> <emph>Child Approaches Peer</emph>: Verbally initiating conversation with a peer—asking for a toy, joining a group, playing a game, sharing information without a request.</p> <p> <emph>Opportunity to Respond</emph>: Teacher directly prompts/asks the target child a question requiring a verbal response.</p> <p> <emph>Multiword Use</emph>: Number of phrases containing two or more words—combining noun with adjective (blue car, big house) or speaking in sentences (I like to ride my bike).</p> <hd id="AN0089770604-17">Code variables not analyzed</hd> <p>A frequency was reported for <emph>Mouthing Words</emph> defined as quiet responses to teacher prompts under his breath (quiet talking behaviors). However, in practice, this variable was not loud enough to be heard by an independent observer for agreement checks. In addition, <emph>Single-Word Use</emph> defined as a number count of single words said in response to a teacher or peer prompt was not analyzed due to low reliability.</p> <hd id="AN0089770604-18">Sampling Plan: Activity and Peer Micronorms for Conversation</hd> <p>Direct observations of Christopher's verbal behavior took place once per week during center time, which lasted for approximately thirty minutes beginning in January through early April. Observations during center time also incorporated data for two male children identified by the classroom teachers as typically performing peers for ongoing social validity ([<reflink idref="bib11" id="ref70">11</reflink>]; [<reflink idref="bib38" id="ref71">38</reflink>]). Observations took place on different days of the week and at different times of center time (randomly sampling at the beginning, middle, and end). Data for peer comparisons were coded every fifth interval during the observation period. The observer alternated teacher-nominated students for peer comparisons for each of the peer comparison (fifth) intervals.</p> <hd id="AN0089770604-19">Technical Adequacy</hd> <p>The teacher daily report had 100% agreement between teachers on nonoccurrence of speech. For the observation code, interobserver agreement data on target variable occurrence were collected on 3/5/08 and 4/9/08 by two independent trained observers coding the same sample of behavior during unstructured free play (center time) between 9 a.m. and 11 a.m. The agreement coefficients were calculated using <emph>interval agreement</emph> and <emph>total agreement</emph> (for single and multiword use; [<reflink idref="bib35" id="ref72">35</reflink>]). The agreement <emph>Mdn</emph> = 86.5%, range was 38% to 100%, <emph>M</emph> = 83.4 (<emph>SD</emph> = 1.41). Observation of single-word use proved to be somewhat problematic (38% and 50% agreement) and was dropped from analysis (the graphed changes maintained by the consultant did show positive changes over baseline consistent with other graphs). Child-approaches-peer was variable. However, the consultant communicated frequently with teachers to confirm observation results allowing for confidence in conclusions for overall change in positive social communication, especially when teachers' independent observations also were considered.</p> <hd id="AN0089770604-20">Intervention Procedures</hd> <p></p> <hd id="AN0089770604-21">Functional hypothesis</hd> <p>Based on consultation and data from observations, the team hypothesized that Christopher was avoiding task demands. Teachers thought he became anxious when confronted with prompts to perform verbally (i.e., [<reflink idref="bib19" id="ref73">19</reflink>]).</p> <hd id="AN0089770604-22">Baseline</hd> <p>Baseline data for Christopher's teacher and peer interactions were based on teacher reports prior to the development of the problem-solving team (reconstructed; [<reflink idref="bib14" id="ref74">14</reflink>]) and confirmed by the preliminary observations during center time.</p> <hd id="AN0089770604-23">Intervention</hd> <p>Consultation with the teachers and Christopher's mother was used for intervention development and goal setting. The intervention in place to support Christopher's behavior was developed by his classroom teachers and consisted of several principles of natural intervention design. The lead teacher decided to explain the intervention rationale to Christopher, telling him that she won't know if he can say letters, numbers, and so on, because he is not using his words. Prompts/practice opportunities were offered to Christopher each day during circle time even though Christopher was not responding to this at first. Both teachers would call on him to answer; however, they would move on to another student if Christopher did not produce a response within approximately three seconds.</p> <p>Positive attention was provided for approximation of speech produced by Christopher. For example, as he began to feel more comfortable in the classroom he started to whisper quietly in response to prompts. The teachers did not, however, draw attention to the speech. Instead they attended to correct responses. The teachers also encouraged students in the class who displayed higher rates of verbal behavior to interact with Christopher during center time, at lunch, during recess, and at snack. Positive attention to peer interactions was to be given if Christopher approached a peer to initiate an interaction or if Christopher responded with a verbal response to an approach by a peer.</p> <hd id="AN0089770604-24">Intervention adherence</hd> <p>Direct observation data on adherence to the intervention was collected on nine occasions from January to April by the practicum student. Adherence on all occasions was 100%. Adherence checks included practice opportunities, positive attention to approximations to speech, and positive attention to interactions with peers.</p> <hd id="AN0089770604-25">Social Validity</hd> <p>Two methods were used to assess social validity. Social validity was assessed each week through consultation with Christopher's teachers by the practicum student and during periodic team meetings. The feedback provided by Christopher's mother and the teachers confirmed that the goals, procedures, and outcomes of this consultation were meaningful to all involved stakeholders. In addition, peer micronorm data were used to compare Christopher's verbal behavior with the verbal behavior of two other students in the classroom for goal setting and ongoing intervention evaluation.</p> <hd id="AN0089770604-26">Accountability Design</hd> <p>The A-B single-case accountability design (baseline followed by intervention) with multiple targets and follow-up ([<reflink idref="bib3" id="ref75">3</reflink>]; [<reflink idref="bib14" id="ref76">14</reflink>]) was used to monitor Christopher's progress with the targeted verbal behavior. The A-B design is a case study design, the building block of other single case designs, and can permit strong accountability for RtI programs ([<reflink idref="bib4" id="ref77">4</reflink>]) in making intervention decisions. In the present Tier 1 consultation the A-B design enabled the team to modify the intervention as needed to meet goals or add resources, and so on. The use of multiple measures strengthens the A-B design. If the data reveal immediate and consistent changes following the introduction of an intervention, some evidence exists that the intervention may have influenced responding, but alternative explanations cannot be ruled out and conclusions about internal validity are limited.</p> <hd id="AN0089770604-27">RESULTS</hd> <p>Observations showed clear positive changes in the target behaviors, and ongoing teacher reports confirmed the increases in appropriate verbal behavior by Christopher throughout the day. Christopher became interested in the activities of his peers, he began to smile and interact with the teachers and students in the classroom, and he began speaking fluently. Teacher daily reports indicated Christopher continued to make progress in each scheduled activity of the day.</p> <p>Figures 1–4 show that Christopher's typical speech and social interactions were at zero levels through January of the 2007–2008 school year by teachers' reports. The classwide support (i.e., Tier 1) provided by his teachers as well as the individualized intervention strategies that made verbal behavior natural may have contributed to Christopher's increasing interest in the activities of his peers (Figure 1) and speaking on his own more frequently (Figures 2 and 3). He also began to use more multiple word phrases (Figure 4). Figures show considerable natural variations in children's social behaviors often due to contextual factors. Figures 1 and 4 show consistent gains over baseline. Figures 2 and 3 show similar patterns between Christopher and peers but also demonstrate greater variation and some overlap with baseline data. Teacher reports help address the positive overall outcomes given that graphed outcomes are based on 30-min samples of Christopher's day. Using multiple variables in measuring outcomes is helpful in making decisions due to variability in single variables.</p> <p>Graph: FIGURE 1 Percentage of intervals of social interactions following practice opportunities and positive attention for Christopher along with peer comparisons.</p> <p>Graph: FIGURE 2 Percentage of intervals of Christopher verbally initiating a conversation with a peer along with peer comparisons.</p> <p>Graph: FIGURE 3 Percentage of intervals of Christopher verbally initiating a conversation with a teacher with peer comparisons.</p> <p>Graph: FIGURE 4 Rate of phrases containing two or more words spoken in response to a prompt from a peer or teacher with peer comparisons.</p> <p>Peer norms show that Christopher's behavior became close to his peers in terms of interacting socially, approaching a teacher, approaching a peer, and using multiword phrases. He no longer relied on the quiet talking (i.e., mouthing words) behavior that he displayed when he first began interacting verbally with his teachers. During the intervention Christopher would point on occasion to express what he wanted; however, he quickly switched to using his words when prompted.</p> <p>Observations by teachers and anecdotal notes recorded by the consultant revealed the following: Christopher developed classroom friends and children approached him on a regular basis as they became aware of his capability of talking with them. Christopher became comfortable with unfamiliar adults in the classroom. For example, when another practicum student helped with interobserver agreement checks, he continued to talk to his friends and play like the other students. Christopher's facial expressions indicated that he was comfortable and happy in his classroom.</p> <p>Graph: FIGURE 5 Percentage of intervals of opportunities to respond verbally presented by Christopher's classroom teachers.</p> <p>Figure 5 shows that the practice opportunities offered by classroom teachers for Christopher to respond verbally increased from 0% of intervals observed in January to 28% of intervals observed in April. Christopher's classroom teachers were reluctant to impose additional requests for a verbal response at the start of consultation as a result of Christopher expressing his discomfort through avoiding eye contact, rocking, and maintaining silence. The data suggest that as consultation progressed and the frequency of Christopher's verbal responses increased, his teachers felt more comfortable requesting verbal responses to questions or prompts presented to Christopher in the classroom. As Christopher demonstrated increasing comfort offering verbal responses in the classroom, his teachers adjusted their interactions with him to maintain this behavior and elicit more verbal responses when the opportunity presented itself.</p> <hd id="AN0089770604-28">DISCUSSION</hd> <p>Consultation for this case was guided by a problem-solving process and principles of natural design within the context of multitiered services. The classroom teachers were using positive strategies in instructing and managing the classroom as a first step in decision making ([<reflink idref="bib10" id="ref78">10</reflink>]; [<reflink idref="bib15" id="ref79">15</reflink>]). The team identified the specific concerns for this student in the classroom, and operational definitions of the target variables were created to measure the identified behaviors. A hypothesis for why the behavior was occurring was developed from multiple sources including teacher interviews and observations as well as a literature review. Data were collected and brought to the team for review and further decision making.</p> <p>When it was apparent that this student was exhibiting difficulty and distress following attempts at verbal interactions with his teachers and other students in the classroom, problem-solving consultation was initiated. Addressing this problem became a priority in January because of his enrollment in kindergarten for the following year. The consultant worked through the sensitive balance of parent and teacher concerns and recommendations and consulted based on reviews of empirically based interventions that could be carried out by teachers with a high degree of sensitivity to risk and careful evaluation ([<reflink idref="bib4" id="ref80">4</reflink>]). Collaboration was a critical component in the development of this consultation. The lead teacher in his classroom wanted the intervention to make verbal interactions as natural as possible without causing further child stress. The intervention procedures implemented by the classroom teachers, therefore, fit within the context of the strong classwide (Tier 1) support that was already in place in their daily interactions with each student. The intervention and assessment plan for this student was the least intrusive approach to progress monitoring and decision making. Instructional planning and delivery were matched to the needs of the student by considering both student and classroom variables. The intervention was part of the teachers' style of working with students; therefore, it was embedded into natural classroom routines. The intervention remained in place, unchanged, because the student was making adequate progress without an intrusive intervention.</p> <p>Parent involvement is another significant aspect of this consultation. Christopher's mother was an important stakeholder present at team meetings. She provided important information about his behavior at home. Overall, this case represented collaborative consultation, data-based decision making, and an ecological focus.</p> <p>The case description also shows that the relation between highly reluctant speech and selective mutism may be unclear in practical situations. In a different educational environment, Christopher's patterns of speech as well as the teachers', his parent's, and the consultant's steps could have led to very different outcomes with regard to diagnosis and specific interventions. Although case studies are limited in inference, first steps in consultation for highly reluctant speech may include relatively brief intervention trials in natural environments with natural contingency management (e.g., [<reflink idref="bib26" id="ref81">26</reflink>]). The decision rule determined by the team was that Christopher's observation data would show improvements in his level of speech so that it became closer to the typical patterns demonstrated by his peers, including natural variations in social behaviors. Lack of improvement compared with these peer comparisons would have led to further consultation and decision making in terms of changing intervention plans.</p> <hd id="AN0089770604-29">Limitations</hd> <p>Limitations of the consultation report include the use of a single-case accountability design and baseline derived from teacher reports. Reconstructed BL is not widely used in single-case research but it offers significant benefits when behavior of concern can be clearly defined, is at a low rate, and is of high importance. Alternatively, the A-B design with repeated measures would enable decisions for intervention changes as necessary. In addition, the consultant was in the classroom weekly and was able to confirm teacher reports regarding Christopher's verbal behavior. The graphs also show some natural variability for peers and Christopher in social behaviors; Figures 1 and 4 show consistent gains whereas Figures 2 and 3 show improvements over baseline and similar patterns between Christopher and peers but also variability and overlap with some baseline data. Teacher reports buttress the positive nature of outcomes. Data collection ended near the end of the school year. Finally, consultation variables were not defined or measured.</p> <p>Although these are limitations for consultation research, decision making based on combined use of teacher reports with independently verified consultant observations using ongoing progress monitoring represents a strong and likely practitioner model for decision making. The sequential and combined use of teacher and consultant observations represents a natural progression of problem analysis methods.</p> <hd id="AN0089770604-30">CONCLUSION</hd> <p>Head Start Services to families and children, and supports to teachers, are based on accurately assessing and prioritizing challenges faced by children, parents, and teachers. High on the list are concerning behaviors and lack of engagement in activities. Successful outcomes for young children often require that environments be changed and that teachers and parents are well supported in carrying out positive intervention plans. Systematic prevention and intervention services can be structured through multitiered (RtI and PBS) models by emphasizing positive qualities of preschool classrooms and natural interaction through consultation. This case description shows intervention decision making as an initial step prior to referrals for more intensive services.</p> <hd id="AN0089770604-31">APPENDIX</hd> <p></p> <hd id="AN0089770604-32">OBSERVATION CODE</hd> <p>Graph</p> <ref id="AN0089770604-33"> <title> REFERENCES </title> <blist> <bibl id="bib1" type="bt">1</bibl> <bibtext> American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders, , 4th ed., Washington, DC: Author.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref28" type="bt">2</bibl> <bibtext> Auster, E.R., Feeney-Kettler, K.A. and Kratochwill, T.R.2006. Conjoint behavioral consultation: Application to school-based treatment of anxiety disorders. Education and Treatment of Children, 29: 243–256.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref75" type="bt">3</bibl> <bibtext> Barlow, D.H., Nock, M.K. and Herson, M.2009. Single case experimental designs: Strategies for studying behavioral change, , 3rd ed., New York, NY: Allyn & Bacon.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref10" type="bt">4</bibl> <bibtext> Barnett, D.W., Pepiton, A.E., Bell, S.H., Gilkey, C.M., Smith, J.J., Stone, C.M. and Hannum, L.H.1999. Evaluating early intervention: Accountability methods for service delivery innovations. Journal of Special Education, 33: 177–188.</bibtext> </blist> <blist> <bibl id="bib5" type="bt">5</bibl> <bibtext> Barnett, D., Bell, S. and Carey, K.1999. Early interventions: A practitioner's guide, New York, NY: Guilford.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref32" type="bt">6</bibl> <bibtext> Barnett, D.W., Daly, E.J.III, Jones, K.M. and Lentz, F.E.Jr.2004. Response to intervention: Empirically-based special service decisions from increasing and decreasing intensity single case designs. Journal of Special Education, 38: 66–79.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref37" type="bt">7</bibl> <bibtext> Barnett, D., Elliott, N., Wolsing, L., Bunger, C.E., Haski, H. and Vander Meer, C.2006. Response to intervention for young children with extremely challenging behaviors: What it might look like. School Psychology Review, 35: 568–582.</bibtext> </blist> <blist> <bibl id="bib8" type="bt">8</bibl> <bibtext> Barnett, D.W., Ihlo, T., Nichols, A. and Wolsing, L.2006. Preschool teacher support through classwide interventions: A description of field-initiated training and evaluation. Journal of Applied School Psychology, 23: 77–96.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref15" type="bt">9</bibl> <bibtext> Barnett, D., Lentz, F.E. and Macmann, G.2002. "Personality assessment: Critical issues for research and practice". In Handbook of psychological and educational assessment of children, , 2nd ed., Edited by: Reynolds, C.R. and Kamphaus, R.W.Vol. 2, 3–29. New York, NY: Guilford.</bibtext> </blist> <blist> <bibtext> Barnett, D.W., VanDer Heyden, A.M. and Witt, J.C.2007. Achieving science-based practice through response to intervention: What it might look like in preschools. Journal of Educational & Psychological Consultation, 17: 31–54.</bibtext> </blist> <blist> <bibtext> Bell, S.H. and Barnett, D.W.1999. Peer micronorms in the assessment of young children: Methodological reviews and examples. Topics in Early Childhood Special Education, 19: 112–122.</bibtext> </blist> <blist> <bibtext> Benedict, E.A., Horner, R.H. and Squires, J.K.2007. Assessment and implementation of positive behavior support in preschools. Topics in Early Childhood Special Education, 27: 174–192.</bibtext> </blist> <blist> <bibtext> Bijou, S.W., Peterson, R.F. and Ault, M.H.1968. A method to integrate descriptive and experimental field studies at the level of data and empirical concepts. Journal of Applied Behavior Analysis, 1: 175–191.</bibtext> </blist> <blist> <bibtext> Bloom, M., Fischer, J. and Orme, J.G.2005. Evaluating practice: Guidelines for the accountable professional, , 5th ed., Boston, MA: Allyn & Bacon.</bibtext> </blist> <blist> <bibtext> Boat, M.B., Carr, V., Barnett, D., Nichols, A., Macmann, G., Moomaw, S. and Pan, W.2009. Instructional change in preschool classrooms: A study of empirically-based teacher support. NHSA Dialog: A Research-to-Practice Journal for the Early Childhood Field, 12: 307–326.</bibtext> </blist> <blist> <bibtext> Bonner, M. and Barnett, D.W.2004. Intervention-based school psychological services: Training for child-level accountability. Preparing for program-level accountability. Journal of School Psychology, 42: 23–43.</bibtext> </blist> <blist> <bibtext> Carlson, J.S., Mitchell, A.D. and Segool, N.2008. The current state of empirical support for the psychopharmacological treatment of selective mutism. School Psychology Quarterly, 23: 354–372.</bibtext> </blist> <blist> <bibtext> Casey, A.M. and McWilliam, R.A.2008. Graphical feedback to increase teachers' use of incidental teaching. Journal of Early Intervention, 30: 251–268.</bibtext> </blist> <blist> <bibtext> Cohan, S.L., Chavira, D.A. and Stein, M.B.2006. Practitioner review: Psychosocial interventions for children with selective mutism. A critical evaluation of the literature from 1990–2005. Journal of Child Psychology and Psychiatry, 47: 1085–1097.</bibtext> </blist> <blist> <bibtext> Crundwell, R.M. A.2006. Identifying and teaching children with selective mutism. Teaching Exceptional Children, 38(3): 48–54.</bibtext> </blist> <blist> <bibtext> Dow, S.P., Sonies, B.C., Scheib, D., Moss, S.E. and Leonard, H.L.1995. Practical guidelines for the assessment and treatment of selective mutism. Journal of the American Academy of Child and Adolescent Psychiatry, 34: 836–846.</bibtext> </blist> <blist> <bibtext> Drewes, K.M. and Akin-Little, A. 2002. Children with selective mutism: Seen but not heard. The School Psychologist, 56(2): 41–42. 54–56.</bibtext> </blist> <blist> <bibtext> Fuchs, L.S. and Fuchs, D.2007. A model for implementing responsiveness to intervention. Teaching Exceptional Children, 39: 14–20.</bibtext> </blist> <blist> <bibtext> Gettinger, M. and Stoiber, K.2007. Applying a response-to-intervention for early literacy development in low-income children. Topics in Early Childhood Education, 27: 198–213.</bibtext> </blist> <blist> <bibtext> Gresham, F.M.2005. Response-to-intervention: An alternative means of identifying students as emotionally disturbed. Education and Treatment of Children, 28: 328–344.</bibtext> </blist> <blist> <bibtext> Hagermoser Sanetti, L.M. and Luiselli, J.K.2009. Evidence-based practices for selective mutism: Implementation by a school team. The School Psychology Forum: Research in Practice, 3(1): 27–42.</bibtext> </blist> <blist> <bibtext> Hart, B.2000. A natural history of early language experience. Topics in Early Childhood Special Education, 20: 28–32.</bibtext> </blist> <blist> <bibtext> Hawkins, R., Barnett, D., Kroeger, S. and Musti-Rao, S.2008. Pre-service training in response-to-intervention: Learning by doing an interdisciplinary field experience. Psychology in the Schools, 45: 745–762.</bibtext> </blist> <blist> <bibtext> Knotek, S.E.2007. "Consultation within response-to-intervention models". In Handbook of response to intervention: The science and practice of assessment and intervention, Edited by: Jimerson, S.R., Burns, M.K. and Van DerHeyden, A.M.53–64. New York, NY: Springer.</bibtext> </blist> <blist> <bibtext> Kratochwill, T.R. and Bergan, J.R.1990. Behavioral consultation in applied settings: An individual guide., New York, NY: Plenum Press.</bibtext> </blist> <blist> <bibtext> Ladouceur, M.C. and Cloutier, R.1982. Reinforcement procedure in the treatment of reluctant speech. Journal of Behavior Therapy and Experimental Psychiatry, 13: 145–147.</bibtext> </blist> <blist> <bibtext> Mace, F.C. and West, B.J.1986. Analysis of demand characteristics association with reluctant speech. Journal of Behavior Therapy and Experimental Psychiatry, 17: 285–294.</bibtext> </blist> <blist> <bibtext> Mitchell, A.D. and Kratochwill, T.R.2013. Treatment of selective mutism: Applications in the clinic and school through conjoint consultation. Journal of Educational and Psychological Consultation, 23: 36–62.</bibtext> </blist> <blist> <bibtext> Nichols, A. and Barnett, D.W.2004. Procedures for coding instructional and caring contacts, Cincinnati, OH: School Psychology Program, University of Cincinnati. Unpublished manuscript</bibtext> </blist> <blist> <bibtext> Page, T.J. and Iwata, B.A.1986. "Interobserver agreement: History, theory, and current methods". In Research methods in applied behavior analysis, Edited by: Poling, A. and Fuqua, R.W.91–121. New York, NY: Plenum Press.</bibtext> </blist> <blist> <bibtext> Phillips, B.M., Clancy-Menchetti, J. and Lonigan, C.J.2008. Successful phonological awareness instruction with preschool children. Topics in Early Childhood Special Education, 28: 3–17.</bibtext> </blist> <blist> <bibtext> Rye, M.S. and Ullman, D.1999. The successful treatment of long-term selective mutism: A case study. Journal of Behavior Therapy and Experimental Psychiatry, 30: 313–323.</bibtext> </blist> <blist> <bibtext> Schwartz, I.S. and Baer, D.M.1991. Social validity assessment: Is current practice state of the art?. Journal of Applied Behavior Analysis, 24: 189–204.</bibtext> </blist> <blist> <bibtext> Sharp, W.G., Sherman, C. and Gross, A.M.2007. Selective mutism and anxiety: A review of the current conceptualizations of the disorder. Journal of Anxiety Disorders, 21: 568–579.</bibtext> </blist> <blist> <bibtext> Stone, B.P., Kratochwill, T.R., Sladezcek, I. and Serlin, R.C.2002. Treatment of selective mutism: A best-evidence synthesis. School Psychology Quarterly, 17: 168–190.</bibtext> </blist> <blist> <bibtext> Sugai, G., Horner, R.H. and Gresham, F.2001. "Behaviorally effective school environments". In Interventions for academic and behavior problems: Preventive and remedial approaches, Edited by: Shinn, M.R., Stoner, G. and Walker, H.M.315–350. Silver Spring, MD: National Association of School Psychologists.</bibtext> </blist> </ref> <aug> <p>By Heather Howe and David Barnett</p> <p>Reported by Author; Author</p> <p></p> <p>Heather Howe, Ed.S., earned her Ed.S. from the University of Cincinnati and is a practicing school psychologist at St. Bernard-Elmwood Place City Schools in Cincinnati, OH.</p> <p>David Barnett, PhD, is a Professor (Emeritus) in school psychology at the University of Cincinnati and was a consultant to the Head Start program where this consultation took place. note: This case study was carried out by the first author in a school psychology practicum under the supervision of the second author. The authors report that to the best of their knowledge neither they nor their affiliated institutions have financial or personal relationships or affiliations that could influence or bias the opinions, decisions, or work presented in this article.</p> </aug> <nolink nlid="nl1" bibid="bib19" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib20" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib22" firstref="ref6"></nolink> <nolink nlid="nl4" bibid="bib36" firstref="ref8"></nolink> <nolink nlid="nl5" bibid="bib39" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib31" firstref="ref11"></nolink> <nolink nlid="nl7" bibid="bib32" firstref="ref12"></nolink> <nolink nlid="nl8" bibid="bib26" firstref="ref17"></nolink> <nolink nlid="nl9" bibid="bib40" firstref="ref18"></nolink> <nolink nlid="nl10" bibid="bib33" firstref="ref22"></nolink> <nolink nlid="nl11" bibid="bib21" firstref="ref25"></nolink> <nolink nlid="nl12" bibid="bib37" firstref="ref26"></nolink> <nolink nlid="nl13" bibid="bib17" firstref="ref30"></nolink> <nolink nlid="nl14" bibid="bib10" firstref="ref33"></nolink> <nolink nlid="nl15" bibid="bib12" firstref="ref34"></nolink> <nolink nlid="nl16" bibid="bib24" firstref="ref36"></nolink> <nolink nlid="nl17" bibid="bib25" firstref="ref38"></nolink> <nolink nlid="nl18" bibid="bib23" firstref="ref40"></nolink> <nolink nlid="nl19" bibid="bib15" firstref="ref42"></nolink> <nolink nlid="nl20" bibid="bib29" firstref="ref43"></nolink> <nolink nlid="nl21" bibid="bib30" firstref="ref44"></nolink> <nolink nlid="nl22" bibid="bib28" firstref="ref49"></nolink> <nolink nlid="nl23" bibid="bib27" firstref="ref53"></nolink> <nolink nlid="nl24" bibid="bib16" firstref="ref57"></nolink> <nolink nlid="nl25" bibid="bib41" firstref="ref58"></nolink> <nolink nlid="nl26" bibid="bib11" firstref="ref61"></nolink> <nolink nlid="nl27" bibid="bib18" firstref="ref64"></nolink> <nolink nlid="nl28" bibid="bib34" firstref="ref67"></nolink> <nolink nlid="nl29" bibid="bib13" firstref="ref69"></nolink> <nolink nlid="nl30" bibid="bib38" firstref="ref71"></nolink> <nolink nlid="nl31" bibid="bib35" firstref="ref72"></nolink> <nolink nlid="nl32" bibid="bib14" firstref="ref74"></nolink>
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  Data: This consultation description reports parent and teacher problem solving for a preschool child with no typical speech directed to teachers or peers, and, by parent report, normal speech at home. This child's initial pattern of speech was similar to selective mutism, a low-incidence disorder often first detected during the preschool years, but the parent and teachers were concerned about making a referral for diagnosis and treatment due to the child's age. Also the agency had accepted tiered services where Tier 1 included classroom interventions, including those that were teacher developed. The intervention was based on building practice opportunities and positive attention to establish typical patterns of classroom language. A single case accountability design with peer norms was used for progress monitoring. Results were positive for social interactions, multiword use, and opportunities to respond. Child approaches peer and child approaches teacher showed more variability but patterns were similar to typical peers. The consultation illustrates the distinctions between highly reluctant speech and selective mutism using Tier 1 and relatively low-intensity teacher-managed interventions.
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            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Journal of Educational & Psychological Consultation
              Type: main
ResultId 1