“issues affecting behavioral interventions”...resume • college 1970-1987 • doctor of...

“Issues Affecting Behavioral

Interventions”[Individuals diagnosed with ID/DD]

Dr. Robb Weiss, Psy. D., BCBA-D

Chief Psychologist

Behavioral Health Services

San Angelo State Supported Living Center

[email protected]

Copyright Dr. Robb Weiss, Psy. D., BCBA-D

2015

25th ANNUAL

HABILITATION THERAPIES

CONFERENCE

October 15-16, 2015


2015

Bio

• Dr. Robb Weiss, Psy. D., BCBA-D is currently the Chief Psychologist and Director Behavioral Health Services at the San Angelo State Supported Living Center in Carlsbad, Texas. He was the Chief of Psychology at Central State Hospital (CSH) in Milledgeville, Georgia. It was the largest mental health facility in the state system. He was also the Coordinator of Psychology of the Developmental Disabilities Division and Coordinator of Psychology of Psychiatric Treatment at CSH. He began employment at CSH 07/01/03. He has an extensive curriculum vitae dating back to 1977. He is licensed to practice in Tennessee, Kentucky, Mississippi, Florida, Georgia, and Texas. He is a Board Certified Behavior Analyst with the Doctoral Designation (BCBA-D). He graduated from Nova Southeastern University (then called Nova University) with his Doctor of Psychology degree on 02/23/87. He bypassed the M.S. in Clinical Psychology degree at Mississippi State University. He has a triple major in his undergraduate studies at the University of South Florida e.g. microbiology, chemistry, and psychology. He obtained an Associate of Arts degree in pre-medical science from Miami Dade Community College (then called Miami Dade Junior College). He is a member of the American Psychological Association, the Texas Psychological Association, and the local chapter of the Psychological Association of Greater West Texas. He is a past member of the following High IQ organizations: ISPE (International Society of Philosophical Enquiry) 99th Percentile, Intertel 99th Percentile, and is a current member of the TNS (Triple Nine Society) 99.9th Percentile. His areas of interest are in Geropsychology and he is credited in a nationwide video and accompanying textbook on providing group therapy in Nursing Homes; and in the field of Intellectual Disabilities/Developmental Disabilities (ID/DD) previously referred to as MR/DD. He is a certified suicide risk assessor with the national QPR organization. He has presented at both the local chapter of the Psychological Association of Greater West Texas, and at the Texas Psychological Association annual convention on “MR/DD: Welcome To My World”.


2015

Professional Background

• 6 active state licenses-TN/KY/MS/FL/GA/TX

• Former member-Intertel-90th percentile IQ

• Former member-International Society for Philosophic Enquiry (ISPE)-90th

percentile IQ

• Current member-Triple Nine Society (999)-99.9th percentile IQ

• Professional background-Mental Health & ID/DD

• Areas of interest-Geropsychology and ID/DD

• Doctor of Psychology-Psy. D.

• Board Certified Behavior Analyst-Doctoral Designation (BCBA-D)

• Certified Risk Assessor-QPR Institute-Eastern Washington University

• Member American Psychological Association

• Member Texas Psychological Association

• Member Psychological Association Greater West Texas

• Adjunct Professor-Angelo State University

• Approved Continuing Education (ACE) coordinator for APDDA

• Performing Forensic Competency Evaluations


2015

Resume

• College 1970-1987

• Doctor of Psychology-Psy. D. granted 02/23/1987

• South Florida School of Professional Psychology

• Florida School of Professional Psychology

• Nova University (Nova Southeastern University)-37th largest private university-APA approved


2015

Favorite Quotes

“You know that you know”

“You know that you don’t know”

“You don’t know that you know”

“You don’t know that you don’t know”-- Albert Einstein


2015

Insanity

“There is nothing that is a more certain sign of

insanity than to do the same thing over and over

and expect the results to be different.”

Albert Einstein


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Faking “Stupid”

You can fake “stupid” but you can’t fake “smart”


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Communication

“Cannot not communicate”-double negative

“Nobody doesn’t like Sara Lee”


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BEHAVIORAL INTERVENTIONS

Grand Rounds Lecture

Central State Hospital

Milledgeville, Georgia

Presented by:

Robb Weiss, Psy. D.

May 18, 2007 1:30-2:30

Fellowship Hall


2015

Objectives

• Identify ten barriers to the effective

implementation of behavioral interventions

• Identify ten opportunities for improvement in

the effective implementation of behavioral

interventions

• Identify ten strategies to enhance

implementation of behavioral interventions


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Habilitation

• Degree to which a person’s behavior

repertoire maximizes short and long term

reinforcers and minimizes short and long term

punishers

• Use to assess meaningfulness of behavior

change


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Determining Habilitation

• Relevance of behavior after intervention

• Necessary prerequisite skills

• Increased access

• Impact on behavior of others

• Behavior cusp

• Pivotal Behavior


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Behavior Cusp

• Behaviors that open person’s world to new

contingencies

– Crawling, reading

• Socially valid

• Generativeness

• Competes with inappropriate responses

• Degree that others are affected


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Pivotal Behaviors

• Once learned produces changes in other

untrained behaviors

– Self-initiation, joint attention

• Advantages for both interventionist and client


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• Age appropriateness

– Normalization

– Philosophy of achieving greatest possible

integration of people with disabilities into society

• Replacement behaviors

– Cannot eliminate or reduce a behavior without

teaching a replacement


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• Actual target goal or indirectly related

– On-task vs. work completion

• Talk v. Behavior of interest

– Primary importance is actual behavior

• Focus on behavior, not end product

– Weight loss or exercise and diet?


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Prioritizing Target Behaviors

1. Threat to health or safety

2. Frequency

– Opportunities to use new behavior

– Occurrence of problem

3. Longevity

4. Potential for higher rates of reinforcement


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5. Importance

– Skill development

– Independence

6. Reduction of negative attention

7. Reinforcement for significant others

– Social validity

– Exercise caution when considering


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8. Likelihood of success

– Research

– Practitioner’s experience

– Environmental variables

– Available resources

9. Cost-benefit

– Costs include client’s time and effort


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Common Attitudes About Behavior

“It’s Just Behavior”

-How often do we do something that is simply a behavior with no reason or explanation for our behavior?

-What factors contribute to challenging behavior?

-Is the behavior a choice the person is making? What is the choice based on?

-Does it indicate that something is wrong?

-Is it an attempt to express or communicate something?


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“He’s just trying to get on my nerves”

-Individual is possibly engaging in challenging

behavior for attention and is getting a reaction

that reinforces the behavior

-Understanding the behavior goes a long way

toward understanding how to respond to the

behavior


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“She just wants to do what she wants to do”

-She is self directed and has a preference for activities that she wants to engage in

-How do we adjust activities to meet her preferences?

-How do we make activities rewarding for her?

-Are we addressing naturally occurring limits?

-Are we teaching her the balance between making choices and following rules and schedules?


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“He knows exactly what he’s doing”

-Most of us know exactly what we’re doing but still make questionable choices

-Smoking…Dieting…Bad Habits…These are behaviors too

-Often the temptation to engage in challenging behavior is difficult to overcome, especially if it may result in a desired outcome or is a long term habit


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“She is a “Behavior” individual or “I have two “Behaviors” in my area”

-I would rather people define my personality by the things that I do well than by what I am working the hardest to change

-Less common nowadays. People first language has taken root in many areas, but sometimes this attitude is apparent

-Often learning to use People First language has resulted in changing attitudes such as these. So has long term experience working with people with IDD


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“She just wants attention”

-We all want attention

-What motivates someone to want more attention all of a sudden? Have we had times in our lives where we needed more attention? How do we learn to seek out attention when we need it? How are we teaching this to individuals?

-Are we teaching appropriate behaviors to get attention?

-Are the individuals who engage in challenging behavior getting more attention than those who do not?


2015


“He doesn’t want to work” or “He doesn’t want to participate”

-Why are we at this conference?

-How often do you and I feel this way?

-Are the rewards of the task/work worth the effort he expends to do the task?

-Is the activity interesting to him?

-We take vacations from work, do individuals need a break sometimes as well?


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The word “Behavior” indicates something someone does that is inappropriate or harmful

-Anything anyone does is a behavior. A behavior is an act that is observable and measurable

-Challenging behavior, or negative behavior, is simply behavior that is not appropriate for the time and place in which it occurs, based on the results of the behavior

-Even inappropriate behavior can have a positive aspect, or indicate a strength that an individual can build upon


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Compliance vs Cooperation

Compliance is the act of doing what we are told

to do. Cooperation is the act of working

together towards a common goal. Which is

more appealing?


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What’s the compelling reason for someone to

engage in a task?

-If someone simply does not want to engage in a

task, then there is no strategy that will directly

result in them engaging in that task

-So, how do we motivate someone, from their

perspective, to engage in a task that we think is

important?


2015


Focus Intervention on essential activities first

-Pick and choose your “battles” very carefully

-Use positive reinforcement and modeling to

encourage general positive social behavior, but

focus structured interventions on areas that will

most affect an individual’s health, safety, and

inclusion


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Are we expecting better behavior from the individuals we work with than we do from ourselves?

-Are the standards we are holding the individuals we work with higher than what the average person living in the community is expected to follow?

-What is a normal standard for behavior, hygiene, etc?

-Do we allow for normal human error in how we define behavior and compliance?


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Are we utilizing the team process to

address/resolve ongoing compliance issues

that result in health and safety hazards?

-Don’t get caught up in a battle of wills with the

people we serve


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Focus on the positive!

-Don’t define someone as “non-compliant”

-For every non-compliant behavior, there are

many more cooperative behaviors that a person

engages in that go unnoticed. No one is

completely uncooperative.

-Recognize and reward cooperative behavior


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Are we utilizing the team process to

address/resolve ongoing compliance issues

that result in health and safety hazards?

-Don’t get caught up in a battle of wills with the

people we serve


2015

Social and Psychological Factors as Determinants

of Emotional and Behavioral Difficulties

• One of the main characteristics of the paradigms (biological, behavioral, cognitive, or psychotherapeutic) that dominate thinking about the emotional and behavioral needs of people with intellectual disability is their focus on identifying the proximal or immediate causes of distress

• There exists a common belief that the closer we can get to understanding the immediate causes of a phenomena, the more credible our explanations (and the greater our chances of designing effective interventions and supports)

• The identification of mediating pathways and immediate (or proximal) causes is critically important in developing a nuanced understanding of any phenomena and does open up the possibility of designing “downstream” interventions that seek to alter these proximal causes

• It is an error, however, to consider that evidence of mediation reduces the scientific or social importance of background (or distal) variables e.g. “The... Causes... Of… The… Causes”

• Such an approach opens up the possibility of developing “upstream” interventions that address background (or distal) variables that may have a broad and pervasive impact on the mental health and well-being of populations

• Understanding and effectively responding to the emotional and behavioral needs of people with intellectual disabilities requires that we address the importance of both “upstream” and “downstream” determinants of the emotional and behavioral health of people with intellectual disabilities


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Upstream Determinants

• Socioeconomic position-more likely than

nondisabled peers

• Poverty-more likely than nondisabled peers

• Disablism-people with intellectual disabilities

are at risk of experiencing systemic and overt

discrimination associated with their disability


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Downstream Determinants

• Psychological Factors as Mediating and Moderating Processes

• People with mild to moderate intellectual disabilities are aware of their social circumstances and, in particular, their stigmatized status

• Internalizing disablist stereotypes

• Resilience-play an active role in negotiating their identities and coping with environmental challenges/internal individual strengths or processes, and reflections on the success of their actions


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Facts

• Intellectual disability affects 1% to 3% of the total population (World Health Organization, 2001)

• Individuals with ID/DD are more likely to demonstrate limitations in various domains including language, motor abilities, social skills, leisure skills, and self-care

• Individuals with disabilities may require specialized and individualized educational services to maximize learning

• People with intellectual disability are more likely to have physical disabilities, vision or hearing impairments, seizures, and obesity than individuals in the general population

• They are also more likely to be diagnosed with chronic medical conditions such as diabetes, gastrointestinal disorders, and infectious diseases

• Individuals with intellectual and developmental disabilities are also at increased risk of a range of clinical conditions, including sleep disorders, pica, feeding problems, psychiatric disorders, and severe behavior problems such as aggression, property destruction, or self-injurious behavior


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Context of Behavioral Issues

• Major barrier to successful inclusion of individuals with developmental disabilities

• Interfere with the development of successful social relationships and limit opportunities for personal independence and self-determination

• Positive behavior support is an organizing framework for the design of effective social environments

• The context in which a person behaves makes a difference

• Organizing settings to enhance appropriate behavior

• Inadvertently placed in conditions that promote dangerous and destructive behavior

• The technology of positive behavior support is in many ways the combination of behaviors, social, and cultural variables to create environments that promote and support positive behavior

• Behavior support has moved beyond the initial focus on reducing undesirable behaviors e.g. behavior management, and into building the broad supports needed for lifestyle success

• Comorbidity of mental health issues and psychopharmacology affecting individuals with intellectual and developmental disabilities

• Medications affect how individuals experience their environment, change how people perceive what is happening around them, and alters their behavior

• Medications can change the ways antecedent events might “trigger” problem behaviors and how medications may alter the effects of “maintaining consequences” associated with other problem behaviors, or even the ability to “glean” reinforcement


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Applied Behavior Analysis (ABA)

Is a science devoted to the understanding and improvement of human behavior

Is a scientific approach for discovering environmental variables that reliably influence socially significant behavior and for developing a technology of behavior change that takes practical advantage of those discoveries

Practice is based on psychological principles and theories


2015

Active Support (AS)

• Key concept is “engagement as a major determinant of quality of life”

• Working with support staff to seek out and create opportunities for resident involvement

• Aim is to identify situations that are meaningful and therefore more likely to provide natural reinforcement and emphasize functional skills

• Opportunity creation is a dynamic and constantly evolving process that needs to be sensitive to the client’s ongoing skill acquisition, needs, and preferences in a way that reflects a process that probably happens in a somewhat less contrived way with people who do not have ID

• Once opportunity has been identified, a trainer then works with the staff on how best to effectively support resident involvement

• Client’s strengths and weaknesses are considered, and this allows tailor-made support to be implemented

• The emphasis is shifted from “doing for” to “doing with”

• It increases client participation in daily activity

• It increases staff/client interaction

• It positively impacts on challenging behavior

• It is hypothesized that this would positively impact mental health difficulties


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Positive Behavior Support (PBS)

• Approach to intervention based on the behavioral sciences, integrated with information from biomedical and system-change strategies that focuses on improving individuals’ quality of life and resolving problem behaviors and other challenges of behavioral adjustment

• Scientific approach that is explicitly accountable to evaluation data and foundation of rigorous experimental and quasi-experimental procedural validation

• Highly pragmatic approach, open to innovation and the incorporation of strategies derived from diverse perspectives, as long as those innovations are subjected to data-based accountability

• Values-based approach, with overt appreciation of person-centered and family-centered perspectives on the appropriateness of intervention techniques and the specific outcomes that should be targeted and evaluated


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Critical features that distinguish PBS

• Comprehensive lifestyle change and improved quality of life

• Recognition that interventions and supports must be seen and implemented from a longitudinal and lifespan perspective

• Focus on ecological validity-strategies of intervention and support must be relevant to, and effective in, real-life settings and situations

• Insistence on collaboration, with principal stakeholders (parents, teachers, friends, employers, siblings) functioning as partners in the development and implementation of PBS

• Emphasis on the social validity of procedures and outcomes

• Acknowledgment that effective, longitudinal support requires system change and multicomponent interventions

• Comprehensive emphasis on prevention, with an understanding that functional (proactive) intervention occurs when problem behaviors are not present

• Utilization of knowledge derived from various types of methodological practices

• Pragmatic appreciation for the contributions of multiple theoretical perspectives

• Based on a functional understanding of the targeted behavior and events in the environment that influence the behavior

• Endorsed in federal and state statutes

• Foundations in Applied Behavior Analysis (ABA)

• Explicit ambition is to develop behavior support plans

• Dynamic process that begins with functional assessment

[Origins in developmental disabilities, it has been applied subsequently with many different populations of individuals with and without disabilities]


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• Experimental functional analysis, usually conducted in artificial settings, can identify the function of problem behavior of individuals with developmental disabilities

• Functional analyses designed to verify hypotheses from functional assessments can be conducted in natural settings

• Interventions based on functional assessment information can lead to reduced problem behavior and increased levels of prosocial behavior

• Aspects related to intervention planning, such as setting events and contextual fit, are feasible and beneficial

• Support for the use of person-centered planning approaches as part of overall planning and support


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Teaching replacement behaviors is a highly effective strategy for building useful competencies and simultaneously reducing problem behavior, though it is important that the replacement behavior be functionally equivalent to the targeted problem behavior, In particular, functional communication training has been shown repeatedly to be effective with a broad range of individuals with developmental disabilitiesIf a problem behavior is to be eliminated or reduced, the practitioner must identify an adaptive replacement behavior and develop contingencies in the intervention plan to ensure the new behavior is learned. This is important because problem behavior serves a function for the client and to eliminate the behavior without replacing it means that access to reinforcement or escape from punishers will be denied. A general goal can result in the focus of intervention being placed on related and indirect behaviors that are not really the intended outcomes of the intervention. A more specific outcome goal should be used that addresses the specific, observable behavior which, when mastered, will result in the more global goal being achieved. For example, a general goal of on-task behavior can be achieved by directly targeting attention to materials, task completion, and remaining seated. A behavior cusp is a behavior that exposes the person to new environments, specifically to new reinforcers and punishers, new responses, new stimulus controls, and new communities of maintaining or destructive contingencies. For example, learning to read. A pivotal behavior is a behavior that produces corresponding modifications or co-variations in other adaptive, untrained behaviors. For example, attending behavior.


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The development other alternative skills (tolerance, self-control) can be a valuable strategy for addressing problem behavior (self-monitoring/self-management)

Building functional skills and employing a strong educational curriculum is an effective approach for behavior support and can serve to limit the frequency and intensity of problem behaviors

The use of differential schedules of positive reinforcement increases targeted prosocial responses and contributes to reductions in problem behavior

Manipulation of antecedent events, identified through functional assessments, produce rapid behavior change

Identification of more distal and contextual stimuli ( e.g., ecological, physiological events) affecting problem behavior (technology of setting event assessment and interventions)

Multicomponent PBS interventions, based on functional assessments, are associated with reductions in problem behaviors and increases in alternative, desirable responding


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Psychotherapeutic Medications and

Positive Behavior Support

• Mental health conditions are state (as opposed to trait) variables that have unique stimulus properties, that change the probability of behavior, and that alter the events that will maintain behavior

• Taxonomy of psychotherapeutic medications based on an analysis of the antecedent state variables, their discriminative stimulus properties, and the consequences that maintain the behavior of concern

• People with intellectual and developmental disabilities receive psychotropic medications to increase learning and attention, to improve health and safety, and for behavioral management


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The Role Of State Variables In

Challenging BehaviorTraits, States, Setting Events, and Establishing Operations

Traits are enduring characteristics inferred from behavioral signs that account for consistency in individual behavior across time and circumstances and are continuous

State is usually a transient or variable condition, often induced by an identifiable antecedent, such as lack of sleep, going without food, or side effects of a drug

Many states are induced by circumstances that have impinged on a person and that increase or decrease the efficacy of reinforcing events and change the probability of behavior maintained by those events, called setting events or establishing operations


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The Role Of State Variables In

Challenging BehaviorFeelings, Tacts, and States

Feeling-Internal feeling

Tacts-Verbal labels of feelings based on internal stimuli associated with foregoing events (lack of sleep, constipation, altercation with mother) that impinged on the person at some earlier time

The events change the probability of a challenging behavior being exhibited and the probability that it will be maintained by the consequences (change value of reinforcers and their mechanisms)

Some transient states have external setting events or establishing operations and some do not e.g. hormonal changes, neurochemical changes


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Behavioral Approaches to Working

with Mental Health Problems• Within the mainstream psychological literature, behaviorism is criticized on many

fronts

• It is often regarded as mechanistic, simplistic, and essentially incapable of providing a plausible explanation for much human behavior

• It is argued that the approach can only deal with observable behavior and consequently ignores thoughts and feelings that happen inside the body e.g. “black box”

• [They are viewed as types of behavior and as such are governed by the laws that govern other, usually overt behaviors-core behavioral processes such as reinforcement, punishment, and extinction, which are usually evoked to explain our overt behavior, are also proposed to be at work in shaping our beliefs, views, thoughts, and indeed our emotions]

• It is suggested that behaviorism views the organism as entering the world as a “blank slate” and consequently that it is only important to examine what happens to the organism during its lifetime

• [Individuals are different, the importance of genetic selection, or learning at the level of the species, how the difference impacts on us will depend, at least to some extent, on what happens to us during our lifetime]


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Behavioral Approaches to Working

with Mental Health Problems• Individuals with particular genetic syndromes have a tendency to display specific behavioral

topographies (e.g. self-injury)

• In such cases, we cannot account for the frequency and intensity of such behaviors by

referencing to learning processes alone, and consequently, it is appropriate to attribute at

least some aspects of behavior in these cases to genetic/biological underpinnings

• In terms of understanding the role of mental health difficulties in people with ID, it is clear

that such influences are relevant

• People with ID cannot process information at the same rate, or at the same level of

complexity as those deemed to be of typical development

• Individuals on the autism spectrum (autism spectrum disorder (ASD)) have difficulty

understanding aspects of communication and social interaction

• To account for these difficulties, we have to evoke genetic/biological causes, as attempts to

account for the presence of these difficulties through learning alone have proven insufficient

• It is not the case that individuals with ASD learn their social and communicative difficulties,

or that these arise from trauma or adversity

• Their presentation is a combination of their genetic and learning history, and the relative

contribution of each will be different in each individual


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Understanding the Development of

Mental Health Problems• Correlation between a diagnosis of ID and the presence of mental health problems

• We need to look beyond a diagnosis of ID alone to explain this correlation

• Many characteristics of the environment that typically surrounds people with ID have a significant influence on the subsequent development of mental health problems

• Chronic poverty, loneliness, boredom, and continued lack of opportunities to exert influence or control over one’s life, friendships, and future are characteristics both of the ID population and causal influences underlying the development of mental health problems in any population

• Be careful not to suggest that it is the diagnosis (as opposed to the enforced lifestyle) of ID that leads to the higher incidence of mental health problems

• Move beyond a view that locates mental health problems inside the heads of people with ID, to a view that sees the immediate environment of people with ID as a legitimate target for the prevention and treatment of such problems


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Behavior analysis and ordinary life

• Risk of denial of access to “ordinary community facilities”

• Aim of intervention focusing on facilitating individuals to access an “ordinary life”

• Enforced denial of access to the minutiae of an “ordinary life” have significantly reduced their skills, learning opportunities, and important opportunities to extract reinforcement from the environment

• Enforced disengagement leads to reduced quality of life

• Enforced disengagement and disempowerment can, in turn, supply the perfect condition for the development of mental health problems

• Mental Health/Protective Factors: making environments more sensitive to individual needs, increasing social contact and engagement, increasing engagement in meaningful activity, increasing an individual’s repertoire of functional skills, and generally improving an individual’s quality of life


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Mental Health Conditions As States

That Change The Probability Of

Behavior• Psychopathological conditions have discriminative properties that impact internal

states

• The internal states determine to a large extent the events that will be reinforcing

• Practitioners occasionally attempt to override the effects of these physiological and biochemical states by applying behavior-analytic techniques more rigorously (without using medications)

• Psychotropic medications can be effective behavioral prostheses (argument for the appropriate use of medication)

• Most of the drugs used to treat mental health problems bind to the same chemical receptors in the brain as do naturally occurring neurotransmitters

• The brain chemical context has changed thus altering the effects of the environmental stimuli making it less aversive

• Psychotropic medications change how readily environmental events will be positively and negatively reinforcing

• One of the major difficulties in treating psychopathological conditions among individuals with developmental disabilities is that so little is known about presenting signs and symptoms in various subpopulations e.g. diagnostic categories


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Psychiatric Issues

• Internal Distress and Overt Behavior

-Increase in internal distress likely results in an

increase in the intensity and frequency, sometimes

duration, of observable challenging behaviors

-Regression in coping and impulse control skills

-Less inhibited, more difficult to manage

behavior

-May not understand the symptoms


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Psychiatric Issues

• Change in behavior must co-occur with significant changes related to symptoms

-Disturbance in sleeping/eating patterns

-Report of depression, anxiety, fearfulness

-Report of hearing voices or being persecuted

-Behavior related to mood or affect (increase in anger, rage, hostility); increase in intensity of the behavior

-Other symptoms related to specific diagnostic criteria

-The presence of challenging behavior alone is not adequate for diagnosis


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Psychiatric Issues

• Issues related to psychiatric services

-Ongoing assessment of internal distress (compare affect/mood before and after treatment)

-For individuals who may have difficulties describing their experience, ongoing assessment, including behavioral assessment, and consultation with the psychiatrist is helpful to assure the most effective overall treatment

-Secondary learning occurs when psychiatric symptoms result in challenging behaviors that are rewarded by the consequences of the behavior. Appropriate behavioral intervention is used to address these challenging behaviors

-Increase positive behavior/skills that strengthen the individual’s ability to manage their behavior when experiencing internal distress: coping skills, relaxation skills, assertiveness skills; reporting to staff


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Medical Issues and Behavior

• Medical issues individuals may have

difficulties reporting or describing to

staff/nurse/physician:

-Headache/Sinus

-Acid Reflux/GERD

-Insomnia (if staff are unaware they are not

sleeping)


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Medical Issues and Behavior

• These medical symptoms may result in behavioral outbursts if the individual simply feels bad and is unable to communicate this to staff

-Stuffing toilet with toilet paper-diarrhea

-Frequent trips to the bathroom-constipation

-Unusual behavior focused on one specific part of the body

-Sudden, unexplained change in mood and behavior, accompanied by physical symptoms or complaints


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What Do We Do?

-Build from a person’s strengths and reward any

positive behavior and effort. Spend time on

“what’s right” with someone instead of talking

about “what’s wrong”

-Provide positive reinforcement and acceptance

as people with thoughts and feelings, before

focusing on challenging behavior


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What Do We Do?

• Know your individuals

-Develop a rapport with the people you work

with

-Take time to learn their history

-Understand their goals, needs and what they

want

-Develop a rapport with the family when

possible


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What Do We Do?

• Provide ongoing training and education to support staff

-Training and assistance with behavior management strategies such as positive reinforcement

-The symptoms/behaviors associated with psychiatric diagnosis

-Coping skills, impulse control skills

-Welcome questions and concerns of support staff no matter how small the concerns may be at the time


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What Do We Do?

• Practice creative problem solving in order to find ways to meet the needs of the individuals you work with

-Consider community resources

-Take the initiative, reward others who take the initiative to address problems

-Be proactive and fix problems before they become big problems

-Take a team approach and communicate effectively with team members


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What Do We Do?

• Maintain a positive rapport with other

professionals who work with the people you

work with

-Professional support staff, doctors, nurses, and

others all have information, observations and

experience that is valuable

-Be open to consultation with others to the

benefit of the individual


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What Do We Do?

• Regarding specific individuals

-Do a thorough assessment (talk to everyone who works with the individual and get all available information that may be relevant)

-Do not disregard information provided as relevant

-Collect baseline data

-Review the history of the individual

-Develop a rapport with family/support staff

-Listen to family and support staff, they spend the most time with the individual and have the most information

-Meet with the team, or as many of the staff as possible at one time and brainstorm

-Be a good detective

-Make appropriate referrals for further assessment when indicated


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Psychopharmacological Interventions

That Alter Mental Health States

Behavioral Mechanisms of Medications Effects

• A medication may make one consequence more

effective in maintaining behavior than another or

may change the relative rates of reinforcement

when choosing one alternative over another

under a concurrent reinforcement schedule

• Reduced efficacy of negative reinforcers is the

behavioral mechanism of drug action (reduces

aversion)


2015

State Intervention Strategies

• The first step in addressing antecedent state factors that affect the behavior of an individual with a developmental disability is to recognize that such a problem exists

• If an individual’s behavior is tracked over time and fluctuates widely, regardless of the educational or behavioral interventions that are in place, then an intermittent biological state variable may be operating

• Part of a functional behavioral assessment (FBA) involves evaluating the role of potential biological state factors


2015

Psychotropic Medications And

Behavioral Mechanisms Of Action

• Psychotropic medications that decrease social demand avoidance

• Psychotropic medications that enhance stimulus control and increase value of weak reinforcers

• Medications that alter response rate and reinforcement rate

• Medications that reduce reinforcing consequences of self-injury


2015

Applied Behavior Analysis

Alternatives to aversive behavior management

Technology of Functional analysis (experimental manipulation of variables) and functional assessment (naturalistic observation)

Motivations and the contextual governance of problem behavior

Interventions based on applied behavior analysis have been demonstrated to improve outcomes for people with intellectual and developmental disabilities across a range of presenting problems and across the life span

Used with individuals

Used with staff

Used with educational approach


2015

Defining Characteristics of

Applied Behavior Analysis

Applied– Investigates socially significant behaviors with

immediate importance to the participant(s)

– Examples include behaviors such as:• Social

• Language

• Academic

• Daily living

• Self-care

• Vocational

• Recreation and/or leisure


2015

Personal History

The difficulties in securing support from Direct Support Professionals in the implementation of behavioral interventions vis a vis PBSPs

Behavioral interventions address reductions in challenging behaviors and increases in replacement behaviors

Barriers to implementation?

Opportunities for improvement?

Strategies for implementation?

What supports need to be in place?


2015

Definition of learning

• “These people can’t learn” (Perhaps staff can’tlearn that these people can learn)

• Unicellular organisms learn

• Change in behavior not due to neurological factors or disease, or trauma

• How do we teach the concept

• Barriers to the effective implementation

• Opportunities for improvement

• Strategies to enhance implementation


2015

Favorite Quotes

• “People behave normally in an abnormal environment”

• Definition of environment-anything/everything outside of the individual

• People’s behavior/density/lack of control/structural/environmental factors, exhaustive list of factors

• Examine environmental contingencies-”they behave well in the restaurant but when they return to the facility…………………………”

• Barriers to the effective implementation




2015

Working With Staff

• Sound support plan

• Implemented proficiently

• Applied Behavior Analysis

• Positive Behavior Support

• Function(s) of challenging behavior

• Available technology is applied in small part

• Advances occurring at faster rate than ability of service personnel to determine how to incorporate them

• Direct Support Personnel don’t implement plans with fidelity therefore there is no treatment (requires strong management and clinical support)

• Reliance on medication, chemical/physical restraint

• DOJ-Civil Rights Violations


2015

Working With Staff

• Establish therapeutic environment to prevent challenging behavior

• Safe environment

• Active engagement

• Enjoyable life

• Functional skill development

• Staff’s effective implementation of support plans

• Means of training staff

• Monitoring and evaluating staff’s implementation of support plans

• Support and maintain staff performance

• Improving staff performance


2015

Agency-Wide Commitment

• Cannot be viewed as only one or some of

agency’s contingent

• Everyone is impacted

• Administration/financial/human

resources/skilled clinical staff

• All components of an agency’s operating

structure and processes


2015

Supervising Implementation of

Behavior Support Plans

• DSPs have a lack of training

• Who is responsible for training

• Should be clinician designing plan due to clinical

expertise and familiarity with plan, however,

clinician is not in supervisory position of DSP

• Chain of command e.g. staff supervisor can cloud

the issue because they have responsibility for DSP

job duties being fulfilled e.g. plan being

implemented


2015

Component Steps Of Outcome

Management

• Specify expected duties of staff-behaviorally specific (enhances monitoring)

• Train staff in the performance skills constituting the expected duties (rationale for plan/necessary skills)-performance based/competency based

• Observe staff perform the duties during the regular work routine-acceptable to staff

• Provide positive support for staff performance observed to be adequate

• Implement corrective action for staff performance observed to be inadequate-corrective feedback


2015

Life Enjoyment

• Individuals who are happy will be less likely to

engage in challenging behaviors

• Staff need to be happy as well to perform

their job duties and they are part of the

environment of the individuals thus enriching

the lives of the individuals


2015

Therapeutic Environment

• Quality of physical and social environments can have significant impact on quality of individual’s mental and behavioral health

• Supportive environment can provide stimulation, interactions, and expectations that contribute to enhanced social development and increased pro-social behavior

• Initially focus on environment and not person

• Challenging behavior may function to obtain what is not being provided in the environment e.g. attention/escape

• Safe/Comfortable/Responsive/Habilitative

• Support and maintain therapeutic environment

• Corrective action to improve environment

• Consistency, trust, boundaries related to history of trauma/abuse-issues for individuals that may precede or supersede PBSP

• Inconsistent approaches by staff set the individual up for failure

• Lack of clustering-avoiding placement of individuals with similar issues/behavioral challenges in the same environment (produces greater stress)

• Appropriate space and size-privacy and freedom of movement

• Normalized conditions-living arrangements close to normal everyday living experienced by the general population


2015

Safety

• Safety for all people at the facility

• Individuals unable to comprehend potentially dangerous situations

• Individuals have difficulty communicating concerns about danger

• “Protection From Harm”

• “Protection From Fear Of Harm”

• Family/legal concerns

• Quality of life is compromised

• Problem behavior increases

• Unusual Incident Report (UIR)


2015

Establishing A Safe Environment

• Inadequate staff ratios

• High consumer density (times/places)-harmful events/safety compromised

• Lack of staff familiarity with consumers-difficulty in communicating needs leads to difficulties

• Inappropriate staff deployment-key is providing adequate consumer support, lack of familiarity, direct interactions, supervision, physical presence of staff supervisor either continuous or spot checks

• Frequent staff absenteeism or turnover-actual number of staff available to provide appropriate levels of support, many issues with pulled/detailed/relief staff affecting individuals and staff

• Title XIX Medicaid regulations for ICF maximum of four individuals sharing a bedroom


2015

Authors Of Behavior Support Plans

• Determine variables that occasion occurrence

of problem behavior

• Conditions affecting like likelihood that

support plans will be implemented in

appropriate manner


2015


• Staff Ratios-sufficient numbers of staff to carry

out plan

• Design plan with less procedural features that

is more likely to be implemented-more readily

understood by DSPs

• Staff motivation-exerting time and effort

necessary to carry out support plans

(rationale/relevance of the plan is important)


2015


• Density-unless addressed plan is not likely to be effective

• Staff familiarity with consumers-knowledgeable about support plans

• Staff deployment-if staff are not in locations where support plan is carried out or do not carry out each component of plan in appropriate manner

• Onsite presence of supervisor-affects proficiency with which staff carry out behavior support plan

• Importance of presence of author of behavior support plan-technical assistance, oversee implementation, encouragement to staff, trouble shooting

• Staff absenteeism and turnover-affect every environmental condition related to treatment plan effectiveness


2015

Promoting Meaningful Consumer

Activity Within Group Situations• Functional Assessment identifies boredom as a factor in the demonstration of challenging

behaviors

• When the environment does not provide stimulation the individual may demonstrate challenging behavior as a means of providing the stimulation

• Interruption/redirection of a challenging behavior in a PBSP requires an activity to redirect the individual to

• Providing the activity after the challenging behavior occurs may reinforce the behavior

• Has to have meaning and enjoyment for the individual

• How many times do we attempt to engage an individual in an activity that the individual seeks to avoid/escape by demonstrating challenging behaviors (we are attempting to reinforce engagement in a task that is aversive to the individual)-alter the task

• Requires diligence and effort by staff

• Purposeful (usual for an individual without disabilities to perform) and age-appropriate(nondisabled individual of the same age group is likely to perform)

• Exception is leisure activity (doing what one wants even if it is age-inappropriate)-have they been afforded familiarity with age-appropriate activities on which to make a choice

• Engaged behavior-not purposeful activity, better than no activity

• Nonadaptive (no participation/stereotypic behavior/off task/life wasting) and is characterized by Aggressive/Disruptive Behavior

• Other behavior-sleeping, ADL, medical attention

• Environment Environment Environment


2015

Teaching Meaningful Skills

• Critical/Under Emphasized Component For Preventing And Treating Challenging Behavior

• Must have skills necessary to participate in meaningful activities

• Must teach individuals those skills-therapeutic environment

• Individuals exhibit challenging behaviors because they have not learned more appropriate ways of expressing wants and needs (or it is in the behavioral repertoire but is not demonstrated e.g. motivational issue)

• What is the individual willing to work for

• Reinforcer sampling: A procedure that enables an individual to come in contact with a potential reinforcer to experience the positive characteristics of the stimulus. The procedure is useful in developing new reinforcing consequences for a given individual

• Leads to independence/leads to control/leads to enjoyment

• Skills must be “Practical, meaningful, and functional”


2015

Guidelines For Determining Functional

Skills For Teaching Programs• Someone else would have to do for an individual if the individual could not do the activities [Problem behavior associated

with staff performing those skills for the individual is eliminated]

• The more frequently a person is likely to perform a skill, the more functional the skill is to teach e.g. greeting

• Skills for which a person can be paid to perform as part of a job are functional skills to teach e.g. generalize to vocational endeavors and based on individual preference [monotonous, repetitive work can be aversive and lead to challenging behavior as a means of escape/avoidance]

• Skills that allow a person to get something wanted or get out of something unwanted without problem behavior are functional skills to teach e.g. functional replacement behaviors

• [how to use the selected communications skill, as well as the appropriate condition in which to use it]

• In some cases trying to get an individual to attend an activity that is aversive does not make sense [change the intrinsic quality of the activity itself to make it more enjoyable]

• The most common reason that people with severe disabilities do not learn the skills targeted in teaching programs is that the programs are not taught frequently enough

• Participation in functional activities is a prerequisite for the PBSP

• Participation in day treatment activities outside of their residence-meaningful daily experiences

• Teaching programs in formal and naturalistic settings e.g. maintenance plan of SAP

• Use in PBSP when challenging behavior occurs-prompt the replacement behavior before the challenging behavior occurs

• Importance of replacement behavior is underestimated [we receive funding for the purpose of habilitation]

• Insufficient focus on replacement behavior as it is not being demonstrated to bring attention to it, insufficient training onreplacement behavior, data collection and the understanding of the importance of replacement behavior

• Insufficient staffing and staff turnover preclude the necessary generalization of learning to occur

• This then becomes a staffing/administrative issue

• Author of the plan assume that direct care staff understand replacement behaviors as they do therefore they do not provide sufficient detailed directions for staff in the plan

• We tend to focus on the reduction of the challenging behavior as it is being demonstrated


2015

Behavioral Treatment Approaches To

Skill Acquisition• Methods of applied behavior analysis have garnered empirical support for promoting skill

acquisition and maintenance among individuals with developmental disabilities

• Application of general principles of operant learning theory, namely positive and negative reinforcement, extinction, shaping, and fading (definitions of terms)

• Occurs in highly structured and contrived conditions as well as in more naturalistic, free-operant situations

• Discrete trials training (DTT)-tightly controlled analog conditions

• Incidental teaching-facilitate generalization, loosely structured

• Skills that are initially targeted for interventions are typically those of severe deficit

• Life skills-or skills that contribute to successful, independent functioning

• Behavior chain-specific sequence of discrete responses, each associated with a particular stimulus condition

• Chaining-various methods for linking specific sequences of stimuli and responses to form new performances Forward chaining-behaviors are linked together beginning with the first behavior in the sequence

• Backward chaining-behaviors are linked together beginning with the last behavior in the sequence

• Shaping-differential reinforcement of successive approximations toward a terminal behavior (successive approximations to the terminal behavior)

• Treatment integrity measures

• Engaged behavior-individual is engaging surrounding environment, but not in an apparently purposeful manner


2015

Behavioral Treatment Approaches To

Clinical Conditions• Autism

• ADHD

• Severe behavior disorders

• Self-Injurious Behavior (SIB)-head banging, self-biting

• Aggression (hitting, kicking others)

• Property Destruction

• Elopement

• Feeding

• Sleep

• Educational Settings-special education

• Medical Settings-distress and noncompliance with medical procedures

• Cause injury to individual, caregiver, disrupt environment

• Results in increased social isolation and decreased educational, vocational, and leisure activities, and increases the likelihood that individuals will require specialized services, including those individuals outside of the home in residential treatment settings or group homes


2015

Treatment of Behavior Disorders

Psychotropic medications are often administered

• Questionable efficacy, risk of negative side effects, and overmedication

• Limited empirical support

• Demonstrated efficacy of behavioral interventions, they are to some extent ignored in clinical practice

• Functional analysis procedures and function-based interventions is the best practice in assessment and treatment of severe behavior problems


2015

Essential Components of Behavior

Support Plan• Functions of behavior: to obtain/to avoid

• Best practice requires a functional assessment

• Obtain best information from involvement of the DSP and it reinforces the “buy in” for the DSP to implement it

• Define challenging behavior-topography is critical, frequency, intensity/severity, duration

• Define replacement behavior accurately

• Environmental supports-should be in place/should not be in place

• Environment-everything outside of the individual

• Antecedent events-occur in the environment just before a given behavior emerges

• Establishing events-occur in the environment prior to a given behavior emerging

• Precursor behaviors-the individual demonstrates that informs you the challenging behavior is emerging

• Establishing operations/motivating operations/abolishing operations-events surrounding the challenging behavior that will either increase or decrease the likelihood of its’ occurrence

• Consequences-for challenging and replacement behaviors

• Use least restrictive consequences before punishment approaches

• Prompt the replacement behavior as early in the behavioral chain as possible to break the cycle of reinforcement for the challenging behavior

• The more understandable the PBSP is, the easier it is to implement the PBSP, the greater likelihood it will be implemented


2015

Essential Procedures For Training Staff

To Implement Behavior Support Plans

• Training must be competency-based and performance-based (role play/in vivo)

• Verbally describe skills to be taught along with rationale-enhances acceptance and motivation

• Provide written description of skills to be taught

• Demonstrate skills to be taught (role play/in vivo) and train the trainer

• Observe trainees performing skills

• Provide feedback

• Repeat steps until proficient


2015

Who Provides The Training

• Person who developed the support plan

(author with knowledge of plan)

• Immediate supervisor (line of authority)

• Designated staff development person

• Any combination thereof


2015

Which Staff Need To Be Trained

• Necessary but not sufficient

• All staff who interact with the individual

• All staff, all shifts, all disciplines,

detailed/pulled/relief

• [How feasible is this]-Time/Staff/Resources

• Cascade training-inherent problems in

consistency of training


2015

Monitoring Staff Implementation

• Staff don’t like to be monitored

• Plan won’t work if not implemented with integrity

• Staff may alter plan informally

• Individual appearing to be worse may in fact be improving e.g. extinction burst

• Extinction related to schedule of reinforcement (interval/ratio)FI VI FR VR

• Decisions must be based on data

• Done covertly-wrong [must be done overtly]

• Not informed of purpose-wrong [think about Title XIX ICF-MR Medicaid survey]

• We accept Medicaid funds therefore we must adhere to their guidelines

• Impolite/rude manner-wrong [always provide a greeting]

• Results not shared-wrong [give feedback immediately and positively]

• “80% Rule”-overall level of proficiency in implementing a support plan based on the total number of correctly implemented aspects of the plan [Measure of Success (MOS)]

• Conduct monitoring sessions during those situations in which the problem behavior is most likely to occur


2015

Guidelines For Monitoring

• Routine monitoring

• The more serious the behavior is the more frequently the monitoring [risk of physical harm]

• Frequent monitoring of newly implemented support plans

• The more difficulties staff experience in carrying out a support plan, the more often their performance should be monitored


2015

Supportive Management

• In conjunction with initial steps of outcome management (previous slides)

• Frequent, positive, sincere, private, verbal feedback

• Find ways to effectively support direct support staff

• Written feedback as a supplement to verbal feedback

• Formal scheduled feedback in addition to informal feedback

• Performance consequences e.g. awards, items, activities or privileges


2015

Corrective Management

• Staff lack skills-provide training opportunities

• Staff lack motivation-involves either working diligently and/or enjoying work

• Begin with empathetic/positive statement

• Emphasize what is done correctly

• Identify incorrect procedures

• Specify how to carry them out

• Field questions

• Inform staff of procedure of observing implementation

• End with positive statement

• If performance improves follow with supportive management

• If performance does not improve follow with disciplinary action


2015

Habilitation versus Rehabilitation

• Habilitation: Learning/teaching that which has not yet been learned

• Rehabilitation: Re-learning/teaching skill that has been lost (psycho-social model)

• How do we teach the concepts?

• What are the implications of teaching a person that which they have never learned or been taught?

• Scapegoating a person for engaging in inappropriate behavior or failure to engage in appropriate behavior.




2015

Person-Centered

• Truly meaningful from the person’s world view

• Involvement of the individual in the design and implementation of the PBSP

• Designed with transition to the larger world (beyond facility)

• Think “Lowes”: You can do it, we can help”

• How do we teach the concept?




2015

Relevance

• Relevance to their job duties from the DSP perspective

• “I don’t have time”

• “What does this have to do with my job”

• “If I do this I can’t do my job”





2015

Logistics

• Logistical issues with respect to training,

implementation, and documentation

• How do we overcome barriers




2015

Psychotropics

• New developments in Psychotropic medications and the integration with behavioral

approaches

• The successful integration of people experiencing mental health problems into the

community relies on the amount and quality of available mental health supports

• The field of developmental disabilities has focused recently on matching appropriate

supports to individuals needs, so the importance of providing highly specialized mental

health supports for people with developmental disabilities has become apparent

• The “silver bullet” versus the “setting event” that enables people to obtain the benefits from

behavioral/environmental interventions

• Facility culture that supports the utilization of psychotropic medications as a first line defense

for addressing behavioral issues e.g. medicalizing the issue, seeking a “quick fix”, behavioral

interventions take work, administering medication does not

• Implications of utilizing psychotropic medications as best practice

• Integration of psychiatry





2015

Behavioral Supports

• Symptoms of a mental illness contribute to challenging behavior

• Historically emphasis has been on ruling out effects of physical illness

• Recognition of mental illness now highlights the role in challenging behavior

• Triggering events-reliably precede challenging behavior

• Contributing events-may combine with triggering event to producechallenging behavior

• Active symptoms of mental health disorder may (in part) trigger or contribute to challenging behavior

• Effective treatment of mental illness may result in only partial remission of challenging behavior

• Continue to need to provide behavioral supports particularly when an adjustment/increase/decrease/titration/discontinuation places the individual at risk of exacerbation of challenging behaviors (look to history and data)


2015

Support/Accountability

• Support/accountability from supervisors and

administration and the implementation of a

monitoring system to assess efficacy and

promote continuous program improvements





2015

Concepts

• Conceptual understanding of Positive Behavior Support versus Behavior Management-setting the person up to succeed)

• Conceptual understanding of the role of the individual (individual needs to have intellectual understanding for intervention to be effective-this is a misnomer)[rat does not need to have intellectual understanding to complete the maze when provided reinforcement]

• Dynamic interventions-ongoing and creative (“we tried this and it did not work”……………………………….then what did you do?)

• Active participation by the individual (He needs to do his part)-this is a misnomer [we need to do our job]

• How do we teach the concepts

• How do we make it relevant




2015

“Buy in”

• “Buy in” by Direct Support Professionals based on how the PBSP is presented/taught and the context in which it is taught

• Providing the rationale for the PBSP (some staff actually may not prefer to have the rationale provided)





2015

Human Beings

Perception of the individuals we support-whole human beings versus one dimensional entities (patient, client, etc.)

“In defining quality of life, we must not draw boundaries and relegate everything beyond those boundaries to the ‘abnormal’. Instead, we must do everything in our power to build the kind of broadminded society in which people living with disabilities do not have to consider themselves ‘handicapped’ and can manifest their full potential”-Daisaku Ikeda from On Being Human/Positive Identity Development-KarynHarvey, Ph. D.

Person first language/language reflects philosophy/language perpetuates stereotypes/people are not their diagnoses

There are no intrinsic differences between those individuals to whom we provide services and to those individuals who provide services.

The only difference is in the relationship to receiving or providing services.

There is no “us” versus “them”….there is only “we”.

How do we teach concepts.




2015

Staff

• Role of staff and their behavioral change vis a vis the PBSP interventions

• Difference between objectives and interventions (who does what)

• Behavioral interventions begin with changing our behavior to effect change in another individual’s behavior





2015

Staff

• Role of staff and their understanding of the concept of behavior change and the role of the environment on behavior change

• Negation of these issues inevitably leads to psychiatric diagnosis and psychoactive medications





2015

Our Behavior

• Focus on our own behavior versus that of the

individual





2015

Staff

• Reinforcement for staff for the correct implementation of the PBSP

• What is reinforcing for staff?

• How do we ensure that interactions between staff and individuals is pleasurable for staff?

• Are we teaching the individuals to engage in positive ways or are individuals teaching staff to engage in negative ways?

• How do we impact on the intrinsic reinforcement




2015

Staff

• Reinforcement for staff for the incorrect, or

lack of, implementation of the PBSP

• What is reinforcing for staff?




2015

Values

• Values/education of Direct Support Professionals

that impact the PBSP implementation (what do

they bring to the job)

• Are their values/education subject to revision?





2015

Mission/Vision

• Mission/vision of the facility





2015

Learn

• Conceptualization of the ability to “learn” and its’ implications (one-celled organisms can learn/rat does not need to “understand” in order to be reinforced to solve the maze)

• “This PBSP will never work”(mind reading 101/it’s all empirical)





2015

Hope

• Hopefulness or hopelessness about their role

and the role of the individual

• This is about their lives

• How do we impact the level of hope




2015

Concepts

• Conceptualization of “mental retardation”, ID, DD (learning occurs but at a slower rate)

• Labels are destructive

• People are not their diagnoses





2015

Medications

• Conceptualization of the usage of medications-convenience/punitive/behavioral control

• What we medicate for and do not medicate for (signs/symptoms of diagnosed psychiatric disorders)

• Why we medicate or do not medicate (to alleviate signs/symptoms that interfere with habilitation)

• Our mission is habilitation

• Reinforcement is teaching





2015

Culture/Paradigm Shift

• Tainted culture by veteran staff to new staff

• How to change culture

• How long does it take





2015

Functional Assessment Preventive

Issues

• Assess basic “preventive behavioral support” procedures are in place (availability of reinforcers, availability of activities, extent to which difficult behaviors are inadvertently reinforced.

• Assess and address potential medical or physical conditions that may be influencing challenging behaviors.




2015

Engagement

• Engagement in the environment as a

prerequisite for success of behavioral

interventions





2015

Safety

• Safe environment

• Foundational for effectiveness of behavioral

interventions

• How do we impact the level of safety




2015

Competency

• PBSP Competency based on a level of understanding that will enhance implementation

• Didactic/Role-Modeling/In-Vivo

• Use of technical jargon

• Length of document

• Extent of information

• Reading level

• Demonstrated competency





2015

Treatment Integrity

• Treatment Integrity/Fidelity- PBSP revisions are based solely on data (not on subjective impressions)

• Does viewing the PBSP as an experiment dehumanize the issue

• Without treatment fidelity there is no treatment

• Staff making changes in the implementation of the PBSP based on “belief” that PBSP is ineffective





2015

Data

• Reliability of data-method of collection (behavioral data sheets/Habscan cards/multiple data collection issues

• Valid-does it measure what it purports to measure

• Accurate-consistent with external source

• “data shmatta”-garbage in/garbage out

• Data collection must be individualized

• Is the data a true reflection of the progress of the PBSP

• Ownership of problems with data (life altering treatment decisions are based on data)

• “Life blood” of facility

• How do we impact on data collection




2015

IOA

• Inter-Observer Agreement-occurrence or non-

occurrence of challenging/replacement

behaviors




2015

Lack of Skills by Staff




2015

Lack of Motivation

• Enjoyable work environment

• How do we impact the environment




2015

Treatment Fidelity

• Critical

• Strong management

• Clinical support

• How do we impact treatment fidelity




2015

Designer of PBSP

• Critical role

• How do we impact the role of the designer on

the implementation




2015

Supervision of PBSP

• Critical

• How do we ensure




2015

Environment

• Critically important

• How do we impact the importance of the total

environment




2015

Staffing

• Critical

• Impacts on so many levels

• How do we impact




2015

Replacement Behaviors


• Capturing the function of the challenging

behavior

• Our mission: Habilitation





2015

Antecedents


• Moments prior or months/years prior-grudges

• Behavioral chains

• Overemphasis on consequences





2015

Train the Trainer

• Critical-consistent training

• Cascade training-logistical issues, training

issues

• Pitfalls





2015

The “C” Word

• Consequences – either positive or negative – only affect future behavior. Consequences select response classes, not individual responses. Reinforcing or punishing consequences are most effective when they are immediate. Consequences select any behavior that precedes them whether or not a behavior change tactic is being practiced. Behavior change tactics are the methods derived from one or more basic principles of behavior and utilized by applied behavior analysts. A principle of behavior is a description of the functional relation(s) between behavior and one or more of its controlling variables that has generality across organisms, species, settings, and behaviors.

• The use of consequences

• The conceptualization of consequences-anything that follows a given behavior (good & bad)

• The broad implications of utilizing progressively restrictive consequences-moral/ethical/legal/clinical/financial/societal/accountability

• The necessary and sufficient data to support ever increasing restrictive consequences e.g. treatment integrity

• “They get away with anything”

• “Their rights………………………..”

• “What are we teaching these people anyway”




2015

Special Supervision

• It is not treatment

• It does not ensure the effective implementation of the PBSP

• Critical thinking is imperative in applying levels of supervision (is it achieving the desired outcome, why is it being applied, why is the particular level being applied, why is the frequency being applied, what is the impact on staffing levels)

• Must have “good faith” plan in place to reduce increased (intrusive) levels of supervision or we are violating civil rights (plan may require extensive time to achieve desired outcome)

• How do we teach the concept?




2015

Dual Diagnosis/Mental Disorders:

Subset with Axis I Psychiatric Disorders• Difficulty in diagnosing psychiatric disorders in those with ID/DD-professional competency, knowledge,

experience, intellectual & developmental issues, DM-ID

• Definition of Mental Disorder-disorder of thinking and/or feelings that results in significant impairment of an individual’s ability to carry on a satisfying and productive life

• Is it Behavioral or Psychiatric-question is nonsensical as it is all about behavior (could we address it with drugs or is there something else we should do?)

• To Medicate or Not to Medicate-Federal regulations/Best Practice requires Psychoactive Medications in some cases/Primary intervention is behavioral/environmental/Adjunct intervention is psychoactive medications only if problem is refractory to primary intervention

• Role/Purpose of Psychiatry-to help patients to consciously control their brain chemistry through pharmacotherapy and psychotherapy/alter neurotransmitter activity thru drugs or psychotherapy/thoughts or physical activity

• Approaches to Treating Mental Disorders-Teach coping skills/Alter environment/Teach behaviors likely to alter brain chemistry in desirable directions/Target with systematic reinforcement/Avoid encouraging “sick” behavior/Medication as indicated for target symptoms

• Role of IDT in mental disorders-explore and implement applicable treatment options as part of ISP/ensure treatment with psychoactive drugs is integrated into ISP that includes non-drug approaches/monitor target symptoms and outcome measures for efficacy

• Role of ICF/MR “Active Treatment” in people with mental disorders-acquisition of behaviors/prevention or deceleration or regression or loss of current optimal functional status/teach them to take care of the functioning of their own brain first and foremost

• To diagnose Axis I or not to diagnose Axis I (that is “not” the question)-the issue is the accurate diagnosis




2015

Which staff do we train

• Full-time assigned staff

• Pulled/detailed/relief staff

• All staff/all shifts/all disciplines/all locations

• Competency/liability issues for disciplines falling

outside of psychology/behavioral health

• Logistical issues




2015

PBSP

• The “genius” in creating a PBSP that is understood by staff will be more readily implemented

• If we continue to do the same thing and expect a change in behavior of another individual we are engaging in scapegoating-definition of insanity

• The change in behavior begins with “us” via the intervention section to effect change in the individual

• Our own behavior is all that we have control of-we can set the stage for behavioral change but ultimately cannot control another human being

• Skill Acquisition Program (SAP)-teaching the component parts of a behavior (motivational issue if behavior occurs at a low frequency)

• Determination as to existence of a given behavior in person’s repertoire vis a vis baseline or at a low level of frequency

• In the absence of data/baseline the default is to assume the behavior is not evident in the behavioral repertoire and thus needs to be trained via a SAP

• Baseline-pre-treatment

• Present level of functioning-ongoing treatment




2015

The PBSP Isn’t Working

• Identify Challenging Behavior

• Functional Assessment results in hypothesized function of challenging behavior

• Functional Replacement Behavior

• PBSP designed

• PBSP does not appear to be working:

-it may be working but data is not accurate

-it may be working but extinction bursts may be

operating

-it may not be implemented with integrity for many

reasons

-no direct correlation with designing a new PBSP


2015

Motivational Aspects

• Displaying learned behavior already existing in the behavioral repertoire versus lack of display of learned behavior in the behavioral repertoire

• Accurate motivational assessment

• Availability of identified motivators

• Control over identified motivators

• Satiety of identified motivators

• Ability to vary identified motivators




2015

The End

Hope you enjoyed my presentation.


2015

“issues affecting behavioral interventions”...resume • college 1970-1987 • doctor of...

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