integrating individualized interventions for students with mental health challenges within a...

Integrating Individualized Interventions for Students with Mental Health

Challengeswithin a School-wide System of

Positive Behavior Supports

CMHACYMay 14, 2015Session 1-A

Lucille Eber Ed.DDirector, Midwest PBIS Network and

National PBIS TA Center Partnerlucille.eber@midwestpbis.org

Describe how interventions for students with mental health challenges can be efficiently delivered within a school-widesystem of Positive Behavior Supports.

Share examples of how individualized interventions, including function-based behavior plans, person-centered wraparound and RENEW plans, can be layered up from an effective school-wide PBS curriculum.

BIG Ideas for Today:

Putting outcomes for students with EBD

into the context of schoolsas systems to educate and support

ALL students.

Some “Big Picture” Challenges

• Low intensity, low fidelity interventions for behavior/emotional needs

• Habitual use of restrictive settings (and poor outcomes) for youth with disabilities

• High rate of undiagnosed MH problems (stigma, lack of knowledge, etc.)

• Changing the routines of ineffective practices (systems) that are “familiar” to systems

What has Changed Since……?

Braaten,S., Kaufman, J.M., Braaten, B., Polsgrove, L., and Nelson, C.M. (1988). The Regular Education Initiative: Patent Medicine for Behavioral Disorders. Exceptional Children, 55(1), 21-27

Knitzer, J., Steinberg, Z and Fleisch, B. (1990). At The schoolouse door. New York: Bank Street College of education

Wood, F. (1989) Students at risk. Supporting the growth of students with emotional and behavioral disorders. The Pointer, 33(4), 20-26

Peacock Hill Working Group, 1991

We Know the Practices that Work for Students with EBD…

• Proactive, strength-based; “set kids up” to experience success

• High rates of consistent, supported instruction; teach/practice/reinforce

• Predictable and consistent environments• Know unique “why?” for each student/problem• Contextual fit: Strategic use of natural supports, and

settings• Careful monitoring of data over time with ongoing

revisions to guide incremental improvements in quality of life

• Behavior support is the redesign of environments, not the redesign of individuals.

• Positive behavior support plans define changes in the behavior of those who will implement the plan. A behavior support plan describes what we will do differently.

Do ALL staff understand the context for effective behavior interventions?

It Takes a System…

…..that builds system capacity for advanced tiers

SupportingStaff Behavior

SupportingDecisionMaking

SupportingStudent Behavior

PositiveBehaviorSupport

SYST

EMS

PRACTICES

DATA

OUTCOMES

Social Competence &Academic Achievement ٭

Adapted from “What is a systems Approach in school-wide PBS?”OSEP Technical Assistance on Positive Behavioral Interventions and Supports. Accessed at http://www.Pbis.org/schoolwide.htm

Core Features of a Response to Intervention (RtI) Approach

• Investment in prevention• Universal Screening• Early intervention for students not at “benchmark”• Multi-tiered, prevention-based intervention approach• Progress monitoring• Use of problem-solving process at all 3-tiers• Active use of data for decision-making at all 3-tiers• Research-based practices expected at all 3-tiers• Individualized interventions commensurate with

assessed level of need

Primary Prevention:School-/Classroom-Wide Systems for

All Students,Staff, & Settings

Secondary Prevention:Specialized Group

Systems for Students with At-Risk Behavior

Tertiary Prevention:Specialized

IndividualizedSystems for Students

with High-Risk Behavior

~80% of Students

~15%

~5%

SCHOOL-WIDE POSITIVE BEHAVIOR

SUPPORT

PBIS Features

Module 1: PBIS TeamModule 2: Faculty CommitmentModule 3: Expectations and RulesModule 4: Lesson PlansModule 5: AcknowledgementModule 6: Discipline ProceduresModule 7: Data Entry and AnalysisModule 8: Classroom Behavior SystemsModule 9: EvaluationModule 10: Implementation Plan

Common Language

Expectations 3-5 overarching school-wide expectations

Behaviors/Rules specific tasks students are to do to achieve the school-wide expectations

Routines/Procedures methods or process for how things are done in non-classroom settings and each classroom

14

The change is an instructional processinstructional processWe change STUDENTSTUDENT behavior

by changingADULT behavior

Interventions = changes in staff procedures & practicesInterventions = changes in staff procedures & practices

How will we teach behavior?When will we teach behavior?

Kick-off events Teaching staff, students and families the expectations and rules

On-going direct instruction Data-driven and scheduled designed lessons Pre-correction Re-teaching immediately after behavioral errors

Embedding into curriculum

Booster trainings Scheduled and data-driven

Continued visibility Visual Displays – posters, agenda covers Daily announcements Newsletters

Guidelines

School-wide reinforcements are for every student Acknowledge the behaviorInclude the students in identifying possible

recognitionsRecognize students other than your own in common

areasRecognition closely follows the desired behaviorKeep it novel

Tier 1/Universal School-Wide Assessment

School-Wide Prevention Systems

SIMEO Tools: HSC-T, RD-T, EI-T

Check-in Check-out (CICO)

Group Intervention with Individualized Feature (e.g., Check and Connect - CnC and Mentoring)

Brief Functional Behavior Assessment/Behavior Intervention Planning (FBA/BIP)

Complex or Multiple-domain FBA/BIP

Wraparound

ODRs,Credits, Attendance, Tardies, Grades, DIBELS, etc.

Daily Progress Report (DPR) (Behavior and Academic Goals)

Competing Behavior Pathway, Functional Assessment Interview, Scatter Plots, etc.

Social/Academic Instructional Groups (SAIG)

Positive Behavior Interventions & Supports:A Response to Intervention (RtI) Model

Adapted from T. Scott, 2004

Tier 2/Secondary

Tier 3/Tertiary

Inte

rven

tio

nAssessm

en

t

Individual Student Information System (ISIS)

USDOE-OSEP Tertiary Demo Project

#H326M0060010

More Students Access Tier 2/3 Interventions When Tier 1/ Universal is in Place

7.94%

4.95%

0%

2%

4%

6%

8%

10%

Partially Implementing

(n=26)

Fully Implementing

(n=125)

% s

tud

en

ts

FY09 School Profile ToolStudents Accessing Tier 2/Tier 3 Interventions

Tier 2/Tier 3…..Changing Existing Systems

• Harder than starting from scratch• Schools think they are “already

doing it”… Need to “deconstruct” some existing

teaming approaches and practices Data not being used except to justify

placements

Examples of Ineffective Secondary/Tertiary Structures

• Referrals to Sp. Ed. seen as the “intervention”

• FBA seen as required “paperwork” vs. a needed part of designing an intervention

• Interventions the system is familiar with vs. ones likely to produce an effect (ex: student sent for insight based counseling at

point of misbehavior)

Example of Change that may be Needed

• “Groups” that are not evidence-based• Clinicians “seeing” students w/o clarity of

intervention and data to determine effectiveness

3-Tiered System of Support

Necessary Conversations (Teams)

Check-In Check-Out

Skills Groups

Group w. individual

feature

Complex

FBA/BIP

Problem Solving Team Meeting

Tertiary Systems Team Meeting

Brief

FBA/BIP

Brief FBA/BIP

Wraparound

Secondary Systems Team

Meeting

Plans schoolwide &

classroom supports

Uses process data; determines overall

intervention effectiveness

Standing team; uses FBA/BIP process for one student at a time

Uses process data; determines overall

intervention effectiveness

UniversalTeam

Meeting

Universal Support

USDOE-OSEP Tertiary Demo Project

#H326M0060010

Coordinator vs. Facilitator

Coordinator• Organizes and/or

oversees the specific interventions such as CICO, S/AIG & Group with Individual Features

• Roles include: scheduling meetings, review & collect data to share during team meetings, etc…

Facilitator• Directly provides

intervention support services to youth/families

• Roles include: meeting with students for CICO, running groups

USDOE-OSEP Tertiary Demo Project

#H326M0060010

USDOE-OSEP Tertiary Demo Project

#H326M0060010

Do Teaming Structures in your school(s) need to change?

Quick Reflection:

1. How many kids have been talked about at ‘______’meeting this year?

2. How many of those discussed got an intervention that you have data to indicate they got an intervention that is working?

Have you ever been at a meeting where you talked about one youth for an hour and at the end you were no closer to having effective strategies than when you started?

Did Henry “need” a restrictive placement?

Quick Student Example #1:Student w/EBD moves to new District

0

20

40

60

80

100

9/3 9/10 9/17 9/24 10/1 10/8

% o

f G

oa

l Ac

hie

ved

%of Daily Total CICO Points

Henry’s Daily Point Data for Behavioral Goals

Did Henry “need” a restrictive placement?

Or effective interventions?

Administrators Need to…

• Have knowledge of behavior support for Tier 2/Tier 3 to guide/lead any “corrections” needed.

• Know why a behavior plan may not be working and need to know how to “troubleshoot” a plan.

• Ensure that systems are in place and interventions are offered routinely and rapidly at all 3 tiers to allow ALL kids to be successful

Failed Interventions are Not Neutral

• They leave a residual effect…

Administrators Role…

• No intervention is administered w/o progress monitoring.

• The Special Education focus changes from “did we deliver the intervention?” to “did the student experience success/get better?”

• Ensure that “research based interventions ”always used; – don’t get to choose not to deliver interventions.

• Equip teachers to be confident to handle.

TIER 2/3: Intervention Examples, Decision-Rules and Tools

Check-in-Check-out (CICO)

• Merely an extension of Tier 1• Some get high frequency scheduled positive

contact with adults• Youth solicit the positive contact/feedback• Low effort for teacher if built on Tier 1• Need to have 7-12% accessing if it is to come

to be a routine in your school(s)• If you only have 1-2% on CICO, those are

likely to be kids who need more….

Why do you want 7-12% on CICO?

1. Kids who here-to-for would have gotten nothing (‘til they ‘got worse”) now get a positive boost of support (sea of ineligibility)

2. All teachers will expect that every day they will have kids cross their threshold who need higher rate of positive contact

3. Quicker/easier to support kids who need Tier 3

4. Structure to build transference and generalizing from Social Skills instructional groups and function-based behavior plans

Social/Academic Instructional Groups

Selection into groups should be based on youths’ reaction to life circumstance not existence of life circumstances (ex. fighting with peers, not family divorce)

Goals for improvement should be common across youth in same group (ex. use your words)

Data should measure if skills are being USED in natural settings, not in counseling sessions (transference of skills to classroom, café etc.)

Stakeholders (teachers, family etc.) should have input into success of intervention (ex. Daily Progress Report)

Choosing or Designing Group Interventions

Choose & modify lessons from pre-packaged material based on the skill needed for the group

and/or

Use already created universal behavior lesson plans or create lesson plans (Cool Tools) to directly teach replacement behaviors

Social Skills/Academic Instructional Groups:Key Points Resulting from ‘Innovation’

• Selection into groups based on youths’ reaction to life circumstance not existence of life circumstances ex. fighting with peers, not family divorce

• Goals for improvement common across youth in same group ex. use your words

• Data used to measure if skills are being USED in natural settings (vs. in counseling sessions) transference of skills to classroom, café etc.

• Stakeholders (teachers, family etc.) have input into success of intervention ex. Daily Progress Report

Daily Progress Report (DPR) Sample

NAME:______________________ DATE:__________________

Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors.

EXPECTATIONS1 st block 2 nd block 3 rd block 4 th block

Be Safe 2 1 0 2 1 0 2 1 0 2 1 0

Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0

Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0

Total Points

Teacher Initials

Adapted from Grant Middle School STAR CLUB

Daily Progress Report (DPR) Sample

NAME:______________________ DATE:__________________

Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors.

EXPECTATIONS1 st block 2 nd block 3 rd block 4 th block

Be Safe 2 1 0 2 1 0 2 1 0 2 1 0

Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0

Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0

Total Points

Teacher Initials

Adapted from Grant Middle School STAR CLUB

“Social & Academic

Instructional Groups”

Walk to classKeep hands to self

Use appropriate language

Raise hand to speak

Bring materials Fill out assignment

notebook

Daily Progress Report (DPR) Sample

NAME:______________________ DATE:__________________

Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors.

EXPECTATIONS1 st block 2 nd block 3 rd block 4 th block

Be Safe 2 1 0 2 1 0 2 1 0 2 1 0

Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0

Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0

Total Points

Teacher Initials

Adapted from Grant Middle School STAR CLUB

Use your wordsUse deep breathing

Keep arm’s distanceUse #2 voice level

when upset

Ask for breaksSelf-monitor with

DPR

“Individualized Student Card After FBA/BIP"

QUICK Reflection

We Know the Practices that Work…

• Proactive, strength-based; “set kids up” to experience success

• High rates of consistent, supported instruction; teach/practice/reinforce

• Predictable and consistent environments• Know unique “why?” for each student/problem• Contextual fit: Strategic use of natural supports, and

settings• Careful monitoring of data over time with ongoing

revisions to guide incremental improvements in quality of life

We Know the System Features Needed to Support the Effective Practices…

• A Team unique to each individual child & family Blend the family/natural supports with the school

representatives who know the child best

• A defined Meeting Process Meet frequently and use data Develop, implement, review range of interventions

• Facilitator Role Bringing team together Blending perspectives; guiding consensus Systematic use of data (strengths and needs)

The person who is supposed to implement the strategy needs to be actively involved in designing it; or it probably won’t work!

Ownership & Voice: A Key to Intervention Design

Interventions…

Tier 3 Interventions

• Person-Centered (voice and choice)• Highly individualized (unique team per student)• Multiple Data Sources (add Tier 3 data- Perception data)

• Complex function-based behavior plans• Wraparound/RENEW/Family Focused Plans

Do All Staff Understand the Context for PBIS?

• Behavior support is the redesign of environments, not the redesign of individuals.

• Positive behavior support plans define changes in the behavior of those who will implement the plan. A behavior support plan describes what we will do differently.

Problem Solving Steps

Step 1: Problem Identification

Step 2: Problem Analysis

Step 3: Intervention Design

Step 4: Response to Intervention

Why is it occurring?

What’s the problem?

What are we going to do about it?

Is it working?

Setting Event Strategies

Antecedent Strategies

Teaching/ Instructional

Strategies

Consequence Strategies

Competing Behavior PathwayBehavior Intervention Plan

Neutralize/eliminate

settingevents

Add relevant & remove irrelevanttriggers

Teach alternative

that is moreefficient

Add effective & & removeineffectivereinforcers

Behavioral PathwaySetting Event

Days with Gym

Antecedent

Less structured activities that involve competition

Problem Behavior

Negative comments about activity and to peers leading to physical contact

Consequence

Sent out of P.E. class

Function

To escape setting

Brief Function-based Interventions

Setting Event Strategies•Add check-in before gym

Teaching Strategies•Teach social skills (getting along with others, friendship, problem solving, sportsmanship) •Teach how to approach gym teacher to ask for a drink of water to leave setting. •Teach student how to re-enter and continue with activity

Consequence Strategies Acknowledging/rewarding student when uses new skills (asking for a drink of water to leave, using respectful language with peers, being a good sport, etc..)

Antecedent Strategies•Behavior Lessons for all students about using respectful language with self and others and how to be a good sport •. More frequent activities with less focus on competition (parachute, 4-square, etc...)

•Pre-correct

Person-Centered Planning: Highly Individualized Tier 3 Intervention

WraparoundWraparound-based RENEW

Wraparound: A SOC Tool• Emerged from practitioners struggling to

implement SOC (grassroots)• Keep/bring youth home• Flexible, creative, non-categorical• Natural support networks• Community-based• Unconditional-Commit to “stay the course”• Let family voice guide service development• Non-traditional supports and services

What is Wraparound?

Wraparound is a process for developing family-centered teams and plans that are strength and needs based

• (not deficit based)

• across multiple settings and life domains.

Examples of Needs Statements:

• The student needs to feel adults and peers respect him.

• The student needs to feel happy about being at school.

• The parent needs to know her son is getting a fair shake at school.

• The student needs to be reassured that he can complete the work.

Implementing Wraparound:

Key Elements Needed for Success

• Engaging students, families & teachers• Team development & team ownership• Ensuring student/family/teacher voice

Getting to real (big) needs

• Effective interventions Serious use of strengths Natural supports Focus on needs vs. services

• Monitoring progress & sustaining• System support buy-in

Wraparound Skill Sets1. Identifying “big” needs (quality of life

indicators)• “Student needs to feel others respect him”

2. Establish voice/ownership 3. Reframe blame4. Recognize/prevent teams’ becoming

immobilized by “setting events”5. Getting to interventions that actually work6. Integrate data-based decision-making into

complex process (home-school-community)

Four Phases of Wraparound Implementation

I. Team Preparation- Get people ready to be a team- Complete strengths/needs chats (baseline data)

II. Initial Plan Development- Hold initial planning meetings (integrate data)- Develop a team “culture” (use data to establish voice)

III. Plan Implementation & Refinement- Hold team meetings to review plans (ongoing data

collection and use)- Modify, adapt & adjust team plan (based on data)

IV. Plan Completion & Transition- Define good enough (Data-based decision-making)- “Unwrap”

Similarities and Differences

What is similar and/or different to the existing systems, data and practicesIn your district/schools?

Quick Reflection

Ben’s Story September 2009, CICO started Mid October, 76% Reverse Request for Assistance November-community based mentor assigned December-Ben request to return to “psych” hospital

saying, “I can’t control myself” (has had three prior admissions)

December 5-Tier 3 team met. Recommended referral to wraparound based on following:

CICO average of 76% 30 Office Disciplinary Referrals 3 Out of School Suspensions At risk for alternative school placement At risk for out of home placement December 15 – Wraparound started with Ben and Barb

Moving Forward• In December, Ben began asking his mother if he

could be admitted to the hospital so he “could get better”. He was experiencing anger, thoughts of hurting himself and he was physically aggressive with classmates and peers. He was verbalizing “I can’t control himself.”

• Ben had three prior psychiatric hospitalizations (before coming to ‘G’ Elementary).

Child and Family Strengths• Ben’s Strengths identified in the first meeting included:

“Ben”: Smart, good at math, reading, writing and playing video games

Mom: Very organized He’s creative and enjoys drawing cartoons Teacher: writing and math;

• Family Strengths: Mom consistently takes “Ben” to his mental health

appointments. This might include getting the city bus for an hour ride, attending

an hour appointment, waiting another 30 minutes for the bus and then riding home and then bringing him to school.

Mom is an active participant at the school, follows through with suggestions.

MISSION STATEMENT: ‘A Happy Home’

The mission statement was developed by the team, Ben, and his mom.

Ben stated that his hopes were “he would yell less at home so that he would see more smiling from his family.” Mom agreed.

Wrap process builds on lower tiered interventions

At the first team meeting family agreed to:Continue CICOContinue mentoringContinue MH services Improved communication with Mental Health

FBA to be completed (home and school)Family YMCA (schedule present at LANS for

funding)

Child & Family Team Meeting Number 2

January 22

•Discussed improved behavior at home and school (not in physical fights at school, turning in his work, helping at home)

•Completed BIP using the FBA (help from the baseline SIMEO data)

•Planned next meeting and Ben wanted to invite mentor to the next meeting

3rd Child & Family Team Meeting

March 5, 2010:

•Reviewed strengths: celebrating that he walked away from two fights at school (he had never done that before)

• Team looked at data/ graphs and Ben led the discussion and interpreted the improvements for the group

•Needs in Ben’s words were that he “still had room to improve”. Ben pointed to areas on the graphs where he said he still needed to work on.

•Mom was going to bring electric bill so the social worker could continue to get YMCA family membership to address the needs (e.g. to do, social activities)

Data…

Tertiary Level “Coaches” Have to Help Establish Capacity (Fidelity) for Wraparound:

• Commitment of time• Commitment to “stay at table”• Willingness to regroup and be solution-focused

• No judging or blaming• Time for listening to stories• Time for venting, validating

• Establishing consensus• Voice of student/family in prioritizing • Establishing ownership

Building Fluency with Tier 3 Implementation through Training,

TA and Coaching

FBA/BIPWraparound

Wrap-based RENEW

Tertiary Interventions Phases of Tier 3 Coaching

Phase 1: Modeling - Coach models the desired skills and competencies

Phase 2: Support and Feedback - Coach provides support and feedback

Phase 3: Monitoring – Coach monitors to ensure fidelity

Primary Prevention:School-/Classroom-Wide Systems for

All Students,Staff, & Settings

Secondary Prevention:Specialized Group

Systems for Students with At-Risk Behavior

Tertiary Prevention:Specialized

IndividualizedSystems for Students

with High-Risk Behavior

80% of Students

15%

5%

SCHOOL-WIDE POSITIVE BEHAVIOR INTERVENTIONS and

SUPPORT