Are Tier 1 Interventions Being Implemented with Integrity?

At the core of any multi-tiered system of support (MTSS; e.g., School-wide positive behavior intervention or Response to Intervention) is the requirement Tier 1 or universal intervention is implemented with adequate fidelity to benefit most students.  If Tier 1 interventions are not implemented with fidelity, too many students will receive more intensive Tier 2 and Tier 3 interventions.  The increased intensity of intervention will also unnecessarily strain school resources.  It is important to remember that MTSS are frameworks, and ultimately the benefit to students depends on adopting empirically-supported interventions and then implementing them well.  Without fidelity measures, it is not possible to know if failing to respond to an intervention is a problem with the intervention or poor implementation.  Often interventions are abandoned for apparent lack of effectiveness when, in fact, the intervention was not implemented with fidelity.

Fidelity is a complex construct that can be measured at different levels and different frequencies.  Each measure yields different types of information.  Until now, we have not known how researchers measured fidelity.  This situation has been partially resolved in a recent review by Bruckman et al. (2021).  Their review measured how researchers assessed treatment integrity, the frequency it was evaluated, and the level (school or individual implementer). 

Bruckman and colleagues reported that measures at the school level were reported about twice as often as at the individual level and assessed once or twice per year.  Treatment integrity measured at this level tells us how well the overall system is functioning with respect to the implementation of the intervention.  Data at this level does not indicate if all students are receiving a well-implemented intervention or if some students are not receiving the intervention as planned.  Measuring treatment integrity at the level of an individual teacher will inform if students in a particular teacher’s classroom are receiving a well-implemented intervention.  Individual-level measures are essential for data-based decision-making when determining if a student should receive more intensive services at Tier 2.  Low levels of fidelity would suggest that rather than increase the intensity of service for a student, it would be wise to invest in improving the individual teacher’s implementation of the intervention. 

Finally, Bruckman and colleagues discussed the limitations of assessing treatment integrity once or twice a year.  Such infrequent measurement does not tell us if implantation with integrity is occurring consistently or not.  The challenge of assessing more frequently is that it places a high demand on resources.  Considerably more research is required to develop effective and efficient methods for evaluating treatment integrity.

Link: https://link.springer.com/article/10.1007/s43494-021-00044-4

Citation for Article:

Buckman, M. M., Lane, K. L., Common, E. A., Royer, D. J., Oakes, W. P., Allen, G. E., … & Brunsting, N. C. (2021). Treatment Integrity of Primary (Tier 1) Prevention Efforts in Tiered Systems: Mapping the Literature. Education and Treatment of Children, 44(3), 145-168.