Treatment of Severe Behavior Problems Changes in Behavioral Approaches in the Last 20 Years Nirbhay N. Singh Professor of Psychiatry, Pediatrics and Psychology

Treatment of Severe Behavior Treatment of Severe Behavior ProblemsProblems

Changes in Behavioral Approaches in the Last Changes in Behavioral Approaches in the Last 20 Years20 Years

Nirbhay N. SinghNirbhay N. SinghProfessor of Psychiatry, Pediatrics Professor of Psychiatry, Pediatrics

and Psychologyand Psychology

Virginia Commonwealth Virginia Commonwealth UniversityUniversity

Richmond, Virginia, USARichmond, Virginia, USA

What Was Happening 20 What Was Happening 20 Years Ago?Years Ago?

By 1982, behavioral research had been published for 14 years in the Journal of Applied

Behavior Analysis (JABA) 12 years in Behavior Therapy 12 years in Behavior Therapy and

Experimental Psychiatry 5 years in Behavior Modification 3 years in Behavioral Assessment


Behavioral research was also being published in many journals, including among others: American Journal on Mental

Retardation Applied Research in Mental

Retardation Journal of Mental Deficiency Research Journal of Autism and Developmental

Disorders


Emphasis in behavioral research was heavily on classroom behaviors—both in enhancing classroom skills (e.g., on-task behaviors; academic skills, social skills) and in controlling classroom disruptive behaviors

There was a small but growing literature on the control and management of severe behavior problems—aggression, self-injury, property destruction, pica, rumination, and stereotypy

Behavioral Treatments 20 Behavioral Treatments 20 Years AgoYears Ago

The behavioral literature was still enthralled with demonstrating, with minor variations, behavioral control across different behavior problems

No effort was made to produce lasting change in experimental studies—no distinction among behavior control, management and treatment

Emphasis on methodology—single case experimental designs, data collection methods, inter-rater reliability, and methods of generalization and maintenance

1982-2001: The Last 20 Years1982-2001: The Last 20 Years

In 1982, Iwata et al. published an experimental methodology for deriving presumed motivations for severe behavior problems exhibited by individuals with developmental disabilities

Although initially promoted as a totally “new” development, it was the operationalizing of a methodology for assessing the functions of a behavior that had originally been advanced by Skinner in 1935 and, more recently, by Ted Carr in 1977.

Functional Analysis of Problem Functional Analysis of Problem BehaviorBehavior

Prior to 1982, virtually all behavioral treatments were derived and assessed on a trial and error basis

From 1982, a technology of functional analysis prior to the development of experimental interventions increasingly became normative for research publications

However, the methodology did not translate into day-to-day clinical practice to any significant level until the late 1990s.

Functional Assessment Functional Assessment ProceduresProcedures

These are of three general types: Indirect assessments—through structured

interviews (O’Neil et al. functional analysis interview) and ratings scales (MAS, QABF, FAST)

Descriptive analysis—direct observation of behavior is used to identify antecedent and consequent events correlated with the occurrence of severe problem behaviors

Functional analysis—arrangement of specific environmental conditions to assess the maintaining contingencies of severe problem behaviors

Functional Assessment Functional Assessment ProceduresProcedures

Used to develop effective behavioral interventions by Identifying and altering antecedent

conditions—establishing operations and setting events or discriminative stimuli—to reduce the likelihood of severe behavior problems from occurring

Functional Assessment Functional Assessment Procedures (cont.)Procedures (cont.)

Minimizing or eliminating the source of reinforcement for severe problem behaviors (e.g., through extinction)

Using the same reinforcer that maintains the severe problem behavior to establish an alternative, socially acceptable response (e.g., communication training)

By eliminating reinforcers and treatment components that may be irrelevant to the overall control of the severe problem behavior

Use of Functional AssessmentsUse of Functional Assessments

Has resulted in Reduction in the use of default

technologies (e.g., punishment) Development of new treatment

procedures (e.g., behavioral momentum) Systematic identification of the reasons

for treatment failures, e.g., mismatch between behavioral function and treatment or a change in function over time

Functions of Severe Problem Functions of Severe Problem BehaviorsBehaviors

Most prevalent functions of severe behavior problems (in decreasing order) include: Social negative reinforcement (escape or

avoidance) [35%] Social positive reinforcement (tangible)

[25%] Non-social reinforcement (automatic)

[25%] Multiple functions [8%] Unknown [7%]

Outcomes of Using a Outcomes of Using a Functional Analysis Functional Analysis

MethodologyMethodology Reduction in use of punishment procedures and

an increase in use of positive procedures Effectiveness of behavioral interventions before

and after the introduction of functional assessments has remained at about the same level—about 80% reduction from baseline to treatment

Functional assessment by itself has not produced enhanced overall effectiveness of behavioral interventions

Data suggest that severe behavior problems are still difficult to treat (e.g., 20-yr data set on aggression)

Why the Lack of Overall Why the Lack of Overall Effectiveness?Effectiveness?

Artifact of research publications—treatment failures are not submitted or accepted for publication

Bias towards positive outcomesActual success in both experimental

studies and clinical practice is unknown at this time

Success is Moderated By Other Success is Moderated By Other FactorsFactors

Reactive treatment is normative rather than proactive programming

Environmental constraints to success—necessary environmental supports are often not readily available

Reinforcement is not ubiquitous in all cultures yet everyone is required to use it

Success is Moderated By Other Success is Moderated By Other Factors (cont.)Factors (cont.)

Lack of behavioral on-site expertiseNecessary treatment exceeds the

skill level of therapistsBehavioral expert is not used to do

the actual treatmentSkilled behavioral technologists use

a recipe approach


Experimental control cannot be readily achieved in the real world

Lack of vital information in journal articles—what happens outside the treatment sessions? Intensity of the behaviors? Severity?

Failure to prepare the treatment environment


The art of programming or ensuring how the treatment will be delivered—the 10-90 rule

Maintaining staff interest when change is slow or slow in coming—look at changes in other variables, such as intensity or severity


Staff give up when severe behavior problem worsens when behavioral treatment is implemented

Severe behavior problem may be episodic and staff do not remember what to do

It is harder to maintain treatment gains in individuals who are lower functioning

What Next?What Next?

Change in behavioral programming began in the late 1980s and it solidified by the 1990s

Behavioral programming was found to be too narrow in scope

Punishment procedures were no longer being used

What Next (cont.)What Next (cont.)

The Positive Behavioral Support (PBS)model of behavior change was developed in the late 1990s

In 1999, the Journal of Positive Behavior Interventions (JPBI) was inaugurated to give voice to the new model

The first national conference on PBS was held in 2002

The Positive Behavior Support The Positive Behavior Support ModelModel

Carr et al. (2002) published a paper on PBS to: Provide a definition of the evolving

science of PBS Described the background sources

from which PBS emerged Gave an overview of the PBS model,

and Articulated a vision for the future of

PBS

Philosophy and Practice of PBSPhilosophy and Practice of PBS

Derived from three sources: Applied behavior analysis Normalization/inclusion movement Person-centered values

Goals of PBSGoals of PBS

Primary goal: To help an individual change his or

her lifestyle in a direction that gives all relevant stakeholders (I.e., teachers, employers, parents, friends, and the target person him- or herself) the opportunity to perceive and to enjoy an improved quality of life

Goals of PBSGoals of PBS

Secondary goal: To render problem behavior

irrelevant, inefficient, and ineffective by helping an individual achieve his or her goals in a socially acceptable manner, thus reducing, or eliminating altogether, episodes of problem behavior

Characteristics of PBSCharacteristics of PBS

Comprehensive lifestyle change and quality of life

Life span perspective Ecological validity Stakeholder participation Social validity Systems change and

multicomponent intervention

Characteristics of PBS (cont.)Characteristics of PBS (cont.)

Emphasis on preventionFlexibility with respect to scientific

practicesMultiple theoretical perspectives

PBS: A Vision of the FuturePBS: A Vision of the Future

Assessment practices Intervention strategiesTrainingExtension to new populations

Plan of Life: Plan of Life: A Holistic Model of HabilitationA Holistic Model of Habilitation

Treating single and multiple “problems” with single and multiple interventions

Traditional treatments—pharmacotherapy, behavior therapy, counseling and case management—limited positive outcomes in terms of quality of life enhancements

By themselves these interventions do not focus on making a difference to the whole person

Plan of Life: Plan of Life: A Holistic Model of A Holistic Model of

HabilitationHabilitation

People are people All people have strengths and

limitations Limitations are no disabilities People have multiple needs, requiring

multiple levels of service Care that enhances quality of life must

address multiple systems that the individuals are embedded in



Focus should be on building and enhancing an individual’s strengths and wellness across multiple domains

Teach and give them experience in alternative methods of coping in the real world

Help them to be as independent as as possible without setting a priori limitations

This is a world of infinite possibilities!



Linear models: Involves history taking, assessments

of specific presenting problems, case formulation, and development of problem-specific interventions

Emphasis is on understanding the individual’s “problems” and then developing a treatment plan or teaching program



Transactional models: Broader Includes consideration of internal and

external ecology Does not take into account the layers

of systems that impact people Not formulated in terms of strengths Focus on causal pathways across

multiple domains



Holistic model Person navigates daily life in layers of

contexts that are determined by the individual, by people who care for the individual, and systems that provide the framework for such care

Person’s internal and external environments (biological, psychological, social, and cultural) determine transactions in life











Plan of Life: Working with the Plan of Life: Working with the Whole IndividualWhole Individual

Extending the vision: The wellness model

Plan of Life (PoL) is an approach that encompasses within one system and one set of documents everything an individual needs for enhancing quality of one’s life—from womb to tomb

Holistic Model in PracticeHolistic Model in Practice

Begins with the adoption of a philosophy of abilities, a strengths perspective, and the co-existence of strengths and limitations

Development of a Plan of Life (PoL) for the individual

Implementation of the PoL

The Plan of Life (PoL)The Plan of Life (PoL)

Integrating

Treatment Planning and Service Delivery

Initial P lan of L ife (PoL) completed within 2 weeks

Admission with pre-admission

information package

Daily Attendance and Partic ipation Data

on each Individual

Program Partic ipation Report (PPR) on each individual

Program Attendance Rosters inc ludes each individual and

his/her PoL objectives

Individual Programming

Schedule

Program Referrals: -group interventions

-indiv. therapy sessions -vocational programs -residential programs -educational programs

inc ludes objectives from PoL

Treatment Conductor

(software program)

Monthly Progress Outcomes

inc ludes each individual’s progress on each

PoL objective

Additional Assessments

inc luding I.E.P .

Comprehensive P lan of Life

completed within 1 month

and reviewed monthly

(to program leaders, residential staff & others)

(to individual)

Treatment Conductor

(software program)

Integrating

Treatment Planning and Service Delivery

Initial P lan of L ife (PoL) completed within 2 weeks

Admission with pre-admission

information package

Daily Attendance and Partic ipation Data

on each Individual

Program Partic ipation Report (PPR) on each individual

Program Attendance Rosters inc ludes each individual and

his/her PoL objectives

Individual Programming

Schedule

Program Referrals: -group interventions

-indiv. therapy sessions -vocational programs -residential programs -educational programs

inc ludes objectives from PoL

Treatment Conductor

(software program)

Monthly Progress Outcomes

inc ludes each individual’s progress on each

PoL objective

Additional Assessments

inc luding I.E.P .

Comprehensive P lan of Life

completed within 1 month

and reviewed monthly

(to program leaders, residential staff & others)

(to individual)

Treatment Conductor

(software program)

Documents

Treatment of Severe Behavior Problems Changes in Behavioral Approaches in the Last 20 Years Nirbhay N. Singh Professor of Psychiatry, Pediatrics and Psychology