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Best Practices Dealing With Problem Behaviour of Children and Adolescents with ASD

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Title: Best Practices Dealing With Problem Behaviour of Children and Adolescents with ASD


1
Best Practices Dealing With Problem Behaviour of
Children and Adolescents with ASDs
  • Sponsored by
  • Childrens Mental Health Ontario
  • Dr. Joel Hundert Dr. Nicole Walton-Allen
  • Behaviour Institute

2
Welcome Sites
Burlington London Sault Ste. Marie
Chatham Markham Sudbury
Dryden Mississauga Thunder Bay
Kapuskasing Ottawa Timmins
Kingston Parry Sound Windsor
Kitchener Peterborough
3
Schedule For the Workshop
  • 130 - 230 Joel Hundert Understanding and
    assessing problem behaviours
  • 230 - 245 Questions
  • 245 - 355 Break
  • 255 - 355 Nicole Walton-Allen Interventions
  • 355 - 410 Questions
  • 410 - 430 Application to school families

4
What is the Behaviour Institute?
  • The Behaviour Institute is a private agency
    providing intensive behavioural intervention for
    young children with autism. Home-based services
    are provided out of Hamilton and Toronto offices
    centre-based IBI services out of Toronto office
  • Training organization for the Ontario Autism
    Initiative

5
  • Sponsor of part-time Masters degree program in
    Behaviour Analysis offered in Toronto by the
    University of Nevada, Reno (42 students)
  • Directors are Dr. Joel Hundert Dr. Nicole
    Walton-Allen, psychologists and Board Certified
    Behaviour Analysts

6
Goals of the Workshop
  • Understanding of the unique behaviour / emotional
    needs of children with ASDs
  • Knowledge of the conceptual and research
    foundations of PBS
  • Knowledge and skills in conducting a functional
    behavioural assessment
  • Knowledge and skills of PBS strategies to
    anticipate and prevent problem behaviours

7
Goals contd
  • Knowledge and skills of PBS strategies to teach
    functional skill alternatives
  • Knowledge and skills of how to use PBS with
    families
  • Knowledge and skills of how to use PBS with
    schools

8
How to Get Materials
  • http//www.behaviourinstitute.com

9
AGENDA
  • Autism
  • Positive Behaviour Support
  • How to Implement PBS
  • Forming a team
  • Functional assessment
  • Develop a hypothesis

10
Agenda Contd
  • Behaviour support plan
  • Anticipate and prevent
  • Teach positive alternatives
  • No longer let the problem behaviour be effective
  • Implement evaluate
  • Promote generalization of positive behaviours
  • Application to schools
  • Application to families

11
Assumptions
  • You are experienced childrens mental health
    clinicians
  • Less experienced in working with children and
    youth with ASDs and their families
  • Have read Best Practices document
  • Have attended or have knowledge of introductory
    and advanced training provided by Geneva Centre

12
CMHO Training Plan
  • Introductory training (1-day)
  • Advanced training (2-days)
  • Specialized training
  • Best Practices for Dealing with Problem
    Behaviours of Children and Youth with Autism
    Spectrum Disorders
  • Best Practices for Children and Youth with
    Aspergers Disorder

13
AUTISM SPECTRUM DISORDERS
14
What We Know About Autism Spectrum Disorders
  • Is a neurodevelopmental disorder with no clearly
    understood cause, although there evidence that it
    runs in families and has a genetic component
  • Is not caused by poor parenting
  • Prevalence is about 1/300 (Yeargin-Allsopp et
    al., 2003) and increasing

15
What We Know contd
  • Can identify by 24 months (Stone et al., 1999)
  • More common in boys (41)
  • No prevention or cure
  • There is a treatment that works (Early Intensive
    Behavioural Intervention)

16
Growth Trajectory
Typically-developing children
Developmental Age
Chronological Age
17
Growth Trajectory
Typically-developing children
Children with autism
Developmental Age
Chronological Age
18
Growth Trajectory
Typically-developing children
Goal of IBI
Children with autism
Developmental Age
Chronological Age
19
Summary of Research on IBI
  • 20 - 40 hours/week of IBI can produce significant
    and long-lasting gains in young children with
    autism to a point where about half achieve
    average IQ and do not need special help in school
  • The success of IBI depends on staff being trained
    and supervised by competent behavioural
    consultants

20
Critical Components contd
  • A large proportion of the childs waking hours
    should involve active engagement in learning

20 hours
100 waking hours
21
Challenges Of CMH Agencies Serving This Population
  • Problems are chronic and episodic
  • Motivational and skill deficits

22
Challenges contd
  • Compared to families of typically-developing
    children and children with other forms of
    developmental disabilities, levels of stress and
    depression is the highest in families of children
    with ASDs
  • Lack of cross-sectorial service coordination
    (e.g., medical, educational, developmental
    services, etc.) is common

23
Problem Behaviours and Children / Adolescents
with ASDs
  • About 50 have significant problem behaviours
    including aggression, tantrums, stereotypic
    behaviours, and self-injurious behaviours
  • No evidence of spontaneous improvement
  • More frequent and severe problem behaviours are
    associated with children / adolescents who have
    more severe symptoms of autism
  • Problem-behaviours crytallize and become more
    entrenched as children get older

24
POSITIVE BEHAVIOUR SUPPORT
  • Origins were to provide an alternative to the use
    of aversives
  • Early researchers Glen Dunlap, Ted Carr, Mark
    Durand, Rob Horner, Robert Koegel
  • Journal of Positive Behavior Interventions
  • Association and annual meeting

25
POSITIVE BEHAVIOUR SUPPORT
  • Origins were to provide an alternative to the use
    of aversives
  • Early researchers Glen Dunlap, Ted Carr, Mark
    Durand, Rob Horner, Robert Koegel
  • Journal of Positive Behavior Support
    Interventions
  • Association and annual meeting

26
PBS contd
  • Since 1997, amendment to Individuals with
    Disabilities Act (IDEA) requires
  • a) PBS and,
  • b) functional behavioural assessment

27
Carr Durand (1985)
  • Problem behaviours have a function
  • Understanding the function of behaviours lead to
    more effective treatment

28
ABA, IBI, and Autism
Psychology
ABA
Autism
IBI
29
ABA, IBI, PBS and Autism
PBS is ABA
PBS
Psychology
ABA
Autism
IBI
30
Core Features of PBS Interventions
  • Driven by functional assessment
  • Result in outcomes that are acceptable to the
    individual, family and the supportive community
  • Fit the contexts within which the behaviour
    occurs

31
Core Features of PBS
  • Consistent with values of those who will
    implement the procedures
  • Consistent with the skills of the people who will
    implement the procedures
  • Consistent with the resources available to the
    people who will implement the procedures and
    matched by administrative support (Horner, 2000)

32
Core Features of PBS Interventions Contd
  • Operate from a person-centred values base
    (Anderson Freeman, 2000)
  • Blend multiple, empirically-based procedures
    (Horner, 2000),
  • Focus on large unit of analysis and intervention

33
PBS is ABA Dressed-Up and Ready to Go Out
ABA
PBS
34
HOW TO DELIVER PBS
35
Case Example
  • Cameron is a six year old boy who has been
    receiving IBI for the past 1.5 years. He attends
    a community school with support from a PDD class
    in the school. Major areas of need
  • Social pragmatics (e.g., conversation)
  • Peer interaction
  • Compliance

36
CAMERON IN IBI
37
CAMERON IN PLAY
38
STEPS
  • Form a team around the child or youth
  • Complete a functional assessment
  • Develop a hypothesis of the triggers and
    maintaining factors
  • Develop a Behaviour Support Plan
  • Implement and evaluate
  • Generalize

39
STEP 1
  • Form a team around the child of individuals who
    can help or hinder the childs adjustment
  • Like Wrap-Around, Person-Centred Planning

40
  • Identify strengths and needs

41
STEP 2
  • Complete a functional assessment

42
  • Problem behaviours do not occur at random. They
    occur to meet a need of the child

43
Functions of Behaviour
  • Obtain Objects
  •  Activities
  •  Attention
  •  Sensory
  • Escape

If positive
If negative
44
Form Function
  • Different forms of problem behaviours may serve
    the same function (e.g., kicking, crying to get a
    desired object)
  • Same form problem behaviours may serve different
    functions (e.g., crying at home to escape, crying
    at school for attention)

45
Identify the Problem Behaviour, Its Form and
Possible Functions
  • David is a 14 year old boy with autism who is
    fascinated by brightly coloured string, shoe
    laces, and other long fabric. He takes the
    string between two cupped hands, rocks while
    making humming noises.

46
Identify the Problem Behaviour, Its Form and
Possible Function(s)
  • Jane is late from work and rushing at the grocery
    store with her son, Andy. At the check out, Andy
    spots the chocolate bars. Andy asked for a candy
    bar. His mother, Jane, said, You cant have
    candy now, its almost dinner time. Andy asked
    for it again and again, began to whine and cry.
    Jane was embarrassed and said, OK, but you
    better eat your dinner tonight.

47
Identify the Problem Behaviour, Its Form and
Possible Function(s)
  • Emily is a four-year with autism and hates to
    have her hair washed. Sometimes when her dad,
    Ron, bathes her, she kicks and screams. When
    this happens, Ron decides to wait for his wife to
    come home to wash Emilys hair that day.

48
Identify The Possible Functions
  • 1. David, a 13-year old is given seat work to do
    at the back of the room which he does not like.
    Periodically, David will run out of the room.
  • a escape situation b obtain attention
  • c escape attention d obtain internal
    stimulation e obtain object or activity

49
Identify The Possible Functions
  • 2. Tommy is a 5 year old who hovers nears other
    children at outdoor play but does not play with
    them. Periodically, he will run by and hit a
    child who is playing in a group.
  • a escape situation b obtain attention
  • c escape attention d obtain internal
    stimulation e obtain object or activity

50
The Importance of Functions
  • Before you develop an intervention for behaviour
    problems, you must understand the function(s) of
    the behaviour and develop an intervention based
    on that understanding. Interventions built on an
    understanding of functions are more effective
    (Carr et al., 1999)

51
Functional Assessment
  • Indirect method
  • interview
  • Direct method
  • Functional Assessment Checklist
  • Functional Assessment Cards (Carr and Durand,
    1985)
  • Scatter Plot
  • Functional Assessment Observation Form

52
Functional Assessment Checklist
53
ABC Record
  • Is not enough

54
Functional Assessment Cards (takes about 5 min to
complete)
  • Identifies factors that trigger the behaviour
  • Identifies the form(s) of the problem
    behaviour(s)
  • Identify factors that may maintain the behaviour
  • Identifies possible function(s) of the problem
    behaviours

55
Functional Assessment Cards contd
56
Functional Assessment Cards contd
57
Functional Assessment Cards contd
  • Hand out 5 - 10 Functional Assessment Cards,
    preferably to different staff
  • Staff complete a card after each incident
  • Once all cards are completed, cards are sorted
    into piles by function (preferably as a group)

58
Exercise Complete a FAC for Throwing Stones
59
(No Transcript)
60
SCATTER PLOT
  • Paul Touchette

61
Scatter Plot (takes about 7 min to complete a day)
  • Method of recording occurrence and non-occurrence
    of behaviours across activities and time periods
  • Suggests patterns that may help to identify
    triggers and functions of problem behaviour

62
Example
7
Away
63
How To Do Scatter Plots
  • Pick the target behaviour
  • Operationally define the target behaviour
  • Record when the behaviour occurs by time
    intervals or by activity

64
Functional Assessment Observation Form (ONeill
et al., 1997)
65
FAO How to Complete
Fill in behaviours
  • Fill in time and activities

66
FAO How To Complete
  • Enter for each episode

67
Interpret
Problem seems to be escape-motivated
68
STEP 3
  • Hypothesize what factors trigger and maintain the
    problem behaviour

69
The Competing Behaviour Model (ONeil, et al.,
1990)
70
Setting Events
Setting events are events that have occurred
earlier that alters the effectiveness of the
consequence e.g. sleep loss, long car ride
A B C
71
Learning Behaviour
  • Setting Event

Triggering Antecedent
Problem Behaviour
Maintaining Consequence
Hitting
Avoid task
Ear infection
Asked to clean up
72
Example
  • Jane is late from work and rushing at the grocery
    store with her son, Andy. At the check out, Andy
    spots the chocolate bars. Andy asked for a candy
    bar. His mother, Jane, said, You cant have
    candy now, its almost dinner time. Andy asked
    for it again and again, began to whine and cry.
    Jane was embarrassed and said, OK, but you
    better eat your dinner tonight.

73
Learning Behaviour
  • Setting Event

Triggering Antecedent
Problem Behaviour
Maintaining Consequence
Crying
Gets candy
Many hours since last eaten
Sees chocolate bar
74
Exercise
  • It is late in the day. Ron, is rushing to get
    his seven year old daughters, (Emily) ready for
    bed. Emily hates to have her hair washed. When
    her dad, Ron, was bathing her, she kicks and
    screams. When this happens, Ron decides not to
    wash her hair that day.

75
Learning Behaviour
  • Setting Event

Triggering Antecedent
Problem Behaviour
Maintaining Consequence
Kicks and screams
Avoid task
Tired, rushed
Wash hair
76
STEP 4
  • Formulate a Behaviour Support Plan

77
Rob Horner
  • Make the problem behaviour irrelevant
  • Make the problem behaviour inefficient
  • Make the problem behaviour ineffective

78
Making the Problem Behaviour Irrelevant ANTICIPAT
E AND PREVENT
79
Neutralizing Routines for Setting Events (Horner,
1997)
80
Horner, Day Day (1997)
  • 3 adolescents with autism and developmental
    disabilities who were self-injurious or
    aggressive
  • Setting events delay in favourite event, lack
    of sleep
  • Neutralizing routines drawing pictures, looking
    through photos, nap

81
SETTING EVENT
IMMEDIATE TRIGGER
AGGRESSION SIB
ESCAPE
NEUTRALIZING ROUTINE
  • Showed that aggression / SIB occurred only when
    setting event occurred before the immediate
    trigger
  • Then showed that the addition of a neutralizing
    routine reduced the problem behaviour to near zero

82
Other Examples of Neutralizing Routines
  • Looking through a favourite book
  • Looking through a picture album
  • Watching a video
  • Eating a favourite snack

83
Delay, Reduce, or Remove Triggers
  • Make activities and materials easier,
  • Add aids to learning
  • Make activities more fun, build in reinforcement
    (e.g., computer-assisted learning)
  • Break activities into small steps

84
Add Visual Information
  • Used to show the sequence of pending activities.
    Typically, child turns over picture at the end of
    one activity and looks at the next activity
    coming.

85
Visual Schedule
86
Play Picture Activity Schedule McClannahan
Krantz (1993)
87
How PAS Differs From Picture Schedules
  • Focuses on the steps of performing an activity
  • Goal is for the child to perform an activity
    without adult prompts
  • Picture schedules have had very little research,
    PAS have had extensive research

88
High-P Requests
  • Give 4 or more high probability requests
  • Return to original request

89
Priming
  • Problem behaviour is more likely to occur in
    unpredictable than predictable environments
    (Flannery Horner, 1994)
  • Consists of child previewing future events (no
    practice)
  • Originally used for children with autism to
    preview a story at home that was read the next
    day in school (Wilde et al., 1992)
  • Video priming (Schriebman, Whalen, Stahmer,
    2000)
  • Cutting hair

90
Making The Problem Behaviour Inefficient
  • Teach Positive Skills That Involve Less Effort

91
Behaviour and Communication
  • There is a direct relationship between problem
    behaviour and communication deficits in children
    with autism
  • Not all behaviour is communication (e.g.,
    echolia)

92
Functional Communication Training by Durand (1990)
  • Select a response modality that would be
    successful for the child (e.g., signs, PECS,
    micro-switch voice generators)
  • Select a response form that the child can learn
    rapidly (e.g., break card) and involves less
    effort than the problem behaviour
  • Maximize natural opportunities for the child to
    learn this communicative response
  • The communicative response is taught during
    teachable opportunities

93
Functional Communication Training Contd by
Durand (1990)
  • Deliver instruction for the child to use a
    communicative response (e.g. "What do you want?")
  • Deliver physical prompt (e.g., The therapist
    gives the child a picture depicting break" and
    puts out his or her hand)
  • Delivers a verbal prompt as the child uses a
    communication response (e.g. "I want a break")
  • The child receives the requested object or
    activity.
  • Prompt to assist the child in responding are
    systematically faded.
  • Generalization of the learned response is
    promoted across people and setting

94
Making the Problem Behaviour Ineffective
  • The problem behaviour is no longer effective in
    meeting the childs needs

95
Match Strategies to Function
  • FIRST STRATGEGY FOR ATTENTION-MAINTAINED
    BEHAVIOURS
  • Give effective instructions
  • Differential reinforcement
  • Planned ignoring of the small stuff
  • SECOND STRATEGY FOR DESIRED OBJECT/ACTIVITY
  • Response cost

96
Match Strategies to Function
  • THIRD STRATEGY FOR SENSATION MAINTAINED
    BEHAVIOURS
  • Interrupt, Redirect, Reinforce
  • FOURTH STRATEGY FOR ESCAPED-MOTIVATED BEHAVIOURS
  • Proceed with caution

97
The First Strategy
  • For problem behaviours maintained by attention

98
Give Effective Instructions
  • Be sure that the child is paying attention
  • State what you want the child to do, rather than
    not do
  • Give only one instruction at a time
  • Be brief and simple
  • Do not repeat your instruction

99
Exercise Identify the Errors
  • Gregory was having a great time at outdoor play
    in the sandbox, but was throwing sand. His
    teacher said, Okay Gregory, stop throwing sand.
    . GREGORY, I SAID STOP THROWING SAND!!!
  • Jean wanted Melissa to clean up the dress-up
    centre. Jean said, Melissa how about you
    picking up the brown shoes and put them over by
    the wall, then gather up the necklaces and place
    then in a bin. Then, put all of the hats on the
    hat rack.

100
Reinforce Compliance
  • Reinforce positive alternative behaviours
  • Use descriptive praise (describe what the child
    did), (e.g., I like the way you stopped what you
    were doing and looked at me.)
  • If praise is not important to the child, pair the
    praise with a tangible reinforcer that is
    effective for the child.

101
Ignore The Small Stuff
  • Dont ignore behaviours that are harmful,
    dangerous or highly disruptive
  • Only ignore behaviours that are maintained by
    attention (e.g., whining)
  • Discuss with the care givers what behaviours can
    and cannot be ignored
  • Biting another child
  • Whining
  • Jumping up and down
  • Screaming

102
Planned Ignoring (Extinction) contd
  • Act in all ways as if the annoying behaviour is
    not occurring
  • Reinforce the alternative behaviour
  • Expect an extinction burst

103
SECOND STRATEGY
  • For problem behaviours maintained by getting
    desired object

104
Removal of Object or Activity (Response Cost)
  • Cameron and his sister, Amy, were playing with a
    truck, pushing it back and forth. Amy decided to
    stop the game and push the truck by herself.
    Cameron wanted a turn too and tried to pull the
    truck away. They began to struggle and cry over
    the truck when their father walked in. He took
    the truck away and said, You need to share your
    toys. After a few minutes he returned the truck
    and reminded them to share.

105
Response Cost
  • Only use for problem behaviours that occur
    occasionally
  • Use for problem behaviour that are motivated to
    get desired object or activity
  • The object or privilege that is removed should be
    naturally connected to the problem behaviour
  • The consequence should be immediate
  • Always reinforce the desired behaviour

106
Exercise How would you use Response Cost?
  • Jason loves to watch the videotape of Lion King,
    particularly one scene that he rewinds and
    replays continuously. In the past he has broken
    VCRs and videos from the constant rewinding.

107
THIRD STRATEGY
  • For problem behaviours maintained by sensations

108
Interrupt, Redirect, Reinforce
109
Stereotypy
  • What is it?
  • Routinized and repetitive actions (may be verbal
    and/or motoric) that occurs often with no
    function
  • Why does it occur?
  • Feels good
  • How does it impact children?
  • Interferes with learning
  • How do you treat it?

110
Treatment of Stereotypy
  • Have functional activities for the child to do
    that keeps him/her busy (e.g.,carry objects
    during a transition, place hands in pockets)
  • When stereotypy occurs
  • Interrupt (e.g., gentle touch)
  • Redirect (e.g., give item to carry)
  • Reinforce (e.g., give reinforcement for carrying
    item)

111
(No Transcript)
112
Also Can Be Used for Aggression To Get
Objects/Activities
  • Brian is beside James at the water table and
    starts to pinch him because he wants the pail.
    The aide then redirects Brian to the vehicle play
    area and reinforces him when he begins to play
    with trucks.

113
Redirection Should Not Be Used for
Escape-Motivated Problem Behaviours
  • Why?

114
FOURTH STRATEGY PROCEED WITH CAUTION
115
Match Intervention to Function of Behaviour
  1. Get attention
  2. Escape request
  3. Get desired object or activity
  4. Sensory
  1. Planned ignoring
  2. Interrupt-redirect- reinforce
  3. Get professional consultation
  4. Response cost

116
Review
  • Make the problem behaviour irrelevant
  • Neutralizing routines
  • Make activities and materials easier,
  • Add aids to learning (e.g., visual schedules)
  • Make activities more fun, build in reinforcement
  • Break activities into small steps
  • Make the problem behaviour inefficient
  • Functional communication training

117
Summary
  • Make the problem behaviour ineffective
  • Planned ignoring and differential reinforcement
  • Response cost
  • Interrupt, redirect, reinforce
  • For escape-motivated behaviour proceed with
    caution
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