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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 QuickTime™ and a Video deco mpressor are needed to see this picture. 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 QuickTime™ an d a H.263 de compressor are need ed to see this p icture . 36 CAMERON IN PLAY QuickTime™ an d a H.263 de compressor are need ed to see this p icture . 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 QuickTime™ and a TIFF (LZW) decompressor are ne eded to see this picture. 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 QuickTime™ and a Video d ecompressor are neede d to see this picture. 58 QuickTime™ and a TIFF (LZW) decompressor are need ed to see this picture. 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 QuickTime™ and a H.263 decompressor are needed to see this picture. 85 Play Picture Activity Schedule McClannahan & Krantz (1993) QuickTime™ an d a Sorenson Video deco mpressor are need ed to see this p icture . 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 QuickTime™ an d a Sorenson Video deco mpressor are need ed to see this p icture . 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 QuickTime™ an d a Sorenson Video deco mpressor are need ed to see this p icture . 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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