Reference Work Entry

Handbook of Clinical Psychology Competencies

pp 1707-1730

Role of the Environment in Prevention and Remediation

  • Sandra TwardoszAffiliated withUniversity of Tennessee
  • , Vey M. NordquistAffiliated withUniversity of Tennessee

Abstract:

The environment, broadly defined, has long concerned clinicians who work with children and families because it impacts prevention and intervention with problems and disorders. In this chapter, we specifically define “environment” as the organization of the individual’s immediate setting in terms of space, time, materials, activities, and people, variables that have received scant attention in the child clinical literature. Operant behavioral and ecological developmental perspectives are presented to describe the processes by which these variables can affect behavior and development, and their relationship to the more distal surroundings of community and culture. Next, we present illustrative research from behavior modification and related literatures which demonstrates that architectural features, spatial divisions, and furnishings; objects, materials, and activities; routines and schedules; and the presence, characteristics, and location of people, affect engagement and modify a wide range of behavior in community settings and homes. Professional psychologists should appreciate the role of the immediate environment in shaping behavior, alone and in conjunction with contingency management and other therapies. They should recognize when a setting must be modified because it is promoting problem behavior or hindering the therapeutic process, and be able to implement changes in the organization of space, time, materials, activities, and people. Changes in the setting may also be effective components of individualized treatment programs, and may be essential for the generalization of treatment effects. Although modifications to the environment cannot usually substitute for contingency management or other therapeutic strategies, they are essential adjuncts and supports to the clinical process, and can contribute to the prevention of dysfunctional and problem behavior.

Abstract:

The environment, broadly defined, has long concerned clinicians who work with children and families because it impacts prevention and intervention with problems and disorders. In this chapter, we specifically define “environment” as the organization of the individual’s immediate setting in terms of space, time, materials, activities, and people, variables that have received scant attention in the child clinical literature. Operant behavioral and ecological developmental perspectives are presented to describe the processes by which these variables can affect behavior and development, and their relationship to the more distal surroundings of community and culture. Next, we present illustrative research from behavior modification and related literatures which demonstrates that architectural features, spatial divisions, and furnishings; objects, materials, and activities; routines and schedules; and the presence, characteristics, and location of people, affect engagement and modify a wide range of behavior in community settings and homes. Professional psychologists should appreciate the role of the immediate environment in shaping behavior, alone and in conjunction with contingency management and other therapies. They should recognize when a setting must be modified because it is promoting problem behavior or hindering the therapeutic process, and be able to implement changes in the organization of space, time, materials, activities, and people. Changes in the setting may also be effective components of individualized treatment programs, and may be essential for the generalization of treatment effects. Although modifications to the environment cannot usually substitute for contingency management or other therapeutic strategies, they are essential adjuncts and supports to the clinical process, and can contribute to the prevention of dysfunctional and problem behavior.

62.1 20.1 Overview

Behavioral, cognitive-behavioral, operant, and other learning-based therapies are used to address a wide range of childhood problems and disorders including anxiety, depression, conduct disorder, social skill deficits, school refusal, enuresis, sleep disorders, tics, learning disabilities, and developmental disabilities. In most cases, family members are an essential aspect of the treatment program, or the main focus of treatment as in child abuse and neglect. Teachers and staff who interact with the child in community settings may also participate and, in some cases, are the primary means by which treatment is delivered.

The therapeutic process typically involves a planned sequence of interactions and a progression of treatment steps directed toward modifying behavior, feelings, and cognitions to ameliorate the presenting problem and to achieve more optimal functioning in everyday life (e.g., Kazdin & Weisz, 2003). Treatment follows the assessment and case conceptualization, and is corrected based on the measurement of progress (e.g., Freeman & Miller, 2002). It can involve didactic instruction, homework, video presentations, and simulations, as well as verbal communication with the therapist and is frequently based in a clinic or office. Therapists also work directly with clients in homes, classrooms, and childcare programs, and in settings deliberately designed to be therapeutic, such as preschool early intervention classrooms and residential treatment centers. Contingency management, gradual exposure to feared stimuli, and the systematic teaching of adaptive behavior are common types of intervention. There has been an increasing focus on developmental and cultural issues, as they pertain to the intervention process (e.g., Barry & Pickard, 2008; Holmbeck, Greenley, & Franks, 2003; Knight & Ridgeway, 2008), and on the need for adjunctive therapy to address the parental depression, extreme stress, and marital conflict that can accompany childhood disorders (e.g., Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Griest et al., 1982).

There is also frequent discussion on the influence of the environment on the development of disorders, the possibility of prevention, difficulties in accessing treatment services, and the likelihood of adherence to treatment (e.g., Ammerman & Hersen, 1997). In these discussions, the word “environment” has multiple meanings and uses. For example, the environment can include anything that interacts with heredity in the etiology of disorders. A wide range of community and societal variables including economic conditions, violence and crime, educational opportunities, the willingness of insurance companies to pay for mental health services, and the availability of drugs also constitute the environment. “Environment” can refer to the countless variables that interact with one another in a home or similar setting including cultural practices, domestic violence, parental psychopathology, household chaos, social networks, family relationships, single parenting, and a host of other factors. The home environment of a child can be described as altered by the participation in therapy and the implementation of a treatment plan. Finally, the “natural environment” is contrasted with the laboratory or clinic as a location for research or service delivery (e.g., Stichter, Clarke, & Dunlap, 2004; Wilson, Mott, & Batman, 2004). Given these and numerous other uses of the term, it is mandatory for us to define what we mean by the environment.

We use the term “environment” to refer to the organization of an individual’s immediate setting in terms of space, time, materials, activities, and people. Specific variables include architectural features, spatial divisions, and furnishings; objects, materials, and activities; routines and schedules, and the presence, characteristics, and location of people in the setting. The way in which these variables function forms part of the context for people’s behavior and interactions, including those involved in therapy. In many cases, they can be modified to encourage or discourage particular types of behavior or to support therapeutic programs.

With some exceptions, the organization of the immediate setting in which treatment occurs or to which the effects of treatment must generalize has received scant attention in the child clinical literature. There is usually little reference to how the organization of a home, classroom, or residential treatment center might support or hinder therapy. It is even rarer for changes in the organization of a setting, such as its routines, materials, or activities, to be a major part of the intervention, or for settings to be designed deliberately to foster appropriate engagement and prevent problem behavior. This is unfortunate because these variables are continually operating in settings where prevention and treatment occur regardless of whether they are made explicit. Almost any therapy will be adversely affected, for example, by the lack of time management skills and family routines that lead to missed clinic appointments and the inability to carry out the treatment tasks. More specifically, a contingency management intervention designed to decrease aggression among children will probably be supported by a setting in which toys and games that prompt violence have been replaced by those that foster cooperation.

A recent descriptive analysis of the content of selected parent training programs illustrates the lack of attention paid to such variables. Prinz and Jones (2003) described the characteristics of ten family-based treatment approaches for preschool and elementary school children’s conduct problems that involved a Parent Management Training Approach delivered either individually or to a group of families. These programs were described in terms of their operational facets (e.g., feedback and coaching, home observation, and modeling), and their content pertaining to increasing positive behavior, managing misbehavior, and building family relations. Of the more than 50 types of content that were found in these ten programs, only two pertained to family organization or context rather than to ways of interacting with, teaching, or disciplining, a child. One of these was “maintaining a predictable routine,” which was part of the content of Reciprocal Skills Training (Barrett, Turner, Rombouts, & Duffy, 2000). The other was “providing engaging activities and environment for child,” which was part of the Triple P-Positive Parenting Program (Sanders, Markie-Dadds, & Turner, 2001). The inclusion of such information in addition to that on teaching and discipline may be a critical feature for parents in the program who do not have predictable family routines or who do not realize the contribution that activities and play materials can make to the encouragement of appropriate behavior. Including this type of knowledge could contribute to the maintenance of treatment gains and the prevention of future problems.

Research on the power of the environment to influence behavior points to four major reasons for clinicians and others involved with treatment and prevention to be cognizant of the impact that the organization of the immediate setting can have on the therapeutic process. First, aspects of the setting may make it difficult or even impossible for treatment procedures to be implemented consistently, or they may be particularly supportive of such procedures. The absence of predictable routines, for example, means that therapy cannot be integrated into them. On the other hand, the presence of a spouse or a relative may make it easier for one parent to focus on therapeutic tasks because someone is available to supervise other children. Second, some aspects of the setting may support the inappropriate or dysfunctional behavior, feelings, or cognitions that are the focus of therapy. A program to address school refusal, for example, may be hampered by a curriculum that is inappropriate for the student and school policies that do not adequately address the issue of bullying. Third, organizational features of the setting can support or hinder maintenance and generalization. An office-based program to teach social skills to an elementary school student requires everyday settings where it is useful to display those skills and where they can be practiced; there may be few opportunities to do so if recess has been eliminated, socialization at lunch prohibited, and where a lack of sidewalks and playgrounds makes it difficult for children to play together after school. Fourth, the need for therapy directed at individual children may, in some cases, be avoided if settings are organized to support engagement and discourage disruption and aggression. A childcare program that subjects children to long periods of waiting makes it likely that some of the children might use the time for aggression, which may become so serious that they are referred for individual therapy. Modifying the schedule may help to eliminate some of the situations in which aggression is most likely to occur.

Although the organization of space, time, materials, activities, and people in the immediate setting does not receive sufficient emphasis, these variables are sometimes mentioned in descriptions of therapeutic procedures or circumstances that give rise to child problems. For example, Harrington (2005) notes that having little to do makes most psychiatric conditions worse. Thus, an hour-by-hour schedule of daily activities is part of the treatment for youth depression. Comprehensive behavior management programs for attention deficit disorder include an emphasis on organization at home, such as having an area for homework and keeping materials in order (Rapport, Kofler, Alderson, & Raiker, 2008). Green (2005) considered the organizational features of child and adolescent inpatient psychiatry units that seemed to be appropriate for the use of cognitive behavior therapy. He described the therapeutic opportunities provided by these settings including intensive supervision when necessary, structuring of the day around school, meal, leisure, and therapeutic activities and the social therapy that can occur in the context of the routines of daily living.

In the remainder of this chapter, we will highlight the role of the environment, defined as the organization of the immediate setting, for prevention and intervention with childhood problems and disorders. First, we will discuss operant behavioral and ecological developmental perspectives on the way in which variables pertaining to the organization of space, time, materials, activities and people are conceptualized and the processes by which they can affect behavior and development. Second, we will discuss illustrative research from behavior modification and related literatures which demonstrate that these organizational variables can affect behavior. Third, we will suggest ways in which clinicians can integrate this knowledge into therapeutic work with children and families.

62.2 20.2 An Operant Behavioral Perspective on the Environment

Although operant approaches to behavior modification have emphasized consequences, especially those mediated by people, as a powerful means of controlling behavior and remediating childhood problems, it has long been recognized that complex antecedents to behavior are also highly influential. These antecedent conditions are referred to as setting events (e.g., Bijou & Baer, 1961, 1978; Kantor, 1959; Twardosz, 1985; Wahler & Fox, 1981) and are of two general types. One type consists of the individual’s immediate surrounding circumstances, such as the presence of particular objects or people that influence stimulus–response relationships, i.e., facilitate or inhibit the occurrence of behavior that is already in an individual’s repertoire. For example, some types of games “set the occasion” for cooperative play; other types make aggression more likely (e.g., Bay-Hinitz, Peterson, & Quilitch, 1994). The immediate surroundings of a shopping mall encourage wandering and exploration, but the presence of several televisions in a home could make sedentary behavior more likely.

A second type of setting event occurs separately in space and time from the behavior it influences and includes the individual’s response to the event. The biological state of an individual, produced by food or sleep deprivation, illness, or drugs (e.g., Carr, Reeve, & Magito-McLaughlin, 1996) can function as a setting event because it changes the way in which the individual responds to a current situation. Teaching parents to be alert, that is, fully focused on the present moment, can be viewed as influencing the neuropsychological state with which an individual copes with child behavior, perhaps leading to the use of more effective interaction strategies (e.g., Singh et al., 2007). Another example of this type of setting event is the influence that events at home on a “bad morning” can have on the likelihood that a child might refuse to follow the teacher’s instructions or get into arguments with peers at school.

Wahler and his colleagues (Wahler, 1980; Wahler & Graves, 1983) viewed the operation of social networks as setting events. On days when mothers of oppositional children had pleasant interactions with friends, they interacted with their children less negatively than on days when such pleasant interactions did not occur. Similarly, coercive interactions that low-income mothers in parent training had with relatives and helping agencies increased their likelihood of becoming involved in coercive interactions with their children on those days and would disable the correct implementation of contingency management procedures. Another example is a schedule in which active play precedes an event that requires focused attention, thereby making it more likely that young children will be inattentive (Krantz & Risley, 1977). Clearly, variables pertaining to the organization of space, time, materials, activities, and people, which are the focus of this chapter, can function as setting events; however, other variables, such as illness or upsetting interactions can function this way as well.

As functional behavioral assessment and intervention with the challenging behavior of individuals with severe developmental disabilities started dominating mainstream applied behavior analysis, the term “establishing operations” was introduced to refer to the way in which some antecedent events function to alter the reinforcing or punishing effectiveness of other events and the frequency of the behavior relevant to those consequences (e.g., Laraway, Snycerski, Michael, & Poling, 2003; McGill, 1999). This term appears to overlap with “setting events” to some extent. Research on establishing operations has typically been conducted in highly controlled situations and focuses on well-established problem behavior. The types of organizational variables that are the focus of this chapter are only occasionally manipulated in such studies within the natural environment of the participants. Those studies are included in our literature review.

A perusal of the behavioral literature indicates that currently there is widespread disagreement about the terminology, with the terms antecedents, setting events, and establishing operations sometimes being used interchangeably and sometimes distinguished from one another (e.g., Kazdin, 2005; Luiselli & Cameron, 1998; Repp & Horner, 1999). We will use the term “setting events”, because it has been associated with behavioral research conducted in a wide range of natural settings, with a great diversity of problems and participants, both typically developing and developmentally disabled, and with research on the effects of complex organizational variables on behavior.

62.3 20.3 A Developmental Perspective on the Environment

Bronfenbrenner’s (1979) ecological model of human development incorporates not only variables operating in the immediate settings of an individual, but also the influences of the larger community, society, and culture on what occurs in those immediate settings (e.g., Anderson & Mohr, 2003; Bradley & Whiteside-Mansell, 1997). Knight and Ridgeway (2008) described the world of the child and family who are in therapy using this model. The child’s psychopathology exists within the family microsystem, where it affects and is affected by events and relationships within that system. The microsystem exists within larger circles of influence comprising interactions among microsystems, such as communication or conflict between home and school, and organizations outside the family, such as workplaces with schedules and sources of stress that impinge upon family time and activities. The values of the society and culture that may be similar to, or different than, the ones held by family members form the outer circle of influence. The authors encourage clinicians to use this model as a rubric when conceptualizing the presenting problem and intervention; they view their clinical work as a process of creating a new microsystem for the child in which change can occur.

However, a later and more elaborated version of Bronfenbrenner’s model (Bronfenbrenner & Ceci, 1994; Bronfenbrenner & Morris, 1998; Ceci & Hembrooke, 1995) is more relevant for our understanding of the influence of the organizational variables in the immediate setting. It focuses more precisely on what occurs within microsystems, which are defined as patterns of activity, social roles, and interpersonal relationships in settings made up of physical, social, and symbolic features that invite or inhibit engagement. Homes, childcare centers, classrooms, residential treatment centers, and other community settings are classified as microsystems. These, in turn, are nested within more distal systems. “Proximal processes”, frequent, stable, reciprocal, and progressively more complex patterns of interaction between an individual and the persons, objects, and symbols that surround them occur within microsystems, and are the means by which development occurs, changing genotypes into phenotypes. Adult–child interaction, playing with objects and peers, acquiring new skills, and caring for others are examples of proximal processes. The number and level of proximal processes in an individual’s microsystems help to determine, in conjunction with the characteristics of the developing person, individual competence or dysfunction.

Proximal processes occur within and draw upon the physical, social, and symbolic resources provided by the immediate environment of the microsystem, including whether or not the physical environment invites exploration and is responsive to behavior and whether or not there is temporal regularity or unpredictability of activities. The microsystem must also import resources, such as knowledge, from the more distal surroundings of the neighborhood and larger society. The presence, absence, and use of resources either supports or hinders proximal processes and is part of what is meant by saying that an individual’s environment is enriched, well organized, and advantaged or impoverished, chaotic, and disadvantaged. A study by Evans, Maxwell, and Hart (1999) illustrates the interplay between a proximal process and the resources of a setting. They found that parents in more crowded homes speak in less complex and diverse ways to their children and are generally less responsive to them than parents in less crowded homes; this effect was unrelated to socioeconomic status or number of children in the family. They proposed that people cope with the unwanted social interaction that accompanies crowding by withdrawing from one another. Too many people in a confined space may be a hindrance for some of the proximal processes involved in language acquisition.

The distinction that Bronfenbrenner and his colleagues draw between proximal processes and the resources of the surroundings is very helpful. Environment is not simply defined as everything that exists or is experienced within a setting, but has a more precise meaning. Organizational features are ways in which the physical and social resources of a setting are arranged to support or hinder individuals’ interactions with people, objects, and symbols (Roskos & Twardosz, 2004). The prevention of childhood problems can be viewed as resulting partially from settings in which these resources support the proximal processes that lead to competence. The consistent implementation of an intervention may be viewed as a proximal process which is surrounded by the way in which space, time, materials, activities, and people are organized and operate in the immediate setting. Some of these resources support the intervention and others do not. Knight and Ridgeway (2008) point out that people in a child’s life can be a resource, because more are available to help with the therapeutic process. However, people can be a hindrance as well if they disagree about the usefulness of therapy.

Both operant behavior modification and developmental ecological perspectives contribute to our understanding of the effects of organizational variables on the individual. As setting events, they are linked to the operation of consequences, to other setting events, and to other antecedent events, such as prompts, that also act to make behavior more or less likely to occur. It connects them to a change-oriented point of view, that is, these variables can and should be changed to benefit children and their families. On the other hand, the bioecological framework connects the genetic makeup of the individual with the surroundings that contribute to gene expression. It focuses attention on the importance of fostering the development of the individual as well as responding to the occurrence of specific problems and disorders. The distinction between proximal processes and the resources that support or hinder them helps bring organizational variables into sharper focus. Both of these perspectives emphasize the critical importance of an individual’s engagement with the surroundings; engagement brings the individual into contact with consequences and is one of the means by which development occurs.

62.4 20.4 Basic Competencies

All professional psychologists should be knowledgeable about how the environment shapes behavior and how manipulations of the physical and social aspects of the immediate setting can be used to achieve desired changes in a client’s behavior, social and family relationships, success in school and other settings, and mental health. They should have skills commensurate with this knowledge and be able to implement such environmental changes. In working with children and families, the basic competencies include: appreciating the relationship between productive engagement and the prevention of problem behavior, and using the environment to increase engagement; recognizing how architectural features, spatial division, and furnishings can influence the shaping of behavior; using materials and planned activities to achieve goals; modifying the organization of time through new routines and scheduling to achieve change; using the presence, characteristics, and location of people to naturally modify behavior; and recognizing that the setting is a system with all the implications for planned and unplanned changes that are involved. This section describes theory, research, and examples of effective practice for each of these competency areas.

62.4.1 20.4.1 Organization of Settings for Prevention and Remediation

Engagement. The productive engagement of people with their surroundings is fundamental to development, learning, and the prevention of problems that may ultimately require intervention (Bronfenbrenner & Ceci, 1994; McWilliam, Trivette, & Dunst, 1985; Risley, 1977, 1996). Individual characteristics, nature of the relationships people have with one another, culture, neighborhood safety, developmental level, and a host of other variables contribute to the amount and type of engagement that occur. The organization of space, time, materials, activities, routines, and people in the immediate setting interact with all of those factors to contribute to engagement, because they operate continuously as setting events, making the occurrence of some types of behavior more likely than others.

Homes, classrooms, and residential facilities where productive engagement is high are likely to be those where angry, disruptive, and aggressive behaviors are infrequent. In those settings, there are no long periods of waiting with nothing to do; children are supervised; there are some planned activities and routines with clear goals; space and materials are organized to support them; there is a predictable schedule; and adults’ relationships with one another are positive and supportive. Adults in these settings are working hard but they are not overwhelmed because characteristics of the setting, such as the right equipment, support them. These are settings that are most likely to support intervention for a specific child problem, disability, or skill deficit because parents, teachers, and staff have the time and energy to implement therapeutic procedures consistently and the organization of the setting does not work against the goals of treatment. Moreover, since people are productively engaged most of the time, there is less need to use procedures to decrease behavior, and when such procedures are necessary, they can be gentle rather than severe (Risley & Twardosz, 1976; Twardosz, 1984).

Lack of productive engagement takes many forms. At home, children may spend hours watching anything that is on television, engage in fights with siblings, and annoy parents with minor complaints and major tantrums. At school, children may have little to do for significant periods of the day, as they transition from room to room and wait for teachers to complete administrative duties or cope with children with challenging behavior. Asking about engagement implies that the operation of setting may be the problem rather than, or in addition to, the individual who has been referred for treatment and that some of the organizational features of the setting may need to be altered. In general, if many children are not productively engaged or are involved in dysfunctional behavior, the setting is viewed as problematic. Not only might the development and learning of everyone in the setting be at risk, but also it would be extremely difficult to make progress with the clinical problem of an individual in that situation.

There are many specific ways in which settings can be organized to promote engagement and discourage dysfunctional behavior. Family or program composition, cultural and socioeconomic circumstances, resources and dangers in the environment outside of the immediate setting, and so forth, will help determine how this occurs. People are also remarkably good at adjusting their behavior to the characteristics of even the most inconvenient settings to meet the challenges of supervising, caring for, and educating children, often at great cost to themselves. However, although there is not just one “right” way to do things, research conducted in natural settings, using primarily single-case experimental designs and direct observation of behavior, does indicate that specific arrangements of organizational variables can promote engagement, discourage dysfunctional behavior, and facilitate adults’ activities and interactions with children. This research can provide clues about why a setting might be functioning well or badly and how the everyday operation of that setting could be altered for the benefit of all the members.

However, no matter how well-organized homes and community-based settings are in terms of promoting productive engagement and preventing problem behavior, individualized therapeutic programs will still be required. These programs rely primarily on the behavior of other people who must, for example, change the way they give instructions, grant or deprive children of privileges, ignore certain types of behavior, assist children in coping with anxiety-provoking situations, and teach specific skills. Modification of aspects of the immediate setting, such as materials and activities, schedules, the structure of routines, and the types of people in the setting can form part of these interventions, perhaps substituting for some of the personal effort.

The illustrative research described here contains examples of both of these uses of organizational variables, that is, to increase engagement and prevent dysfunctional behavior and to address the problems of individual children. The research was conducted in group care settings, classrooms, and homes, and involved typically developing children including children with disabilities, as well as their parents, caregivers, and teachers. Reversal and multiple baseline experimental designs and the direct observation of behavior were the primary methods used in these studies. Definitions of engagement varied across studies, sometimes including a broad range of behavior appropriate to an activity or time of day, and sometimes focusing more specifically on behaviors such as cooperation with peers, language use, or compliance. (Common measures of engagement can be found in Nordquist & Twardosz, 1992.)

Architectural features, spatial division, and furnishings. The architectural features of existing settings cannot be easily modified; people typically adapt to them but can also become more aware of how they may impact their activities. A limited number of architectural features have been examined in the behavioral literatures for their effect on ease of supervision and engagement. For example, how open (not divided by many permanent walls) or closed a space is can make supervision easy or more difficult. Twardosz, Cataldo, and Risley (1974) conducted experimental studies using movable partitions in infant and toddler day care classrooms. They found that open space did not interfere with children’s sleep or participation in preacademic activities, but it did make it easier for staff to see children or to bring them into view in just a few steps. It also made it easier for the supervisor to see the staff. However, these classrooms were divided into areas by low barriers and furnishings. Not only can this practice increase engagement, but it can also provide a degree of privacy and seclusion in group care settings.

Spatial definition, the degree to which parts of a setting are differentiated from one another and contain the resources necessary for the intended activity was found by Moore (1986) to be associated with more exploration, immersion in activities without interruption, cooperation among children in preschool classrooms, and teacher encouragement rather than attempts to control. The division of space into areas furnished to set the occasion for particular types of play is the most common and effective way to design group care settings for young children. It is also currently used as a means of encouraging independent or group work in elementary school classrooms. Weinstein (1977) addressed problems in the way second and third grade students were using a classroom that was divided into subject areas. Design changes were made to areas that were infrequently used or that were used for unintended purposes, such as roughhousing in the reading and writing area. They included the addition of shelving, chairs and tables so that materials could be used more easily, and the addition of a cardboard house that provided some private space. No changes or additions were made to materials or equipment. Results indicated that children were dispersed more evenly across areas after the changes, they engaged in a greater range of appropriate behavior, and girls used the science and games area more frequently. However, the author noted that design changes did not necessarily counter children’s strong preferences or dislikes for certain activities.

Consideration of the ways in which architectural features can support engagement, supervision, and privacy extend to community-based treatment settings and to homes. For example, semi-private rooms arranged along a corridor in residence and day treatment programs provide more privacy for clients. Unfortunately, they also make it easier for assaults, self-injury, tantrums, and other dysfunctional behavior to occur without staff knowledge, whereas open-ward conditions facilitate more immediate delivery of consequences or other forms of therapy (Clark, Ichinose, & Naiman, 1990).

In homes, parents must continually adjust their supervision and children’s access to privacy as their children develop; the effort required to do this varies depending on how homes are constructed. Given the number of permanent walls in many homes, supervision of activities such as the use of computer, television, and video games may be facilitated by locating them in the more public, open spaces of a home. Spatial division in homes, with areas set aside deliberately for activities that require extra support, such as doing homework, may encourage engagement in these activities. An oft-repeated recommendation for encouraging children to read for pleasure at home is to provide a sheltered space with books nearby that is quiet and comfortable (e.g., Morrow & Temlock-Field, 2004).

Materials and planned activities. The judicious use of materials and activities is probably one of the most effective ways of insuring that a setting promotes engagement and discourages disruption, aggression, and other dysfunctional behavior. Studies indicate that simply providing specific types of materials can set the occasion for social rather than isolated play in an after-school recreation program (Quilitch & Risley, 1973) and in an integrated summer program for prekindergarten children (Martin, Brady, & Williams, 1991); for attention and play rather than self-stimulation and handling of medical equipment on a pediatric intensive care unit (Cataldo, Bessman, Parker, Pearson, & Rogers, 1979), and for the incorporation of literacy themes into children’s play (Neuman & Roskos, 1992).

Books can also be useful for keeping students productively engaged when teachers are working with other students or engaged in administrative tasks. This was the practice in a middle school religion class; nevertheless, the disruptive behavior of a 12-year-old boy who had been diagnosed with AD/HD and oppositional defiant disorder (ODD) persisted until a book without pictures was replaced with religious comics or books with pictures. Disruptive behavior decreased – an effect that was enhanced by moving him away from preferred peers. It should be noted that this classroom was part of a residential facility, in which a token economy and other behavioral programming operated (Hoff, Ervin, & Friman, 2005).

McGee and Daly (1999) evaluated arrangements of play materials within a therapeutic preschool program serving both children with autism and typical children. The explicit philosophy of this program was to encourage engagement and discourage dysfunctional behavior through setting organization; individual treatment occurred in this context. The most effective condition for promoting engagement and decreasing negative behavior during freeplay was twice weekly toy rotations and inclusion of hobby boxes that contained materials preferred by individual children. Teacher behavior remained consistent throughout all the conditions of the study, lending more credibility to the conclusion that it was the materials and not differences in teacher attention that were responsible for the behavior changes.

Determining which materials are preferred through direct observation or designing toys specifically for individuals with developmental disabilities who may have difficulty becoming productively engaged has a long history (e.g., Favell & Cannon, 1977; Murphy, Carr, & Callias, 1986; Reid, DeCarlo, Schepis, Hawkins, & Stricklin, 2003). The purpose of this approach is to promote engagement and discourage dysfunctional behavior by enhancing the everyday environment with preferred materials. The following studies extend this idea to games and to the combined use of organizational variables and contingency management.

Murphy, Hutchinson, and Bailey (1983) addressed the problem of aggression on an elementary school playground where more than 300 children congregated in the morning by experimentally evaluating the provision of organized games (races and jump rope). The number of aggressive incidents dropped drastically as soon as the games were introduced. Although a time-out procedure was implemented along with the games, it was seldom used despite the fact that several hundred instances of aggression occurred daily during baseline. Similar results with preschool children’s aggression and cooperation were obtained by providing competitive versus cooperative games (Bay-Hinitz et al., 1994).

Teaching parents to use planned activities in conjunction with contingency management was investigated in a group of studies with parents whose preschool-aged children were difficult to manage. Sanders and Dadds (1982) focused on the problems parents had using contingency management procedures outside of the home, when shopping or waiting in doctors’ offices, or when they were occupied at home, such as talking on the telephone, and there was little for children to do. They trained parents first to anticipate that problems might arise in certain situations and then to arrange the situation to minimize their occurrence by briefly discussing rules in advance, and providing activities for children in those settings (games that could be played in the car, finding items on a shopping list). The addition of Planned Activities Training (PAT) to a package of contingency management procedures (CMT) resulted in improvements above and beyond what was found with CMT alone.

PAT has been evaluated in combination with CMT (Sanders & Christensen, 1985; Sanders & Plant, 1989) and alone (Huynen, Lutzker, Bigelow, Touchette, & Campbell, 1996). In the latter study, mothers of children with developmental disabilities who had sought help for their children’s disruptive and noncompliant behaviors were taught a variety of planning, interaction, and teaching strategies for problems that occurred at specific times of the day and in the community. Praise and mild consequences for inappropriate behavior were included in this version of PAT, but the majority of the training involved preventing the problems through arranging setting events. The skill of designing planned activities for situations that are likely to set the occasion for children’s undesirable behavior is also included in Project SafeCare, an in-home ecobehavioral approach for treating and preventing child neglect and abuse (e.g., Gershator-Molko, Lutzker, & Wesch, 2002).

The provision of materials and planned activities not only helps to prevent problems but also assists children’s learning, because both the materials and peers provide feedback that may lead to increased skill development. Specific arrangements of materials also form an essential part of the context of highly developed teaching strategies to assist children with language difficulties (e.g., Hancock & Kaiser, 2006). However, simply providing materials is often not sufficient to increase engagement; some children with disabilities will require individualized instruction and reinforcement to promote even the simplest types of materials’ use. Any child, however, will need adult guidance, teaching, and encouragement with materials that they cannot use productively alone. The presence of such materials in homes can provide opportunities for parent–child interaction.

Organization of time through routines and scheduling. The way in which routines are structured, predictability of scheduling, precedence of certain activities over others, and the way people share responsibility for managing routines in home and community settings can function as complex setting events for engagement and inappropriate behavior. Two studies illustrate the way in which replacing cafeteria-style with family-style dining can set the occasion for particular types of engagement. Doke, Feaster, and Predmore (1977) evaluated family-style dining with youths at a psychiatric treatment facility who obtained their trays, ate, and then left the dining room to smoke and socialize in a poorly supervised area. When family-style dining, which included table-setting and cleanup tasks, serving one’s food from bowls, music, and rules for appropriate behavior, was implemented, the youths remained in the dining room and participated longer compared with conditions of cafeteria-style dining and youths who did not eat in family-style. This effect was replicated in a residential facility for developmentally disabled boys, where family-style dining simply involved helping oneself to portions from serving bowls rather than obtaining food on a tray (VanBiervliet, Spangler, & Marshall, 1981). Staff did not sit at the tables with the boys or serve the food but simply supervised residents in the entire dining room. Not only did the boys remain at the table longer, but they also talked more to one another and their comments went beyond asking for food. If the boys had been involved in structured programs to encourage more elaborate language, this situation would have provided the opportunity for generalization of those skills.

There are few existing studies in which scheduling was viewed as an independent variable, systematically changed, and the effects on engagement observed. Much like architectural features, the schedule that operates in group care settings or homes may be viewed as something unchangeable to which people must adjust their behavior. The following examples indicate that this need not be the case. Several studies conducted in compensatory preschool classrooms demonstrated that a schedule comprising concurrent activities, where children could leave an activity when they were finished and become involved in another activity, was superior in promoting engagement compared with sequential schedules where all children were required to finish an activity before any of them could move to the next one (Doke & Risley, 1972; LeLaurin & Risley, 1972). It is easy to imagine what could occur during the lengthy periods of waiting that often accompany sequential scheduling. In these kinds of situations, children have little to do except whine, bicker, and perhaps become aggressive. When periods of waiting are repeated day after day, children who are more likely to respond with negative behavior will have ample opportunity to engage in it. Under these circumstances, any type of adult attention that follows negative behavior may function as a reinforcer. Concurrent schedules require that teachers divide the responsibilities by supervising the different areas in which activities occur, rather than accompanying specific groups of children as they move from area to area. This is the division of responsibilities that often occurs in families when one adult assists a child with homework and another cleans the kitchen, answers the phone, and supervises another child in doing a chore.

Another aspect of the organization of time is the predictability of schedules. This dimension was investigated by Frederiksen and Fredericksen (1977) in a classroom for developmentally delayed adolescents. Activities in the classroom occurred in a fixed sequence and then in random order; the teacher was instructed to apply the same consequences for appropriate and inappropriate behavior throughout the study. Random schedules resulted in more disruptions and less task completion. Effects were more serious for students who had performed most poorly during the predictable schedule. However, there was some indication that students were responding more favorably to the unpredictability by the end of the study.

Krantz and Risley (1977) compared the alteration of a setting event to contingency management for their effects on kindergarten children’s attention during story periods. When an active period of dancing, musical chairs, or outdoor play preceded book reading children took a longer time to transition to the activity, displayed a lower amount of attention, and engaged in a much greater number of disruptions. These problems were remediated using contingent praise and privileges, but they were prevented by preceding storytime with a brief heads down period. In this situation, a mild problem was addressed just as effectively by modifying a setting event as by using consequences.

Sometimes changes in a personal schedule or routine can be effective in the remediation of individuals’ severe challenging behavior that does not appear to be related to opportunities for engagement in the immediate setting. Functional assessment was used to investigate the problem behavior of two students with severe disabilities who were attending a special education class at a high school (Kennedy & Itkonen, 1993). It was determined that when one of the students overslept a series of events occurred, including needing help to get dressed, that culminated in aggression toward herself and other students during the school day. For another student, problem behaviors seemed to be provoked by the particular route taken by the aide who drove her to school. Insuring that the former student woke up on time so that her morning routine went smoothly and that the aide took the highway rather than the city route all but eliminated the problem behaviors in both students.

Routines and schedules obviously provide some of the basic structure for family life and can serve as the context for the implementation of treatment procedures. This point will be illustrated in the clinical cases presented at the end of this chapter.

Presence, characteristics, and location of people. Simply locating children who need to acquire or elaborate their skills with children who already display those skills can be an effective intervention. Buell, Stoddard, Harris, and Baer (1968) demonstrated this effect experimentally when they deliberately used teacher attention to increase the time that a socially isolated preschool girl spent on outdoor play equipment. Simply being where other children were playing led to social interaction with them and improvement in several social skills with no further teacher direction. Another use of peer presence and characteristics was Furman, Rahe, and Hartup’s (1979) study involving 24 children from 19 childcare classrooms who were mildly socially withdrawn. They were randomly assigned to play sessions outside of the classroom with younger peers or same age peers. Although both treatments were effective compared with a control group in increasing classroom peer interaction, play with younger peers produced greater improvement for a larger number of children, perhaps because they had more opportunity to exercise leadership with younger children. The results of these studies draw attention to variables that are operating in natural settings continually and that can sometimes be used effectively to address mild childhood problems.

Mixed income groupings of children in preschool classrooms are currently being evaluated as a strategy for increasing the gains in language development for low-income children. It has been argued that middle-income peers may provide more modeling of diverse vocabulary and perhaps prompt adults to engage in more child-directed talk in contrast with preschools composed entirely of low-income children (Schechter & Bye, 2007). Preliminary evidence confirmed that there were gains in receptive language without additional language instruction. Unfortunately, direct observation in the classrooms did not occur, so we do not know the process by which these gains might have been produced. It is important to remember that locating children together will only be the first step in an intervention program for children with serious social and language deficits. The existence of numerous approaches for the deliberate development of social competence, including language acquisition and use, is testament to the fact that setting the occasion for these behaviors may be a small part of the intervention effort (e.g., Brown, Odom, & McConnell, 2008).

Another dimension of settings pertaining to the presence of people is how many occupy a defined space. It was mentioned previously that Evans et al. (1999) found that parents in crowded homes speak in less complex and diverse ways with their children. As noted by McAfee (1987), there is conflicting evidence about the effects of crowding on negative behaviors such as aggression in group care settings for children, partly because teachers may adapt more structured and directive styles, children may isolate themselves, and the activity that is occurring may affect the outcome. McAfee used an alternating treatments design and observed developmentally delayed adolescents in two public school classes using a portable partition to reduce work space per child. The results indicated that, although aggression was quite variable across children, the vast majority of them exhibited more aggression during the crowded conditions.

Krantz and Risley (1977) experimentally addressed crowded and uncrowded conditions during kindergarten storytime and teacher demonstration periods. They systematically varied the density of children by seating them apart or together on a blanket, and found that much higher rates of on-task behavior occurred in the uncrowded condition. Contingent praise and classroom privileges, however, were effective in increasing such behavior during the crowded conditions. Studies like these point to the obvious fact that it is sometimes more reasonable and efficient to set the occasion for engagement rather than to provide consequences that are necessary in large part because of the inefficient arrangement of the setting.

62.4.2 20.4.2 The Setting as a System

Most of the research described in the preceding text focused on changes produced in engagement or problem behavior when one organizational feature of a setting was changed. However, each of these elements depends on the others and also on the behavior of people in the setting (e.g., Nordquist & Twardosz, 1990; Thompson, Robinson, Dietrich, Farris, & Sinclair, 1996). Specific architectural features, such as openness for supervision, make it possible for a greater number of concurrent activities to occur because another adult does not need to be present for the space on the other side of a wall to be used. This, in turn, can prevent the problems that may occur from crowding. Similarly, an abundance of toys and books that attract the attention of children in a household may not exert much effect on learning if children’s schedules do not leave sufficient time for play and parents’ schedules do not include time for them to help their children use the materials.

Nordquist, Twardosz, and McEvoy (1991) investigated the effects of combined changes in spatial division, availability of materials and activities, the daily schedule, and division of teacher responsibilities. They reorganized two classrooms for children with autism that operated in a mental health facility. Each classroom served three school-aged boys with a teacher and aide. Lack of child engagement and teacher frustration characterized these classrooms before the study. The rooms were divided into instruction and freeplay areas of equal size with some toys, many of which were broken, located on shelves. All children and both teachers moved from the instruction area to freeplay together, approximately every 20 min in a sequential schedule. During instruction, one teacher moved from one child to another administering discrete trial training while the aide tried to prevent the other two children from self-stimulating and becoming disruptive. Instructional materials often were out of reach of the teacher, which caused even more waiting. During freeplay, the children typically lay on beanbag chairs, manipulated materials, often in a stereotyped fashion, or wandered around the classrooms; there were no organized activities or games. It was concluded that the organization of the setting was the primary problem because it was promoting dysfunctional behavior and preventing the efficient implementation of individual therapy. Reorganization was implemented in a multiple baseline design and was comprehensive. Most of the classroom space was devoted to freeplay with a smaller area for discrete trial instruction. Freeplay was divided into areas for art, music, small manipulatives, water play, and large motor toys; approximately one-third of these were rotated each week, partially based on children’s preferences, which were recorded daily by the teachers. Children rotated individually through short periods of discrete trial training and longer periods of freeplay, which usually meant that the opportunity to engage in preferred activities followed successful task completion. Teachers assumed responsibility for areas and were not given any instructions about how to interact with children in freeplay other than asking them at the beginning of the intervention to encourage the children to use the materials.

This comprehensive reorganization resulted in substantial increases in children’s engagement with materials and compliance in both the instruction and freeplay areas. These increases could not be explained by changes in concurrent teacher attention, prompts, or the use of time-out. An unexpected and more surprising result was the immediate and sustained increases in smiling and affectionate statements teachers directed toward the children, even though there was little increase in the total amount of adult attention children received. The complex combination of setting events that characterized these classrooms at the end of the study clearly served as a quite different context for the individually tailored clinical programs designed for these children.

Space considerations do not permit a comprehensive review of the research on organizational variables or the numerous applications of the results in fields devoted to improving the circumstances of individuals with developmental disabilities and challenging behavior. Additional sources on the use of setting events include a discussion by Kern and Clemens (2007) on classwide and individual applications of antecedent strategies to enhance motivation and prevent problems in schools. Many of these strategies involve changes in the presentation of academic tasks (e.g., Munk & Karsh, 1999), a topic that has not been discussed in this chapter.

62.5 20.5 Expert Competencies

The expert clinician is able to apply all of the basic competencies in everyday practice; such a clinician’s practice may be defined by the creative use of environmental modification to achieve goals with or without the concurrent use of contingency management or other therapeutic strategies. These psychologists are recognized in their communities as the people to be contacted for consultation or assistance in solving complex problems. These experts understand the implications of the basic competencies for clinical practice and, in each assignment or client case, creatively answer three questions while designing and implementing changes. We begin this section with a review of the implications for clinical practice of the basic competencies and present the questions about the immediate environment employed by experts to shape their practice.

62.5.1 20.5.1 Implications for Clinical Practice

Research on the environment, defined as the organization of space, time, materials, activities, routines, and people, shows that these variables can affect behavior in a wide range of settings where prevention and remediation occur. This research points to the importance of considering the organization of settings as part of the clinical process similar to the importance of considering developmental and cultural issues and the impact of the more distal environment such as the safety of neighborhoods or economic and social policies. Knowledge about how spatial division, schedules, routines, people, materials and activities can be arranged to produce specific effects can assist with the modification of settings that are contributing to problem behaviors and the design of interventions for individual childhood problems and disorders. It can inform clinical practice and add to clinical competency. Although attention to the organization of settings is not absent in the clinical literature, it is a topic that deserves much more specific focus.

As setting events, organizational variables can produce changes quickly because they depend upon previously acquired behavior for their effects and some of these changes may be broad in scope. However, this also means that they cannot substitute for the individualized therapeutic programming required to remediate well-established dysfunctional behavior or skill deficits. They can, however, be used in conjunction with and in support of such programs and can help insure that settings in which the child practices newly acquired skills provide opportunities and reinforcement for them, and that settings do not, themselves, promote the dysfunctional behavior that is the target of treatment. Modifying such variables often does not require the influx of additional resources but simply the rearrangement of what is already present in a setting.

62.5.2 20.5.2 Integrating Environmental Considerations into Clinical Practice

There are three broad questions that can guide clinicians and others involved in prevention and remediation as they consider the role of the immediate setting while working with the unfolding circumstances of a particular case. The first question is: “Does the organization of the home, classroom, residential treatment center or other community-based setting generally promote children’s safety, supervision, and productive engagement, minimize the occurrence of dangerous situations and dysfunctional behavior, and leave the adults with enough time and energy to participate in the therapeutic process?” In extreme circumstances, of course, danger to children is addressed by removing them from the home or closing a group care setting. Disorganization coupled with desperate economic circumstances, family violence, or drug abuse can lead to referral to agencies concerned with family survival. In some cases of neglect or abuse, intensive training in basic household safety, cleanliness, healthcare, and parent–child interaction may be warranted, such as the in-home training provided by Project SafeCare (e.g., Lutzker & Bigelow, 2002; Lutzker, Bigelow, Doctor, & Kessler, 1998). Even if children are safe and supervised, they may be involved in so little productive engagement that it may be necessary to implement changes to the setting before or in conjunction with treatment for individual problems, just as adjunctive therapy for mental health problems or marital conflict might accompany parent training for the management of conduct disorder. For example, within a residential treatment program, clinical work to address the high and dangerous levels of aggression of one child could occur concurrently with modification of the schedule and activities of his living unit where there are low levels of productive engagement and many of the children are frequently aggressive.

Parents who are economically secure and who do not suffer from mental illness or marital strife may simply be overwhelmed with responsibilities that prevent them from completing treatment programs, despite the fact that they know a problem exists and desire assistance. For example, a mother with a preschool-aged child who is becoming increasingly noncompliant, aggressive, and unhappy may be unable to handle the additional responsibility of learning how to implement contingency management procedures if she also has two other young children, a husband who works very long hours and is required to travel, and no relatives or friends nearby that she can rely upon for help. In addition, because she finds it impossible to set up and maintain a predictable schedule of daily routines, partly because of the child’s noncompliant, disruptive, and aggressive behavior, the situation is rapidly becoming worse. Even if a mother in such circumstances manages to find a suitable treatment program, she may soon discontinue attending sessions, adding to the high dropout rates for behavioral parent training that are only partially understood (e.g., Barkley et al., 2000; Brinkmeyer & Eyberg, 2003). The stress she experiences just getting through each day would detract from learning new ways of responding to the child and simply getting to the clinic would be a challenge. It is unlikely that continued refinements in parent training methodology or high levels of approval from the therapist would be sufficient to overcome these obstacles; however, discussion and specific guidance about how to modify some of the organizational features of the home, including obtaining assistance from her husband or other sources, could make it easier for her to meet all of her responsibilities and make it more likely that she could implement contingency management procedures to address her child’s noncompliant and aggressive behavior.

Another question that is helpful for guiding the use of this knowledge in clinical practice is: “Can a change in some aspect of the organization of space, time, materials, activities, routines, or people constitute part of a treatment program for a childhood problem or disorder?” In this case, the focus is on the individual problem rather than the setting as a whole, but changes in the way that some part of the setting is organized could contribute to the treatment, perhaps making it easier to implement or adding to its effectiveness. Evidence that spatial division, materials and activities, routines and schedules, and the characteristics and location of people can affect behavior has appeared throughout this chapter. The case examples provided below show how changes in these features can be tailored to contribute to the treatment for individual children.

A family sought clinical assistance because their 5-year-old daughter filled the time between dinner and bedtime with noncompliance, tantrums, and aggression toward parents, which made it very difficult for their school-aged son to complete his homework or interact with friends. Although it was agreed that contingency management would be a major part of treatment, it soon became clear that the absence of a predictable sequence of routines, including time shared with a parent doing a preferred activity, was probably contributing to the problem and would work against the implementation of treatment. Moreover, the setting was not structured to help produce compliance. Thus, in addition to training in contingency management, the clinician assisted the parents in using routines, scheduling, and materials to set the occasion for the desired behavior. They designed a predictable order of evening routines that culminated in reading to the child before bed. The preferred activity of reading followed cleaning up toys and taking a bath, which was resisted by the child. Adding toys to the tub was a technique used to make it more likely that the child would comply with the instruction to get in the tub and could then be praised by the parent. Although training in contingency management was still a critical component of intervention, it is likely that the reorganized evening routines and materials helped to produce the decrease in noncompliance and increase in cooperation that occurred.

Combining contingency management with modification of some of the organizational features of the home was also used with a mother who sought treatment because her 15-year-old daughter would not do her homework and had begun to receive failing grades at school. This was one of several problems that had worsened after she and her husband divorced, and it added to their frequent arguments. The mother worked full-time and was taking two classes at night to earn a nursing degree but she was uncomfortable because she feared that her daughter’s boyfriend was at the house in her absence. The mother reported that two previous attempts to obtain treatment had ended poorly. One clinician did talk with her about her concerns but did not provide suggestions for improving the problems. Another clinician recommended the use of a token economy at home and at school; however, the teachers refused to cooperate saying that this strategy did not work with adolescents.

Because the mother was under a great deal of stress and showed signs of depression, the therapist referred her to a psychiatrist who prescribed a mild antidepressant and provided cognitive therapy. The therapist also persuaded her to drop one of her evening classes and promised to assist her in obtaining a modified work schedule so that she could take a class during the day if her situation at home improved. Mother, daughter, and therapist collaborated to develop the following intervention. A homework chart was devised so that the daughter could record homework assignments and obtain teacher signatures. The consequence for not doing homework was loss of phone privileges until it was completed. In addition, a number of changes to the space, routines, and schedules of the home were implemented to set the occasion for homework completion and more pleasant interaction between the mother and daughter.

First, rather than beginning homework right after school as previously required, the schedule was changed so that the daughter could talk on the phone, listen to music, or engage in other preferred activities provided that friends did not come over. When the mother returned from work, they would prepare a meal or eat out and converse only about positive topics. This was perhaps easier to do now because there was no need to argue about why homework had not been done. Dinner was followed by a 1 hour study period that took place in the dining room rather than the daughter’s bedroom. Small shelves were bought for books and supplies and the computer was set up on the table. Rather than doing her own studying late at night, the mother studied with the daughter. Phones and the TV were off, although music could be played if they both agreed. If homework was completed, the rest of the hour could be spent reading. Getting ready for bed was followed by another period of preferred activities. This schedule was followed from Sunday through Thursday, including the night the mother was in class.

This combination of procedures quickly produced very favorable outcomes in terms of homework completion, improvement in grades, a decrease in arguments, and discontinuation of the homework chart. Within 6 months, the mother was off the antidepressant and had obtained a change in her work schedule so that she could take a class during the day. It is important to note that changes to the setting were made without any visits to the home by the therapist. The therapist included a consideration of organizational variables in discussions with the mother and daughter about factors in the home that might be contributing to the problem, and how they might be changed as part of an intervention. Specific questions were asked about how space, time, materials and activities, routines, and the presence of people operated in that particular home.

The final question is: “Does the organization of the immediate setting provide any specific supports for a planned intervention or are there any clear hindrances to its implementation?” Given that we often take the details of our immediate setting for granted and fail to appreciate the power they might have over our behavior, it is likely that parents, teachers, and staff do not realize what they have on hand to assist them in the implementation of treatment. Flexible space, predictable schedules, the willingness of both parents (or other adults in the household) to share responsibility for the children, well-established routines, and a network of relatives and friends who can be relied upon for help can obviously make it much easier for intervention to be implemented consistently (Dolezal-Sams, Nordquist, & Twardosz, in press). Some family members might also have particular characteristics or knowledge that would be useful for developing ties with a child’s classroom teacher who might then be more willing to change some features of the classroom routine for a particular student. Similar supports could be listed for classrooms, residential treatment centers, and other community settings.

On the other hand, it is critical to take stock of the hindrances to treatment implementation that exist in the immediate setting, particularly those that are not amenable to change. Crowded space, lack of people who can be counted on for help, constant distractions, work schedules that do not permit family members to spend much time together, and economic circumstances that do not permit the purchase of materials are realities for many families and community settings that also face difficulties with an individual child who needs intervention. Other hindrances may be more specific to the problem that is being addressed with individual therapy, such as lack of space to exercise for children who are in treatment for obesity, or the lack of transportation that prevents a child from remaining after school for social activities that might contribute to some phases of therapy for social anxiety. Obtaining detailed information about potential hindrances and the supports that could compensate for them would contribute to the design of interventions that would fit into and take advantage of the child’s setting.

62.6 20.6 Summary

The environment, broadly defined, has long been a concern for clinicians who work with children and their families because it can impact efforts to prevent and intervene with problems and disorders. Research on the environment, defined as the organization of space, time, materials, activities, routines, and people in the immediate setting of the individual, indicates that these variables not only affect behavior, but also are amenable to change in clinical situations. Knowledge about how they work together to promote productive engagement and help prevent problems, and how they can supplement and support interventions designed to treat the problems and disorders of individual children can inform clinical practice and add to clinical competency.

Clinicians can integrate existing knowledge about the organization of the immediate environment into prevention and remediation efforts by asking: (1) whether or not a setting generally promotes productive engagement and discourages dysfunctional behavior and if modification of the setting should be part of the intervention plan; (2) whether changes in the setting should be part of the intervention directed at the problem of an individual child; and (3) if specific supports or hindrances to intervention exist in the organization of a setting. The information gathered as a result of asking these questions will prove extremely useful for clinicians regardless of the setting in which they work.

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