Galindo E, Candeias AA, Pires HS, Grácio L and Stück M (2018) Behavioral Skills Training in Portuguese Children With School Failure Problems. Front. Psychol. 9:437. doi: 10.3389/fpsyg.2018.00437 This paper postulates that psychology can make an important contribution at an individual level to help children with school failure problems in a context where too little applied research has been conducted on the instructional needs of these children. Some data are analyzed, revealing that, despite some progress, school failure is still a main educational problem in many countries. In this study, Behavioral Skills Training (BST) was applied in Portugal to train children with school failure difficulties. BST is a method based on Applied Behavior Analysis, a teaching package consisting of a combination of behavioral techniques: instructions, modeling, rehearsal, and feedback. Two empirical studies are presented. Their main purpose was to develop behavioral diagnostic and training techniques to teach lacking skills. School success was defined in terms of a set of skills proposed by teachers and school failure as a lack of one or more of these skills. The main instrument was a package of training programs to be applied in three areas: basic behavior (precurrents), academic behavior, or social behavior. The second instrument is a package of check-lists, aimed to determine the level of performance of the child in an area. This check-list was applied before (pre-test) and after (post-test) training. In the first study, 16, 7- to 8-year old children were trained. They were attending the second or third grades and having academic difficulties of different origins. The effects of the training programs are evaluated in terms of percentage of attained objectives, comparing a pre- and a post-test. The results showed an increase in correct responses after training in all cases. To provide a sounder demonstration of the efficacy of the training programs, a second study was carried out using a quasi-experimental design. A multiple baseline design was applied to three 10- to 11-year-old children, referred by teachers because of learning difficulties in the fourth grade. Results showed few performance changes without training. Increases in behavior following BST were evident in all cases, indicating that training generated improvement in all three children. In both studies, comparable results occurred across students, demonstrating replication of the effects of the training programs.

Keywords: school failure, academic behavior, applied behavior analysis, behavioral skills training, educational psychology

# INTRODUCTION

There are several definitions of school failure. Fernandez Enguita et al. (2010, p. 18) propose one, which is adequate to our purposes:

. . . school failure is the situation of the student who, in trying to achieve the minimum objectives set forth by the institution, (. . . ) fails to do so and withdraws after having been categorized as a failure. . .

Nevertheless, in this article a pragmatic working definition has been chosen: children with school failure are those referred by the teachers because they have repeated grades at least once or because they are currently at risk of having to repeat a grade.

School failure is a main educational problem in Portugal. Recent data by the European Commission/Directorate-General for Education and Culture (EC DGEC) (2016, p. 39) show that Portugal has one of the highest rates of early school leaving (as measured by the number of individuals 18–24 years of age that did not finish school and do not attend school for each 100 individuals of the same age). The Portuguese figure of 14% compares to 3% in Croatia and 11% percent across the UE. In spite of improvements since 2005, early school leaving is still a main problem in Portugal. Fourteen 14% of people between 18 and 24 years who have not finished have, nevertheless, quit attending.

These data do not address the reasons behind the phenomenon. Yet, it might be supposed that at least 14% of children had some kind of academic problem at an early school age. Dropping out of school is largely determined by school failure in primary school (Justino et al., 2014, p. 54).

There are several types of school failure in Portugal: early school leaving, successive failure leading to a gap between grade and the chronological age of children (rate of retention), and dropping out of primary schooling (10–15 years). **Table 1** compares some aspects of the problem in Portugal and other European countries for 2009. At the primary school level (ISCED 1) Portugal had by far the greatest proportion of pupils repeating at least once year of primary education, (22.4%), vs. 12.2% for the next highest, Spain, and 7.7% for the European mean. This means that, in Portugal, 22.4% of children between 6 and 12 years have some kind of learning problems at school.

Additional data show an urgent need for intervention in the early school years, such as Portuguese sources (Gabinete de Estatística e Planeamento da Educação, 2010, p. 18) that point out that the yearly rate of retention and dropouts at basic school in 2008 was 7.6 for ISCED 1 (grades one to four) in 2008. These data

TABLE 1 | Proportion of 15 years old pupils who had repeated at least once in primary education (ISCED level 1) in 2009, a selection of some countries (Adapted from Eurydice, 2011, p. 36).

EU, European Union; BG, Bulgaria; CZ, Czech Republic; DK, Denmark; DE, Germany; FR, France; ES, Spain; It, Italy; AT, Austria; PT, Portugal.

show significant improvement from 1999 to 2008, as retention and dropout rates fell from 12.1 to 7.6%. Nevertheless, the rate remains significantly high, since it means that, in the first three grades, 7.6% of children either drop out of school or do not pass to the next school year.

The Organization for Economic Cooperation and Development [OECD] (see OECD, 2010), the European Union and international educational agencies identified the problem many years ago. A set of causes and recommendations for fighting school failure were proposed.

Commonly cited causes included cognitive deficiencies of children, unstable family environments (conflicts, divorce, parental disorders), socioeconomic issues such as low SES (poverty or social exclusion), and then, inadequate quality or functioning of the educational system (bad teaching methods, faulty school organization, or unorganized curricula; Webster-Stratton et al., 2008). The failure of any one child is most likely the result not of one factor but rather the interaction of many, as in the case of the children participating in this study. However, from the point of view of treatment, the cause of school failure is not especially pertinent. It is urgent to find intervention strategies able to cope with the problem independently of the cause.

Scientists have proposed several strategies to deal with the problem, such as increased preschool education, adapting schools to children's needs and possibilities, preparing more and better teachers and specialists, innovating teaching and evaluation methods, improving relations between school and the social environment or between schools and families (Carbonero et al., 2017), and applying personalized teaching methods, according to specific needs and characteristics of each child (Marchesi and Hernández Gil, 2003). This last proposal is the basis of our work. At an individual level, the one main task of psychology is to develop differential teaching methods to be applied as early as possible. On the other hand, very little applied research has been conducted on the instructional needs of these children. Poche et al. (1981, p. 323) observed that "Students with learning disabilities who experience difficulties in mathematics are frequently taught multiplication facts using the same procedures and sequences that are used with students without difficulties, that is, repetition drills. . . " This also appears to be true for children with problems of school failure, who are frequently taught reading, writing and arithmetic with the same methodology that has failed to work in the past.

# Applied Behavior Analysis and Behavioral Skills Training

Applied Behavior Analysis (ABA), also called Behavior Modification, is the applied part of the Experimental Analysis of Behavior, based on the principles of conditioning as they were defined originally by I. P. Pavlov and B. F. Skinner. ABA techniques have proved to be useful tools for coping with a broad range of behavior problems. A great deal of research is available about the application of ABA to the training and rehabilitation of people with different kinds of learning difficulties. Authors like Whitman et al. (1971) came up with this process while training mentally retarded children in

instructions following, imitation, selfcare, eating, verbal, and social behavior. Since then, behavioral programs have been applied successfully to train people with intellectual disabilities in academic skills such as reading (Saunders et al., 2003) and using computers (Jerome et al., 2007). Another example has been training people with hearing and visual impairments (Green et al., 2005; Toussaint and Tiger, 2010), and others with autism (Axe and Sainato, 2010; Rodriguez-Medina et al., 2016) or with learning disabilities (Wood et al., 1998; Levingston et al., 2009). The analysis of school failure has accompanied this development. Adelman and Taylor (1993) analyzed the problems of learning at school, including the types, causes and consequences of these problems as well as some proposed solutions, emphasizing the use of behavioral techniques. Hallahan et al. (1999) and Wallace et al. (1992) analyzed the causes of school failure, pointing to individual, family and school system factors, in much the same way. This work also identified a very important cause of individual school failure, namely, the absence of antecedent behaviors, such as language, social and cognitive repertoires, which are a prerequisite for the learning of reading, writing, and arithmetic. Research in other countries has confirmed the importance of those cognitive, behavioral, verbal, or social pre-academic competencies for the learning of reading, writing, and arithmetic in the early school years (Carroll et al., 2003; Neef et al., 2003; DiLalla et al., 2004; Leppänen et al., 2004; Connor et al., 2005; Guevara and Macotela, 2006).

Behavior Skills Training (BST) is based on Applied Behavior Analysis, which can be used to teach a wide variety of important skills to individuals of different ages and difficulties. Actually, it is a teaching package bringing behavioral techniques together which have been used for many years to train disadvantaged or disabled children, school children or adults. It is "an effective training package that consists of instructions, modeling, rehearsal, and feedback" (Ward-Horner and Sturmey, 2012, p. 75). Instructions consist of explaining how to carry out a determined task. During modeling, the task is demonstrated by the trainer while the trainee observes. Next, the trainee practices the task. A good chain of responses is reinforced, and errors are corrected in the last, or feedback, phase.

As mentioned above, the components of BST have been in used independently or together by behavior analysts since the 1970s. Nevertheless, the term was first used by Sarokoff and Sturmey (2004).

In recent decades, several researchers have used the four components of BST without using the term. Danish et al. (1976) outlined components of a "skills training" in a course of helping relationships, which were: (1) identifying behavior objectives; (2) practicing skills; (3) group discussion; (4) understanding the reason for using the skills; (5) presenting the skills; (6) active participation by trainees; (7) modeling of techniques; and (8) immediate feedback. Evidently, these eight steps are quite similar to BST. At that time, the authors described the existence of "skills training groups" that focused on teaching skills required to implement specific behaviors. In a program for parents, Gordon and Davidson (1981) applied a "behavior skills training" containing the elements of: (1) training parents to focus on observable behavior; (2) teaching parents concepts of learning theory; and (3) helping parents to apply the concepts when working with their children. Although the "behavior skills training" in these papers differs slightly from that of the BTS in ABA research, it is an important antecedent to the current behavior principles.

Other training packages contain all of the components of BST without labeling it as such. Bornstein et al. (1977) used all of the components of BST to train four non-assertive children in skills such as eye contact, loudness of speech, speech duration, and requests for new behavior. Children learned all behaviors with good results in generalization and maintenance. Minkin et al. (1976) also used the components of BST to teach a social skill, showing the effectiveness of instructions, modeling, rehearsal, and feedback to increase assertive conversational skills and general social conversation skills. Wurtele et al. (1989) used the components of BST to teach sexual abuse prevention skills to children.

Some studies have analyzed the effects of the individual components of BST, and have demonstrated the importance all four steps. In this line, Yeaton and Bailey (1983) applied a package to train guards about how to teach children to cross the street; they then analyzed the effectiveness of the different steps. They found that the rehearsal, feedback and praise components were necessary to produce effective behavioral change, while isolated components were not so effective. In a study of the prevention of child molestation, Poche et al. (1981) used modeling, rehearsal, and social reinforcement to teach children how to correct verbal and motor responses. The results revealed the success of modeling and rehearsal, when used together. Parsons and Reid (1995) used instructions, role-plays, and feedback to train supervisors. They found that staff skill performance endured as a result of feedback.

Since then, several researchers have successfully used BST to teach children a variety of skills. Johnson et al. (2005) examined successfully the effectiveness of individual behavioral skills training in teaching 13 preschool children abduction prevention skills in naturalistic settings. All the children maintained the skills in the 2-week and 1-month follow-ups. Similar results were obtained by Miltenberger et al. (2009) and Pan-Skadden et al. (2009). Homlitas et al. (2014) evaluated the effectiveness of a behavioral skills training package to teach the picture exchange communication system (PECS) to teachers employed at a therapeutic center for children with autism. Similar results were obtained by Barnes et al. (2011), Gianoumis et al. (2012), and Nigro-Bruzzi and Sturmey (2010) with children with autism. Seiverling et al. (2012) used successfully a package of BST to teach parents of 3 children with autism to apply a treatment for food selectivity. Results were reflected in increases in children food acceptance and decreases in disruptive behavior. Similar results were obtained by Mueller et al. (2003). Miles and Wilder (2009) applied BST to increase correct implementation of guided compliance by caregivers of 3 children with autism who exhibited noncompliance. The skills were successfully trained and they were exhibited in different settings 3–6 weeks after training ended.

Galindo et al. (2013) and Galindo (2009) applied ABA techniques to train children with intellectual, sensorial, social, and academic deficiencies. These works are the direct antecedents of the current project. The current study extends BST research to students experiencing school failure, adapts the procedures to children at educational risk, and evaluates the intervention with a multiple baseline.

# The Present Study

The current research on school failure was carried out in two different phases. The first interventions were carried out in low income, public elementary schools surrounding Lisbon. Participating children were often victims of social exclusion, i.e., members of ethnic minorities or living in extreme poverty. In one case, the parents were often absent. Data from this period have been published (Galindo, 2015). The second phase began in 2013 and applied the same package of Behavioral Skills Training to another type of child, residents of the Alentejo, a disadvantaged region of Portugal. Results of this second intervention are analyzed below. Nevertheless, a global explanation of the intervention strategies in both phases will be given, in order to provide a clearer image of the field.

The main goal of these studies was to develop behavioral diagnostic and training techniques to teach academic and social skills to children with school failure problems. School success was defined as a set of skills proposed by teachers. School failure was then understood as a lack of one or more of these skills. The skills to be mastered by a single child were defined in terms of behavioral objectives, according to the expectations of the teacher. The nature, scope and probable origins of the child's academic problems were extremely varied.

The specific goals of these interventions were:

On the basis of a precise description of the problems of each child, one (or more) intervention program(s) was specifically tailored for that learner, following the logic of Behavioral Skills Training. A token economy was introduced to motivate children (Ayllon and Azrin, 1968), i.e., children earned points through good responses. The points were then exchanged for privileges chosen by the children (for instance, playing with the teacher).

Three main areas of intervention were defined on the basis of preliminary observations of academic problems at school:

Children referred to the program by teachers for having school failure problems were evaluated and trained on an individual basis by specially trained psychology or special education students (tutors). These tutors mentored one child during a semester (15–16 weeks) and worked with them for 2–4 h a week at school. All skills training programs had the same structure (see **Table 2**), including a pre and a post-test. Consequently, results were evaluated mainly by comparing the percentage of skills which were defined in terms of attained objectives in pre- and post-tests. However, training time was also taken into account.

The training programs were highly varied, since the nature of target skills was widely different. For example, "reading" means recognizing letters for one child, but spelling words for another one. This means leads to wide variation in the reading intervention for each child under the same label. Additionally, some children received training in one subject, some in two, some in three, and so on. Training duration also varied. The data comparing pre and post-test measures showed a positive effect in most cases but, evidently, a sounder demonstration of the efficacy of the program was necessary.

Consequently, a study was carried out with a quasiexperimental, multiple baseline design in order to reinforce the scientific bases of the skills training programs. Data from this study suggested that the progress by participant children was the result of the intervention programs rather than other factors (Galindo, 2015). A replication of this study will be presented below.

Training has been successful if the child attains at least 80% of correct responses

# TRAINING CHILDREN WITH SCHOOL FAILURE PROBLEMS IN THE ALENTEJO: STUDY 1

An average of 14 children was trained every semester between 2013 and 2016. In the following description, only data from one semester (2013–2014) is analyzed.

# Materials and Methods

### Participants and Setting

Sixteen children aged seven to eight in the second and third grades were referred to the program due to academic problems (see **Table 4**). All of them were at risk of failing the school year. They had similar SES, as they belonged to the lower middle class of a small Portuguese town. The causes of their problems were difficult to determine. Nevertheless, according to their teachers, family problems (like divorce or separation of the parents) were often present. The training took place at a public elementary school in Evora, a small city in the Alentejo region. Sessions were conducted at tables located in school corners.

### Instruments

The main instrument is a package of behaviorally designed training programs to be applied in three areas, namely, basic behavior (precurrent), academic behavior (subjects of Portuguese ISCED 1), or social behavior (see **Tables 2**, **3**). Every program was designed to solve a specific problem (writing, spelling, articulation, etc.). Tutors are explicitly instructed to develop their own programs on the basis of the pre-existing musters (Galindo, 2015). Nevertheless, all programs had the same structure: (1) a general objective, (2) skills defined in terms of specific objectives (a set of correct responses to be given by the child), (3) a definition of the previous skills necessary to learn the new skill (precurrents), (4) a pre-test (% of attained

TABLE 3 | Check list: recognizing letters.

objectives/correct responses), (5) a training package based on instructions, modeling, rehearsal, and feedback, (6) a post-test (% of attained objectives/correct responses). The specific objectives of the program are defined in terms of responses given by a specific child. Every program has a set of previously established correct responses Evaluation of the efficacy of the program was carried out by comparing the percentage of attained objectives before (pre-test) and after training (post-test).

The second instrument is a package of behaviorally designed check-lists (Galindo, 2015) intended to determine the level of performance of the child in an area, i.e., basic behavior, academic behavior, and social behavior. Every list was designed by the tutor to evaluate a specific skill of the child (e.g., their articulation problems). Nevertheless, every check-list had the same structure (see **Table 3**).

## Procedure

Before any contact with children, written informed consent was obtained from the parents. Before the assessment period, children were informed of the nature of the intervention and were told that the programs were expected to help them in their school subjects. Behavioral Skills Training was applied by ABA trained Psychology students (tutors) for 2 h a week (2 sessions × 1 h) during a semester (15 weeks). Each tutor took on a child and worked with them throughout the intervention. Before the training began, the tutors gathered all the information they could about their child. Existing and non-existing skills, as well as the possible aims of the intervention were defined together with the teacher. The first week served for the tutors to get acquainted with the child, and the tutor then applied a set of check-lists to identify as precisely as possible the specific problems of the child in each subject. All information was used to elaborate a hierarchy of problems. On this basis, an intervention strategy was designed, elaborating specific training programs for the child. The specific objectives of the program were the goals of the intervention. The percentage of correct responses in a given program attained before and after intervention are the main data. The child must attain at least 80% of correct responses in a given program. During intervention, the tutor would collect the children from the classroom and work with them in another room for an hour, always in coordination with the teacher. An intervention might last a few weeks or the whole semester, depending on the children's needs. A post-test was carried out following the training.

# Results

**Table 4** shows a list of participants, the pre-test and post-test results and the number of sessions (including testing). Ten children (three girls and seven boys) were 7 years old and were in second grade. Five students (two girls and four boys) were eight and attended the third school year. They were trained mainly in school subjects like reading, writing, arithmetic, and environment, but some of them received additional training in precurrent behaviors like language (articulation), fine motor skills and good classroom social behavior (sitting in the chair and/or concentration). The objective of sitting in the chair for

In such a case, a more precise evaluation of the errors is necessary

The table shows training programs applied to every child, the results obtained before (pre-test) and after training (post-test), as well as the number of sessions. 1 session = 1 h.

30 min was defined by the teacher as good enough to work in the classroom.

Children 4, 14, and 16 were trained in two programs, the others in only one. Most of the children attained more than 80% of correct responses by the end of the training. Exceptions were children 1, 3, and 16, who were not able to complete the program before the end of the semester. Child 1 was trained in writing. She improved from 55 to 75% correct responses in 18 sessions (18 h), even though failing to achieve the target 80%. Child 2 was referred because of hyperactivity in the classroom. He was trained to sit still for 30 min while concentrating on a task and he advanced from 7% (2.1 min) to 100% (30 min) in 13 sessions (13 h). Child 3 received math training. He advanced from 34 to 73% in 12 sessions (12 h). Child 4 was referred because of reading problems. Our evaluation showed a language problem. Consequently, he was trained first in articulation, where he advanced from 40 to 100% in 10 sessions (10 h) and then in reading, where he advanced from 74 to 100% in 10 sessions (10 h). Child 5 was trained in reading and he advanced from 30 to 100% of correct responses in 10 sessions (10 h). Child 6 also received reading training. A detailed assessment revealed language problems and he was trained in articulation, whereupon he advanced from 0 to 100% correct responses in 14 sessions (14 h). Reading training was planned for the following semester. Child 7 was referred because of hyperactivity. Detailed observations revealed he could sit 24 min (80%). Nevertheless, he was trained in sitting and concentration, and managed to attain 100% (30 min) in 17 sessions. Child 8 was trained in environment (Natural Sciences) and she improved from 73 to 86% correct responses in 12 sessions. Child 9 was trained in math and increased from 75 to 100% in 10 sessions (10 h).

Child 10 was referred because of "lack of attention and disruptive behavior" in the classroom. Our observations revealed he could work without distraction 12 min (40%). Consequently, he was trained to concentrate on a task without getting distracted during 30 min, advancing to 100% (30 min) in 12 sessions (12 h). Child 11 received math training; he improved from 68 to 81% correct responses in 12 sessions (12 h). Child 12 was referred because of hyperactivity. Our observations showed he could sit on his chair for 18 min (60%). After 8 sessions, he was able to sit and concentrate on his work for almost 26 min (85%). Child 13 was already in the 3rd grade, but she could not hold her pen properly and had problems completing writing tasks. Our observations revealed she had few motor skills problems, but they were enough to slow her writing. She received fine motor skills training consisting of pre-writing exercises and advanced from 92 to 100% of correct responses in 20 sessions (20 h). Child 14 had problems with writing and math. It was decided to prioritize math and he received 13 training sessions (13 h) and improved from 43 to 86% of correct answers. He also received math training, where he advanced from 35 to 100% correct responses in 9 sessions (9 h). Child 15 was referred due to reading difficulties. Further analysis revealed an articulation problem and he received 12 training sessions, advancing from 66 to 96%. Child 16 had problems with reading and writing. The tutor decided to start with writing and the child advanced from 55 to 84% in 9 sessions. It was considered a good result and a training program in reading was applied, where he advanced from 33 to 60% in 9 sessions.

A comparison of pre- and post-test results showed an increase in correct responses following training in all cases. The number of sessions necessary to train a skill is highly variable, ranging from 8 to 20 sessions. For instance, articulation problems were solved in 10 sessions (child 4), in 14 sessions (child 6), or in 9 sessions (child 16).

An independent-samples t-test was run. It showed there are no outliers in the data, i.e., the results of children's performances were normally distributed, as assessed by Shapiro–Wilks test (p > 0.05). Additionally, a paired-sample t-test was run to determine if there were significant differences in the performance of children before training (pre-test) and after training (post-test). **Table 5** shows that there was an increase in the mean values (39.31 points more) and a greater homogeneity in post-test results (less dispersion in Student deviation). A statistically significant difference in mean values was also found (t = −5.72, p > 0.000). Therefore, it is possible to say the increase in the performance of children was with 99% probability a result of the training programs.

#### Discussion

The data show the positive and negative aspects of the training programs. On one hand, it seems that all training programs (independently of the problem treated) led to increased correct responses in all children (independently of gender or age), in a relatively short time (8–20 h of training). In other words, every child managed to quickly learn a previously lacking skill. It seems then that the strategy used to identify the lacking skills and to train the identified skills produced an overall positive change in children's behavior. Teachers' subjective opinions confirmed this supposition. Nevertheless, in at least two cases, the teacher complained the children were "behaving better" but lacked any obvious improvements in academic performance. This is probably due to the fact that teachers were more focused on concrete results in academic subjects and were not accustomed to paying attention to precurrent skills like sitting still, concentration, articulation, or fine motor skills. These results coincide thoroughly with results of other interventions carried out with the same instruments, strategies, and procedures in other settings (Galindo, 2015).

On the other hand, the possibility should be considered that the children's improvements were not the result of the applied training, but of the work performed by teachers or due to the natural maturation process. It is still necessary to demonstrate that the positive behaviors were the direct result of the applied training programs.

Methodologically, these training programs represent a problem because it is difficult to compare a collection of such different cases since each child had a special problem and the training program was tailored for them.

TABLE 5 | Study 1. A comparison of the performance of children before training (pre-test) and after training (post-test).

In the next study, a quasi-experimental multiple baseline design (Johnston and Pennypacker, 2009) was applied in an attempt to resolve this issue. In a former work (Galindo, 2015), the successive application of the variable training to four children seemed to confirm that the results were caused by the intervention programs. In the following study, a replication of that work is carried out.

# TRAINING CHILDREN WITH SCHOOL FAILURE PROBLEMS IN ALENTEJO: STUDY 2

# Materials and Methods Participants and Setting

Three 10- to 11-year-old fourth graders were referred to the program because of academic problems. They had a similar SES, as they belonged to the lower middle class of a Portuguese village. The causes of their problems were not determined, but at least one had family problems (separation of the parents). They were selected according to the following criteria: (1) they belonged to an average Portuguese family without a history of immigration; (2) they had failed at least one grade; (3) they had no reports of intellectual incapacity; (4) they had been referred by the teacher because of similar academic problems; and (5) they had taken part without success in other programs for children at educational risk.

Child A, a girl aged 10, had repeated the 3rd grade and was at risk of failing again. According to her teacher, she had difficulties understanding texts and verbal instructions (comprehension) and a lack of concentration skills and motivation. As a consequence, she had problems in math, environment and Portuguese (reading and writing).

Child B, a boy of 11, had repeated the 3rd grade. He had had delayed language development and behavioral (emotional) problems since his parents had divorced, and had been treated by a speech therapist and a psychologist. According to his teacher, he was disorganized, had difficulties concentrating on tasks, language problems, hyperactivity, and a lack of motivation. He had comprehension problems, poor spelling (orthography) and other writing problems.

Child C, a boy, aged 10, had suffered a health problem with secondary effects on his motor skills, as well as having moved house and school several times. He had repeated the last preschool year because of a lack of the necessary skills. According to his teacher, he presented oppositional behaviors, concentration problems and lack of motivation, and was consequently experiencing difficulties in all subjects. Regarding Portuguese reading and writing, he committed numerous and varied spelling errors.

The institution was a public elementary school situated in Arraiolos, a village in the Alentejo with retention rates higher than average in Portugal (Direção-Geral de Estatísticas da Educação e Ciência (DGEEC), 2014). It was a mixed class, where 18 children in the 2nd (7 students) and the 4th grades (11 students) were taught together. Obviously, having students from two different courses in the same class can influence the development of student learning. Most of the children had already repeated a grade. Training sessions were conducted at a table in a separate room of the school.

#### Instruments and Materials

The main instrument relied on three behaviorally designed training programs to be applied in verbal comprehension (VC), reading (R), and spelling/orthography (O). The programs were designed to solve the specific problems of the three children according to a set of objectives set by the teacher. All programs had the structure explained in Study 1: (1) general objective, (2) specific objectives, (3) definition of precurrents, (4) pre-test, (5) training packaged based on instructions, modeling, rehearsal, and feedback, and (6) post-test. A first difference with respect to programs applied in Study 1 related to the content: all skills were defined according to the handbooks and materials of the 4th grade. A second difference was that the same program was applied to all three children.

The second instrument, a package of behaviorally designed check-lists aimed to assess the level of performance of the child in a determined area were also applied, following the same explained strategies.

### Procedure

The assessment began once parents gave written informed consent and the children were in agreement. Each child was evaluated according to the previously described strategy. It was verified that all three children had roughly the same academic problems. After assessment, Behavioral Skills Training was applied to the three children by an ABA trained tutor for 3 h a week (2 sessions × 1 ½ h) during 21 weeks. The tutor took charge of all 3 children and worked with them from the beginning to the end of intervention. Procedures were applied following the same lines of Study 1. All information gathered was used to design training programs for the children, according to a set of objectives set by the teachers. The target skills, defined as specific objectives, were the goal of the intervention. The percentage of correct responses in a given program attained before (pre-test) and after training (post-test) were the main data.

A multiple baseline design across subjects was used to evaluate the effects of the training problems, much in the way as that used by authors treating similar problems (Wood et al., 1998; Levingston et al., 2009; Krohn et al., 2012). In the current study, the package training as independent variable was applied successively to all three children.

A baseline assessment (BL) based on the application of the training programs pre-test for VC, R, and O was conducted in week 1 (BL1), week 5 (BL2), and week 9 (BL3). The final post-test assessment (FA) was conducted in week 21. Following baseline assessment, all children received training consisting of multiple baseline. Training was then applied to the three children (see **Figure 1**). They were assigned randomly to one of 3 different training conditions:

CONDITION A: Child A was evaluated once before training (BL1). She then received 19 weeks of training and a final assessment (FA) was carried out in week 21.

CONDITION B: Child B was evaluated twice without training in weeks 1 (BL1) and 5 (BL2), and he was then trained for 15 weeks and a final assessment (FA) was performed in week 21.

CONDITION C: Child C was evaluated three times without training in weeks 1 (BL1), 5 (BL2), and 9 (BL3). He then received training for 11 weeks and a final assessment (FA) was made on week 21.

# Results

The results of the multiple baseline analysis for all three children participating in Study 2 are presented in **Figure 1**. Children A, B and C were trained in 3 subjects (verbal comprehension, reading, and spelling/orthography), but the onset of training was different for every child. Assessments were carried out in weeks 1, 5, 9, and 21. The percentage of correct responses attained by each child in every assessment is shown. Child A was evaluated once before training in week 1 (BL1) and once after 19 weeks training (FA). Child B was evaluated twice without training in weeks 1 (BL1) and 5 (BL2) and once after 15 weeks training (FA). Child C was evaluated three times without training in week 1 (BL1), week 5 (BL2), and week 9 (BL3) and once after 11 weeks' training (FA).

Overall, changes in all 3 children after training were evident. The most obvious took place in reading, where all three children attained 100% of correct responses in FA (week 21). An analysis of the individual results reveals other positive changes.

Child A showed clear increases from BL1 (week 1) to FA (week 21), advancing from 60 to 90% of correct responses in verbal comprehension, from 75 to 100% in reading, and from 73 to 89% in spelling (orthography). This improved performance seemed to have occurred in 19 weeks of training, i.e., 57 h.

Child B was evaluated without training in week 1 (BL1) and week 5 (BL2). Starting in week 6, a training procedure was applied for 15 weeks. The final evaluation (FA) was carried out in week 21. A comparison between BL 1 (week 1) and BL2 (week 5) showed little change. Indeed, change was negative, with the percentage of correct responses decreasing from 60 to 50% in verbal comprehension, from 65 to 64% in reading and from 63 to 62% in spelling (orthography). In other words, the child seemed to have gotten worse during training. On the contrary, a comparison of last BL2 (week 5) with FA (week 21) showed great increases, from 50 to 90% in verbal comprehension, from 64 to 100% in reading, and from 62 to 77% in spelling. This child's improvement seems to have occurred in a period of 15 weeks, i.e., 45 h.

Child C was evaluated without training in week 1 (BL1), week 5 (BL2), and week 9 (BL3); he was then trained for 11 weeks. A last evaluation (FA) was performed after training, in week 21. A comparison of BL1 (week 1) with BL2 (week 5) shows an increase of correct responses in verbal comprehension (from 60 to 70%), but decreases in reading and spelling/orthography (from 58 to 56% in both cases). A comparison of BL2 (week 5) with BL3 (week 9) shows a decrease from 70 to 60% in verbal comprehension, and slight increases in reading (from 56 to 58%) and spelling (from 56 to 60%). A comparison of BL1 (week 1) with BL3 (week 5) revealed that the student obtained the same values for verbal comprehension (60%) and reading (58%) and advanced slightly in spelling (from 58 to

2015).

60%). Finally, a comparison of BL3 (week 9) with FA (week 21) showed considerable increases in verbal comprehension (from 60 to 100%) and in reading (from 60 to 100%) and a modest increase in spelling (from 60 to 75%). This child's improved performance seems to have occurred with 11 weeks' training, i.e., 33 h.

# Discussion

These data seem to show that increases in positive responses occur consistently after training. Improvements without training were rare, but they did occur, such as, with child B (from week 1 to 5 in verbal comprehension), showing that positive changes can also result from other variables (probably the teaching at school). Nevertheless, decreases of correct responses occurred frequently without training, for instance with child B from BL1 to BL2 in all programs, revealing that regular teaching at school does not seem to improve these children's results and that a lack of systematic training might produce negative changes. The results of this study suggest that there was little change in children's performance following normal school activities (without training). When changes did occur, they were small and performance decreases were more common than increases. On the other hand, increases in academic and pre-academic behavior following the Behavioral Skills Training were evident in all cases and in all subjects. The following introduction of treatment resulted in considerable increases over baseline levels. These changes were obtained without corresponding changes in untreated baselines. The results of this multiple baseline analysis indicate that training generated improvement in all three children. It effectively enhanced performance in verbal comprehension, reading and spelling. All three children showed an obvious increase in the percentage of correct responses following the application of the training programs. This is to say that the multiple baseline analysis indicated that changes from baseline levels occurred only when training was directed to a specific child. The extent of the changes in the targeted child provides strong support for the effectiveness of the training package used. These results coincide with data obtained by Galindo (2015) with a similar quasi-experimental design, applying the same teaching strategies to students of a different environment, namely, children of a very low SES living in the slums of a big city, with problems of marginalization due to poverty or ethnic origins. In the Alentejo, these children were not living in conditions of exclusion. Their school failure problems coincided with family difficulties (Child B) or with health problems (Child C) or had no identifiable origin (Child A). In both multiple baseline studies, comparable results occurred across students, demonstrating the replication of the effects of the training programs.

# GENERAL DISCUSSION AND CONCLUSIONS

The results from both of the current studies show an apparent improvement of all children following Behavioral Skills Training. It seems that the observed advanced resulted from the intervention programs and not daily classroom teaching. These results confirm earlier findings (Galindo, 2008, 2013, 2015) and coincide with those of authors working in the same line in different countries (Carroll et al., 2003; DiLalla et al., 2004; Leppänen et al., 2004; Connor et al., 2005; Guevara and Macotela, 2006), especially in relation to the kinds of behavioral repertoires that should be addressed in the case of school failure, i.e., not only academic, but also precurrent behaviors.

"Precurrent behaviors are those that increase the effectiveness of a subsequent (current) behavior in obtaining a reinforce." (Polson and Parsons, 1994, as cited by Levingston et al., 2009, p. 361). These behaviors are skills that are essential, as they form the basis for learning other skills. Many children fail to learn reading and writing for one of the following reasons: because they cannot discriminate forms and colors; or they lack motor coordination; or they have problems in verbal behavior. A lack of just one precurrent skill can have devastating consequences in the acquisition of reading, writing, or arithmetic. That is also the conclusion of Levingston et al. (2009) and Neef et al. (2003) in the teaching of arithmetic. Academic behavior is the main concern of teachers and scientists interested in school failure. Now, it is essential to define precisely, for each case, what the teacher is expecting and what the child can actually do. Social skills must be an integral part of any intervention. Many children with school failure problems also have behavioral problems and it is difficult to say if one is a cause or a consequence of the other. In either case, in order to solve academic failure, you might have to work simultaneously with social and academic skills (Monjas et al., 2014).

A word about the motivational is necessary. Most children with these kinds of problems do not want to learn. It is necessary to create a motivational system. A token economy seems to be the best solution.

In general terms, teachers reported significant positive changes in the children's behavior at school. Nevertheless, some complained that no changes were evident in academic behavior. It must be recognized that the developmental aims of the child and the academic aims of the teacher do not necessarily coincide.

It is difficult to determine the exact causes of the problems addressed, but all children belonged to a low SES and many had bad family relationships (parents in conflict or in a process of separation) or former health problems, or all those combined. Finding possible causes in the past development or in the present situation is always possible, but most of the time it is impossible to identify clearly the cause of school failure in individual cases. It seems that the individual problems of a child are a result of a set of bad coincidences at an important stage of development: the child missed the chance to learn the expected thing at the right moment for some reason and is not able to learn it later for other reasons. It is important to develop effective training procedures, independently of the factors causing the problem. Our results seem to show that programs of this kind can be applied successfully at school in order to train these kinds of skills, whose absence causes academic difficulties. Nevertheless, the present study is only a first contribution toward resolving school failure, for the following reasons:

Although in this study the number of participants was relatively small, these ABA techniques already have a long history of success in training of people with intellectual, sensorial, physical, and social incapacities. Thus, it is not surprising to find they can be adapted to train children at educational risk. The current studies have demonstrated that BST techniques can be successfully applied to train children with problems of school failure. It has also been shown that a multiple baseline design can be a good choice for demonstrating the effects of training on a varied set of students. A further development of these training programs might constitute a sound psychological contribution to solving school failure as a social problem.

# ETHICS STATEMENT

This research was carried on in the frame of an agreement between University of Evora (signed by Vice-Reitor Paulo Quaresma) and Malagueira School Group (signed by Diretora Isabel Gomes) and approved by an Ethic Commission of the University of Evora (President Prof. Armando Raimundo). Written informed consent was obtained from the parents of the participants.

# AUTHOR CONTRIBUTIONS

EG and AC: Conceptualization; EG: Methodology; MS: Formal analysis and supervision; HP and LG: Investigation; AC: Writingreview and editing.

# REFERENCES

# FUNDING

This research did not receive any grants from funding agencies in the public, commercial, or non-profit sectors. Publication is financed with National Funds through FCT – Foundation for Science and Technology, within the scope of the project Center for Research in Education and Psychology-(CIEP)- UID/CED/04312/2016 and the School of Social Science (ECS) of the University of Évora. Neither funding entity participated in any way in the study design, data analysis, or write up, nor in decisions regarding submission for publication.

# ACKNOWLEDGMENTS

Portions of the present findings were obtained by Coradinho (2015) as a part of her Master's thesis.

adults with developmental disabilities. J. Appl. Behav. Anal. 40, 185–189. doi: 10.1901/jaba.2007.41-06

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2018 Galindo, Candeias, Pires, Grácio and Stück. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

# A National Early Intervention System as a Strategy to Promote Inclusion and Academic Achievement in Portugal

#### Vitor Franco1,2 \*, Madalena Melo1,3, Graça Santos1,2, Ana Apolónio<sup>4</sup> and Leonor Amaral<sup>5</sup>

<sup>1</sup> Department of Psychology, University of Évora, Évora, Portugal, <sup>2</sup> Research Center for Education and Psychology, University of Évora, Évora, Portugal, <sup>3</sup> Interdisciplinary Center for History, Culture and Societies, University of Évora, Évora, Portugal, <sup>4</sup> Associação Portuguesa de Pais e Amigos do Cidadão Deficiente Mental, Évora, Portugal, <sup>5</sup> ISPA-Instituto Universitário, Lisbon, Portugal

Early intervention with children at risk or facing developmental problems is a practice defined by three fundamental characteristics: being family-centered, being based on the community and on the child's life context, and being conducted by a team with transdisciplinary practice. In this paper we wish to present how the SNIPI-National System of Early Intervention, implemented in Portugal over the past 15 years, contributes to promote maximum development and the full inclusion of children up to 6 years of age and works to prevent school failure. The SNIPI covers the entire territory and intends to respond to the needs of children with developmental disorders or those in at risk situations. This community-based early intervention model is linked to the health, education and social care systems, involving the three responsible Ministries. In the present community case study, we present the implementation of this program in the Alentejo region, involving 31 local teams and almost 2500 children. Through the regional structure's reports and the responses of parents and professionals in impact studies, we demonstrate how the system is established and how it tackles school failure and improves the educational inclusion of these children. The impact of this Early Intervention model has been significant not only on children's developmental outcomes, but also for the health, education and social care professionals who work in a transdisciplinary perspective, as well as for the families who became more skilled at evaluating the children's needs and the support provided. This approach to implementing a familycentered Early Intervention program can contribute to full inclusion. It facilitates the transition to schooling based on a non-discriminatory approach and educational achievement by aiding development and an adapted contextualization in pre-school education. This program system introduces significant innovation within the framework of existing educational policies that promote development and inclusion, and has therefore earned the interest of the scientific community and policy-makers alike. It has been possible to implement some of principles already studied but it had never been tested. The Early Intervention program in Alentejo, as part of the SNIPI, can be an example of good practices, with its own characteristics that allowed to create a network of integrated and comprehensive responses to the needs of the population in this region.

#### Edited by:

Edgar Galindo, University of Évora, Portugal

#### Reviewed by:

Maria Joao Beja, University of Madeira, Portugal Jose-Maria Roman, University of Valladolid, Spain

> \*Correspondence: Vitor Franco<EMAIL_ADDRESS>
#### Specialty section:

This article was submitted to Educational Psychology, a section of the journal Frontiers in Psychology

Received: 10 February 2017 Accepted: 21 June 2017 Published: 05 July 2017

#### Citation:

Franco V, Melo M, Santos G, Apolónio A and Amaral L (2017) A National Early Intervention System as a Strategy to Promote Inclusion and Academic Achievement in Portugal. Front. Psychol. 8:1137. doi: 10.3389/fpsyg.2017.01137

Keywords: Early Intervention, inclusion, school achievement, developmental psychopathology, social network

# INTRODUCTION: A COMMUNITY BASED MODEL OF EARLY INTERVENTION IN PORTUGAL

# Historical Perspective

fpsyg-08-01137 July 5, 2017 Time: 11:53 # 2

In recent years, Portugal has implemented a National System for Early Intervention (SNIPI) has been implemented. This system covers the entire territory and is intended to respond to the needs of the children with disabilities or at serious risk of developmental delay.

This Early Intervention community based model has, as its first fundamental and innovative feature, the articulation between health, education and social security services, and it is supported by a specific legal framework (Decreto-Lei 281/2009, 2009) resultant from the work of three Ministries.

Usually, care for children with developmental disorders is distributed between three institutions: The Ministry of Social Security is responsible for rehabilitation institutions and organizations working with people with disabilities; The Ministry of Health oversees therapeutic and clinical interventions; and the Ministry of Education safeguards children's educational needs. Each of these fields has its own methodologies and emphases and all tended to work separately and without major articulation in the past.

The care of children with developmental disorders has progressed in Portugal, as in other countries, since the 1970s with the emergence of expert centers and non-governmental associations. These tried to address the needs of specific groups of children or people with disabilities or some other issues such as intellectual disabilities, cerebral palsy, etc. Later, more alternatives emerged (catering to the children under the age of six) and some of them reflected an effort to combine different fields, in particular health, education and social security.

Prior to the aforementioned regulatory legislation, a dispatch issued by the Government in 1999 (Despacho Conjunto 891/99, 1999) supported more or less the responses already in place throughout the country. These alternatives included the traditional approaches with regards to rehabilitation and reduction of problematics hinging on isolated measures: therapy and special education. All of these interventions focused on the problem and on the child.

The publication of these regulations constituted a fundamental landmark in Early Intervention in Portugal. This new legislation has determined the implementation of a national system, within the framework of a privileged partnership between the three subscribing Ministries, Education, Health and Labor and Solidarity, with the involvement of the NGO's, legally defined as support entities of the Local Intervention Teams (LIT).

The legal framework of these teams was enacted through the conclusion of cooperation agreements. The concerted action of all these entities gave body to and framed the constitution of multidisciplinary teams. The aim was to provide direct support to children and their families in the context of their daily lives and with the involvement of the community.

For the first time, a type of organization and methodology was defined: A community-centered workgroup based on the capabilities and functioning of the different contexts of the child's life, and a family-centered intervention methodology.

This organizational system met some implementation difficulties at a national level, but has since matured in some regions where it was possible to create the network of teams that were able to test the feasibility and effectiveness of a nation-wide project.

After a lengthy review process, new legislation (Decreto-Lei 281/2009, 2009) created the National System of Early Intervention (SNIPI) and provided the tools for its implementation throughout the national territory. This legislation preserved the principles of the previous law and reinforced the role of health services in early detection and referral of children with developmental disorders or at risk of serious delay.

# The Structure of the National Early Intervention System (SNIPI)

At the present, the National Early Intervention System is in place across the country, with some small discrepancies in the coverage and even in the operation mode. The SNIPI has a central structure, which is national and which articulates the general policies of operations, involving representatives of the three Ministries involved. There are intermediate structures (regional level) that ensure the implementation of these policies on the ground and provide coordination and supervision of local team's operations.

At the base of this pyramid, we find LIT which are composed of professionals from different fields. They provide the interventions with families and children, and the coordination with other services and institutions. Some fundamental structural principles are assumed as the basis for professional training and the production of guidelines (Carvalho et al., 2016). Three fundamental premises are emphasized: working with a family centered perspective, this model has to be based on the community and on the child's contexts, and the interventions have to be conducted by a transdisciplinary team (Guralnick, 2005).

The local teams and the system itself, have as guiding aims for the interventions, to promote the maximum development and also the maximum inclusion of children up to the age of 6. When, at this age, children enter in Basic schooling (which is always done in mainstream schools) is expected that those whose development is altered or threatened will have better success because of the work already developed by early intervention.

# EARLY INTERVENTION AND PREVENTION OF EDUCATIONAL FAILURE

The entry into compulsory Basic education represents an important challenge, for any child and family, one sometimes experienced with contradictory feelings. Research has shown

that the process of transition to formal schooling implies the involvement of the educational agents (i.e., families, teachers, staff) and the interaction between the various organizational contexts of the mesosystem (Bronfenbrenner and Morris, 2006) in order to enable a smooth transition that encourages the development of the child and their sense of belonging to school (O'Kane, 2016).

In the case of children with developmental problems, issues related to the transition to formal education systems (kindergarten, school) are particularly important (Barnes-Holmes et al., 2013), especially regarding school readiness (UNICEF, 2012). But school readiness does not concern simply the child; it involves three interrelated dimensions: (a) ready children; (b) ready schools; and (c) ready families. "Children, schools and families are considered ready when they have gained the competencies and skills required to interface with other dimensions and support smooth transitions" (UNICEF, 2012, p. 3).

As systematically and clearly demonstrated by research, inclusive educational settings give children with special educational needs (SENs) greater academic and social gains.

There are several educational transitions throughout the child's life, beginning with the passage from the family context (home) to the nursery or kindergarten (including changes of setting in the preschool context: micro-transitions). But the transition to the school context represents the most important educational transition in the child's life (O'Kane, 2015). Many studies show that positive transition experiences are predictors of better social, emotional, and educational outcomes (Peters, 2010; Sayers et al., 2012; O'Kane, 2015).

The transition to school of children with SENs is particularly stressful for families (Peters, 2010; Barnes-Holmes et al., 2013), in particular due to concerns toward non-continuity of specialized support.

In the case of the national Early Intervention system, these concerns also seem to make sense. Indeed, this system promotes the mutual collaboration between families and technicians for the integral development of the child. By age 6, the child is integrated in a system that is family-centered and community-based.

The Early Intervention teams prepare the transition to preschool and their path in the kindergarten is followed attentively in close cooperation with the families in order to meet any potential emergent needs of the children.

In most cases, SNIPI teams and families are actively engaged in the child's process of transition of the child to preschool, planning and establishing effective communication with kindergartens and clarifying the roles of the various educational agents, which is a practice that promotes the development of the child and his educational and social success (Peters, 2010; Burgon and Walker, 2013; Ministry of Education, 2014).

The entry into primary school, however, implies more profound changes, both in the expectations of the child's roles (Bronfenbrenner, 1979) and in the demands of the context itself. Firstly, because the focus is more now on the child and less on the family, as well as on an individual educational plan. But secondly, because entry into formal schooling usually implies a change in child support services; they are now under the responsibility of special educational services (Ministry of Education), which represents a fundamental change regarding the philosophy of Early Intervention approaches.

These changes are accompanied by major concerns of the families, not only regarding the school readiness of their children (UNICEF, 2012), but particularly with regards to potential social relationships in which they may be involved. The issue of child social relationships appears to be one of the main concerns of the families related with their children's entrance to school (Burgon and Walker, 2013; Ministry of Education, 2013).

Early intervention contributes meaningfully to positive educational transitions, emphasizing collaborative work between all participants involved in the development of the child, reducing risk factors for the child (or increasing the child's ability to cope with these risk factors), and promoting their mental health – an essential condition to increase the welfare, the possibilities of educational success, and the healthy development of children with SENs (Dunst, 2002; Hirst et al., 2011).

# COMMUNITY CASE STUDY: EARLY INTERVENTION NETWORK IN ALENTEJO

# The Early Intervention System in Alentejo

In order to highlight the impact of the Early Intervention System, we can look at how this network has been established in one of the first regions that successfully implemented this system.

Alentejo is the largest region of Portugal occupying one third of the national territory, including most of the south of the country. It consists of 3 districts, and part of another, for a total of 47 counties. The average population density is 23, 4 inhabitants per Km<sup>2</sup> , the lowest in the country and one of the lowest in Europe.

The settlement is mostly concentrated around the district capitals (Évora, Beja and Portalegre) with a significant part of the rural population living in geographical and social isolation. High percentages of aging populations and low school enrollment rates are both present.

In 2015, there were 189 residents aged 65 and over for every 100 under 15 years, which is considerably higher than the national averages.

In Alentejo, the current organization of Early Intervention services began in 2001 with the constitution of the regional and district coordination teams and an initial survey of needs, which led to the construction of a network of county-based teams, including a few isolated teams already working in disabilitylinked institutions.

In 2002 there were 15 teams, supporting a total of 605 children with developmental problems and, in the years to follow, the number of children supported by Early Childhood Intervention teams significantly increased as this network spread throughout the region. Nowadays, there are 31 LIT that support the needs of children and families in Alentejo, according with the actual legislation (Decreto-Lei 281/2009, 2009), that enforces the national system.

# The Current Early Intervention Network

The current network is organized in a decentralized structure, with three levels of geographic organization depending on a Subcommission of Regional Coordination, which responds to the Commission of National Coordination and assures the management of the necessary resources for the implementation of the system in the region, in accordance with a national plan of action. The LIT have a multidisciplinary makeup. Each team has childhood educators, psychologists, social workers, physical, occupational and speech therapists, and sometimes doctors and nurses, in a total of nearly 300 professionals.

The system also includes 29 NGO's that ensure the legal framework for the teams through the celebration of Cooperation Agreements with the three responsible Ministries.

In 2015, 2471 children under the age of 6 years were supported in Alentejo (SNIPI-National System of Early Intervention, 2016): 60% of which had a developmental delay without known etiology, 18% were diagnosed with a specific condition or disability, and in 22% cases some development risk factors were identified.

The current model of early childhood intervention requires that the support be provided in the child's natural setting, with the active participation of parents and principal caregivers, in a partnership based on a trusting and close relationship. During 2015, 14% of the children received support exclusively at home, 37% in the educational setting (kindergarten) and 41% benefited from the support in a mixed setting, that is, at home and at the kindergarten. In 8% of cases it was necessary to resort to another context of intervention, such as primary healthcare facilities and other specialized centers (SNIPI-National System of Early Intervention, 2016).

# Main Concepts and Framework

The evolution in the structure of the SNIPI was accompanied by a conceptual modification. Early Intervention is defined as a measure of integrative support the aim of which is to develop specific actions of a preventive nature in the field of education; health and social security for children from 0 to 6 years, with disabilities, developmental delay or with serious risk of developing handicaps, and their families (Decreto-Lei 281/2009, 2009).

This care system should take into account a perspective of intervention in children's natural settings of life and to actively involve the principal caregivers, as developmental enhancers, in order to promote social inclusion.

The underlying Early Intervention concept, which has changed over time and according to the prevailing paradigms relating to child support and disability, relies on three fundamental pillars.

Firstly, Early Intervention recognizes the contributions of the neurosciences and the advances of knowledge of brain functions, including the cerebral plasticity (Johnston et al., 2001) as the ability of the brain to remodel according the experiences of life. The malleability and the fast maturation of the central nervous system of the newborn allows acting on possible injuries or disorders, in order to prevent future follow-ups, but it also means that, in situations of risk, the harmful stimuli have a greater impact in the development than in older children, due to the same plasticity. This can lead to a timely intervention (Shonkoff, 2010; Shonkoff and Levitt, 2010).

The knowledge resulting from the studies about child development, enhances the importance of the early times of life for the establishment of future skills, with a special emphasis on the mother–infant relationship and attachment as a secure base from which the child explores the world and acquires developmental skills. The transactional approach to development (Sameroff, 1983, 2010; Sameroff and Mackenzie, 2003) has been especially important in the field of early intervention. Research has equally shown children's precocious abilities to establish relationships to be crucial to their development. This perspective justifies an intervention focused on the family.

Bioecological contributions and perspectives are equally important (Bronfenbrenner, 1979; Bronfenbrenner and Morris, 2006) and enhance the systemic importance of life contexts in the promotion of development. Hence the support should be geared at strengthening the abilities needed for the child to reach autonomy and social inclusion (Guralnick, 2008, 2011).

SNIPI constructs its theoretical framework on the evidencebased research (Shonkoff, 2010) and presents itself as an intervention framework that whilst representing an investment, is a more effective application of resources with a improved development quality, thereby avoiding higher costs in the future (Guralnick and Conlon, 2007).

# Innovative Aspects of the Program

This regional program presents innovative aspects which have led to a successful outcomes, more so than in other regions of the country, where the implementation has been much more difficult. The recognition that the needs of children with development disorders can only be fully evaluated, interpreted and tackled within the family and social setting the development takes place, implies community actions and with them the involvement of all local and broader resources throughout the region. Proximity solutions allowed a significant reduction of the children and families transport costs, which were almost entirely supported by the health system.

Furthermore, this program allowed a reduction in social and economic costs for families, given the presence of professionals in their home settings. At present, teams have cars, acquired by the Regional Health Administration of Alentejo, with community co-financing resources, which facilitates professional visits, and children and family travel, mainly in situations of great geographic isolation.

Building strong partnerships enabled creating adequate responses to the needs of children and families, with the involvement of the regional administrations of health services, education and social security. The articulation of these services has further developed the program and the monitoring of responses in order to reduce imbalances and avoid overlaps.

Other partnerships have been established with the secondary healthcare system, particularly with several hospitals that have ensured the support and the monitoring of children in pediatric subspecialties.

The articulation with higher education institutions, which ensures the program's theoretical and scientific support, was promoted, as well as with the Schools of Education of Portalegre, Beja and the Department of Psychology of Évora University. These institutions organize training and research activities on a regular basis.

At a local level, working groups promote combined efforts to ensure several services that ensure answers to families' needs. At present, the program counts on the collaboration of 217 services: local authorities, health centers, schools, local social action services, other Social Solidarity institutions, security forces, volunteer firefighters, commissions for the protection of children, local development associations, amongst others.

Health services, especially family doctors, play an important role by signaling problematic situations and providing quick referral. Many early intervention teams are based in the health centers and this facilitates the articulation and the interconnection between the services and promotes early detection of developmental disorders.

All this networking increases the ability to provide solutions for complex problems inside the community, problems that go beyond the sectorial fields of education, health and social action, but which require integrated approaches/responses.

# Network Impact: Children, Families and Community

The theoretical framework that supports the early intervention network emphasizes that it can obtain several types of results. At the development level, it aims to optimize the use of brain plasticity and the children's developmental potential, reducing the secondary effects of chronic disease and other disabilities. It promotes and reinforces attachment as a determinant factor in development, minimizes the negative influence of risk factors, and strengthens as well as enhances the child's ability to live in society. This prepares the children for the entry and progression in the education system from the age of 6.

For the family, it reinforces appropriate patterns of interaction and parental skills, helping to reduce family stress brought on by the situation. It also allows for the strengthening of formal and informal networks of social support for the family and can help reduce elements of social exclusion.

At the community level, it also plays an important role by promoting the articulation between services and bringing them closer to the target population, increasing quality and making resources more cost effective. Finally, it promotes social inclusion, because the different partners are focused on problemsolving.

A study carried out to evaluate the effective impact of the Early Intervention network in the Alentejo (Franco and Apolónio, 2008) has equally shown the effectiveness of its accomplishments:

(A) There is an effective strengthening of the role of health centers in the detection, signaling and referral of cases and an increase in the skills of health professionals in the assessment of development disorders. The impact on the detection and referral of cases to LIT and on the beginning of the intervention by those professionals is especially important as it has significantly reduced the age of diagnosis and the onset of the intervention.

(B) Early Intervention teams are an important element of the families' social support networks, being in many cases considered the most important element.

(C) Creation of the early intervention network had a strong impact on the activity of systems and services resulted in modifications in the practices of its professionals. With the increase of family centered work and a transdisciplinary functioning, professionals identified a strong impact on activity and services systems and a change in their own practices.

(D) Families found out a positive impact on children's development and on being more responsive to their needs.

The Early Intervention program in Alentejo, as part of the SNIPI, can be an example of good practices, with its own characteristics that allowed the creation of a regional network of integrated and comprehensive responses to the needs of the population. Its innovative character has been recognized, nationally and internationally, by being awarded two prizes. In October 2009, the program won the 2nd Prize of Good Health Practices in the context of their participation in the "Award for good practices on fairness, effectiveness and efficiency in health," awarded by APDH/HOPE & FIH, with Novartis Oncology support. In 2010, this same program was distinguished by WHO – World Health Organization with the United Arab Emirates Foundation Prize for Health, for the contribution to the development of health in Portugal. These distinctions reinforced the importance of the work already done and the necessary commitment to reinforce the positive aspects and overcoming constraints that still exist, in order to expand this model across the country.

# CONCLUSION

By looking at how children who receive early intervention find themselves in a better position to face the challenges of schooling and by evaluating the impact of the early intervention network at the level of the educational system, we confirm that:

(a) Children with developmental or educational problems need to receive support from a team of early intervention, with an effective network coverage;

(b) Kindergarten teachers who integrate these teams are experienced professionals. Most of them possess a specialized course, and all of whom have some experience in the field of early intervention (Dunst, 2009). They also consider themselves to be well-informed about early intervention (its theoretical foundations as well as its practices) and believe they have think they have increased their knowledge about development problems;

(c) Most of the teachers working in kindergarten classrooms do not possess any training in early intervention. However, their level of information about the early intervention system is high: they know how the network works, how to contact the LIT, and have in fact an effective contact with it and they know how to use the referral process;

(d) Each teacher works with a considerable number of children and families (about 10), and most of the children are aged from 3- to 5-years-old. There seems to be a good margin of progression in early intervention, and the number of children under 3 years is increasing;

(e) Children go to early intervention mainly as a result of being at risk situations because of family and social factors. Disability cases, or cases of severe developmental delays cases are significantly less. It is therefore important to:

(f) The transition to elementary school is a very sensitive aspect, and includes the monitoring of other entities responsible for the protection of the child as well as for the social support to the family;

(g) Teachers recognize their practices reflect changes due to the work within the Early Intervention System. The bigger the use of specific assessment tools and intervention planning strategies, the more relevant change is brought on as result, empowering teachers ability to assess the needs of the child and the family and to promote changes in their own contexts. More than 80% of interventions are made at the child's or in the kindergarten/nursery, twice a week or once a week (with a duration of over an hour each).

(h) The intervention of the teachers is no longer focused only on the child, but also on their parents, on other teachers inside the kindergarten and even on other professionals the child works with. The family-centered intervention is considered one of the most significant benefits brought to the practice of these early intervention teachers, such as the ability to recognize the strengths and capabilities of the child and his family. Their work with families is mainly providing information, referrals and counseling, in the context of a close relationship. The

# REFERENCES

transdisciplinary perspective is enhanced and hones skills such as the ability to spot difficulties shown by the children.

A global network operation contributes to:

(a) Inclusion: facilitating the transition, based on a non-discriminatory approach and that repudiates exclusion. On the contrary, the child receives care and support in a specific setting and the family assumes the center stage in this interventions.

(b) Educational achievement: by strengthening the development, and an adapted contextualization in pre-school education. That can also be possible because the children go to school with an effective screen of their developmental needs as well as the level of support necessary for each of them.

Consequently the system introduces major innovation within the framework of educational policies that promote development and inclusion, which has deserved the interest of the scientific community and of policy makers. It has been possible to implement some of principles already studied but it had never been tested at this level. It must be said that, for their implementation they require a proper educational policy context.

# AUTHOR CONTRIBUTIONS

VF: Conception and design, manuscript preparation, and final approval of the version to be published. MM: Contributions to the conception of the work and drafting of the work. GS: Contributions to the design of the work, critical revision, and final approval of the version to be published. AA: Study design and data collection. LA: Study design, data collection, and final revision.

# FUNDING

This paper was financed with National Funds through FCT – Foundation for Science and Technology, within the scope of the project CIEP-UID/CED/04312/2016.

**Conflict of Interest Statement:** The handling Editor declared a shared affiliation, though no other collaboration, with several of the authors VF, MM, GS, and states that the process nevertheless met the standards of a fair and objective review.

The other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2017 Franco, Melo, Santos, Apolónio and Amaral. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.


**4. Results**

#### *4.1. Implementation of RES for the Estimation of Weighted Coefficients*

In this section, the results of the application of the RES method in the Attica Region are presented, such as the interactions among the selected parameters, the calculation of their weighting coefficients and finally the instability index accompanying with charts and tables which they decode and translate the geodata. As it was previously presented, the interaction matrix shown in Table 3 was coded using the Expert Semi-Quantitative method. For example, regarding the effect of lithology (P4) on rainfall (P6), it can be stated that there is no influence at all (coding: 0), whereas rainfall does affect lithology through the infiltrating and weathering-erosion process that may alter not only the mineralogical composition of a specific rock or soil of the slope but also influence their hydrogeological behavior too (coding: 2).

Note that, in Table 3, the sum of cause-and-effect (C + E) value for each parameter represents the "interaction intensity" term, which means how active that parameter is within the matrix system (i.e., the slope stability). On the contrary, the (C − E) value represents how dominant the variable is within the system: positive values of (C − E) represent a dominant variable, whereas negative values of (C − E) represent that the system is affecting the variable more than the variable is affecting the system [7]. More specifically, from Table 3 and Figure 7, it can be seen that the hydrogeological conditions are the most interactive parameter (C + E = 39) [e.g., has the greatest value (concerning C + E)], meaning those conditions play the most decisive role for landslide activation, whereas elevation is the least interactive (C + E = 18). This suggests that elevation does not depend on the influence of the other parameters, but it is an independent agent.

**Table 3.** Coding values for the interaction matrix of Attica Region.

**Figure 7.** Histogram of interaction intensity.

From the RES model and by focusing on the weights assigned to each parameter, it can be clearly reported that hydrogeological conditions contribute the most to landslide occurrence out of all the factors, followed by distance from streams, lithology, slope angle, rainfall, distance from roads, land use, distance to fault lines, aspect and elevation.

In Figure 8, the form of C vs. E constellation in relation to C = E line, defines the number of parameters that will be needed for calculating the instability index. So, according to the interaction intensity–dominance diagram (Figure 6b), the form of the C vs. E constellation is (almost) perpendicular to the C = E line, which means that (based on the aforementioned RES analysis) there is little range in parameter interaction intensity. On the contrary, there is a wide range in dominance (C − E values), so all the selected parameters will be required for the calculation of the instability index for each examined slope.

**Figure 8.** Cause–Effect diagram.

Supplementary, the following Table 4, decode and "translate" simultaneously the geodata acquired from our research and contribute in giving the necessary objective answer to the prognosis of the potential instability of the examined slopes of Attica Region. This can be accomplished by the estimation of the instability index, as clearly explained in Section 3.2.1.

A characteristic sample, 10 out of 220 cases of the computation results regarding the instability index, is given in Table 4. In this table, each examined slope (is depicted in the column "Slopes") is ranked according to Table 1 rating, taking into account in parallel the specific geological conditions that characterize it according to either the ad-hoc technical report we collected or field study we carried out. Afterward, for each slope site, every ranking of each parameter (each parameter is depicted in the second line under the title "Parameters", named as 1, 2, 3, ... , 10) is multiplied by its weighted coefficient (last line of the Table) respectively and each outcome, based on Equation (1) is added in order to yield the instability index for each slope. For example, the instability index of Slope (1) is estimated as follows:

Σ [Parameter (1): 4 \* 2.39 + Parameter (2): 1 \* 2.77 + . . . + Parameter (10): 2 \* 1.72] = 71 (3)

> In Table 5, the classification for relative landslide susceptibility is listed as proposed by Brabb et al. (1972) [50].

**Table 4.** Calculation of Instability Index based on Rock Engineering System methodology for a characteristic sample of 10 slope failures out of 220 ones in Attica Region.

> **Table 5.** Classification for relative landslide susceptibility proposed by Brabb et al. (1972) [50].

As it is shown in this table, the generated instability index that is greater than 53%, corresponds to extremely high relative susceptibility up to slope failure and that this is the crucial point for a planner or a researcher for producing a landslide susceptibility map for a particular examined area. This remark is going to be used extensively in the following sessions of this study.

#### *4.2. Correlation of Spatial Distribution of Slope Failures with the Predisposing Factors Using Statistical Analysis*

Based on the information of Table 4, and according to the ranking of parameters of Table 2, the following useful findings come out during the generation of the susceptibility map of the Attica region. Based on this analysis, it can be concluded that 211 out of 220 (96%) slope failures are in a distance from roads up to 50 m.

Concerning the aspect parameter, 37% of the examined slopes are primarily more abundant on Southeast-facing and secondly on Northwest-facing (34%). Based on the rating assigned to each geological formation (e.g., lithology), the highest (40%) one is observed at flysch (and debris) and secondly to carbonate rocks (37%). This remark was expected since the former ones are the most statistically frequent formations prone to landslides in Greek territory, whereas the latter ones are associated mainly with rockfall incidents in many parts of Greece.

Regarding hydrogeological conditions, carbonate rocks with medium to high permeability due to karstification and secondary fragmentation correspond to the highest (35%) category of permeable rocks in this study. Based on the comparison among rainfall data and landslide occurrences, it was established that landslides are more likely to take place

when the mean annual rainfall is between 400–800 mm. As far as land use parameter is concerned, landslides reported mostly in urban areas (62%) while based on the results given for the elevation, it was found that the landslides develop preferentially on 0–200 m of altitude (63%).

Furthermore, a large portion of landslides (58%) are located near to the hydrographic network in relation especially to the undermining of the banks between 0 m and 50 m. Such places were recorded in many streams (mostly) in the Athens basin (such as those of Kifisos river, Chelidonous, Sapfous, Penteli, Eschatia stream).

Summarizing, the percentages of landslides per each class of predisposing factor are illustrated in the following Figure 9.

**Figure 9.** *Cont*.

**Figure 9.** Percentage of landslides in each class of the causal and triggering factor of landslide occurrence.

#### *4.3. Landslide Susceptibility Map*

The subdivision of the predisposing parameters into subclasses (from Table 2) was used for the evaluation of the final slope failure susceptibility map. This map was generated in a GIS environment, through the use of different layers-thematic maps (Figure 10a–j). The data used for the preparation of these layers were obtained from different geodata sources among which are the Digital Elevation Model from Hellenic Cadastre S.A. and a mosaic geological map from the Hellenic Survey of Geological and Mineral Exploration. All data layers were digitized either from the original thematic maps or derived from spatial GIS calculations and finally were converted into grids with a cell size of 20 × 20 m. Afterward, weights and rank values to the reclassified raster layers (representing predisposing factors) and to the classes of each layer were assigned, respectively. This was realized with the use of the previously extended analyzed methodology of RES. Finally, the weighted raster thematic maps with the assigned ranking values for their classes were multiplied by the corresponding weights and added up (through the ArcGIS tool of the weighted sum) to yield the slope failure map where each cell has a certain landslide susceptibility index value. The reclassification of this map represents the final susceptibility map of the study area, divided into susceptibility zones according to Brabb et al. (1972) [50] classification (Figure 11). The landslide susceptibility index (LSI) values in the final susceptibility map were classified into five categories, namely "Low-Middle", with Instability index (Ii) < 25, "High" with 25 < Ii < 42, "Very High" with 42 < Ii < 53, "Extremely high" with 53 < Ii < 70", and "Landslide" with Ii > 70%. From this classification, it can be clearly notified that the higher the LSI, the more susceptible the area is to landslides (instability index higher than 70%).

**Figure 10.** *Cont*.

**Figure 10.** *Cont*.

**Figure 10.** Thematic raster maps of the ten (10) landslide parameters used for the estimation of Attica region susceptibility: (**a**) Distance from roads, (**b**) Slope, (**c**) Aspect, (**d**) Reclassified geological map, (**e**) Hydrogeological conditions, (**f**) Rainfall, (**g**) Land use, (**h**) Distance from streams, (**i**) Distance from tectonic elements, (**j**) Elevation.

> From Figure 11, some further findings that come out are as follows (Table 6, Figure 12):

**Table 6.** Correlation between instability index and susceptibility coverage class in km2.

From the above pie diagram, it is clear that 43.09% (39.85% + 3.24%) of the examined area is associated with an instability index greater than 53%. Furthermore, it can be added that 122 km2 (3.24%) of the total examined area are correlated to potential landslide occurrence. Public authorities responsible for auditing and supervising technical works should be aware of these findings, so as to take the appropriate advance, mitigation measures against the possible initiation of potential disastrous landslide phenomena taken place in these proposed, for slope failures, areas.

**Figure 11.** The Susceptibility map of Attica Region.

**Figure 12.** Pie diagram depicting the landslide susceptibility coverage class in km2 for Attica region.

#### *4.4. Validation of the Landslide Susceptibility Map*

For having scientific significance in any generated model, the most important component in prediction modelling, is to implement a validation of the prediction results [51]. Thus, in the final landslide susceptibility map, we compared the results with the distribution of the 220 slope failure events that had occurred in the examined area. The predicted map showed very satisfactory results and particularly, at the susceptibility map of the Attica region, 68% of the locations of actual and potential landslides correspond to the "Extremely high" and 21% are associated with a landslide (Figure 13, Table 7).

**Figure 13.** Correlation among number of examined slope failures, instability index, and susceptibility classification. Blue color corresponds to the number of slope failures, orange color is linked with instability index percentage associated with susceptibility categories.

**Table 7.** Correlation among number of examined slope failures, instability index, and susceptibility classification.

Moreover, another method for validating the above mentioned, was the implementation of the confusion matrix. It is a table that is often used to describe the performance of a classification model on a set of test data for which the true values are known [52]. We used the confusion matrix for a binary classifier e.g., ( α) the existence of landslides with instability index greater than 53% and (b) the no existence of landslides (with instability index less than 53%). Each row of the matrix represents the instances in an actual class while each column represents the instances in a predicted class (or vice versa). In our case, In Table 8, four different combinations of predicted and actual values were used.

**Table 8.** Confusion matrix of the landslide susceptibility map validation.

Where: TN means when the examined slope does not correspond to landslide, how often does it predict no, FP means when the examined slope does not correspond to landslide, how often does it predict yes, FN means the falsely predicted landslide, TP means when the examined slope correspond to landslide, how often does it predict yes.

The following is a list of rates that were computed from the confusion matrix for a binary classifier:

• Accuracy: Overall, how often is the classifier correct?

$$(\text{TP} + \text{TN})/\text{total} = (174 + 3)/220 = 0.80\tag{4}$$

• Precision: Out of all the positive classes we predicted correctly, how many are actually positive.

$$\text{TP/predicted yes} = 174/195 = 0.89\tag{5}$$

• Prevalence: How often does the yes condition actually occur in our sample?

$$\text{actual yes/total} = 196/220 = 0.89\tag{6}$$

From the above, analytically presented, it is clear that the described RES methodology has 89% precision.

In addition, the validation of the generated susceptibility map was tested with two additional landslide databases. These are (a) the 98 polygons derived from Oregon methodology as previously mentioned, and (b) erosion lines derived from a project delivered by the Hellenic Survey of Geological and Mineral Exploration concerning the Mandra area flooding susceptibility [53]. Particularly, it was found that regarding the Oregon protocol, in the generated landslide susceptibility map of the Attica region, 49% of the

defined polygons correspond to the "Extremely high" category and 33% are associated with landslides. Concerning the rest of the delineated areas, it is proposed to conduct geological–geotechnical investigations to define the potential of the slopes to failure.

Finally, the erosion lines which were defined by the aforementioned research institute were in accordance with the instability index greater than 70%.

Practical use of the final susceptibility map is the implementation it may have during the planning, design and construction of various important infrastructure projects. Even though it is not advisable to be used for local or site-specific planning, C.J. Van Westen (2016) [54], recommends the following use of the above-mentioned susceptibility classes.

## **Low susceptibility zones**

In those areas, with respect to planning and constructing civil engineering projects, no special care should be taken by planners and engineers.