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8/29/14 1 Welcome! Your webinar will begin shortly. There is nothing to hear at present. Make sure your speakers are turned on. If you have not already done so, please run the audio wizard (refer to directions in your registration email.) In the meantime, can you think of a caption for this picture? What is the boy saying to his friend? Please type your suggestion in the chat box. 2 Phoebe Rinkel, M.S. TASN KITS TA Coordinator, Part B/619 Preschool TA Provider [email protected] Chelie Nelson, Ph.D. TASN – KITS Part B/619 Preschool TA provider [email protected] If you experience technical problems during the webinar contact: Kim Page TASN – KITS ECRC Coordinator [email protected] (620) 4216550 extension 1638 Part I: PreventTeachReinforce for Young Children (PTRYC) Essen%al Preven%on Prac%ces for Reducing Challenging Behaviors in Early Care and Educa%on Se9ngs Participants Will Be Able To… Define “serious” challenging behavior Iden%fy and describe five classroom prac%ces essen%al to preven%ng the development or escala%on of serious challenging behavior Learn about specific strategies for implemen%ng and monitoring the five essen%al classroom prac%ces Learn about a stepbystep process to guide teams in developing individualized interven%on plans when serious challenging behavior persists in spite of implementa%on of essen%al preven%on prac%ces Intro to PTRYC Features of PTRYC Researchbased prac%ces Specific applica%on of posi%ve behavior interven%ons and support (PBIS) Designed for use by typical prac%%oners in typical preschool and child care se9ngs A collabora%ve model of teamdriven decision making Emphasis on implemen%ng with fidelity Detailed steps for designing and implemen%ng posi%ve interven%ons

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Page 1: PTR-YC Part 1 8 28 14 - University of Kansaskskits.dept.ku.edu/.../PTR_YC_Part1WebinarHandout8_28_14.pdf · 8/29/14 1 Welcome! Your webinar will begin shortly. There is nothing to

8/29/14  

1  

Welcome! Your webinar will begin shortly.

There is nothing to hear at present. Make sure your speakers are turned on. If you have not already done so, please run the audio wizard

(refer to directions in your registration email.)

In the meantime, can you think of a caption for this picture? What is the boy saying to his friend?

Please type your suggestion in the chat box.

2

   Phoebe  Rinkel,  M.S.  TASN  -­‐  KITS    TA  Coordinator,    Part  B/619  Preschool    TA  Provider  [email protected]        

   Chelie  Nelson,  Ph.D.  TASN  –  KITS  Part  B/619  Preschool  TA  provider  [email protected]      

             

 If  you  experience  technical  problems  during  the  webinar  contact:  

 

 Kim  Page  TASN  –  KITS  ECRC  Coordinator  [email protected]    (620)  421-­‐6550  extension  1638    

   Part  I:  Prevent-­‐‑Teach-­‐‑Reinforce  for  

Young  Children  (PTR-­‐‑YC)    

Essen%al  Preven%on  Prac%ces  for  Reducing  Challenging  Behaviors  in  Early  

Care  and  Educa%on  Se9ngs    

Participants  Will  Be  Able  To… •  Define  “serious”  challenging  behavior    •  Iden%fy  and  describe  five  classroom  prac%ces  essen%al  to  

preven%ng  the  development  or  escala%on  of  serious  challenging  behavior    

•  Learn  about  specific  strategies  for  implemen%ng  and  monitoring  the  five  essen%al  classroom  prac%ces  

•  Learn  about  a  step-­‐by-­‐step  process  to  guide  teams  in  developing  individualized  interven%on  plans  when  serious  challenging  behavior  persists  in  spite  of  implementa%on  of  essen%al  preven%on  prac%ces  

Intro  to  PTR-­‐‑YC Features  of  PTR-­‐‑YC •  Research-­‐based  prac%ces  •  Specific  applica%on  of  posi%ve  behavior  interven%ons  and  support  (PBIS)  

•  Designed  for  use  by  typical  prac%%oners  in  typical  preschool  and  child  care  se9ngs  

•  A  collabora%ve  model  of  team-­‐driven  decision-­‐making  

•  Emphasis  on  implemen%ng  with  fidelity    •  Detailed  steps  for  designing  and  implemen%ng  posi%ve  interven%ons  

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Who  are  These  Kids? Young  Children  with  Serious    

Challenging  Behavior

The  targeted  students  are  young  children  (ages  0-­‐8)  who  

demonstrate  pa:erns  of  significantly  challenging  behaviors.    

These  behaviors  may  be  internalizing  or  externalizing  

behaviors,  are  of  a  nature  that  is  beyond  developmental  norms  

in  frequency,  duraDon,  and/or  intensity,  and  impede  learning  

and/or  parDcipaDon  in  age-­‐appropriate  acDviDes  for  the  child  

and/or  others. KASEA Research Committee, February 2014

Young  Children  with  Serious  Challenging  Behavior

“…young  children  whose  behaviors  are  serious  

enough  that  they  interfere  with  the  child’s  ability  to  

engage  in  posi%ve  rela%onships,  form  friendships,  

play  with  others,  and  learn  expected  skills.  “  

     Dunlap,  Wilson,  Strain,  &  Lee  (2013)  

Evidence  of  Growing  Problem

•  Rising  rates  of  problem  behavior  in  preschool  se9ngs  

•  Higher  expulsion  rate  in  preschools  than  K-­‐12  grades  

•  Early  childhood  staff  reques%ng  more  training  and  support  for  classroom  management  and  for  individual  children  

Increasing Rate and Intensity!

•  In  1980s,  10-­‐15%  of  preschoolers  exhibited  mild  to  moderate  problem  behaviors.      

•  In  2002,  22-­‐39%  of  preschoolers  exhibited  clinically  significant  levels  of  problem  behaviors.  

•  In  2008,  child  care  providers  reported  more  young  children  engaging  in  more  severe  challenging  behaviors  at  a  younger  age.  

•  In  2009,  approximately  20%  of  young  children  in  the  general  popula%on  and  70%  of  young  children  with  special  needs  engaged  in  significant  challenging  behavior.  

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National  Trends  in  Expulsion  and  Suspension—For  Preschool???

Children  are  expelled  from  pre-­‐kindergarten  classrooms  at  a  rate  3.2  %mes  higher  than  the  expulsion  rate  for  K-­‐12  students.    "

" " " " "Gilliam, 2005"

Why  the  Concern    About  Behavior  of  LiPle  Kids?

For  no  other  group  of  young  children  is  the  trajectory  so  certain  and  so  dismal  as  it  is  for  children  with  

challenging  behaviors  who  do  not  receive  effecDve  services  (Vinh,  2011).    

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What  Does  PBIS  Look  Like    for  Young  Children  (Birth  to  6)?

[Assessment-based interventions result in individualized behavior support plans.]

Prev

entio

n

Unive

rsal

Prom

otion

Trea

tmen

t Few children

Children at-risk

All Children

CSEFEL,  2010

What  Does  PBIS  Look  in  Preschool?

•  Promo%ng  and  suppor%ng    young  children’s  social  and  emo%onal  development;  

•  Individualizing  interven%ons;  •  Promo%ng  skill  building    

with  intensity;  •  Implemen%ng  strategies  in  context,  and  •  Modifying  strategies  to  meet  diverse  needs.  

CSEFEL, 2010

Outcomes  of  Program  Wide    Adoption  of  Pyramid  Model

•  Reduc%ons  in  child  challenging  behavior  •  Increases  in  children’s  social  skills  •  Increased  sa%sfac%on  of  program  staff  and  families  •  Reduced  turnover  in  the  program  •  Increases  in  teachers  competence  and  confidence  in  the  support  of  children  

•  Changes  in  classroom  and  program  climate  •  Sustained  implementa%on  of  the  Pyramid  Model  

TACSEI, 2014

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High  Quality  PBIS  Practices  in  EC   Before  We  Talk  about  Intensive  Individualized  Supports.  .  .  

Implementa%on  of  PTR-­‐YC    •  Requires  %me,  effort,  and  commitment  •  Is  only  possible  for  1-­‐2  children  at  a  %me  •  Is  more  likely  to  be  successful  in  a  classroom  with  program  wide  PBIS  in  place  

Essential  Classroom  Practices  for  Success  of  PTR-­‐‑YC

•  Implementa%on  of  essen%al  universal  classroom  prac%ces  in  preschool  can  reduce  the  need  for  individualized  interven%ons,  or,    

•  If  individualized  interven%ons  are  necessary,  they  may  not  need  to  be  as  intensive  or  effordul.  

   Dunlap,  et  al..  (2013)  

Essential  Practices  for    Preschool  Classrooms

1.   Providing  5:1  ra%o  of  posi%ve  vs.  correc%ve  feedback  

2.   Using  schedules  in  a  way  that  is  likely  to  prevent  challenging  behavior  

3.   Suppor%ng  rou%nes  within  rou%nes  across  the  day  4.   Teaching  the  specific  behaviors  we  want    

to  see  for  each  classroom  rou%ne  5.   Providing  explicit  peer-­‐related  social                    skills  

       Dunlap,  et  al.,  2013!

Assessing  Essential    Classroom  Practices

1.   Are  we  providing  posi%ve  feedback*  to  children  with  persistent  challenging  behavior  at  five  %mes  or  more  the  rate  that  we  are  giving  correc%ve  feedback  for  challenging  behavior?    *Posi%ve  feedback:    Encouraging  comments  to  the  child  about  his  or  her  behavior.    Making  requests,  giving  direcDons,  or  asking  quesDons  count  as  negaDve  comments,  even  if  stated  in  a  posiDve  tone  or  nicely  asked.  

Resources  Supporting    Implementation  of  5:1  Ratio

•  Building  Posi%ve  Rela%onships  with  Young  Children  hjp://csefel.vanderbilt.edu/modules/module1/handout5.pdf  

•  Posi%ve  Ajen%on  Data  Sheet    hjp://csefel.vanderbilt.edu/modules/module1/handout6.pdf  

•  Some  Starters  for  Giving  Posi%ve  Feedback  and  Encouragement  for  Effort,  Thinking,  Problem  solving  hjp://csefel.vanderbilt.edu/modules/module1/handout7.pdf  

•  Building  Posi%ve  Teacher-­‐Child  Rela%onships    What  Works  Brief  Training  Kit  #12  hjp://csefel.vanderbilt.edu/kits/wwbtk12.pdf  

•  Acknowledging  Children's  Posi%ve  Behaviors  What  Works  Brief  Training  Kit  #22  hjp://csefel.vanderbilt.edu/briefs/wwb_22.pdf  

•  School-­‐wide  Classroom  Support:    5  to  1  Ra%o:    Increasing  Specific  Praise  www.signetwork.org/file_ajachments/321/download  �  

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Assessing  Essential    Classroom  Practices

2.   Are  we  using  schedules  in  a  way  that  is  likely  to  prevent  challenging  behavior?    q Prominently  display  the  daily  schedule  at  children’s  eye  level?  q Use  words  and  pictures  to  represent  entries  on  the  schedule?  q Design  schedule  so  that  you  can  remove  an  item  or  indicate  its  

comple%on?  q Review  the  schedule  daily  with  the  whole  group  and  with  individual  

children  prior  to  making  a  transi%on?  q Preview  upcoming  changes  with  children?  q Keep  things  new  and  exci%ng:    a  predictable  schedule  doesn’t  mean  

doing  the  exact  same  thing  every  day    

   

Resources  to  Support  Use  of  Schedules  to  

Prevent  Challenging  Behavior   •  Helping  Children  Understand  Rou%nes  and  Classroom  Schedules    

What  Works  Brief  Training  Kit  #3  hjp://csefel.vanderbilt.edu/kits/wwbtk3.pdf  

•  How  to  Make  a  Visual  Schedule  to  Support  Young  Children.    TTYC:    Teaching  Tools  for  Young  Children  with  Challenging  Behavior.    hjp://challengingbehavior.fmhi.usf.edu/do/resources/teaching_tools/toc/folder5/5b_how_make_vis_sched.pdf  

•  How  to  Use  Visual  Schedules  to  Help  Your  Child  Understand        Expecta%ons  (for  families).    TACSEI  Backpack  Connec%on  Series.  hjp://challengingbehavior.fmhi.usf.edu/do/resources/documents/bkpk_visual_schedules.pdf    

•  Au%sm  Internet  Modules:    Visual  Supports  hjp://www.au%sminternetmodules.org/  

 

Assessing  Essential    Classroom  Practices

3.   Do  we  have  rou%nes  within  rou%nes  within  rou%nes  across  the  preschool  day?      q Think  about  developmental  goals  for  each  rou%ne  (e.g.,  peer  interac%on,  communica%on,  fine  motor  skills)  

q Create  picture  sequences  of  behavioral  expecta%ons  for  each  rou%ne  

q Directly  teach  the  sequences  using  fun  ac%vi%es  q Make  picture  sequences  available  for  all  rou%nes  

Resources  for  Routines  Within  Routines  Within  Routines  Across  the  Preschool  Day

•  TACSEI  Teaching  Tools  for  Young  Children:      o  Folder  5—Visual  Strategies    

hjp://challengingbehavior.fmhi.usf.edu/do/resources/teaching_tools/jyc_toc.htm  

o  Folder  1–  Rou%nes  Based  Support  Guide  hjp://challengingbehavior.fmhi.usf.edu/do/resources/teaching_tools/toc/folder1/1e_rou%ne_based.pdf  

•  TACSEI-­‐CELL  Integra%on  Level  2  –  How  to  Make  a  First/Then  Board  hjp://earlyliteracylearning.org/TACSEI_CELL/project_files/content/level_2/pdf/2_2e_Howto_firstboard.pdf  

•  Planning  Transi%ons  to  Prevent  Challenging  Behavior  (2008)  hjp://journal.naeyc.org/btj/200805/pdf/BTJ_Hemmeter_Transi%ons.pdf    

Assessing  Essential    Classroom  Practices

4.   Have  we  taught  children  the  specific  behaviors  we  want  to  see  for  each  classroom  rou%ne?  q Iden%fy  1-­‐3  expecta%ons  for  every  rou%ne    q Teach  expecta%ons  to  all  children  using  fun  ac%vi%es  and  pictures  q Post  pictures  of  behavioral  expecta%ons  where  they  can  be  used  

to  prompt,  remind,  or  redirect  children  q Prac%ce  expecta%ons  beforehand  (priming)  q Provide  opportunity  for  all  children  to  prac%ce  expecta%ons  daily  q Remember  5:1  ra%o  and  catch  children  exhibi%ng  appropriate  

behavioral  expecta%ons  q Adjust  level  of  expecta%ons  across  the  year  

Resources  for  Teaching  Behavioral  Expecta%ons  Across  Preschool  Se9ngs

•  Na%onal  Center  on  Quality  Teaching  and  Learning  15  Minute  Inservice  Suites/Well  Organized  Classrooms      Sta%ng  Behavioral  Expecta%ons  (Trainer  Version)    hjp://eclkc.ohs.acf.hhs.gov/hslc/ja-­‐system/teaching/prac%ce/ISS/state-­‐t.html  

•  TACSEI  Make  and  Take  It  Workshops:    Reducing  Challenging  Behavior  by  Clarifying  Expecta%ons,  Rules,  and  Rou%nes  hjp://challengingbehavior.fmhi.usf.edu/communi%es/make_n_take/make_n_take_home.html  

•  PreSET3.2  Manual  hjp://pbisnetwork2010conference.wikispaces.com/file/view/PreSET3.2+manual.pdf    

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Assessing  Essential    Classroom  Practices

5.   Are  we  providing  explicit  peer-­‐related  social  skill  instruc%on  on  skills  such  as  sharing,  taking  turns,  and  following  another  child’s  lead  throughout  the  day?  q What  social  skills  goals  do  I  have  for  individual  children  in  my  class?  q What  do  I  typically  do  for  the  children?  q Could  a  child  do  this  task  or  job?  q  Is  this  an  ac%vity  that  happens  frequently?    q Can  I  ensure  that  support  will  be  available  for  children  carrying  out  

the  task  or  job?                

Resources  to  Support  Explicit  Peer-­‐‑Related  Social  Skill  Instruction  Throughout  the  Day  

•  Using  Classroom  Ac%vi%es  and  Rou%nes  as  Opportuni%es  to  

Support  Peer  Interac%on    What  Works  Brief  Training  Kit  #5  hjp://csefel.vanderbilt.edu/kits/wwbtk5.pdf  

•  Promo%ng  Posi%ve  Peer  Social  Interac%ons    What  Works  Brief  Training  Kit  #8  

•  hjp://csefel.vanderbilt.edu/kits/wwbtk8.pdf  •  Implemen%ng  the  LEAP  Curriculum  in  Inclusive  Preschool  

Se9ngs:    Keystone  Learning  Services  hjp://www.kskits.org/webinars/LEAP/LEAP_test.swf  

           

More  Essential  Practices    for  Preschool  Classrooms?

Hemmeter, Fox, & Snyder, 2014

ü  Children  are  ac%vely  engaged  in  meaningful,  developmentally  appropriate  ac%vi%es  throughout    

       the  day  

ü  Teachers  connect  with  families  on  an  

       individual  basis  using  ongoing    

       systems  of  bi-­‐direc%onal    

       communica%on  

! "Hemmeter, Fox, & Snyder, 2014"

Self-­‐‑Assessment  Action  Plan Which  of  the  5  prac%ces  do  you  need  to  work  on  implemen%ng  with  consistency  in  your  preschool  se9ng?    What  are  the  specific  strategies  you  will  learn  and/or  teach  the  rest  of  your  team?    Write  a  goal  for  yourself  or  your  team:          

       

Good  News

•  ImplemenDng  the  five  universal  classroom  pracDces  can  lead  to  surprising  and  dramaDc  reducDons  in  challenging  behavior  to  the  extent  that  individualized  and  relaDvely  efforNul  intervenDons  are  no  longer  needed.  

Dunlap,  et  al.,  2013  

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Bad  News •  Some  challenging  behaviors  do  persist  even  when  high  quality  classroom  pracDces  are  used.    Children  with  these  behaviors  are  in  need  of  individualized,  assessment-­‐based  intervenDon  strategies.      

Dunlap  et  al.  (2013)  

Young  Children  with  Serious  Challenging  Behavior

The  behaviors  persist  even  in  response  to  carefully  created  systems  of  

posiDve  behavior  supports,  intenDonal  teaching  of  social  skills/

strategies,  and  targeted  intensive  supports  that  have  been  implemented  

with  consistency  and  true  fidelity  (including  data  collected  and  analyzed  

from  a  behavior  intervenDon  plan  derived  from  funcDonal  assessment  of  

problem  behaviors  that  includes  prevenDon  strategies  and  teaching  of  

replacement  behaviors).         KASEA Research Committee, February 2014

PTR-­‐‑YC  Part  2:    Implementing  PTR-­‐‑YC  for  Young  Children

Save  the  Date:  

October 15, 2014, 4:00 p.m. October 17, 2014, 11:30 a.m.

Watch for registration announcement on KITS List Serv

and on TASN and KITS Calendars

PTR-­‐‑YC  Intervention  Steps 1) Teaming  and  goal  se9ng  2) Prac%cal  data  collec%on  3) Func%onal  behavioral  assessment  4) Interven%on  5) Follow  up  and  next  steps  

Get  a  Free  Copy  of    PTR-­‐‑YC

• Webinar  par%cipants  will  find  out  how  to  obtain  a  free  copy  of  Prevent-­‐Teach-­‐Reinforce  for  Young  Children,  courtesy  of  the  Kansas  Technical  Assistance  System  Network  (TASN)!  

Complete  the  Electronic  Sign-­‐‑In  and  

Webinar  Evaluation  to  Receive  a  Certificate

Cer%ficates  Send  and  email  message  to  Karen  Lawson  –  [email protected]    including  the  following  informa%on  for  each  par%cipant:  

o  Name  o  Posi%on  o  Email  address  o  USD  Number  o  Essen%al  Prac%ce(s)  I  am  working  on:  _____________________________  

Electronic  Evalua%ons  –  Your  feedback  is  important  to  us!  •  Session  One  (8/28/14)  

hjp://ddesurvey.com/tarequest/WorkshopSurvey.aspx?ID=2283  •  Session  Two  (8/29/14)  

hjp://ddesurvey.com/tarequest/WorkshopSurvey.aspx?ID=2284  

Page 8: PTR-YC Part 1 8 28 14 - University of Kansaskskits.dept.ku.edu/.../PTR_YC_Part1WebinarHandout8_28_14.pdf · 8/29/14 1 Welcome! Your webinar will begin shortly. There is nothing to

8/29/14  

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Questions?  

KSDE  TASN  hjp://www.ksdetasn.org    Phoebe  Rinkel  [email protected]  

Presentation References!•  Cornely,  P.  and  Bromet,  E.  (1986).    Prevalence  of  behavior  problems  in  three-­‐‑year-­‐‑old  

children  living  near  three  mile  island:    A  comparative  analysis.    Journal  of  Child  Psychology  and  Psychiatry,  27,  489-­‐‑498.

•  Dunlap,  G.,  Iovannone,  R.,  Kincaid,  D.,  Wilson,  K.,  Christiansen,  K.,  Strain,  P.,  &  English,  C.  (2010)    Prevent  Teach  Reinforce:    The  school-­‐‑based  model  of  individualized  positive  behavior  support.    Baltimore,  MD:    Brookes  Publishing.

•  Dunlap,  G.,  Wilson,  K.,  Strain,  P.,  &  Lee,  J.  (2013)    Prevent  Teach  Reinforce  for  Young  Children:    The  early  childhood  model  of  individualized  positive  behavior  support.    Baltimore,  MD:    Brookes  Publishing.

•  Dunlap,  G.,  Strain,  P.  S.,  Fox,  L.,  Carta,  J.,  Conroy,  M.,  Smith,  B.,  et  al.  (2006).  Prevention  and  intervention  with  young  children’s  challenging  behavior:  A  Summary  of  current  knowledge.  Behavioral  Disorders,  32,  29-­‐‑45.  h\p://www.challengingbehavior.org/do/resources/documents/prevention_dunlap_11.06.pdf

•  Earls,  F.  (1980).    Prevalence  of  behavior  problems  in  3-­‐‑year  old  children:    A  cross  national  replication.    Archives  of  General  Psychiatry,  37,  1153-­‐‑1157.

•  Fox,  L.,  Veguilla,  M.,  and  Perez  Binder,  D.  (2014).  Data  Decision-­‐‑Making  and  Program-­‐‑  Wide  Implementation  of  the  Pyramid  Model.  Roadmap  to  Effective  Intervention  Practices  #7.  Tampa,  Florida:  University  of  South  Florida,  Technical  Assistance  Center  on  Social  Emotional  Intervention  for  Young  Children.  

•  Hemmeter,  M.L.,  Fox,  L.,  &  Snyder,  P.    (2014).    Teaching  Pyramid  Observation  Tool  (TPOT™)  for  preschool  Classrooms  manual,  Research  Edition.    Baltimore,  MD:    Brookes  Publishing  Co.

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Presentation References!•  lovannone,  R.,  Greenbaum,  P.,  Wang,  W.,  Kincaid,  D.,  Dunlap,  C,  &  Strain,  P.  (2009).  

Randomized  control  trial  of  a  tertiary  behavior  intervention  for  students  with  problem  behaviors:  Preliminary  outcomes.  Journal  of  Emotional  and  Behavioral  Disorders,  77,213-­‐‑225.

•  Joseph,  G.,  &  Strain,  P.  (2008).    Early  Care  providers’  first  responses  to  children’s  challenging  behavior.    Paper  presented  at  Division  for  Early  Childhood  Conference,  Minneapolis,  MN.  

•  Kaiser  A.,    Cai,  X.,  Hancock,  T.,  &  Foster,  E.    (2002).    Teacher-­‐‑reported  behavior  problems  and  language  delays  in  boys  and  girls  enrolled  in  Head  Start.    Behavioral  Disorders,  28  (1),  23-­‐‑39.

•  Powell,  D.,  &  Dunlap,  G.  (2009).  Evidence-­‐‑Based  Social-­‐‑Emotional  Curricula  and  Intervention  Packages  for  Children  0-­‐‑5  Years  and  Their  Families  (Roadmap  to  Effective  Intervention  Practices).  Tampa,  Florida:  University  of  South  Florida,  Technical  Assistance  Center  on  Social  Emotional  Intervention  for  Young  Children.  h\p://challengingbehavior.fmhi.usf.edu/do/resources/documents/roadmap_2.pdf

•  Steed,  E.,  &  Pomerleau,  T.  (2012).    Preschool-­‐‑Wide  Evaluation  Tool:    PreSET  Manual  Research  Edition.    Baltimore,  MD:    Brookes  Publishing  Co.

•  Vinh,  M.  (2011)    Policy  Brief:    The  Importance  of  early  intervention  for  young  children  who  engage  in  challenging  behaviors.    Pyramid  Plus:    The  Colorado  Center  for  Social  Emotional  Competence  and  Inclusion      h\p://www.pyramidplus.org/sites/default/files/images/policy_brief_challenging%20_behaviors_final_3_11.pdf

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