breakout session - 2:15 pm 9/19/2017dhhr.wv.gov/bhhf/sections/programs/programspartnerships... ·...

Breakout Session - 2:15 PM 9/19/2017

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Multimodal Functional Behavior Assessment:incorporating multiple perspectives

for people with intensive needs

Tim Moore PhD, LP, BCBA-D

Director of Positive Behavior Support

9/14/2017 Minnesota Department of Human Services | mn.gov/dhs 1

Welcome

• With thanks to Dr. Jodi Dooling-Litfin and Dr. Jonna von Schulz

• Objectives

• Describe the importance of a comprehensive, multimodal approach to FBA

• Describe and identify the essential components of multimodal FBA

• Identify how the results of multimodal FBA guide comprehensive interventions and supports in human services, educational, and family settings

Structure of the session

• Section 1: What is Multimodal FBA?

• Section 2: Gathering the information

• Section 3: Linking assessment to support planning

• Section 4: A nod to the importance of measuring implementation and behavior change


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What is Multimodal Functional Behavior

Assessment?


FBA – what circumstances contribute to behavior?

•Context

•Antecedent

•Behavior

•Consequence

• Context…big picture circumstances• Who’s around

• What’s happening

• Where is it happening

• When in the day is it happening

• Antecedents…triggers for behavior• Demands, denials, lack of attention

• Consequences…outcomes that work for the person

• Enhanced attention, escape from demands

Information gathering

1. Indirect assessment - records review

2. Indirect assessment - interviews, rating scales

3. Direct assessment - observing the behavior


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Hypothesis of function & link to support plan

• Hypothesis statement

• A conclusion about the relationship between a behavior, the circumstances that set it into motion / keep it in motion, and the outcomes it produces.

• “When Jessica is told to start her occupational therapy exercises she starts screaming and throwing things, which results in the demand for exercises being removed.”

• Link to support plan

• Proactive strategies: choices instead of demands

• Reinforcement strategies: praise and hugs for doing her exercises

• Positive responses to problem behavior: offer collaboration

APBS guidance PBS Standards of Practice: Individual Level (2013)

Comprehensive assessments result in information about the focus individual in at least the following areas:

1. Lifestyle

2. Preferences and interests

3. Communication/social abilities & needs

4. Ecology

5. Health and safety

6. Problem routines

7. Variables promoting and reinforcing problem behavior:

a. Preferences/reinforcers b. Antecedents

c. Setting events

d. Potential replacement behavior

8. Function(s) of behavior

9. Potential replacement behaviors


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Multimodal FBA

“A ‘final common pathway’ of a person’s functional adaptations to environmental,

physical, and social demands as well as disturbances in neurochemical and

physiological functioning.”

Multimodal FBA

• Multimodal inquiry expands emphasis on the Cs of CABC

• Biology

• Psychology

• Social/environmental

• Quality of life

Vulnerabilities contributing to behavior - Occurrence- Persistence- Variability

BIO SOCIAL

PSYCHO

QOL

- Acute conditions- Chronic conditions- Medication reactions- Neurological- Sleep- Diet

- People/interpersonal- Physical settings- Environmental conditions- Demand characteristics- Stability vs changed

routine

- Mental illness vs wellness

- Trauma- Skill deficits- Emotions- Memory- Perception

- Home- Community- Work- Income- Relationships- Decisions


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Context Antecedent Behavior Consequence

Bio Psych Social/Env QOL Social/Environmental Bio Psych Social/Env QOL

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Griffiths, D. M., Gardner, W. I., & Nugent, J. A. (1999). Behavioral Supports: Individual-centered interventions – a multimodal functional approach.

Teaming

• MFBA allows for all members of interdisciplinary team to play meaningful role in FBA

• Established team members experience being valued, vehicle to add new members

• Challenges teams that do not already include needed members (e.g., medical, psychological)

Gathering Information



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Gathering information: Context

• Biological

• Acute, chronic, medication-related, sleep, diet

• Psychological

• Mental health/wellness, intellectual functioning, history of trauma, emotions

• Social/environmental

• People, settings, environmental conditions, stability, demand characteristics

•Quality of Life

• Home, work, community, income, relationships, decision-making

Biological Factors

• Types of questions to consider and explore: • How is the person’s diet?

• Any current or history of sleep issues (falling or staying asleep)?

• Any known chronic medical conditions?

• Is the person dealing with hormonal changes?

• Does the person experience pain regularly?

• How is the person’s dental health?

• Any known genetic disorders?

• How much daily physical activity?

• When was their last hearing and vision screening?

Psychological Factors

• Symptoms (e.g., hallucinations, anxiety, mania)

• Experienced trauma

• Intellectual and developmental disabilities

• Personality

• Refer for professional evaluation as needed to clarify presence & impact of psychological symptoms (e.g., depression, anxiety, suicidal ideation) and appropriate treatment.


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Psychological Factors

• Types of questions to consider and explore: • Has the person experienced trauma?

• Does he/she have a mental illness? What are the primary symptoms? How does it occur for them?

• Does the person have an intellectual disability?

• Other history or current neurological or psychological disorders?

• Do the person report thoughts about hurting themselves?

• Medications: Which ones? Side effects? What time of day? Are they adherent?

• How is any ongoing treatment working? What effects is it producing?

Social/environmental context

• Many people using services have limitations on choice:

• With whom they live, work, and associate

• The communities in which they live

• The job they have / school they attend

• Romantic relationships

• Support providers

• Work income capped to preserve disability income

• In educational or community settings:

• Staff/teacher turnover

• Chaotic / unstable environments are common

Social/environmental context

• Types of questions to consider and explore:

• Does the person get along with housemates, workmates?

• Does he/she have good rapport with people giving support?

• Are problem behaviors more likely…

• at certain times of day

• with certain people

• during certain activities

• What skills has the person learned recently that they use in their daily life?

• Do any of those skills replace a former problem behavior?

• What supports have worked and not worked?


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Quality of Life

1. Emotional well-being – contentment, self-concept, lack of stress

2. Interpersonal relations – interactions, relationships, supports

3. Material well-being – financial status, employment, housing

4. Personal development – education, personal competence, performance

5. Physical well-being – health and health care, activities of daily living, leisure

6. Self-determination – autonomy / personal control, personal goals, choices

7. Social inclusion – community integration and participation, roles, supports

8. Rights – legal, human (respect, dignity, equality)

Robert Schalock / communitylivingbc.ca See also SAMHSA Eight Dimensions of Wellness

Antecedents

Task demand

Social approach

Denied request

Terminated activity

Reduced attention

Inquiring minds want to know…

What behaviors do they trigger?

How reliably?

Under what contextual circumstances?

Operationally define the behavior

• Title of the behavior

• Exhaustive description of the topography (physical movements involved) of the behavior that is observable and measurable

• Example & non-example of the behavior

Aggression: a punch or open-hand hit to any part of the body at any

intensity. Example: John punches Bob in the arm. Non-example: John

swipes a mosquito off Bob’s shoulder.


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Behavior

Add/Acquire Remove/Avoid

Internal stimulation

People/Attn Internal stimulation

PeopleObjects Activities Settings

DrugFlavor

ProprioceptionSexual

ColdScents

SocialComfort

HelpPraise

TV remoteFoodCar

ComputerCigarettes

Money

CommunityCooking

Front seatJob

Video games

ItchHeadache

NauseaHeart rateHeartburn

ThirstPerseveration

HousemateStaffSister

DentistParents

BullyDoctor

StoreRestaurant

SchoolWorkHome

Tx group

Tasks

ChoresJobs

HygieneExerciseSchool

Tx groupHomework



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Linking Assessment to

Support Planning



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Developing the support plan

• All voices heard

• Linking assessment results to specific interventions for physical health, mental health, skill development, quality of life

• Instruction/teaching specific to skill needs *

• Stakeholders / the person using supports can have the loudest voice –what is most important TO them re: where to start?

Case example

Marcus – 5 years old

• Diagnoses: PTSD, mild motor delays

• Behaviors: physical aggression, tantrums

• Kindergarten setting is most challenging but also problems at home with mom




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Behavior

Aggression: Marcus hits and kicks peers. Occurs 3-5 times per day in the kindergarten room.

Tantrum: Marcus screams and rolls around on the floor. Occurs following ~75% of mother’s task demands / attempts at engaging him in new activities.

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ContextBiological Psychological Social/Environmental QOL

Allergic to pollen and dust year-round, wheezing and runny eyes/nose, irritable; when on Benadryl, he is sleepy

PTSD (physical abuse byfather, mother’s boyfriends); history of mother leaving kids alone

Inconsistent schedule, mother’s anxiety & depression,brother’s medical condition

Little opportunity for choices, financialinsecurity at home, inconsistent caregivers at home

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AntecedentSocial/Environmental

- Teacher is attending to peers- Peers are attending to teacher or other peers- Marcus is not engaged in interaction with teacher or peers

- Mom requests a non-preferred activity or to end a preferred activity

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Consequence

Biological Psychological Social/Environmental QOL

Aggression relievesphysiological symptoms of anxiety by activating other physiological symptoms

Intermittent Benadryl when Marcus tantrums may relieve allergy symptoms as well

Attention resulting from aggression reduces fears of abandonment

Sense of control over his behavior and his day

Marcus gets attention from childcare providers when he aggresses toward peers

Marcus avoids undesired tasks through tantrums, and mom often allows him continued access to preferred activities instead

Marcus gets to stay home with mom if suspended from school

Marcus gets choices in his day as a result of his tantrumsA

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Behavior

Aggression: Marcus hits and kicks peers. Occurs 3-5 times per day when in kindergarten room.

Tantrum: Marcus screams and rolls around on the floor. Occurs following ~75% of mother’s task demands / attempts at engaging him in new activities.

Social approach: ask peers to play with him, ask mom or teacher for a high five or a hug

Marcus hands mom a ‘just a minute’ card when she asks him to do an activity he does not want to do right away.

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ContextBiological Psychological Social/Environmental QOLAllergic to pollen and dust year-round, wheezing and runny eyes/nose, irritable; when on Benadryl, he is sleepy

PTSD (physical abuse byfather, mother’s boyfriends); history of mother leaving kids alone

Inconsistent schedule,mother’s anxiety & depression, brother’s medical condition

Little opportunity for choices, financial insecurity at home, inconsistent caregivers at home

Treat allergies proactively

Referral to mental health clinic for Marcus and Mom

Support for Mom to provide more consistency, respite funds to access supports

Family support grant through county for mom to learn developmentally-appropriate support skills and put skills to use at home (more time at home), also for morerobust child care assistance when not home

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AntecedentSocial/Environmental

- Teacher is attending to peers- Peers are attending to teacher or other peers- Marcus is not engaged in interaction with teacher or peers

- Mom requests a non-preferred activity or to end a preferred activity- Teacher delivers rich schedule of attention proactively- Schedule activities for Marcus and peers together- Assign a peer buddy during free time

- Mom uses choices of activities (acceptable to her) instead of demands - Mom provides more proactive help and support when allergies really

act up

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Consequence

Biological Psychological Social/Environmental QOL

Aggression relievesphysiological symptoms of anxiety by activating other physiological symptoms

Intermittent Benadryl when Marcus tantrums may relieve allergy symptoms as well

Attention resulting from aggression reduces fears of abandonment

Sense of control over his behavior and his day

Marcus gets attention from childcare providers when he aggresses toward peers

Marcus avoids undesired tasks through tantrums, and mom often allows him continued access to preferred activities instead

Marcus gets to stay home with mom if suspended from school

Marcus gets choices in his day as a result of his tantrums

Manage physiological symptoms of anxiety through relaxation techniques and planned exercise

Provide timely allergy management

Build consistent peer relationships

Provide more consistent schedule at home, including reduced # people coming in and out

Decrease attention for aggression while reinforcing new attention-getting skills

Honor requests for ‘just a minute’ before bringing him into new activities

Through increased positive and predictable time with mom at home, mom can vary fun activities and attention based on positive behavior (or not)

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A Nod to Implementation and Measuring Change



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Measuring clinical outcomes

• Before you implement the support plan:

• Measure how often challenging behavior is occurring

• Measure how often positive behavior is occurring

• Measure other targets the team identifies – psychiatric symptoms, nutrition, activity engagement, etc

• Measure quality of life quality factors targeted for improvement

• After you begin implementing the support plan:

• Continue measuring these things to see if they improve

Measuring implementation

• People can’t benefit from supports they don’t receive

• Support your staff to implement with fidelity (and measure it) – create a system that works for you

• Implementation: stages…cycles…teams…drivers

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Baseline Support plan in place

Thank you!

[email protected]

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breakout session - 2:15 pm 9/19/2017dhhr.wv.gov/bhhf/sections/programs/programspartnerships... ·...

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