Behavioral Management for Children and Adolescents: Assessing the Evidence

Problem behavior early in life can be related to later development of negative outcomes, such as school dropout, academic problems, violence, delinquency, and substance use; in addition, early childhood delinquent behavior may predict criminal activity in adulthood (1–7). Therefore, interventions designed to address problem behavior and increase prosocial behavior are important for children and adolescents and for families, teachers, school officials, community members, and policy makers. This article provides an assessment of behavioral management interventions for children and adolescents who have behavior problems.

This article reports the results of a literature review that was undertaken as part of the Assessing the Evidence Base Series (see box on next page). For purposes of this series, the Substance Abuse and Mental Health Services Administration (SAMHSA) has described behavioral management as a direct service that is designed to help a child or adolescent develop or maintain prosocial behaviors in the home, school, or community. Examples of these behaviors include demonstrating positive, nonaggressive relationships with parents, teachers, and peers; showing empathy and concern for others; and complying with rules and authority figures. Table 1 presents a description of the service and its components. Behavioral management interventions are individualized to the person’s needs.

The treatment literature includes a variety of behavioral management interventions that are designed to address problem behaviors (for example, externalizing or acting-out behaviors) of children and adolescents when implemented in various settings. Given the breadth and variations of these interventions, behavioral health policy makers, providers, and family members may benefit from a brief review of specific behavioral management interventions and their value as covered services in a benefit package.

The purposes of this article are to describe behavioral management services and highlight specific behavioral management interventions that are implemented in community settings, rate the level of evidence (methodological quality) of existing studies, and describe the effectiveness of these services on the basis of the research. We identify three models of behavioral management interventions that can be implemented, depending on the intervention setting and the needs of children or groups of children and their families. To facilitate use by a broad audience of mental health services personnel and policy makers, we provide an overall assessment of research quality and briefly highlight key findings. The results will provide state mental health directors and staff, policy officials, purchasers of health services, and community health care administrators with a simple summary of the evidence for a range of behavioral management services and implications for research and practice.

Description of behavioral management

Behavioral management for children and adolescents is a general category of intervention that is often incorporated as part of a variety of clinical practices that differ by setting and populations of focus. These interventions share common goals, which are listed in Table 1. Behavioral management interventions for children and adolescents included in this review address various problem behaviors, including noncompliance at home or at school, disruptive behavior, aggressive behavior, rule breaking, and delinquent behaviors. For purposes of this article, clinical components of behavioral management interventions for children were compiled from various practice-relevant sources (8–11).

Behavioral management is grounded in social learning theory and applied behavior analysis. Social learning theory asserts that people learn within a social context, primarily by observing and imitating the actions of others, and that learning is also influenced by being rewarded or punished for particular behaviors (12). Based on the principles of social learning theory, applied behavior analysis uses general learning principles, direct observation, objective measurement, and analytic assessment to shape behavior and solve problems that are clinically significant for an individual or family (11). The approach often is used for children with autism spectrum disorders; however, applied behavior analysis principles and techniques can be used more generally with behavioral management interventions for various child behavior problems.

Examples of specific behavioral management treatment activities include observing and documenting child behaviors, identifying antecedents of behaviors, utilizing motivating factors in reinforcement strategies, developing behavioral plans to address identified problem behaviors, coordinating interventions across different settings in which children function, and training other individuals in a child’s life to address specific behavioral objectives or goals. Behavioral management services typically are delivered through an individualized plan that is based on a clinical assessment. An assessment identifies the needs of the child or adolescent and the family and establishes goals, intervention plans, discharge criteria, and a discharge plan. Behavioral management plans are implemented through teaching, training, and coaching activities that are designed to help individuals establish and maintain developmentally appropriate social and behavioral competencies. Services may involve coordination of other care or referral to complementary services.

Behavioral management interventions may be delivered by family members, teachers, professional therapists, or a team of individuals working in concert to address the needs of a child or adolescent. A behavioral management therapist collaborates with the child or adolescent and the family to develop specific, mutually agreed-upon behavioral objectives and interventions to alter or improve specific behaviors. The resulting behavioral management treatment plan may also include a risk management or safety plan to identify risks that are specific to the individual. In some cases, a contingency plan is developed to address specific risks should they arise. Behavioral management professionals work in partnership with family members or teachers to implement a behavioral plan and monitor the child’s behavior and progress.

Three basic models of behavioral management interventions in the research literature are family-centered behavioral interventions, school-based behavioral interventions that can include services implemented across grades or classrooms or as individually targeted services, and integrated home-school programs. We focus on behavioral management interventions for children who are evidencing problem behavior and on interventions that include families and have some level of personalization that addresses the child’s needs.

Family-centered behavioral interventions

Family-centered interventions emphasize the role of parents or other caregivers in helping to manage problem behaviors of children, and they frequently focus on parenting practices. The interventions can be clinic based or offered in community settings or in the home. Behavioral parent training interventions are among the more commonly used family-centered behavioral management models. These interventions specifically target individual children with identified behavior problems and their families and generally teach parents to increase positive interactions with children and reduce harsh and inconsistent discipline practices. Behavioral parent training programs are delivered in a variety of formats. For example, some behavioral parenting interventions may involve parents, children, or teachers, and some may be delivered only to parents. Behavioral parent training interventions also vary in the extent to which they are customized to specific needs of the child. For purposes of this article, we focus on behavioral parent training interventions that involve planning for specific behavior problems that are expressed by a child and working with the parent and child, rather than group-based parent training programs that do not involve the child or are not customized based on specific behavioral needs.

Two family-centered behavioral interventions that meet the criteria for this review are Parent-Child Interaction Therapy (PCIT) and the Incredible Years programs. PCIT uses live coaching of parents during parent-child interactions to help parents establish nurturing relationships with their children, clear parent-child communication and limit setting, and consistent contingencies for child behavior (13,14). The Incredible Years parent training and child training programs involve addressing problem behavior of children aged two to ten years who have a diagnosis of a disruptive behavior disorder or are exhibiting subclinical levels of problem behavior (15,16). During treatment, a therapist works with parents and children in group settings and uses vignettes, focused discussions, role plays, and problem-solving approaches to illustrate and discuss specific behavioral management techniques. Both of these interventions incorporate behavioral management strategies of rewarding prosocial behavior, limiting reinforcement of inappropriate behavior, and delivering appropriate consequences for misbehavior.

School-based behavioral interventions

School-based behavioral interventions specifically target problem behaviors that occur in the school setting, and they use teachers and school staff as interveners in the management of student behaviors. One model that is commonly used in school settings is Positive Behavior Support (PBS). This model describes strategies that are implemented with the whole school to improve behavior and school climate and to prevent or change patterns of problem behavior (17). Based on applied behavior analysis, person-centered planning (an approach designed to assist the individual in planning his or her life and supports, often to increase self-determination and independence), and inclusion principles, PBS aims to support behavioral success by implementing nonpunitive behavioral management techniques in a systematic and consistent manner (18,19). PBS models of intervention seek to prevent problem behavior by altering conflict-inducing situations before problems escalate while concurrently teaching appropriate alternative behaviors (8).

Specific school-based interventions developed based on the PBS model include Positive Behavioral Interventions and Supports (20) and Safe & Civil Schools (21). These school-based interventions implement behavioral management strategies and tailor the level of intervention for the unique needs of a child or adolescent. PBS interventions utilize three levels of treatment: a primary tier, applied to the entire school setting to prevent challenging behaviors; a secondary tier, targeting individuals who display emerging or moderate behavior problems; and a tertiary tier for students who evidence more significant behavior problems and require complex and individualized team-based support beyond what is delivered at the primary and secondary levels (10). Interventions at the tertiary level involve tailored behavioral management strategies outlined in a behavioral management plan (22). To direct this review to treatment approaches for children with identified behavior problems, we focused on school-based behavioral management interventions that fall within the tertiary tier of intensity.

Integrated behavioral interventions

Integrated interventions combine school- and family-centered treatment components to create cohesive programs that address child behaviors in school and home settings. Three integrated programs are assessed in this review: Fast Track, Child Life and Attention Skills (CLAS), and the Adolescent Transitions Program (ATP). The Fast Track program is a long-term intervention that is designed to prevent antisocial behavior and psychiatric disorders among children identified as demonstrating disruptive behavior by parents and teachers. It uses a combination of parent behavioral management training, child social cognitive skills training, tutoring or mentoring, individualized home visits, and a classroom curriculum (23). The CLAS program is designed to reduce inattention symptoms and improve organizational and social skills among children with attention-deficit hyperactivity disorder (ADHD), inattentive type, through a combination of teacher consultation, parent training, and child skills training (24). ATP is a communitywide, family-centered intervention delivered through schools that takes a multilevel approach to addressing adolescent behavior problems (25). Similar to the three-tiered system of intervention described with school-based PBS, ATP uses tiered universal, selected, and indicated interventions to address different groups of children and families, depending on the child’s level of symptom expression. That is, universal interventions are designed for all parents and children in a school setting, selected interventions are for families and children at elevated risk, and indicated interventions are for families of children with early signs of problem behavior that do not yet meet clinically diagnosable levels of a mental disorder. The indicated level of intervention entails a variety of family treatment services, including brief family intervention, a school monitoring system, parent groups, behavioral family therapy, and case management services. These components vary depending on the individual needs of the child and family.

Methods

Search strategy

To provide a summary of the evidence and effectiveness for behavioral management, we conducted a survey of major databases: PubMed (U.S. National Library of Medicine and National Institutes of Health), PsycINFO (American Psychological Association), Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature.

We reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. We also examined bibliographies of major reviews and meta-analyses. We used combinations of the following search terms: behavioral management, behavior management, behavioral management therapy, behavior specialist, mental health, substance abuse, children, and adolescents. Additional citations were gathered from reference sections of articles. We used an independent consensus process when reviewing abstracts found through the literature search to determine whether a study used a behavioral management approach, on the basis of the conceptual definition of behavioral management provided above.

Inclusion and exclusion criteria

This review included U.S. and international studies in English of the following types: randomized controlled trials (RCTs), quasi-experimental studies, and review articles, such as meta-analyses and systematic reviews. The focus of this review was on clinical intervention approaches for children or adolescents who presented with problem behaviors or elevated risk at the beginning of the intervention. Included in the search were studies of family-focused parent training interventions that involved individualization based on the needs of the child and that involved the child and family members. Also included were studies of interventions in which the child or adolescent was selected for inclusion on the basis of the presence of problem behaviors that were targeted for change during the active treatment period.

Some populations and intervention programs were excluded to ensure basic similarities of the participants, interventions, and outcome measures and to be able to draw conclusions about whether the behavioral management intervention itself (as opposed to other intervention components) was associated with the outcomes. Studies that focused on children with autism spectrum disorders or other pervasive developmental disorders, intellectual disabilities, or fetal alcohol spectrum disorder were excluded. There is a large body of literature on behavioral management interventions for children with autism spectrum disorders and developmental disabilities, which we believe would be more appropriately reviewed in a separate article. Also excluded were universal preventive interventions that are not part of a multitiered program, because of our focus on individualized clinical intervention approaches. Universal preventive interventions address all individuals in a population, regardless of symptom severity or level of risk; as a result, the strategies and approaches used are distinct from those of more targeted interventions and more appropriately reviewed in a separate article. Finally, we excluded intervention models that may incorporate behavioral management components but are not exclusively behavioral management interventions or do not explicitly focus on child and adolescent behavior problems, such as Homebuilders, Multisystemic Therapy, Functional Family Therapy, individual cognitive-behavioral therapy, and behavioral management interventions in residential treatment centers and psychiatric hospitals.

Strength of the evidence

The methodology used to rate the strength of the evidence is described in detail in the introduction to this series (26). The research designs of the studies identified by the literature search were examined. Three levels of evidence (high, moderate, and low) were used to indicate the overall research quality of the collection of studies. Ratings were based on predefined benchmarks that considered the number and quality of the studies. If ratings were dissimilar, a consensus opinion was reached.

In general, high ratings indicate confidence in the reported outcomes and are based on three or more RCTs with adequate designs or two RCTs plus two quasi-experimental studies with adequate designs. Moderate ratings indicate that there is some adequate research to judge the service, although it is possible that future research could influence initial conclusions. Moderate ratings are based on the following three options: two or more quasi-experimental studies with adequate design; one quasi-experimental study plus one RCT with adequate design; or at least two RCTs with some methodological weaknesses or at least three quasi-experimental studies with some methodological weaknesses. Low ratings indicate that research for this service is not adequate to draw evidence-based conclusions. Low ratings indicate that studies have nonexperimental designs, there are no RCTs, or there is no more than one adequately designed quasi-experimental study.

We accounted for other design factors that could increase or decrease the evidence rating, such as how the service, populations, and interventions were defined; use of statistical methods to account for baseline differences between experimental and comparison groups; identification of moderating or confounding variables with appropriate statistical controls; examination of attrition and follow-up; use of psychometrically sound measures; and indications of potential research bias.

Effectiveness of the service

We described the effectiveness of the service—that is, how well the outcomes of the studies met the service goals. We compiled the findings for separate outcome measures and study populations, summarized the results, and noted differences across investigations. We considered the quality of the research design in our conclusions about the strength of the evidence and the effectiveness of the service.

Results and discussion

Level of evidence

Five reviews of family-centered behavioral interventions (16,27–30), two reviews of school-based behavioral interventions (9,19), and one review of integrated behavioral interventions (25) were identified. Twelve RCTs that had been published after the previous reviews had been conducted were also identified. Their topics were family-centered behavioral interventions (31–34), school-based behavioral interventions (35–37), and integrated behavioral interventions (23,24,38–40). Tables 2 and 3 summarize the reviews and the RCTs, respectively.

Participants who received behavioral management interventions included children in preschool, elementary, middle, and high school grades. Studies included a range of racial-ethnic groups and rural and urban populations. Across studies, children who received behavioral management interventions typically were described as exhibiting problem behaviors or externalizing behaviors.

Overall, given the strength of the research designs in more than three RCTs, the level of evidence for the various types of behavioral management interventions was rated as high. However, the complexities of evaluating school-based interventions have resulted in somewhat less rigor in that area of behavioral management research. Reviews and individual studies of family-based and integrated family- and school-based behavioral management interventions included in this review used strong RCT designs, and several included intent-to-treat analyses.

RCTs of family-centered behavioral interventions (as defined for this article) have been examined in multiple review articles (27–30) and individual studies. Across both types of publications, the evaluations examining the effects of PCIT and Incredible Years behavioral parenting programs had adequate statistical power to detect treatment effects, used well-designed RCTs, utilized interventions with treatment manuals and fidelity data, and measured clinical outcomes with reliable and valid assessment instruments. Findings for both programs have also been replicated in multiple RCTs conducted by independent investigators.

Researchers have noted that most studies evaluating the effectiveness of tertiary-level school-based interventions have included students with significant disabilities in self-contained classrooms, which limits the generalizability of the evidence to general education students in typical classroom settings (37,41). Researchers also noted that studies in this body of literature generally have small samples, lack RCTs, use single-subject or within-group research designs, do not always use standardized behavioral management protocols, and are limited in their ability to report whether school personnel were implementing the interventions with fidelity (37,41–43). However, in this review we included three studies of tertiary-level school-based interventions using RCTs (35–37). Researchers indicated various limitations of the design (which varied across studies), including the lack of fidelity measures of team implementation of the intervention, attrition over time, limited measurement of interrater reliability of observational data, lack of validated assessment measurement, and lack of statistical analyses to account for school-level differences.

Integrated behavioral management intervention studies included in this review used strong RCT designs, had adequate statistical power to detect treatment effects, and used intent-to-treat analyses (23–25). One limitation is that these integrated behavioral management interventions have been studied primarily by program developers. The literature would be strengthened if these RCTs were replicated by independent researchers and demonstrated similar results.

Effectiveness of the service

Family-centered behavioral interventions.

Family-centered parent training interventions have been reviewed extensively and have demonstrated strong effects in reducing and preventing problem behaviors across a range of ages and populations when compared with wait-list control groups (16,28–30). Reviews found PCIT to be effective in reducing disruptive behavior of young children. Eyberg and colleagues (16) reviewed two well-designed RCTs with wait-list control groups and indicated that PCIT was superior in reducing disruptive behavior of children aged three to six years. The comparison groups in the two studies were not active controls or placebo treatment conditions, which resulted in a “probably efficacious” rating for PCIT (16). A meta-analysis of PCIT included 13 studies from eight cohorts and three research groups (28). The researchers compared children who received PCIT with children in nonclinical comparison groups and concluded that mothers of children who received PCIT reported greater declines in problem behaviors. There were large effects for positive behaviors observed in the classroom.

Adaptations and abbreviated versions of PCIT and the Incredible Years program showed preliminary positive effects in various populations, including Mexican-American families (44), Chinese families (33,45), African-American families (46), children in Head Start (47,48), and children identified in pediatric medical settings (31,32,49). Various forms of the Incredible Years program implemented for children with significant needs reduced problem behaviors among children with a diagnosis of ADHD (34) and oppositional defiant disorder (50) six months after the intervention. Overall, compared with control groups, these family-centered parent training programs had strong effects in reducing externalizing behaviors (immediately after the intervention and at follow-up) among children across a range of ages.

School-based interventions.

Research findings were mixed on the effectiveness of tertiary-level school-based interventions. Two meta-analyses of tertiary-level interventions that used functional behavioral assessments found that these interventions were effective in reducing problem behavior across a range of disabilities and grades (9,19). However, these results should be interpreted with caution, because the studies evaluated in these reviews had methodological limitations (for example, single-participant research designs and small samples). Two RCTs with elementary school students found effects in reducing externalizing behavior, compared with control groups, at the end of the intervention (36) and at the follow-up 14 months after the pretest (37), as indicated by self-reported scores on standardized instruments and observer ratings of student behavior. Compared with students in control groups, students in the intervention group also evidenced higher ratings of self-reported social skills; improvements were also seen in time engaged in academic activities, as measured by independent observational assessment (36). These positive effects were not replicated in a rigorous RCT that examined the effects of a three-tiered, schoolwide aggression intervention in early- and late-grade elementary schools in an inner city and in an urban poor community (35). Researchers found that compared with the control condition, the tertiary-level intervention had significant effects on aggressive behavior when it was delivered to children during the early school years in the urban poor community. Aggressive behavior was measured through a composite of standardized assessment instruments. However, none of the interventions were effective in preventing aggression among older elementary school children.

Integrated behavioral management interventions.

Integrated interventions demonstrated promising findings in preventing and reducing problem behaviors among diagnosed and at-risk children. The Fast Track program had a significant impact on lowering the likelihood of diagnosis of conduct disorder and externalizing behavior among children identified as being at the highest risk of antisocial behavior; however, the intervention did not have an impact on the resulting diagnoses of children who had moderate baseline risk levels (23). In a recent article that assessed the impact on the onset of various disorders of random assignment to the Fast Track intervention, researchers found that the intervention implemented over a ten-year period prevented externalizing psychiatric disorders among the highest risk group, including during the two years after the intervention ended (40). In another study, youths who had participated in the Fast Track program had reduced use of professional general medical, pediatric, and emergency department services for health-related problems, compared with youths in a control group, ten years after the first year of the intervention (39). These findings indicate that this program could be very beneficial and cost-effective if targeted to high-risk children.

The CLAS program also demonstrated significant positive results; children receiving this intervention showed decreased inattention symptoms and increased social and organizational skills compared with peers who were assigned randomly to a control group (24). For families randomly assigned to ATP, adolescents had lower rates of antisocial behavior and substance use, and families reported stronger parent-child interactions and parenting practices, compared with those in control conditions (25,38). Overall, the effectiveness of integrated behavioral management interventions can be characterized as relatively strong.

Conclusions

Evidence is promising regarding the effectiveness of specific behavioral management interventions. Although these effects vary depending on setting and intervention type and some studies had methodological limitations, a number of reviews and subsequent studies have reported positive results of these interventions for improving child behavior in multiple settings. The level of evidence is in the high range, particularly among family-centered and integrated family-school program models (see box on this page). The benefits of integrated family-school models include service access for families. If implemented early, such interventions may assist in early detection and treatment of problem behaviors before they become more severe. Children and adolescents have been shown to benefit from these interventions, and given the importance of early intervention to reduce the potentially negative consequences of disruptive behavior later in life, these findings are encouraging. In addition, integrated family-school approaches appear to allow strategies that are implemented in the home to be reinforced in school settings, thus providing an additional level of collaboration and support between the school and family.

For policy makers and payers (for example, state mental health and substance use directors, managed care companies, and county behavioral health administrators), the findings of this review suggest a number of benefits to the implementation of behavioral management interventions. Detection and intervention at early stages of problem behavior generally are less costly than intensive services for severe problem behavior. Implementation of effective treatment when children exhibit early signs of problem behavior may prevent future engagement in criminal activity, substance use, and juvenile justice system involvement. It may also reduce the need for costly emergency services or residential treatment. There has been limited research examining the long-term outcomes of behavioral management interventions; however, some studies—such as those investigating Fast Track (39,40)—have shown positive long-term results into young adulthood. There could be considerable cost savings if these interventions demonstrate long-lasting impacts; thus, future research should continue to examine the long-term outcomes of these types of behavioral management programs.

Studies need to be replicated by independent investigators in ethnically and racially diverse populations to confirm the strength of the evidence base and generalizability of the results. The level of evidence is somewhat dependent on the implementation setting assessed, and research findings are mixed on the effectiveness of school-based interventions that are not integrated with family interventions. There is a need for further research to examine for whom and under what conditions tertiary school-based interventions are effective, and research suggests that starting early in development may be a particularly effective approach.

For decision makers, research has established the value of behavioral management approaches to address problem behavior, and we recommend that behavioral management be considered as part of covered services. However, additional research is needed to examine the effects of behavioral management interventions implemented in school settings, given various methodological limitations in the literature. Current limitations of research conducted in this area are related to generalizability, measurement, study design, and long-term outcomes. Also, as researchers have highlighted, interventions that are designed to address the behavioral needs of children in school settings should examine not only the treatment effects but also the conditions under which an intervention in a school setting is most effective (35). Factors such as symptom severity, school characteristics, and the child’s race, ethnicity, language (including language fluency of the parents), and sex are important moderating variables to examine when determining the effects of a school-based intervention. In addition, future research on behavioral management interventions should specifically examine the various treatment components included in the intervention to determine whether there are “key ingredients” associated with particular outcomes that are effective without commercial packaging or whether the specific combinations of practices contained in these intervention packages are required to produce the reported results.