Treatment of Severe Behavior Problems Changes in Behavioral Approaches in the Last 20 Years

1. Treatment of Severe Behavior ProblemsChanges in Behavioral Approaches in the Last 20 Years Nirbhay N. Singh Professor of Psychiatry, Pediatrics and Psychology Virginia Commonwealth University Richmond, Virginia, USA

2. What Was Happening 20 Years Ago? • By 1982, behavioral research had been published for • 14 years in the Journal of Applied Behavior Analysis (JABA) • 12 years in Behavior Therapy • 12 years in Behavior Therapy and Experimental Psychiatry • 5 years in Behavior Modification • 3 years in Behavioral Assessment

3. What Was Happening 20 Years Ago? • Behavioral research was also being published in many journals, including among others: • American Journal on Mental Retardation • Applied Research in Mental Retardation • Journal of Mental Deficiency Research • Journal of Autism and Developmental Disorders

4. What Was Happening 20 Years Ago? • Emphasis in behavioral research was heavily on classroom behaviors—both in enhancing classroom skills (e.g., on-task behaviors; academic skills, social skills) and in controlling classroom disruptive behaviors • There was a small but growing literature on the control and management of severe behavior problems—aggression, self-injury, property destruction, pica, rumination, and stereotypy

5. Behavioral Treatments 20 Years Ago • The behavioral literature was still enthralled with demonstrating, with minor variations, behavioral control across different behavior problems • No effort was made to produce lasting change in experimental studies—no distinction among behavior control, management and treatment • Emphasis on methodology—single case experimental designs, data collection methods, inter-rater reliability, and methods of generalization and maintenance

6. 1982-2001: The Last 20 Years • In 1982, Iwata et al. published an experimental methodology for deriving presumed motivations for severe behavior problems exhibited by individuals with developmental disabilities • Although initially promoted as a totally “new” development, it was the operationalizing of a methodology for assessing the functions of a behavior that had originally been advanced by Skinner in 1935 and, more recently, by Ted Carr in 1977.

7. Functional Analysis of Problem Behavior • Prior to 1982, virtually all behavioral treatments were derived and assessed on a trial and error basis • From 1982, a technology of functional analysis prior to the development of experimental interventions increasingly became normative for research publications • However, the methodology did not translate into day-to-day clinical practice to any significant level until the late 1990s.

8. Functional Assessment Procedures • These are of three general types: • Indirect assessments—through structured interviews (O’Neil et al. functional analysis interview) and ratings scales (MAS, QABF, FAST) • Descriptive analysis—direct observation of behavior is used to identify antecedent and consequent events correlated with the occurrence of severe problem behaviors • Functional analysis—arrangement of specific environmental conditions to assess the maintaining contingencies of severe problem behaviors

9. Functional Assessment Procedures • Used to develop effective behavioral interventions by • Identifying and altering antecedent conditions—establishing operations and setting events or discriminative stimuli—to reduce the likelihood of severe behavior problems from occurring

10. Functional Assessment Procedures (cont.) • Minimizing or eliminating the source of reinforcement for severe problem behaviors (e.g., through extinction) • Using the same reinforcer that maintains the severe problem behavior to establish an alternative, socially acceptable response (e.g., communication training) • By eliminating reinforcers and treatment components that may be irrelevant to the overall control of the severe problem behavior

11. Use of Functional Assessments • Has resulted in • Reduction in the use of default technologies (e.g., punishment) • Development of new treatment procedures (e.g., behavioral momentum) • Systematic identification of the reasons for treatment failures, e.g., mismatch between behavioral function and treatment or a change in function over time

12. Functions of Severe Problem Behaviors • Most prevalent functions of severe behavior problems (in decreasing order) include: • Social negative reinforcement (escape or avoidance) [35%] • Social positive reinforcement (tangible) [25%] • Non-social reinforcement (automatic) [25%] • Multiple functions [8%] • Unknown [7%]

13. Outcomes of Using a Functional Analysis Methodology • Reduction in use of punishment procedures and an increase in use of positive procedures • Effectiveness of behavioral interventions before and after the introduction of functional assessments has remained at about the same level—about 80% reduction from baseline to treatment • Functional assessment by itself has notproduced enhanced overall effectiveness of behavioral interventions • Data suggest that severe behavior problems are still difficult to treat (e.g., 20-yr data set on aggression)

14. Why the Lack of Overall Effectiveness? • Artifact of research publications—treatment failures are not submitted or accepted for publication • Bias towards positive outcomes • Actual success in both experimental studies and clinical practice is unknown at this time

15. Success is Moderated By Other Factors • Reactive treatment is normative rather than proactive programming • Environmental constraints to success—necessary environmental supports are often not readily available • Reinforcement is not ubiquitous in all cultures yet everyone is required to use it

16. Success is Moderated By Other Factors (cont.) • Lack of behavioral on-site expertise • Necessary treatment exceeds the skill level of therapists • Behavioral expert is not used to do the actual treatment • Skilled behavioral technologists use a recipe approach

17. Success is Moderated By Other Factors (cont.) • Experimental control cannot be readily achieved in the real world • Lack of vital information in journal articles—what happens outside the treatment sessions? Intensity of the behaviors? Severity? • Failure to prepare the treatment environment

18. Success is Moderated By Other Factors (cont.) • The art of programming or ensuring how the treatment will be delivered—the 10-90 rule • Maintaining staff interest when change is slow or slow in coming—look at changes in other variables, such as intensity or severity

19. Success is Moderated By Other Factors (cont.) • Staff give up when severe behavior problem worsens when behavioral treatment is implemented • Severe behavior problem may be episodic and staff do not remember what to do • It is harder to maintain treatment gains in individuals who are lower functioning

20. What Next? • Change in behavioral programming began in the late 1980s and it solidified by the 1990s • Behavioral programming was found to be too narrow in scope • Punishment procedures were no longer being used

21. What Next (cont.) • The Positive Behavioral Support (PBS)model of behavior change was developed in the late 1990s • In 1999, the Journal of Positive Behavior Interventions (JPBI) was inaugurated to give voice to the new model • The first national conference on PBS was held in 2002

22. The Positive Behavior Support Model • Carr et al. (2002) published a paper on PBS to: • Provide a definition of the evolving science of PBS • Described the background sources from which PBS emerged • Gave an overview of the PBS model, and • Articulated a vision for the future of PBS

23. Philosophy and Practice of PBS • Derived from three sources: • Applied behavior analysis • Normalization/inclusion movement • Person-centered values

24. Goals of PBS • Primary goal: • To help an individual change his or her lifestyle in a direction that gives all relevant stakeholders (I.e., teachers, employers, parents, friends, and the target person him- or herself) the opportunity to perceive and to enjoy an improved quality of life

25. Goals of PBS • Secondary goal: • To render problem behavior irrelevant, inefficient, and ineffective by helping an individual achieve his or her goals in a socially acceptable manner, thus reducing, or eliminating altogether, episodes of problem behavior

26. Characteristics of PBS • Comprehensive lifestyle change and quality of life • Life span perspective • Ecological validity • Stakeholder participation • Social validity • Systems change and multicomponent intervention

27. Characteristics of PBS (cont.) • Emphasis on prevention • Flexibility with respect to scientific practices • Multiple theoretical perspectives

28. PBS: A Vision of the Future • Assessment practices • Intervention strategies • Training • Extension to new populations

29. Plan of Life: A Holistic Model of Habilitation • Treating single and multiple “problems” with single and multiple interventions • Traditional treatments—pharmacotherapy, behavior therapy, counseling and case management—limited positive outcomes in terms of quality of life enhancements • By themselves these interventions do not focus on making a difference to the whole person

30. Plan of Life: A Holistic Model of Habilitation • People are people • All people have strengths and limitations • Limitations are no disabilities • People have multiple needs, requiring multiple levels of service • Care that enhances quality of life must address multiple systems that the individuals are embedded in

31. Plan of Life: A Holistic Model of Habilitation • Focus should be on building and enhancing an individual’s strengths and wellness across multiple domains • Teach and give them experience in alternative methods of coping in the real world • Help them to be as independent as as possible without setting a priori limitations • This is a world of infinite possibilities!

32. Plan of Life: A Holistic Model of Habilitation • Linear models: • Involves history taking, assessments of specific presenting problems, case formulation, and development of problem-specific interventions • Emphasis is on understanding the individual’s “problems” and then developing a treatment plan or teaching program

33. Plan of Life: A Holistic Model of Habilitation • Transactional models: • Broader • Includes consideration of internal and external ecology • Does not take into account the layers of systems that impact people • Not formulated in terms of strengths • Focus on causal pathways across multiple domains

34. Plan of Life: A Holistic Model of Habilitation • Holistic model • Person navigates daily life in layers of contexts that are determined by the individual, by people who care for the individual, and systems that provide the framework for such care • Person’s internal and external environments (biological, psychological, social, and cultural) determine transactions in life

35. Plan of Life: A Holistic Model of Habilitation

36. Plan of Life: A Holistic Model of Habilitation

37. Plan of Life: A Holistic Model of Habilitation

38. Plan of Life: A Holistic Model of Habilitation

39. Plan of Life: A Holistic Model of Habilitation

40. Plan of Life: Working with the Whole Individual • Extending the vision: The wellness model • Plan of Life (PoL) is an approach that encompasses within one system and one set of documents everything an individual needs for enhancing quality of one’s life—from womb to tomb

41. Holistic Model in Practice • Begins with the adoption of a philosophy of abilities, a strengths perspective, and the co-existence of strengths and limitations • Development of a Plan of Life (PoL) for the individual • Implementation of the PoL

42. The Plan of Life (PoL)