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Integrating Individualized Interventions for Students with Mental Health Challenges

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Title: Integrating Individualized Interventions for Students with Mental Health Challenges


1
CMHACY May 14, 2015 Session 1-A
Integrating Individualized Interventions for
Students with Mental Health Challenges within a
School-wide System of Positive Behavior Supports
Lucille Eber Ed.D Director, Midwest PBIS Network
and National PBIS TA Center Partner lucille.eber_at_m
idwestpbis.org
2
BIG Ideas for Today
Describe how interventions for students with
mental health challenges can be efficiently
delivered within a school-wide system of Positive
Behavior Supports. Share examples of how
individualized interventions, including
function-based behavior plans, person-centered
wraparound and RENEW plans, can be layered up
from an effective school-wide PBS curriculum.
3
  • Putting outcomes for
  • students with EBD
  • into the context of schools
  • as systems to educate and support ALL students.

4
Some Big Picture Challenges
  • Low intensity, low fidelity interventions for
    behavior/emotional needs
  • Habitual use of restrictive settings (and poor
    outcomes) for youth with disabilities
  • High rate of undiagnosed MH problems (stigma,
    lack of knowledge, etc.)
  • Changing the routines of ineffective practices
    (systems) that are familiar to systems

5
What has Changed Since?
Braaten,S., Kaufman, J.M., Braaten, B.,
Polsgrove, L., and Nelson, C.M. (1988). The
Regular Education Initiative Patent Medicine for
Behavioral Disorders. Exceptional Children,
55(1), 21-27
Peacock Hill Working Group, 1991
Knitzer, J., Steinberg, Z and Fleisch, B. (1990).
At The schoolouse door. New York Bank Street
College of education
Wood, F. (1989) Students at risk. Supporting the
growth of students with emotional and behavioral
disorders. The Pointer, 33(4), 20-26
6
We Know the Practices that Work for Students
with EBD
  • Proactive, strength-based set kids up to
    experience success
  • High rates of consistent, supported instruction
    teach/practice/reinforce
  • Predictable and consistent environments
  • Know unique why? for each student/problem
  • Contextual fit Strategic use of natural
    supports, and settings
  • Careful monitoring of data over time with ongoing
    revisions to guide incremental improvements in
    quality of life

7
  • Behavior support is the redesign of environments,
    not the redesign of individuals.
  • Positive behavior support plans define changes in
    the behavior of those who will implement the
    plan. A behavior support plan describes what we
    will do differently.

Do ALL staff understand the context for
effective behavior interventions?
8
It Takes a System
  • ..that builds system capacity for advanced tiers

9
?
Positive Behavior Support
Social Competence Academic Achievement
Supporting Decision Making
Supporting Staff Behavior
Adapted from What is a systems Approach in
school-wide PBS?OSEP Technical Assistance on
Positive Behavioral Interventions and Supports.
Accessed at http//www.Pbis.org/schoolwide.htm
Supporting Student Behavior
10
Core Features of a Response to Intervention (RtI)
Approach
  • Investment in prevention
  • Universal Screening
  • Early intervention for students not at
    benchmark
  • Multi-tiered, prevention-based intervention
    approach
  • Progress monitoring
  • Use of problem-solving process at all 3-tiers
  • Active use of data for decision-making at all
    3-tiers
  • Research-based practices expected at all 3-tiers
  • Individualized interventions commensurate with
    assessed level of need

11
Tertiary Prevention Specialized
Individualized Systems for Students with
High-Risk Behavior
SCHOOL-WIDE POSITIVE BEHAVIOR SUPPORT
5
Secondary Prevention Specialized Group Systems
for Students with At-Risk Behavior
15
Primary Prevention School-/Classroom- Wide
Systems for All Students, Staff, Settings
80 of Students
12
PBIS Features
  • Module 1 PBIS Team
  • Module 2 Faculty Commitment
  • Module 3 Expectations and Rules
  • Module 4 Lesson Plans
  • Module 5 Acknowledgement
  • Module 6 Discipline Procedures
  • Module 7 Data Entry and Analysis
  • Module 8 Classroom Behavior Systems
  • Module 9 Evaluation
  • Module 10 Implementation Plan

13
Common Language Common Language
Expectations 3-5 overarching school-wide expectations
Behaviors/Rules specific tasks students are to do to achieve the school-wide expectations
Routines/Procedures methods or process for how things are done in non-classroom settings and each classroom
14
The change is an instructional process We change
STUDENT behavior by changing ADULT
behavior Interventions changes in staff
procedures practices
15
How will we teach behavior? When will we teach
behavior?
  • Kick-off events
  • Teaching staff, students and families the
    expectations and rules
  • On-going direct instruction
  • Data-driven and scheduled designed lessons
  • Pre-correction
  • Re-teaching immediately after behavioral errors
  • Embedding into curriculum
  • Booster trainings
  • Scheduled and data-driven
  • Continued visibility
  • Visual Displays posters, agenda covers
  • Daily announcements
  • Newsletters

16
Guidelines
  • School-wide reinforcements are for every student
  • Acknowledge the behavior
  • Include the students in identifying possible
    recognitions
  • Recognize students other than your own in common
    areas
  • Recognition closely follows the desired behavior
  • Keep it novel

Effective Efficient
17
Positive Behavior Interventions Supports A
Response to Intervention (RtI) Model
Tier 1/Universal School-Wide Assessment School-W
ide Prevention Systems

ODRs,Credits, Attendance, Tardies,
Grades, DIBELS, etc.
Tier 2/ Secondary Tier 3/ Tertiary
Check-in Check-out (CICO)
Intervention
Assessment
Social/Academic Instructional Groups (SAIG)
Daily Progress
Report (DPR) (Behavior and
Academic Goals)
Group Intervention with Individualized Feature
(e.g., Check and Connect - CnC and
Mentoring)
Competing Behavior Pathway, Functional
Assessment Interview,
Scatter Plots, etc.
Brief Functional Behavior Assessment/ Behavior
Intervention Planning (FBA/BIP)
Individual Student Information
System (ISIS)
Complex or Multiple-domain FBA/BIP
SIMEO Tools HSC-T, RD-T, EI-T
USDOE-OSEP Tertiary Demo Project H326M0060010
Wraparound
Adapted from T. Scott, 2004
18
More Students Access Tier 2/3 Interventions When
Tier 1/ Universal is in Place
FY09 School Profile Tool Students Accessing Tier
2/Tier 3 Interventions
19
Tier 2/Tier 3.. Changing Existing Systems
  • Harder than starting from scratch
  • Schools think they are already doing it
  • Need to deconstruct some existing teaming
    approaches and practices
  • Data not being used except to justify placements

20
Examples of Ineffective Secondary/Tertiary
Structures
  • Referrals to Sp. Ed. seen as the intervention
  • FBA seen as required paperwork vs. a needed
    part of designing an intervention
  • Interventions the system is familiar with vs.
    ones likely to produce an effect
  • (ex student sent for insight based counseling at
    point of misbehavior)

21
Example of Change that may be Needed
  • Groups that are not evidence-based
  • Clinicians seeing students w/o clarity of
    intervention and data to determine effectiveness

22
3-Tiered System of Support Necessary
Conversations (Teams)
Problem Solving Team Meeting
Tertiary Systems Team Meeting
Secondary Systems Team Meeting
Universal Team Meeting
Standing team uses FBA/BIP process for one
student at a time
Uses process data determines overall
intervention effectiveness
Uses process data determines overall
intervention effectiveness
Plans schoolwide classroom supports
Check-In Check-Out
Universal Support
Skills Groups
Complex FBA/BIP
Wraparound
Brief FBA/BIP
Group w. individual feature
Brief FBA/BIP
USDOE-OSEP Tertiary Demo Project H326M0060010
23
Coordinator vs. Facilitator
  • Coordinator
  • Organizes and/or oversees the specific
    interventions such as CICO, S/AIG Group with
    Individual Features
  • Roles include scheduling meetings, review
    collect data to share during team meetings, etc
  • Facilitator
  • Directly provides intervention support services
    to youth/families
  • Roles include meeting with students for CICO,
    running groups

24
USDOE-OSEP Tertiary Demo Project H326M0060010
25
USDOE-OSEP Tertiary Demo Project H326M0060010
26
Do Teaming Structures in your school(s) need to
change?
Quick Reflection
  • How many kids have been talked about at ______
  • meeting this year?
  • How many of those discussed got an intervention
    that you have data to indicate
  • they got an intervention that is working?

Have you ever been at a meeting where you talked
about one youth for an hour and at the end you
were no closer to having effective strategies
than when you started?
27
  • Did Henry need a restrictive placement?

28
Quick Student Example 1 Student w/EBD moves to
new District
Henrys Daily Point Data for Behavioral Goals
29
  • Did Henry need a restrictive placement?

Or effective interventions?
30
Administrators Need to
  • Have knowledge of behavior support for
    Tier 2/Tier 3 to guide/lead any corrections
    needed.
  • Know why a behavior plan may not be working and
    need to know how to troubleshoot a plan.
  • Ensure that systems are in place and
    interventions are offered routinely and rapidly
    at all 3 tiers to allow ALL kids to be successful

31
Failed Interventions are Not Neutral
  • They leave a residual effect

32
Administrators Role
  • No intervention is administered w/o progress
    monitoring.
  • The Special Education focus changes from did we
    deliver the intervention? to did the student
    experience success/get better?
  • Ensure that research based interventions always
    used dont get to choose not to deliver
    interventions.
  • Equip teachers to be confident to handle.

33
TIER 2/3 Intervention Examples, Decision-Rules
and Tools
34
Check-in-Check-out (CICO)
  • Merely an extension of Tier 1
  • Some get high frequency scheduled positive
    contact with adults
  • Youth solicit the positive contact/feedback
  • Low effort for teacher if built on Tier 1
  • Need to have 7-12 accessing if it is to come to
    be a routine in your school(s)
  • If you only have 1-2 on CICO, those are likely
    to be kids who need more.

35
Why do you want 7-12 on CICO?
  • Kids who here-to-for would have gotten nothing
    (til they got worse) now get a positive boost
    of support (sea of ineligibility)
  • All teachers will expect that every day they will
    have kids cross their threshold who need higher
    rate of positive contact
  • Quicker/easier to support kids who need Tier 3
  • Structure to build transference and generalizing
    from Social Skills instructional groups and
    function-based behavior plans

36
Social/Academic Instructional Groups
  • Selection into groups should be based on youths
    reaction to life circumstance not existence of
    life circumstances (ex. fighting with peers, not
    family divorce)
  • Goals for improvement should be common across
    youth in same group (ex. use your words)
  • Data should measure if skills are being USED in
    natural settings, not in counseling sessions
    (transference of skills to classroom, café etc.)
  • Stakeholders (teachers, family etc.) should have
    input into success of intervention (ex. Daily
    Progress Report)

37
Choosing or Designing Group Interventions
  • Choose modify lessons from pre-packaged
    material based on the skill needed for the group
  • and/or
  • Use already created universal behavior lesson
    plans or create lesson plans (Cool Tools) to
    directly teach replacement behaviors

38
Social Skills/Academic Instructional Groups Key
Points Resulting from Innovation
  • Selection into groups based on youths reaction
    to life circumstance not existence of life
    circumstances
  • ex. fighting with peers, not family divorce
  • Goals for improvement common across youth in same
    group
  • ex. use your words
  • Data used to measure if skills are being USED in
    natural settings (vs. in counseling sessions)
  • transference of skills to classroom, café etc.
  • Stakeholders (teachers, family etc.) have input
    into success of intervention
  • ex. Daily Progress Report

39
Daily Progress Report (DPR) Sample NAME_________
_____________ DATE__________________ Teachers
please indicate YES (2), SO-SO (1), or NO (0)
regarding the students achievement in relation
to the following sets of expectations/behaviors.
EXPECTATIONS 1 st block 2 nd block 3 rd block 4 th block
Be Safe 2 1 0 2 1 0 2 1 0 2 1 0
Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0
Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0
Total Points
Teacher Initials
Adapted from Grant Middle School STAR
CLUB
Adapted from Responding to Problem Behavior in
Schools The Behavior Education Program by Crone,
Horner, and Hawken
40
Daily Progress Report (DPR) Sample NAME_________
_____________ DATE__________________ Teachers
please indicate YES (2), SO-SO (1), or NO (0)
regarding the students achievement in relation
to the following sets of expectations/behaviors.
Social Academic Instructional Groups
EXPECTATIONS 1 st block 2 nd block 3 rd block 4 th block
Be Safe 2 1 0 2 1 0 2 1 0 2 1 0
Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0
Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0
Total Points
Teacher Initials
Walk to class Keep hands to self
Use appropriate language Raise hand to speak
Bring materials Fill out assignment notebook
Adapted from Grant Middle School STAR
CLUB
Adapted from Responding to Problem Behavior in
Schools The Behavior Education Program by Crone,
Horner, and Hawken
41
Individualized Student Card After FBA/BIP"
Daily Progress Report (DPR) Sample NAME_________
_____________ DATE__________________ Teachers
please indicate YES (2), SO-SO (1), or NO (0)
regarding the students achievement in relation
to the following sets of expectations/behaviors.
EXPECTATIONS 1 st block 2 nd block 3 rd block 4 th block
Be Safe 2 1 0 2 1 0 2 1 0 2 1 0
Be Respectful 2 1 0 2 1 0 2 1 0 2 1 0
Be Responsible 2 1 0 2 1 0 2 1 0 2 1 0
Total Points
Teacher Initials
Use your words Use deep breathing
Keep arms distance Use 2 voice level when upset
Ask for breaks Self-monitor with DPR
Adapted from Grant Middle School STAR
CLUB
Adapted from Responding to Problem Behavior in
Schools The Behavior Education Program by Crone,
Horner, and Hawken
42
QUICK Reflection
43
We Know the Practices that Work
  • Proactive, strength-based set kids up to
    experience success
  • High rates of consistent, supported instruction
    teach/practice/reinforce
  • Predictable and consistent environments
  • Know unique why? for each student/problem
  • Contextual fit Strategic use of natural
    supports, and settings
  • Careful monitoring of data over time with ongoing
    revisions to guide incremental improvements in
    quality of life

44
We Know the System Features Needed to Support the
Effective Practices
  • A Team unique to each individual child family
  • Blend the family/natural supports with the school
    representatives who know the child best
  • A defined Meeting Process
  • Meet frequently and use data
  • Develop, implement, review range of interventions
  • Facilitator Role
  • Bringing team together
  • Blending perspectives guiding consensus
  • Systematic use of data (strengths and needs)

45
Interventions
Ownership Voice A Key to Intervention Design
The person who is supposed to implement the
strategy needs to be actively involved in
designing it or it probably wont work!
46
Tier 3 Interventions
  • Person-Centered (voice and choice)
  • Highly individualized (unique team per student)
  • Multiple Data Sources (add Tier 3 data-
    Perception data)
  • Complex function-based behavior plans
  • Wraparound/RENEW/Family Focused Plans

47
Do All Staff Understand the Context for PBIS?
  • Behavior support is the redesign of environments,
    not the redesign of individuals.
  • Positive behavior support plans define changes in
    the behavior of those who will implement the
    plan. A behavior support plan describes what we
    will do differently.

48
(No Transcript)
49
Competing Behavior Pathway Behavior Intervention
Plan

Setting Event Strategies
Antecedent Strategies
Teaching/ Instructional Strategies
Consequence Strategies
Neutralize/ eliminate setting events
Add relevant remove irrelevant triggers
Teach alternative that is more efficient
Add effective remove ineffective reinforcers
50
(No Transcript)
51
Behavioral Pathway
Setting Event Days with Gym
Problem Behavior Negative comments about
activity and to peers leading to physical contact
Consequence Sent out of P.E. class
Function To escape setting
Antecedent Less structured activities that
involve competition
52
Brief Function-based Interventions
  • Setting Event Strategies
  • Add check-in before gym
  • Teaching Strategies
  • Teach social skills (getting along with others,
    friendship, problem solving, sportsmanship)
  • Teach how to approach gym teacher to ask for a
    drink of water to leave setting.
  • Teach student how to re-enter and continue with
    activity

Consequence Strategies Acknowledging/rewarding
student when uses new skills (asking for a drink
of water to leave, using respectful language with
peers, being a good sport, etc..)
  • Antecedent Strategies
  • Behavior Lessons for all students about using
    respectful language with self and others and how
    to be a good sport
  • . More frequent activities with less focus on
    competition (parachute, 4-square, etc...)
  • Pre-correct

53
Person-Centered Planning Highly Individualized
Tier 3 Intervention
  • Wraparound
  • Wraparound-based RENEW

54
Wraparound A SOC Tool
  • Emerged from practitioners struggling to
    implement SOC (grassroots)
  • Keep/bring youth home
  • Flexible, creative, non-categorical
  • Natural support networks
  • Community-based
  • Unconditional-Commit to stay the course
  • Let family voice guide service development
  • Non-traditional supports and services

55
What is Wraparound?
  • Wraparound is a process for developing
    family-centered teams and plans that are strength
    and needs based
  • (not deficit based)
  • across multiple settings and life domains.

56
Examples of Needs Statements
  • The student needs to feel adults and peers
    respect him.
  • The student needs to feel happy about being at
    school.
  • The parent needs to know her son is getting a
    fair shake at school.
  • The student needs to be reassured that he can
    complete the work.

57
Implementing Wraparound Key Elements Needed for
Success
  • Engaging students, families teachers
  • Team development team ownership
  • Ensuring student/family/teacher voice
  • Getting to real (big) needs
  • Effective interventions
  • Serious use of strengths
  • Natural supports
  • Focus on needs vs. services
  • Monitoring progress sustaining
  • System support buy-in

58
Wraparound Skill Sets
  • Identifying big needs (quality of life
    indicators)
  • Student needs to feel others respect him
  • Establish voice/ownership
  • Reframe blame
  • Recognize/prevent teams becoming immobilized by
    setting events
  • Getting to interventions that actually work
  • Integrate data-based decision-making into complex
    process (home-school-community)

59
Four Phases of Wraparound Implementation
  • I. Team Preparation
  • - Get people ready to be a team
  • - Complete strengths/needs chats (baseline data)
  • II. Initial Plan Development
  • - Hold initial planning meetings (integrate data)
  • - Develop a team culture (use data to establish
    voice)
  • III. Plan Implementation Refinement
  • Hold team meetings to review plans (ongoing data
    collection
  • and use)
  • - Modify, adapt adjust team plan (based on
    data)
  • IV. Plan Completion Transition
  • - Define good enough (Data-based decision-making)
  • - Unwrap

60
Quick Reflection
Similarities and Differences What is similar
and/or different to the existing systems, data
and practices In your district/schools?
61
Bens Story
  • September 2009, CICO started
  • Mid October, 76
  • Reverse Request for Assistance
  • November-community based mentor assigned
  • December-Ben request to return to psych
    hospital saying, I cant control myself (has
    had three prior admissions)

62
  • December 5-Tier 3 team met. Recommended referral
    to wraparound based on following
  • CICO average of 76
  • 30 Office Disciplinary Referrals
  • 3 Out of School Suspensions
  • At risk for alternative school placement
  • At risk for out of home placement
  • December 15 Wraparound started with Ben and
    Barb

63
Moving Forward
  • In December, Ben began asking his mother if he
    could be admitted to the hospital so he could
    get better. He was experiencing anger, thoughts
    of hurting himself and he was physically
    aggressive with classmates and peers. He was
    verbalizing I cant control himself.
  • Ben had three prior psychiatric hospitalizations
    (before coming to G Elementary).

64
Child and Family Strengths
  • Bens Strengths identified in the first meeting
    included
  • Ben Smart, good at math, reading, writing and
    playing video games
  • Mom Very organized
  • Hes creative and enjoys drawing cartoons
  • Teacher writing and math
  • Family Strengths
  • Mom consistently takes Ben to his mental health
    appointments.
  • This might include getting the city bus for an
    hour ride, attending an hour appointment, waiting
    another 30 minutes for the bus and then riding
    home and then bringing him to school.
  • Mom is an active participant at the school,
    follows through with suggestions.

65
MISSION STATEMENT A Happy Home
  • The mission statement was developed by the team,
    Ben, and his mom.
  • Ben stated that his hopes were he would yell
    less at home so that he would see more smiling
    from his family. Mom agreed.

66
Wrap process builds on lower tiered interventions
  • At the first team meeting family agreed to
  • Continue CICO
  • Continue mentoring
  • Continue MH services
  • Improved communication with Mental Health
  • FBA to be completed (home and school)
  • Family YMCA (schedule present at LANS for
    funding)

67
Child Family Team Meeting Number 2
  • January 22
  • Discussed improved behavior at home and school
    (not in physical fights at school, turning in his
    work, helping at home)
  • Completed BIP using the FBA (help from the
    baseline SIMEO data)
  • Planned next meeting and Ben wanted to invite
    mentor to the next meeting

68
3rd Child Family Team Meeting
  • March 5, 2010
  • Reviewed strengths celebrating that he walked
    away from two fights at school (he had never done
    that before)
  • Team looked at data/ graphs and Ben led the
    discussion and interpreted the improvements for
    the group
  • Needs in Bens words were that he still had room
    to improve. Ben pointed to areas on the graphs
    where he said he still needed to work on.
  • Mom was going to bring electric bill so the
    social worker could continue to get YMCA family
    membership to address the needs (e.g. to do,
    social activities)

69
Data
70
Tertiary Level Coaches Have to Help Establish
Capacity (Fidelity) for Wraparound
  • Commitment of time
  • Commitment to stay at table
  • Willingness to regroup and be solution-focused
  • No judging or blaming
  • Time for listening to stories
  • Time for venting, validating
  • Establishing consensus
  • Voice of student/family in prioritizing
  • Establishing ownership

71
Building Fluency with Tier 3 Implementation
through Training, TA and Coaching
  • FBA/BIP
  • Wraparound
  • Wrap-based RENEW

72
Tertiary Interventions Phases of Tier 3 Coaching
  • Phase 1 Modeling - Coach models the desired
    skills and competencies
  • Phase 2 Support and Feedback - Coach provides
    support and feedback
  • Phase 3 Monitoring Coach monitors to ensure
    fidelity

73
Tertiary Prevention Specialized
Individualized Systems for Students with
High-Risk Behavior
SCHOOL-WIDE POSITIVE BEHAVIOR INTERVENTIONS
and SUPPORT
5
Secondary Prevention Specialized Group Systems
for Students with At-Risk Behavior
15
Primary Prevention School-/Classroom- Wide
Systems for All Students, Staff, Settings
80 of Students
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