PREVENT-TEACH-REINFORCE (PTR): AN EFFICACIOUS TIER 3 BEHAVIOR INTERVENTION

Presented at the 2010 PBIS Leadership ForumChicago, IL

Rose Iovannone, Ph.D., BCBA-DUniversity of South Floridaiovannone@fmhi.usf.edu

813-974-1696

The contents of this training were developed under grant H324P04003 from the Department of Education.

OBJECTIVES

Participants will: Describe the 5-step PTR Tier 3 support model Identify the critical components that enhance the

success of Tier 3 behavior supports Discuss application at district level

AGENDA

Rationale and conceptual foundation Research method/outcomes Overview of PTR process Suggestions for district-wide application

TIER 3 FUNCTION-BASED BEHAVIOR INTERVENTIONS IN SCHOOLS

Issues Absence of uniform policies & practices Form versus a process Expert driven versus collaborative effort Occasionally contextual fit considered Limited support/follow-up/training for teacher

provided Result--limited impact on student behavior

WHAT IS PREVENT-TEACH-REINFORCE (PTR)?

Research project funded by U.S. Department of Education University of South Florida University of Colorado, Denver

Evaluate effectiveness of PTR process vs. “business as usual” Randomized controlled trial Intervention “Package”

ONE ‘P’revent; ONE ‘T’each; ONE ‘R’einforce Based on ABA principles and individual Positive

Behavior Support

WHAT IS PREVENT-TEACH-REINFORCE (PTR)?

Primary Research Questions: Is the PTR intervention more effective than

control conditions (‘business as usual’) in decreasing severe problem behaviors and increasing pro-social and academic skills of students? Repeated measures—baseline, post-test, follow-up

Social Skills Rating System (SSRS)-Problem Behavior and Social Skills subscales

Academic Engaged Time (AET)

PARTICIPANTS K-8th grade Behavioral difficulties

Intensity– disruption to the learning environment

Frequency— minimum of 1 time per weekDuration– minimum 6 months

General or Special EducationAll cognitive levelsAll disabilities

Teachers volunteered & nominated 1-3 studentsTop externalizersSystematic Screening for Behavior

Disorders (SSBD)

PROCESS

Standardized Individual Positive Behavior Support approach

Intervention teams provided manual, assignments, homework

Five step process aligned with problem solving facilitated by PTR Consultant Team Development Goal Setting Assessment Intervention and Coaching Evaluation

OUTCOMES OF PTR PROCESS

STUDENT DEMOGRAPHICS BY PRIMARY DISABILITY

Disability N Percent

Autism 25 9.8

Developmental Delay 5 2.0

Emotional Disturbance 38 14.9

Mental Retardation 28 11.0

Multiple Disabilities 4 1.6

OHI (not ADD/ADHD) 1 .4

OHI (ADD/ADHD) 8 3.1

Specific Learning Disability 20 7.8

Speech/Language Disability 10 3.9

Visual Impairment 2 .8

General Education 99 38.8

TOTAL 245

STUDENT DESCRIPTIONGrade Level

K12345678

N345353413016

783

%13.921.621.616.712.2

6.52.93.31.2

Lunch StatusRegularFree/Reduced

77150

31.461.2

GenderFemaleMale

45200

18.481.6

Baseline Post-test0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

AET

Treatment n = 126

Control n=98

Time Interval

AE

T r

atio

p<..01g = .51

Cross-Over Treatment Results

Baseline Post-test76

78

80

82

84

86

88

90Social Skills

Social Skills

p <.01d = .85

Baseline Post-test110

112

114

116

118

120

122

124

Problem Behavior

Problem Behavior

p <.00d = 1.03

Baseline Post-test0

10

20

30

40

50

60

AET

AET

p <.01d = .64

TEACHER OUTCOMES

Fidelity Majority of teachers achieved .80 Mean # coaching/training sessions = 3.5 Prevention higher than Teach and Reinforce

Social Validity Modified Teacher Acceptability Rating Form

(TARF; Reimers & Wacker, 1988)—15 items 5-point Likert Scale 124 teachers Overall—4.16 (.52)

Willingness to carry out plan—4.80 (0.42) Like the procedures—4.46 (0.64)

PTR: THE PROCESS

STEP 1: TEAMING Purpose:

Evaluate strengths and weaknesses of team functioning Outline roles and responsibilities Determine a consensus-making process

Members (desired Person with knowledge of student (e.g., Classroom teacher,

instructional assistant, parent) Someone with expertise in functional assessment,

behavioral principles (PTR consultant, school-based consultant)

Someone with knowledge of context (e.g., administrator or designee)

Tools Work style survey

Teacher and Teacher Assistant Teaming survey

STEP 2: GOAL SETTING

Purpose: Identify behaviors of greatest concern to the

team and possible replacement behaviors (teach)

Prioritize and operationalize behaviors Develop teacher friendly baseline data collection

system Targeted Areas:

Problem behaviors Social skills Academic behaviors

Case Study—Step 2: Goal Setting

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reas

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road

Mike will communicate his wants and needs appropriately

Mike will interact with peers appropriately

Mike will comply with non-preferred activities and requests

Mike will decrease screaming, hitting, and getting out of his seat

Mike will decrease hitting, screaming at, and bossing his peers

Mike will decrease screaming and hitting

Mike will ask for a break or for attention when needed

Mike will initiate peer interactions using his Dynamite

Mike will engage in non-preferred activities and communicate his frustration using his Dynamite or an appropriate tone

Behavior Social Academic

STEP 2: DATA COLLECTION SYSTEM

Behavior Rating Scale Direct Behavior Rating (DBR)—Hybrid assessment

combining features of systematic direct observations and rating scales

Efficient and feasible for teacher use Provides data for decisions Prioritized and defined behaviors measured Requires minimum of 1 appropriate and 1

inappropriate behavior

CASE STUDY - MIKE: OPERATIONAL DEFINITIONS

Problem behaviors Screaming—loud, high pitched noise heard

outside the classroom Hitting—anytime Mike touches peers or adults

with an open hand, fist, foot, or object while screaming or protesting

Replacement/Appropriate Behaviors Express frustration appropriately using

Dynamite, pictures, or signs to ask for a break or attention

Transition to non-preferred activities: Moving to non-preferred activity and engaging with appropriate verbal expression

Case Study- Mike: Behavior Rating Scale Behavior

Screaming 9+ times7-8 times5-6 times3-4 times0-2 times

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Hitting 8+ times6-7 times4-5 times2-3 times0-1 times

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Expressing Frustration

40%+30-40%20-30%10-20%0-10%

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Transition to Non-preferred

Whimper or squealLouder than indoor voice

Outdoor play voiceLouder than outdoor play

Ear penetrating

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Dat

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BRS PSYCHOMETRICS (PRELIMINARY)

Kappa coefficients of: Problem Behavior 1 (n = 105): .82 Problem Behavior 2 (n = 90) : .77 Appropriate Behavior 1 (n = 103): .65 Appropriate Behavior 2 (n = 56): .76

STEP 3: PTR ASSESSMENT (FBA)

PTR Assessment (FBA) Each team member independently answers a

series of questions related to: Observed antecedents/triggers of problem behaviors Functions of the problem behaviors Consequences ordinarily associated with the problem

behaviors PTR facilitator summarizes input and develops

draft hypothesis Team reaches consensus

STEP 3: CASE STUDY – MIKEASSESSMENT SUMMARY TABLE OF PROBLEM BEHAVIOR

Prevention Data Teach Data Reinforce Data

Non-preferred taskReading, Math

Other students upset/madTeacher attending to othersTransition

Preferred to non-preferredChange in schedule

Denied item, told no, or to fix something

Gain attentionPeers, adults

Delay

Access to items

RedirectedReprimandedCalm/soothe

Personal spaceLater must complete task

Loss of or delay in reinforcement

Scr

eam

ing,

Hitt

ing

STEP 3: CASE STUDY – MIKEASSESSMENT OF APPROPRIATE BEHAVIOR

Prevention Data Teach Data Reinforce Data

Independent workOne-on-one attentionSpecials

Peer interactionGetting attentionRaising handSharing attentionConversation skillsTaking turnsWaitingSelf-managementAsking for breakExpressing emotions

Treasure boxMovieAttentionHelping teacherGoing to media centerGoing outsideWalkFood

Pro

soci

al

STEP 3: CASE STUDY – MIKE HYPOTHESES

When…. he will As a result…

Mike is asked to complete non-preferred tasks (Reading, Math), stop preferred activity or transition to non-preferred activity, fix an error, or when teacher is attending to other students

scream and hit Mike is able to gain attention and delay the transition/activity

Mike is asked to complete non-preferred task (Reading, Math), stop preferred activity or transition to non-preferred activity, fix an error, or when teacher attending to other students

express his frustrations appropriately

complete the assigned task

Mike is able to delay the transition/activity

Mike is able to gain attention

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op

riate

STEP 4: BEHAVIOR INTERVENTION PLAN

Team selects interventions from each component (P-T-R)

Detailed behavior plan developedConsultant provides training and

on-site assistance with plan implementation

Implementation fidelity evaluated

Prevent Strategies

Specific Strategy steps

Environmental Support

A wait card will be placed on Mike’s desk to assist him in remembering to wait his turn.

1. Prior to group work, tell Mike, “Remember, when it is someone else’s turn, you sit quietly and wait,” while pointing to his card.2. If Mike calls out, point to his visual to remind him what to do. 3. Use a verbal prompt if the point prompt does not work.

Step 4: Case Study – Mike’s BIP

Prevent Strategies

Specific Strategy steps

Environmental Support

Mike’s visual schedule will be modified to detail the number of and type of activities he is to complete during non-preferred activities. For example, if math involves listening to a lesson, doing a hands-on activity, and completing a worksheet, his visual schedule will list each activity under math using either a picture of the type of activity or using numbers that correspond to a number on the worksheet.

1. Prior to the start of the activity, Mike should review the visual schedule.2. As Mike completes an activity, he should X off the activity.

Mike’s Intervention Plan

Mike’s Intervention Plan

Prevent Strategies

Specific Strategy steps

Curricular Modification

Mike will be given an easy, independent activity, such as a worksheet, to complete upon transitioning to a non-preferred activity or an activity that requires him to wait, such as group activities

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Teach Strategies

Specific Strategy Steps

Replacement Behavior

Mike will be taught to use his voice output device to express his need to calm down.Steps:1. Mike’s device will be programmed to say “I need to calm

down.”2. Prior to transitioning to a non-preferred activity or at the end

of a preferred activity, say “If you start to get mad, you can choose to calm down.”

3. As soon as Mike starts to get upset, prompt him to use his device (hierarchy—hand-over-hand, gesture, verbal).

4. Once Mike communicates “I need to calm down”, present him with the choice board of calming strategies and ask him, “What do you want?”

5. As soon as he is calm, praise him (e.g., “You made a good choice.”.

6. Allow Mike to engage in his choice until he is calm for 1-minute.

7. If Mike does not want to leave his choice, then start becoming animated with students in the non-preferred activity.

Teach Strategies

Specific Strategy Steps

Self-Management

Mike will be taught to independently use his calming strategies.

1. A tracking sheet with smiley faces and sad faces will be given to Mike at the start of each day.2. Role-play with Mike about when he needs to make the choice to calm down.3. Practice completing the tracking sheet.4. Set and review the daily goal for using the calming strategies. 5. Prompt Mike to complete the tracking sheet if needed

Reinforce Strategies

Specific Strategy Steps

Replacement Behavior

Anytime Mike “says” “I need to calm down”, his choice board should be given.1. Praise Mike for communicating (“thank you for telling me

what you need.”)2. Provide his choice board.3. Allow him to calm for 1 minute4. Praise him as soon as he is quiet5. Praise him for returning to the group

Self-Management

Anytime Mike scores his behavior, attention should be given.

1. When Mike marks his tracking sheet, praise him for doing so.

2. At the end of the day, review the sheet with Mike.3. Talk about the sad faces.4. Provide his reward if his goal is met.

Waiting Mike will earn a skittle paired with attention if he waits. This will be faded to an intermittent schedule.

Reinforce Strategies

Specific Strategy Steps

Transition Mike will earn stars during Reading Centers if he transitions and completes his work without screaming.

1. A social story will be reviewed prior to Reading Centers to remind Mike that he can earn a star if he comes to centers and works.

2. At the end of each reading center, an adult will review Mike’s behavior with him and ask him if he earned his stars.

3. Provide his stars if earned.4. During the teacher’s group, Mike can earn 2 stars: 1

for transitioning to the group and 1 for working during group.

5. Allow Mike to participate in his chosen activity if he earned his stars.

STEP 4: PTR INTERVENTION COACHING/FIDELITY

Provide training to practice the plan without student (30-90 min.)

PTR Consultant present first day of implementation with student

Provide support in the classroom Model the plan Provide feedback Discuss need for modifications if applicable

Case Study: Sample Coaching Checklist/Fidelity for Mike

Task Analysis of Intervention D

iscu

ss

Q &

A

Ver

bal

R

ole-

pla

y O

bse

rve

Fee

db

ack

Training

Review

PREVENT – Environmental Support 1. Mini schedule of group & center time available Yes No Yes No

2. Schedule reviewed prior to task Yes No Yes No

3. Schedule reviewed & items crossed off Yes No Yes No

TEACH – Replacement Behavior

1. Remind to use Dynamite prior to transition Yes No Yes No

2. Provided choice board and honored choice Yes No Yes No

REINFORCE –Replacement Behavior

1. Verbally or gesturally acknowledge ASAP Yes No Yes No

2. Allowed to cool off for 1-minute Yes No Yes No

TOTAL (# Yes/ # Total) Fidelity Score ( .00 – 1.00)

STEP 5: EVALUATION

Is it working? Daily ratings of behavior Continuous progress monitoring

BRS Other data collection forms

Is it being implemented consistently and accurately? Fidelity ratings

Do we need more data? Does the plan need to be modified or

expanded? Plan for generalization and maintenance

Screaming

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BaselineIntervention

Definition Changed

Step 5: Mike Evaluation

Hitting

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BaselineIntervention

Step 5: Evaluation

Step 5: Evaluation

Expression of Frustration

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BaselineIntervention

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Transition to Non-Preferred

BaselineIntervention

STEP 5: EVALUATION

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STEP 5: EVALUATION MIKE OUTCOME DATA

Measure Baseline Post-test Change

SSRS-PB 123 112 -11

SSRS-SS 87 102 +15

AET .34 .57 +23

REVIEW PTR PROCESS

Five-step team-based process Teacher/team driven Support provided to teacher/team to

implement interventions Mean number of days for PTR process = 71

References• Manual

• Dunlap, G., Iovannone, R., English, C., Kincaid, D., Wilson, K., Christiansen, K., & Strain, P. (2010). Prevent-Teach-Reinforce: A school-based model of individualized positive behavior support. Baltimore:Paul H. Brookes

• Journal articles• Iovannone, R., Greenbaum, P., Wei, W., Kincaid, D., Dunlap, G., & Strain, P.

(2009). Randomized controlled trial of a tertiary behavior intervention for students with problem behaviors: Preliminary outcomes. Journal of Emotional and Behavioral Disorders,17, 213-225.

• Dunlap, G., Iovannone, R., Wilson, K., Strain, P., & Kincaid, D. (2010). Prevent-Teach-Reinforce: A standardized model of school-based behavioral intervention. Journal of Positive Behavior Interventions, 12, 9-22

• Iovannone, R., Greenbaum, P., Wei, W., Kincaid, D., & Dunlap, G. (in review). Reliability of the Individualized Behavior Rating Scale-Strategy for Teachers (IBRS-ST): A Progress Monitoring Tool.  Manuscript submitted for publication.

• Next steps:• Facilitating schools to scale up• Training key school staff and team members to do process

APPLICATION OF TIER 3 DISTRICT LEVEL

STEP 1: ASSESS CURRENT STATUS

PBS TEAM STRUCTURE

Goals: Teams to support all students (general ed. and

ESE) throughout tiered (levels) continuum of support

System for monitoring outcomes at all levels Access to technical assistance Link between all three tiers of behavior support Link between school, home, community

PBS TEAM STRUCTURE IN A SCHOOL SWPBS team—for all students (gen. ed. &

ESE) Monitor implementation of universal intervention Monitor school-wide data Guide implementation of new initiatives, braid

with SWPBS Tier 3 PBS team—“Standing team”—for all

students (gen. ed. & ESE) Progress monitor students in targeted and

intensive interventions Guide intervention selection for students

selected for IPBS Student-focused teams—“Ad hoc” for all

students (gen. ed. & ESE) Conduct FBAs and build support plans

TIER 3 BEHAVIOR SUPPORT IN A SCHOOL: TEAM OPTION

“Ad-hoc” team—student focused (both gen. ed. & ESE) Responsibilities of team (problem solving process)

Conduct FBA Build function-based support plan Provide coaching/support to teacher to implement interventions Collect and review fidelity and student outcome data Make decisions based on data

Membership—Three levels of knowledge represented Someone with expertise in FBA and function-based intervention

plans (school psychologists, CABAs, BCBAs, behavior specialists, counselors, social workers……)

Someone with knowledge of the student and his or her behaviors (Teacher(s), aides, parents, students)

Someone with knowledge of the context in which the support plan will be implemented (administrators or designees)

TIER 3 PROCESS—CONSISTENT AND FEASIBLE

MULTIPLE LEVELS OF TIER 3 (FBA)

Brief FBA FBA/BIP developed in one meeting (60 minutes

or less) Best used for high frequency/low intensity

behaviors (e.g., noncompliance, minor disruptions, etc.) Example: Brief PTR, ERASE

Comprehensive FBA More complex FBA/BIP procedure May take 2 or more meetings or one lengthy

meeting (>1 hour) Best used for chronic, durable, intense

behaviors Example: PTR

MULTIPLE LEVELS OF TIER 3

Wraparound Involves multiple agencies Support plan includes practices that may go

beyond scope of school Best used for students with mental health issues

and/or complex life events

DATA TRACKING—TIER 3

Systemic Data Tracking Examples Florida School Districts

Monroe Martin University of Oregon

QUESTIONS?

FOR COPIES OF FORMS, E-MAIL:

iovannone@usf.edu