may benefit from behavior analysis · what is behavior analysis? • science of behavior • based...
TRANSCRIPT
November 2018
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Melissa Richards, Ph.D., LBA, BCBA-DSenior Vice President of Clinical
Operations
A Behavioral Approach: Beyond AutismPennsylvania’s 2018 Dual Diagnosis Conference
May Benefit from Behavior Analysis
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What is Behavior Analysis?
• Science of behavior• Based in philosophy of Behaviorism
– a theory of learning – behavior is a product of the environment
• Experimental Analysis of Behavior– basic research on principles of behavior
• Applied Behavior Analysis– application and research of principles of
behavior to problems of social significance
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What is Behavior Analysis?
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Who Provides Behavior Analysis Services?
• Board Certified Behavior Analyst• Board Certified Assistant Behavior Analyst• Registered Behavior Technician• Licensed Behavior Analyst• “Behavior Therapist”• “Behavior Specialist”
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What Do Behavior Analysts Do?
• Use the principles of reinforcement to change behavior
• If something “good” happens after you emit a behavior, you will be more likely to emit that behavior in the future.
• If something “bad” happens after you emit a behavior, you will be less likely to emit that behavior in the future
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Positive Reinforcement
Child wants mom’s
attentionChild cries
Child gets mom’s
attention
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Child wants mom’s
attention again?
Extinction
Child wants mom’s
attentionChild cries
Mom walks away
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Child wants mom’s
attention again?
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Teach Replacement Behavior
Child wants mom’s
attentionChild cries
Mom walks away
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Behavior Analyst prompts child to
say “mom”
Child says “mom”
Child gets mom’s attention
Child wants mom’s
attention?
Functional Assessment
We must find out why a behavior is occurring in order to know how to change the behavior
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? Child cries ?
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Functional Assessment
Jackie is a 47 year old man diagnosed with a mild intellectual disability.
He was referred for a functional assessment by his support coordinator as a result of frequent self‐injurious behavior (SIB)
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FA - Interviews
The BCBA starts by conducting interviews with• the support coordinator• direct support professionals• JackieThe BCBA needs to know• what the behavior looks like• when it occurs and doesn’t occur• what happens before and after the
behavior
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FA - Interviews
Topography (what the behavior looks like)
DSPs report that Jackie balls his right hand into a fist and forcefully punches himself in the face, primarily in the mouth or eyes
Support Coordinator reports that Jackie has had 2 black eyes and a busted lip in the last 2 months
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FA - Interviews
Jackie reports that he hits himself when he gets upset at his DSP. When asked what makes him upset, he states he doesn’t know.
DSPs report that Jackie hits himself whenever they ask him to do something he doesn’t want to do. They report he never hits himself when he is just hanging out watching tv with them
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FA – Direct Observation
Based on the interviews, the BCBA decides to observe Jackie in his home during evening leisure time and during afternoon when chores and hygiene activities are scheduled.
The BCBA observes on 5 separate days at different times of the day.
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FA - Results
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DSP asks Jackie to take out
trash
Jackie hits himself
DSP says “ok you can do it
later”
DSP asks Jackie to take a shower
Jackie hits himself
DSP says “ok you can do it after tv time”
DSP asks Jackie to take his plate
to the sink
Jackie hits himself
DSP says “go watch tv, I’ll get
it”
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Why does Jackie Hit Himself?
• Because he has a disability?• Because he doesn’t like staff?• To avoid tasks he finds aversive?• To get to keep watching TV?
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What Can We Do?
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DSP asks Jackie to do
somethingJackie hits self
DSP removes request
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PSYCHIATRIC DISORDERS
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What is a “Dual Diagnosis?”
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Mental Illness
AddictionID/DD
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Prevalence
General Population People with Intellectual Disabilities
Mental Illness 20% 32 – 40%
OCD 1.2% 3.5%
Borderline P. D. 1.4% 10 – 13%
ADHD 4.4% 17 – 52%
Schizophrenia .25 ‐ .64% 3%
Dementia (over 65 years of age)
6.5 – 13% 5%
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Challenges
“Children and adults who have ID coexistent with psychiatric disorders may be one of the most underserved populations in the United States. These individuals may fall through the cracks in service delivery systems when neither the local mental health service system nor the developmental disability service system is willing or able to assume responsibility for their treatment, services and support.” Fletcher, Loschen, Stavrakaki and First (2007)
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Werner, Stawski, Palakiewicz, & Levan (2013)
• 90% stated they “lack specific training in diagnosis and treatment” of ID
• 87% strongly agreed with the need for training
• 34% lack knowledge about psychotropic treatment for people with ID
• 40% lack knowledge of diagnosing psychiatric disorders in people with ID
• 68% believe people with DD receive a poor standard of psychiatric care
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Diagnostic & Treatment Challenges
• Limited verbal skills• Desire to please/tendency to agree• Fear of reprisal• Baseline behaviors• Incomplete/inaccurate information
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How Can We Help?
Help the person communicate– Identification of feelings– Self-advocacy– Honest reporting
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How Can We Help?
Collect and share data• what is “normal” for this
person?• what is happening now?• Yes, but…..
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How Can We Help?
Educate mental health practitioners• Doctors• Emergency responders• Mental health crisis responders
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How Can We Help?
Use all available resources• Psychotropic medication• Psychotherapy/Counseling• Support groups• Social Skills groups• Natural supports• Behavior Analysis
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An Unlikely Alliance?
Behavior Analysis
Mental Health
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“BAs don’t think people have feelings”
Fact: behavior analysts know that people have thoughts, feelings and emotions
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“BAs Don’t Think Feelings are Important”
Fact: behavior analysts do not want people to use thoughts, feelings and emotions as excuses for behavior
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Annie, why Annie, why did you hit Bill? You shouldn’t do that.
It’s not my fault, he made me mad!
Feelings, Thoughts & Emotions
• They exist• They are important• They don’t “cause” behavior• They can “affect” behavior
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OBSESSIVE-COMPULSIVE
DISORDER
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A Hypothetical Example
Carol has OCD
Repeatedly flips light switches
If OCD is the “cause” how can we help her?
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If OCD doesn’t
“cause” the behavior,
what does?
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Let’s find out! We will conduct a functional assessment.
Step 1 – Ask Carol
Carol says she engages in this behavioral routine because it keeps her from experiencing extreme anxiety.
What is Anxiety?
For Carol, Anxiety includes:• a racing heart• sweating• thinking obsessively that she left a light on
and that the house is going to burn down• inability to attend to and enjoy the
activities• a desire to go home and check on the
house
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The Function
Carol engages in the behavior to avoiduncomfortable thoughts and feelings.
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Preparing to leave house
Flips switchesAvoid or minimize anxiety
Preparing to leave house
Does not flip switches
Extreme anxiety
OCD and Anxiety do not cause behavior
If Carol were to avoid going down a certain street on her daily run because there is a person on that street who she doesn’t like or want to talk to, did that person “cause” her to avoid the street?No, the “cause” of her avoiding that street is to avoid talking to someone she doesn’t like.
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How Can a BCBA Help Carol?
“Extinction” is when we don’t allow the behavior (switch flipping) to produce the reinforcer (avoid anxiety)
“Habituation” is when we allow the response (anxious thoughts and feelings) to dissipate over time
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Response Blocking
Do not allow Carol to flip switches or return home to check • May have a physical struggle• Carol would experience extreme anxiety• Wouldn’t enjoy the community activity• May become aggressive
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Preparing to leave house
Flips switchesMinimize anxiety
Habituation
Eventually, the anxiety would dissipate.
Carol would return home to find the house just as she left it.
Each time this is repeated, the anxiety would be less intense and last less time.
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Exposure and Response Prevention
• Cognitive Behavior Therapy• Effective for many forms of anxiety and
phobias• Must occur under direction of a professional• Exposure is gradual (not like in Carol’s
example)• Sometimes involves things the average
person would not do.
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Exposure and Response Prevention
Options for Carol• Block response and gradually increase
time away from home (5 minutes, 15 minutes, etc.)
• Allow gradually fewer responses (only flip twice, then once, etc. or 5 switches, then 4, etc.)
• Do things the average person wouldn’t do (intentionally leave all lights on, toaster plugged in etc.)
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DEMENTIA
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Dr. Margaret Chan, WHO
“I can think of no other disease that has such a profound effect on loss of function, loss of independence, and the need for care. I can think of no other disease so deeply dreaded by anyone who wants to age gracefully and with dignity. I can think of no other disease that places such a heavy burden on families, communities, and societies. I can think of no other disease where innovation, including breakthrough discoveries to develop a cure, is so badlyneeded.”
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Signs of Dementia
• Memory Loss that disrupts daily life• Challenges in planning or solving problems• Difficulty completing familiar tasks• Confusion with time or place• Trouble understanding visual images and spatial
relationships• New problems with words in speaking or writing• Misplacing things and losing the ability to retrace
steps• Decreased or poor judgment• Withdrawal from work or social activities• Changes in mood or personality
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Dementia Screening
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• Limited fine motor skills• Doesn’t know numbers• Doesn’t tell time• Can’t hear instructions
And never could!
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Is the Clock Test Appropriate for Everyone?
Dementia describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities.
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457
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1011. 21
612 4
57810
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612 4
57810
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NTG-EDSD
used for the early detection screening of those adults with an intellectual disability who are suspected of or may be showing early signs of mild cognitive impairment or dementia
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Recommended Usage
• Annual basis or as needed• Adults with Down syndrome over 40• Individuals with ID/DD showing cognitive
change• Administered by anyone who has known the
person at least 6 months• Takes 15 – 60 minutes
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Things to know about NTG -EDSD
• It is NOT a diagnostic tool. • There is NO scoring system. It provides
qualitative review of changes that may be associated with dementia.
• Signal items: Those items throughout the NTG-EDSD that are linked to the general warning signs of MCI or early dementia
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Early Detection Screen for Dementia
• 63 questions• Answer choices:
– Always been the case – Always but worse – New symptom in past year – Does not apply
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Early Detection Screen for Dementia
• Activities of Daily Living (7)• Language & Communication (6)• Sleep-Wake Change Patterns (8)• Ambulation (4)• Memory (9)• Behavior & Affect (17)• Self-Reported Problems (6)• Notable Significant Changes Observed by
Others (6)
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Results
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• Share with physicians• Keep on file• Determine when you will reassess• Make referrals to appropriate service
providers– Behavior challenges – BCBA– Ambulation issues – PT– Communication - SLP
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What can a BA work on?
Challenging Behaviors• Verbal Aggression• Physical Aggression• Wandering• Noncompliance
Skill Deficits• Recall Behavior• Engagement• Manding/Verbal
Behavior• Adaptive Daily
Living Skills
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Environmental Modifications
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Environmental Modifications
5958
Communication Skills
Familiar people
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Communication Skills
Familiar places
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Summary
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Behavior Analysis: It’s not just for autism any more.