Implementing Behavioral Support Part III Amy Alford, M.E.d. Clinical Consultant Bureau of Autism Services Amy begins

Agenda Review John’s BSP/CIP Direct/Consultative Roles and Responsibilities Implementation of the BSP/CIP for John Within natural environments/supports Across existing services  

BSP/CIP Review- John

John’s challenging behaviors Home Community Day Program -Refusing to clear the table -Leaving dinner table and staying in room all night -Hits head on wall, table, or with closed fist -Refuses to run errands with Mom -Curses loudly or yells inappropriate verbalizations at Dad -Curses loudly or yells inappropriate verbalizations when in church, mall, bowling alley -Refuses to work on meal prep skills -Hits head on wall or with closed fist -Curses loudly or yells inappropriate verbalizations at co-workers and quality of work performed -Leaves area and spends significant amounts of time in men’s room

Hypothesis Statement – John - Condition: On days when bowling gets cancelled (or schedule changes) and John is prompted by his mother to help with chores/tasks around the house (e.g. emptying the dishwasher), - Behavior: John will yell obscenities as he leaves the room and hit self in the head with his fist, on the desk, or on the wall, Function: in order to escape the request.

Hypothesis Statement – John - Condition: At the bowling alley, when prompted by CI staff, “15 minutes until we have to leave,” - Behavior: John will begin yelling at other people in the bowling alley (e.g. “Get out of my lane,” “It’s my turn,” “Don’t talk to me”) and hit self on head with his fist - Function: in order to remain at the bowling alley for a longer amount of time.

Hypothesis Statement – John Condition: When at his day program, with more than 4 people and asked to help someone complete a last minute activity, - Behavior: John will yell obscenities or tell them to “hurry up already” - Function: in order to get out of finishing the project and go home early.

Desired Behavioral Outcomes

Raul FBA HYPOTHESES DESIRED BEHAVIORAL OUTCOME Through observations and/interviews with those who know John well we know…. Hypo #1 HYPOTHESES Condition: On days when bowling gets cancelled (or schedule changes) and John is prompted by his mother to help with chores/tasks around the house (e.g. emptying the dishwasher), Behavior: John will yell obscenities as he leaves the room and hit self in the head with his fist, on the desk, or on the wall, Function: in order to escape the request. DESIRED BEHAVIORAL OUTCOME Behavior: John will utilize a coping strategy to verbalize his displeasure in the situation Criteria: with no prompts for 90% of the opportunities for one quarter.

Raul FBA HYPOTHESES DESIRED BEHAVIORAL OUTCOME Through observations and/interviews with those who know John well we know…. Hypo #2 HYPOTHESES Condition: At the bowling alley when prompted by CI staff “15 mins. until we have to leave” Behavior: John will begin yelling at other people in the bowling alley (e.g. get out of my lane, it’s my turn…) and hit self on the head with fist, Function: in order to remain at the alley for a longer amount of time. DESIRED BEHAVIORAL OUTCOME Behavior: John will use his breathing and strategy of, “oh well, I’ll be back again soon” and start to pack up Criteria: with no more than one verbal prompt for 90% of the opportunities for one quarter.

Review of John’s Behavior Support Plan HYPOTHESIS AND DESIRED BEHAVIORAL OUTCOME for John Antecedent Strategies Replacement/Alternative Skills Strategies Consequence Strategies -White board to explain chores -Reminders of breathing -Reminders that he can take a break -Calendar to review preferred events -Timer/watch -Reminders of polite and rude -Reminders of coping strategies -Choice -Increase preferred items- more bowling, more RC car folks- club? -Encourage music in background -Alternate preferred and non-preferred Teach him to: -ask- how much do I have to do? -to check white board -to ask for a break -to look at calendar for next op to see preferred activity -to put on music -Teach others to respond to his RC car interest -Practice role play how to voice disappointment- -Use sibling -Social skills-Teach polite and rude- think language in public! -Use video examples -Verbally praise John- in an age appropriate way for using the new skills. -Help explain to him the items on the white board chore chart when he goes to it. -Redirect language- appropriate words! -After John finishes chore immediately go to reinforcer activity- cars, look at books, or more music. -If John starts to hit his head block the hits as you must keep him safe. Speak in a quiet, calm voice. Review of John’s Behavior Support Plan

Lifestyle Interventions for John Think about day activities Different job/volunteer stuff RC car club- dad can’t always be there RC magazines, chat rooms Schedule time with brother

Review of John’s Crisis Intervention Plan

Crisis Intervention Plan for John Before During After -Use all the antecedent strategies, -Use visuals, have these with you, -Know that when he leaves room, when he starts clenching fists, talking to self, remind him to start the breathing, -Try to get him into more private area. -Speak calmly -Use short phrases -Use visuals -Block head banging Insure safety- not a teaching moment -Clear extra folks -Staff notify other staff via cell phone- walkie-talkie, etc. -Bx that crisis has ended?- breathing normal, no attempts to hit, sitting not pacing, -Return to previous setting if possible -Modify task- gather things -Follow-up with team -Encourage him to apologize to others -Review with John for next time what to do -Talk about things that went right -Can occur later not right after -Document

Next Steps The FBA is complete; BSP/CIP are written Enter BSP/CIP into HCSIS Submit Desired Behavioral Outcomes as Objectives to SC Behavior Specialist is now required to train all team members This process will look differently for each participant due to: Services Behaviors of Concern Individual Participant Dynamics

Direct and Consultative Roles and Responsibilities

Roles and Responsibilities- Direct Services Train the participant and team members (family, friends, waiver providers, and other support persons) Purpose, objectives, methods, and documentation of the BSP or revisions of the plan with the participant present. Train at least with Participant and Family initially All providers must be trained face-to-face at some point CIP components should also be included within initial training (BSS description in Adult Autism Waiver)

Roles and Responsibilities Consultative Services Train the participant and team members (family, friends, waiver providers, and other support persons) Train to the purpose, objectives, methods, and documentation of the BSP or revisions of the plan without the participant present Monitor and analyze data to report on progress of goals monthly and quarterly Re-train members of the team if revisions are made or new FBA is complete Report quarterly progress to Supports Coordinator (BSS description in Adult Autism Waiver)

Guidelines for Training all Team Members All service providers and family members must be trained in face-to-face setting Initial team meeting must be with participant and family, at minimum A team meeting must be conducted following completion of BSP/CIP. Reach out to service providers to find most convenient time to provide this training

What would a team meeting look like for John? Who might be present: John John’s parents SC CI staff (preferably someone who works directly with John) Day program staff (preferably someone who works directly with John) Behavior Specialist Not everyone may be available- consider this!

What would a team meeting look like for John? Possible structure of meeting Review FBA (show the Graphs!) Explain hypothesis statements Share Desired Behavioral Outcomes Review components of BSP/CIP Discuss any changes or updates to the ISP, as well as changes to services or weekly schedule Explain next steps **Ask for INPUT from team. Remember these are NOT final documents

Next steps for AFTER the meeting Behavior specialist will show HOW to prompt John to use a strategy when upset Teach in the settings John will use strategy, when possible Behavior Specialist will explicitly show parents and staff to collect data Modify materials and teaching plans- simple terms Don’t forget to teach John! This may occur in natural setting (think: incidental teaching) OR separate time at home, when other services are not occurring.

Important! Allow extra time for questions and clarification Provide feedback where necessary Explain change is gradual Be readily available (phone or in-person) to family and service providers, especially at the beginning Keep ENTIRE team in-the-loop about any changes in bx or support plan

Sample teaching plan when bowling Before exiting car in parking lot, Quickly review expectations with John (use appropriate language, please/thank you, etc…) Remind John of strategies he can use if upset (deep breaths, take short walk, talk to someone) Also remind John of reinforcer he can access if he uses strategies appropriately Help John set alarm on watch for “15 minutes” until it is time to leave

Sample teaching plan when bowling Once inside Remind John after he has his bowling ball and shoes, staff/parents will sit at nearby table so he can interact with members of bowling league E.g. “If you need me, I will be sitting at this table. You can ask teammates for help as well.” Observe for any changes in behaviors or signs of frustration (closer proximity to John if needed) Offer positive praise when strategies are used (age appropriate and without bringing extra attention)

Sample teaching plan when bowling After bowling has ended (and back in car) When John transitions without challenging bx’s: Praise for using strategies (be specific!) Allow John to access preferred reinforcer (as previously determined) When John has difficulty transitioning: Define what bx’s suggest “difficult transition”- be consistent! Remind him of expectations when in the community Allow extra time to practice strategies, if possible Remind him he will have another chance to practice next time he goes bowling.

Let’s talk more about John…

What actually happened at John’s initial meeting? BS, Parents, John, and CI staff were present. Day program called into mtg. BS sent docs to everyone 3 days BEFORE the meeting began Parents felt overwhelmed with implementing these strategies all at once at home Team discussed ways to prioritize and focus on one thing at a time- consistently across settings

John’s initial team meeting Team realized John was bored at day program and began exploring possible job services. Gradually re-structured his week Faded day program to 2 days per week, 4 hours per day (in the morning) Increased CI hours Job Assessment and Job Finding were added and found John enjoyed working with his hands and being outside. He worked best when minimal people were present. Dad’s lumberyard was only volunteer. John wanted paid employment

How did everything else come together for John? John’s brother’s friend is a landscaper and expressed a need for someone to help him with projects in the community. 1-2 afternoons a week, weather was a factor After about 2 months, work thinned, team had to explore other job options John began working at Lowe’s with SE Gradually increased from 5 to 15 hours per week Alternated between gardening section and lumber section

What happened with CI? John joined the bowling league, 2 times per week (afternoon with CI, evening with Dad) Coping skills were taught. Bx’s decreased Staff supports have significantly faded to other members of bowling team Instead of focusing on actual cooking, explored grocery shopping, meal planning, and budgeting Will re-visit cooking in 6 months

Support at Home Whiteboard contained weekly and daily schedules- easily accessible Chores were spread evenly across the week New chores slowly introduced John goes on Skype with his brother once per week John continues to play with RC cars with Dad, but also with a neighbor up the street

Monitoring Progress

Means of Monitoring/Evaluating Should capture the BEST way to show a decrease in the problem and/or increase in the appropriate behavior. Should be part of the function/replacement link. If you are looking to decrease inappropriate comments be clear what these may be as this varies according to participant’s age, culture and setting.

Monthly Data Collection No required form, but must be reported to the SC Service Providers may be collecting data MEANS OF MONITORING: Progress/Update Data will be used to complete Quarterly Review Form Complete new FBA for new behaviors Change components of BSP/CIP as needed Any changes require re-training family and providers

Quarterly Review Form Documents participant’s progress towards objectives Submitted quarterly to the SC based upon Eligibility/Plan Effective Date SC will enter into HCSIS Comment upon “New Concerns” Sample Quarterly Report can be found in VTC

Sample Data Collection Sheet- John Date Coping Strategy Cursing/ Inappt. Statements Hitting Self Comments Day 4 III I Day 5 II Day 6 IIII Day 7 Bx began as soon as bowling started Day 8 IIII II Strategies used independently

What to walk away with… Individualize documents, teaching strategies, etc… Include the participant in discussions, where appropriate Think: age appropriate, respectful Inform team of ANY changes re: bx support Frequently analyze data (monthly, quarterly, yearly- at minimum)- Graphs are powerful! Ask questions, ask for clarification

Next Week Thursday, Feb. 24th 1 – 2pm BSS Provider Training: Appropriate and Creative Supports/Services Review AAW's values of supporting participants to become more independent and live, work and play in least restrictive environments.