Targeting Appropriate Needs within the BSP Amy Alford, M.Ed., BCBA Clinical Consultant Bureau of Autism Services

Why this topic? Patterns emerging from BSP/CIP reviews Questions raised from Behavior Specialists, SCs, Regional Office, and Clinical teams Increased participant needs (law enforcement, sexuality, family dynamics, skill deficits, etc…) Strong BSPs are needed to address these concerns

BSS BSS is… BSS is not… A service designed to address problematic behaviors Assessment–based: An FBA identifies the needs and drives the development of a BSP/CIP Data-driven: Initial and ongoing data inform the BS of changes needed to the BSP/CIP monthly, quarterly, and annually Designed to work with other services, providing face-to- face training and implementation of BSP CI, job services, family training, res hab, day hab, respite, etc… Working on the same goals may occur (e.g. money mgmt), but clear distinction must be made. Responsible for developing objectives for other services Each service has own set of responsibilities

Agenda Taking a Step Back: A Quick Review The Do’s and Don'ts of the BSP/CIP (with examples) Patterns, Themes, and Questions

Taking a Step Back Think: 2-Day FBA training* Defining behavior Observable, measurable terms Prioritizing behavior Destructive, Disruptive, Disturbing Targeting the A-B-Cs What is happening right before and right after bx Data Collection Drives the BSP- Critical; Think beyond frequency *New FBA Training- Fall 2012

Taking a Step Back Think: 2-Day FBA training, cont… Hypothesis Statement Identify the function- escape or obtain? More than one may be needed Antecedent, Replacement Bx, Consequence Strategies Multi-component and comprehensive; Re-visit the hypothesis statement(s) One strategy will NOT do the trick! Desired Behavioral Outcomes Objectives; link back to the hypothesis statement Training the team Initial and ongoing

Don’t forget to… Summarize FBA data and share with the team Completing an interview form is not summarizing! HCSIS does not capture everything Include graphs Revisit and Revise: The FBA process is ongoing and BSP/CIP should be updated accordingly Don’t forget to inform SC of any changes needed to the ISP

A little bit more about the strategies Do’s and Don’ts

Antecedent Strategies Do’s Don'ts Don’t highlight what specific providers will do E.g. CI will identify where he wants to live. (Instead: think across environments and people) Don’t focus on replacement skills within this section E.g. CI will teach budgeting skills. Don’t describe triggers to behaviors Those should be in hypothesis Don’t only list one or two strategies Don’t include the specific teaching plan Think proactive How can we set up the environment/situation to eliminate or decrease the problem behavior from occurring in the future? Should be simple, least- restrictive The more the better Think specific to the problem bx Link back to the condition of the hypothesis!

Antecedent Example Hypothesis condition: “When at home and asked to complete a non-preferred task (e.g. cleaning room, vacuuming, dusting, etc…) …” Possible antecedent strategies: Provide choice between two activities (more than 2 choices and he will refuse) Alternate preferred and non-preferred (embed into his daily routine) Provide a schedule or checklist Limit the amount of demands placed within a specific amount of time (e.g. 1 task per hour) Be specific (what exactly does it mean to clean his bedroom) Provide reminders if he did not begin a task within 10 min of initial prompt (repeat every 10 min); Prompts should vary (verbal, gesture toward schedule or activity)

Replacement Behaviors Do’s Don'ts Prioritize Pick one at a time Provide brief description for HOW the replacement behavior will be taught (e.g. role play) Remember: the goal is to teach bx’s that are more effective and efficient than the problem bx Don’t focus on the intent of the provider or what the family should do Remember: this is about the participant! Don’t describe how to respond to the bx That’s consequence strategies Don’t include the entire teaching plan But still be specific Don’t identify behaviors that require too many steps, rules, or skill sets beyond person’s abilities

Replacement Behavior Example Hypothesis Behavior of Concern: “… Sean will yell in close proximity to another person’s face, screaming “I won’t do this. You can’t make me” for at least 2 minutes and will then leave the room to play video games…” Possible Replacement Strategy Teach Sean different means of appropriately communicating that he does not want to complete task right now (e.g. asking for a 15 min break, choosing a different activity to complete, asking for help, etc…). Role-play and model scenarios with Sean using verbal as well as physical cues.

Consequence Strategies Do’s Don'ts Describe how to respond to the replacement bx AND problem bx Think: Reinforcement (increase) and punishment (decrease) Focus on strategies that are easy to follow- through on and are motivating to participant Think age-appropriate, consider the environment Don’t only give “verbal praise” or “verbal redirection” Don’t include steps of CIP Don’t take away earned reinforcers Don’t delay reinfocers for an extended period of time (have back-ups if needed or give small amounts until bigger reinforcer can be obtained) Don’t assume reinforcers will never change

Consequence Examples Hypothesis Function: … in order to escape the demand Possible Consequence Strategies for Replacement Bx: When he uses his replacement strategy, honor request immediately and give enough time (15 min) before restating prompt. If task is completed within reasonable amount of time after using a strategy appropriately, acknowledge completion with praise and provide reinforcer (e.g. coffee, itunes download, choice of TV show, etc…). Perhaps only one task per day in beginning with extended amt of time with reinforcer (identify ahead of time). If more than one need to be completed, increase amt of time between tasks. Keep track of times he completes a task without any problem bx. Once he completes 5 tasks consecutively without behaviors, provide bigger reinforcer (TBD)

Consequence Examples Hypothesis Function: “… in order to escape the demand.” Possible Consequence Strategies for Problem Bx: When he yells or walks away, remind him of strategy to use (only remind 1 time then wait 5 minutes) If yells, but then completes task, acknowledge, but with less enthusiasm. Allow for short break (nothing highly reinforcing) then place another demand. Remind him of expectation (e.g. If you do not complete one task now, you can complete it later, but it must be done by the end of the day). Follow-through on request. If the day ends and still hasn’t completed it, place same prompt the following day.

Crisis Intervention Plans Do’s Don’ts Ask: How will others respond if all strategies within BSP have been utilized and behaviors escalate? Emphasize safety of participant and others Hold a team mtg within 10 days after a crisis occurred and report in EIM. Revisit and revise BSP/CIP! Encourage other providers and family members to contact BS when crisis is occurring Don’t highlight behaviors already captured within the BSP While some may be pre- cursors to a crisis, if bx does not escalate, it is not a crisis Don’t emphasize teaching skills Intent is to ensure safety of participant and others Don’t call 911 or crisis without stating it should be used as a last resort

CIP Example Before During While Sean may go to room and yell, he may begin pacing around the house, breathing heavy. Remind him of strategies to use if upset or needs a break If strategy is not used or he is unable to calm self, he will begin hitting self on arm or head and will curse obscenities at anyone within eyesight. If objects are in his way (e.g. on the floor), he may kick or throw them During Remove prompts and any objects within vicinity he could kick or throw (excluding furniture). Remove self from room, but keep close earshot . Physically check on him every minute, briefly, but without any verbal interaction with Sean.

CIP Example, cont… After Hitting self and kicking objects will end first. Cursing may continue for up to 10 minutes, but volume will decrease. He may go to his room and play video games. He will not come and find you- will make every attempt to avoid other people. Give him at least 30 minutes to further calm self after he returns to his room. Knock on door before entering room. Do not place demand right away, but ask him to come to another room when he is ready. When he leaves room, acknowledge he was upset and remind him of strategies to use next time. Also tell him the bx does not exclude him from having to complete activity, but it doesn’t have to happen right away. Hold team mtg within 10 days, revise BSP/CIP

In Summary… Considerations in Strategy Development Ensure you are addressing the function! Teach something that the participant may not have in their repertoire But still make it manageable Link the Hypothesis and Desired Behavioral Outcome to the Strategies Analyze the situations that may be promoting the problem behavior Meaningful days are key to quality of life Communication should always be examined!

Patterns, Themes, and Questions: -Collaboration with other Services -Family Dynamics -Formatting/HCSIS

BSS and other providers addressing similar skills We see this a lot when same provider is delivering multiple services (BSS and CI) There MUST be a clear distinction BSS can provide tools and techniques for how to teach specific skills, but be careful of duplication of services! Task Analysis, Checklists, Resources, Data Collection, Communication Materials Each service has their own responsibility to develop objectives and provide quarterly updates. It is not BSS responsibility to do it all! One goal may be linked to more than one service, but separate objectives MUST be developed

How to target one skill differently across services- Examples Social Skills BSS: Ryan will talk inappropriately to strangers, pick nose, and try to touch other people during conversation. BSS would teach appropriate ways to interact. CI: Teaching Ryan to greet others, and start and maintain a conversation. Community Integration BSS: After 5min of participating in the activity, Ben will begin touching himself in order to leave the activity. BSS would teach appropriate ways of asking to leave an activity. CI: Teaching Ryan to choose and participate in meaningful /motivating activities for longer than 5 minutes (while also reminding him of strategies to use when in the community, trained by BS)

How to target one skill differently across services- Examples Money Management BSS: Anxiety, defined in observable/measurable terms around managing money CI: Teaching specific skills using task analysis to develop budgeting skills, going to the bank to deposit money, paying for items in the store Independent Living Skills BSS: Think- Sean example. Focus on coping strategies to address problem bx for when demands are placed to complete a task/chore around the home CI: Teach how to complete each task/chore using a task analysis or other means

Training Provides and Families: Initial Training As soon as BSP/CIP is developed, schedule a team mtg (do not have to wait until quarter or annual). Review the FBA (if you haven’t already) BEFORE you discuss the BSP So there is an understanding for WHY certain strategies will be implemented Work with each person individually, including participant face-to-face Don’t simply train around the kitchen table. Specifically train EACH ITEM within the BSP Ask questions, check for understanding, do not assume Obtain signatures or sign-off sheet when training is complete Provide details for how to collect data (and how to share collected data with you) Give examples, model, observe

Training Providers and Families: Ongoing Training Provide regular check-ins. Remember: BS needs to report progress at least monthly (enter into HCSIS directly) and quarterly (submit to SC) Observe participant and providers “in the field” Ask/provide feedback, input, suggestions What’s working, what’s not Revise FBA and BSP if new behaviors emerge or RETRAIN when any component changes E.g. if Marty recently got a job and there is an increase in anxiety, conduct another FBA and incorporate new outcome into BSP Review the Data; Summarize Findings, SHARE WITH THE TEAM (in a graph) If you can’t schedule face-to-face on a regular basis, send an email and set up a phone call.

Differences Between BSS Direct and BSS Consultation Does NOT occur at the same time Direct: With the participant present Teaching strategies directly to participant Modeling implementation of plan with participant and provider/family present Initial and Ongoing Consultation: Without the participant present Schedule regular meetings with family and providers Monitor and analyze data, report on progress Training, modeling, reviewing plan with provider/family Revise BSP/CIP

Participant/Family wants BSS, but there is no need or justification First and foremost: BSS is based on NEED. However… Participant/Family “wants” must balance the “needs.” Strategies: Set up a meeting asap with family to discuss- Don’t wait Review roles and responsibilities of the service SHOW DATA! Suggest decreasing units (e.g. only 1 hour per week of consultation to check-in, collect data, etc…) Remind families BSS can always be added back on the plan at any point, if needed. Make sure other providers are thoroughly trained before BSS ends Update BSP in HCSIS to ensure accuracy Contact BAS for additional support.

Participant/Family wants BSS, but there is no need or justification, cont… Additional questions to ask/ things to consider during team meeting: If BSS was addressing a destructive or disruptive bx, but have since decreased to 0, are there other disturbing bx’s that could now be addressed (e.g. social skills)? Perhaps new FBA should be completed and BSP revised. Don’t forget to save the former outcomes in a separate word document in case bx’s emerge again! How comfortable are other providers or parents with the BSP? If BSS was removed and something occurred that triggered a bx, would CI know how to respond and support participant? Is everyone on the same page? Ask for input from team for the benefit of keeping BSS (besides “what-if”)

Participant/Family wants BSS, but refuse to participate or follow-through Hold mtg asap to discuss roles and responsibilities Contact BAS if you feel additional support is needed Provide copies of service description; Send ahead of time so family can review and come to mtg with questions Walk through entire BSP. Are there strategies the family is not comfortable implementing? Ask for suggestions, ensuring recommendations are appropriate and make the changes Increase Consultation hours (at least temporarily) to work more closely with the family Frequent check-ins may help with accountability. You can collect data over the phone via reports from family instead of asking family to document

Participant/Family wants BSS, but refuse to participate or follow-through, cont… Ensure family is in close proximity when you are working with participant or other providers Or have a follow-up meeting immediately after session ends with family Suggest other providers model different strategies when families present Encourage providers and families to communicate with each other and ask for help if needed. Prioritize needs- perhaps there are too many outcomes on the plan at one time

Participant/Family wants BSS, but refuse to participate or follow-through, cont… Review family dynamics that may be contributing to the family’s lack of follow- through Evaluate need for any other services in addition to BSS But keep in mind- Family Training should NOT occur when BSS is also on the plan, as it may look too similar to BSS Break down the BSP into simple, easy-to- follow steps, possibly not in HCSIS format Remove behavioral jargon!

Info/Language Concerns within the BSP Issue: BSPs state- “CI will plan and grocery shop for meals with Mary” Why this is an issue: Not specific to the problem bx, BSP is not a teaching plan for CI or other services nor is it designed to focus only goals CI will address. Solution: Revisit the FBA and hypothesis statement and focus specifically on the behaviors of concern. Remember- one hypothesis or outcome statement could generalize across many settings or situations

Info/Language Concerns within the BSP Issue: More info is captured within each section than should be Why this is an issue: Becomes overwhelming for others to read, may not be applicable to related section, etc… Solution: Summarize all FBA data, graphs, etc.. into document to share with team, share info with SC to incorporate into ISP, review trainings to ensure you are capturing the correct info in the correct place

HCSIS format is not detailed enough There is more than one way to develop an FBA and write a BSP. Info related to record reviews, interviews, data collection, etc… are not captured in HCSIS BUT are still a critical piece! We expect MOST behavior specialists will have supplemental documents to support what is in HCSIS E.g. FBA Summary, BUT a completed interview form is NOT a summary; it is simply an interview form. Summarize, synthesize, and make sure it there is a link to what is entered into HCSIS You cannot upload graphs, but should still have them

Sample BSP Hypothesis: Desired Behavioral Outcome: Condition: When at home and asked to complete a non- preferred task (e.g. cleaning room, vacuuming, dusting, etc…) Behavior: Sean will yell in close proximity to another person’s face, screaming “I won’t do this. You can’t make me” for at least 2 minutes and will then leave the room to play video games Function: in order to escape the demand. Desired Behavioral Outcome: Behavior: Sean will begin task within 10 minutes of demand without yelling or playing video games Criteria: 4 out of 5 consecutive opportunities, for one month, with less than 2 prompts.

Sample BSP Antecedent Strategies Replacement Behaviors Provide choice between two activities (more than 2 choices and he will refuse) Alternate preferred and non-preferred (embed into his daily routine) Provide a schedule or checklist Limit the amount of demands placed within a specific amount of time (e.g. 1 task per hour) Be specific (what exactly does it mean to clean his bedroom) Provide reminders if he did not begin a task within 10 min of initial prompt (repeat every 10 min); Prompts should vary (verbal, gesture toward schedule or activity) Replacement Behaviors Teach Sean different means of appropriately communicating that he does not want to complete task right now (e.g. asking for a 15 min break, choosing a different activity to complete, asking for help, etc…). Role-play and model scenarios with Sean using verbal as well as physical cues.

Sample BSP Consequence Strategies- Replacement Bx: When uses replacement strategy, honor request immediately and give enough time (15 min) before restating prompt. If task is completed within reasonable amount of time after using a strategy appropriately, acknowledge completion with praise and provide reinforcer (e.g. coffee, itunes download, choice of TV show, etc…). Perhaps only one task per day in beginning with extended amt of time with reinforcer (identify ahead of time). If more than one need to be completed, increase amt of time between tasks. Keep track of times he completes a task without any problem bx. Once he completes 5 tasks consecutively without behaviors, provide bigger reinforcer (TBD)

Sample BSP Consequence Strategies- Problem Bx When he yells or walks away, remind him of strategy to use (only remind 1 time then wait 5 minutes) If yells, but then completes task, acknowledge, but with less enthusiasm. Allow for short break (nothing highly reinforcing) then place another demand. Remind him of expectation (e.g. If you do not complete one task now, you can complete it later, but it must be done by the end of the day). Follow- through on request. If the day ends and still hasn’t completed it, place same prompt the following day.

Sample BSP Means of Monitoring: For sample CIP- See Slides 17 and 18 Describe bx for which data is collected: Yelling, Leaving room to play video games, and completing task around the home Type of measurement: Latency for when prompt is given and task begins, Duration for how long it takes to complete each task and how long he spends in room/yelling, and Frequency of task completion. Frequency of data collection: Weekly, but data collected at each opportunity For sample CIP- See Slides 17 and 18

Resources ra-basprovidersupprt@state.pa.us Provider Support Mailbox ra-basprovidersupprt@state.pa.us Virtual Training Center- Check out the new look! http://bastraining.tiu11.org/ Provider Information and Trainings BSS Manual