1. Role of Health Care Professionals in Team-based Problem Solving for Children with Chronic Behavioral Needs Rob Horner University of Oregon www.pbis.org

2. Objectives Define a team-based approach to designing behavior support with three key features. 1. Assessment : Define a problem with precision before building a plan 2. Plan Design : Build comprehensive plans that prevent, teach and reward positive behavior while minimizing reward of negative behavior. 3. Contextual Fit : Make the elements of a plan “fit” the values, skills and resources of the performance context.

3. Major Changes in Behavior Support Prevention Teaching as the most effective approach (communication skills) Environmental redesign, Antecedent Manipulations Function-based support Functional assessment (move from “cookbook” approach) Separate “crisis intervention” from active support. Comprehensive Interventions Link Behavior Support to Lifestyle Outcomes (Values) Multiple elements/components “Fit” elements of behavior support to values, skills and resources. Systems Change Intervention at the “whole-school” level Durable systems that nurture and sustain effective practices

4. Problem Behavior Behavior is a function of: Physiology Learning History Current Context

5. A Context for PBS Effective behavior support involves understanding Physiology and Learning History and changing the Current Context. Behavior support is not the redesign of individuals Pay as, or more, attention to what happens between problem behavior bouts as to what happens during instances of problem behavior. (Edward Carr) Positive Behavior Support plans define changes in the behavior of those who will implement the plan.

6. Purposes of Behavior Support Plan Define critical features of environments where the focus person will be successful. o Behavior support plans describe what we will do differently to establish these critical features. Facilitate consistency across multiple implementers. Provide professional accountability.

7. Identify Problem with Precision What, Who, When, Where, Why and How Often

8. Implement Solution with High Integrity Implement Solution with High Integrity Identify Goal for Change Identify Goal for Change Identify Problem with Precision Identify Problem with Precision Monitor Impact of Solution and Compare against Goal Monitor Impact of Solution and Compare against Goal Make Summative Evaluation Decision Make Summative Evaluation Decision Meeting Foundations Team-Initiated Problem Solving (TIPS II) Model Identify Solution and Create Implementation Plan with Contextual Fit Identify Solution and Create Implementation Plan with Contextual Fit Collect and Use Data

9. Defining a Problem with Precision What is a problem? A “problem” exists when there is a difference between what you want and what you have.

10. Defining a Problem with Precision A major error is to launch into problem solving BEFORE the problem has been defined with precision. Typical pre-emptive solutions o What we did last year o What my cousin did with her son o What I can buy (or download) as a package on the internet o What I can buy as a training from an expert Pre-emptive solutions o Often do not work o Usually are more expensive o Typically do not “fit” the context.

11. What When Where Who Why Designing Effective Behavior Support How Often

12. Start with Primary Problem Statements Look at the Big Picture. Then use data to refine the problem to a Precise Problem Statement. Move to Precise Problem Statements Office discipline referrals for 3 rd graders are above national median for schools our size. Referrals for physical aggression among third grade students from 11:30-12:30 in the cafeteria have increased to 3-4 per day. We believe that physical aggression is rewarded by peer attention.

13. Precise or Primary Statement? PrecisePrimary Indicates a difference between what is happening and what is desired. What, Who, Where, When, Why, and How Often

14. Primary versus Precision Statements Primary Statements o Too many referrals o September has more suspensions than last year o Gang behavior is increasing o The cafeteria is out of control o Student disrespect is out of control Precision Statement o There are twice as many ODRs for aggression on the playground than last year. These are most likely to occur during first recess, with a large number of students, and the aggression is related to getting access to the new playground equipment.

15. Primary versus Precision Statements Primary Statements o Derek screams at dinner o Emily bites her hand o James swears o Philip has ASD, and finds bright lights a problem. He will hid under furniture when lights are on. Precision Statement Elaine is 4 years old and refuses to go to bed about 4 nights per week. She cries and screams when put in bed until allowed to get up and play or get a story. She is effective at working herself into a physical state that makes sleep less likely, and she obtains a great deal of adult attention.

16. Precise or Primary Statement ? Darin uses inappropriate language with a high frequency in the presence of both adults and other children. This is creating a sense of disrespect and incivility in the school. Tantrums in the van are creating unsafe travel.

17. Precise or Primary Statement? James D. is hitting others in the cafeteria during lunch at least five times a week, and his hitting is maintained by peer attention. Boys are engaging in sexual harassment. Three 5 th grade boys are name calling and touching girls inappropriately during recess in an apparent attempt to obtain attention. This is occurring at least 5 times a week.

18. Precise or Primary Statement? Minor disrespect and disruption are occurring daily, increasing over time, and are most likely during the last 15 minutes of our block periods when students are engaged in independent seat work. This pattern is most common in 7 th and 8 th grades, involves many students, and appears to be maintained peer attention. Danielle is 9 years old and refuses to follow parental requests to pick up toys, help with dishes, do homework. She will sulk and pout until we get frustrated and send her to her room.

19. Your Turn Define a PRIMARY problem Transform that description in to PRECISE problem statement. Who What Where When Why How Often

20. Comprehensive Behavior Support Pans Focus first on prevention, teaching and rewards Consider how to prevent problem behavior from being inadvertently rewarded. Be clear about how to intervene with safety. Avoid plans that only focus on consequences

21. Behavior Support Plan Elements Prevent Teach Prompt Reinforce Extinguish or Withhold Reward Correction Safety Data Change the context to avoid the problem situation? Teach what you want. Teach a socially acceptable replacement. Encourage opportunities for the desired behavior. Reward for the desired behavior. Prevent the problem behavior from being rewarded. Use negative feedback if needed. Add safety procedures if needed. Define data to monitor implementation fidelity and impact

22. Behavior Support Plan Elements Prevent Teach Prompt Reinforce Extinguish or Withhold Reward Correction Safety Data Pre-correction Play with me… special toy to share Pre-empt recruiting play No extra reward needed… peer attention very effective (praise recruiting play) Brief time out (no toy or peer) for any aggression (verbal or physical) toward others Practice the right way to recruit peer play Increased supervision Number of aggressions… number of play initiations

23. Behavior Support Plan Elements Prevent Teach Prompt Reinforce Extinguish or Withhold Reward Correction Safety Data Rayette

24. Behavior Support Plan Elements Prevent Teach Prompt Reinforce Extinguish or Withhold Reward Correction Safety Data Reading

25. Contextual Fit The elements of a behavior support plan should fit the values, skills and resources of the people who will implement and receive support. One of the major reasons why behavior plans are NOT implemented is because of poor contextual fit. Bennazi

26. Summary Building effective behavior support involves designing contexts based on assessment, comprehensive planning, and attention to contextual fit Assessment: Who, What, Where, When, Why, How Often Comprehensive Planning : Prevent, Teach, Prompt, Reward, Extinction, Safety, Data Contextual Fit: Attention to values, skills and resources of those who implement and receive support.