Evaluate, Collaborate, CapacitateVictoria Hatch B.A. PG Dip

Patricia Newman, MS, CBIA, BCBA, NYS-LBAPaul Rogers BCBA, WA-LBA

• Diagnostic Priority and Funding• The metaphorical “cliff”:

• Discontinuity of evidence based, structured services

• Risks

• Regional accessibility- NY

• Learning History: Assess, Teach, Establish• Personal Development: Baseline, Socially Significant and

Functional/Attainable Outcomes• Choice and Level of Independence: Safety, PCP, Least Restrictive,

Individual Rights & Choice• Provider Networks: Structure of Support, Change/Loss/Growth• Compliance Standards: CI, PCP, Billing Standards

• Enhancing Adult Supports• Effective interventions and teaching methods through

adherence to the ABA model: Globalized Approach• Teaching Methodologies• Behavioral Interventions• Data Collection, Monitoring, and Sharing • Sensory Integration • Collaboration • HRC/PCP• Training

• ABA in training• Enhancement of basic training modules to those

based on the 4th Ed. Task List (BACB)• Fundamentals/Foundations • Topic Specific • Individual Specific• Data Driven Decision Making• MOs and Schedules of Reinforcement

• Measurement and Monitoring

• Competency Measures: Objective outcomes• Pre and Post-Test Examinations • Visual Analysis of Data

• Future Training Needs• Critical information for managers

• Observations and Monitoring• Reports: high reliability and validity• Standard Deviation curve• Recommendations, Signatures, Transparency• Frequency• Incentives

Avg Site Score-Pre

Avg Site Score-Post Avg % Change

Locust n= 11 60 87 45%Belmont n= 8 54 81 50%Katonah n= 7 60 75 25%Day Pgm n= 10 53 76 43%Waterbury n= 4 63 81 29%STR n= 1 56 67 20%Hayden n= 2 64 81 27%Nursing n= 1 50 100 100%

Total n= 44 57.5 81 44%

Program Pre-Test Post-Test % Change3 Locust 67 89 33%4 Locust 56 83 48%5 Locust 56 78 39%6 Locust 44 83 89%7 Locust 56 83 48%8 Locust 61 83 36%9 Nursing 50 100 100%

10 Hayden 72 83 15%11 Hayden 56 78 39%12 Katonah 72 89 24%13 Katonah 50 72 44%14 Katonah 78 72 -7%15 Katonah 44 56 27%16 Katonah 72 78 8%17 Waterbury 61 94 54%18 Belmont 61 78 28%19 Belmont 61 78 28%20 Katonah 56 100 79%21 DayHab 89 100 12%22 Belmont 61 100 64%23 Belmont 61 83 36%24 Belmont 50 72 44%25 Belmont 44 78 77%26 Locust 50 94 88%27 Locust 72 89 24%28 Waterbury 72 89 24%29 Waterbury 56 72 29%30 DayHab 28 61 117%31 DayHab 33 67 100%32 DayHab 61 89 46%33 DayHab 61 83 36%34 Locust 67 94 40%35 Locust 67 89 33%

36 Locust 67 94 40%

Year Number of Visits

Number of Individuals

Necessitating Visits2016 21 6

2017 11 6

2018 3 1

Emergency Room Visits Due to Behavioral Challenges

Fading Individual Restrictions

SCIP interventions according to approved

hierarchy in BSP

Reliance on a BSP for behavioral management

Overcorrection procedures

Medication prescribed for behavioral management

Heightened staffing ratios/ level of

supervision

Plans to contact EMS in the event of significant behavioral issues with

Door chimes Incorporation of ability to stay home alone

Behavioral interventions formerly necessitated due to an individual’s

communication deficit, causing significant

behavioral challengesDoor/cabinet/van or

car/refrigerator/household item locks

Incorporation of ability to travel independently

Use of adult undergarments/chucks

Based on Data collected from the CMCS Human Rights Committee and Program Team, between January 2017 and

June 2018 a fading of restrictions has been documented for 30 of the 99 individuals who receive residential services at CMCS.

Such restrictions include but are not limited to the above

The above data indicates the number of Emergency Room (ER) visits per year for individuals receiving

services at CMCS, both residentially and at day program. The data reflects ER visits which were

initiated from the residence or day program setting. This data does not include statistics regarding ER

visits that originated when the individual was under the care of another party, such as a family member. Further, this data does not reflect visits to an Urgent

Care or similar facility.

Instances of Physical Aggression 5/2016-5/2018

0

100

200

300

400

500

600

0

2

4

6

8

10

12

14

0 5 10 15 20 25

Ave

rage

PA

per

mon

th

Month

Average PA per month

Linear (Average PAper month)

• Through the demonstration of attaining measureable outcomes:

• ABA IRAs• LOIs• DH/SEMP • Consultancy• Community Supports and Collaboration• Education/Certification• Programmatic Expansion of ABA Training/Practice• Revenue Development• Recruitment

• Responding to the need: • 1st ABA ARS program in NYS

• Locust Rd Enhanced IRA, Ossining NY (2011)

• History and Transition• EI-ABA Programming• CRS • Home Based Programming• ARS ABA Programming

“ABA adult services have saved Jack’s life. Otherwise he would be in a psyche ward on meds in my opinion. It has allowed him to go into the community and be part of [it], enjoy recreation, volunteer in the community, learn new skills like going to the movies, and has helped to reduce his behaviors. The structure

has allowed him to learn new skills like cleaning and landscaping so that he can finally do things that people in the “normal community” do and be seen by others as a valuable,

contributing member of society.” -Jack’s Mom

• Behavior and Diagnoses• SIB, PA, Elopement, T (F/D)

• Diagnoses• Autism• Impulse Control D/O• Severe ID• PICA• Mixed E-R Language D/O• Mood D/O- 2016/2017

“My guess is that Jack has always been bi-polar or had anxiety disorder and/or OCD as well as autism and we were always just treating the autism. Once we introduced the correct meds for the mood disorder as well he is now a different person. But he never would have learned any skills, generalized skills and behavior, or kept behavior rates

lower and learned to generalize without ABA.” -Jack’s Mom

• Progress and Success• Functional Communication• Community Integration• Socialization Skills• Lessening of Restrictions• Reduction in Medication• Development of Functional Skills

• Volunteering• SEMP• Progress in Residential/DH goals

“He has become more social and connected and more independent and able to actually have an inclusionary life. His communication

skills have increased such as using an iPad to speak in full sentences . And he has acquired vocational skills and maybe someday will even

work.” -Jack’s Mom

07/01/2016- 12/31/2016 01/01/2017- 06/30/2017 07/01/2017- 12/31/2017 01/01/2018- 06/30/2018 06/30/2018- 12/31/2018

SIB Object 395.00 134.00 101.00 126.00 40.00SIB Hand 3661.00 2001.00 1236.00 1908.00 497.00Tantrum 800.00 433.00 387.00 450.00 69.00Tantrum(D) 9498.00 2837.93 2120.67 2194.79 360.00AGG 49.00 59.00 38.00 45.00 0.00SCIP 23.00 15.00 1.00 4.00 0.00

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

7000.00

8000.00

9000.00

10000.00

07/01/2016-12/31/2016

01/01/2017-06/30/2017

07/01/2017-12/31/2017

01/01/2018-06/30/2018

06/30/2018-12/31/2018

SIB Object

SIB Hand

Tantrum

Tantrum(D)

AGG

SCIP

0.00500.00

1000.001500.002000.002500.003000.003500.004000.00

07/01/2016-12/31/2016

01/01/2017-06/30/2017

07/01/2017-12/31/2017

01/01/2018-06/30/2018

06/30/2018-12/31/2018

SIB Hand

SIB Hand

0.0050.00

100.00150.00200.00250.00300.00350.00400.00450.00

07/01/2016-12/31/2016

01/01/2017-06/30/2017

07/01/2017-12/31/2017

01/01/2018-06/30/2018

06/30/2018-12/31/2018

SIB Object

SIB Object

0.00100.00200.00300.00400.00500.00600.00700.00800.00900.00

Tantrum

Tantrum

0.001000.002000.003000.004000.005000.006000.007000.008000.009000.00

10000.00

Tantrum(D)

Tantrum(D)

2012 2013 2014 2015 2016 2017 2018SIB Oject Avg/Month 28.60 14.80 47.00 66.00 59.00 19.50 13.00SIB Hand Avg/Month 460.25 313.00 444.00 292.00 440.00 270.00 200.00Tantrum Avg/Month 103.00 44.50 114.00 72.00 103.50 68.00 43.00Tantrum(D) Avg Min/Month 234.30 254.20 374.00 192.00 960.00 413.25 212.00AGG Avg/Month 16.50 19.75 25.00 9.30 5.30 8.00 3.75SCIP Avg/Month 5.80 2.50 2.75 2.30 2.30 1.30 0.30

• Progress and Success• Functional Communication• Community Integration• Lessening of Restrictions• Reduction in Medication• Development of Functional Skills

• Volunteering• SEMP• Progress in Residential/DH goals

• A Collaborative Process• Evidence Based Practice• Empowering Stake Holders• Reducing Dependence on DSPs

Paul Rogers BCBA LBASchool Therapist

Northwest School of Innovative Learning ,Seattle Washington

• Highly individualized, evidence-based, informed by:▪ Family Systems Therapy▪ Behavior Analysis▪ Constructional Approach▪ Positive Behavior Support▪ Human Performance Technology

• Principles of Family Foundations:▪ Collaboration▪ Focus on strengths ▪ Building optimism▪ Capacity building▪ Individualization ▪ Trusting relationships▪ Maintaining boundaries

• Initial assessment conducted Dec. 2013 when she was 16. Now 21. • Diagnosis: Autism, medical complications in utero led to additional intellectual

disability. • Lives at home with parents and twin sister who shares Autism Diagnosis.• Severe problem behavior: Aggression, Self-injury, Property Destruction,

Disrobing, Yelling. • Full hand over hand assistance required for daily self-care and household

routines. • History of unsuccessful behavioral interventions from other providers.

• Follow a schedule independently• Manage a schedule independently• Wipe table• Fold towels, shirts, pants• Unload dishwasher• Sort silverware• Unload and put away groceries• Put away clothes• Vacuum • Put on shoes• Go for a walk (of up to a mile)

• Shred paper• Wash hands• Use the bathroom (#1)• Take a shower• Follow a leisure time schedule independently• Ride in the car• Enter the house after a car trip• Put away laundry• Wait in a line• Play a simple board game• Identify and clean dirty area of surface

• Hadn’t considered questions like• How will I interrupt her preferred activity to get her to do work?• What will happen if we have to go out of order? • What if I am missing something she needs or I’m not ready when she is?• How will I manage problem behavior in this situation?

• Parent coaching sessions mired in comfortable work around the table.

• Teaching new routines was the work of the therapists.

• Taught key skills (accept disruption to preferred, respond flexibly to problems encountered during nonpreferred activities)

• Built parent and caregiver participation into the mastery criteria for our acquisition routines.

• Used parent coaching sessions to plan next routine based intervention for ABA sessions and to create topical interventions using the same template (e.g. Drop off at respite home)

• Began looking for the right routine for parents to assume leadership roles.

• Picked a goal no one believed that we could meet. • Guided parent participation to develop plan over several visits. • Took everything we know about Kelli and organized it in service of this

one goal. It became an annotated tutorial on setting up a routine based intervention and included:▪ Convening of home, school, medical, and ABA teams▪ Group discussions about values and their link to action▪ Formal roles for parents and team members based on strengths▪ Scripts, role plays, fidelity checklists, daily data collection▪ Public recognition of Kelli’s success, and group contingency for milestones

reached.

Jan 22, 20173 opp, 9 min(total)

June 9, 20173 opp, 140 min (total)

• Set table before dinner (~20 step routine)▪ Designed together for only family to use. Over several coaching sessions,

taught backwards chaining and embedding prompts into the environment (e.g. napkins)

• Night time routine from dinner to bedtime▪ Meet at home once with parents and brother to rewrite evening routine using

RBI template. Assign roles, create schedule, mix in self-care, vocational skills, and dance parties with parents.

• Meal time routine• Serve self-food at meal time, take dishes to sink when, clean table where

seated, initiate evening schedule.• Originally a dinner time extension of set table routine. • Parents worked together to design and implement without any assistance.• Extended to other meals as well (even though table is only set before dinner).

• Breakfast• Incorporated successful elements of dinner routine as well as teaching Kelli to

make toast.*

• Supermarket trips▪ Used a changing criterion design to work their way up to purchasing an item.▪ Planned and executed solely by parents until they trained caregivers.

• Safeway-McDonalds-LA Fitness ▪ Daily trips to shop, get a milkshake, and then hit the gym. ▪ Parent design, Parent probe + initial teaching, one Coach ride along ▪ Parents taught respite care-Respite care adapt and implement.▪ Nov. 2018. Kelli was spending long enough in the gym to do 20 sit ups.

• Taught Kelli routines. Taught routines according to a routine. Taught parents to see much of life as a routine of routines that could be taught according to a routine.

• Getting parents involved harnessed their strengths and improved interventions as it built their skills and their confidence.

• With each routine taught, key strategies were identified and added to the team’s repertoire. ‘Things that work,’ organized using RBI form.

• ‘Pivotal’ routine demonstrated that even big challenges can be addressed by teaching little skills. In this case, skills taught to parents.

• Parents began generating from there.

Victoria Hatch B.A. PG DipCBI Consultants

Vancouver British Columbia

• CBI Consultants (Communication, Behaviour and Instruction) has been providing professional support services for a variety of individuals since 1988

• CBI has supported over 10,000 individuals and their teams in Positive Behaviour Support, Lifestyle Development, Functional Behaviour Assessment, and/or Customized Employment

• CBI also provides individual, team, and agency wide training and has expanded to add a Technical Training and Assistance Centre

• CBI Supports individuals across the province of British Columbia, the country of Canada, and has recently expanded worldwide providing direct consultation and training to China, India and Japan

• Often we are building PBS teams from the ground up• Staff change over is high (difficulty with gaining staff due to high cost

of living in Vancouver)• Building team capacity-identify and support a key trainer is our

model-• Data collection is difficult (and occasionally the inter rater reliability is

low)• social validity is not always easy to assess and maintain due to the

above

• Videos of strategies - library created• Or created by the team• Online training modules• Write strategies- create BSP with the “big Three”

▪ Scheduling▪ Choice▪ Get a life (based on the work of Todd Risley and Shalocks QOL )

(Malette, P., Miranda, P., Kandborg, T., Jones, P., Bunz, T., Rogow, S., 1992)

a) Initial selection of personnel with the skills to conduct assessment, instruction, and behavior support;

b) Initial and ongoing training needed for families, teachers, and employers; c) Coaching and performance feedback that is so critical to matching effective

practices to unique contexts;d) Data systems that help guide effective decision making through the support

process; ande) Establishment of administrative capacity to support durable, efficient, and

scalable implementation

Horner & Sugai 2018)

CBI’s movement forward includes the 4 main items noted in Horner and Sugai 2018) where they indicate need for:

▪Measure what we value▪Conduct research ▪Focus on systems that are needed for effective practice ▪Document the Implementation process

• Browning-Wright, D., Mayer, G.R., & Saren, D. (2006). The behaviour support plan quality evaluation guide – Version II. Retrieved October 30 2018, Available from http://www.pent.ca.gov/beh/qe/bipscoringrubric.pdf [accessed 30 October 2018].

• Dunlap. G., Hieneman., Knoster.T.,Fox.L., Anderson. J., & Albin. R. (2000) Essential Elements of Inservice Training in Positive Behavior Support. Journal of positive behavior interventions, 2 (1) , 22-32.

• Hieneman. & Dunlap. G. (2000) Factors Affecting the Outcomes ofCommunity-Based Behavioral Support. Journal of positive behavior interventions, 4 (3), 161-169.

• Hieneman, M., Yeagley, M., Cessna, T., Smith-Kong, T., Downs, H., Fazzio, D., Spiker, S., & DeFranco, R. (2015) PBS quality of Life Questionnaire. Available from https://hcpbs.org/practical-resources-tools/resources-quality-of-life/ [Accessed February 11, 2019].

• Horner. R., & Sugai.G. (2018) Future Directions for Positive Behavior Support: A Commentary. Journal of positive behavior interventions, 20 (1), 19-22.