This study provides evidence of a positive impact of a universal preventive intervention on later service use by males, though not by females, for problems with emotions, behavior, or drugs or alcohol. Impact was seen across both cohorts with regard to the use of school-based services by highly aggressive, disruptive males. The primacy of the education sector in the delivery of mental health services is well established in the services literature; it is the most common sector for service use and often the only sector in which services are received, particularly for children and youth whose problems do not meet a diagnostic criterion (Burns et al., 1995
; Farmer et al., 2003
; Leaf et al., 1996
). This study extends these findings by reporting that males whose teachers rated them high on aggressive, disruptive behavior in the fall of first grade benefited most from GBG with regard to service use through childhood and into young adulthood. In Cohort 1, the proportion of these males in internal control classrooms ever receiving school-based services for problems with behavior, feelings, or drugs and alcohol by young adulthood was 33% compared with 17% of these males in GBG classrooms. In Cohort 2, the proportions were 33% and 18%, respectively.
That the GBG impact was for children at highest risk of poor outcomes, males with high levels of aggressive, disruptive behavior in the fall of first grade, is in keeping with previous reported work from our trials as well as other trials of universal preventive interventions in which intervention impact was found for the students who entered the intervention period at the highest risk (Brown and Liao, 1999
; Curran and Muthèn, 1999
; Muthèn and Curran, 1997
; Muthèn et al., 2002
; Stoolmiller et al., 2000
). GBG aims at reducing aggressive, disruptive behavior in the first-grade classroom through socializing first graders to the role of student. Although we could not perform formal analysis of mediation, the positive impact of GBG on a subsequent reduction in the use of school-based services appears to be operating through early aggressive, disruptive behavior for males, the target of GBG.
In addition to the consistent pattern of the impact of GBG on use of school-based services by males who entered first grade with higher levels of aggressive, disruptive behavior across both cohorts, there were several less consistent results. Males who had been in GBG classrooms in Cohort 2 reported significantly less service use from mental or medical health professionals than their counterparts in internal GBG control classrooms, 9.4% versus 26%, respectively, whereas in Cohort 1 the GBG and internal GBG control the rates were nearly identical. There was also a positive impact of GBG on ever using social services by young adulthood for the combined population of Cohort 1 females and males (2%) compared with their counterparts in internal GBG control classrooms (6%). This effect was not seen for Cohort 2.
Of note is the consistent positive relationship between early aggressive, disruptive behavior and service use for males. For males in Cohort 1, this relationship was seen across a range of sectors: mental or medical provider, school-based services, drug treatment, juvenile or adult justice system, and social services. The relationship of early aggressive, disruptive behavior and later service use was seen for school-based services and social services for Cohort 2. We saw that GBG disrupted this association for school-based services for males with high levels of early aggressive, disruptive behavior.
For the most part, the absence of any consistent GBG impact for females makes theoretical sense given that early aggressive, disruptive is not consistently associated with later service use for females. However, for females in Cohort 1, there was an unexpected effect such that in GBG classrooms, aggressive, disruptive behavior in the fall of first grade was positively associated with later service use in some sectors by young adulthood, whereas there was almost no relationship between early aggressive, disruptive behavior and later service use for females in GBG internal control classrooms. This finding is in contrast to the findings reported above for males and is in the opposite direction from our hypotheses. Although this impact of GBG was not specific to any service sector and was not seen for Cohort 2 females, it suggests that our understanding of pathways to service use for females are not as clear as for males.
There are several limitations to consider in this study. The universal preventive intervention, GBG, was experimentally manipulated, but service use from childhood to adulthood was not. Therefore, this study did not allow us to test the overall effectiveness of an integrated service system. However this naturalistic study of service use after the delivery of a preventive intervention does provide evidence that a universal intervention is a worthwhile first stage in crafting an integrated service system. The range of services captured in our definition of service use for each sector is quite broad in terms of cost, intensity, type, and quality. However, the results are strong and establish that a fairly simple universal classroom-based intervention aimed at aggressive, disruptive behavior reduced cumulative service use from school-based mental health services over the remainder of the school years. This paper relied on self-reports of mental health service use across the entire life span to young adulthood. However, it is likely that these young adults were under-reporting, not over-reporting, service use, particularly for services received earlier in life (Horwitz et al., 2001
; Leaf et al., 1996
4.1 Policy Implications
Over the past decade, the prevention of aggressive, disruptive behavior, violence, and drug use have become specific foci of concern to educators in response to schools' concerns for keeping students safe. Increasingly, federal funding for school initiatives is tied to the use of evidence-based programs (i.e., Public Law 107-110
). Society at large and communities in particular have to make choices about the allocation of resources and funds. This study, along with the other papers in this issue (Brown et al., in press, this issue
; Kellam et al., in press, this issue
; Petras et al., in press, this issue
; Wilcox et al., in press. this issue
) and prior research (Aos et al., 2004
), offers data to suggest that it is money well spent to focus on a continuum of interventions and services beginning with the GBG, a relatively inexpensive universal intervention that strengthens the classroom learning environment by giving teachers a tool that many do not have. This study revealed, using an epidemiological sample of first graders followed over development, that for males, early aggressive, disruptive behavior is related to service use across a wide spectrum of service providers and that GBG, a classroom-based universal intervention delivered to all children and aimed at the specific early risk factor of aggressive, disruptive behavior in the classroom, reduced mental health service use received through school-based services by young adulthood. The finding that GBG has an impact on school-based mental health service use has policy implications because service use is a clear, measurable indicator that can be used in economic analysis. By and large, programmatic decisions such as adopting GBG in a school system are most commonly made in the system in which they are implemented. Although the long-term economic impacts of GBG, such as ASPD, drug and alcohol dependence, and suicide ideation, are important to school system personnel from a prevention and theoretical standpoint, these outcomes may be less likely to influence the spending of school system funds than outcomes directly related to school system spending, such as the use of school-based mental health services.
As the first level in an integrated system of services across development, universal interventions such as GBG are important in several ways.
- As we saw in this study, GBG, a universal intervention aimed at a specific risk factor, reduces the proportion of youth who receive services at a later date, specifically males at high risk in first grade.
- Students' responses to GBG and other universal interventions can provide critical information about risk and the types and targets of backup interventions and services needed for students who do not respond.
- Universal interventions often focus on strengthening the environment, which makes them particularly appealing as a first-level intervention. GBG is delivered in the classroom context as an integral part of the school day by the teacher, whose role is precisely defined as providing a positive classroom environment with the students. GBG is in contrast to interventions that focus on individual students or a small group of students and can undermine the interactive group process of teachers and students sharing responsibility for the classroom environment.
- GBG as a universal intervention is aimed at classroom environment and avoids the stigma that children experience by being removed from the classroom.
- GBG is a strategy, not a curriculum. Hence, it does not compete for instructional time. In fact, with less aggressive, disruptive behavior occurring in the classroom, there is more time for instruction in GBG classrooms.
- GBG is relatively inexpensive compared with the benefits (Aos et al., 2004). Although precision in implementation is required, the initial training and continued mentoring and monitoring can be aligned with the professional development programs of a school system.
4.2 Next Stage of Research
The next stage of research will bring together researchers and practitioners from several disciplines, including prevention science, public health, services research, economics, and education research and practice. Above, we note that understanding students' response to GBG over time provides important information about the type, mode, and target for backup services for non-responders across development. Developing multi-level systems of assessment to provide this information is critical to ensuring that all children receive the most appropriate level and kind of care (Ialongo et al., 1999
; Kellam and Rebok, 1992
; Poduska and Kendziora, 2001
). The field of public health has much to offer the field of education, as state and local departments of education create databases that allow following students over time; these databases are reminiscent of the registries common in the public health sector in the middle of the last century and can provide information both across development and across service sectors.
Although GBG has been found to be relatively inexpensive (Aos et al., 2004
), economic analyses on the immediate costs to an organization for scaling up and maintaining GBG over time, as well as longer term cost-benefit analyses, are needed. Administrators and policymakers determining resource allocations need this type of information to make well-informed decisions. Epidemiological concepts such as attributable risk, preventive fraction, and positive and negative predictive ability need to be joined with economic analyses to provide practitioners and policymakers with the information they need to make informed decisions. As interventions are deemed to be “effective and evidence-based,” research on moving research into practice is required. Although as an intervention GBG is relatively simple to implement, maintaining a high level of precision in practice is required to ensure the results we report. In the first generation of trials, no structures were in place in the system to support the first-grade teachers continuing the practices into the second year, and there was little support from the research team. In addition, the training provided to the second-grade teachers was minimal compared with the training and support offered to the first-grade teachers. As reported in this issue (Brown et al.; Kellam et al.; Petras et al.
; Wilcox et al.
), intervention impact for GBG has been strong across a range of outcomes from childhood into young adulthood for the first cohort of students who participated in the first-generation trial. Although in many cases the same pattern of intervention impact has been found with the second cohort of first graders in the first-generation trial (Kellam et al., in press, this issue
) the impact has not been as strong. We hypothesize that the initial train-the-trainer model was somewhat naïve and that without structures in place for ongoing support across the multiple levels of authority and organization, practices are not likely to be maintained. This conclusion is in keeping with the research on sustainability and implementation of programs in schools (Berman and McLaughlin, 1975
; Datnow and Castellano, 2000
; Elliott and Mihalic, 2004
; Greenwood et al., 1975
; McLaughlin, 1990
; Olds et al., 2003
). We have begun to explore the types of support structures and the level of monitoring and mentoring required for reaching and maintaining precision of practice over time.