an overview of mental health issues concerning individuals with
DESCRIPTION
An Overview of Mental Health Issues concerning Individuals with Intellectual Disabilities and Positive Behavioral Supports Peter Tolisano, Psy.D. Director of Psychological Services Connecticut Department of Developmental Services. Goals of Presentation - PowerPoint PPT PresentationTRANSCRIPT
Goals of PresentationGoals of Presentation
•Identifying IQ Functioning along the Bell CurveIdentifying IQ Functioning along the Bell Curve
•Learning about Focal Regions of the BrainLearning about Focal Regions of the Brain
•Appreciating the IQ IndexesAppreciating the IQ Indexes
•Better Understanding Adaptive FunctioningBetter Understanding Adaptive Functioning
1 Percentile Rank 100
25
Less intelligentthan average
More intelligentthan average
40 55 70
Intellectual Developmental Disorder: Intellectual and Intellectual Developmental Disorder: Intellectual and adaptive deficits with onset during the developmental periodadaptive deficits with onset during the developmental period
• Mild 85%• Moderate
10%• Severe 3%• Profound 2%
BRAIN HEMISPHERES AND REGIONSBRAIN HEMISPHERES AND REGIONS
• Contra-lateralizationContra-lateralization• Frontal versus Temporal Lobe FunctioningFrontal versus Temporal Lobe Functioning
Intellectual Functioning IndexesIntellectual Functioning Indexes
Verbal Comprehension:General knowledge and reasoning skills. Related to formal and informal education. Language is central our ability to label, organize and manage our internal experiences and the external environment.Difficulty putting feelings and needs into words makes individuals prone to frustration, aggression, and depression.
Perceptual Organization: •Visual-spatial skills.•Ability to create solutions, especially in novel situations.
Intellectual Functioning IndexesIntellectual Functioning Indexes
Working Memory:•In-the-moment reasoning tied to attention, concentration, and short-term memory. •Important to learning, flexibility, planning, and self-monitoring. •Sensitive to anxiety and depression. Processing Speed:•Ability to work quickly and efficiently. •Sensitive to motivation and persistence. •PS may negatively effect overall cognitive functioning.
Intellectual impairment is often related to problems delaying gratification, controlling impulses, and tolerating frustration.
Build on strengths and minimize weaknesses.
ADAPTIVE FUNCTIONINGADAPTIVE FUNCTIONING
Refers to how effectively people cope with common life demands across multiple environments.Domains of Practical, Conceptual, and Social skills. Measures include the Vineland Scales and the BASC.
Self-careSelf-care Expressive and Receptive Communication Expressive and Receptive Communication Social and Community ActivitiesSocial and Community Activities Independent living skills (e.g. housekeeping)Independent living skills (e.g. housekeeping) Health and safetyHealth and safety Vocational abilitiesVocational abilities Self-directionSelf-direction
Understanding Mental Health IssuesUnderstanding Mental Health IssuesGoals of the PresentationGoals of the Presentation
Acknowledge that co-occurring mental health conditions are Acknowledge that co-occurring mental health conditions are frequent in intellectual disability with three to four times higher frequent in intellectual disability with three to four times higher
rates than the general population. rates than the general population.
Develop a basic understanding of the common Develop a basic understanding of the common DSM-5DSM-5 psychiatric disorders that might affect those with intellectual psychiatric disorders that might affect those with intellectual
disability.disability.
Identify the pharmacological interventions that are often used to Identify the pharmacological interventions that are often used to treat these disorderstreat these disorders..
Neurodevelopmental Disorders: Neurodevelopmental Disorders:
Childhood OnsetChildhood Onset
Autism Spectrum Disorder: Autism Spectrum Disorder: Persistent deficits in Social communication, Social interaction, Persistent deficits in Social communication, Social interaction, and Repetitive behaviorsand Repetitive behaviors
Attention-Deficit/Hyperactivity Disorder: Attention-Deficit/Hyperactivity Disorder: Inattentive versus Hyperactive/Impulsive TypesInattentive versus Hyperactive/Impulsive TypesEvidence before age 12Evidence before age 12
Disruptive Disorders:Disruptive Disorders:
•Intermittent Explosive DisorderIntermittent Explosive Disorder
•Oppositional Defiant Disorder: Oppositional Defiant Disorder: Irritable, Argumentative, and VindictiveIrritable, Argumentative, and Vindictive
•Conduct Disorder: Conduct Disorder: Destructive, Deceitful, Rules violations, and Precursor to Destructive, Deceitful, Rules violations, and Precursor to
Antisocial PersonalityAntisocial Personality
*Difficulties related to impulsivity and hyperactivity are easily *Difficulties related to impulsivity and hyperactivity are easily misinterpreted as aggressionmisinterpreted as aggression
Mood DisordersMood Disorders
Depressive DisordersDepressive Disorders Dysthymia/Persistent Depression Major Depression Premenstrual Dysphoric Disorder Disruptive Mood Dysregulation Disorder
Bipolar Disorders Bipolar Disorders Formerly Manic Depression Cyclothymia Type I vs. Type II Episodes
• Children vs. Adult Presentation• Mood Instability vs. Affective Shifts
Acting
ThinkingFeeling
Unlocking the Process
Problems with communication affect Problems with communication affect predisposition, assessment, and treatment. Always predisposition, assessment, and treatment. Always check with knowledgeable informants and review check with knowledgeable informants and review
the behavioral data.the behavioral data.
Signs and Symptoms of Mood DisturbanceSigns and Symptoms of Mood Disturbance
Presentation CryingCrying Changes in Appetite and SleepChanges in Appetite and Sleep IrritabilityIrritability Agitation and AggressionAgitation and Aggression Tiredness and Lethargy Tiredness and Lethargy
Thinking Negative beliefs about past, present, and futureNegative beliefs about past, present, and future Feeling Worthless or UnlovableFeeling Worthless or Unlovable Perceptions of Helplessness and HopelessnessPerceptions of Helplessness and Hopelessness Loss of EnjoymentLoss of Enjoyment Suicidal IdeationSuicidal Ideation DistractibilityDistractibility Psychomotor SlowingPsychomotor Slowing
Emotions SadnessSadness GuiltGuilt DespairDespair
Signs and Symptoms of Mood DisturbanceSigns and Symptoms of Mood Disturbance
Presentation CryingCrying Changes in Appetite and SleepChanges in Appetite and Sleep IrritabilityIrritability Agitation and AggressionAgitation and Aggression Tiredness and Lethargy Tiredness and Lethargy
Thinking Negative beliefs about past, present, and futureNegative beliefs about past, present, and future Feeling Worthless or UnlovableFeeling Worthless or Unlovable Perceptions of Helplessness and HopelessnessPerceptions of Helplessness and Hopelessness Loss of EnjoymentLoss of Enjoyment Suicidal IdeationSuicidal Ideation DistractibilityDistractibility Psychomotor SlowingPsychomotor Slowing
Emotions SadnessSadness GuiltGuilt DespairDespair
Signs and Symptoms of Mood DisturbanceSigns and Symptoms of Mood Disturbance
PresentationPresentation CryingCrying Changes in Appetite and SleepChanges in Appetite and Sleep IrritabilityIrritability Agitation and AggressionAgitation and Aggression Tiredness and Lethargy Tiredness and Lethargy
ThinkingThinking Negative beliefs about past, present, and futureNegative beliefs about past, present, and future Feeling Worthless or UnlovableFeeling Worthless or Unlovable Perceptions of Helplessness and HopelessnessPerceptions of Helplessness and Hopelessness Loss of EnjoymentLoss of Enjoyment Suicidal Ideation DistractibilityDistractibility Psychomotor SlowingPsychomotor Slowing
EmotionsEmotions SadnessSadness GuiltGuilt DespairDespair
Anxiety DisordersAnxiety Disorders
Separation AnxietySeparation AnxietySpecific PhobiasSpecific PhobiasPanic Attacks vs. Panic DisorderPanic Attacks vs. Panic DisorderSocial PhobiaSocial PhobiaGeneralized Anxiety DisorderGeneralized Anxiety DisorderAgoraphobiaAgoraphobia
Other Anxiety-Related Disorders
Obsessive-Compulsive SpectrumObsessive-Compulsive Spectrum Obsessive and Compulsive “Loops”Obsessive and Compulsive “Loops” Differential Diagnosis Differential Diagnosis Domains: Domains:
HoardingHoarding ContaminationContamination Fear of Harm and CheckingFear of Harm and Checking Symmetry and OrderSymmetry and Order
Posttraumatic Stress DisorderPosttraumatic Stress Disorder Symptom ClustersSymptom Clusters
Re-ExperiencingRe-Experiencing ArousalArousal AvoidanceAvoidance
Trauma and Stress-Related Disorders
I. Secondary to Insufficient Care1. Reactive (Inhibited) Attachment Disorder
2. Disinhibited Social Engagement Disorder
II. Developmental Trauma Disorder•Repeated inconsistency, often involving abandonment, rejection,
abuse, or neglect, in early life causes negative effects on neurocognitive, emotional, and psychosocial development.
Signs and Symptoms of Anxiety DisordersSigns and Symptoms of Anxiety DisordersStates vs. TraitsStates vs. Traits
PresentationPresentationAvoidanceAvoidanceSeeking reassuranceSeeking reassuranceSleeplessnessSleeplessnessRestlessness Restlessness TensionTension
ThinkingThinkingImpaired Attention and ConcentrationImpaired Attention and ConcentrationCatastrophic beliefsCatastrophic beliefsPreoccupationsPreoccupations
EmotionsEmotionsNervousnessNervousnessFearFearWorryWorry
Schizophrenia Spectrum and Schizophrenia Spectrum and Psychotic DisordersPsychotic Disorders
PsychosisPsychosis HallucinationsHallucinations DelusionsDelusions
Schizophreniform Disorder: Prodromal PhaseSchizophreniform Disorder: Prodromal PhaseSchizophrenia SubtypesSchizophrenia SubtypesSchizoaffective DisorderSchizoaffective Disorder
Self-reported versus endorsed symptomsSelf-reported versus endorsed symptoms
Features of Thought DisordersFeatures of Thought Disorders
PresentationPresentation Negative Symptoms: Negative Symptoms: “Taken Away”“Taken Away”
o Disheveled, Lethargic, Diminished emotional expression, AvolitionDisheveled, Lethargic, Diminished emotional expression, Avolitiono Abnormal Motor Behavior: Catatonic, Pacing, RegressedAbnormal Motor Behavior: Catatonic, Pacing, Regressed
ThinkingThinking Poor insight into nature of the illnessPoor insight into nature of the illness Disorganized thinking, such as tangential, circumstantial, ideas of Disorganized thinking, such as tangential, circumstantial, ideas of
reference, and a flight of ideas.reference, and a flight of ideas. Positive Symptoms: Positive Symptoms: “Added On”“Added On”
o Hallucinations (e.g., auditory, visual, tactile, olfactory, gustatory) Hallucinations (e.g., auditory, visual, tactile, olfactory, gustatory) o Delusions (e.g., grandiose, paranoid, persecutory, religious)Delusions (e.g., grandiose, paranoid, persecutory, religious)o Responses to Internal StimuliResponses to Internal Stimuli
EmotionsEmotions Blunted or flat affectBlunted or flat affect Depressed to ExcitedDepressed to Excited Irritable Irritable AggressiveAggressive AnhedoniaAnhedonia
Personality FunctioningPersonality Functioning
•Behaviors across people and situationsBehaviors across people and situations
•Rooted in four components:Rooted in four components: TemperamentTemperament CharacterCharacter Cognitive FunctioningCognitive Functioning Morals and ValuesMorals and Values
Understanding Personality DysfunctionUnderstanding Personality Dysfunction
•Ego Syntonic vs. Ego DystonicEgo Syntonic vs. Ego Dystonic
•Categorical vs. Dimensional ApproachCategorical vs. Dimensional Approach
•DSM Classifications DSM Classifications (Enduring Pattern of Features and Traits) (Enduring Pattern of Features and Traits) versusversus Levels of Organization and Functioning Levels of Organization and Functioning (Themes)(Themes)
For example, Borderline Personality Disorder “proper,” as For example, Borderline Personality Disorder “proper,” as compared to Borderline Level of Personality Organization (i.e., compared to Borderline Level of Personality Organization (i.e., identity diffusion, primitive defenses, and variable reality identity diffusion, primitive defenses, and variable reality testing)testing)
General DSM Characteristics of General DSM Characteristics of
Personality DisorderPersonality Disorder
• MisperceptionsMisperceptions• ReactivityReactivity• Interpersonal IssuesInterpersonal Issues• ImpulsivityImpulsivity
Personality DisordersPersonality DisordersDSM PhenomenologyDSM Phenomenology
Cluster A: Cluster A: Odd disordersParanoid: Paranoid: Irrational mistrust and suspicion Schizoid: Schizoid: Detached from social relationships and restricted emotionsSchizotypal: Schizotypal: Odd beliefs and discomfort interacting socially
Cluster B: Cluster B: Dramatic, emotional or erratic disorders•Histrionic: Histrionic: Attention-seeking behavior and excessive emotions•Narcissistic: Narcissistic: Grandiose and unempathic•Antisocial: Antisocial: Exploitative, disregard for rights of others, even psychopathy•Borderline: Borderline: Instability in relationships, identity, and emotions
Cluster C: Cluster C: Anxious or fearful disordersDependent: Dependent: Excessive need for caring and reassuranceAvoidant: Avoidant: Socially inhibited and sensitive to negative evaluationObsessive-Compulsive: Obsessive-Compulsive: Rigid, controlling, and perfectionistic
Substance-Related and Substance-Related and Addictive DisordersAddictive Disorders
AlcoholAlcoholCaffeine and TobaccoCaffeine and TobaccoCannabisCannabisHallucinogensHallucinogensCocaineCocaineInhalantsInhalantsOpioidsOpioidsStimulantsStimulantsSedativesSedativesGamblingGambling
Substance-Related and Substance-Related and Addictive DisordersAddictive Disorders
Formerly Abuse versus DependenceFormerly Abuse versus DependenceGeneral Criteria: General Criteria:
Impaired ControlImpaired Control Social ImpairmentSocial Impairment Risky UseRisky Use Pharmacological Pharmacological
Stage of Change ModelStage of Change Model
Precontemplation: Precontemplation: Characterized by denial, poor awareness, or rebellion.Characterized by denial, poor awareness, or rebellion.
Goal is to raise consciousness without confronting or create a discrepancy.Goal is to raise consciousness without confronting or create a discrepancy.
Contemplation:Contemplation:Ambivalent feelings. Reflect both sides by weighing pros and cons.Ambivalent feelings. Reflect both sides by weighing pros and cons.Explore Explore functionfunction of the behavior. Avoid dwelling on consequences. of the behavior. Avoid dwelling on consequences.
PreparationPreparation::Taking proactive steps about imminent change.Taking proactive steps about imminent change.
Verbal commitment to a concrete plan within 30 days. Verbal commitment to a concrete plan within 30 days.
ActionAction: : Demonstrate a commitment to a plan in real life.Demonstrate a commitment to a plan in real life.
MaintenanceMaintenance::Staying changed at least for 6 months. Staying changed at least for 6 months.
Focus on relapse prevention skills. Focus on relapse prevention skills.
General ConsiderationsGeneral Considerations::Change Change into into andand out out of behaviors.of behaviors.
Vacillate between stages and phases of each.Vacillate between stages and phases of each.Transition from Transition from Contemplation-to-ActionContemplation-to-Action tends to be most difficult. tends to be most difficult.
Sleep-Wake DisordersSleep-Wake DisordersInsomniaInsomniaHypersomnolenceHypersomnolenceBreathing-Related Disorders (Obstructive Breathing-Related Disorders (Obstructive vs. Central Apnea)vs. Central Apnea)Circadian Rhythm DisruptionCircadian Rhythm Disruption
Eating DisordersEating DisordersAnorexia and BulimiaAnorexia and Bulimia
Neurocognitive DisordersNeurocognitive DisordersDelirium vs. DementiaDelirium vs. DementiaAcquired vs. Traumatic Brain InjuryAcquired vs. Traumatic Brain Injury
Sexual DisordersSexual DisordersParaphiliasParaphilias
•PedophiliaPedophilia
•HebephiliaHebephilia
•FetishismFetishism
•FrotteurismFrotteurism
•ExhibitionismExhibitionism
Psychotropic MedicationsPsychotropic MedicationsUnderstanding NeurotransmittersUnderstanding Neurotransmitters
•GABAGABA
•SerotoninSerotonin
•NorepinephrineNorepinephrine
•DopamineDopamine
•AcetylcholineAcetylcholine
•GlutamateGlutamate
Pharmacodynamics and PharmacokineticsPharmacodynamics and Pharmacokinetics
Psychotropic MedicationsPsychotropic Medications
• Neurocognitive Disorders: Acetylcholinesterase and Glutamate Inhibitors (Aricept, Excelon, Namenda)
•Substance Use Disorders: Antabuse, Methadone, Naltrexone, Buprenorphine, Soboxone, Chantix
•Sleep Disorders: Sedatives, Hypnotics, and Antidepressants (Ambien, Lunesta, Remeron)
•Impulse Control Disorders and Behavioral Dyscontrol: Antidepressants, Mood Stabilizers, Antipsychotics, and Antihypertensives (Inderal, Tenex)
•Sexual Disorders: Antidepressants and Depo-Provera
Psychotropic MedicationsPsychotropic Medications
•Personality Disorders: Psychotherapy for Cognitive and Defensive Restructuring , as well as Life Skills Building
•Eating Disorders: Psychotherapy for Symptom Management
•Intellectual Disability: None
*Please avoid “working backwards” by using the response to prescribed medications as the guide to arrive at a working diagnosis.
Treatment Paradigm
Level of Intellectual Disability
Possible Treatment Modalities
Mild • Interpersonal and Insight-Oriented Psychotherapy
• Cognitive-Behavioral Interventions
• Psychoeducation• Positive Behavioral
Supports• Positive Self-Attribution
Moderate • Skills Building• Positive Behavioral
Supports
Severe-to-Profound • Positive Behavioral Supports with emphasis on environmental strategies
Goals of Positive Behavioral Support Training:Goals of Positive Behavioral Support Training:
Understanding the Concepts, Terms, and Understanding the Concepts, Terms, and StrategiesStrategies
Identifying the Functions that Influence BehaviorIdentifying the Functions that Influence Behavior
Appreciating Individual Challenges and Systems Appreciating Individual Challenges and Systems IssuesIssues
Measuring Effectiveness with Data Collection Measuring Effectiveness with Data Collection and Graphingand Graphing
Anyone who has broken a New Year’s Resolution appreciates the difficulty of behavioral change. There is no single solution that works for everyone.
We often expect individuals we work with to immediately change a behavior that they have used over a lifetime of repetition and reinforcement.
We need to remember that we are striving for progress toward new behaviors, rather than perfection in getting rid of the old ones.
Is it possible for an individual Is it possible for an individual to change their behavior?to change their behavior?
Why Use a Positive Behavioral Approach?
Humanistic
Evidenced-Based Best Practices Accountability Sustainability
Medical Model Maladaptive behaviors are conceptualized as a sign of an
underlying disease process, rather than serving a function.
That is, it assumes that “abnormal” behavior is a symptom of the diagnosis. For example, “Joe acts out because he has schizophrenia. That is just how he is.”
Expert-driven.
Positive Behavioral Perspective Holistic approach that views behaviors as goal-directed
and interconnected with physiology, situational context, cultural factors, thoughts, and feelings.
Consumer- and family-centered.
Applied Behavioral Analysis:Applied Behavioral Analysis: Understanding how the individual interacts with the Understanding how the individual interacts with the
environment.environment.
Positive Behavioral Supports:Positive Behavioral Supports: Comprehensive functional assessmentComprehensive functional assessment Proactive teaching of expectations and acceptable behaviors Proactive teaching of expectations and acceptable behaviors Building behavioral repertoiresBuilding behavioral repertoires Reinforcement of existing appropriate behaviorsReinforcement of existing appropriate behaviors Managing environmental antecedentsManaging environmental antecedents Monitoring problem behaviorsMonitoring problem behaviors Data-driven decisions and evaluation effectiveness Data-driven decisions and evaluation effectiveness Intense efforts for supportIntense efforts for support Improving quality of lifeImproving quality of life Integrity with implementation and responsivenessIntegrity with implementation and responsiveness
1) Observation and Correlation (e.g., ABC analysis) and 1) Observation and Correlation (e.g., ABC analysis) and then 2) Hypothesis Testing (i.e., Identifying what then 2) Hypothesis Testing (i.e., Identifying what precipitates and maintains the negative behavior)precipitates and maintains the negative behavior)
Operational Operational Description of Description of
Challenging Challenging BehaviorBehavior
Person-Centered Person-Centered PlanningPlanning•GoalsGoals•StrengthsStrengths•BarriersBarriers•ResourcesResources
Identify the Function Identify the Function of Problem Behaviorsof Problem Behaviors
Physical, Physical, Medical, Medical, Psychological, Psychological, and Social and Social IssuesIssues
Positive Behavioral Support Flowchart Positive Behavioral Support Flowchart Case ConceptualizationCase Conceptualization
Proactive StrategiesProactive Strategies•Teaching replacement Teaching replacement behaviorsbehaviors•Strengthening adaptive Strengthening adaptive skillsskills•Team ProcessTeam Process•ModelingModeling
Foundational and Foundational and Lifestyle StrategiesLifestyle Strategies•CommunicationCommunication•PreferencesPreferences•ActivitiesActivities•RoutinesRoutines•RelationshipsRelationships
Setting Events and Setting Events and PredictorsPredictors
•Problem Problem SituationsSituations•AntecedentsAntecedents•ExpectationsExpectations•Task DemandsTask Demands
Reactive StrategiesReactive Strategies•ReinforcementsReinforcements•Maintaining Maintaining Desired BehaviorsDesired Behaviors•Crisis PlansCrisis Plans
InterventionsInterventions
Situational SpecificitySituational Specificity
Behavior is related to the context and the Behavior is related to the context and the environment in which it occurs.environment in which it occurs.
What situations is the behavior most and least likely What situations is the behavior most and least likely to occur?to occur?
Environmental and Behavioral Components in Functional Environmental and Behavioral Components in Functional AssessmentAssessment
Setting Events and VulnerabilitiesSetting Events and Vulnerabilities Situations in the environment combined with individual’s deficits Situations in the environment combined with individual’s deficits Broader setting events (i.e., unpredictability, medical conditions {e.g., Broader setting events (i.e., unpredictability, medical conditions {e.g.,
unstable blood sugar, undiagnosed seizure activity, untreated sleep unstable blood sugar, undiagnosed seizure activity, untreated sleep problems, medication side effects)problems, medication side effects)
Antecedents and TriggersAntecedents and Triggers What occurred immediately What occurred immediately beforebefore the behavior? Fast versus slow the behavior? Fast versus slow
precipitants? precipitants? External External (e.g., a conflict earlier in the day) versus (e.g., a conflict earlier in the day) versus InternalInternal antecedents antecedents
(e.g., feeling isolated and lonely influences behavioral choices)(e.g., feeling isolated and lonely influences behavioral choices) Lifestyle issues (e.g., remote stresses, interpersonal relationships, Lifestyle issues (e.g., remote stresses, interpersonal relationships,
problems accessing preferred activities)problems accessing preferred activities)
PrecursorsPrecursors What noticeable actions in body language came before the behavior of What noticeable actions in body language came before the behavior of
concern? (e.g., pacing, pressured speech, rolling their eyes, clinching their concern? (e.g., pacing, pressured speech, rolling their eyes, clinching their fists)fists)
Maintaining ConsequencesMaintaining Consequences What occurred immediately What occurred immediately afterafter the behavior of concern? the behavior of concern? How did the caregivers respond? How did the caregivers respond?
Intrapersonal Reinforcement (e.g., emotional
reinforcement) or Interpersonal Reinforcement
(e.g., help-seeking behavior)
PositivePositive or or NegativeNegative
ReinforcementReinforcement
FUNCTIONAL ASSESSMENT OF FUNCTIONAL ASSESSMENT OF BEHAVIORBEHAVIOR
BETTER UNDERSTANDING WHY INDIVIDUALS ENGAGE IN BETTER UNDERSTANDING WHY INDIVIDUALS ENGAGE IN MALADAPTIVE BEHAVIORS ESPECIALLY THOSE SEEN WITH MALADAPTIVE BEHAVIORS ESPECIALLY THOSE SEEN WITH INTELLECTUAL DISABILITY AND PSYCHIATRIC DISORDERSINTELLECTUAL DISABILITY AND PSYCHIATRIC DISORDERS
FUNCTIONAL ASSESSMENT OF FUNCTIONAL ASSESSMENT OF BEHAVIORBEHAVIORTeaching adaptive behaviors renders Teaching adaptive behaviors renders maladaptive behaviors unnecessary and maladaptive behaviors unnecessary and irrelevant.irrelevant.
Overapplication of Attention-Seeking, Overapplication of Attention-Seeking, Manipulation, and Escape as possible functions Manipulation, and Escape as possible functions of behavior. of behavior.
*If attention-seeking is the function, when would *If attention-seeking is the function, when would the behavior be displayed?the behavior be displayed? With staff present or With staff present or absent?absent?
Underdeveloped Support PlansUnderdeveloped Support Plans
Lacks background information, such as learning Lacks background information, such as learning disabilities, medical conditions, trauma history, and disabilities, medical conditions, trauma history, and psychiatric issues.psychiatric issues.
Inadequate functional assessment to “anchor” the Inadequate functional assessment to “anchor” the interventions.interventions.
Interventions are mismatched with the individual’s level Interventions are mismatched with the individual’s level of functioning and their readiness to change.of functioning and their readiness to change.
Caregivers feel they do not understand the plan or are Caregivers feel they do not understand the plan or are poorly prepared to implement it.poorly prepared to implement it.
Consult templates of what constitutes a well-written plan.Consult templates of what constitutes a well-written plan.
Serving all Aspects of an IndividualServing all Aspects of an Individual
Person-centered : Person-centered : Respects dignity and individual strengthsRespects dignity and individual strengths Not a “cookbook” approachNot a “cookbook” approach
Focus on Positive Changes in the Environment:Focus on Positive Changes in the Environment: Identify ways to consistently support new skills across Identify ways to consistently support new skills across
settingssettings Eliminate negative consequences, coercion, and Eliminate negative consequences, coercion, and
restrictionsrestrictions
Collaborative: Collaborative: Caregiver training for competency is key to Caregiver training for competency is key to
effectivenesseffectiveness Keep everyone involved as part of the interdisciplinary Keep everyone involved as part of the interdisciplinary
team (e.g., individual-served, family members, team (e.g., individual-served, family members, psychiatrist, occupational therapist, psychotherapist, psychiatrist, occupational therapist, psychotherapist, job coach)job coach)
Feedback loops between direct care staff, caregivers, Feedback loops between direct care staff, caregivers, and teamand team
Individual ChallengesIndividual Challenges
Difficulty Difficulty learninglearning new behaviors due to cognitive difficulties. new behaviors due to cognitive difficulties.
Problem behavior is rooted in Problem behavior is rooted in negative emotionsnegative emotions..
Ameliorating Ameliorating psychiatric symptoms psychiatric symptoms is needed to reduce is needed to reduce challenging behaviors.challenging behaviors.
Unwilling or unmotivated Unwilling or unmotivated to engage in positive behaviorto engage in positive behavior
Problem behaviors Problem behaviors continue to workcontinue to work meeting their needs meeting their needs..• ““If I scream, then I always get the snacks I want.”If I scream, then I always get the snacks I want.”
Caregiver ConsiderationsCaregiver Considerations
• Difficulty being empathic Difficulty being empathic
• Negative attitude toward PBSNegative attitude toward PBS
• Consequence and reward mentalityConsequence and reward mentality
• Authoritarian styleAuthoritarian style
• Personal stressesPersonal stresses
• Difficulty performing in a crisisDifficulty performing in a crisis
• Fear of disruptive behaviorsFear of disruptive behaviors
Targeted Positive Behaviors:Targeted Positive Behaviors: To instill, increase, and maintain.To instill, increase, and maintain.
Increase emotional regulation through coping strategies, self-Increase emotional regulation through coping strategies, self-soothing, healthy diversions, and opportunities to learn self-control. soothing, healthy diversions, and opportunities to learn self-control.
Become more adaptive and self-reliant by building autonomy, Become more adaptive and self-reliant by building autonomy, mastery, confidence, and self-direction.mastery, confidence, and self-direction.
Increase prosocial skills and participation in community activitiesIncrease prosocial skills and participation in community activities
Behaviors of Concern:Behaviors of Concern:
To decrease or eliminate.To decrease or eliminate.
These include verbal outbursts, physical These include verbal outbursts, physical aggression, and refusals. aggression, and refusals.
Are challenging and aberrant behaviors being Are challenging and aberrant behaviors being inadvertently reinforced by environmental inadvertently reinforced by environmental responses?responses?
REACTIVE VS. PROACTIVE INTERVENTIONSREACTIVE VS. PROACTIVE INTERVENTIONS
Reactive Interventions Reactive Interventions
Caregivers actions Caregivers actions afterafter behaviors of concern occur. How to behaviors of concern occur. How to handle challenging behaviors appropriately.handle challenging behaviors appropriately.
For limited use about 5% of the time. For limited use about 5% of the time.
These should be used to help situations from escalating.These should be used to help situations from escalating.
For example, prompting alternative behaviors, using For example, prompting alternative behaviors, using distractions, redirecting away from triggers, or establishing distractions, redirecting away from triggers, or establishing control when harm to self and others.control when harm to self and others.
Affected by state-dependent learning.Affected by state-dependent learning.
May include crisis response, respite care, and hospitalization.May include crisis response, respite care, and hospitalization.
Proactive or Preventative InterventionsProactive or Preventative Interventions
Caregivers actions designed to help the Caregivers actions designed to help the person to avoid engaging in challenging person to avoid engaging in challenging behaviors. behaviors.
These should be used 95% of the time. These should be used 95% of the time.
Multimodal: Verbally-mediated, Visual-spatial, Multimodal: Verbally-mediated, Visual-spatial, Hands-on, and Contextually-drivenHands-on, and Contextually-driven
Be Familiar with the Behavior Plan!Be Familiar with the Behavior Plan!
Avoid Triggers and Eliminate ProvocationsAvoid Triggers and Eliminate Provocations
Positive Setting Events: Prompting and CueingPositive Setting Events: Prompting and Cueing
Set Expectations ProactivelySet Expectations Proactively
Well-Understood and Predictable Daily RoutineWell-Understood and Predictable Daily Routine
Adherence with the ScheduleAdherence with the Schedule
Active ListeningActive Listening
Affirmative CommunicationAffirmative Communication
Concrete Directions to Compensate for ImpairmentsConcrete Directions to Compensate for Impairments
Be Person-Centered and Context-SensitiveBe Person-Centered and Context-Sensitive
Sensory ModalitiesSensory Modalities
Multimodal Approach: Visual Aids and Hands-on ModelingMultimodal Approach: Visual Aids and Hands-on Modeling
Building a Positive Sense of SelfBuilding a Positive Sense of Self
Team ApproachTeam Approach
Meaningful and Non-Contingent ActivitiesMeaningful and Non-Contingent Activities
Natural Supports with Family, Friends, and VolunteersNatural Supports with Family, Friends, and Volunteers
Directions given and reviewed at regular intervals. They Directions given and reviewed at regular intervals. They should be very specific and easily convey the expected should be very specific and easily convey the expected behavior.behavior.
Tell the person what you want them to do, rather than Tell the person what you want them to do, rather than what you do not. what you do not.
““Use an ‘inside’ voice,” instead of “Stop talking so Use an ‘inside’ voice,” instead of “Stop talking so loudly”loudly”
““Keep your hands down,” rather than “Don’t hit”Keep your hands down,” rather than “Don’t hit” ““Let’s relax with some slow breathing,” not “Stop being Let’s relax with some slow breathing,” not “Stop being
so nervous”so nervous”
Learning problems and memory deficits may interfere Learning problems and memory deficits may interfere understanding and remembering what constitutes understanding and remembering what constitutes “appropriate” behavior.“appropriate” behavior.
Learning occurs in small steps, so have realistic Learning occurs in small steps, so have realistic expectations. expectations.
Be consistent with language across settings.Be consistent with language across settings.
Asking Important Questions: Asking Important Questions: WhyWhy is the behavior is the behavior happening, happening, WhatWhat functions it serves for the individual, functions it serves for the individual, and and HowHow can we help them meet their needs adaptively.can we help them meet their needs adaptively.
Targeted positive behaviors should have direct Targeted positive behaviors should have direct “correspondence”“correspondence” to the behaviors of concern they are to the behaviors of concern they are replacing. replacing.
The The aimaim is the presence of targeted adaptive and is the presence of targeted adaptive and prosocial behaviors through prosocial behaviors through teachingteaching, not just the , not just the absence of challenging behavior. absence of challenging behavior.
Problems with Consequence-Based InterventionsProblems with Consequence-Based Interventions
Ethical concernsEthical concerns
Do not teach new replacement behaviorsDo not teach new replacement behaviors
Negative side effects, such as lowered self-Negative side effects, such as lowered self-esteem, frustration, and rejection, esteem, frustration, and rejection, even even from minor coercionfrom minor coercion
Attempting to control behavior through adverse Attempting to control behavior through adverse consequences. It is different than natural and logical consequences. It is different than natural and logical consequences. consequences.
It may include the following:It may include the following: Ignoring (spontaneous and planned)Ignoring (spontaneous and planned) Taking away rights and privilegesTaking away rights and privileges Response costResponse cost Forcing apologies Forcing apologies Threatening restraint or seclusionThreatening restraint or seclusion
When minor coercion that was once effective ceases to When minor coercion that was once effective ceases to work, caregivers tend to increase the level of coercion, work, caregivers tend to increase the level of coercion, rather than decrease it. rather than decrease it.
Ways to Modify and Manage Ways to Modify and Manage BehaviorBehavior
Classical and Operant Classical and Operant ConditioningConditioning
Role ModelingRole Modeling Teaching New BehaviorsTeaching New Behaviors Positive Self-Attribution with Positive Self-Attribution with
a Centering Construct a Centering Construct
ReinforcementReinforcement Immediate (Immediate (within 30-60 secondswithin 30-60 seconds) and explicit, rather ) and explicit, rather
than delayed verbal praise.than delayed verbal praise.
PairingPairing Associates behavior with positive or negative Associates behavior with positive or negative
reinforcement.reinforcement.
ShapingShaping Rewards Rewards “successive approximations” “successive approximations” to the desired to the desired
goal. goal.
Critical SchedulingCritical Scheduling Less preferred activities followed by more preferred Less preferred activities followed by more preferred
activities to increase motivation. For example, activities to increase motivation. For example, ““When/After/FirstWhen/After/First you take a shower, you take a shower, thenthen we can go to we can go to lunch.lunch.” ”
ScaffoldingScaffolding Fade assistance as the individual's competency and Fade assistance as the individual's competency and
confidence develop toward independence with the task.confidence develop toward independence with the task.
Helpful PBS Strategies Helpful PBS Strategies
Guidelines for Replacement Behaviors
1. Serve the Same Purpose:Serve the Same Purpose:
Putting feelings into polite words to communicate.Putting feelings into polite words to communicate.
2. 2. Get Reinforcement as Soon or Sooner:Get Reinforcement as Soon or Sooner:
Self-soothing with ice pack, rather than self-injurious behavior.Self-soothing with ice pack, rather than self-injurious behavior.
3. 3. Receive as Much or More Reinforcement:Receive as Much or More Reinforcement:
Caregivers quickly attend when he says “again please”, as much as if he Caregivers quickly attend when he says “again please”, as much as if he had expressed his demands with an outburst. had expressed his demands with an outburst.
4. 4. Just as Easy or Easier to Do:Just as Easy or Easier to Do:
Following directions in one-to-two steps is easier than refusing an Following directions in one-to-two steps is easier than refusing an appointment or missing an outing.appointment or missing an outing.
PROACTIVE VERSUS REACTION INTERVENTION PROACTIVE VERSUS REACTION INTERVENTION POINTSPOINTS
Return to Baseline
Reactive InterventionsFor Limited Use
The Crisis Cycle
Sufficient Empathic Validation
Redirection and Limit Setting
External Support and Guidance as Necessary
Problem Solving
AcknowledgeAcknowledge Perspectives: Perspectives: Active listening by being attuned Active listening by being attuned Accurate reflection to defuse negative emotions Accurate reflection to defuse negative emotions Validation means Validation means acknowledgementacknowledgement, not necessarily , not necessarily
agreementagreement Repeat information back to confirm your understandingRepeat information back to confirm your understanding SufficientlySufficiently validate before redirecting, limit setting, or validate before redirecting, limit setting, or
finding solutionsfinding solutions
Remember the Remember the ContextContext:: Know the situation (e.g., “It sounds like your tired Know the situation (e.g., “It sounds like your tired
because you didn’t sleep well”)because you didn’t sleep well”) Understand the individual’s “story” (e.g., “I know this Understand the individual’s “story” (e.g., “I know this
time of year is hard because it’s the anniversary of your time of year is hard because it’s the anniversary of your dad’s passing away.”)dad’s passing away.”)
Obstacles to Implementation
Lack of Communication and Consistency Caregiver-to-CaregiverCaregiver-to-Caregiver Shift-to-ShiftShift-to-Shift Provider-to-Family Provider-to-Family Residential Program-to-Vocational ProgramResidential Program-to-Vocational Program
Inadvertent Reinforcement Strategic versus Wholesale Capitulation
TEAM COORDINATION AND TEAM COORDINATION AND COMMUNICATIONCOMMUNICATION
For optimal performance in plan implementationFor optimal performance in plan implementation
Who is responsible in carrying out each component of the planWho is responsible in carrying out each component of the plan
Reduces “splitting,” answer shopping,” and absorbing anger Reduces “splitting,” answer shopping,” and absorbing anger directly through a “unified front”directly through a “unified front”
Identifies stakeholdersIdentifies stakeholders
Top-Down versus Bottom-Up approachesTop-Down versus Bottom-Up approaches
Progress monitoring for accountability and fidelityProgress monitoring for accountability and fidelity
Measuring Effectiveness: Measuring Effectiveness:
Why Collect Data?
Generate a “data probe” to determine the most salient Generate a “data probe” to determine the most salient problem behaviors to addressproblem behaviors to address
Clarify the frequency, rate, intensity, and duration of Clarify the frequency, rate, intensity, and duration of challenging behaviorschallenging behaviors
Identify precipitantsIdentify precipitants
Compare intervention data to baseline dataCompare intervention data to baseline data
Track changes over time, such as the individual response Track changes over time, such as the individual response to interventions, medication changes, and caregiver fidelity to interventions, medication changes, and caregiver fidelity with the planwith the plan
DocumentationDocumentation
Interval Spoilage Sheets Interval Spoilage Sheets
Shift
Activity Refusal
Physical Aggress
Self- Injury
Agitation Property Destruct
Running Away
Sleep Problem
Verbal Threats
1 III
2
3
Antecedent-Behavior-ConsequenceAntecedent-Behavior-Consequence
Date/Time Duration
of
Episode
General Mood
Antecedent and
Precursor
Behavior
Behavior
of Concern
Maintaining Consequences
Comments Initials
12/18/111 PM
5 min. Upset, fixated
on dinner
Eating dinner with
roommate
TakingFood
without asking
Moved JC to opposite end
of table
He followed
directions when
they were given slowly
JM
Caregiver’s Initials and Comments
Time Period Were expectations set and reviewed?
Category of Targeted Positive
Behavior
Circumstances in which behavior
occurred
J.T. 8:00AM Yes 3Waited with a good attitude when nurse was running
late with medications
1. Kept hands down
2. Stayed calm
3. Waited patiently
4. Helpful
5. Followed directions
6. Finished chores
Fidelity Tracking Form
Bar Graph Sample: Comparing and Summarizing Data
Graphing
Line Graph Sample: Longitudinal Trends
Graphing
Strategies and PracticesStrategies and Practices
A process of “defusing” and “deflating” as we try to A process of “defusing” and “deflating” as we try to coach calmness in a situation without physical coach calmness in a situation without physical intervention.intervention.
Strive for three practical goals: Strive for three practical goals: Safety, Connection, and Safety, Connection, and EmpowermentEmpowerment
General Techniques: General Techniques: Show concern and ask questions with kindnessShow concern and ask questions with kindness Use coaxingUse coaxing Conceal your anger and fearConceal your anger and fear Reassure availability of the teamReassure availability of the team Give hope about generating solutionsGive hope about generating solutions Ground in current reality especially with trauma historyGround in current reality especially with trauma history Do not focus only on negative actionsDo not focus only on negative actions Congratulate steps toward regaining controlCongratulate steps toward regaining control Refocus on the individual’s purpose and mission in lifeRefocus on the individual’s purpose and mission in life
Special Topic: Special Topic: Crisis InterventionCrisis Intervention
Special Topic: Special Topic: Sample Crisis Plan
I. Identify Behaviors that lead to Hospitalization. I. Identify Behaviors that lead to Hospitalization. Describe past successful interventions. Proceed from least to most restrictive.Describe past successful interventions. Proceed from least to most restrictive.
AggressionAggression: Hitting and property destruction triggered by invading her personal space or interrupting rituals. : Hitting and property destruction triggered by invading her personal space or interrupting rituals. Proactive Interventions:Proactive Interventions: Avoid confrontations and direct commands. Use a gentle approach. Avoid confrontations and direct commands. Use a gentle approach.Reactive interventions:Reactive interventions: Give space. Provide distractions (country music, non-caffeinated beverages). Give space. Provide distractions (country music, non-caffeinated beverages). Call Call 9-11 9-11 to secure to secure support support if she makes repeated physical contact. if she makes repeated physical contact. ElopementElopement by running away from staff in the community when overstimulated by noise. by running away from staff in the community when overstimulated by noise. Proactive interventions:Proactive interventions: Assess his willingness. Avoid loud crowds. Be sensitive to room filling with people. Assess his willingness. Avoid loud crowds. Be sensitive to room filling with people. Reactive interventionsReactive interventions: Give him space to burn off anxiety. Validate his decision to leave. Ca: Give him space to burn off anxiety. Validate his decision to leave. Call 9-11 ll 9-11 immediately immediately if he runs away because he lacks awareness of safety issues and is difficult to track. if he runs away because he lacks awareness of safety issues and is difficult to track.
Refusing Refusing to attend medical appointments. to attend medical appointments. Proactive interventions:Proactive interventions: Give early notice to process something new. Make pre-appointment with provider Give early notice to process something new. Make pre-appointment with provider to discuss his questions and concerns. to discuss his questions and concerns. Reactive Interventions:Reactive Interventions: Re-approach later. Don’t force the issue. Have him call preferred staff to discuss Re-approach later. Don’t force the issue. Have him call preferred staff to discuss options and hear their comforting voice. options and hear their comforting voice.
II. List Environmental Modifications to reduce frustration: Ample space to walk, low calorie snacks, calendar II. List Environmental Modifications to reduce frustration: Ample space to walk, low calorie snacks, calendar to track visits, and easy access to soothing objects (soft pillows, weighted blanket)to track visits, and easy access to soothing objects (soft pillows, weighted blanket)
III. Preferred Medications to be used only in dealing crisis situations: AtivanIII. Preferred Medications to be used only in dealing crisis situations: Ativan
IV. Approvals: [ ] Individual-Served [ ] Family [ ] Team IV. Approvals: [ ] Individual-Served [ ] Family [ ] Team
Special Topic: Special Topic: Sample Safety Plan
When I am thinking of hurting myself, I will take the following steps:When I am thinking of hurting myself, I will take the following steps:
1.1.Use what I learned in therapy to figure out what is upsetting me. I will realize that Use what I learned in therapy to figure out what is upsetting me. I will realize that thinking I don’t thinking I don’t belong belong bothers me.bothers me.
2.2.I will talk about and write down some positive ways (I will talk about and write down some positive ways (non-suicidal responsesnon-suicidal responses) to ) to deal with what is bothering me.deal with what is bothering me.
3.3.I will do things that, in the past, have helped me feel better (e.g., listening to I will do things that, in the past, have helped me feel better (e.g., listening to music, watching DVD movies, playing sports).music, watching DVD movies, playing sports).
4.4.If the suicidal thoughts continue or if I find myself preparing to hurt myself, I will If the suicidal thoughts continue or if I find myself preparing to hurt myself, I will call the people who can help me to stay safe.call the people who can help me to stay safe.
5.5.If I feel that I cannot control my behavior, I’ll ask staff to go to the nearest If I feel that I cannot control my behavior, I’ll ask staff to go to the nearest emergency room or call 9-11.emergency room or call 9-11.