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Best Practices Dealing With Problem Behaviour Behaviour Institute

VIEWS: 7 PAGES: 117

									  Best Practices Dealing With
 Problem Behaviour of Children
  and Adolescents with ASD’s
              Sponsored by:
     Children’s Mental Health Ontario

Dr. Joel Hundert & Dr. Nicole Walton-Allen
           Behaviour Institute
                                             1
              Welcome Sites

Burlington     London         Sault Ste. Marie
Chatham        Markham        Sudbury
Dryden         Mississauga    Thunder Bay
Kapuskasing    Ottawa         Timmins
Kingston       Parry Sound    Windsor
Kitchener      Peterborough

                                                 2
     Schedule For the Workshop

   1:30 - 2:30 Joel Hundert: Understanding and
    assessing problem behaviours
   2:30 - 2:45 Questions
   2:45 - 3:55 Break
   2:55 - 3:55 Nicole Walton-Allen: Interventions
   3:55 - 4:10 Questions
   4:10 - 4:30 Application to school & families




                                                     3
         What is the Behaviour
              Institute?
•   The Behaviour Institute is a private agency
    providing intensive behavioural intervention
    for young children with autism. Home-
    based services are provided out of
    Hamilton and Toronto offices; centre-based
    IBI services out of Toronto office
•   Training organization for the Ontario Autism
    Initiative

                                              4
•   Sponsor of part-time Master’s degree
    program in Behaviour Analysis offered in
    Toronto by the University of Nevada,
    Reno (42 students)
•   Directors are Dr. Joel Hundert & Dr.
    Nicole Walton-Allen, psychologists and
    Board Certified Behaviour Analysts

                                               5
       Goals of the Workshop
•Understanding  of the unique behaviour /
emotional needs of children with ASDs
Knowledge of the conceptual and research
foundations of PBS
Knowledge and skills in conducting a
functional behavioural assessment
Knowledge and skills of PBS strategies to
anticipate and prevent problem behaviours
                                             6
                     Goals
                     cont’d
   Knowledge and skills of PBS strategies to
    teach functional skill alternatives
   Knowledge and skills of how to use PBS
    with families
   Knowledge and skills of how to use PBS
    with schools


                                                7
      How to Get Materials

http://www.behaviourinstitute.com




                                8
             AGENDA
•   Autism
•   Positive Behaviour Support
•   How to Implement PBS
    1. Forming a team
    2. Functional assessment
    3. Develop a hypothesis


                                 9
                  Agenda
                  Cont’d
    4. Behaviour support plan
       • Anticipate and prevent
       • Teach positive alternatives
       • No longer let the problem behaviour be
          effective
    5. Implement & evaluate
    6. Promote generalization of positive
        behaviours
•    Application to schools
•    Application to families
                                                  10
                Assumptions

   You are experienced children’s mental health
    clinicians
   Less experienced in working with children and
    youth with ASD’s and their families
   Have read Best Practices document
   Have attended or have knowledge of
    introductory and advanced training provided
    by Geneva Centre

                                                    11
         CMHO Training Plan
   Introductory training (1-day)
   Advanced training (2-days)
   Specialized training
        • Best Practices for Dealing with
          Problem Behaviours of Children and
          Youth with Autism Spectrum
          Disorders
        • Best Practices for Children and Youth
          with Asperger’s Disorder


                                                  12
AUTISM SPECTRUM
   DISORDERS




                  13
    What We Know About Autism
        Spectrum Disorders
•    Is a neurodevelopmental disorder with no
     clearly understood cause, although there
     evidence that it runs in families and has a
     genetic component
•    Is not caused by poor parenting
•    Prevalence is about 1/300 (Yeargin-Allsopp
     et al., 2003) and increasing



                                                   14
             What We Know
                cont’d
•   Can identify by 24 months (Stone et al.,
    1999)
•   More common in boys (4:1)
•   No prevention or cure
•   There is a treatment that works (Early
    Intensive Behavioural Intervention)


                                               15
                    Growth Trajectory
                        Typically-
Developmental Age

                    developing children




                        Chronological Age

                                            16
                    Growth Trajectory
                     Typically-developing
Developmental Age

                           children

                                            Children with autism




                        Chronological Age

                                                              17
                    Growth Trajectory
                     Typically-developing
Developmental Age

                           children
                                                Goal of IBI
                                            Children with autism




                        Chronological Age

                                                              18
    Summary of Research on IBI
   20 - 40 hours/week of IBI can produce
    significant and long-lasting gains in
    young children with autism to a point
    where about half achieve average IQ
    and do not need special help in school
   The success of IBI depends on staff
    being trained and supervised by
    competent behavioural consultants


                                             19
             Critical Components
                    cont’d
 •   A large proportion of the child’s waking
     hours should involve active
     engagement in learning

                                  20 hours
100 waking
hours



                                                20
    Challenges Of CMH Agencies
      Serving This Population
   Problems are chronic and episodic
   Motivational and skill deficits




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                                                                                      21
                Challenges
                 cont’d
   Compared to families of typically-
    developing children and children with
    other forms of developmental disabilities,
    levels of stress and depression is the
    highest in families of children with ASD’s
   Lack of cross-sectorial service
    coordination (e.g., medical, educational,
    developmental services, etc.) is common


                                             22
    Problem Behaviours and Children
        / Adolescents with ASD’s
   About 50% have significant problem
    behaviours including aggression, tantrums,
    stereotypic behaviours, and self-injurious
    behaviours
   No evidence of spontaneous improvement
   More frequent and severe problem behaviours
    are associated with children / adolescents who
    have more severe symptoms of autism
   Problem-behaviours crytallize and become
    more entrenched as children get older

                                                     23
      POSITIVE BEHAVIOUR
            SUPPORT
   Origins were to provide an alternative to
    the use of aversives
   Early researchers: Glen Dunlap, Ted
    Carr, Mark Durand, Rob Horner, Robert
    Koegel
   Journal of Positive Behavior
    Interventions
   Association and annual meeting

                                                24
      POSITIVE BEHAVIOUR
            SUPPORT
   Origins were to provide an alternative to
    the use of aversives
   Early researchers: Glen Dunlap, Ted
    Carr, Mark Durand, Rob Horner, Robert
    Koegel
   Journal of Positive Behavior Support
    Interventions
   Association and annual meeting

                                                25
                     PBS
                    cont’d
   Since 1997, amendment to Individuals
    with Disabilities Act (IDEA) requires:
    – a) PBS; and,
    – b) functional behavioural assessment




                                             26
Carr & Durand (1985)
Problem behaviours have a function
Understanding the function of
  behaviours lead to more effective
  treatment




                                      27
 ABA, IBI, and Autism




                    Psychology
ABA      IBI   Autism



                             28
ABA, IBI, PBS and Autism
                         PBS is ABA



        PBS
                         Psychology
                Autism
ABA       IBI



                                      29
         Core Features of PBS
            Interventions
   Driven by functional assessment
   Result in outcomes that are acceptable
    to the individual, family and the
    supportive community
   Fit the contexts within which the
    behaviour occurs



                                             30
         Core Features of PBS
   Consistent with values of those who will
    implement the procedures;
   Consistent with the skills of the people
    who will implement the procedures;
   Consistent with the resources available
    to the people who will implement the
    procedures and matched by
    administrative support (Horner, 2000)

                                               31
    Core Features of PBS Interventions
                 Cont’d

   Operate from a person-centred values
    base (Anderson & Freeman, 2000)
    Blend multiple, empirically-based
    procedures (Horner, 2000),
   Focus on large unit of analysis and
    intervention


                                           32
PBS is ABA Dressed-Up and
     Ready to Go Out




    ABA        PBS
                            33
HOW TO DELIVER PBS




                     34
              Case Example

   Cameron is a six year old boy who has
    been receiving IBI for the past 1.5 years.
    He attends a community school with
    support from a PDD class in the school.
    Major areas of need:
   Social pragmatics (e.g., conversation)
   Peer interaction
   Compliance

                                                 35
CAMERON IN IBI




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                                     36
CAMERON IN PLAY




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                                      37
                     STEPS

1.   Form a team around the child or youth
2.   Complete a functional assessment
3.   Develop a hypothesis of the triggers and
     maintaining factors
4.   Develop a Behaviour Support Plan
5.   Implement and evaluate
6.   Generalize


                                                38
                 STEP 1
•   Form a team around the child of
    individuals who can help or hinder the
    child’s adjustment




•   Like Wrap-Around, Person-Centred
    Planning
                                             39
•   Identify strengths and needs




                                   40
                 STEP 2

   Complete a functional assessment




                                       41
•   Problem behaviours do not occur at
    random. They occur to meet a need of
    the child




                                           42
     Functions of Behaviour

Obtain                    • Objects
         If positive      • Activities
                          • Attention
                          • Sensory

Escape      If negative


                                         43
         Form & Function

• Different forms of problem behaviours may
  serve the same function (e.g., kicking,
  crying to get a desired object)
• Same form problem behaviours may serve
  different functions (e.g., crying at home to
  escape, crying at school for attention)




                                                 44
  Identify the Problem Behaviour, Its
     Form and Possible Functions

David is a 14 year old boy with autism who
is fascinated by brightly coloured string,
shoe laces, and other long fabric. He takes
the string between two cupped hands,
rocks while making humming noises.




                                          45
  Identify the Problem Behaviour, Its
    Form and Possible Function(s)

Jane is late from work and rushing at the
grocery store with her son, Andy. At the
check out, Andy spots the chocolate bars.
Andy asked for a candy bar. His mother,
Jane, said, “You can’t have candy now,
it’s almost dinner time.” Andy asked for it
again and again, began to whine and cry.
Jane was embarrassed and said, “OK,
but you better eat your dinner tonight.”
                                              46
  Identify the Problem Behaviour, Its
    Form and Possible Function(s)

Emily is a four-year with autism and hates
to have her hair washed. Sometimes
when her dad, Ron, bathes her, she kicks
and screams. When this happens, Ron
decides to wait for his wife to come home
to wash Emily’s hair that day.


                                             47
Identify The Possible Functions
1. David, a 13-year old is given seat work
to do at the back of the room which he does
not like. Periodically, David will run out of
the room.
a] escape situation; b] obtain attention;
c] escape attention; d] obtain internal
stimulation e] obtain object or activity


                                           48
 Identify The Possible Functions

2. Tommy is a 5 year old who hovers nears
   other children at outdoor play but does not
   play with them. Periodically, he will run by and
   hit a child who is playing in a group.
a] escape situation; b] obtain attention;
c] escape attention; d] obtain internal stimulation
   e] obtain object or activity


                                                  49
  The Importance of Functions

Before you develop an intervention for
behaviour problems, you must understand
the function(s) of the behaviour and
develop an intervention based on that
understanding. Interventions built on an
understanding of functions are more
effective (Carr et al., 1999)

                                           50
        Functional Assessment
   Indirect method
    • interview
   Direct method
    • Functional Assessment Checklist
    • Functional Assessment Cards (Carr and
      Durand, 1985)
    • Scatter Plot
    • Functional Assessment Observation Form


                                               51
Functional Assessment
      Checklist



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                                                                               52
               ABC Record
•   Is not enough




                            53
     Functional Assessment Cards
    (takes about 5 min to complete)
•    Identifies factors that trigger the
     behaviour
•    Identifies the form(s) of the problem
     behaviour(s)
•    Identify factors that may maintain the
     behaviour
•    Identifies possible function(s) of the
     problem behaviours
                                              54
Functional Assessment Cards
           cont’d




                              55
Functional Assessment Cards
           cont’d




                              56
    Functional Assessment Cards
               cont’d
•   Hand out 5 - 10 Functional Assessment
    Cards, preferably to different staff
•   Staff complete a card after each
    incident
•   Once all cards are completed, cards
    are sorted into piles by function
    (preferably as a group)


                                        57
             Exercise:
Complete a FAC for Throwing Stones




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                                               58
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                                                                            59
           SCATTER PLOT

   Paul Touchette




                          60
               Scatter Plot
      (takes about 7 min to complete a day)
•   Method of recording occurrence and
    non-occurrence of behaviours across
    activities and time periods
•   Suggests patterns that may help to
    identify triggers and functions of
    problem behaviour


                                              61
Example
 7




     Away

            62
     How To Do Scatter Plots

•   Pick the target behaviour
•   Operationally define the target
    behaviour
•   Record when the behaviour occurs by
    time intervals or by activity



                                          63
Functional Assessment Observation
    Form (O’Neill et al., 1997)




                                    64
           FAO: How to Complete
Fill in time and activities   Fill in behaviours




                                                   65
         FAO: How To Complete
Enter # for each episode




                                66
Interpret Problem seems to be
             escape-motivated




                                67
                  STEP 3

   Hypothesize what factors trigger and
    maintain the problem behaviour




                                           68
The Competing Behaviour
        Model
  (O’Neil, et al., 1990)




                           69
                   Setting Events
   Setting events are events that have occurred
   earlier that alters the effectiveness of the
   consequence e.g. sleep loss, long car ride



                A                B                C
Setting        Antecedent                         Consequence
                                Problem
Event          Stimuli          Behaviour
“Slow          “Fast
Triggers”      triggers”



                                                            70
                Learning & Behaviour
Setting Event     Triggering   Problem     Maintaining
                  Antecedent   Behaviour   Consequence




   Ear             Asked to      Hitting      Avoid
   infection       clean up                   task




                                                         71
                 Example
Jane is late from work and rushing at the
grocery store with her son, Andy. At the
check out, Andy spots the chocolate bars.
Andy asked for a candy bar. His mother,
Jane, said, “You can’t have candy now, it’s
almost dinner time.” Andy asked for it
again and again, began to whine and cry.
Jane was embarrassed and said, “OK, but
you better eat your dinner tonight.”

                                              72
                Learning & Behaviour
Setting Event     Triggering   Problem     Maintaining
                  Antecedent   Behaviour   Consequence




   Many            Sees          Crying       Gets
   hours           chocolate                  candy
   since           bar
   last
   eaten



                                                         73
                 Exercise
It is late in the day. Ron, is rushing to get his
seven year old daughter’s, (Emily) ready for
bed. Emily hates to have her hair washed.
When her dad, Ron, was bathing her, she
kicks and screams. When this happens, Ron
decides not to wash her hair that day.



                                              74
                Learning & Behaviour
Setting Event     Triggering   Problem      Maintaining
                  Antecedent   Behaviour    Consequence




   Tired,          Wash         Kicks and      Avoid
   rushed          hair         screams        task




                                                          75
               STEP 4

Formulate a Behaviour Support Plan




                                     76
              Rob Horner

•   Make the problem behaviour irrelevant
•   Make the problem behaviour inefficient
•   Make the problem behaviour ineffective




                                         77
Making the Problem
Behaviour Irrelevant
ANTICIPATE AND PREVENT



                         78
Neutralizing Routines for
     Setting Events
       (Horner, 1997)




                            79
      Horner, Day & Day (1997)
   3 adolescents with autism and
    developmental disabilities who were self-
    injurious or aggressive
   Setting events = delay in favourite event,
    lack of sleep
   Neutralizing routines = drawing pictures,
    looking through photos, nap


                                             80
SETTING     IMMEDIATE    AGGRESSION
 EVENT       TRIGGER                      ESCAPE
                            SIB

NEUTRALIZING
  ROUTINE
  •   Showed that aggression / SIB occurred
      only when setting event occurred before
      the immediate trigger
  •   Then showed that the addition of a
      neutralizing routine reduced the problem
                                                 81
      behaviour to near zero
        Other Examples of
       Neutralizing Routines
•   Looking through a favourite book
•   Looking through a picture album
•   Watching a video
•   Eating a favourite snack




                                       82
    Delay, Reduce, or Remove
            Triggers
•    Make activities and materials easier,
•   Add aids to learning
•   Make activities more fun, build in
    reinforcement (e.g., computer-assisted
    learning)
•   Break activities into small steps


                                             83
      Add Visual Information

Used to show the            Allan
                             calendar
sequence of pending
activities. Typically,
child turns over picture
at the end of one
activity and looks at the
next activity coming.

                                        84
             Visual Schedule




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                                                                      85
Play Picture Activity Schedule
           McClannahan & Krantz (1993)




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                                          86
    How PAS Differs From Picture
            Schedules
•    Focuses on the steps of performing an
     activity
•    Goal is for the child to perform an
     activity without adult prompts
•    Picture schedules have had very little
     research, PAS have had extensive
     research

                                              87
           High-P Requests
•   Give 4 or more high probability
    requests
•   Return to original request



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                                                 88
                Priming
 Problem behaviour is more likely to occur in
  unpredictable than predictable
  environments (Flannery & Horner, 1994)
 Consists of child previewing future events
  (no practice)
 Originally used for children with autism to
  preview a story at home that was read the
  next day in school (Wilde et al., 1992)
 Video priming (Schriebman, Whalen, &
  Stahmer, 2000)
 Cutting hair
                                                 89
        Making The Problem
        Behaviour Inefficient



Teach Positive Skills That Involve Less Effort




                                                 90
Behaviour and Communication

   There is a direct relationship between
    problem behaviour and communication
    deficits in children with autism
   Not all behaviour is communication (e.g.,
    echolia)



                                                91
     Functional Communication
             Training
                     by Durand (1990)


• Select a response modality that would be
  successful for the child (e.g., signs, PECS,
  micro-switch voice generators)
• Select a response form that the child can
  learn rapidly (e.g., break card) and involves
  less effort than the problem behaviour
• Maximize natural opportunities for the child to
  learn this communicative response
• The communicative response is taught
  during teachable opportunities

                                                    92
      Functional Communication
          Training Cont’d
                       by Durand (1990)
•   Deliver instruction for the child to use a
    communicative response (e.g. "What do you
    want?")
•   Deliver physical prompt (e.g., The therapist gives
    the child a picture depicting ”break" and puts out
    his or her hand)
•   Delivers a verbal prompt as the child uses a
    communication response (e.g. "I want a break")
•   The child receives the requested object or
    activity.
•   Prompt to assist the child in responding are
    systematically faded.
                                                     93
•   Generalization of the learned response is
     Making the Problem
     Behaviour Ineffective

The problem behaviour is no longer effective in
meeting the child’s needs




                                                  94
    Match Strategies to
        Function
FIRST STRATGEGY: FOR ATTENTION-
  MAINTAINED BEHAVIOURS
 • Give effective instructions
 • Differential reinforcement
 • Planned ignoring of the small stuff

SECOND STRATEGY: FOR DESIRED
 OBJECT/ACTIVITY
 • Response cost

                                         95
     Match Strategies to
         Function
THIRD STRATEGY: FOR SENSATION
 MAINTAINED BEHAVIOURS
 • Interrupt, Redirect, Reinforce

FOURTH STRATEGY: FOR ESCAPED-
 MOTIVATED BEHAVIOURS
 • Proceed with caution



                                    96
         The First Strategy

•   For problem behaviours maintained by
    attention




                                           97
Give Effective Instructions
        •   Be sure that the child is
            paying attention
        •   State what you want the
            child to do, rather than
            not do
 1      •   Give only one instruction
            at a time
        •   Be brief and simple
        •   Do not repeat your
            instruction               98
    Exercise: Identify the Errors
•   Gregory was having a great time at outdoor
    play in the sandbox, but was throwing sand.
    His teacher said, “Okay Gregory, stop
    throwing sand.” …. “GREGORY, I SAID STOP
    THROWING SAND!!!”
•   Jean wanted Melissa to clean up the dress-up
    centre. Jean said, “Melissa how about you
    picking up the brown shoes and put them over
    by the wall, then gather up the necklaces and
    place then in a bin. Then, put all of the hats
    on the hat rack.”
                                                 99
        Reinforce Compliance
•   Reinforce positive alternative
    behaviours
•   Use descriptive praise (describe what
    the child did), (e.g., “I like the way you
    stopped what you were doing and
    looked at me.”)
•   If praise is not important to the child,
    pair the praise with a tangible reinforcer
    that is effective for the child.
                                                 100
          Ignore The Small Stuff
•    Don’t ignore behaviours that are harmful,
     dangerous or highly disruptive
•    Only ignore behaviours that are maintained
     by attention (e.g., whining)
    – Discuss with the care givers what
       behaviours can and cannot be ignored:
      •   Biting another child
      •   Whining
      •   Jumping up and down
      •   Screaming                         101
    Planned Ignoring (Extinction)
               cont’d
•    Act in all ways as if the annoying
     behaviour is not occurring
•    Reinforce the alternative behaviour
•    Expect an “extinction burst”




                                           102
      SECOND STRATEGY
•   For problem behaviours maintained by
    getting desired object




                                       103
   Removal of Object or Activity
        (Response Cost)
Cameron and his sister, Amy, were playing
with a truck, pushing it back and forth. Amy
decided to stop the game and push the truck
by herself. Cameron wanted a turn too and
tried to pull the truck away. They began to
struggle and cry over the truck when their
father walked in. He took the truck away and
said, “You need to share your toys.” After a
few minutes he returned the truck and
reminded them to share.
                                          104
               Response Cost
•   Only use for problem behaviours that occur
    occasionally
•   Use for problem behaviour that are motivated
    to get desired object or activity
•   The object or privilege that is removed should
    be naturally connected to the problem
    behaviour
•   The consequence should be immediate
•   Always reinforce the desired behaviour

                                                 105
  Exercise: How would you use
        Response Cost?
Jason loves to watch the videotape of Lion
King, particularly one scene that he
rewinds and replays continuously. In the
past he has broken VCR’s and videos
from the constant rewinding.




                                         106
       THIRD STRATEGY
•   For problem behaviours maintained by
    sensations




                                       107
Interrupt, Redirect, Reinforce




                                 108
                      Stereotypy
•       What is it?
    •     Routinized and repetitive actions (may be
          verbal and/or motoric) that occurs often
          with no function
•    Why does it occur?
    • Feels good
•    How does it impact children?
    • Interferes with learning
•    How do you treat it?
                                                      109
       Treatment of Stereotypy
•    Have functional activities for the child to
     do that keeps him/her busy (e.g.,carry
     objects during a transition, place hands
     in pockets)
•    When stereotypy occurs:
    • Interrupt (e.g., gentle touch)
    • Redirect (e.g., give item to carry)
    • Reinforce (e.g., give reinforcement
        for carrying item)
                                               110
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                                     111
    Also Can Be Used for Aggression To Get
              Objects/Activities


•    Brian is beside James at the water
     table and starts to pinch him because
     he wants the pail. The aide then
     redirects Brian to the vehicle play area
     and reinforces him when he begins to
     play with trucks.


                                                112
    Redirection Should Not Be Used for
       Escape-Motivated Problem
                Behaviours
•   Why?




                                         113
FOURTH STRATEGY: PROCEED WITH
           CAUTION




For behaviour that are escape-motivated, the
most effective intervention is often to prevent
the escape by restricting the child’s movement
and potentially leading to “extinction burst”.

For this reason, you should only proceed with
informed parental consent and with a
behavioural consultant                            114
 Match Intervention to Function
         of Behaviour
a)   Get attention        1)   Planned ignoring
b)   Escape request       2)   Interrupt-redirect-
c)   Get desired object        reinforce
     or activity          3)   Get professional
d)   Sensory                   consultation
                          4)   Response cost


                                               115
                    Review
•    Make the problem behaviour irrelevant
    • Neutralizing routines
    • Make activities and materials easier,
    • Add aids to learning (e.g., visual
      schedules)
    • Make activities more fun, build in
      reinforcement
    • Break activities into small steps
•    Make the problem behaviour inefficient
    • Functional communication training


                                              116
                Summary
•    Make the problem behaviour ineffective
    • Planned ignoring and differential
      reinforcement
    • Response cost
    • Interrupt, redirect, reinforce
    • For escape-motivated behaviour
      proceed with caution


                                          117

								
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