The contribution of ABA and psychiatry to the emerging model of positive behavioursupport

Royal College of Psychiatrists Faculty of Intellectual Disability Psychiatry Annual Conference 2016Dr Ashok Roy & Dr Sandy ToogoodCardiff September 29th 2016

Introduction

PBS emerging as the approach of choice.

RCP endorsed (2007 / 2015).

Questions about the definition of PBS and contribution of stakeholder and professional groups.

Overview

Review definitions of PBS.

Review contributions from psychiatry and behaviour analysis.

Review two case studies.

Discuss in small groups for 20 minutes.

Feedback and review to full group for 20 minutes.

Defining PBS

Comprehensive life-style change and quality of life.

Lifespan perspectives.

Ecological validity.

Stakeholder participation.

Social validity.

Systems change and multi-component intervention.

Emphasis on prevention.

Flexibility with respect to scientific practices.

Multiple theoretical perspectives.

(Carr et al. 2002)

Defining PBS

Values:

Prevention and reduction of challenging behaviour occurs within the context of increased quality of life..

Constructional approaches ... build stakeholder skills and avoid aversive and restrictive practices.

Stakeholder participation.

(Gore et al. 2013)

Defining PBS

Theory:

Challenging behaviour develops to serve important functions for people.

Use of applied behaviour analysis to assess and support behaviour change.

Use of other complementary, evidence-based approaches to support behaviour change at multiple levels of a system.

(Gore et al. 2013)

Defining PBS

Process:

A data-driven approach to decision making.

Functional assessment to inform function-based intervention.

Multicomponent interventions to change behaviour (proactively) and manage behaviour (reactively).

Implementation support, monitoring and evaluation of interventions over the long term.

(Gore et al. 2013)

Defining PBS

This definition includes both preferred labels for PBS: approach and framework.

PBS is not inclusive of all approaches to behavioral support, but rather is restricted to only those approaches that share the qualities contained in the definition.

PBS is inclusive of strategies and approaches from an array of disciplines … and from evidence-based procedures that may currently exist in other fields or may emerge in the future.

Defines a PBS approach as dynamic and continually evaluating and incorporating relevant technology and knowledge.

It also promotes the critical analysis of strategies that are evidence-based or have emerging evidence.

(Kincaid et al. 2015)

Defining PBS

A tiered approach

Contribution of ABA – the Four term contingency

The four term contingency

– Motivative

– Discriminative

– Behaviour

– Consequences

Learning History

Rule governed behaviour

– Verbal rules that control behaviour.

– Describe and override contingencies of reinforcement and punishment.

– Rule-following is reinforced by contingencies.

Biopsychosocial perspectives from Psychiatry

High prevalence of comorbid conditions

Multiaxial diagnosis and formulation

– Psychiatric

– Intellectual (level of functioning)

– Developmental (ASD, ADHD)

– Physical

– Psychosocial ( environment, family)

Tom

32yr with SLD & autism

Poor physical state

1,893 instances of CB in 9 days

IncreaseSIB

IncreaseMeds

IncreaseSIB

IncreaseMeds

Challenging behaviour

Self-injury

– Head-hitting, head-banging, kicking,

– Skin-picking

Physical aggression

Damage to property

Negative vocalisation

Attention

deprivation

or threat of

attention

deprivation

Evokes an

instance or

episode of

self-injury

or

aggression

or

disruption

Tom

receives

attention or

demand is

removed

Staff

experience

self-injury

as aversive

and are

motivated

to stop it

Staff

deliver

attention or

moderate,

delay or

remove

task

demand

Attention

deprivation

or aversive

task

demand is

abolished.

Aggression

& self-

injury

cease

Tom’s learning

history: self-

injury and

aggression

reliably evoke a

response from

staff and

remove

demands.

Staff learning

history:

responding to an

instance of self-

injury and

aggression reliably

terminates the

behaviour. Making

few demands

minimises risk of

self-injury and

aggression.

Sid

e effects of m

edicatio

n

amp

lify atten

tion d

epriv

ation

and

aversiv

e task d

eman

d

Aversive task

demand or

threat of

aversive task

demand

Equilibrium:

Continuous staff attention

& low task demand

maintains low level

aggression & self-injury

Staff presence

& actual or

potential

absence

signals

attention is

available / not

available.

Activity

materials &

staff

instruction

signal likely

oncoming

demand.

And establishes low stimulus

conditions that evoke skin

picking

Sensory

Intervention

Directly managed programme in 3 phases

– Withdrawal medication (PBS)

– FCT (PBS)

– Skills teaching (AS)

– Direct intervention (PBS)

– Enrichment – home & community (AS)

– Personal routines (AS)

– Hobby (AS)

– Relationships (AS)

0

10

20

30

40

50

60

1st

Qtr

2nd

Qtr

3rd

Qtr

4th

Qtr

5th

Qtr

6th

Qtr

7th

Qtr

8th

Qtr

// 1st

Qtr

2nd

Qtr

3rd

Qtr

4th

Qtr

5th

Qtr

6th

Qtr

7th

Qtr

8th

Qtr

13 week periods

% 1

0m

in

terv

als

Aggression SIB Damage Vocalise

Retrospective incident & ABC records 2008-09

Intervention data 1997-98

Tim

14 years at commencement

Diagnosis of autism and severe ID

High rate and high impact SIB and aggression since early childhood.

Excluded from all services and communities.

Entered a university sponsored residential school.

Working Hypothesis

Establishing operations, task

demand, social avoidance &

access to tangibles.

Internal mood state

determines the threshold at

which environmental

establishing operations come

into effect

Dynamically related system

Low mood

Stable mood

Elevated mood

Environmental

EO comes into

effect

0

1

2

3

4

5

6

Design

Baseline (A)

Brief Experimental Functional Analysis

Treatment Phase B1 & B2

Treatment 1

Functional Analysis

Treatment 2

Functional Analysis

Withdrawal

Functional Analysis

Reinstatement or

Treatment Phase C

Treatment

Functional Analysis

Withdrawal

Functional Analysis

Reinstatement or

Treatment Phase D

Functional Analysis

Withdrawal

Functional Analysis

Reinstatement or review

Descriptive Analysis

A = No treatment

B1 = Lo-Risperidone

B2 = Hi-Risperidone

C = Fluoxetine

D = Lithium Carbonate

Continuous measurement in the natural

environment of operationally defined Hi-SIB (PIR

15m).

Continuous measurement of operationally defined

mood (hourly on a 7-point anchored scale).

Measurement

Hi-SIB EFA Hi-SIB Descriptive Mood Descriptive

Setting Classroom All natural settings All natural settings

Procedure

Iwata et al. (1982) + social avoidance & tangible

4 x assessments

Operationally defined.

Continuous direct observation

Operationally defined

Continuous direct observation

Measures Partial Interval 6s Partial Interval 15mHourly rating.

7-point anchored scale.

Analysis & presentation

Multi-element

Daily records inspected & transformed to give % intervals per week with Hi-SIB, plotted across treatment phases over

time.

Colour map of mood with Hi-SIB

superimposed.

Conditional probabilities of Hi-SIB by mood

rating.

Phi correlation

Yule’s Q

Pre-Baseline Mood Rating: Colour Map

Pre-baseline:

Conditional probabilities: Hi-SIB loaded heavily onto low mood (.69)

Hi-SIB and low mood:

(Phi = .609 p < .000).

Yule’s Q Hi-SIB & mood:

Distressed v Happy = .91

Distressed v Steady = .91

Steady v Happy = .04

0

5

10

15

20

25

0

5

10

15

20

25

0

5

10

15

20

25

0

5

10

15

20

25

Social

escapeTask

Demand

Alone Social

AttentionSocial

Ambiguity Control

* *

Num

be

r o

f 6

s inte

rva

ls w

ith

Hi-

SIB Baseline 2 (A)

Baseline 1 (A)

Lo-Risperidone 1 (B1)

Baseline 3 (A)

Re

su

lts (

3a

) B

rie

f E

xp

eri

me

nta

l A

na

lysis

*

Baseline 4 (A)

Fluoxetine 1 (C)

Fluoxetine 2 (C)

Fluoxetine 3 (C)

0

5

10

15

20

25

0

5

10

15

20

25

0

5

10

15

20

25

0

5

10

15

20

25

1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 111 116 121 126 131 136 141 146 151 156 161 166 171 176 181 186 191 196 201 206 211 216 221 226 231 236 241 246 251 256 261 266 271 276 281 286 291 296 301

**

Social

escape

Task

DemandAlone

Social

Attention

Social

AmbiguityControl

Re

su

lts (

3b

) B

rie

f E

xp

eri

me

nta

l A

na

lysis

Num

be

r o

f 6

s inte

rva

ls w

ith

Hi-

SIB

Natural environment

Comments

Behavioural intervention or medication change alone would not have delivered these outcomes.

Systematic and evidence-based approach to selecting intervention components.

Intervention effects evaluated in detail with robust data.

DiscussionPBS an integrated approach

20 minutes small group

20 minutes feedback and comment

Suggested topic areas -

– Feasibility

– Desirability

– Opportunities

– Barriers