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Integrating Individualized Interventions for Students with Mental Health
Challengeswithin a School-wide System of
Positive Behavior Supports
CMHACYMay 14, 2015Session 1-A
Lucille Eber Ed.DDirector, Midwest PBIS Network and
National PBIS TA Center [email protected]
Describe how interventions for students with mental health challenges can be efficiently delivered within a school-widesystem of Positive Behavior Supports.
Share examples of how individualized interventions, including function-based behavior plans, person-centered wraparound and RENEW plans, can be layered up from an effective school-wide PBS curriculum.
BIG Ideas for Today:
Putting outcomes for students with EBD
into the context of schoolsas systems to educate and support
ALL students.
Some “Big Picture” Challenges
• Low intensity, low fidelity interventions for behavior/emotional needs
• Habitual use of restrictive settings (and poor outcomes) for youth with disabilities
• High rate of undiagnosed MH problems (stigma, lack of knowledge, etc.)
• Changing the routines of ineffective practices (systems) that are “familiar” to systems
What has Changed Since……?
Braaten,S., Kaufman, J.M., Braaten, B., Polsgrove, L., and Nelson, C.M. (1988). The Regular Education Initiative: Patent Medicine for Behavioral Disorders. Exceptional Children, 55(1), 21-27
Knitzer, J., Steinberg, Z and Fleisch, B. (1990). At The schoolouse door. New York: Bank Street College of education
Wood, F. (1989) Students at risk. Supporting the growth of students with emotional and behavioral disorders. The Pointer, 33(4), 20-26
Peacock Hill Working Group, 1991
We Know the Practices that Work for Students with EBD…
• Proactive, strength-based; “set kids up” to experience success
• High rates of consistent, supported instruction; teach/practice/reinforce
• Predictable and consistent environments• Know unique “why?” for each student/problem• Contextual fit: Strategic use of natural supports, and
settings• Careful monitoring of data over time with ongoing
revisions to guide incremental improvements in quality of life
• Behavior support is the redesign of environments, not the redesign of individuals.
• Positive behavior support plans define changes in the behavior of those who will implement the plan. A behavior support plan describes what we will do differently.
Do ALL staff understand the context for effective behavior interventions?
It Takes a System…
…..that builds system capacity for advanced tiers
SupportingStaff Behavior
SupportingDecisionMaking
SupportingStudent Behavior
PositiveBehaviorSupport
SYST
EMS
PRACTICES
DATA
OUTCOMES
Social Competence &Academic Achievement ٭
Adapted from “What is a systems Approach in school-wide PBS?”OSEP Technical Assistance on Positive Behavioral Interventions and Supports. Accessed at http://www.Pbis.org/schoolwide.htm
Core Features of a Response to Intervention (RtI) Approach
• Investment in prevention• Universal Screening• Early intervention for students not at “benchmark”• Multi-tiered, prevention-based intervention approach• Progress monitoring• Use of problem-solving process at all 3-tiers• Active use of data for decision-making at all 3-tiers• Research-based practices expected at all 3-tiers• Individualized interventions commensurate with
assessed level of need
Primary Prevention:School-/Classroom-Wide Systems for
All Students,Staff, & Settings
Secondary Prevention:Specialized Group
Systems for Students with At-Risk Behavior
Tertiary Prevention:Specialized
IndividualizedSystems for Students
with High-Risk Behavior
~80% of Students
~15%
~5%
SCHOOL-WIDE POSITIVE BEHAVIOR
SUPPORT
PBIS Features
Module 1: PBIS TeamModule 2: Faculty CommitmentModule 3: Expectations and RulesModule 4: Lesson PlansModule 5: AcknowledgementModule 6: Discipline ProceduresModule 7: Data Entry and AnalysisModule 8: Classroom Behavior SystemsModule 9: EvaluationModule 10: Implementation Plan
Common Language
Expectations 3-5 overarching school-wide expectations
Behaviors/Rules specific tasks students are to do to achieve the school-wide expectations
Routines/Procedures methods or process for how things are done in non-classroom settings and each classroom
14
The change is an instructional processinstructional processWe change STUDENTSTUDENT behavior
by changingADULT behavior
Interventions = changes in staff procedures & practicesInterventions = changes in staff procedures & practices
How will we teach behavior?When will we teach behavior?
Kick-off events Teaching staff, students and families the expectations and rules
On-going direct instruction Data-driven and scheduled designed lessons Pre-correction Re-teaching immediately after behavioral errors
Embedding into curriculum
Booster trainings Scheduled and data-driven
Continued visibility Visual Displays – posters, agenda covers Daily announcements Newsletters
Guidelines
School-wide reinforcements are for every student Acknowledge the behaviorInclude the students in identifying possible
recognitionsRecognize students other than your own in common
areasRecognition closely follows the desired behaviorKeep it novel
Tier 1/Universal School-Wide Assessment
School-Wide Prevention Systems
SIMEO Tools: HSC-T, RD-T, EI-T
Check-in Check-out (CICO)
Group Intervention with Individualized Feature (e.g., Check and Connect - CnC and Mentoring)
Brief Functional Behavior Assessment/Behavior Intervention Planning (FBA/BIP)
Complex or Multiple-domain FBA/BIP
Wraparound
ODRs,Credits, Attendance, Tardies, Grades, DIBELS, etc.
Daily Progress Report (DPR) (Behavior and Academic Goals)
Competing Behavior Pathway, Functional Assessment Interview, Scatter Plots, etc.
Social/Academic Instructional Groups (SAIG)
Positive Behavior Interventions & Supports:A Response to Intervention (RtI) Model
Adapted from T. Scott, 2004
Tier 2/Secondary
Tier 3/Tertiary
Inte
rven
tio
nAssessm
en
t
Individual Student Information System (ISIS)
USDOE-OSEP Tertiary Demo Project
#H326M0060010
More Students Access Tier 2/3 Interventions When Tier 1/ Universal is in Place
7.94%
4.95%
0%
2%
4%
6%
8%
10%
Partially Implementing
(n=26)
Fully Implementing
(n=125)
% s
tud
en
ts
FY09 School Profile ToolStudents Accessing Tier 2/Tier 3 Interventions
Tier 2/Tier 3…..Changing Existing Systems
• Harder than starting from scratch• Schools think they are “already
doing it”… Need to “deconstruct” some existing
teaming approaches and practices Data not being used except to justify
placements
Examples of Ineffective Secondary/Tertiary Structures
• Referrals to Sp. Ed. seen as the “intervention”
• FBA seen as required “paperwork” vs. a needed part of designing an intervention
• Interventions the system is familiar with vs. ones likely to produce an effect (ex: student sent for insight based counseling at
point of misbehavior)
Example of Change that may be Needed
• “Groups” that are not evidence-based• Clinicians “seeing” students w/o clarity of
intervention and data to determine effectiveness
3-Tiered System of Support
Necessary Conversations (Teams)
Check-In Check-Out
Skills Groups
Group w. individual
feature
Complex
FBA/BIP
Problem Solving Team Meeting
Tertiary Systems Team Meeting
Brief
FBA/BIP
Brief FBA/BIP
Wraparound
Secondary Systems Team
Meeting
Plans schoolwide &
classroom supports
Uses process data; determines overall
intervention effectiveness
Standing team; uses FBA/BIP process for one student at a time
Uses process data; determines overall
intervention effectiveness
UniversalTeam
Meeting
Universal Support
USDOE-OSEP Tertiary Demo Project
#H326M0060010
Coordinator vs. Facilitator
Coordinator• Organizes and/or
oversees the specific interventions such as CICO, S/AIG & Group with Individual Features
• Roles include: scheduling meetings, review & collect data to share during team meetings, etc…
Facilitator• Directly provides
intervention support services to youth/families
• Roles include: meeting with students for CICO, running groups
USDOE-OSEP Tertiary Demo Project
#H326M0060010
USDOE-OSEP Tertiary Demo Project
#H326M0060010
Do Teaming Structures in your school(s) need to change?
Quick Reflection:
1. How many kids have been talked about at ‘______’meeting this year?
2. How many of those discussed got an intervention that you have data to indicate they got an intervention that is working?
Have you ever been at a meeting where you talked about one youth for an hour and at the end you were no closer to having effective strategies than when you started?
Did Henry “need” a restrictive placement?
Quick Student Example #1:Student w/EBD moves to new District
0
20
40
60
80
100
9/3 9/10 9/17 9/24 10/1 10/8
% o
f G
oa
l Ac
hie
ved
%of Daily Total CICO Points
Henry’s Daily Point Data for Behavioral Goals
Did Henry “need” a restrictive placement?
Or effective interventions?
Administrators Need to…
• Have knowledge of behavior support for Tier 2/Tier 3 to guide/lead any “corrections” needed.
• Know why a behavior plan may not be working and need to know how to “troubleshoot” a plan.
• Ensure that systems are in place and interventions are offered routinely and rapidly at all 3 tiers to allow ALL kids to be successful
Failed Interventions are Not Neutral
• They leave a residual effect…
Administrators Role…
• No intervention is administered w/o progress monitoring.
• The Special Education focus changes from “did we deliver the intervention?” to “did the student experience success/get better?”
• Ensure that “research based interventions ”always used; – don’t get to choose not to deliver interventions.
• Equip teachers to be confident to handle.
TIER 2/3: Intervention Examples, Decision-Rules and Tools
Check-in-Check-out (CICO)
• Merely an extension of Tier 1• Some get high frequency scheduled positive
contact with adults• Youth solicit the positive contact/feedback• Low effort for teacher if built on Tier 1• Need to have 7-12% accessing if it is to come
to be a routine in your school(s)• If you only have 1-2% on CICO, those are
likely to be kids who need more….
Why do you want 7-12% on CICO?
1. Kids who here-to-for would have gotten nothing (‘til they ‘got worse”) now get a positive boost of support (sea of ineligibility)
2. All teachers will expect that every day they will have kids cross their threshold who need higher rate of positive contact
3. Quicker/easier to support kids who need Tier 3
4. Structure to build transference and generalizing from Social Skills instructional groups and function-based behavior plans
Social/Academic Instructional Groups
Selection into groups should be based on youths’ reaction to life circumstance not existence of life circumstances (ex. fighting with peers, not family divorce)
Goals for improvement should be common across youth in same group (ex. use your words)
Data should measure if skills are being USED in natural settings, not in counseling sessions (transference of skills to classroom, café etc.)
Stakeholders (teachers, family etc.) should have input into success of intervention (ex. Daily Progress Report)
Choosing or Designing Group Interventions
Choose & modify lessons from pre-packaged material based on the skill needed for the group
and/or
Use already created universal behavior lesson plans or create lesson plans (Cool Tools) to directly teach replacement behaviors
Social Skills/Academic Instructional Groups:Key Points Resulting from ‘Innovation’
• Selection into groups based on youths’ reaction to life circumstance not existence of life circumstances ex. fighting with peers, not family divorce
• Goals for improvement common across youth in same group ex. use your words
• Data used to measure if skills are being USED in natural settings (vs. in counseling sessions) transference of skills to classroom, café etc.
• Stakeholders (teachers, family etc.) have input into success of intervention ex. Daily Progress Report
Daily Progress Report (DPR) Sample
NAME:______________________ DATE:__________________
Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors.
EXPECTATIONS1 st block 2 nd block 3 rd block 4 th block
Be Safe 2 1 0 2 1 0 2 1 0 2 1 0
Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0
Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0
Total Points
Teacher Initials
Adapted from Grant Middle School STAR CLUB
Daily Progress Report (DPR) Sample
NAME:______________________ DATE:__________________
Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors.
EXPECTATIONS1 st block 2 nd block 3 rd block 4 th block
Be Safe 2 1 0 2 1 0 2 1 0 2 1 0
Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0
Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0
Total Points
Teacher Initials
Adapted from Grant Middle School STAR CLUB
“Social & Academic
Instructional Groups”
Walk to classKeep hands to self
Use appropriate language
Raise hand to speak
Bring materials Fill out assignment
notebook
Daily Progress Report (DPR) Sample
NAME:______________________ DATE:__________________
Teachers please indicate YES (2), SO-SO (1), or NO (0) regarding the student’s achievement in relation to the following sets of expectations/behaviors.
EXPECTATIONS1 st block 2 nd block 3 rd block 4 th block
Be Safe 2 1 0 2 1 0 2 1 0 2 1 0
Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0
Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0
Total Points
Teacher Initials
Adapted from Grant Middle School STAR CLUB
Use your wordsUse deep breathing
Keep arm’s distanceUse #2 voice level
when upset
Ask for breaksSelf-monitor with
DPR
“Individualized Student Card After FBA/BIP"
QUICK Reflection
We Know the Practices that Work…
• Proactive, strength-based; “set kids up” to experience success
• High rates of consistent, supported instruction; teach/practice/reinforce
• Predictable and consistent environments• Know unique “why?” for each student/problem• Contextual fit: Strategic use of natural supports, and
settings• Careful monitoring of data over time with ongoing
revisions to guide incremental improvements in quality of life
We Know the System Features Needed to Support the Effective Practices…
• A Team unique to each individual child & family Blend the family/natural supports with the school
representatives who know the child best
• A defined Meeting Process Meet frequently and use data Develop, implement, review range of interventions
• Facilitator Role Bringing team together Blending perspectives; guiding consensus Systematic use of data (strengths and needs)
The person who is supposed to implement the strategy needs to be actively involved in designing it; or it probably won’t work!
Ownership & Voice: A Key to Intervention Design
Interventions…
Tier 3 Interventions
• Person-Centered (voice and choice)• Highly individualized (unique team per student)• Multiple Data Sources (add Tier 3 data- Perception data)
• Complex function-based behavior plans• Wraparound/RENEW/Family Focused Plans
Do All Staff Understand the Context for PBIS?
• Behavior support is the redesign of environments, not the redesign of individuals.
• Positive behavior support plans define changes in the behavior of those who will implement the plan. A behavior support plan describes what we will do differently.
Problem Solving Steps
Step 1: Problem Identification
Step 2: Problem Analysis
Step 3: Intervention Design
Step 4: Response to Intervention
Why is it occurring?
What’s the problem?
What are we going to do about it?
Is it working?
Setting Event Strategies
Antecedent Strategies
Teaching/ Instructional
Strategies
Consequence Strategies
Competing Behavior PathwayBehavior Intervention Plan
Neutralize/eliminate
settingevents
Add relevant & remove irrelevanttriggers
Teach alternative
that is moreefficient
Add effective & & removeineffectivereinforcers
Behavioral PathwaySetting Event
Days with Gym
Antecedent
Less structured activities that involve competition
Problem Behavior
Negative comments about activity and to peers leading to physical contact
Consequence
Sent out of P.E. class
Function
To escape setting
Brief Function-based Interventions
Setting Event Strategies•Add check-in before gym
Teaching Strategies•Teach social skills (getting along with others, friendship, problem solving, sportsmanship) •Teach how to approach gym teacher to ask for a drink of water to leave setting. •Teach student how to re-enter and continue with activity
Consequence Strategies Acknowledging/rewarding student when uses new skills (asking for a drink of water to leave, using respectful language with peers, being a good sport, etc..)
Antecedent Strategies•Behavior Lessons for all students about using respectful language with self and others and how to be a good sport •. More frequent activities with less focus on competition (parachute, 4-square, etc...)
•Pre-correct
Person-Centered Planning: Highly Individualized Tier 3 Intervention
WraparoundWraparound-based RENEW
Wraparound: A SOC Tool• Emerged from practitioners struggling to
implement SOC (grassroots)• Keep/bring youth home• Flexible, creative, non-categorical• Natural support networks• Community-based• Unconditional-Commit to “stay the course”• Let family voice guide service development• Non-traditional supports and services
What is Wraparound?
Wraparound is a process for developing family-centered teams and plans that are strength and needs based
• (not deficit based)
• across multiple settings and life domains.
Examples of Needs Statements:
• The student needs to feel adults and peers respect him.
• The student needs to feel happy about being at school.
• The parent needs to know her son is getting a fair shake at school.
• The student needs to be reassured that he can complete the work.
Implementing Wraparound:
Key Elements Needed for Success
• Engaging students, families & teachers• Team development & team ownership• Ensuring student/family/teacher voice
Getting to real (big) needs
• Effective interventions Serious use of strengths Natural supports Focus on needs vs. services
• Monitoring progress & sustaining• System support buy-in
Wraparound Skill Sets1. Identifying “big” needs (quality of life
indicators)• “Student needs to feel others respect him”
2. Establish voice/ownership 3. Reframe blame4. Recognize/prevent teams’ becoming
immobilized by “setting events”5. Getting to interventions that actually work6. Integrate data-based decision-making into
complex process (home-school-community)
Four Phases of Wraparound Implementation
I. Team Preparation- Get people ready to be a team- Complete strengths/needs chats (baseline data)
II. Initial Plan Development- Hold initial planning meetings (integrate data)- Develop a team “culture” (use data to establish voice)
III. Plan Implementation & Refinement- Hold team meetings to review plans (ongoing data
collection and use)- Modify, adapt & adjust team plan (based on data)
IV. Plan Completion & Transition- Define good enough (Data-based decision-making)- “Unwrap”
Similarities and Differences
What is similar and/or different to the existing systems, data and practicesIn your district/schools?
Quick Reflection
Ben’s Story September 2009, CICO started Mid October, 76% Reverse Request for Assistance November-community based mentor assigned December-Ben request to return to “psych” hospital
saying, “I can’t control myself” (has had three prior admissions)
December 5-Tier 3 team met. Recommended referral to wraparound based on following:
CICO average of 76% 30 Office Disciplinary Referrals 3 Out of School Suspensions At risk for alternative school placement At risk for out of home placement December 15 – Wraparound started with Ben and Barb
Moving Forward• In December, Ben began asking his mother if he
could be admitted to the hospital so he “could get better”. He was experiencing anger, thoughts of hurting himself and he was physically aggressive with classmates and peers. He was verbalizing “I can’t control himself.”
• Ben had three prior psychiatric hospitalizations (before coming to ‘G’ Elementary).
Child and Family Strengths• Ben’s Strengths identified in the first meeting included:
“Ben”: Smart, good at math, reading, writing and playing video games
Mom: Very organized He’s creative and enjoys drawing cartoons Teacher: writing and math;
• Family Strengths: Mom consistently takes “Ben” to his mental health
appointments. This might include getting the city bus for an hour ride, attending
an hour appointment, waiting another 30 minutes for the bus and then riding home and then bringing him to school.
Mom is an active participant at the school, follows through with suggestions.
MISSION STATEMENT: ‘A Happy Home’
The mission statement was developed by the team, Ben, and his mom.
Ben stated that his hopes were “he would yell less at home so that he would see more smiling from his family.” Mom agreed.
Wrap process builds on lower tiered interventions
At the first team meeting family agreed to:Continue CICOContinue mentoringContinue MH services Improved communication with Mental Health
FBA to be completed (home and school)Family YMCA (schedule present at LANS for
funding)
Child & Family Team Meeting Number 2
January 22
•Discussed improved behavior at home and school (not in physical fights at school, turning in his work, helping at home)
•Completed BIP using the FBA (help from the baseline SIMEO data)
•Planned next meeting and Ben wanted to invite mentor to the next meeting
3rd Child & Family Team Meeting
March 5, 2010:
•Reviewed strengths: celebrating that he walked away from two fights at school (he had never done that before)
• Team looked at data/ graphs and Ben led the discussion and interpreted the improvements for the group
•Needs in Ben’s words were that he “still had room to improve”. Ben pointed to areas on the graphs where he said he still needed to work on.
•Mom was going to bring electric bill so the social worker could continue to get YMCA family membership to address the needs (e.g. to do, social activities)
Data…
Tertiary Level “Coaches” Have to Help Establish Capacity (Fidelity) for Wraparound:
• Commitment of time• Commitment to “stay at table”• Willingness to regroup and be solution-focused
• No judging or blaming• Time for listening to stories• Time for venting, validating
• Establishing consensus• Voice of student/family in prioritizing • Establishing ownership
Building Fluency with Tier 3 Implementation through Training,
TA and Coaching
FBA/BIPWraparound
Wrap-based RENEW
Tertiary Interventions Phases of Tier 3 Coaching
Phase 1: Modeling - Coach models the desired skills and competencies
Phase 2: Support and Feedback - Coach provides support and feedback
Phase 3: Monitoring – Coach monitors to ensure fidelity
Primary Prevention:School-/Classroom-Wide Systems for
All Students,Staff, & Settings
Secondary Prevention:Specialized Group
Systems for Students with At-Risk Behavior
Tertiary Prevention:Specialized
IndividualizedSystems for Students
with High-Risk Behavior
80% of Students
15%
5%
SCHOOL-WIDE POSITIVE BEHAVIOR INTERVENTIONS and
SUPPORT