Integrating approaches to maximize therapy outcomes

Integrating approaches to maximize therapy outcomes

NADD International Conference, Miami, FL 5/8/2014

V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 1

Integrating approaches to maximize therapy outcomesVERONIQUE PARENT, NATHAN LAMBRIGHT, AND MELANIE DUBARDTHE MAY INSTITUTE, RANDOLPH, MASSACHUSETTS (USA)

NADD INTERNATIONAL CONFERENCE, MIAMI, FLORIDA,8 MAY 2014

Acknowledgements

May Center School for Autism and Developmental Disabilities Students & their families Clinical and educational staff Psychology and counseling interns

Disclaimer

The authors have no conflict of interest to report

Examples of clinical resources are provided in this presentation for information purposes only

Presentation Outline

Intro: CBT and Developmental Disabilities (DD)(5-10 min)

Intervention (60 min) Baseline phase (20 min) Skill acquisition (20 min) Skill generalization (20 min)

Conclusion (5 min)

Questions? (5-10 min)

Emotion regulation in individuals with DD

Bio-psycho-social vulnerabilities

High-risk population Comorbidity with mental health disorders Complex medical needs Behavior problems (e.g., aggression, self-injury, threats) and

adaptive skills deficits Psychiatric hospitalizations Other: homelessness, trouble with law enforcement

Condillac, 2007; Dozier et al., 2010; Lunsky & Balogh, 2010

Interventions and DD

Behavior treatments Relaxation training

Self-monitoring

Function-based treatments (e.g., applied behavior analysis, positive behavior supports)

Cognitive-behavior therapy (CBT) Anxiety and mood disorders

Anger management and emotion regulation

Social skills training Brown et l., 2013; Condillac, 2007; Dozier et al., 2010; Lang et al., 2010; Mullins & Christian, 2001; Paclawskyj, 2011




Why combining treatment approaches?

Most therapy models = general population Individual variability and need to adapt treatment Difficulty with generalization High-risk clinical population

I – Baseline AssessmentINTERVENTION PHASE (1/3)

Initial steps

Screening Interviews with caregivers Classroom observations

Prerequisite skills Emotion recognition Understanding of social situations Cognitive and communication abilities

Baseline assessment Standardized measures

Behavioral and socio-emotional functioning Child Behavior Checklist (CBCL, Achenbach) Behavior Assessment System for Children, 2nd edition (BASC-II, Reynolds &

Camphaus) Beck Depression Inventory, 2nd edition (BDI-II, Beck, Steer & Brown) Beck Anxiety Inventory (BAI, Beck) Rosenberg Self-Esteem Scale Social Skills Improvement Scale (SSiS, Gresham & Elliott)

Adaptive functioning Vineland Scales of Adaptive Behavior, 2nd edition (Sparrow, Cicchetti, & Balla) Scales of Independent Behavior, Revised (SIB-R, Bruininks, Woodcock,

Weatherman, & Hill)

Baseline assessment (cont’d)

Classroom data collectionMaladaptive behaviors

Main behavioral concern in the classroom: how often? how difficult to manage? How detrimental? What function?

Consider an FBA (if not available already) Skill development

What would be a functionally-equivalent skill to develop? Does student already know the skill?

Consider including self-monitoring measures

Target definitions

Maladaptive behaviors and/or symptoms Emotional difficulties: feelings of anxiety, sadness or anger Behavior problems: aggressive behavior, self-injury, property

destruction, threatsOther behavior: cognitive rigidity, social pragmatics, stereotypy

Skill development Self-regulation skills Social skills Participation in daily activities Problem-solving abilities




Outcomes evaluation

Pre-post standardized measures (e.g., CBCL, BDI, Vineland, SSiS)

Classroom data collection (e.g., coping strategy use, engagement)

Behavior Support Plan (BSP) daily data collection (if available)

Qualitative reports from student, parents, and teachers

Assessment challenges

Difficult items Rewording, give examples, show Always supplement verbal instructions with visual supports Consider developing your own instruments

Self-report biases Use multiple informants, across settings Use multiple methods (e.g., observations + questionnaires) Get both student’s + caregivers’ perspective

Rewording items

How would you reword the following items? “I am more critical of myself than I used to be” “I have much greater difficulty in making decisions that I

used to be” “Numbness or tingling” “Wobbliness in legs” “I feel I do not have much to be proud of”

Developing assessment tools

What are we measuring? Good definition = clear, objective, and complete Test your definitions Clarify definitions, as needed

How are we measuring it? Dimensions of behavior measured: frequency, intensity, duration, etc. Density (how often?): minutes, hours, sessions, weeks, pre-post, etc. Procedures: event recording, time sampling, datasheets, instruments,

etc.

Definition of “Escalation Signs”:Non-examples

Any instances when student looks upset. Any instances when student becomes upset in order to get

what he wants. Every time student starts hitting others.

Questions Are the definitions clear? What is missing? Using frequency vs. episodes? How much time does it take to calm

down?

Definition of “Escalation Signs”:Example

Signs of escalation: Any episodes when student appears to be upset, as noted by the presence of the following physical or verbal behavioral signs: a. Physical: body tensing (e.g., such as clenched jaw or fists), hitting the

table or the wall with his fists, and moving his arms/fists as if punching something in front of him.

b. Verbal: raising his voice, telling people to stop “imitating” him or stop “looking” at him, and making verbal threats to others.

Episodes are separated by 5 minutes intervals. If student presents symptoms during that time interval, count as the same behavioral episode.




Definition of “Coping Skills”:Example

Coping strategy use: Any instances when student uses one of the following coping strategies: a. Take a deep breath: student takes deep breaths to relax. Student

tries to have a calm body while taking deep breaths, this includes calm legs, arms, and head. Student’s eyes can be opened or closed to his preference while taking deep breaths.

b. Help strategy: Student reaches out to staff when upset and asks for their help or tells them what’s wrong (e.g., “I’m upset” or “Can you help me?”).

Developing assessment tools (cont’d)

Data validity Inter-observer agreement (IOA) -> data collection

% of agreement between 2 observers/ raters (Total Agree/ Total Agree + Disagree) x 100Goal = IOA >80%

Treatment integrity -> implementation% steps in treatment plan completed accuratelyGoal = 100% steps correct

Example: Treatment integrity and IOA Data validity (cont’d)

Social validity (e.g., target behavior, instrument use)Qualitative: Pre/post interviews with caregivers + students Quantitative: improvement in daily functioning (e.g., ability

to participate in academic activities, independent level)

Ongoing monitoring of IOA + Treatment Integrity Provide corrective feedback and training, as needed

Data analysis: Line graphs

Data analysis:Bar graphs




Data analysis:Within subject comparisons (clinical scores)

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Pretest Posttest

Self-esteem (self-report)

Rosenberg Scale

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Pretest Posttest

Symptoms of anxiety (self-report)

BAI

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Pretest Posttest

Symptoms of depression (self-report)

BDI

II – Skill AcquisitionINTERVENTION PHASE (2/3)

Introductory sessions

Build rapport Familiarize individual with process Identify student’s interests and preferences Identify optimal participation times Identify significant others (e.g., favorite staff) Individual’s perception of his/her own strengths /

weaknesses

Teaching prerequisite skills: Emotion identification Present students with age-appropriate facial expressions

Receptive: ID: Ask: “Show me the child who looks happy/ sad/ mad?” Expressive ID: Ask: “How is he/she feeling?”

Electronic resources Teaching prerequisite skills: Reading social situations Present students with age-appropriate social situations pictures

Receptive: ID: Ask: “Show me the one which is okay/ not okay?” Expressive ID: Ask: “What is happening here?,” “is it okay or not okay?,”

“How is he/she feeling?”




Therapy model and goals

Feel

Do Think

Increase self-awareness of: Learn and develop:

Problem-solving skillsMaladaptive thoughts and actions

Feelings + precursor signs

Situation triggers

Coping skills

Relaxation skills

Identifying triggers and related emotions

Use matching exercisesAsk student to draw pictures of situations that

make him/her feel happy, sad, etc.

Play board games:Children resources

Board games:Adolescents and young adults resources

Create your own! Teaching precursors and warning signs

Use human body picture and ask: “where do you feel it in your body when you are ___?,” “what do you feel/do?”

Ask student to color, put “x,” point, etc. Use everyday examples Discuss situations that happened in the last week Ask student to draw a picture or create a story Prepare a hand-out with different pictures and ask

student to point




Electronic resources Connecting body signs to emotions:Worksheet

Teach self-monitoring

Rating scales Create a hierarchy (mild, moderate, and severe

upsets) Journaling Have student develop his/her own rating scale

Example of rating scale

Rating scale:Visual hand-out

Rating scale:Feeling thermometer




Self-monitoring results –Student with generalized anxiety

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Anxiety about people leaving

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4Anxiety about graduation

Identifying actions and thoughts

Use cartoons and thought bubblesUse dark cloud analogyUse story board to create A-B-C stories

A: Trigger B: Action C: Consequence

Create pros/cons action listCognitive restructuration activities

Creating social stories Cognitive restructuration exercise

Quizz and challenge irrational beliefs

Relaxation skills

My quiet place (e.g., bean bag, bedroom, picture) What to do to calm down?

Take deep breaths Calm body posture Words I can use (e.g., self-talk) Calm picture to look at Provide reminders




Relaxation skills:Written hand-out

Relaxation skills:Visual hand-out

Distraction strategies

Counting Signing a favorite song Wearing headphones Keeping hands busy

Problem-solving skills “Break” strategy

How to request a break? For how long? “Help” strategy

Identify “safe” people across settingsHow to reach out for help? Telling what’s wrong

Social skills (e.g., conversation, conflict resolution) Review events of the week (+ and -) and develop

alternate actions for difficult situations

Develop a personal toolbox

• Personal talents

• Coping skills

• List of safe people

Before moving to next treatment phase…

Monitor student’s progress during therapy session Program for next intervention phase

Develop + implement visual supports (e.g., rating scales, relaxation tools)

Develop behavior protocol Triggers and precursors (e.g., math exercises, hands in fist)Define target behaviorsDefine coping skills to prompt when noticing triggers/precursors




III – Skill GeneralizationINTERVENTION PHASE (3/3)

Skills generalization

Programming for skills generalization and maintenance is a key component to any CBT treatment and any

behavioral intervention with children with ASD or developmental disabilities

Skills generalization

“The occurrence of relevant behavior under different non-training conditions

without the scheduling of the same events in those conditions”

Stokes & Baer, 1977

Environmental supports: Implement a behavior protocol

Include the following: Triggers and precursors (e.g., math exercises, hands in fist)Define target behaviorsDefine coping skills to prompt when noticing

triggers/precursors Prompting and differential reinforcement strategies Preventive antecedent strategiesDe-escalation strategies for crisis situations

Monitor effectiveness and follow-up

Data collection + analysis, IOA, treatment integrity Staff training + corrective feedback Identification of new triggers and precursors Need to add new coping strategies Need to update student’s clinical tools

In-session supports

Review events of the week Develop solutions for new challenges Prepare for upcoming transitions or stressors Practice, role-play, develop new tools Progressive fade out of individual sessions Replaced by classroom consultations with student and

teachers




Conclusion CBT + BT can be effective with students with DD Baseline, skill acquisition + skill generalization treatment

phases Goal = skills maintenance Treatment sessions modifications Outcomes evaluation Treatment integrity Ecological validity

Questions?

For more information: [email protected]

Documents

Integrating approaches to maximize therapy outcomes