Implementation of PBIS in a Children’s Residential Mental Health Treatment Program

1. Implementation of PBIS in a Children’s Residential Mental Health Treatment Program Lisa Davis, LMFT, Clinical Director Eleanor Castillo, Ph.D., Director, Outcomes & Quality Assurance 3rd International Conference on Positive Behavioral Supports Reno, NV March 2006

2. Overview I. Description a. EMQ and Residential Services b. Population Served II. Context for redesign a. Overview of change process and changes implemented b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors b. Challenges V. Next steps

3. EMQ Mission and Vision • To work with children and their families to transform their lives, build emotional, social and familial well-being and to transform the systems that serve them. • EMQ will lead the nation in service excellence, innovation and social policy improvement for children and families.

4. EMQ Children & Family Services Chemical/Alcohol Dependency Education & Prevention In Home Family Treatment Sexual Abuse Treatment Foster Care-Professional Parent, ITFC Family Partnership Institute • Services in 18 California counties • Wraparound • Residential Treatment • Therapeutic Behavioral Services • School Based Mental Health Services • Mobile Crisis Intervention • Outpatient Treatment

5. Core Philosophy Consistent with the Child and Adolescent Service System Program Principles (CASSP) • Strengths Based • Family Centered • Community Based • Culturally Competent • Individualized • Natural Supports • Team Based/Collaborative • Persistence • Outcome Based

6. Agency-wide # of Youth(FY2004-2005)

7. EMQ Referral Sources (FY2004-2005) N = 2738

8. Residential Referral Sources(FY2004-2005)

9. Logic Model Program draws from the following theories: Positive Behavioral Intervention and Supports, Bronfrenbrenner, Love & Logic Parent Training Program, Family Finding Model of Catholic Community Resources, and systems theory

10. Residential Service Goals • Establish permanency for youth in a safe, loving and supportive family. • Provide 24-7 structure, supervision and therapeutic intervention. • Stabilize acute behaviors and improve daily functioning.

11. Residential Services Description • 4 RCL (Rate Classification Level) 14 cottages • Two units for children ages 6-12 years • Two units for youth ages 12-18 years • 3 are co-ed and 1 is all male • Each unit has capacity to serve up to 10 children

12. Staff Resources • Clinical Director • Clinical Program Manager • Clinician/Case Manager • Residential Cottage Supervisor • Milieu Activity Therapist • Psychiatrist • Educational Resources • Recreational Therapist • Registered Nurse

13. Array of Services • Academic support • Family Finding • Family Partner Services • Medical/Dental Assessment and Linkage • Recreational, Music and Art Therapy • Therapeutic milieu based on PBIS principles • Comprehensive assessment of all life domains • Family Therapy • Individual Therapy • Intensive case management and linkage to community activities • Nursing services • Psychiatric Assessment and Treatment • Psychoeducational and psychotherapeutic groups

14. Cottage Structure • Schedule of activities • Points system • Level system • Incentive and behavior management system • Team meetings • Day treatment • Mental health model

15. Overview I. Description a. EMQ and Residential Services b. Population Served II. Context for redesign a. Overview of change process and changes implemented b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors b. Challenges V. Next steps

16. Residential Targeted Population • Children with Severe Emotional Disturbances • Youth who are experiencing: • Maladaptive response to trauma • Severe impairment in capacity to function in their daily activities • Psychotic features or dangerousness to self or others • Need repetitive, consistent interventions that structure their environments and teach adaptive behaviors • Many with co-morbid disorders (primarily mood disorders and behavioral disorders) • Need 24/7 supervision, support, and observation under clinical direction of a therapist and psychiatrist, to maintain safety

17. Youth Characteristics

18. Youth Characteristics(cont.)

19. Youth Characteristics(cont.)

20. Overview I. Description a. EMQ and Residential Services b. Population served II. Context for redesign a. Overview of change process and changes implemented b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors b. Challenges V. Next steps

21. Context for Change • Concern sited nationally regarding poor outcomes for residential services • Concern regarding the negative effects of congregate care for certain youth • High cost of services, particularly in context of diminishing resources • Effectiveness of community based services, which highlights the question of the need for residential services • Focus on the right for permanency and the result foster care has had on severing family connections • The need to re-conceptualize residential in thinking about services as a 24/7 clinical intervention versus an emphasis on a living environment

22. Why Re-design Residential Services? To implement evidence based services including PBIS, Trauma Focused CBT, and Parent Management Training To utilize residential services as an intervention, not as a placement To achieve improved outcomes Increase youth and family connections Develop sustainable community supports Ensure permanency for youth in a loving, supportive family To ensure consistent implementation of a strength based, needs driven, family centered, individualized and culturally relevant philosophy in all aspects of care To partner with families and ensure family involvement in all aspects of care Maintain families connection with their community and increase natural supports

23. SAMHSA’S Residential Best Practice Principles • Strengths imbedded in ALL aspects of care • Focus on resiliency and developmental needs • Families are full partners • Focus on permanency planning • Truly individualized and culturally competent • Focus on the need to be successful in community • Full integration of residential services into the community and continuum of services • Comprehensive developmentally appropriate assessments (psychosocial, trauma, physiological, cognitive, language, safety, etc.) • Use of specific evidence-based interventions • Respectful, strength-based relationships and interactions are acornerstone

24. The Role of Residential Services • In partnership with the family and youth, meet unmet needs with the goal of returning youth to the home and community as soon as possible. • Short-term stabilization when all other resources have been unable to maintain safety. • To provide short-term intensive services to sustain family stability and maintain permanency. The level of intensity of service supports accelerated healing and change. • Multidisciplinary assessment to understand the youth and family’s needs. • Frequent psychiatric intervention and observation to stabilize functioning and meet needs so that community resources can be effectively utilized.

25. Change Process • Work team approach with inclusive decision making • Established a leadership team • Well developed communication plan • Use of change methodology-Implementation Management Associates (IMA) • Business Case for Action • Charter • Use of quality improvement techniques • 3 phase change process: • Gathering data/information • Implementation • Evaluation

26. Redesign Work Teams

27. Redesign Work Teams

28. Phases of Change Process Phase 1 - Data Gathering • Focus groups with families and children • Staff questionnaires • Customer questionnaires • Reviewed 7 years of internal data • Literature review of Evidence-Based Practices • Benchmarking other residential programs • Attendance at “Best Practices” conferences

29. Phases of Change Process Phase 2 – Implementation • Implemented PBIS • Family Finding • Family Inclusion Practices and Procedures • Community Based Practices • Switch to Mental Health Model vs. Day TX. • Developed Transitional Services

30. Why PBIS? • Evidence in schools that approach creates pro social positive environments • Alignment with agency philosophy • Goodness of fit: congruent with behavioral approach already utilized • Focus on increasing quality of life, achieving broad goals and supporting portable skills • Use of a proactive and educative approach to support elimination of “control based” interventions including restraints • Eber, Sugai, Smith, & Scott (2002); Scott & Eber (2003 a & b)

31. PBIS Implementation Strategies • PBIS Overview Training for all staff • Consultant Role: • Observed each cottage to understand current operations, staff skills and knowledge and population • Provided 3 8-hour trainings for all 60 staff on development of Functional Behavioral Assessment and Behavior Support Plans • Between trainings staff practiced skills and brought plans back to each training

32. PBIS Implementation Strategies Training Model Booster Training Staff – FBA, BSP CPMs Directors Consultation Exposure

33. PBIS Implementation Strategies • PBIS implementation work team created to discuss operational issues (director, managers, program sups, clinicians, MATs and consultant) • Meet two times a month • Developed “Support team” • Consultant/Trainer provides bi-monthly consultation • Membership includes 4 line staff and 2 therapists • Consultant attended team meetings to discuss plans and provided booster trainings

34. PBIS Implementation Strategies • Management Infrastructure • Develop behavior and cottage management system • Reviewed past point and level system, develop new systems based on values matrix • Establish core values/expectations and settings • Develop universal rules • Provide consultation and problem solve barriers • Development of internal training capacity to sustain PBIS • Develop and adapt all program policies and procedures to reflect PBIS implementation

35. PBIS Implementation • Currently entering daily point sheets into SPSS database to analyze trends • Goal is to revise point and level system using newly developed behavioral goals and expectations and have point and level system support the positive values and expectations • Ultimate goal is to have staff enter daily point totals into the agencies electronic record system for each child at the end of each shift • This will enable real time analyses of data trends within each cottage

36. PBIS Implementation • Core values/expectations chosen • Respect, Safety, Responsibility and Cooperation. • Process of choosing settings • Examples are meal times, community time, family visits, hygiene, chores etc. • Translation from school based to residential based different • Settings activity based vs. physical environment • Accommodate 24-7 vs. school hours • Focus on daily living skills, participation in treatment program etc.

37. Overview I. Description a. EMQ and Residential Services b. Population served II. Context for redesign a. Overview of change process and changes implemented b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors b. Challenges V. Next steps

38. Living Situation at Exit

39. Reason for Discharge

40. Average Number of Runaways Per Month

41. Average Number of Restraints Per Month

42. Average Number of Assaultive Behaviors Per Month

43. Case Presentation 1: “Roger” • Male, 13 years old • Caucasian • Referred from The Dept of Social Services as a result of failed foster home placement and lower group home level • Primary Diagnosis- ADHD • Co-morbid diagnoses- ODD, Tourette’s

44. Case Presentation 1: “Roger” • Broad goals: Making and keeping friends • Strengths: Friendly, cares about others • Challenges: Low cognitive ability, no strong familial relationships • Target behaviors: hitting, kicking, throwing playground equipment • Baseline frequency- 6-10 times a day during activities • Types of data collected • Interviews with the Milieu Activities Therapist • Observations conducted by several staff • Record reviews

45. Case Presentation 1: “Roger” • Antecedents: When in a physical activity involving peers, specifically when there is down time or during a transition and he has easy access to sports equipment • Consequences: Usually staff attention for misbehavior and peer agitation • Hypothesized function: Self-stimulation or adult attention

46. Case Presentation 1: “Roger” • Proactive strategies • Keep tactile object in pocket to use during transition times • Engage in energy release prior to transitions • Educative strategies • Describe what happens when he throws an object without others awareness • Teach how to use equipment appropriately • Functional/consequence-based strategies • Earn sticker as a reward for positive behaviors; • Get more staff attention at bedtime if he uses equipment safely

47. Case Presentation 1: “Roger” • Outcomes of Plan: • Behavior has reduced to 1-2 times daily during activities • Increased more self esteem and enjoys physical activities more often • Improved peer interactions during physical activity • Other positive effects • Made one friend • Seeks positive attention from staff more frequently

48. Case Presentation 2: “Charles” • Male, 9 years old • Latino American • Referred from the Dept of Social Services • Primary Diagnosis: ODD • Co-Morbid Diagnoses: Depressive D/O NOS, Anxiety D/O NOS, Cognitive Disorder NOS, ADHD

49. Case Presentation 2: “Charles” • Broad goals: Decrease aggressive behaviors and make friends. • Strengths: Intelligent, cute, good sense of humor, strong sense of loyalty. • Challenges: Disrespectful of others feelings, rude and defiant. • Target behaviors: Telling others what to do • Baseline frequency- 15-20 times a day • Types of data collected • Interviews with the Milieu Activities Therapist, therapist, Foster Parent and Social Worker. • Observations conducted by several staff using ABC scatter plots. • Record reviews

50. Case Presentation 2: “Charles” • Antecedents: Interacting with peers and when others are getting negative attention. • Consequences: Looses points, staff engage with him/set limits and give time outs. • Hypothesized function: Attention seeking