Tier two interventions implemented within the context of a tiered prevention framework

Tier Two Interventions Implemented within the
Context of a Tiered Prevention Framework
Barbara S. Mitchell, Melissa Stormont, and Nicholas A. Gage
University of Missouri
ABSTRACT: Despite a growing body of evidence demonstrating the value of Tier 1 and Tier 3
interventions, significantly less is known about Tier 2 level treatments when they are added within
the context of a tiered continuum of support. The purpose of this article is to systematically review
the existing research base for Tier 2 small group intervention studies conducted within a tiered
prevention framework. Results indicated that few studies documented fidelity of Tier I
implementation prior to the addition of Tier 2 interventions. Methods for identifying students to
receive Tier 2 supports varied across investigations, but included teacher nomination, use of student
data, and/or screening score results. More than half of the reviewed studies demonstrated use of the
Behavior Intervention Program: Check-in/Check-out (BEP/CICO), although social skill instructional
groups and academic instructional groups were also employed as Tier 2 interventions. Overall,
positive results for reducing problem behavior were reported. In addition, school-based personnel
implemented the Tier 2 intervention in nearly half of the investigations. Among studies that reported
measures of social validity teacher and student perceptions of the treatments were largely positive.
Implications for future research are evaluated using criteria from the Society for Prevention Research
(Flay et al., 2005).
• A substantial number of children and
adolescents have or are at risk for developing
emotional and behavioral disorders (EBD)
(National Research Council and Institute of
Medicine [NRC & IOM|, 2009; Van Landeghem & Hess, 2005). Outcomes for students
experiencing EBD are very poor and include
drop out, incarceration, homelessness, psychopathology, diminished functioning, inability to find and maintain employment, and
problems developing healthy interpersonal
relationships (Lehr, Johnson, Bremer, Cosió,
& Thompson, 2004; NRC & lOM, 2009).
Unfortunately, although signs of EBD can be
detected at an early age, many children and

youth who experience symptoms and disorder
are often inadequately supported, delayed in
accessing services, or receive no treatment at
all (NRC & lOM, 2009).
In response to the growing concern for
students who experience EBD, a number of
practices have shown evidence for preventing,
treating, and/or reducing symptoms. Use of a
tiered intervention framework such as SchoolWide Positive Behavior Support (SWPBS) is
one promising avenue for delivering schoolbased prevention efforts. Derived from a
public health disease prevention model (Gordon, 1983), SWPBS is the application of a
three-tiered continuum of supports for students
in school settings (Lewis & Sugai, 1999; Sugai
Behavioral Disorders, 36 (4), 241-261

et al., 2000; Walker et al., 1996). SWPBS is a
systematic approach to plan, develop, and
provide primary prevention to all students (Tier
1); specialized group or targeted support to
some students who may be at risk for
academic and/or behavioral problems (Tier
2); and intensive, individualized support for a
small percentage of students who already
exhibit patterns of chronic and persistent
failure (Tier 3) (Sugai & Horner, 2008).
The purpose for delivering Tier 1 supports
to all students is to reduce new cases of
problem behavior and/or academic failure
(Lewis & Sugai, 1999; Sugai et al., 2000; Sugai
& Horner, 2008). Specific to behavioral

outcomes. Tier 1 prevention components
include clearly identified expectations and
rules that are specifically taught to students, a
systematic process for acknowledging appropriate behavior, and consistent reteaching and
response for inappropriate behavior (Lewis &
Sugai, 1999; Sugai et al., 2000). These
practices are embedded throughout instruction
across classroom and nonclassroom settings.
The vast majority of students, approximately
80%, respond to this level of support. A large
body of evidence shows that these features can
be implemented by school personnel (Colvin,
Kameenui, & Sugai, 1993; Lewis, Sugai, &
Colvin, 1998); these practices are effective in
reducing office discipline referrals, school
August 2011 / 241


suspensions, and problem behaviors (Colvin,
Sugai, Good, & Lee, 1997; Lewis, Colvin, &
Sugai, 2000; Lewis et al., 1998); and improvements in student behavior and perceptions of
school safety are associated with increased
academic outcomes (Bradshaw, Koth, Bevans,
lalongo, & Leaf, 2008; Bradshaw, Mitchell, &
Leaf, 2010; Horner et al., 2009).
In addition to the research outcomes for
Tier 1 supports, a number of studies also
demonstrate the effectiveness of functionbased, individualized planning that is characteristic of Tier 3 interventions (Fairbanks, Sugai,
Guardino, & Lathrop, 2007; Ingram, LewisPalmer, & Sugai, 2005; March & Horner, 2002;
Todd, Horner, & Sugai, 1999). Tier 3 support

typically involves the use of functional behavioral assessment (FBA) and/or functional analysis results to determine patterns across setting
event, antecedent, and maintaining consequence conditions of problem behavior. Information from a FBA is then used to develop
individualized intervention plans for students.
School, family, and community agencies may
also collaborate to coordinate intervention
planning and efforts. At the Tier 3 level, the
goal is to reduce the severity and intensity of
existing cases of chronic behavior and/or
academic failure (Sugai et al., 2010). Due to
the high level of technical expertise and the
extensive amount of resources required. Tier 3
support is generally reserved for a small number
of children, approximately 5%, who demonstrate persistent failure or serious, violent, and
dangerous types of behavior, and/or when Tier
1 and Tier 2 interventions are determined to be
inadequate (Sugai et al., 2010).
Tier 2 is identified as specialized group or
targeted systems designed for students considered at risk. The goal at this level is to reduce
current cases of problem behavior and/or
academic failure to prevent student problems
from escalating to an intensity that requires
individualized planning (Sugai et al., 2010).
Hallmark characteristics of Tier 2 include
rapid access to intervention that is continuously available, low-effort teacher implementation facilitated by a team-based approach,
and frequent monitoring of progress to determine the effectiveness of the intervention and/
or need for further support (Mclntosh, Campbell, Carter, & Dickey, 2009; Sugai et al.,
2010). An estimated 10-15% of a school's
population may potentially be identified as atrisk, so the need for interventions that are both
effective and efficient is pressing.
242 / August 2011

Specific to students with EBD, it is
estimated that currently only 25% of children
who have these disorders are actually identified and served in schools, and this typically occurs after the opportunity for Tier 1 and
Tier 2 prevention has long passed (Kauffman,
2005). The systematic use of tiered models
for intervention is a way to serve these
individuals before their problems are exacerbated. Although extensive research has
been conducted for both Tier 1 and Tier 3
supports, less is known about the level of Tier
1 implementation prior to adding supplemental supports, the feasibility of Tier 2
implementation by typical school personnel,
and the perceived value in relation to time
and effort when Tier 2 supports are provided
as part of a prevention framework (Mclntosh
et al., 2009).
A wide range of interventions is highlighted
as potentially beneficial for at-risk children and
youth. Recommended Tier 2 interventions have
included: The Behavior Education Program,
which includes a daily check-in/check-out with
an adult at school (BEP/CICO); First Step to
Success, which is a school- and home-based
intervention for primary level children; Check
and Connect, a drop-out prevention and mentoring program; social skill instructional groups;
and academic supports (Sugai et al., 2010).
Although many evidence-based interventions
are available to support individuals who have
behavior problems, the details and logistics of
providing Tier 2 intervention within a tiered

framework have not been clearly articulated in
the literature (Campbell & Anderson, 2008;
Mclntosh et al., 2009; Sugai & Horner, 2008). A
number of issues remain in question.
The purpose of this review is to explore the
existing research base for Tier 2 group intervention studies conducted within the framework of
a tiered continuum of supports. Group interventions are specifically selected as an area of
interest because they hold potential for effectively serving a number of students in the same
fashion, and may demonstrate efficient use of
limited resources. Emphasis on studies conducted within a tiered model is also an important
distinction. A number of investigations already
demonstrate positive outcomes for use of small
group supports provided in isolation, but less is
known about how these interventions can be
used within a framework of tiered intervention
(Campbell & Anderson, 2008; Mclntosh et al.,
2009; Sugai & Horner, 2008). Specific research
questions for this review include:
Behavioral Disorders, 36 (4), 241-261


1. To what extent has integrity of Tier 1
implementation been assessed prior to the
addition of Tier 2 interventions among
studies in the existing research base?
2. What are the characteristics of students
who have participated in Tier 2 group
interventions and how was identification
for these additional supports determined?
3. What outcomes are most often targeted,

which types of group interventions have
been implemented, and what effects do
they show within a tiered framework?
4. Have school-based teams demonstrated
capacity to implement and sustain Tier 2
interventions, or have these efforts largely
been conducted by research personnel?
5. Have Tier 2 interventions rated by schoolbased personnel as socially valid (i.e.,
important, effective, and feasible)?

Method
The following strategies were used to
complete a comprehensive search for published studies of interventions provided as Tier
2 level supports within a tiered prevention
framework: (1) database search, (2) journal
review, (3) application of inclusion criteria,
and (4) ancestral review. Use of these techniques led to an initial pool of 67 possible
studies. These steps and processes are described in detail in the following sections.
Database Search
First, a search was conducted using two
databases, the Education Resources Information
Center (ERIC) and PsyclNFO with the following
terms: check-in/check-out, effective behavior
support, positive behavior support, school-wide
positive behavior support, and the behavior
education program. Because the phrase "positive
behavior support" located the greatest number of
entries in both databases it was then used as a key
word combined with each of the following
additional terms: at-risk students, behavior

change, behavior problems, behavior modification, benchmarking, check-in/check-out, early
intervention, high-risk students, identification,
intervention, outcomes of education, outcomes
of treatment, prediction, prevention, program
effectiveness, referral, response to intervention,
screening instruments, screening tests, secondary
intervention, small group intervention, targeted
intervention, teacher nomination, the behavior
Behavioral Disorders, 36 (4), 241-261

education program, and tier two intervention.
Using these procedures, 41 potential articles
from the ERIC database and 11 additional articles
from the PsyclNFO search were located.
Journal Review
Second, an examination of ten peerreviewed journals that frequently publish
articles about SWPBS, prevention, and special
education was conducted. In most cases, each
journal was reviewed from 1984 or the
earliest published volume through the most
current edition. This year was identified
because a three-tiered support continuum
was first established as a disease prevention
model in the early eighties (Gordon, 1983)
and shortly after, the tiered prevention model
was applied to social behavior in school
settings (Walker et al., 1996). Five experts in
the area of EBD and/or SWPBS nominated
journals that were likely to publish work in
the subject of Tier 2 intervention. Each of the

selected experts has worked and published in
the area of special education and positive
behavior supports for a number of years
within a research university. Based on expert
recommendations the following journals were
included in this search: Behavioral Disorders,
Education and Treatment of Children, Exceptional Children, Journal of Behavioral Education, Journal of Emotional and Behavioral
Disorders, Journal of Positive Behavior Interventions, Psychology in the Schools, Remedial and Special Education, School Psychology
Quarterly, and School Psychology Review.
For two of the selected journals the search
years were modified based on the availability
of volumes. School Psychology Quarterly was
reviewed from 2001-2009 and Education and
Treatment of Children was examined from
1989-2009. Using this procedure, another 15
articles were identified.

Application of Inclusion Criteria
Each of the initial 67 articles located were
then reviewed according to the following
inclusionary criteria: (a) an intervention study
published in a peer-reviewed journal; (b)
explicit statement within text of the article that
the study was conducted in a setting implementing one of the following: SWPBS, a tiered
prevention model that includes social behavior, a continuum of supports, or a systemsbased response to intervention approach; (c)
August 2011 / 243


the independent variable described in the
study was a supplemental (i.e.. Tier 2) group

intervention applied to a selected set of
students, in which two or more students
received the same intervention rather than
individualized planning; (d) participants were
determined to be at risk by one or more
criteria, such as teacher nomination, results of
a screening instrument, office discipline referral data, and/or direct observation data; and
(e) results of the study examined a social or
behavioral outcome such as change in disruptive behavior, office discipline referral
rates (ODR), peer relationships, and/or social
skill competency. Studies that primarily examined academic outcomes such as increased
writing performance, phonological awareness, or college entrance exam scores were
included if they met the first four criteria and
adhered to the fifth criteria by also reporting
some type of social or behavioral outcome.
Studies that reported academic outcomes
alone, even if conducted within SWPBS, a
three-tiered model of support, or a Response
to Intervention (Rtl) approach, were not
considered for this review (e.g., Kamps &
Greenwood, 2005; Lane et al., 2008; Lane,
Robertson-Kalberg, Mofield, Wehby, & Parks,
2009). In addition, articles reporting outcomes
of a class-wide or grade level intervention
were also excluded (e.g., Mclntosh, Chard,
Boland, & Horner, 2006; Nelson, Martella, &
Marchand-Martel la, 2002; Todd, Haugen,
Anderson, & Spriggs, 2002).
To ensure that inclusion criteria were well
defined and studies were accurately accepted

or disqualified, a second reviewer was used.
To complete this process, each of the studies
located by the previously described methods
were given to a second reviewer with specific
experience and expertise in SWPBS who
completed an independent review of potential
studies. After independent review, the two
reviewers developed a comprehensive list of
studies that met all inclusion criteria. In the
case of disagreement, the publication was
reexamined and discussed until consensus
was reached or communication with an author
verified a decision.
Ancestral Review
Einally, two reviewers also conducted a
search of references listed in each of the
accepted studies. No additional studies were
located using this technique.
244 / August 2011

Excluded Studies
A number of studies considered for acceptance were disqualified and warrant specific
mention to provide additional clarity about the
nature and type of work that is included. Eor
example. First Step to Success is a targeted
intervention program for young children exhibiting antisocial or aberrant behavior with a
robust evidence base of single-subject, quasiexperimental, and random-clinical trial research (Walker et al., 1998; Walker et al.,
2009). First Step to Success consists of three
modules (screening, school intervention, and
parent intervention) designed to be used

together to identify students with emerging
behavioral and social concerns, and to improve social adjustment and academic performance through coordinated support from
parents, teachers, and peers (Sprague &
Perkins, 2009; Walker et al., 1997). However,
the program utilizes its own screening module
for student identification; therefore, to date,
the literature base has not investigated implementation within a tiered model, such as
SWPBS, which was an inclusion criterion for
this study.
Second, literature supporting Check and
Connect, a mentoring and dropout prevention
program was also examined and considered
for acceptance but is not included in this
review. Studies of Check and Connect have
been completed among students with disabilities at both the elementary and secondary
levels and show outcomes for improving
attendance rates and engagement in school.
Although many investigations of Check and
Connect met one or more of the inclusion
criteria, there were no reports that indicated or
described this intervention as provided within
a tiered prevention framework; thus these
studies were excluded.
Finally, two studies of BFP/CICO were
also determined ineligible for this review
(March & Horner, 2002; Hawken & Horner,
2003). March and Horner (2002) designed a
two part investigation to examine the effects
of BEP/CICO for 24 middle school students
and then used FBA results to modify the

intervention for three students who did not
demonstrate initial success. Later, Hawken
and Horner (2003) examined the effects of
BEP/CICO on problem behavior and academic engagement among four students (Hawken
& Horner, 2003). Although both studies
showed positive outcomes for use of the
BEP/CICO intervention, neither included an
Behavioral Disorders, 36 (4), 241-261


explicit statement that these supports were
provided within a SWPBS continuum or a
tiered prevention framework, thus they were
not included for review.

Results
From the multi-method search, a total of
13 studies met all inclusion criteria and are
reported in this review. The studies range in
date of publication from the earliest in 2002
to the most recent in 2009. Among the 13
studies reviewed, a total of three different
research methods were utilized: seven studies
incorporated exclusive use of single subject
designs, five studies were quasi-experimental,
and one was a descriptive case study (see
Table /).
Tier 1 Level of Implementation
To date, a number of published studies
speak to the effectiveness of Tier 1 behavioral

supports and provide details for how to
employ these techniques. In addition, specifically within the context of SWPBS, a number
of research-validated instruments and tools
are available to help assess integrity of
implementation, monitor progress toward
school-wide goals, and evaluate outcomes
of Tier 1 prevention efforts. Examples of such
instruments include The Team Implementation Checklist (TIC; Sugai, Horner, & LewisPalmer, 2009), The School Safety Survey
(SSS; Sprague, Colvin, & Irvin, 2002), The
Effective Behavior Support/Self Assessment
Survey (EBS/SAS; Sugai, Horner, & Todd,
2000), and The Benchmarks of Quality (BoQ;
Cohen, Kinkaid, & Childs, 2007). However,
The School-wide Evaluation Tool (SET;
Horner et al., 2004) is perhaps the most well
known metric for assessing Tier 1 implementation and was developed specifically as a
research tool.
Among the studies included for review,
only a disappointing few gave documentation
of their Tier 1 efforts, either by describing
specific features in place or by a measure of
implementation fidelity such as the numerous
instruments listed above. In the four studies
that did provide SET results, overall implementation of Tier 1 prior to the addition of Tier
2 was high, ranging from a mean of 80-100%
of features in place (Fairbanks et al., 2007;
Hawken et al., 2007; Mclntosh et al., 2009;
Todd et al., 2008; see Table 1).
Behavioral Disorders, 36 (4), 241-261

Identification of Tier 2 Participants
Table 1 provides a brief description of
participant demographic characteristics. Use
of a systematic process to identify students
who require additional intervention is of vital
importance within a tiered continuum of
support. As such, it is imperative to know
how these students were identified. Methods
for identifying student participants varied
across the 13 studies reviewed. In general,
student identification for participation was
based on one or a combination of the
following: (a) nomination process in which a
classroom teacher, a parent, or a problem
solving team identified the student as at-risk;
(b) use of student data—typically office
discipline referral information—to indicate
that the student was unresponsive to the Tier
1 prevention efforts or to a Tier 2 intervention;
or (c) use of behavioral screening score
results.
Nomination Process
Among studies that identified students
through a nomination process, the referral
was based on perception of need in most
examples. For example, Campbell and Anderson (2008) reported on two students who were
referred to the school's problem solving team
by a classroom teacher because of disruptive
and noncompliant
behavior.

Similarly,
McCurdy, Kunsch, and Reibstein (2007) documented use of a prereferral intervention team
nomination process. Participants were included based on demonstration of behavioral
difficulties in the classroom and/or existence
of a behavior plan. Mclntosh and colleagues
(2009) accepted students nominated by teachers because of classroom problem behavior
and perceived lack of responsiveness to the
Tier 1 prevention efforts. Fairbanks and colleagues (2007) also incorporated a teacher
nomination process to identify students. Participants in this study were referred based on
increasing office referrals and problem behavior in the classroom, but neither the number of
referrals nor the level of classroom problem
were defined. Finally, the investigation completed by Todd, Campbell, Meyer, and Horner
(2008) identified student candidates through a
multi-informant process, which included administrator nomination, teacher verification of
problem behavior, parental consent, and
student willingness to participate in the intervention.
August 2011 / 245


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Student Data
None of the 13 studies reviewed relied
exclusively on use of student data alone to
determine participation in a Tier 2 intervention.
Among studies that included use of student
data, office discipline referral (ODR) information was relied upon most heavily. Several
authors provided a specific number of ODR as
criteria for participation. For example, five or
more ODR was cited as part of an identification
process in one study (Hawken, 2006), and two
or more ODR was considered in another
investigation (Hawken, MacLeod, & Rawlings,
2007). Robertson and Lane (2007) provided
perhaps the most specific use of student data by
combining one or more disciplinary referrals
within the first four months of school, additional
indicators of grade point average less than or
equal to 2.7, and a screening score demonstrating moderate or high risk. Filteretal. (2007)
reported outcomes for students from three
different schools buteach school developed its
own identification process. These processes
were not specified other than that a behavior
support team submitted student candidates
based on office referral data as part of the

decision-making process. Finally, Lane et al.
(2002) used school academic data combined
with screening score results as an identification
process. In this study, students performing in the
bottom third of their class in terms of literacy
skills and receiving a score of four or higher
using the Student Risk Screening Scale (SRSS;
Drummond, 1993) were considered to be
candidates who would benefit from intervention.
Screening Score Results
Results from use of a behavioral screening
instrument were used in three studies. Lane et
al. (2003) included student participants who
were identified by classroom teachers using
scores from the SRSS (Drummond, 1993). A
criterion for inclusion in the intervention was a
total raw score of 9 or more after the schoolwide prevention plan was implemented for
three months. In the second example, Cresham. Bao Van, and Cook (2006), used a
multigated procedure after school-wide universal prevention efforts were provided to all
students. In stage one, teachers identified and
rank ordered 10 students who fit a provided
definition for social skill problems. Stage two
considered student scores on the Social Skills
Rating System (SSRS; Gresham & Elliott, 1990)
250 / August 2011

and the Critical Events Index (CEI) of the
Systematic Screening for Behavior Disorders
(SSBD; Walker & Severson, 1990). Finally,
stage three identified students with social skill

acquisition deficits as determined by SSRS
social skill and problem behavior scores. In the
most recent example Marchant et al. (2007)
also used the SSBD (Walker & Severson,
1990). As part of the SWPBS process all
students in the participating school were
screened. In this example, students identified
with internalizing concerns who scored in the
high-risk range during the direct observation
stage of the SSBD were also assessed using the
Internalizing Symptoms Scale for Children
(ISSC; Merrell & Walters, 1998) or the Preschool and Kindergarten Behavior Scales,
Second Edition (PKBS-2; Merrell, 2002).

Target Outcomes, Intervention Types and
Effects Shown
Outcomes Targeted
The majority of studies (12 out of 13)
measured behavioral outcomes alone. However, Lane et al. (2002) examined both
behavioral and academic indicators. Among
the investigations of behavioral outcomes
alone, measurement of problem behavior was
included in 10 of the 13 studies (Campbell &
Anderson, 2008; Fairbanks et al., 2007; Filter
et al., 2007; Cresham et al., 2006; Hawken,
2006; Hawken et al., 2007; Lane et al., 2003;
Lane et al., 2002; Mclntosh et al., 2009; &
Todd et al., 2008). Within those 10 studies,
definitions of problem behavior varied. Six of
the 10 studies identified specific parameters

for problem behavior, which frequently included: non-compliance, disruption, negative
physical or verbal interaction, out of seat, offtask, and talking out. Three of the 10 studies
defined problem behavior by rate of office
discipline referral (Filter et al., 2007; Hawken
et al., 2007; Hawken, 2006). One study
defined problem behavior in terms of ODR
and behavior ratings using the Behavioral
Symptoms Index (BSI) component of the
Behavior Assessment Scale for Children 2
(BASC-2; Mclntosh et al., 2009).
Within the group of 10 studies that measured problem behavior, two authors also
included secondary measures to examine appropriate behavior (Lane et al., 2003; Mclntosh
et al., 2009). Lane et al. (2003) measured
academic engaged time (AET) as defined by
amount of time spent doing one or more of the
Behavioral Disorders, 36 (4), 241-261


following: looking at or attending to the teacher
or instructional materials, engaged in or completing a required activity, and seeking assistance in an appropriate manner. While Mclntosh et al. (2009) included a measure of
prosocial behaviors through use of the BASC-2
Teacher Report Scale Form, which considers
adaptability, social skills, leadership, study
skills, and functional communication.
Among the 13 studies reviewed, three
investigations measured appropriate behavior
alone. Marchant et al. (2007) examined rates
of effective communication and appropriate
peer play in a playground setting. McCurdy et
al. (2007) considered percentage of daily

points earned in a BEP/CICO program as the
dependent variable. Robertson and Lane
(2007) examined post-treatment scores for
knowledge and use of study skills and conflict
resolution skills.
Interventions and Effects
In terms of the specific interventions used,
the 13 studies reviewed fall across three
distinct intervention categories: (a) The Behavior Education Program: Check-in/Check-out
(BEP/CICO), (b) social skill instructional
groups, and (c) academic instructional groups.
Eight of the 13 studies report outcomes and
effects of BEP/CICO (Campbell & Anderson,
2008; Fairbanks et al., 2007; Filter et al., 2007;
Hawken, 2006; Hawken et al., 2007;
McCurdy et al., 2007; Mclntosh et al., 2009;
Todd et al., 2008). Beyond the BEP/CICO
literature, four studies used a social skill
instructional intervention (Gresham et al.,
2006; Lane et al., 2003; Marchant et al.,
2007; Robertson & Lane, 2007). Finally, one
author reported a small group literacy instruction intervention and examined both the
academic and behavioral outcomes after
treatment (Lane et al., 2002). Among the
studies reviewed, 12 reported positive results
which included decreases in observation of
problem behavior or office discipline referral
rates, and/or an increase in academic engagement, increases in use and/or rating of social
skills, or an increase in academic skill.
The Behavior Education Program: Checkin/Check-out (BEP/CICO). Among eight reports

of the BEP/CICO intervention, five studies
followed a standard treatment protocol for
delivery of the support (Filter et al., 2007;
Hawken, 2006; Hawken et al., 2007;
McCurdy et al., 2007; Todd et al., 2008). A
Behavioral Disorders, 36 (4), 241-261

standard treatment of BEP/CICO includes the
following five components: (a) daily check-in,
(b) feedback from classroom teachers at
regular intervals throughout the day, (c) daily
check-out, (d) data collection with progress
monitoring, and (e) parent feedback (Hawken
& Horner, 2003). Within the five studies that
delivered a standard version of BEP/CICO,
there were a total of 53 participants. Of those,
approximately 70% demonstrated positive
outcomes that included a decrease in ODR
(Filter et al., 2007; Hawken, 2006; Hawken et
al., 2007), a decrease in percentage of
intervals engaged in problem behavior (Todd
et al., 2008), or a percentage of daily points
earned averaging 80 percent or higher
(McCurdy et al., 2007).
In a different investigation, Mclntosh and
colleagues (2009) also provided a standard
BEP/CICO treatment with an additional 34
participants, but examined results according to
group rather than by individual student. The
purpose was to identify effects of BEP/CICO for

students with attention-maintained behavior
(n = 18) versus students with escape-motivated
behavior (n = 16). Outcomes showed statistically significant reductions in problem behavior
ratings and ODR rates, and a statistically
significant increase in prosocial behavior
rating for participants with attention-maintained behaviors. Results for the escapemotivated group were not statistically significant on any measure.
Fairbanks and colleagues (2007) also
demonstrated positive results for BEP/CICO.
In this study, a cohort of 10 students received a
standard treatment of BEP/CICO and results
were monitored. A unique aspect of the
investigation was the report of outcomes in
relation to typically developed classmates.
Four of the 10 students who received intervention demonstrated decreases in problem
behavior that were near to or below the level
of an observed peer.
Last, Campbell and Anderson (2008) also
demonstrated use of a distinct feature as a
supplement to the BEP/CICO treatment. This
investigation reported the addition of an
incentive that allowed access to peer attention
was sufficient for increasing the success of two
participants who initially showed low levels of
responsiveness to the standard group intervention. Study participants were permitted to sit
with a preferred peer during lunch and to
check-out with a preferred peer at the end of
the day. Using the function-based adaptation
August 2011 / 251

of BEP/CICO, Campbell and Anderson demonstrated decreases in problem behavior
across two settings for both students (2008).
Social Skill Instructional Group. Four of
the 13 studies examined the use of a social
skill instructional intervention (Gresham et al.,
2006; Lane et al., 2003; Marchant et al., 2007;
Robertson & Lane, 2007). Robertson and Lane
(2007) provided study skill instruction or study
skill plus conflict resolution instruction to 65
middle school students identified as at-risk.
Both intervention groups showed only lowlevel increases in their knowledge of study
skills after intervention. Students who also
received the conflict resolution instruction
showed some increase in their knowledge of
these strategies. Overall, even though results
indicated increases in knowledge of study
skills or conflict resolution skills, the increased
knowledge did not transfer to a change in use
of these skillsfor either group. In the remaining
three examples for use of a social skill
instructional intervention, each of the 14
participants demonstrated positive results.
In the Gresham and colleagues (2006)
investigation, four elementary age students
identified as having social skill acquisition
deficits participated in 60 hours of social skill
instruction using a published curriculum, the
Social Skills Intervention Guide (SSIG; Elliott &
Gresham, 1991). Use of skills taught during
lessons was supported by differential reinforcement of other behavior across settings. Direct

observation data showed positive outcomes for
each of the four students across the three
problem behaviors. Using a social skill-rating
instrument, the group mean for total social
skills increased from the 7th to the 50th
percentile between pre- and postintervention
ratings, and the group mean for total problem
behavior decreased from the 95th percentile to
the 58th percentile. However, the intervention
had no discernable effect on academic competence.
Lane and colleagues (2003) provided a
total of 10 hours of small group social skill
instruction over 10 weeks for seven elementary
age students who were identified as at-risk
based on screening scores from the SRSS
completed by their classroom teachers (Drummond, 1993). To identify target skills, students
in the group were rated using the Social Skills
Rating System (Gresham & Elliott, 1990) and
the Critical Events Index of the SSBD (Walker
& Severson, 1990). From these results, a
comprehensive list of acquisition deficits was
252 / August 2011

generated and lessons from the SSIG (Elliott &
Gresham, 1991) were selected and taught. The
seven research participants were divided
among three groups that also included typically developing peers. Results of the intervention were reported in terms of individual
and group effect sizes, and indicated decreases
in disruptive behavior and negative social
interactions with increases in academic engaged time.

The last study (Marchant et al., 2007) used
a social skill instructional group and was
unique in two facets. First, it was the only
study among those reviewed that specifically
addressed needs for students with an internalizing concern, such as socially withdrawn
behavior. Second, the investigation was conducted exclusively in a playground setting.
Participating students received social skill
instruction for effective communication acts
and appropriate play, combined with use of a
self-management strategy, peer and adult
mediated attention, plus positive reinforcement for meeting behavioral goals. Results
showed increases from baseline in both
communicative acts and appropriate play for
each of the three participants across conditions
of training, peer mediation, and adult mediation.
Academic Instructional Group. Lane and
colleagues (2002) was the only study found
that examined behavioral outcomes after
providing a small group, supplemental, academic intervention. This study included seven
elementary age students identified as academically and behaviorally at-risk. Classroom
teacher reports of literacy skills in the bottom
third of their first grade class and SRSS
(Drummond, 1993) screening score results
were used to select candidates for intervention. Participants received 15 hours of literacy
instruction within the general education classroom, provided in 30-minute sessions, three to
four times per week, over a period of 9 weeks.
Phonemic awareness; sound-symbol relationship; high frequency word identification; and
reading, dictation, and writing practice were
components of the lessons. Individual effect
sizes were calculated and reported for each

participant across two academic variables,
nonsense word fluency (NWF) and oral reading fluency (ORF), and across two behavioral
variables, total disruptive behavior (TDB) and
negative social interactions (NSl). Among the
five students who completed the entire 9 weeks
of instruction, individual effect sizes for NWF
Behavioral Disorders, 36 (4), 241-261


were large, but mixed results were found for
ORF. Related to behavioral outcomes, the
intervention showed decreases in TDB for each
of the five students who completed the entire
treatment and decreases in NSI among four of
the five students. An important implication of
the study was demonstration of the inverse
relationship between increases in academic
skill and decreases in problem behavior.
Implementation of Intervention
Among the studies reviewed, a variety of
implementers provided intervention. For example, a number of studies incorporated the
use of school personnel including classroom
teachers, behavior support teams, paraprofessional teaching assistants, and counselors as
intervention providers. A second cluster of
work relied on a combination of researcher
and school-based implementation. Finally,
three studies involved use of an intervention
delivered by the research team alone (see
Table 1 for further detail).
Fidelity of Tier 2 Implementation by Schoolbased Personnel

Six of the 13 studies reviewed demonstrate
examples of intervention provided by schoolbased personnel but only three of these
investigations documented results for fidelity
of implementation (Fairbanks et al., 2007;
Filter et al., 2007; Hawken et al., 2007). In
the first example, a school counselor collected
fidelity measures for implementation of BEP/
CICO. Results indicated high levels of implementation (averages of 88% and 94% accuracy) by each classroom teacher (Fairbanks et
al., 2007).
Similarly, teachers, staff, or administrators
who participated in the Filter and colleagues
(2007) investigation completed a 5-item
checklist related to their experiences implementing the BEP/CICO program. Results indicated high levels of implementation for three
components of the intervention—daily checkin, regular teacher ratings, and daily check-out
(94-100% of respondents reported consistent
implementation). A slightly lower level of
implementation for use of student data to
make decisions was documented (82% of
respondents reported consistent implementation). However, fewer than half of respondents
(41%) indicated that the family feedback
component was consistently implemented.

Behavioral Disorders, 36 (4), 241-261

Using a different method, Hawken and
colleagues (2007) conducted a review of
permanent products on randomly selected
school days. Results indicated high levels of
implementation (averages ranging from 94100%) for four components of the intervention
(check-in, regular feedback, check-out, and

data collection). However, similar to results of
Filter and colleagues (2007), implementation
of the family review and feedback component
was low (average 36%).
Social Validity Measures and Outcomes
Measures and results of social validity
were reported in 9 of the 13 studies reviewed
(see Table 2). Among the four investigations
that did not include social validity measures,
three of the studies involved use of a BEP/
CICO treatment (Campbell & Anderson,
2008; Hawken, 2006; Mclntosh et al.,
2009) and the fourth demonstrated a social
skill instruction intervention (Gresham et al.,
2006). Of the nine studies that did provide
social validity data, the respondents were
most often teachers/staff/administrators (eight
out of nine studies). Student perceptions
were included in six of the nine investigations. Notably, parent perceptions were
measured in only one investigation (Hawken
et al., 2007).

Discussion
The question of selecting an intervention is
seldom "is there evidence?" but instead, "is
there su/i/c/enf evidence to allow unequivocal
documentation that a practice is effective?"
(Horner, Sugai, & Anderson, 2010, p. 3). The
purpose of this review was to explore the
existing research base for Tier 2 small group

intervention studies conducted within a tiered
prevention framework. Specific research questions included:
1. To what extent has integrity of Tier 1
implementation been assessed prior to the
addition of Tier 2 interventions?
2. What are the characteristics of students
who have participated in Tier 2 group
interventions and how was identification
for these additional supports determined?
3. What outcomes are most often targeted,
which types of group interventions have
been implemented, and what effects do
they show within a tiered framework?
August 2011 / 253


TABLE 2
Social Validity
Study

Measure

Findings

Fairbanks, Sugai, Cuardino,
& Lathrop (2007)

Context-specific 5-point,
5-item Likert rating scale

Teachers reported that CICO was easy to implement,
improved the general climate of the classroom, and
was a positive experience for the students.

Filter et al. (2007)

Context specific 6-point Likert
rating scale

All respondents perceived CICO as being generally
effective, with "ease of implementation" receiving
the lowest rating (M = 3)

Hawken, Macteod,
& Rawlings (2007)

BEP Acceptability Questionnaire
(6-point Likert scale)

Mean response for intervention effectiveness was
4 points and mean response for the ease of
implementation and whether or not teachers would
recommend the program to others was 5 points.

Lane et al. (2003)

Intervention Rating Profile
(IRP-15; 6-point Likert scale)

Three general education teachers completed the IRP15, rated the intervention as favorable, and noted

variability in student outcomes.
All seven students rated the intervention as
acceptable on the CIRP, and all of the students
indicated that they wished the intervention could
have lasted longer.

Children's Intervention Rating
Profile (CIRP; 6-point Likert scale)

Intervention Rating Profile
(IRP-15; 6-point Likert scale)

The students' general education teacher completed
the IRP-15 and reported that the procedures were
acceptable, but that the intervention was not
appropriate for addressing academic and
behavioral concerns. Additionally, she reported
that none of the students' behaviors changed
(which was contradictory to the study results).

Children's Intervention Rating Profile
(CIRP; 6-point Likert scale)

Four of the five students rated the intervention as
favorable on the CIRP; one student rated it as
unfavorable.

Marchant et al. (2007)

Context specific pre/post

questionnaire

Teachers, peers, and the target students overall rated
the intervention as effective. The least favored
component was the peer-mediated intervention
and the most popular component was the social
skills instruction and the reward system.

McCurdy, Kunsch,
& Reibstein (2007)

Intervention Rating Profile (IRP)

IRP results indicated that teachers had strong
satisfaction with the intervention.
Students reported a high degree of satisfaction with
the intervention on the CIRP.

Lane et al. (2002)

Children's Intervention Rating
Profile (CIRP)
Robertson & Lane (2007)

Children's Intervention Rating
profile (CIRP)

No statistically significant differences were found
between the groups, and both rated the intervention
high.

Todd, Campbell, Meyer,
& Horner (2008)

CICO Program Acceptability
Questionnaire (6-point Likert scale)

At the end of the intervention, 5 of the 10 respondents
agreed that problem behaviors had decreased and
that CICO was relatively easy to implement; 9 of 10
reported they would recommend CICO to other
schools to use with similar students.

4. Have school-based teams demonstrated
capacity to implement and sustain Tier 2
interventions or have these efforts largely
been conducted by research personnel?
5. Have school-based personnel rated Tier 2
interventions as socially valid (i.e., important, effective, and feasible)?
Interestingly, the published research to
date is less than 10 years old. Taken as a
whole, the results of this review indicate that
254 / August 2011

the practice of providing Tier 2 intervention
within a continuum of supports is promising.
The nature of the current body of research
provides a valuable starting point, but a
stronger base of rigorous investigation is
needed, using a variety of designs, which

may include (but are not limited to) single
subject cases. Responding to the question
posed by Horner and colleagues, whether
there is sufficient evidence that this practice is unquestionably effective, the answer
Behavioral Disorders, 36 (4), 241-261


is no, not yet. A number of issues warrant
consideration.
First, less than one third of studies demonstrated fidelity of Tier 1 implementation
using a research-based measure. This calls into
question the validity of "risk" among students
identified for additional support in each of the
studies that did not include measurement of
Tier 1. Without documentation that effective
Tier 1 prevention efforts were provided, it is
difficult to determine whether identified students were truly in need of additional support
or rather that they simply had not been
provided with adequate primary prevention.
To move forward in clearly defining the value
and effectiveness of Tier 2 practices, systematic use of these interventions in addition to
measured Tier 1 efforts are needed. For
example, do students in schools implementing
Tier 1 with integrity benefit more or in different
ways when a Tier 2 intervention is implemented than similar students in schools who are not
using a tiered prevention based approach?
Second, each of the studies reviewed
included descriptions of how students were
identified for additional intervention (e.g.,
teacher nomination, student data, screening

score) but the characteristics of students who
benefit the most from Tier 2 support are in
need of additional clarification and qualification. For example, are these practices valuable
and effective for students with ADHD? Are
they effective for students with escape-maintained behavior? Are there differences in
outcomes across age, gender, ethnicity and/or
socio-economic status, and ultimately, does
use of Tier 2 interventions actually reduce the
number of students experiencing risk for EBD?
Third, related to techniques for identification of at-risk candidates, it is unfortunate to
note that the use of a nomination process or
student data indicators did not elicit any
students with risk for internalizing concerns.
In addition, among studies that incorporated
use of a screening instrument, only the
Marchant and colleagues (2007) investigation,
which depended on results from two screening
instruments, demonstrated identification and
intervention for students with internalizing
difficulties. Although students with internalizing concerns are at greater risk for social
withdrawal, anxiety, depression, and suicide,
children with these characteristics are rarely
nominated for prereferral intervention or
placed in special education for having an
EBD, thus delaying access to intervention and

Behavioral Disorders, 36 (4), 241-261

treatment (Cresham & Kern, 2004). The
existing research base for Tier 2 group

interventions is notably lacking with regard to
identification and service among students at
risk for internalizing concerns.
Fourth, while a number of the existing
studies demonstrated reductions in problem
behavior, absence of problem behavior alone
does not indicate that increases in appropriate
behavior were also occurring. Investigations
targeting significant increases in appropriate
behavior and academic engagement, as well
as longer-term outcomes (i.e., increases in
grade point average, credit accrual, graduation
rates) are important to add to the emerging
research base for Tier 2 supports.
In addition, the types and intensity of
treatments that are considered effective as Tier
2 interventions need further investigation.
There is promising evidence for the use of
the BEP/CICO intervention, but less support for
social skill and academic instructional groups
is available within the context of a continuum
of supports. Compounding this challenge, the
literature also demonstrated a vast difference
in treatment within social skill instructional
groups. For example, the Cresham et al. (2006)
study provided 60 hours of social skill instruction while Lane and colleagues (2003) demonstrated positive outcomes with only 10 hours
of instruction for students with similar concerns. These differences among treatment
implementations make it difficult to determine
what level of intervention is required to
demonstrate ideal effects. Similarly, a number

of other group treatments are often noted as
Tier 2 interventions (e.g.. First Step to Success,
Check and Connect, Think Time), but demonstrations of how these practices operate with
measured fidelity within the context of a tiered
prevention framework have yet to be investigated. Finally, the availability of data indicating that a student will continue to demonstrate
desired outcomes once an intervention is
removed was notably absent.
Fifth, capacity for school-based implementation of Tier 2 interventions has yet to be
sufficiently documented. To begin, there are
only a small number of studies demonstrating
Tier 2 intervention within a tiered framework,
and among those, implementation by school
personnel occurred in less than half of the Tier
2 studies. Further, measurement for fidelity
implementation was also limited. There were
only three examples in which Tier 2 implementation by school personnel was measured.
August 2011 / 255


While results in each of the three studies
indicated high fidelity of implementation,
additional verification is needed.
Overall, the outcomes related to social
validity were promising. Among the investigations that documented stakeholder perception
of interventions, both students and teachers
indicated Tier 2 treatments as important,
effective, and feasible. If participants believe
Tier 2 interventions are valuable, it may
increase the likelihood that there will be
additional and continued effort to implement

these practices with high fidelity.

Implications for Tier 2
Intervention within a Tiered
Prevention Framework
In a recent publication, Horner, Sugai, and
Anderson (2010) applied the following criteria
from the Society for Prevention Research (Flay
et al., 2005) to assess SWPBS as a whole: (1)
The practice and participants are defined with
operational precision. (2) The research employs valid and reliable measures. (3) The
research is grounded in rigorous designs. (4)
The research documents experimental effects
without iatrogenic outcomes. (5) The research
documents sustained effects. The same framework is useful for analyzing the existing
research base for Tier 2 level treatment within
a continuum of tiered supports; accordingly,
the 13 studies reviewed in this manuscript are
discussed with regard to the criteria applied by
Horner, Sugai, and Anderson (2010).
1. The practice and participants are defined
with operational precision. Given the
results of this review, the existing literature
appears to describe sufficiently only one
Tier 2 treatment, BEP/CICO, that can be
effectively implemented with high fidelity
among typical school personnel and
achieve strong social validity. This is
evident both by the number of studies
conducted and the commonality of components used within this intervention.

Dissimilarly, with regard to social skill
and academic instructional groups, the
smaller number of studies calls into question whether the practice is adequately
defined within the present review.
As a group, the processes for identifying
participants were reasonably well defined
and included a variety of techniques, such
as teacher nominations, student data indi-

256 / August 2011

cators, and screening score results, but the
characteristics of students who received
Tier 2 support once they were identified
were inconsistently described among the
studies reviewed. Failure to provide basic
student characteristics in every study does
not make a compelling case for precisely
defined participants.
2. The research employs valid and reliable
measures. Each of the 13 studies reviewed
included operational definitions of target
behaviors measured and described data
collection procedures that aligned with the
intended target. A number of studies
included direct observation data and reported high inter observer agreement
among raters (e.g., Campbell & Anderson,
2008; Fairbanks et al., 2007; Gresham
et al., 2006; Todd et al., 2008). In addition,
a number of studies included multiple

measures such as direct observation with
office referral data (Hawken et al., 2007) or
social skill ratings (Gresham et al., 2006;
Marchant et al., 2007).
3. The research is grounded in rigorous
designs. Within special education, single
subject methodology is an accepted and
valid design to demonstrate intervention
effects (Horner, Sugai, & Anderson, 2010;
Kazdin, 1982). Through manipulation of
variables, the researcher can control for
extraneous factors and demonstrate functional relationships between independent
and dependent variables. Use of single
subject design accounted for more than
half the studies in the present review. More
problematic, however, were the remaining
six studies, which were largely quasiexperimental and included one case study.
While these types of studies are beneficial
for describing possible hypotheses about
potential treatment effects, they do not
constitute a strong evidence base. More
rigorous research is needed to add to the
current literature base. Larger-scale studies
could include randomized control trials to
investigate different Tier 2 interventions
within the context of tiered systems.
4. The research documents experimental effects without ¡atrogenic outcomes. As a
group, the studies conducted for Tier 2
intervention demonstrate decreases in
problem behavior, office discipline referrals, minor behavioral incidents, alone

time, and negative social interactions
(e.g., Campbell & Anderson, 2008; FairBehavioral Disorders, 36 (4), 241-261


banks et al., 2007; Filter et al., 2007). In
addition, use of this practice also demonstrates increased teacher ratings of prosocial behavior, direct observation of student
academic engagement and appropriate
behavior, and increases in academic decoding skill (e.g., Gresham et al., 2006;
Lane et al., 2003; Lane et al., 2002).
Although the number of studies is limited,
a pattern of change in behavioral outcomes
is evident. Marchant and colleagues (2007)
did report undesirable effects associated
with the peer mediation component in their
investigation for use of a particular treatment package. The package was designed
to increase effective communication and
appropriate peer play on a playground
setting and consisted of social skill instruction, peer mediation, and self-management
with positive reinforcement. Peer partners
were instructed to prompt target students
for appropriate social skills by inviting
other children to play with them or by
joining a group of children who were
already at play. After 3 weeks, this aspect
of the intervention was replaced with adult
mediation. An unexpected and adverse
outcome was a negative impact on the
social interactions of the peer partner; their
friends no longer played with them while
they mediated social interactions for the

target student.
5. The research documents sustained effects. It
is disappointing that, in this review, only 4
of the 13 studies provided follow-up data for
effects of the Tier 2 intervention. Three of
the investigations that included this data
demonstrated positive effects after a social
skill instructional intervention, and one
study sustained positive outcomes with use
of an academic instructional treatment.
Unfortunately, the body of work that was
most frequently represented in this review—
studies of BEP/CICO—does not have evidence to indicate that positive effects are
maintained over time. Future research
should investigate maintenance of treatment
effects and how the BEP/CICO support can
be successfully faded over time.

Conclusion
Students with EBD are at risk for challenges
across home, school, and community settings
that lead to poor life outcomes. The importance

Behavioral Disorders, 36 (4), 241-261

of early identification and intervention among
students at risk for EBD is well documented as
both a priority and necessity. Implementation of
SWPBS, or a tiered prevention framework, is a
potential mechanism for using data to identify

potential candidates, developing practices that
reduce risk, and sustaining intervention efforts
over time. Although procedures for implementation and outcomes for Tier 1 and Tier 3 are
more thoroughly established and documented,
less is known about how to embed Tier 2
supports within a prevention continuum.
Schools are a natural context for coordinating
efforts to promote healthy development, prevent EBD problems from occurring, encourage
early intervention, and provide ongoing assistance for students with persistent concerns
(Adelman & Taylor, 2006). In fact, because of
the amount of time children spend with
schools, they are recommended as a primary
location for identification and support with
social, emotional or behavioral health issues
(U.S. Public Health Service, 1999). Although
schools alone cannot meet every need, it is
imperative that education providers are
equipped to address factors that directly impact
learning (U.S. Public Health Service, 1999).
Schools can accomplish this by adopting
approaches that support the provision of
evidence-based practices to prevent or ameliorate mental, emotional and behavioral problems. The use of tiered supports as an approach
for promoting positive social and academic
outcomes among all students is burgeoning as
an evidence-based practice. However, less is
known about some of the individual parts that
contribute to the whole. What we know about
Tier 2 intervention as a practice is important.
The compilation of research to date provides a
valuable starting point, but for now this work is

far from finished.

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23(4), 462^73.
Bradshaw, C. P., Mitchell, M. M., & Leaf, P. J.
(2010). Examining the effects of school-wide
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August 2011 / 257


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AUTHORS' NOTE
Address correspondence to Barbara Mitchell,
University of Missouri, Department of Special
Education, MU Center for SW-PBS & MO
SW-PBS, 303 Townsend Hall, Columbia, MO

65211; E-mail:

MANUSCRIPT
Initial Acceptance: 4/14/11
Final Acceptance: 5/4/11

August 2011 /261


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