IMPLEMENTING POSITIVE BEHAVIOR SUPPORT WITHIN ORGANIZATIONS SERVING INDIVIDUALS WITH ASD AND IDD Bob Putnam, Ph.D., LABA, BCBA-D Shannon Barry, Ph.D., NCSP Catherine Rossi, Ph.D.

Thanks to: • Rob Horner • George Sugai • Tim Lewis • Dean Fixsen • Don Kincaid • Lauren Solotar

Service Locations

Facts about the May

1955 2016 • # of Programs 1 140 • # of Residences 0 90 • # of States 1 11 • # of Staff 65 2036 • # of Individuals 36 5859 Served Annually

Four Divisions of May Institute

• Educational Services – Five Private Schools – 13 Community-Based Residences

• Adult Services – Six Day Programs/Vocational Programs – 82 Community-Based Residences – Shared Living

• Consultation Services – School, Home-Based and Early Intervention Services – Home and Center-Based ABA Services to Military

Families across the US (14 States) • Behavioral Health

– Three Clinics – Day Treatment – Children's Therapeutic Afterschool Program

May Institute Mission

• May Institute proudly serves individuals across the lifespan with autism, developmental disabilities, intellectual disabilities, neurological disorders, behavior disorders, and mental illness to promote independence, choice, dignity, and respect. We provide compassionate and caring educational, therapeutic, habilitative, and consulting services grounded in evidence-based practice.

Applied Behavior Analytical

• May Institute was the first nonprofit human services organization in the country to receive top national honors from the Society for the Advancement of Behavior Analysis (SABA) and the Association for Behavioral and Cognitive Therapies (ABCT).

• The Institute received the 2005 Outstanding Training Program Award from ABCT and the 2007 Award for Enduring Programmatic Contributions in Behavior Analysis from SABA.

• Almost 100 BCBAs

Improvement in Services

• How can we improve… –Effectiveness –Efficiency –Quality

Agencies as Effective Organizations

“Organizations are groups of individuals whose collective behaviors are directed toward a common goal & maintained by a common

outcome” (Skinner, 1953, Science of Human Behavior)

Common vision &

objectives Common language

Common experiences & routines

Quality leadership & coaching

PBIS is

Framework for enhancing adoption & implementation of

Continuum of evidence-based interventions to achieve

Quality of life & behaviorally important outcomes for

All individuals

Primary Prevention: System-wide Wide Systems for All Indiviuals, Staff, & Settings

Secondary Prevention: Specialized Standardized Systems for Individuals with At-Risk Behavior

Tertiary Prevention: Specialized Individualized Systems for Individuals with High-Risk Behavior

CONTINUUM OF SYSTEM-WIDE INSTRUCTIONAL & POSITIVE BEHAVIOR SUPPORT

ALL

SOME

FEW

Response to Intervention

PRACTICES

Supporting Staff

Behavior

Supporting Individual Behavior

OUTCOMES

Supporting Quality of Life and Prosocial Skills

Supporting Decision Making

Emphasize: 4 Integrated Elements

Quality of Life

• We aim to provide environments that promote – wellness – happiness – self advocacy – active engagement

• for ALL individuals, through

universal systems, practices, and routines.

PRACTICES

OUTCOMES

Data Based Decision Making

Problem Identification Identify the issue

Problem Analysis Develop a hypothesis

Discuss and Select Solutions

Develop an action plan

Plan Implementation Implement the action

plan

Plan Evaluation Determine if it’s working Collect

and Use Data

Team Initiated Problem Solving (TIPS)

Implementation Levels

Agency

Division

Program/School

Individual/Student

Where Do You Begin?

• Commitment from President/CEO • Build readiness • Develop a Board Approved PBIS Strategic Plan • Build data systems that allow you to make data

based decisions around – Treatment fidelity – Person outcomes

Agency-Wide Representative Leadership Team

Systems: Teams

• Agency-wide Leadership Team • Universal Program Team (Tier 1) • Intensive Systems Team (Tier 3) • Individual behavior support / clinical team

Systems: Coaching and Training

• Internal professional development (“PBIS Academies”) for both divisions – Facilitated by internal agency-level PBIS coaches and

agency leadership

Primary Prevention: System-wide Wide Systems for All Indiviuals, Staff, & Settings

Secondary Prevention: Specialized Standardized Systems for Individuals with At-Risk Behavior

Tertiary Prevention: Specialized Individualized Systems for Individuals with High-Risk Behavior

~80% of Individuals

~15%

~5%

CONTINUUM OF SYSTEM-WIDE INSTRUCTIONAL & POSITIVE BEHAVIOR SUPPORT

ALL

SOME

FEW

Response to Intervention

Universal (Tier 1) Supports

• Universal, system-wide standards and expectations

• Universal, system-wide practices (ABA) – Teaching – Reinforcement – Correction

• Ongoing data collection procedures

• Planned environmental design • Treatment integrity check

ALL

Purpose of Tier 1

• To provide environments that promote happiness, wellness, engagement, and self advocacy for ALL individuals, through universal (program/school-wide) systems, practices, and routines and data based decision making.

• To establish and maintain universal standards that meet the needs of all students through implementation of evidence-based practices and ongoing data-based decision-making.

Universal Supports

• Universal supports are intended to improve quality of life by ensuring there are: – Evidence-based practices implemented across all

individuals and settings – Agreed upon routines and standards that support

improved outcomes for all individuals – Sensible expectations in all settings – Social appropriate behavior is reliably encouraged – Individuals are given choices and have ample

opportunity to engage in preferred activities, and – That staff are caring and skilled in their work

Tier 1 Data-based Decision Making

Are interventions, systems, and practices implemented with fidelity?

What systems, practices, and routines do we have in place universally, that will reach all of our individuals?

Is what we have in place effective for most of our individuals?

Overall, are individuals’ behavior improving, staying the same, or getting worse? Have they acquired skills?

Are there trends or patterns across all our individuals’ behavior?

Where and when are challenging behaviors most often occurring? What are the most common behaviors?

ALL

Systems Implementation and Monitoring: Tier I Tiered Fidelity Inventory (IDD)

What systems, practices, and routines do we have in place

universally, that will reach all of our individuals?

Are interventions, systems, and

practices implemented with fidelity?

Incident Report and Behavior Trend Analysis

• Purpose: To have an easy and efficient way to input, aggregate, disaggregate and analyze incident data patterns across the agency, as well as, by individual in an electronic format.

Is what we have in place effective for

most of our individuals?

Are there are trends or patterns

across all our individuals’ behavior?

Where and when are challenging behaviors most often occurring?

What are the most common behaviors?

Behavioral Incident Data-based Decision Making The “Big Five”

How often are problem behaviors

occurring?

What are the major problem

behaviors?

Where are the major problem

behaviors occurring?

When are the major problem

behaviors occurring?

Who is responsible for

the major problem behaviors?

Incidents per

month

Incidents per

behavior

Incidents per time of day and day

of week

Incidents per

location

Incidents per

individual

Incident Report Data-based Decision Making

• What do our “Big Five” data tell us? What can we do to prevent incidents from occurring? – Re-teach routines to individuals – Provide active supervision during those times – Acknowledge expected behavior – Train staff – Monitor specific individuals through more intensive team

Communication Screening

• How do individuals communicate?

• Do they have access to their communication system?

Universal Standards -- Communication

• Training and setting of expectations for management

• Mandatory re-training of direct staff regarding communication rights, Total communication, and Functional communication

• Review and augmentation of data tracking process • Operational supports (e.g. charging stations,

battery packs, revised procedures, icon stores, etc.)

Meaningful Engagement

• Are individuals actively engaged in activities that are meaningful to themselves and/or the environment?

• How often are individuals actively engaged in meaningful activities?

Universal Team: Adult Services

• Staff manager • Clinical staff • Direct care • Other relevant staff • Individual(s) • Family member(s)

Quality of Life

• Wellness: Physical and dental visits, Medications, BMI

• Happiness: Consumer satisfaction survey, Preference assessments

• Engagement: Play Check, Direct assessment

• Self-advocacy: Communication screenings

Tier 1 / Universal Plan

• Common purpose and approach to practice • Clear set of positive expectations & behaviors • Procedures for teaching expected behavior • Continuum of procedures for encouraging expected

behavior • Continuum of procedures for preventing and

discouraging inappropriate behavior • Procedures for on-going monitoring & evaluation

Tier 1 Expectations: Adult Day Program

Universal Team: Educational Services

• Administrator • Clinical staff • Educational staff • Other relevant staff • Family member(s)

Needs Assessment

Quality Indicators of Effective Supports • Instruction in areas related to core

deficits of autism • Curriculum and Instruction –

Academics and Specials • Communication and Interaction • Behavior Supports • Systems / Infrastructure • Relationships and Interaction

Needs Assessment

• Each school selected who they wished to complete the assessment , primarily clinical leadership teams and major stakeholders at each building

• Identified top 3-5 priorities for each building including: – Quality supervision of staff and improved staff training – Identifying community engagement opportunities – Generalization of skills across settings and transferring

stimulus control – Ensuring students are workings towards appropriate

goals and target behaviors

Needs Assessment

• Next Steps: – Customizing assessment for each school’s specific

needs – Expanding assessment to include community and

residential settings – Developing opportunities for caregivers to provide

feedback

Tier 1 in School

3 School-wide expectations were pulled from the mission statement

Staff and Family Language • Promote Educational

Success • Foster a Safe

Learning Environment

• Respecting Our Community

Student Language • School Success • Safety • Respect

Intensive (Tier 3) Supports

• High risk • Individualized strategies,

interventions, and practices • Intensive teaching,

acknowledgement, and correction procedures

• Frequent monitoring and data analysis, and treatment integrity

FEW

Tier 3 System

• Purpose: To provide a venue for teams to systematically analyze behavioral data, make decisions based on those data, and monitor individuals’ progress

• Goal: To prevent problem behaviors by using data based decision making.

• Objective: To find the simplest solution that will make the biggest change in the behavior problem

Tier 3 Data-based Decision Making

What do we have in place for our most intensive population? And are the systems and practices implemented with fidelity?

Is what we have in place effective for those with high risk behavior?

Are interventions implemented with fidelity?

Are there trends or patterns across those individuals’ behavior?

Overall, are individuals’ behavior improving, staying the same, or getting worse? Have they acquired skills?

Tier 3 Team

• Administrator/operational expertise • Clinical staff • Educational staff • Program staff • Behavioral expertise

Tier 3 Team System Meetings

• Each person is discussed during the meeting for no more than 2 or 3 minutes.

• Graphs of the daily frequency of no more than 3 of their most challenging behaviors over the past 60 days are reviewed.

• Determine current trends by using trend line and/or mean frequency per day of behavior • Decreasing trend/Behavior improving (+) • About the same/No change in behavior (0) • Increasing trend/Behavior not improving (-)

• Decisions are made as to what should be done to address the problem behaviors that are not improving • Develop an action plan

Data Collection Measures

• Individual-specific data and graphs – Excel© graphs displayed for each student and each Tier 3

behavior reviewed • Center- and Agency-wide data and graphs (incident

reports) – Center-specific data presented at Tier 3 meetings – Division and Agency-wide data shown at PBIS Academies

• Quarterly Tiered Fidelity Inventory (TFI) – Adapted slightly from survey (PBIS Apps) to fit our

population – Three consecutive quarters of 80% implementation Æ

annual completion

Systems Implementation and Monitoring: Tier 3 Tiered Fidelity Inventory (TFI)

What do we have in place for our most

intensive population? And are the systems and practices implemented with fidelity?

Are interventions, systems, and practices implemented with fidelity?

Data Based Decision Making

Modification: Some change needs to be made • FBA • Preference

assessment • Medical • Treatment integrity Monitor: Continue to observe for change

Tier 3 Inclusion Criteria: Educational Services

• Student has been reviewed using DESE hold criteria (2 holds in a week) for at least 2 weeks within a calendar month

• Students who show high intensity, low incidence or other dangerous/problematic behaviors, but not included within DESE review whose team decides is clinically appropriate for higher level of review

• Students identified as clinically appropriate for higher level review for behaviors that do not pose an acute but long term risk (e.g. pervasive lack of progress, flopping for most of day, etc.)

• The student will go on Tier 3 for the setting in which the holds occur (specifically school vs. residential setting)

Tier 3 Exclusion Criteria: Educational Services

• Multiple of the same event or hold happening within single episode or single day

• Student cannot be excluded for 2 consecutive months

• Decision to exclude students based on above criteria should be made by consensus of Tier 3 team at Tier 3 meeting

• Clinical Directors will compile list of students who will possibly qualify for Tier 3 and will send list of names to Tier 3 team to discuss at meeting

Tier 3 Exit Criteria: Educational Services

• Three straight months of progress (improvement in behavior/s)

• If a student has been monitored at Tier 3 for 3 consecutive months and no longer meets inclusion criteria.

• This exit criteria is only implemented when deemed appropriate by consensus of Tier 3 team.

Criteria for Placement in Tier 3: Adult Services

• The individual has required 2 or more physical holds within a 24-hour period or over a 30 day period to insure their safety or that of others

or • The individual has engaged in behaviors that are

dangerous to themselves or others on a regular basis, not necessarily requiring physical holds.

• The individual has had long standing behavior problems which has not been responsive to current interventions

• The most frequently recorded behavior problems are aggression, self-injury, elopement, and property destruction.

Tier 3 Outcomes

•20 individuals •4 females, 16 males •All are diagnosed with ASD

•14 have additional diagnoses including Down’s Syndrome, PTSD, TBI, and Schizoaffective Disorder

•All attend and/or live in May Institute day and residential programs

Lessons Learned

• Obtain commitment from agency leadership • Focus on your strengths • Use data for problem-solving to assess fidelity &

impact – Assume continuous improvement is essential for

sustainability

• Build the systems (team structure, policies, data sources) that support high fidelity implementation

• Invest in scaling-up durable applications of effective practices

bputnam@mayinstitute.org sbarry@mayinstitute.org crossi@mayinstitute.org