plenary - neurodiversity is a civil...

Neurodiversity is a Civil Right!

Rage to Reason

Behavioral Intervention and Treatment for Explosive Behaviors in Children with Emotional Disorders

Amy Buie, MEd, BCBA, [email protected]

“ Everyone is a genius! But if you judge a fish on it’s ability to climb a

tree, it will live it’s whole life believing it is stupid”

Albert Einstein

Understanding Emotional Disorders

• Oppositional Defiant Disorder• Disruptive Mood Dysregulated Disorder• Intermittent Explosive Disorder• Obsessive Compulsive Disorder• Reactive Attachment Disorder• Generalized Anxiety Disorder• Bipolar and Mood Disorders

Behavioral Descriptions

• Defiant• Aggressive• Angry• Raging• Resistant• Stubborn• Non compliant (Can be shut down or sleeping)• Challenging

Understanding Why

Complete a Functional Behavior Assessment:

EscapeTangibleSensoryAttention

ABC AnalysisAntecedent Behavior Consequence

Teacher presents work Student has aggressive tantrum Student sent to Office

Teacher attends to another Student uses profanity Teacher tells studentStudent that there will be

a consequence

A child is playing with a toy Student hits child, the child Student plays with toydrops toy and runs to tell the teacher

Escape/Avoid functions:

We assume that the behavior is working for them. In other words, the behavior (often

explosive) works to make academic demands go away

What does this mean?

The Child learns that arguing and tantrums are an effective means of coercing teachers and

adults into “giving in” to his or her wishes or to make demands disappear.

This may be true for tantrums

We see this with the “terrible two’s”

Goal: Self Evident

Teach teachers and other adults to be more consistent so as to help the child learn his/her arguing and tantrums will not coerce adults into

“giving in” or making demands “go away”.

What does that look like?

1. Target Behavior: Compliance

2. Determine a menu of rewards and punishments to give child the incentive to comply with adult directions

3. Develop a currency system—points, stickers, tokens, levels, etc.

However, we have to ask:

Do these children have behavior because of bad parenting or bad teaching?

In other words, is it as simple as us “giving in” or letting them “get out of the work” that is

causing the problem?

Transactional or Reciprocal ModelDr. Ross Green

The child’s out come is a function of the degree of “fit” or “compatibility” between the child and adult

Increased level of compatibility=Good outcomeDecreased level of compatibility=Bad outcome

Explosive Behavior is viewed as one of many manifestations of adult-‐child incompatibility

Incompatibilities

• Child Maltreatment• Anxiety• Depressed Mood• Social Withdrawal• Substance Abuse

Moves away from “fix the problem child” or “fix the problem adult”.

Transactional Perspective

The goal of treatment is to improve compatibility between the child and adult.

Such a goal requires an understanding of characteristics of both child and adult and

include both in treatment

“Children do well if they can”Ross Greene

What are some of the Characteristics?

Children have lagging skills in the area of flexibility/adaptability, frustration tolerance and

problem solving

Definition of Compliance?

Compliance is defined as the capacity to defer or delay one’s own goals in response to the imposed goals or standards of an authority

figure.

This can be considered one of many developmental expressions of the skills of

flexibility, frustration tolerance, and problem solving.

Teachers and Adults then can understand that the child difficulties are not due to a deficit in motivation or adult ineptitude but rather a

deficit in cognitive skills.

In fact…

• We often feel very compelled to give kids rewards and consequences so they “learn” that explosive behavior is not acceptable.

• I believe they already know this

Deficits in Executive Functions

The Executive functions are a set of processes that all have to do with managing oneself and one’s resources in order to achieve a goal.

It is the umbrella term for the neurologically-‐based skills involving mental control and self regulation

Executive Function

• It’s a “producing difficulty” not a “learning difficulty”

• It’s a function of the frontal lobe• It develops throughout a person’s lifetime• It wires and routes how we think and function• It impacts reading and writing• It’s not about learning a new skill but demonstrating the skill that executive function deficits are apparent

Executive Function Deficits

• Inhibit (class clown) “The ability to stop one’s own behavior”

• Shift (Hard headed) “ To move freely as a circumstance demands or changes from one thing to another”

• Emotional Control (Meltdowns) “ The ability to Regulate emotions”

• Initiate (Lazy) “Begins a task or generates ideas”

Executive Function Deficits

• Working Memory (Forgetful) “Holding information in mind for a task”

• Monitor (Clueless) “Self Regulation”• Plan/Organize (Scatter brain) “ Ability to manage task demands”

• Organizing materials (Don’t care) “Collect and Store”

Examples• Trouble stopping when silly or acts wilder in groups• Does not transition well especially from preferred activities

• Over reacts to small problems and “moody”• Explosive angry outbursts• Must be prompted to begin a task• Easily distracted and forgetful• Does not ask for help when needed• Unaware of how their behavior affects others• Unorganized• Loses everything and very unorganized

Emotional Regulation• Sometimes leads to a chronic level of irritability, depressions and or anxiety

• Minor things = Big Deal!!

• Transactional model: Someone irritable and anxious paired with an adult that responds in an impatient, inflexible, rigid manner or misinterpret irritability as a “bad attitude” would result in incompatibility.

Cognitive Flexibility Skills• Concrete, black and white thinker• Rule oriented• Concerned with details—not the “big picture”• Like predictability, routines and has significant frustration when things are outside of the norm or are unpredictable

• Cognitive Distortions that are rigid and inaccurate “I’m stupid.” “It’s not fair.” “You always blame me.” “No body likes me”

• Transactional: Someone with literal thinking with sarcasm would create incompatibility

Social Skills• Recognizing the impact on one’s own behavior• Comprehending how one is coming across• Attending to social skills• Appreciating social nuances• Accurately interpret, benefit from and respond to social feedback– Sharing, entering a group, starting a conversation, taking turns in a conversation, recognizing boredom in an interactive partner, regulating pitch and volume, maintaining eye contact and orientation to the speaker, recognizing when someone says something different that what they actually mean

The four primary emotions people feel under stress:

1. Frustration2. Anxiety3. Tension4. Fear

LaVoie, 1998 and Mandt, et. Al. 2008

Anxiety and Behavior

• People with trauma and anxiety process all information in an S-‐R fashion first, then ABC

• The higher the anxiety and stress, the more difficult it becomes to follow direction and handle frustration

Anxiety and Crisis

Jennie L Long, PH DUniversity of Kansas

Sense of Time

Extended Future

DaysHours

HoursMinutes

MinutesSeconds

Loss of sense of Time

Cognition Abstract Concrete “Emotional” Reactive Reflexive

Mental State

Calm Alert Alarm Fear Terror

Behavior Typical or normal

Vigilance or Avoidance

ResistanceNon-‐Compliance

DefianceDisassociation

Aggression or Black out

Anxiety and Stress

Breaking Point Breaking Point

STRESSFEAR

OVERWHELMANXIETYStress

FearOverwhelmAnxiety

Emotional Regulation is the Foundation for Mental

Health

Rage to Reason

Behavioral Intervention and Treatment for Explosive Behaviors in Children with Emotional Disorders

Amy Buie, MEd, BCBA, [email protected]

RegulationThe ability to experience and maintain stress within one’s window of tolerance. Generally referred to as being calm, focused or relaxed. This term is utilized by literally every scientific disciplineDysregulationThe experience of stress outside of one’s window of tolerance. Generally referred to as being stressed out, or in a state of distress. It is believed that affect dysregulation is a fundamental mechanism involved in all psychiatric disorders (Taylor, et. Al 1997)

Dysregulation Dysregulation

Hyper-‐arousal Hypo-‐arousal

• Unable to focus or sit still• Will not adhere to rules• Aggressive• Resistant to directives• Argumentative• Anxious before tests• Impulsive• Risk-‐Taking Behavior

• Defiant• Withdrawn from peers• Tardy• Absent• Disassociates-‐shuts down• Avoids tasks• Numbs out— “I don’t care”• Forgetful

Communication of Needs

• Communicating that he is in a state of stress

• Voicing his needs• Unequipped to self regulate• Unable to calm his own nervous system

Planned Ignoring

An extinction procedure for behavior maintained by positive reinforcement of

attention.

No longer give attention to the behavior so that it is no longer reinforced and therefore

extinguishes the behavior

What about using planned ignoring when a child is dysregulated?

When problem behavior occurs:

1. Determine the function of the behavior2. Determine the reinforcement 3. Determine consequences

Immediately following a problem behavior we typically ask ourselves, “What should I do about this behavior?”

This leads to consequences

New questions

FIRST: “What can I do at this very moment to improve my relationship with this student?”

SECOND: “What do I want them to do instead?”

Heather ForbesBeyond Consequences

Creating a Trauma Sensitive Classroom!

Create a sense of belonging

• Historically, humans lived in multi-‐generational and multi-‐cultural settings

• We are biologically designed to be in a community

• We all need to belong and fell like we are important

• “You are one of us” verses “You are not one of us”

Create a sense of belonging• Take time to talk and acknowledge each student. When the student walks into the classroom, convey the message, “Welcome. This class would not be the same without you here today!”

• Recognize that student’s moods and help to regulate instead of ignoring or criticizing the moods

• Listen to the student (you don’t have to agree)• Smile at the student and stay in a warm place in your heart, no matter their attitude or disposition

• Take an interest in what’s important to each student• Ask the students for help with things and share their ideas with others.

Perhaps it’s not attention seeking behavior but rather a cry that they NEED your attention.

They can’t do it without you.

Pro-‐Active Strategies

1. Regulation

2. Academic Modifications

3. Prompting Most to Least

4. Empathy and problem solving

Regulation

Self Regulation is the ability to:• Detect how you are feeling• Match emotions to events• Change level of behavior and emotion to match environment and cultural expectations

Brenda Smith Myles

Regulation

The Incredible 5 Point Scaleby Kari Dunn Buron and Mitzi Curtis

During a meltdown (level 5), children lose up to 30 IQ points in their ability to understand directions, process language and learn from consequences.

Ross Greene

Regulation

It’s important to know that you can not operate under the belief that he or she knows what or how to do something just because he or she has done it in the past.“I know he knows it. He’s done it before”

Every opportunity to respond and their success is based on the level of dysregulation!

The Zones of RegulationLeah Kuypers

Three ways to teach regulation1. Sensory and Movement2. Relaxation3. Cognitive Behavior Strategies

Stress Management Station-‐-‐Sensory

Tension release activitiesStress/mad basketExerciseRunning an errandWorking in ways that do not involve sitting in a chair

Stress Management Station-‐-‐Relaxation

• Lazy 8 breathing• The six sides of breathing• Visualization• Music with head phones• Time in

Stress Management Station-‐-‐CBT

• Big Problem vs. Little problem• Flex brain vs Rock brain• Positive affirmations– I am smart– I am successful– I am beautiful– I am fun– I am happy

Cognitive/Academic Strategies

• The Stopping Point Strategy• Visual Prediction• Warm up activities• Modified work (someone else to write, shortened assignments, etc.)

• Checklists• Self monitoring• Voice Control Monitor• Organizational binder system• Have back up items

“Think Three”

1. Does he understand?2. Is the reinforcement clear?3. Have you incorporated choice?

One: Does he understand?

• Visual Prediction• Curriculum Adaptations• Most to Least Prompting• Behavior Momentum

Two: Is the Reinforcement Clear?

• Consequence Maps• “As soon as…”• “I am working for…”

www.behaviormappingmaker.com

Three: Have you incorporated choice?

• Do you want to do this one or this one? (Two different math papers or math and reading)

• Do you want to do it with the crayons or markers?

• Do you want to do it sitting here or there?• Do you want me to do the first one or do you want to do the first one?

Research on Rage to Reason

• Dr. Wayne W. Fisher, Monroe Myer Institute

• Research shows that FCT is effective and preferred but is it practical?

• Using FCT and EXT with a signal

Beginning “Rage to Reason”

1. Stress Management Station2. Functional Behavior Assessment3. Reinforcement

Functional Behavior Assessment

Determine behaviors that are maintained by escape and avoid, specifically to following academic demands

R2R’s FBA Guide can get you started.

It does not constitute a full Functional Behavior Assessment

Functional Behavior Assessment Guide

• Does the behavior occur in response to requests to do academic work?

• Does the behavior occur in response to demands to follow directions (classroom routines)?

• Are there types of academic work that increase the likelihood of behavior like writing or reading out loud?

• Do these behaviors occur frequently during classroom instruction and less likely during free time or recess?

Student Directed Functional Behavior Assessment

“We are meeting today to find ways to change school so you like it more. This interview will take about 30 minutes. I can help you best if you answer honestly. You will not be asked anything that might get you in trouble.”

R2R Phase 1: “Assessment and Reinforcement”

• Determine Reinforcement• Reduce all anxiety (no demands)• No work—play and build relationships• Create an A and a B list• Practice transitions

Reinforcement

• Preference assessment• Observation• Reinforcement Inventory• Ask the student• Create an A list of highly preferred activities and a B list of preferred activities

No academic demands

• Play• Build relationships• Reduce anxiety/dysregulation• Determine reinforcement

Practice Transitions

Practicing Transitions

• Set a timer of 20 minutes• Ask student to get to a stopping point• Student stops activity• Student can pick another activity. It can be the same one he just finished or a new one

If he does not end the activity

• After getting to a stopping point, physically assist student to stop activity

• Maintain safety• When calm, the student can pick another activity however, the activity that they refused to terminate will NOT be an option until the next transition

Example

• Billy is on the computer for 20 minutes• The timer goes off and Billy gets to a stopping point

• Billy turns off the computer• Billy chooses the same activity or a new activity

Example• Billy is on the computer for 20 minutes• The timer goes off and Billy gets to a stopping point• Billy refuses to turns off the computer• The teacher turns off the computer for Billy• The teacher keeps Billy safe• Once Billy is calm he can choose a new activity. The computer is NOT a choice because he did not stop when asked (after the stopping point) the last time

• Billy chooses new activity• After the new activity is over and Billy transitions, the computer is available again as a choice

R2R Phase 2: “Functional Communication Training”

• Prepare a schedule such as math at 9:00 and social studies at 10:00, or use the current schedule

• Tell the child, “Let’s check your schedule”• Use the green “ask and get” card and the FCT map

• Allow the student to say, “No thanks”• Student chooses an activity from the A or B list

Phase 3 “Differential Reinforcement”

Introduce the A list and the B list

• Present a Green• Choosing “no thanks” get the B list and doing the work gets the A list

R2R Phase 4: “Extinction”

• Continue to have student, “Check the Schedule”

• Introduce the red “Must and No” card along the with red Extinction map

• Tell the child that a red means he has to do it

Phase 4: “Extinction”• Use most to least prompting• Start with a very simple task like one addition problem

• Wait him out until he does the task• Use an “As soon as” statement “As soon as you do your math, you can have freetime.”

• Ignore any behaviors (verbally) but block and redirect as needed

• As soon as he finishes the task, let him pick an A list activity

What if I wait him out and he does not comply? How long do I wait and what do I do?

If the child is young (third grade or below) or you believe you can successfully use physical guidance:

• After 15-‐20 minutes say, “It’s time for math. This is a red. As soon as you do your math you can have free time. I’m setting a timer for 1 minute. When the timer goes off I will help you.”

• Set a timer and walk away• After the time goes off say, “Ok a red means you have to do

it so I am going to help you. 3-‐2-‐1” (Count with 2 seconds between each number)

• Use physical assistance to complete the task• Do an A list activity

Physical Guidance

This should absolutely take no more than 3 weeks. If you are still using physical guidance after this time, or you need to use it for longer than one minute, stop immediately and use the “Wait Out Procedure”

If the Child is older (third grade and above) or can not tolerate physical assistance, or after 3 weeks of using the physical guidance procedure without success:

Use the “Wait Out” Procedure:• Incorporate “Think Three” (Give a choice)• Give direction and wait until he complies even if that means

for a significant amount of time after school.• Give water, snacks if needed and take a break for lunch• Make arrangements to follow through for as long as it takes!• If he tries to leave, block with the least amount of physical

assistance.• If he sleeps, have his stay at his desk if possible.• Use the “As soon as” statement• When he is finished, do an A list activity or let him go home

and do an A list activity first thing when he walks in the door.

“Increasing Work”

• Increase the work on a red and give two choices (Think Three)

• May want to start a token system• Use most the least prompting• Do not increase the difficulty, just the amount (1 addition problem to 3 addition problems)

• Do an A list activity

Case Study -‐ SamBASELINE

• Samuel is a 10 year old boy • Medical diagnosis of Autism Spectrum Disorder, Intellectual

Impairment, Attention Deficit Hyperactive Disorder, and Oppositional Defiant Disorder

• History of aggression, property destruction, refusal, and inappropriate language

• In November hospitalization • Learning Momentum was contracted starting in January • 3.25 hours of school each day, in isolation, 1 teacher and 1

para• 16.3 behaviors per day (one behavior every 11 minutes)

Phase 1

• No Demands • Build relationships • 2 behaviors occurred across 4 days(both inappropriate language)

• Average .5 per day • Practicing transitions

0

10

20

30

40

50

60

70

Daily Total of Challenging Be

haviors

Challening Behaviors in Student throughout Rage to Reason Program

Baseline No

Intervention

Phase 1No

Phase 2FCT

Phase 3Extinction

Phase 4 Increasing Work

16.3 per day .5 per

day

20.6 per day

5.8 perday

1.3 per day

Phase 2

• Functional Communication Training

• Present work as a choice and student can say….

• Average of 20.6 behaviors per day

0

10

20

30

40

50

60

70


haviors


Baseline No

Intervention

Phase 1No

Phase 2FCT

Phase 3Extinction


16.3 per day .5 per

day

20.6 per day

5.8 perday

1.3 per day

Phase 3

• Extinction • Add the “Red” tasks which are “have tos”

• Average of 5.8 behaviors per day

0

10

20

30

40

50

60

70


haviors


Baseline No

Intervention

Phase 1No

Phase 2FCT

Phase 3Extinction


16.3 per day .5 per

day

20.6 per day

5.8 perday

1.3 per day

Phase 4

• Increasing work • Add more Red tasks• Average 1.3 behaviors per day

0

10

20

30

40

50

60

70


haviors


Baseline No

Intervention

Phase 1No

Phase 2FCT

Phase 3Extinction


16.3 per day .5 per

day

20.6 per day

5.8 perday

1.3 per day

Case Study -‐ Bobby

BASELINE• 10 year old boy• Medical diagnoses of Bi-‐Polar, Attention Deficient and Hyperactivity Disorder, and Obsessive Compulsive Disorder

• Behaviors reported; threatening, aggression, property destruction, inappropriate language, cursing, and making unreasonable demands

• Student was on homebound and previously hospitalized

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1/5/2015*

1/7

1/9

1/13

1/16

1/26 2/3

2/9

2/11

2/19

2/23

2/25

2/27 3/3

3/5

3/9

3/11

3/13

3/17

3/19

3/23

3/25

3/27

3/31 4/2

4/8

4/10

4/14

4/16

4/20

4/22

4/24

4/28

4/30 5/4

5/6

5/8

5/12

5/14

5/18

5/20

5/22

5/27

Percentage of Day Spent Engaged in Behavior

Phase 2FCT

Phase1

Phase 3Extinction

Phase 4IncreasingWork

Avg. 16% Avg. 4%Avg. 2%

Phase 3

• Extinction • Add the “Red” tasks which are “have tos”

• Average 4% of day spent engaged in challenging behaviors

• Introduced “Coping Skills”

Coping Skills

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1/5/2015*

1/7

1/9

1/13

1/16

1/26 2/3

2/9

2/11

2/19

2/23

2/25

2/27 3/3

3/5

3/9

3/11

3/13

3/17

3/19

3/23

3/25

3/27

3/31 4/2

4/8

4/10

4/14

4/16

4/20

4/22

4/24

4/28

4/30 5/4

5/6

5/8

5/12

5/14

5/18

5/20

5/22

5/27

Percentage of Day Spent Engaged in Behavior

Phase 2FCT

Phase1

Phase 3Extinction

Phase 4IncreasingWork

Avg. 16% Avg. 4%Avg. 2%

Rage to Reason

www.learningmomentum.comwww.behaviormappingmaker.comamy@learningmomentum.com

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