a perspective on “in-home behavioral services” mark levine ms bcba lmhc lpc behavioral...

A Perspective on A Perspective on “In-home Behavioral Services”“In-home Behavioral Services”

Mark Levine MS BCBA LMHC LPCMark Levine MS BCBA LMHC LPC

Behavioral Counseling and Research Center LLCBehavioral Counseling and Research Center LLC

(Listener take note)

•My conception of service …only mine

Service Recipients?

© Behavioral Counseling and Research Center LLC 2009

Behavioral ServicesBy Statute (Mainly)

Behavioral ServicesVia Class Action Lawsuit

Behavioral Health = Mental Health

“Behavioral” in Behavioral Health ≠ “Behavioral” as in Behavioral

Interventions

“Behavior Management”

My Preference: Behavior Analysis


The science in which procedures derived from [learning] principles are systematically applied to improve socially significant behavior to a meaningful degree and to demonstrate [empirically] that the procedures employed were responsible for the improvement in behavior.

Thanks to (Cooper, Heron & Howard. Applied Behavior Analysis. Columbus OH. Merrill. p.14) and Behavior Analyst Certification Board

•Driven by behavior than diagnosis•More challenging behaviors•Can be diagnostic clusters •Often dual diagnoses

Based on significance of single factor: e.g. severity) or sum of 2 or more dimensions: e.g. severity + frequency (or duration)severity + frequency + duration © Behavioral Counseling and Research Center LLC 2009

Sire, May I suggest an Applied Behavior Analysis consultant

What kinds of behavior?

•Lack of cooperation•Verbal abuse

•Destroying property•Aggression

•Arson•Sexually inappropriate

•Theft•AWOL

•VERBS© Behavioral Counseling and Research Center LLC 2009

Behavior problems are maintained by environmental/antecedent conditions, learning history and skill absences

Behaviors happen within contexts.

They do not happen in vacuums or spontaneously


Committed to established principles of

behaviorFocus on observable

behavior. Data Driven


Behavior plans are created when social significance justifies.


Medical and other inherent conditions that can affect behavior and learning are considered.


Create behavior plans that are based on the function of the person’s behavior

Antecedent and reinforcement interventions are used but not aversives


Absent skills are acquired and inappropriate skills are altered through the teaching of replacement skills

Skills and other youth assets are building material for intervention strategies


A well-chosen, well-trained and well-supervised staff that does it the behavioral way

Collaborate with other parties in the youth’s life



(Bring your CANS)

Antecedent is a stimulus that is present when a behavior occurs.It does not necessarily produce the behaviorBut can develop control

Behavior – interaction with the environment

Consequence – an environmental change following the behavior that alters the probability of future occurrences of that behavior

•Added•Removed © Behavioral Counseling and Research Center LLC 2009

Antecedent Behavior Consequence

Asked to pick

up sweater

Pulled own

hair for 5 min

Had him sit to

calm down

Steve entered

room

Making loud

noises

Told

repeatedly to

stop until he

did


Lately, I’ve discovered that I’m my own worst antecedent

ECOLOGICAL•Cold/Hot Places•Crowded/Noisy environments•Novel places ACTIVITY RELATED•Activity transition time•After making an error•Given an initiating instruction•Given a terminating instruction•No structured activity

INTERPERSONALCorrective feedbackDenial of a requestFollowing reinforcementPeer receives attentionPresence of specific adult/peer

SCHEDULE RELATEDParticular activityParticular hourParticular day


INTRAPERSONAL

Engagement in other misbehaviorFearful stimuliFollowing administration of medicationNeed cannot be made knownNegative verbalizations


Positive ReinforcementNegative Reinforcement aka EscapeExtinctionPunishment

What Occurs Next?


Obtain Attention•Praise•Acknowledgement•Criticism Obtain Tangible •Money•Objects•FoodObtain Activity

Positive Reinforcement


Escape/Delay•Demands•Activity•Person or Behavior a Person•Anxious situation

ESCAPE IS BIG!!


Harold, Makes A Communicative Statement

Current Behavior

Function(s)AntecedentsConsequences

SkillDeficits

Replacement Behavior(s)

Thanks to Maag, J. Behavior Management. Singular. 1999

Hypothesize from Correlation

Interventions Derive from Antecedents, Consequences, Functions.


PROACTIVE VS REACTIVE

EliminateAlterInterrupt ChainControl (SC)Compete


I’ll have an ounce of prevention.

Example of altering the impact of an antecedent: response to initiating instruction •Reduce complexity of the instruction or the number of steps to follow. •Provide a verbal reminder of the reinforcer that will follow cooperation.•Give choices regarding when to follow the direction (now or at a specific other time) and how to follow the instruction.•-Start the activity with the person. Or do the first parts of it.•Use proximity cues if needed. Stand close when giving the direction rather than across the room.•The less instructions given the better. The less given verbally the better


response to initiating instruction

–Initiating instructions are more likely to be followed if they are part of a routine or schedule. Developing an event-based schedule helps the individual to predict when demands will be made and what they will be. The schedule can include visual along with written cues.

–Correspondence Training. This involves getting a person to commit verbally something. If cooperation is subsequently achieved the cooperation is reinforced socially as well as completion of the task.

-Don’t give the instruction

Is there a method of escape?


Joe creates a sense of predictability through scheduling

Replace the behavior with an appropriate one, preserving the function.

•Most common choice: communicative

Independence skillsChoice MakingCooperationVocational skills ($)Leisure skillsSocial skills (Heavy interaction with sexual behaviors) © Behavioral Counseling and Research Center LLC 2009

Reinforce:

•alternative behavior•less behavior•other behavior•any behavior

•Incompatibility_______________

•Interrupt/extinguish reinforcement of undesired behavior


Just try to reinforce him when he isn’t hitting you.

NOT A LEARNING MOMENT


Who implements?Typically…•Family Members•Behavior(al) Management Monitor•Other paraprofessionals in the youth’s life

***Monitored by data collection**© Behavioral Counseling and Research Center LLC 2009

HIRINGTRAININGQUALITY CONTROL

Task/Data Driven


Someone who has done the above

Direct experience working with youth as well as from directed training mentoring personnel in the relevant methods to successfully reach objectives

Professional performance in program design andin understanding exactly how change happens

Academic and clinical problem solving along with an ability to use feedback constructively.

Experience gleaned from “being there and trying that” over multiple trials with a wide range of populations.


• Developing and drafting of functional assessments and plans

• Supervising paraprofessionals • Overseeing implementation of plans

(Dealing with non-clinical factors)• Collection and analysis of data • Evaluation and monitoring of outcomes• Collaboration with teams


Experience as directly related as possible w/populationExperience with anticipated behaviorsExperience as directly related as possible w/para tasks SmartsSOCIALLY REINFORCING / ENGAGINGProactiveCareer orientedPositive modelsAgree behaviors to be addressed scientifically, not in own wayWill not take behaviors personally


•Eliminating or altering antecedents to create behavior change•Employing positive reinforcement to increase replacement target behaviors and reduce challenging behavior•As instructed, not being reactive to unwanted behaviors•Observing and defining, with the help of a supervisor, target behaviors to alter•Collecting data on target behaviors•Collecting data on skill deficits•Defining and obtaining data on “replacement behaviors”, under the guidance of a supervisor•Implementing plans as written


•Providing prompts and cues to trigger appropriate behavior•Repeating skill training across the day and in multiple environments•Employing “Functional Communication Training”•Reporting plan obstacles immediately•Handling emergencies as directed and reporting ASAP•Assisting in a problem solving approach with new behaviors until an effective plan is formulated


BEHAVIOR ANALYSIS THEORY – PERTINENT to the job e.g. •Building skills in communication, compliance, and cooperation•Interpreting Functional Behavioral Assessments•Behavioral Strategies (Shaping, Chaining, Task Analysis)•Social Skills, Circles of Support•Precision Teaching•Sexuality•Data Collection and Analysis•Engaging and working with families© Behavioral Counseling and Research Center LLC 2009

TRAIN TO THE SPECIFICS OF THE YOUTH’S PROGRAM

CONFIDENTIALITY IN HOME AND COMMUNITY SETTINGS

CRISIS MANAGEMENT TRAINING

•Working in the community•Professional boundaries•Normal child development•Inclusion strategies•Specific Dual Diagnoses (ADHD; Asperger’s…)


In ABA supervision at all levels—including peer supervision—is expected

Direct professional supervision of paraprofessionals

Task driven supervision. Checklists

Ample literature


•Parents and Caregivers are people too•Plan for them as well

•Personnel. Absences. No shows. Substitutes•Place a system into action ahead of time

•Practice of skills with caregivers and paras•Paperwork

•System to meet the standards without interfering with services


•Protection from Harm/Safety – Various environs•Training and supervision; follow-thru on plans•Prudence•Presence of family member/caregiver (or other)Privacy and Confidentiality in Homes and Community•Persistent training with scenarios•Physicians. Med Changes

•Provide Data•Please Don’t Go

•Plan Ahead. Data-base.•Possible Conflict with Other Services•Be the first to collaborate and…


•Are based on established principles of behavior•Are linked to the data of the youth’s behavior•Develop and implement behavior plans that are based on the function of the person’s behavior•Focus on teaching replacement behaviors (skills) that displace unwanted behaviors but preserve function•Use antecedent interventions and reinforcement but not aversives


PREVENTTEACH

REINFORCE


Functional Assessment and Program Development for Problem Behavior: A Practical Handbook (Paperback)by Robert E. O'Neill, Robert H. Horner, Richard W. Albin, Keith Storey, Jeffrey R. Sprague. Cengage

a perspective on “in-home behavioral services” mark levine ms bcba lmhc lpc behavioral...

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