How to Baffle and then Appreciate
a Psychiatrist:
A Look at Complex Needs and Setting Event Strategies
for Individuals with Intellectual Disabilities
Presenters:
Dr. John C.C. Chan, M.Sc., M.D., FRCPC
John Kosmopoulos, B.A., BST, MA(c)
March 25th, 2011
Kingston, ON
Objectives
§ Applied Behavior Analysis & Behaviour Consultation
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Setting Events: Definitions & Types
Traditional & Expanded Models of Behaviour Analysis
Biopsychosocial & Setting Events Assessment Models
Assessment of Setting Events
Setting Event Intervention Model
§ Psychiatry & How The Two Disciplines Shall Meet
o Interdisciplinary Support Flowchart
o Complex Cases: Interactive Vignettes
o Setting Events & Biopsychosocial Intervention Models
Applied Behavior Analysis
& Behaviour Consultation
SETTING EVENTS
Setting Events
• Setting events are often referred as “slow triggers” or “setting
the stage” for the likelihood of behaviour.
• Setting events are types of antecedents that can precede or
occur at the same time as a problem behaviour.
• In specific terms, setting events may be defined as broad,
complex and distant antecedent events or conditions that
may occur days before or simultaneously with immediate
antecedents across different settings and temporarily alter
the effectiveness and value of reinforcers (Alberto and
Troutman, 2006).
Setting Events
• Setting events strategies address the specific
events that increase the likelihood that
immediate antecedent events will evoke a
problem behaviour
• Setting event strategies make the behaviour
less likely.
Setting Events
Example:
• few hours of sleep or is tired (presence of
setting events / slow trigger)
• less likely to fulfill a request to do a task at
work (immediate antecedent / fast trigger) or
any other setting
• Would normally be cooperative with the same
request because they got a good night’s sleep
(absence of setting events / slow trigger).
Traditional & Expanded Model
of Behaviour Analysis
(Adapted From: Sprague & Horner, 1999)
Antecedent
• Setting Event
•Includes
Motivation
•Momentary
Effect of SE (and
motivation) on
Value of
Consequences
•
Antecedent
Behaviour
• Behaviour
Consequence
•Consequence
Types of Setting Events
• Physiological
• Environmental
• Social
• Motivational
Physiological / Biomedical
Setting Events
• Not enough exercise
• Agitation due to
emotions,
• Physiological conditions
• Sleep disturbance
• Illness
• Pain
• Allergies
• Infections
• Injury Mood
• Mental illness
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Hunger/Thirst
Hypothyroidism
Menses
Medication changes
Mediation dosage and
administration
problems
Medication side effects
Difficulty sleeping
Constipation
Headache
Stomach problem
Lethargy
Environmental Setting Events
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Crowded conditions
Barren environment
Noise level
Heat/Cold
Time of day
Music
Physical lay out of
environment
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Group instruction
Independent seatwork
Curriculum
Being late for school
Staffing patterns
Moving to new
school/home
• Transitions
Social Setting Events
• Major life changes
• Fight with peers
• Negative social
interactions
• Family divorce/Discord
• Certain individuals
• Losing a game
• Changes in teacher or
classmates
• Fight on the bus or
playground
• Loss of a loved one
• Expectations
• Lack of rapport
Motivational Setting Events
• To escape aversive situations
• To obtain attention or tangible
• To escape / remedy / decrease anxiety, medical
events, discomfort, pain, etc.
• To relieve boredom
• To increase or decrease stimulation
• Deprivation of biological reinforcers (e.g., hunger,
thirst, etc.), environmental and social reinforcers
(e.g., quiet environment, adequate support and
resources)
• To make things easier (less effortful)
Examples Of The Traditional ABA
Models
Antecedent
Asked To Do
Task (Demand)
Consequence
Behaviour
Yelled & Hit
Ignored &
Redirected
Behaviour
• Why did the task, that the person is able to do and would
normally comply with, provoke problem behaviour?
Example of Expanded Model of
Behaviour Analysis
Setting Events
(SE)
SE Effects on
Consequences
Antecedent
• Lack of
sleep
• Hungry
• Increase
motivation
to escape
task
• Asked to do
Task
(A)
Behaviour
Consequence
(B)
(C)
• Yell & Hit
• Ignored &
redirected
behaviour
back to task
• The setting event (slow trigger) “sets the stage” and “increase the
likelihood and motivation” for problem behaviour when a demand is
placed.
The Synergy Of Setting Events
• Notice how each of these potential setting events may be available
at the same time for the challenging behaviour of hitting:
╬ Physiological Setting Event = cold / flu
╬ Environmental Setting Events = high noise level & density of
people
╬ Social Setting Event = aversive demand situation(s)
╬ Motivational Setting Event = to escape (by hitting) / deprivation
or satiation states / to be left alone / to enter a peaceful
environment / to help her cold / flu symptoms
• Psychiatric symptoms (e.g., negative affect) may be a synergy or
cumulative impact of setting events (Carr et al., 2003; Durand &
Mapstone, 1998).
Biopsychosocial Model (BPS)
• Biological
o Medical conditions, medication side effects, syndromes,
developmental, etc.
• Psychological
o Mental / emotional health, psychiatric, cognitive
abilities, coping with stressors
• Social
o Social and physical environments (interactions and
supports), stimulation, choices, motivation
Biopsychosocial & Setting Events
Assessment Models
• Both are compatible and complimentary
• Both are forms of comprehensive assessment
o BPS: used as an overall assessment of a clinical problem or
problem behaviour for possible diagnosis and biological,
behavioural, psychological remediation
o SE: used as an overall assessment specific to the likelihood,
context and function of problem behaviour
• Both are “holistic” (they consider the whole person)
• Both are best practice and evidence-based
• Psychiatrists and behaviour consultants use both models
but conceptualization is different based on each discipline
Setting Events:
Assessment Methods
• Example assessment procedures & tools
o Interviews
o Functional Assessment Interview (O’Neill et al., 1990)
o Scales
o Setting Events Checklist (Gardner et al., 1986)
o Problem Behavior Questionnaire (Lewis et al., 1994)
o Contextual Assessment Inventory (McAtee et al., 2004)
o Analysis of Setting Events Questionnaire (Kosmopoulos, 2006)
Analysis of Setting Events Questionnaire (ASEQ)
(Kosmopoulos, 2006)
o Comprehensive, multi-itemed (117) rating scale.
o Single or Inter-observer administrations.
o Likert-type scale (0-3) to determine the degree of
relationship or the level of association between the
specific target behaviour and various setting events
(currently or within the last month).
o 2-1 Scale (setting events & function of behaviour).
o Reviewed and supported by psychologists.
o Data analysis section and graph
o Good overall psychometric properties
o Other scales limited in scope, diagnoses, settings and
psychometric properties (based on research)
ASEQ – 4 SETTING EVENT CATEGORIES
ASEQ VARIABLES – TRADITIONAL & “UNIQUE” SE
Physiological
Environmental
Social
Motivational
Traditional: medical illness, medication change, moods,
allergies, constipation, diet, etc.
Unique: family history, syndromal features, brain injury or
dementia, licit / illicit drug use
Traditional: time of day, physical environment, routines,
seasons
Unique: stressful family environment, access to transportation,
professional assistance, medical / dental appointments
Traditional: demands, lack of choices, critical incident,
disappointments, proximity, level of attention, etc.
Unique: specific treatments provided, language barrier, limited
coping abilities, inconsistent implementation of strategies
Traditional: to access attention, to escape or avoid an
aversive situation, to relive boredom, to access tangibles,
communicate wants and needs, etc.
Unique: as a category in SE assessment tools; to satisfy a
biological need or deprivation state (e.g., hunger, thirst, sleep);
response effort
ASEQ – Who can benefit?
• User-friendly and versatile in its breadth as it was
designed to be utilized across:
 ages (i.e., children, adolescents, adults)
 behaviours (e.g., tantrums, SIB, property destruction)
 diagnoses (e.g., autism, DD, dual diagnosis, syndromes,
mental health, etc.)
 settings (i.e., home, school, treatment centre, group
home, community, etc.)
• Comments section after each category of setting
events
ASEQ-FS (Function Subscale)
• Specific items from each of the setting event categories are
itemized according to functions similar to the QABF:
 Attention
 Escape
 Tangible
 Sensory I (Physical)
 Sensory II (Alone / Non-Social)
• On The ASEQ Scale, there are red tags to correspond to
items found in the ASEQ-FS data analysis table.
ASEQ – SAMPLE PAGE
On The ASEQ Scale, there are red tags to correspond to
items found in the ASEQ-FS data analysis table.
SETTING EVENT INTERVENTION MODEL
• Behaviour support plans that include the setting events
treatment model for individuals that present with complex
needs compliment interdisciplinary investigations and
multimodal treatments.
• The setting events strategy models emphasize a reduction of
specific behavioural challenges and behavioural health
problems and an enhancement of adaptive alternative and
coping behaviours.
• Several setting event intervention models have demonstrated
effectiveness and success in their use.
Setting Event Intervention Model
(Adapted: Gardener et al., 1986, Carr & Owen-DeSchryver, 2006)
1. Eliminate or minimize the setting events
2. Neutralize setting events
3. Redesign the physical environment
4. Increase positive interactions and positive
reinforcers
5. Teach coping and communication skills
Setting Events Intervention Model
1. Eliminate or Minimize the Setting Event
– Modify or minimize the likely occurrence of the setting event for
problem behaviour
• Medical and behavioural advice for illness, pain, sleep problems,
overwhelming anxiety, etc.
• Decrease crowding, change fluorescent lights to prevent seizures,
decrease noise level, consider visuals within a class, etc.
• Decrease or eliminate demands when tired, reinforce cooperation
and communication around setting events, etc.
• Use of communication for seeking medical and emotional support
• Provide greater 1:1 attention if required, etc.
– Early intervention for warning signs of behavioural agitation or
possible health symptoms
Setting Events Intervention Model
2. Neutralize the Setting Event
– Intervene after the setting event occurs but before
the antecedent for problem behaviour
o Decrease demands and aversive events
o Increase preferred activities and routines
o Directly change the individual's response to the setting
event (e.g., instead of fighting, prompt use of
negotiation or relaxation)
Setting Events Intervention Model
• 3. Redesign the Physical Environment
• Is the physical environment stressful or unpleasant to the
individual?
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Change the physical layout of the environment
Create opportunities to respond in socially appropriate ways
Availability of social interactions
Availability of stimulating activities
Consider lighting, noise levels, density of people, proximity to
others
Minimize distractions
Increase visual systems
Adaptations for mobility, navigation, easy entrance and exit
safety
Setting Events Intervention Model
4. Increase Positive Interactions & Positive
Reinforcers
– Does the person have access to a sufficient variety of preferred
stimulating activities?
– Does the person have the skills and opportunities to engage in preferred
stimulating activities?
– Does the person have sufficient access and choice of foods?
– Does the person have sufficient access to items and activities that are
reinforcing to that person?
– Is the activity boring or monotonous to the person?
– Are the expectations unclear due to a lack of routine?
– Are the established routines inappropriate for that person (i.e. doing
homework before bedtime when they are too tired to think; setting a
chore to be done during their weekly TV program; or having a schedule
that does not include chosen activities)?
– Is the person’s daily schedule so flexible that the environment seems
unpredictable?
– Are there recent changes in caregivers, teachers, staff or peers?
Setting Events Intervention Model
4. Increase Positive Interactions & Positive
Reinforcers (continued)
o Increase motivation for appropriate responses
o Decrease effort for appropriate responses
o Increase preferred activities
o Encourage choices
o Etc.
Setting Events Intervention Model
5. Teach Coping & Communication Skills
o Teach tolerance for waiting, lack of attention, etc.
o Teach specific coping skills (e.g., what to do if it’s
noisy, crowded, the bus is late or takes a different
route, etc.).
o Teach communication skills re: illness, mood
states, discomfort, etc.
o Reinforce all functional communication around
the need for support.
PSYCHIATRIC SUPPORT &
APPLIED BEHAVIOR ANALYSIS:
A COMPLIMENTARY PERSPECTIVE FOR INDIVIDUALS WITH
COMPLEX NEEDS
CASE VIGNETTES
TO BAFFLE & APPRECIATE
Objectives
• Interdisciplinary Flowchart
• Clinical case vignettes
• Evidence & observation-informed treatment
rationale
• Discussion
Interdisciplinary Support: Flowchart
Behavioural Assessment
Psychiatric Assessment
(Biopsychosocial and
Expanded Behaviour
Analysis models)
(Biopsychosocial model
– may include
Behavioural model)
Biomedical?
Behavioural? Both?
Possible Diagnosis &
Medications
Function? Ethics?
Additional setting event
and behavioural
strategies
Data?
Referral for Biomedical Assessment
Monitoring & Evaluation
Behavioural Suggestions & Training
Additional referrals
Monitoring & Evaluation
Collaborations with Behaviour
Consultant and other
Professionals
Collaborations with Psychiatrist
and other Professionals
Vignette 1
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16 yo female
Non-verbal
No History of Violence
One wk history of  sleep,  frustration
tolerance,  obsession
• On Prozac for anxiety
• Family members worry about his sleep
Changes
• Few days graduate from school with months
of transition
• Pt uncle passed away a week ago
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Physical Observation
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Rocking Back and forth
Slightly febrile and increase pulses
Physical examination grossly normal
OTITIS MEDIA on the Left Ear
Rx - Amoxicillin
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Discussion
• Environmental Changes (Consider setting
event and other behavioural strategies)
• Biological Organic Medical difficulties
• Sleep issue
• Non-verbal is an issue
• Physical exam by medics is very important
• Cold? Allergies? Constipation? Dental
Caries? Etc…
Vignette 2
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13 yo male
Short phrase and single words
Some ADL but not all
IQ = 65
Just started a new school
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Vignette 2
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Decrease speech except for a few words
Sleep disruption at night & nap during the day
Enuresis & Smearing feces after BM (new)
Irritable, isolated and oppositional (worsen)
Agitation while waiting at the ER
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Medical Exam
• ‘Normal’
• ER MD referral to Beh. Neurologist or C&A
psychiatrist.
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Significant Behavioural Regression
• Physical abuse
• Sexual abuse
• Emotional abuse
Significant Behavioural Regression
Sleep problem + language regression + ADL
regression
 New onset of seizure?
 Bimodal onset: < 5yo & onset of puberty
Vignette 3
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14 yo male
Autism and Sever MR
 agitation and  aggression
Recent move to new group home
Difficulties in adjustment
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Clinical Rationale
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WHY NOW?
Victimized in new environment?
Significant difference in routine?
Puberty  Mood disorder ‘equivalents’
New seizure disorder?
Medical Biological Organic?
Vignette 3
• Behavioural specialist working with group
home staff to address increase pacing, anger
outburst and minor physical aggression
• He struck a staff member
• Certified for involuntary Psychiatric
assessment in 72 hours at Schedule 1 facility
Vignette 3
Recently adjusted medication…
• Paroxetine (Paxil) 20 mg po qam (NEW)
• Divalproex Sodium (Epival) 250 mg po bid
• Quetiapine (Seroquel) 50 mg po bid
Medication
• New agents added or removed chronologically
related to behaviour?
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Vignette 4
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21 year old mild/borderline DD young female
Recent ER visit for slashing wrist
Three prior overdoses on medication
Recent breakup with boyfriend – feeling hopeless
She hoped to “just get his attention”
Impulsive
Brief & intense relationships
Abusive relationships
Criminal record for mischief
missed social cues
BPS & SE?
Medical
Organic
Biological
Psychiatric
Psychological
Social
Environmental
Motivational
Clinical picture
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Lack of awareness
Blame other people for their problems
Cannot cope adequately with stress
Tend to responds in ways that are
stereotypical (not tailored to the situation)
• Their inflexibility – vicious cycles of
consequences
Personality disorder
• A set of inflexible, maladaptive character traits
• Functional impairment
• May cause significant subjective distress to the
person
• Affect 2 or more of these areas
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cognition
emotion
interpersonal relationship
impulse control
Healthy Personality
• Enable a person to adapt to stressful
situations
Personality Disorder
• They tend to have trouble with
relationship, employment or the law
Because personality traits are so
ingrained, it is difficult to help people
with personality disorders to develop
healthier coping styles
Not all annoying personality traits are
symptoms of a personality disorder!
Borderline Personality Disorder (BPD)
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Unstable self-image
Unstable emotion
Chronic feeling of emptiness & fear of abandonment
Intense & inappropriate anger
Recurrent thoughts of self-harm
Impulsive
Unstable & intense relationships
Idealize or devalue other person
Approach to clients
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Inherent difficulty with relationship
Chronic problem
Coexisting mental disorder
Often idealize and devalue staff
Approach to clients
• Crystal clear professional boundary
• Clear, consistent interaction style
• Avoid manipulation – help clients to adjust
their expectation (reality check)
• Validate the clients’ subjective reality of crises
• Encourage clients’ problem-solving skills
Treatment
• No Pill can Cure Borderline Personality
Disorder!
• Dialectic Behavioral Therapy
• Cognitive Behavioral Therapy
• Intervention for substance abuse
• Family or Group therapy
• Treat coexisting mental disorder
Pearls of Wisdom for Staff
• Always remember the bio-psycho-social and
setting event models
• NEVER underestimate the environmental,
social, psychological and motivational factors
• Medical ailments can contribute to
challenging behaviours in DD population
Pearls of Wisdom for Staff
• Medication can help but can BACKFIRE!!!
• DD population is exquisitely sensitive to
psychotropic medication
• Limited evidence for psychotropic usages
THANK YOU!!!
• For further information on the ASEQ or for
future presentations, please contact:
John Kosmopoulos
johnkos@rogers.com