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APPLIED BEHAVIOR ANALYSIS IN THE SCHOOL SETTING: BASELINE TO INTERVENTIONPRESENTED BY: AMANDA BROUSSEAU, M.A., BCBA, LABA AND JENNIFER DERDERIAN M.S., M.ED., BCBA, LABA
MAY CENTER SCHOOL FOR BRAIN INJURY AND NEUROBEHAVIORAL DISORDERS
INTRODUCTION
Amanda Brousseau
Assistant clinical director
Employed at the May since 2011
Served as direct care staff and classroom teacher previously
Amanda received a bachelor’s degree (psychology) and a master’s degree (psychology with a focus in Applied Behavior Analysis) from UMass Dartmouth. Currently pursuing a second master’s degree in special education from Bridgewater University
Board Certified Behavior Analyst since 2014 and licensed by the state of MA (LABA)
Jennifer Derderian
• Oversees clinical services at the May Center for Brain Injury and Neurobehavioral Disorders
• Employed at the May for over 12 years
• Served as a lead classroom teacher and Behavior Specialist.
• Jennifer received a bachelor’s degree from James Madison University in Psychology, master’s degree in Applied Behavior Analysis from Northeastern University, and a second master’s degree in Education from Bridgewater State University
• Jennifer has been a Board Certified Behavior Analyst since 2009, and currently is licensed by the State of Massachusetts in Severe Special Education and Behavior Analysis
INTRODUCTION
Private, nonprofit school and residential program serving students age 5-22 years old
Focus on both education and rehabilitation of children and adolescents with brain injury or neurological disease
We provide full-day, year-round educational, behavioral, medical, and rehabilitative services, and use proven methods of treatment and teaching based on the latest clinical and applied research
AGENDA
Deficits related to Traumatic Brain Injury
Introduction to ABA
Literature review on ABA and challenging behaviors
Baseline process
Data collection
Assessment – break out session
Behavior support development
Case Studies
Question and Answer session
BRAIN INJURY: CHALLENGES AND DEFICITS
Can be almost anything!
Using and understanding language
Social skills
Emotional control, flexibility and coping
Academic/learning difficulties
Difficulties learning contingencies or predicting patterns
Planning, organizing, remembering
Personality changes
Poor or abnormal attention
Gross & fine motor deficits
Easily fatigued
Difficulties with generalization and maintenance
BRAIN INJURY: CHALLENGES AND DEFICITS
Brain injury may affect an individual’s ability to function well at work, school, home, and in other settings, causing difficulties in the following areas:
Cognitive:
memory loss, organizational difficulties, speech and/or communication problems, difficulty in reasoning and problem solving
Behavioral:
impulsiveness, aggression, and decline in social skills
Physical:
impairment or changes in vision, hearing, coordination, balance and muscle tone
BRAIN INJURY: CHALLENGES AND DEFICITS
Some challenging behaviors that can present in individuals with brain injury and neurobehavioral disorders:
Aggression
Destruction
Self-Injury
Elopement
Stealing
Inappropriate sexual behaviors
Inappropriate social behaviors
Swearing, peer instigation, perseveration
INTRODUCTION TO ABA
ABA is a methodology, or framework, that applies scientific interventions to address behavioral needs
ABA facilitates the development of language, social interactions, and independent living by applying basic behavioral practices — positive reinforcement, teaching in small steps, prompting, and repeated practice
ABA can also help reduce both everyday social problems and serious behavior disorders, as well as to teach new skills and increase independence
ABA AND CHALLENGING BEHAVIORS
Several studies have looked at decreasing challenging behaviors exhibited by individuals with traumatic brain injury, as well as increasing appropriate replacement skills
Dixon and Tibbetts (2009) evaluated the effects of choice on self-control for three adults with brain injury and found participants were willing to complete more work in order to access larger, delayed reinforcers.
Tasky and colleagues (2008) demonstrated that providing 3 individuals with TBI the opportunity to choose their chore from a predetermined list, increased on-task engagement.
Heinicke, Carr and Mozzoni (2009) evaluated contingency specific rules and a token economy on task latency with a 16 year old girl with an acquired brain injury. When the participant was explicitly told that she could earn tokens by completing work within a pre-specified time, an immediate reduction in latencies to comply for each instruction was observed.
Fyffe and colleagues evaluated functional communication training plus extinction for inappropriate sexual behavior (ISB) maintained by access to attention. During treatment the participant was taught to hand over a talk card and all instances of ISB were blocked but no other attention was provided, resulting in a decrease in ISB and increase in FCT.
BASELINE PROCESS
BASELINE PROCESS
Initial Baseline Data is collected
To determine the needs of the student
To identify target behaviors
Behaviors are “in baseline” when procedures have not been developed
BASELINE PROCESS
Intervention procedures during Baseline
Staff may give demands
Refusal of demands is followed by no consequences
No specific contracts for reinforcement should be implemented
Staff may give verbal praise
Maladaptive behaviors are ignored and the student is redirected back to task
No consequences are implemented (e.g., time out)
BASELINE PROCESS
Phase I (2 -3 weeks)
Data taken to estimate frequency and intensity of maladaptive behaviors
Data taken on academic skills, Activities of Daily Living (ADL), Social and Communication skills
Preference Assessment Completed
BASELINE PROCESS
Peer Review Meeting I
Review baseline data sheets
Identify target behaviors
Develop individualized data sheet
BASELINE PROCESS
Phase II (3rd or 4th week)
Baseline data taken on target behaviors
Without baseline data we run the risk of:
Continuing an ineffective intervention
Stopping an effective intervention
Functional Assessment completed for each target behavior
Identify potential antecedents to the target behaviors
Identify potential consequences maintaining the target behavior
BASELINE PROCESS
Peer Review Meeting II
Review graphs of baseline data
Review functional assessment data
Develop Behavior Support Plan based on a review of the data
Follow - Up
Following implementation of Behavior Support Plan data continue to be graphed and reviewed
Students are reviewed as needed at peer review
All students are reviewed at quarterly clinical review meetings
DATA COLLECTION
Measurement of behavior involves recording various aspects of behavior when it occurs
How many times it occurs
How long it occurs
Percentage of time it occurs
The most common types of measurement
Frequency
Duration
Interval Recording
DATA COLLECTION
Mode: paper and pencil, electronic data collection,
Materials needed: stop watch, timer, clock, electronics and software for electronic data collection, paper and pencil for paper data collection,
Staff training: practice taking data during role play, IOA, monitoring and feedback
Review data regularly, with the team (parents, school district, & other agencies) at quarterly clinical meetings, and available to doctors (neurologist, psych, pediatrician, etc.)
Remember to add in phase lines for changes in intervention (BSP) and indicators for change in medication administration, change in classroom/residential setting, etc.
FUNCTIONAL BEHAVIOR ASSESSMENT
A process for identifying the variable or variables maintaining a behavior
Formal or informal
Results have important implications for treatment
Possible functions of behavior:
Escape
To get out of something
Attention
To get attention from someone
Tangible
To get something
Automatic Reinforcement
To get sensory stimulation
FUNCTIONAL BEHAVIOR ASSESSMENTCONTINUED
Informal Assessments
Interview: staff, parent/caretaker, student if appropriate
Observation: ABC data collection (charts/checklists), conditional probabilities
Ecological Assessment (lights, furniture placement, schedule)
FUNCTIONAL BEHAVIOR ASSESSMENT CONTINUED
Formal Assessments
Motivation Assessment Scale (MAS)
FAIR-T
Functional Analysis Screening Tool (FAST)
Functional Analysis (FA)
PREFERENCE ASSESSMENT
Sometimes the individual is not able to indicate their likes and dislikes
Preference assessment aims to identify preferred items and activities so that they can potentially be used a reinforcers
Types of preference assessments: free operant, single stimulus, multiple stimuli with or without replacement, paired stimuli
Chazin and Ledford, 2016
PREFERENCE ASSESSMENT
Free operant
Appropriate for students who engage in challenging behaviors when preferred items are removed
Typically not used with edibles
Student has unrestricted access to numerous activities
Staff record duration that the student engages in each activity; longer duration indicates stronger preference
No response requirements, available and within reach, items are never removed after selection
Single Stimulus
Appropriate for students who have difficulty choosing between high and low preference items (right/left side bias)
One item presented at a time and in random order
Staff record duration that the student engages in the activity & reaction (i.e., push away) to presentation of activity.
Each item presented several times and in varied order
Cooper, Heron and Heward, 2007
Chazin and Ledford, 2016
PREFERENCE ASSESSMENT
Multiple stimuli with replacement (MSW)
Allows us to create a hierarchy of preference
Appropriate for students who engage in challenging behaviors when items are taken away
Place array of items (2-3) in front of student and allow student to choose one
Following interaction with item, replace unselected items with new items and include the selected item
Items selected the most are most preferred and those selected least are least preferred.
Chazin and Ledford, 2016
PREFERENCE ASSESSMENT
Multiple stimuli without replacement (MSWO)
Allows us to create a hierarchy of preference
Appropriate for students who are able to choose from an array of preferred items
Place all items in front of the student and allow to choose one
The chosen item is no longer available for selection in the array and a new item is included- this is continued until all items are chosen or the student no longer chooses items from the array
Items chosen in first few trials are most preferred and items chosen lastly are less preferred
Ward and Graff, 2015
Chazin and Ledford, 2016
PREFERENCE ASSESSMENT(BREAK OUT SESSION)
Paired Stimulus
Allows us to create a hierarchy of preferences
Appropriate for students who can choose highly preferred over less preferred items but are unable to scan between more than two items
Not appropriate for students who engage in challenging behaviors when items are removed
Present two items in each trial and prompt the student to “choose”
Once the student chooses an item, two new items are presented for choice
The item selected during the most number of trials is most preferred item and the item selected in the least number of trials is least preferred item
Pick a partner and practice!
Chazin and Ledford, 2016
PREFERENCE ASSESSMENT REMINDERS
Not all preferences function as reinforcers
Preference assessments should be conducted frequently as preferences can change
Assess possible side bias by rotating items (MSW, MSWO, and paired stimuli)
To ensure that the student is making choices based on preference, one may include known preferred and non-preferred items
Important to know if student: (a) student can scan the table top to choose items and (b) if the student engages in challenging behaviors when preferred items are removed
Chazin and Ledford, 2016
CASE STUDY: PREFERENCE ASSESSMENT
FBA: Template
CASE STUDY: FBA
FBA: CASE STUDY
Aggression
John was observed to engage in aggression during work demands and when transitioning from preferred to nonpreferred activities. The topography of aggression included pinching, hitting, biting, and attempts to pull hair. Most instances of aggression were in the form of slaps or pinches which did not cause tissue damage to staff, however on occasion John was observed to bite staff with significant force. When John engaged in aggression staff typically engaged in response blocking, utilized de-escalation strategies (i.e. asking “what do you need/want”), and prompting him back to task. Although all these strategies provide some form of attention, it is likely his learning history likely involved having to give over highly preferred tangibles when presented with a work demand. The hypothesized function of aggression is to access preferred items/activities or to escape nonpreferred activities.
Head directed self-injury and other self-injury
John was observed to engage in head directed self-injury during transitions, especially transitions from preferred activities tononpreferred work demands. Instances of head directed self-injury were observed when John transitioned out of his stroller in the morning, as well as when transitioning from rest period back to academic demands. It is important to note that John wore his doctor prescribed helmet for most of the day, however there were break opportunities throughout the day when John would not wear his helmet. During these times, soft mats were available if he attempted any head directed self-injury. The rate of head directed self-injury was low, with a range of 4 to 0 instances per hour. During the assessment period, John engaged in self-injury on three days, with a rate of less than 1 instance per hour. The hypothesized function of head directed self-injury is to access preferred items/activities or to escape nonpreferred activities.
CASE STUDY: FBA
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John Functional Analysis of Aggression and Self-Injury
PlayAttentionDemandTangible
BEHAVIOR SUPPORT PLAN DEVELOPMENT
BEHAVIOR SUPPORT DEVELOPMENT
Start with Antecedent and De-escalation Procedures
This will be individualized, but here are some common antecedent strategies used with student with brain injury
Schedules
Pre-teaching
Transition warnings
Choice
Tone and Engagement
Functional Communication
SCHEDULES
Just like most aspects of a BSP, schedules are individualized
May be in written or visual form, some students may benefit from a digital planner
The number of activities can vary: 1 item schedule, first then board, a daily schedule, or even monthly
Schedules show students the order of events and can be used to remind the student what preferred item they can look forward to for completing less preferred items
Schedules can increase independence and can be used to reduce staff prompts
Schedules can be used across environments and can help generalize this independence
BONUS – it can be helpful to new or novel staff!
HELPFUL HINT – try color coding preferred and nonpreferred activities to make set up easy
PRE-TEACHING
We should engage in the same behaviors that we expect the students to Appropriate language, walking versus running in the hallway, cleaning up after ourselves,
etc. We should clearly state what our expectations are Pre-teaching who, what, where, when, and why
Frequent reminders Contingencies
HELPFUL HINT – have students repeat back part of the expectation to check for understanding
TRANSITION WARNINGS
Prior to changing activities, staff should provide students with several transition warnings
Whenever possible transitions should be concrete and not time based
For example, “Julie we are going to answer 3 more questions and then we are going to use the iPad.”
HELPFUL HINT: Pair transition warning with a choice
Time of transition: Do you want 1 more minute or 2 more minutes?
Mode of transition: Do you want to walk to the gym or take your stroller?
Timer or no timer
You have 1 more minute, do you want to clean up by yourself or do you want help?
CHOICE
Several research studies have demonstrated the large success of offering choices in an effort to reduce inappropriate behaviors and increase appropriate behaviors (Cannella, O’Reilly, & Lancioni, 2005)
We control so much of our students’ day, it is important to offer choice whenever possible
Example: order of work, color of pen, where to go on a walk
Give choices PRIOR to problem behavior, not just during
Make sure both choices are available
HELPFUL HINT: Offer choice even if there isn’t really a choice
“Do you want to do 8 math problems or 10 math problems?” “Do you want to leave the gym in 3 minutes or 5 minutes?”
TONE AND ENGAGEMENT
LOTS of praise for appropriate behaviors!
Genuine verbal and nonverbal positive tone
Frequent
Immediate
Specific to the behavior you are trying to increase
Variety
Age and developmentally appropriate
Differentiate praise based on the behavior
Provide a rationale and/or tie to contingency
For some students, pair with physical attention – high five, pats on the back, fist bump
MODEL APPROPRIATE BEHAVIOR
Most people learn through watching and interacting with others - what we do matters!
Model what we want our students to do
Emotional responses
Frustration tolerance
Interacting with others
Asking for help
Communicating
Praise others engaging in appropriate behavior
Some students will need more direct instruction
DELIVERING DEMANDS
We need our students to do certain things
However, should not issue directives in a demanding or authoritative manner
Students are more likely to comply to a friendly, yet assertive, directive than a demand
Examples: “It’s time for ____”, “Let’s go do ___”, “Let’s finish ____”
Should not pose as a question
HELPFUL HINT: Let’s try to get away from “when your ready” most of our students don’t know what “ready” means or will never be “ready” (what’s the motivation?). Use statements such as, “its time to sit”
DENYING REQUESTS
Avoid just saying “no” – imagine how you would feel!
Alternatives: provide another choice similar to the request, or if you have to delay/deny “Not right now”, “maybe later”, “sure, right after ____”
Use first, then statements
If you must use “no”, pair it with a simple explanation and/or redirection
“The break room is not available right now, but you can take a break at your desk”
APPROPRIATE REPLACEMENT SKILLS: FUNCTIONAL COMMUNICATION
Students should be taught an appropriate way to request access to the same class of reinforcement as identified in maintain problem behaviors
How to select response topography?
Consider response effort
Consider the likely speed of response acquisition
Will novel communication partners respond appropriately?
Verbal, gestural, picture exchange, voice/text output device
Break Card, Talk Time, No Thank You Pass, Nap Time
CASE STUDY: APPROPRIATE REPLACEMENT SKILLS
Appropriately Escaping Demands and Requesting to Chat with Staff
George should have a break card and a chat card available in his area.
If George begins to show signs of escalation (i.e., inappropriate interaction, noncompliance, etc.), staff should remind him, “George, if you need a break away from this you can ask for a break or if you need to chat you can let me know.”
Staff should honor George’s requests for a break or to chat immediately upon request.
A break should be George putting the task at hand aside for 2 minutes or going to the quiet room to take space for 2 minutes. When the break is over, staff should tell George that the break is over and if he needs additional time he can request 1 additional minute.
Staff should present the original demand to George when the break is finished.
CASE STUDY: APPROPRIATE REPLACEMENT SKILLS
Appropriately Requesting Tangibles/Sensory
Sally should have access to her communication device at all times
If Sally begins to show signs of escalation (i.e., yelling, stomping feet, etc.), staff should prompt her to make a request using her device.
Staff should honor Sally’s requests for hand massage for 1 minute, and then prompt Sally back to task.
Staff should make sure to honor all requests, not just when Sally engages in precursor behaviors.
FUNCTION BASED INTERVENTION
Even with antecedent strategies in place, challenging behaviors can still occur
Individual, function based procedures are written into the behavior support plan to address these target behaviors
Reinforcement and Consequence strategies
CONSEQUENCE STRATEGIES
Strategies for responding to problem behaviors
Will not necessarily stop the behavior in THAT moment, but will teach contingencies to the student to decrease problem behavior in FUTURE moments
Consistency is key! Takes repeated pairings of behavior- consequence for some students to learn contingencies
We, ourselves, receive delayed gratification
CONSEQUENCE STRATEGIES
Remain neutral…this is hard!
We naturally react to things that are unusual, challenging, make us uncomfortable or irritate us
Regardless of experience, dealing with challenging behaviors can be stressful
But…DO NOT REACT
With your words, body or facial expressions (sigh, arm cross)
Even “negative” attention may be reinforcing!
Keep calm internally – how?
REINFORCEMENT
Non contingent Reinforcement
Differential Reinforcement of Other Behavior (DRO)
Differential Reinforcement of Alternative Behavior (DRA)
Differential Reinforcement of Incompatible Behavior (DRI)
Differential Reinforcement of Low/High Rates of Behavior (DRL or DRH)
Cooper, Heron and Heward, 2007
CASE STUDY: DIFFERENTIAL REINFORCEMENT
CASE STUDY: DIFFERENTIAL REINFORCEMENT
CONSEQUENCE INTERVENTIONS
Response cost
removing reinforcement for an undesirable or disruptive behavior and decreases future likelihood of the behavior
Extinction
removing reinforcement for previously reinforced behavior and decreases future likelihood of the behavior
Re-direction
introduction of a prompt, comment, or other distractors when an interfering behavior is occurring. The distractor is designed to divert the learner's attention away from the interfering behavior and decreases future likelihood of the behavior
TRAINING AND MONITORING
STAFF TRAINING
So you have your plan – what now?
Our training protocol:
Have staff read the BSP and complete the accompanying quiz
Formal training
Go through each section step by step
Role play
Time for questions
Ongoing observation and feedback should be provided on a consistent basis
TREATMENT INTEGRITY AND FEEDBACK
TREATMENT INTEGRITY AND FEEDBACK
MONITORING DATA/ PEER REVIEW PROCESS
Peer review is a multi-disciplinary, data-based meeting
Any staff member may request a peer review
Some common reasons a peer review meeting is scheduled include:
Student is exhibiting new behavior or change in topography/intensity of behavior
After completing integrity checks, staff are following the plan but behavior still increasing
Medical instability or psychiatric concerns
Problems with implementing BSP – resources, staff training/turn over
Family concerns/issues
Student is not making academic progress
Safety/ Environmental concerns
PLAN UPDATES
There should be on-going monitoring of behavior support plans, and they should be updated as often as needed
Some reason a plan may need updating
Changes to operational definitions
Start to see a new behavior
Student no longer exhibits a challenging behavior – woohoo!
Updates to schedule of reinforcement
Change in environment (classroom, residence, etc.)
TROUBLESHOOTING
Call a peer review
Get staff together to try and think of new ways to address the challenges
Consult your colleagues
Other behavior analyst and members of the multi-disciplinary team
Consult the research
Peer review journals, attend conferences and webinars
CASE STUDIES
CASE STUDY: STEPHANIE
Referred to The May Center school for Brain injury and Neurobehavioral Disorders in 2012 ; 12 year old
Attended from 2012-2018
Challenging behaviors to target upon admittance: self-injurious behavior, inappropriate interaction, elopement, noncompliance
Functional behavior assessment suggested that all challenging behaviors were multiply maintained by escape and attention
10/23/2012 initial behavior support plan created
STEPHANIE: BEHAVIOR SUPPORT PLAN
Challenging behaviors to target: noncompliance, minor elopement, peer instigation, SIB
Antecedent strategies: schedule, choice, environmental arrangement, transitions, demands and tone, pre-teaching, walks
Interventions: see handout
STEPHANIE: GRAPHS
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10/1/12 10/15/12 10/29/12 11/12/12 11/26/12 12/10/12 12/24/12 1/7/13 1/21/13 2/4/13 2/18/13 3/4/13
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ST Q4 Non Compliance
10/23/12, BSP 12/24/12, revised noncompliance intervention;prompt once each minute until compliance is gained
STEPHANIE: GRAPHS
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ST Q4 Minor Elopement
10/23/12, BSP 1/23/12, warning for out of seat; escort to QR for n/c
12/24/12, warning given for running around classroom; escort to QR for n/c
STEPHANIE: GRAPHS
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-Red lines indicate criteria for earning mystery calendar, cash-in, and trophy day
STEPHANIE: GRAPHS
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Changed definition of SIB on 12/4/12 to include only instances when tissue damage is caused or worsened.
10/23/12, BSP
FAST FORWARD TO STEPHANIE 2018
Peer instigation and noncompliance are still being tracked
Stephanie no longer engages in elopement and self-injurious behavior (YAY!); no longer being tracked
Transitioned to a less restrictive setting, a public high school and is in a substantially separate special education classroom and participates in specials with general education students
Transitioned without any major issues and continues to maintain low rates of challenging behavior
FAST FORWARD TO STEPHANIE 2018
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CASE STUDY: JULIE
19 yr. old female diagnosed with Spastic quadriplegic cerebral palsy
She attends a private school for students with brain injury and neurobehavioral disorders.
Challenging behavior: self injurious head banging
Prior interventions including demand fading and DRO fixed time 10 minute reinforcement schedule
Levels of SIB were decreased throughout the day, however persisted during meal times
Peer review called to address challenging behaviors during mealtimes
MEASUREMENT SYSTEM
Dependent variable
Tantrum - any attempt to forcefully bang head on an object (e.g. wall, floor, chair, etc.), paired with yelling, crying, or aggression.
Data collection
Duration of behavior
Frequency of behavior
TREATMENT ANALYSIS
Baseline
Errorless Feeding and DRO
Errorless Feeding, DRO, and meal prep away
Errorless Feeding, DRO, meal prep away, and weights
Fading
TREATMENT ANALYSIS OF MEAL TIME TANTRUM
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Treatment Analysis of Meal Time Tantrum
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Treatment Analysis of Meal Time Tantrum
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Treatment Analysis of Meal Time Tantrum
RESULTS
• Errorless feeding was effective in decreasing mealtime tantrums.
• Decrease in mealtime tantrums was replicated across settings for frequency and duration in classroom and residential settings.
• Fading procedures were effective for increasing mealtime independence. That is, Julie was able to eat with only minimal assistance at her wrist from a caretaker.
• Performance varied across residential and classroom settings.
RESOURCESCanella, H.I., O’Reilly, M.F., and Lancioni, G.E. (2005). Choice and preference assessment research with people with severe to
profound developmental disabilities: a review of the literature. Research in developmental disabilities. 26, 1-5.
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