COMPREHENSIVE FUNCTIONAL ASSESSMENT REPORT
AND RECOMMENDED SUPPORT PLAN
Client Confidential
Date of Report: December 18, 2003
Referral Date: March 7, 2003
Period of Report: August 25 December 18, 2003
IDENTIFYING INFORMATION
Name: Mike Chow
Date of Birth: May 20, 1994
Address: 1729 Henderson Dr.
Greer, CA xxxxx
(xxx) xxx-xxxx
Referral Source: Mr. and Mrs. Chow
REASONS FOR REFERRAL
Mike was referred by Mr. John and Mrs. Linda Chow, his father and mother,
for an evaluation. The purposes of the evaluation were to assist Mike in securing
the educational services and programming which would enable him to develop and
to use his capabilities, to get the most out of the educational opportunities that can
be made available to him and to enable him to develop and to use his capabilities
for more independent, normal living and more productive activity than his behavior
problems presently permit. Accordingly, it was requested that the evaluation focus
on these behavior problems, which were characterized tantrums, and the type(s) of
behavioral services, support strategies, programming, professional competencies
and skills, and environments required to eliminate, minimize, or manage them.
Specifically, his parents believe that while he would benefit from a full
inclusion program, his school only has him partially included because of his
aggression and tantrum behavior. Mr. and Mrs. Chow’s specific request is for a
behavioral support plan that would allow Mike to be fully included, so that he could
benefit most from his education.
The timing of this assessment was delayed because of parent/school
disagreements as to whether this it was necessary, given that the school had
separately arranged for one by Dr. Sam Jones. Once the conditions under which
the performance of this separate assessment were negotiated, further delays we
incurred due to scheduling conflicts with my own calendar.
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Mike Chow
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DESCRIPTION OF ASSESSMENT ACTIVITIES
This assessment is based on information obtained from the following
sources:
A.
Interviews with Mr. and Mrs. Chow, his teacher, Ms. Susan Stone, his
one-to-one instructional aide, Mr. Jerry Pitman and other school
personnel, and his in home service staff from PEAK;
B.
Direct Observations of Mike in both his home and school settings;
C.
Review of all the records provided by parents and by the school
district; and
D.
A Reinforcement Survey completed by interview with his parents.
BACKGROUND INFORMATION
I.
Brief Client Description.
A.
General. Mike is a very good looking nine-year-old boy with neatly
crew cut, dark brown hair and dark brown eyes. When I first saw him in his parents
home on a Monday morning, he was dressed in a clean red T-shirt, blue shorts and
was barefoot. He was with his in home service staff from PEAK, an in-home
support agency, and was playing a computer game. When, shortly after I arrived,
he lost the game, he had a bit of a tantrum, including crying, throwing himself on the
floor, grabbing staff around their legs and hitting them, pushing furniture with his
legs, pulling the computer key-board off the computer table, and smashing the
“mouse” against the floor. Once he calmed down, he worked cooperatively with
staff and after they left, his mom was able to mange him quite well in a number of
independent play activities. Throughout my visit he sought out a number of
interactions with his mother, seeming to want and enjoy tickling and other physical
contact with her. Mike faces life with the challenge of autism. The characteristic
associated with this problem were amply apparent during my visit, including his total
disinterest or curiosity about my presence in his home.
Other characteristics include his ritualized behavior, his lack of tolerance for
change, and the obsessive-compulsive quality characterized by so many of his
behaviors. These included, but certainly are not limited to his ritual like water play,
his insistence on using paper towels, only from the paper towel dispenser, when at
school, his “need” to remove his shoes when he enters his home and his “need” to
answer the phone when it rings at home, his difficulty in stopping certain activity,
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such his computer play, his “need” to get out of his seat in, and to move around in
the classroom.
As is increasingly recognized for those facing the challenge of Autism, Mike
may have a "movement disturbance." A movement disturbance is defined as a
disruption in the regulation of movement which involves the loss of typical
movements and excessive atypical movements which affects the person's ability to
initiate, switch, efficiently perform, or continue any action, including those involving
communication, social interaction or performing useful activities. Each episode of
movement disturbance may vary in its frequency, duration, intensity, and
composition, given different contexts, emotions, and physical states. Further, the
phenomenon of kinesia paradoxa, adds to the complexity of understanding
movement disturbance in which the individual who typically experiences severe
difficulties with the simplest of movements may suddenly perform complex and
skilled movements and then return to the prior inactivity. (Leary and Hill, “Moving
On: Autism and Movement Disturbance" Mental Retardation, Vol. 34, No. 1, 39-53,
Feb. 1996).
Mike has a number of characteristics that are compatible with movement
disturbance, as described above and as will be further described in subsequent
sections of this report. Other characteristics consistent with movement disturbance
include abnormal body movements such as the way he leaves his chair and moves
around the classroom, slowness in completing tasks, non-social speech, lack of
initiation and apparent lack of interests (except for his “obsessions”) and motivation,
and sudden physical aggression and explosive episodes, such as when he pulled a
fellow (girl) student’s hair (who was facing away from him) and when he recently
physically attached his teacher, Ms. Stone. While these and related behaviors may
serve some communicative function in any given context, behaviors may also have
more of a non-volitional neurological base. If these and others of Mike's problems
reflect a true movement disturbance, our challenge may be to assist Mike in finding
a way to regulate and modulate these behavioral states rather than to eliminate
them per se.
B.
Language and Communication Skills. In an excellent Speech and
Language Assessment Report carried out in December, 2002, by Ms. Boone, a
Speech-Language Pathologist with the Mid-County School District, Mike’s was
described as having “severely delayed receptive and expressive language abilities,
specifically in the areas of semantics, auditory comprehension, syntax and
morphology and pragmatics.” On the Peabody Picture Vocabulary Test, he had an
age equivalent score of 4 years, 1 month. On the Preschool Language Scale, he
had an age equivalent score of 2 years, 4 months for expressive communication and
3 years, 7 months for auditory comprehension. For example, he is able to correctly
label body parts, animals and certain objects but he has difficulty with identifying
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categories. That is, rather than naming the category when shown pictures of
various animals, he instead labeled each of the individual animals.
Receptively, he can identify colors and certain descriptive concepts, such as
long or short, and shows an understanding of object use, such as those used to eat.
He can also listen to a simple sentence and point to the corresponding picture, for
example, “the girl is pushing the baby.” Based on this formal assessment, however,
“auditory comprehension decreases with sentence length and complexity increase,”
including those that include conjunctions, such as “because’ and “and,” temporal
concepts, such as “before” and “after,” past or future tense, such as “walked” and
“will walk,” comparative concepts, such as “heavier,” and “sequencing, making
inferences, and identifying higher-level body parts (wrist, heel).
He also
demonstrated difficulty following novel directions, although, as his parents
described, he can follow contextual directions, such as “go into the room and get me
the phone.”
Expressively, Mike even has more difficulty. He is able to combine three or
four words, such as “no more,” and “I want chips,” or even somewhat longer
sentences such as “I want to go to bathroom.” However, he is not able to reliably
answer simple yes/no questions or use the little speech he has to get his needs met
in a social context with others outside his immediate family. Both home and school
report that Mike uses the Picture Exchange Communication system (PECS) to
initiate communication to have his needs met and can use that system to put
together simple sentences, including the use of adjectives.
In addition to the challenge of autism and the effect this has had on his
speech and language development, another factor that may have had an influence
the fact that his parents speak both Vietnamese and Cantonese. In fact, they use
Cantonese at home among themselves and when speaking to Mike’s younger sister,
while, realizing his difficulty in this area, speaking only in English with Mike. In fact,
a Speech and Language Assessment in January of Mike’s communication skills in
Cantonese revealed even less ability with this language, being able to identify only
one body part and only the phrase in Cantonese “go to the bathroom.”
C.
Cognitive and Academic Abilities. Mike clearly has areas of strength in
which he his cognitive and academic abilities show at their best. For example, he is
quite capable of operating the computer and can fluently use the computer key
board. He is described by his parents as having a photographic memory and, for
example, learned to operate the VCR when he was only three or four years old
simply by watching others use it. He can put 24-piece, even 50-piece puzzles
together with ease and tell time by the hour. He can read books such as “The Cat in
the Hat,” “Goldilocks and the Three Bears,” and “The Shy Little Kitten,” and “Golden
Books” at a similar level of difficulty. Further, he is able to sound out unfamiliar
words using phonics. During my observation in the classroom, I observed first hand
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some of the skills he had. The teacher was reading/singing a book (The Shirt Song)
to the students in the class and they were supposed to be following/singing along
with their own books. Mike did not seem to be paying attention at all and required
frequent prompting to stay in his chair. However, he spontaneously turned the page
without prompting at exactly the place, at the end of every page. This not only
demonstrated his ability to follow the written work but suggested that he may be
taking more in than is apparent when his attention seem to be wandering or directed
elsewhere.
Related to his reading skills, Mike is also able to spell. His parents report that
he is very good with the “Jump Start-Spelling” CD ROM, which is pitched for ages
five through eight. He is able to legibly write his name and write answers to open
ended questions such as “What do you do with a book” and “What do you do with a
towel” with the correct answer, such as “read with it” and “dry myself with it,”
respectively. He can find whole words in an word puzzle in which three to seven
letter words are embedded in a 8-letter by 12-letter matrix. He is able to find the
listed words that are embedded either left to right or top to bottom somewhere in the
matrix. He is able to answer questions on a multiple choice test with questions such
as “What school do you go to,” “What city do you live in,” “What is your mother’s
name,” etc., with the correct answer listed along with three distracters. He achieved
100% correct responding on the 11-question, multiple-choice, “Safety Questions”
test I reviewed. He is also able to respond correctly to simple open-ended tests
such as sentence completion exercises. For example, with the written instruction to
“fill in,” he was able to complete the statement “My eyes are ______” with the
correct answer “black,” correctly spelled, of course.
With math, he is able to do addition problems, but is not yet always able to
carry over successfully. On one worksheet I reviewed, he received a 100% correct
score for all 24 questions with addition problems such as 32 + 5 and even 38 + 7.
What makes a totally clear picture of his academic ability difficult to determine is his
need for frequent, and on occasion, even continuous prompting. It is not always
clear whether he needs to prompting to keep attending and responding, due to his
movement disturbance, or whether he needs “hints” as to the correct answer. Even
so, his ability to exhibit many of these skills on the computer, which is essentially
programmed to provide the former but not the latter, and in isolated instances when
he clearly is demonstrating a skill, such as when he turned pages at the correct
time, suggest that he may actually have significant academic ability - and potential.
Formal testing carried out a year ago by the Mid-County school district, the
most recent formal test results available to me, the following interpretation was
made of his cognitive functioning, based on the Universal Nonverbal Intelligence
Test (UNIT):
On this measure, Mike attained a standard score of 90, in the
average range. Without considering intervening factors, Mike’s scores
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are likely to fall with a range of 85-97 standard scores at a 90%
confidence level, falling within the low average to average range. In
addition, the following scores were also obtained: Memory Quotient
standard score 91, Reasoning Quotient standard score 91, Symbolic
Quotient standard score 87, and Nonsymbolic Quotient standard score
94.
Based on the Wechsler Individual Achievement Test-II (WAIT-II), he
performed at the age equivalent level of 7:0, 6:4, 4:0 and 6:8 for Word Reading,
Math Operations, Math Reasoning, and Spelling, respectively. Based on thee
BRIGANCE Comprehensive Inventory of BASIC SKILLS, he performed at the grade
equivalent level of 2nd, 1st, 1st, and 1st in the areas word recognition, oral reading,
spelling and math, respectively.
D.
Self Care Skills. Mike also has fairly well developed self-care skills.
He can eat the a fork and spoon, although he doesn’t yet use a knife, and can drink
through a straw (he is particular about what he eats and won’t each the typical pizza,
hot dog, MacDonald’s “junk food” that so many other children tend to favor). He can
dress and undress himself and is independent in putting on his shoes with the
Velcro lace. He can zip and button and is know learning to tie traditional laced
shoes. He is fully toilet trained and even if in the car he will let you know if he needs
to use the restroom. If you don’t stop for him, he will have a Tantrum. He is able to
wash himself during bath time but does need help putting on the shampoo. He is
also able to brush his own teeth using an electric toothbrush, including applying the
toothpaste, and gargle his mouth clean after he is done. This was a sequence of
skills, the performance of which I had the opportunity to observe myself during my
visit in the family home.
E.
Domestic Skills. Right now, there are no chore expectations for him at
home. However, Mike is very “neat” and puts his shoes in the closet when he takes
them off when he enter his home and puts his clothes in the clothes basket when he
takes them off. While these are skills, Mike’s performance of them is ritualized. He
would Tantrum if he were not allowed to complete these tasks or, for example, if his
shoes were kept or put somewhere else, for example by his bed. Another
manifestation of his movement disturbance is his insistence on picking up the phone
when it rings, exhibiting a Tantrum if someone else answers it first. In terms of his
skills in and around the kitchen, he is able to independently help himself to crackers,
a piece of fruit, and to go into the refrigerator to get and open a yogurt for himself.
He is also able, for further example, to get the milk or juice out of the refrigerator
and to pour himself something to drink.
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F.
Community Skills.
Mike has minimal skills for navigating the
community successfully. He can tell you his home telephone number and address,
but he is not able to cross streets safely. When shopping, he will tend to just grab
and want to leave with a lot of things, even more than one of the same thing, and
you may find yourself having to pay for more than you had planned. His parents are
trying to teach him to tell them what he wants.
G.
Recreation and Leisure Skills. There are a number of ways that Mike
likes to spend his recreational and leisure time. At home, he can spend hours
playing on the computer or with his Game Boy and has his favorite TV shows and
characters, e.g., Elmo and Barney (especially), that he enjoys watching. He also
enjoys coloring books and cut and paste activities. He particularly likes parties,
especially birthday parties and even enjoys just listening to the happy birthday song.
Outdoors, Mike enjoys riding his tricycle and trips to the beach where he can play in
the water and sand.
H.
Social Skills. As would be expected for a boy facing life with the
challenge of autism, it is in the area of social skills that Mike has the most difficulty.
He often appears to be, if not unaware, totally uninterested in the people in his
presence. He seemed oblivious of the other students in his special education
classroom, in the inclusion (math) classroom, and out on the playground, where he
played in the sandbox isolated from the others. When I was observing in his home
and at his school, while I introduced myself to him, he appeared not to be interested
in me or curious about what I was doing. A typical example of his characteristic
apparent lack of social awareness or interest in other people is illustrated by an
interaction I observed between him and the principle of his school. While
transitioning with his aide to the inclusive (math) classroom from his home room the
Principal was passing by and said hello to Mike. Mike did not acknowledge this
greeting at all. However, when the Principal insisted that he respond, Mike did
respond in kind by saying “good morning.”
It would be easy to conclude that Mike has neither social skills nor social
interest, that he is no interest in nor wants to be with other people, whether children
or adults. There is quite a bit of evidence that would belie this. For example:

His Tantrums were at a minimum when his cousins from the East
Coast, a girl of 9 and a boy of 2, were visiting.

He will often ask to visit his cousins who live in the area, saying, for
example, “I want to go to Kimberly’s house.”
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
When he is with his cousins, he asks them to play with him.
example, with Candy Land.

He enjoys going over and visiting at Grandma’s house.

He is attached to his instructional aide and is upset when he moves
away or pays attention to someone else.

He is obviously attached to and loves his mother, often seeking her out
for a tickle, a kiss and/or an embrace, and laughs and smiles when
with her.

He will often seek his father out for help.

At night, when he needs to use the toilet, he won’t go or stay alone
because he is “afraid” of the night and the dark and seeks the
reassurance and security of having one of his parents with him.
For
These are not indicators of a boy who has no interest in other people nor a
boy totally lacking in social skills. Rather, it draws a picture of a boy who finds it
difficult to establish relationships with other people and who is only confident with
those with whom he has a trusting history. The lack of skills may be at the front end
of a relationship, during initial meeting and in establishing the predictable basis on
which back and forth interactions will occur.
II.
Living Arrangement and Family History. Mike lives at home with his parents
and his and his sister Allison, who is seven-years-old. His mother, Linda Chow,
works as a clerk for the LA Daily Journal, and his father, John Chow, a college
graduate, has worked in a photo lab but now does free lance graphic design. He
acknowledges, however, that for the last year or two he has mostly been
preoccupied Mike and advocating for him. For example, Mr. Chow sought and
received formal training for himself in using the Picture Exchange Communication
System (PECS) that seems to be a relatively successful communication modality for
Mike. Mike and his sister were both born in the United States but his parents and
many of his extended family immigrated to the US and speak both Vietnamese and
Cantonese. At home, Mike’s parents tend to speak Cantonese to each other and to
Allison but use English when speaking with Mike.
(See Language and
Communication Skills above.)
The family home is a three-bedroom house on a pleasant tree-lined street in
Greer, California. The third bedroom is set up as a computer room (which Mike
uses a lot) and the children share a bedroom, although in practice the children sleep
with their parents. In addition to the three bedrooms, there is a small kitchen and
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breakfast room, a dining room, and a living room. The home is beautifully and
tastefully furnished and decorated and the living room has room for both a large
screen TV but also a piano, on which both Allison and Mike have received lessons.
The small backyard also has a trampoline for Mike.
Mike day is typically very structured and busy. On a typical day after school,
he receives two hours of in-home service each day, Monday through Friday from 3
PM to 5 PM. These services are based on the principles of Applied Behavior
Analysis and are aimed at teaching and improving various skills and at improving
problem behavior. Mike has received such in-home services since 2001 and PEAK
is the current service provider. He has benefited significantly as reflected by his
mastering the instructional objectives established for him in the various areas, such
as social skills, language and communication skills and self-care skills. As only a
minor example of this, Mike is now able to button his cloths and correctly answer
more than five safety questions, such as “what is your name” and “where do you
live,” both of which were objectives pursued by PEAK. 6 PM is bath time with dinner
from 6:30 to 7:30 PM and bedtime from 7:30 to 8:30 PM on a typical week day night.
Mike does not present any particular problem behavior around bedtime.
Weekends also have some regularity to them. On Saturdays, Mike receives
on hour of Social Therapy from 1 to 2 PM and an hour of Yoga instruction from 2:45
to 3:45. On Sundays, the family often will go ice skating, swimming and/or to the
park for the kids to play and run around. The Tangs are blessed to have many
members of their extended family living in relatively close proximity, so visits to
Grandma’s house or having some cousins over or visiting them is a frequent rather
than a rare occurrence. This is to Mike’s benefit as he enjoys visiting with his
relatives and will in fact ask to visit grandma or his cousins. When with his cousins
(and sister), he will ask them to play and generally shows more social awareness
and interest in playing and interacting with them than with other children.
Mr. Chow’s statement that he has been occupied with Mike for the last two
years may be an accurate assessment. Not only is Mike’s life a full and productive
one, his parents continue to seek out further assessments from various
professionals to increase their understanding of all of the aspects of Mike’s
challenges and to assertively pursue the acquisition of those services that would be
of benefit to him, for example, occupational therapy and music therapy. However,
they seem disappointed in what they perceive as the lack of inclusion opportunities
for him in school and concerned about the Tantrum behavior, which causes
increasing difficulty at home and that has become the major barrier to having these
opportunities. Given the situation, the time may be right for the family to adopt a
strategy of working toward the consolidation of the services that is currently
available to him rather than pursue additional assessments and services at this time.
That is, what may benefit Mike most at the current time is not so much a new
assessment or service but a consolidation of a coordinated plan across all settings,
representing the needed services that have already been identified.
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III.
Daytime Services Received and Day Service History. Mike is currently
attends the Sam Houston Elementary School (at 409 W. Lake Blvd., in Greer,
California) in a special education classroom for students who have the problems
associated with autism. His teacher has experience working with this population
and his one-to-one aide, Mr. Jerry Pitman has worked with him for four years. In
addition, Mike has his math class in with typical students, during which time, he is
accompanied by Mr. Pitman. Both Mr. Pitman and his teacher, Ms. Susan Stone,
have received training from Positive Behavior Consultants, Inc. (PBC) on Discrete
Trial instructional methods and other procedures and strategies that are based on
the principles of Applied Behavior Analysis (ABA) and continue to receive
consultation and training from that well respected agency regarding Mike and his
educational and behavioral needs. This has included formal recommendations for
addressing Mike’s Tantrum and other challenging behavior. For example, PBC
guided the school on the use of a “wait” card to help mitigate Tantrum behavior.
PECS is used as much as possible. While PEAK is the provider of Mike’s ABA
services in the home, PBC is the provider of ABA services in the school.
There has been disagreement between the school and Mike’s parents about
his educational program. On the one hand, Mike’s parents have advocated for Mike
to have the opportunity for full inclusion, as they believe that this would provide him
with the opportunity to receive optimum benefit from his educational program, both
in terms of his academic growth and in his development of communication and
social skills. While he was previously receiving more inclusion in the past, his
problem behavior and the school feeling that he wasn’t receiving educational benefit
led to its sharp curtailment.
Mike’s current IEP includes a formal “Positive Behavior Intervention Plan”
derived from the FAA carried out by Dr. Sam Jones. In addition, there are goals and
objectives for developing social/emotional skills (independent class work,
communication using system like PECS); visual motor skills (writing); expressive
language (making requests); receptive language (answering “do you want_____?”
questions, understanding prepositions), pragmatics (engaging in verbal exchanges
with other students); academic reading (decoding two-syllable words); functional
academics (demonstrate understanding of common signs); academic writing (writing
three self-generated sentences in response to a topic or picture); and academic
math (adding and subtracting 20 mixed double-digit problems, not involving
regrouping, solving adding and subtracting work problems, identifying hour and 1/2hour on a clock).
While the IEP is exemplary in many ways, including the use of discrete trial
methods, my concerns are for some of the elements of the behavioral support plan
and for maximizing the opportunities for and benefit of inclusion opportunities.
These concerns are discussed in subsequent sections below.
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IV.
Health, Medical and Psychiatric Status. Mike’s general health is considered
to be excellent. His hearing and vision are considered to be within normal limits, as
are his fine motor and gross motor skills. He does not have any known motor nor
physical disabilities or limitations, although his tactile defensiveness to certain food
textures is considered to be the reason he has such constricted food preferences.
He has no history of seizure activity. However, funny eye movements and facial
twitching led to the suspicion of Tourette’s Syndrome. Various neurological
evaluations were carried out and findings were negative for Tourette’s. However,
the findings concluded that there was an abnormal EEG due to the presence of
generalized background slowing suggestive of a diffuse encephalopathy. A
trial of Clonidine was initiated but discontinued when no beneficial effects were
noted. The “tics” were observed to improve and he is not now receiving any
medication, nor, other than the Clonidine, has he received medications in the past.
V.
Previous and Current Treatments. Over the years, in his young life, Mike has
received various treatments and therapies. These have included intensive Applied
Behavior Analysis services, both in the home and school, aimed at both skill
development and behavior, social therapy, speech and language therapy,
occupational therapy, adapted physical education, music therapy and, as described
above, one attempt to address some of his problems with medication. While there
is no doubt that his skill development has grown over the years, his behavior has,
while having ups and downs, not significantly improved and his parents believe that
at the present, they are getting worse. A more detailed description of the history of
these problems and the methods that have been attempted in the past are provided
in the History of the Problem section below.
FUNCTIONAL ANALYSIS OF PRESENTING PROBLEMS
While Mike exhibits a number of problem behaviors, many of them can occur
together, and as a class can be considered to be “tantrum” behavior. Aggression, of
particular concern in school, when it occurs, is also often a precursor to or can occur
in conjunction with a Tantrum. Accordingly, a functional analysis was conducted for
Tantrums as the priority problem. This analysis endeavored to identify the events
that control the emission and non-emission of these clinically important problems. It
is therefore organized around six specific subcategories of analysis: (1) Description
of the Problem. This analysis attempts to describe the presenting problems in such
detail that they can be objectively measured. It presents the topography of the
behavior, the measurement criteria for quantifying the rate of occurrence and
episodic severity of the behavior (as applicable), the course of the behavior, i.e.,
how it progresses during an event, and the current strength of the behavior (i.e., the
behavior’s current estimated rate of occurrence and degree of episodic severity).
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(2) History of the Problem. This analysis presents the recent and long-term history
of the problem. The purpose here is to better understand Mike's learning history,
and the historical events that might have contributed to the problem(s). (3)
Antecedent Analysis. The antecedent analysis attempts to identify the conditions
that control the problem behaviors. Some of the specific antecedents explored
include the setting, specific persons, times of the day/week/month, and specific
events that may occur regularly in Mike's everyday life. (4) Consequence Analysis.
The consequence analysis attempts to identify the reactions and management
styles that might contribute to and/or ameliorate the presenting problems. It also
focuses on the effects that the behaviors might have on the immediate social and
physical environment, on the possible function(s) served by the problem behaviors
and on the possible events that might serve to maintain or inhibit their occurrence.
(5) Ecological Analysis. The ecological analysis attempts to identify the critical
mismatches that may exist between the physical, interpersonal and programmatic
environments and Mike’s needs and characteristics. (6) Analysis of Meaning. The
analysis of meaning is the culmination and synthesis of the above analyses and
attempts to identify the functions served by the problem behaviors. The functional
analysis of Tantrums, organized around these headings, follows:
A.
Description of Tantrums and Operational Definition.
1.
Topography.
Tantrum include yelling, screaming and/or crying;
throwing himself on the floor; while on the floor, physical aggression, i.e., kicking,
grabbing, scratching, biting and/or hitting at people or pulling their hair; banging his
own head with his hands or against a hard surface, and/or knocking objects off table
and/or throwing them.
2.
Measurement Criteria.
a.
Occurrence Measure (Cycle: Onset/Offset). A Tantrum is
considered to have begun with the occurrence of any of the above topographies and
is considered over with their absence for 15 consecutive minutes.
b.
Episodic Severity Measure(s). The severity of an episode of
Tantrum behavior can be quantified in two ways. The first is by the duration of the
event. The second is through the use of a severity scale, as follows:
Level 1 – The Tantrum includes one or more of the above
topographies, excluding physical aggression.
Level 2 - The Tantrum includes two or more of the above
topographies, including physical aggression towards and adult.
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Level 3 - The Tantrum includes two or more of the above
topographies, including physical aggression towards another child.
Level 4 - The Tantrum results in someone being injured
requiring first aide or medical attention.
3.
Course. There are a number of precursors that can indicate a
Tantrum may be about to occur, often depending on how the adult authority figure
responds to these warning signs. These precursors include, darting around the
room, often away from the supervising adult, grinding his teeth, engaging in
stereotypic, repetitive actions, or communicating an unfulfilled need or desire.
Following precursor behavior, often depending how the supervising adult(s)
responds, the topographies of Tantrum behavior occur in various and varying
combinations. The Tantrum I observed during my observation in Mike’s home was
apparently typical, although, at nine minutes, perhaps somewhat less severe than
usual. He had been playing a computer game and lost. He starting crying and
threw himself on the floor, and proceeded to behave as described above. With staff
encouragement, he did tend to calm down, but after 30-seconds or so, would start
up again, crying, kicking out and hitting and grabbing at staff. This all occurred
during a break time from his “work” and he eventually calmed down for good, being
cooperative with staff when the timer went off indicating it was time to get back to
“work,” a tooth brushing. This pattern of a single Tantrum being interspersed with
sort periods of relative calm is typical, being described, as well, by Dr. Jones in his
report dated March 7, 2003, based on an incident he observed in the school setting
on January 9th.
While a Tantrum can be over in as little as 5-minutes, on occasion, such
episodes can last up to 30 to 45 minutes or, although rarely, even longer. Once its
over, it seems to be forgotten, and Mike seems willing and able to participate in an
adult directed activity.
4.
Strength.
a.
Rate. Although his parents report that Tantrum behavior is
becoming more frequent and severe at home, currently, it would seem that there are
approximately five Tantrums a day, on average, with a range of from one to ten.
Formal data for this problem, as described above, have not been collected either in
the school setting or at home. At school, the report is that the average occurrence
of Tantrum behavior is two times a day.
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Mike Chow
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b.
Episodic Severity. Again, while formal data have not been
collected, from reports and interviews, Tantrums last from 5 to 45 minutes, with an
estimated average of 20-minutes in length. Further, on the 3-point scale of severity
described above, the average level of severity would be placed at 2, with very few
incidents involving physical aggression toward children and equally few being free of
physical aggression toward adults.
B.
History of The Problem. Young children often exhibit Tantrum behavior,
however, in Mike’s situation Tantrums have not improved and are reported by both
home and school to be worse. Physical Aggression also has been present for
several years, sometimes as part of a Tantrum and sometimes quite separately.
This is reflected in a Special Education Plan from the West San Gabriel Valley
dated March 24, 2000 “…He will come and hit the person in order to communicate
his needs.” In a behavior plan from the Fremont School dated September 14, 2000,
Physical Aggression, Yelling and Screaming and Throwing himself and the floor
were targeted to be eliminated or decreased.
As indicated above, Physical Aggression can also occur as part of a Tantrum,
such as was described by a not by his teacher, Mrs. Kee Lui on September 11, 2001
“…I was called to help Jerry with Mike…Mike was crying and screaming…Mr. Chow
came to pick Mike up from school…Mike cried and screamed and sometimes hit his
dad.” to pick Mike up at school…Mike continued to cry and scream. He also hit his
Father.” These problem continue up to the present time and their have been a
number of attempts to carry out a functional assessment to understand these
behaviors and to develop plan to reduce and/or eliminate them. Part of the difficulty
in resolving these problems include imprecise and varying definitions of exactly what
the problem is. I believe the has contributed to the difficulty people have had on
getting a handle on just what the problem is and what might be done solve it. An
example of these floating and varying targets is illustrated from various reports,
plans, data records, etc. over the last several years:
Dates
Agency
Document
3/00
Harvest Valley
Special Ed. Plan
hits and bites
9/00
Fremont School
Behavior Plan
Physical Aggression
Yelling/Screamin
Throwing self on floor
10/01
Cleveland
Beh. Assessment
Problem Behavior(s)
Eloping
Aggressive behavior
Tantrums
Self Stim. Behavior
Disruptive Behavior
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Self Injurious Behavior
Rigidity
11/02
PBC
Beh. Int. Plan
Tantrums
3/03
Sam Jones, Ph.D. FAA
Harm to self
Harm to others
Property Damage
Disruptive Behavior
Repetitive...Behavior
Offensive Behavior
4/03
Harvest Valley Pos. Beh. Int. Plan
Harm to others
Disruptive Behavior
Property Damage
9/03
Mid-County School Data Sheets
Physical aggression
Yelling/screaming
Throwing self on floor
Expose/touch genetils
Throwing objects
Vocalization noises
Other behavior
Off task
Licking objects
Spitting/saliva play
Taking off shoes
Scratch
back
on
objects
There are a number of difficulties with this myriad of target behaviors. First,
there is no commonality for the definition for these different “target behaviors.” For
example, The Cleveland assessment lists and doesn’t really define Tantrum
behavior but defines Disruptive behavior separately as including screaming,
laughing and giggling for no apparent reason. In contrast, Dr. Jones’s report defines
disruptive behavior as “…yelling screaming, laughing loudly for no apparent reason,
crying for not apparent reason, and tantrums on the floor.” Variations in target
behaviors and their definitions makes it difficult to get accurate estimates of the
changing rates of these various behaviors over the years.
A second problem is that in listing different topographies, such as is
illustrated above, without integrating the information, it is not clear how often
problem behavior actually occurs. For example, in Dr. Jones’s report, he reports the
following rates in the school setting:
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Harm to self:
1 to 10 times a day.
Harm to other:
1 to 10 times a day…1 to 6 times a week.
Disruptive behavior:
1 to 10 times a day…1 to 6 times a week.
Not withstanding the ambiguity of suggesting that a behavior that is reported
to occur at least once a day is also occurring at least once a day, a mathematical
impossibility, it is also unclear with these event can occur during a single “Tantrum,”
or whether these behavior occur separately. That is, can harm to self and harm to
others happen as part of an episode of disruptive behavior, i.e., a Tantrum, or do
they always occur separately.
Finally, the way school/classroom staff track and record behavior is not
consistent with the how these behavior are targeted and defined on the behavior
plan. Dr. Jones’s report does not make any particular recommendations regarding
data recording. The school’s plan dated April, 2003 lists harm to other, disruptive
behavior and property damage as the targets and vaguely says that for interfering
behaviors, that they “…will be tracked via a weekly survey, provide that interfering
behaviors remain stable or continue to decrease. If behaviors are reported to
increase for more than a two week period, tracking and reporting will increase to
daily until behavior re-stabilizes and then return to the weekly survey method. Even
so, the behaviors for which data are being collected by Mid-County School, as list
above, from physical aggression to scratching his back on the floor, don’t even
include harm to self, disruptive behavior or property damage. Therefore, these rates
can’t be compared against the baseline rates established in the plan and, at least to
that extent, suggests that Dr. Jones’s assessment has not been taken on board.
As there have been various definitions and formulations of Mike’s behavior
problems over the years, so there have been various proposals on how to solve
these problems. These previous proposals are summarized as follows:
Dates
Agency
Document
Intervention Plan
3/00
Harvest Valley
Special Ed. Plan
Redirect and if he is
going to hit, give him a “high five” and ask him to show them
what he wants.
9/00
Fremont School
Behavior Plan
Physical Aggression:
remove from classroom. Call Parents to take him home.
Yelling/Screaming: Tell him to stop by the count of ten; redirect
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him with books or other materials; if he continues, time-out and
returns to classroom when he stops yelling. Throwing self on
floor: “It’s time to stop, what do you want?; Told to get at count
of ten, take by hand to stand him up; redirect him with books or
other materials; stay with him until he complies. Positive
Reinforcement: Verbal praise; high five (not otherwise detailed or
specified).
10/01
Cleveland
Beh. Assessment Differential reinforcement of
appropriate behavior, combined with extinction and planned
ignoring, and teach him replacement skills using discrete trial
training techniques.
11/02
PBC
Beh. Int. Plan
Prevention:
Reinforcement sampling; ubiquitous use of PECS system; high
density of behavior specific praise (e.g., good sitting); visual
schedules through out day; visual timers and verbal countdowns
when access to preferred item is to be restricted; identify break
area in the classroom; a separate room for completing follow
through with demand tasks during Tantrums; Frequent
opportunities to ask for bread and granting them when asked
vocally or through PECS; Practice situations for making requests
when they will not be restricted. Procedures when Tantrums
Occur: Planned ignoring combined with redirection; if disruptive
to regular education, escort to planned area and present demand;
after he follows instruction for 3-minutes, prompt to use break
card; “if he throws items, a restitution procedure will be
implemented before he is granted access to a break. For
example, staff will use graduated guidance…to prompt him to
restore the environment to its original state”; breaks will be
limited to 3-minutes. Reinforcement Schedule; All functionally
equivalent alternative responses should be reinforced on a
continuous reinforcement schedule until objectives have been
reached and then thinned to intermittent reinforcement schedule.
3/03
Sam Jones, Ph.D. FAA
Small setting, staff
trained in autism, gradual introduction to mainstream as he is
able to benefit; carryout neurological review; use of common
communication system across setting which he can learn to use
without prompting; data collection of staff device for social
interactions; collect data of independent vs. prompted work &
associated occurrence of “interfering” behavior; incorporation of
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consistent strategies (unspecified) that address his difficulty with
change; setting up social situations for him to interact in a more
structured manner with peers, e.g., with a brief structured game;
review of behavior plan in four to six weeks.
4/03
Harvest Valley Pos. Beh. Int. Plan
General
Strategies:
Provide frequent and immediate access to various “rewarding”
events; Easily recognized and identified transition times; Require
common communication. Schedules of reinforcement: Increased
level of Tantrums, reinforce every few minutes or even once a
minute; the density of reinforcement should be almost twice a
frequent as the Tantrum behavior.
Strategies for building
adaptive and social behavior: Countdowns for transitions and
end of preferred activities; Staff should take a “check in”
approach rather than staying by his side to reduce his need for
their close proximity, gradually increasing the time and distance
away from him; “Rewarding him for saying “I want a bread” or
making similar requests; Get him involved in social interactions
with peers, beginning, for example, with exchange of preferred
items. Managing interfering behaviors: Behavioral momentum,
i.e., preceding requests to engage in non-preferred activities with
several requests with high compliance histories; Interspersed
requests, i.e., alternating more preferred with less preferred
activities; positive practice, i.e., when an interfering behavior
occurs, practice an incompatible behavior a number of times,
using verbal rewards; One Minute Manager, i.e., a brief script for
getting into close proximity and providing him with a specific
verbal request to engage in an incompatible behavior, using
praise; hair pulling: use prescribed physical management
techniques.
There are a number of observations that can be made about these previous
plans. First, there is no doubt that they have become more comprehensive and
sophisticated, as simpler plans have proved not to solve the problems identified.
Second., more typically than not, there is not sufficient detail for staff to understand
the exact specifics they are supposed to follow. For example, Dr. Jones’s
recommendation to incorporate consistent strategies to address Mike’s difficulty with
change, without specifying the specifics of those strategies, leaves staff on their own
for figuring this out. Third, the lack of specificity, either in the plans themselves or in
other documents, as might be provided in procedural protocols, makes it impossible
to carry out quality checks to determine if staff are in fact being consistent in
implementing the behavioral component of the IEP. Fourth, none of the plans call
for such quality checks for determining whether a lack of progress is a function of
inconsistent implementation of the plan or the ineffectiveness of the specific
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Mike Chow
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strategies that comprise the plan. There is a total lack of data in the files regarding
quality checks and staff consistency in the implementation of the behavioral
procedures incorporated into the IEP. Fifth, none of the schedules of reinforcement
recommended over the years have been well designed. Even with more specificity
and even with consistent implementation, they are not likely to have improved
Mike’s Tantrum behavior and Physical Aggression. For example, in the last plan
dated April 3, 2003, the schedules are structured in such a way the a high rate of
Tantrum behavior results in a density of reinforcement and a low rate of this
behavior results in a low density of reinforcement. This, even if consistently
implemented, would be likely to reinforce and result in a higher rate of Tantrum
behavior. The likelihood of this is not addressed in the plan, nor safeguards against
it described.
C.
Antecedent Analysis. In an antecedent analysis, one tries to identify the
events, situations and circumstances that set the occasion for a higher likelihood of
the behavior and those that set the occasion for a lower likelihood. Further, in both
categories, one tries to identify both the more distant setting events and the more
immediate triggers that influence the likelihood of the behavior. Below is firstly an
analysis of those setting events and triggers, i.e., those antecedents, that increase
the likelihood of Tantrums and their escalation and secondly an analysis of those
that decrease the likelihood. Substantiating examples substantiating, based on
actual incidents, are also included.
A number of antecedents can be identified which increase the likelihood of
Tantrum behavior. These include unexpected or undesired outcomes, such as
when he loses a computer game, placing demands on him to do things that he
doesn’t want to do, for example, to complete a worksheet at school, requiring him to
stop certain activities before he is finished, especially those that have a ritual, almost
compulsive quality to them, such as his playing with water in the bathroom, taking
off his shoes and putting them away when he enters his home, getting out of his
seat and running around the classroom, or playing with the computer, transitions
(such as moving from an activity in the classroom to one outside), adults directing
their attention away from him, people not understanding or not complying with his
request for help or for something else, changes in routine, finding things out of
place, being required to wear anything other than the narrow range of clothing he
insists on, and having to wait for something he wants. A setting event that increases
the likelihood of Tantrum behavior is physical discomfort, such as occurred in April,
2002 when he was experiencing skin itchiness. Also, once he has had a Tantrum
earlier in the day, he is more likely to have one later that day. Further, if supported
by unfamiliar staff he is more likely to exhibit Tantrum behavior. Finally, his longterm, one-to-one aide in school, or for that matter, any supervising adult, not being
by his side giving him frequent prompting, is a setting event or, on occasion, even a
trigger for making Tantrum behavior more likely to occur.
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There are a number of illustrations of such antecedents. I had the
opportunity to observe one of these triggers myself when, as described above,
during my home observation he lost a computer game he was playing, which event
immediately triggered a Tantrum. In school, it has been reported that he falls on the
floor and Tantrums when the paper towel dispenser is empty (“he will not accept
paper towels from any other source.” On September 7. 2001, Mike exhibited
Tantrum behavior “…the first day that Linda (unfamiliar staff) was covering for Jerry
(familiar staff). During Dr. Gales observation in the school, While Mike was writing
letters, his aide left his side to introduce himself. Within 15-seconds, Mike “…threw
himself out of his chair onto the floor and began to wail.” On another occasion, Dr.
Jones reported observing Mike being prompted by his aide to finish his work for five
more minutes and then it would be time to go to P.E. However, two minutes later,
“…the phone rang and the teacher was informed that Mike would be tested this
morning, Jerry prepared to take him which was followed by an immediate and
extreme reaction by Mike who began to scream and flail his body…” This is an
example of where unannounced and unprepared changes in expected routines or
activities can trigger Tantrum behavior.
While these antecedents predictably increase the likelihood of Tantrum
behavior, there are also a number that decrease the likelihood. These include
giving him what he is asking for, not interrupting him, explaining things to him before
hand, offering to help him with a problem he is having, and giving him an option.
Providing him with a visual orientation as to what is going to happen is also
associated with a lower likelihood of Tantrum behavior. Low likelihood setting
events include having his aide in close proximity, providing him with necessary
prompts to continue with the assigned activity as is being in good health and not
having any physical discomfort.
D.
Consequence Analysis. As described above in the History of the Problem
section, a number of attempts to solve the problem using consequences, both with
intent to reinforce better behavior and to discourage inappropriate behavior, have
been tried over the years. Not only have these strategies not solved the problem,
on occasion, for example, when forced responding (“restitution procedure”) was
used, they may have exacerbated the problem. Also, as described above, this may
be due to the lack of specificity in procedural design, the lack of systems to assure
consistency, and the poor design of these strategies. That is, with the current
recommendation in place to increase the density of reinforcement when he is
exhibiting high rates of problem behavior and to lower the density of reinforcement
when he is exhibiting low rates of problem, my concern would be that if there were
consistency in implementing this strategy, it is likely that contingent reinforcement
will lead to an increase in the rate of problem behavior.
Reactions to and consequences for his problem behavior and for alternative
responses has varied over time and across and within settings, including both home
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and school settings. Further, the reactions and consequences have been and are,
to this day, both planned and unplanned. In addition to the planned consequences
described above under History, further reactions and consequences include taking
him outside (as his aide will do in school), prompting him to calm down, e.g., “Your
OK,” encouraging him to communicate what he wants using PECS, distracting him
with something he enjoys, such as the harmonica, giving him his Game Boy, “timeout” (i.e., bringing him and having him stay outside the classroom until he has
calmed down), and taking him into bathroom and wiping his face with a face cloth
(as his dad sometimes does at home). Prompting and guiding him through a
problem solving process, such as PEAK staff did when I observed his Tantrum at
home when he lost the computer game he was playing, is also used. At school, the
plan has also included calling his father to come and take remove him from school
as a consequence for his Tantrum behavior. While these strategies, as planned or
unplanned and consistent or inconsistent as they may have been, may not have
produced lasting change in the frequency of occurrence of Tantrum behavior, they
have often tended to resolve the events with lower episodic severity, i.e., quicker
resolution and resolution without or with only minor physical aggression.
Proprioceptive feedback may also act to resolve a situation, as Dr. Jones reported in
his assessment. On the other hand, other reactions and consequences tend to
escalate the situation to higher levels of episodic severity. These include having
him restore the environment, verbal reprimands, direct physical intervention, for
example, when he is pulling someone’s hair, and planned ignoring.
In spite of the lack of good design in the reinforcement procedures that have
been attempted in the past to influence the frequency of his problem behavior and
the lack of any encouraging results to date, there is evidence that he will work for
access to some preferred events. For example, when his piano teacher tried to
motivate him to work for candy, he was not willing. On the other hand, when he was
asked to work in order to get access to Game Boy, he was willing to put significant
effort into his piano lesson. The right events made available in the right format
might very well motivate the desired change in his behavior.
In the pattern of Mike’s behavior, one can see obvious suggestions of the
what may be contributing to the maintenance of these problems. These include the
acquisition of desired things, like Game Boy and computer access, and escape,
e.g., from the classroom and other demand situations. Such interpretations of his
behavior are common across virtually all of the assessments that have been carried
out over the years. For example:
March 7, 2003: Looking at factors triggering behavior, it appears that
there are four motivational factors: 1. Desire for social attention,
occasional desire for tangible rewards; 2. Attempt to escape
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Mike Chow
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from unpleasant tasks; 3. Sensory stimulation /reinforcement; 4.
Schedule changes.
November 12, 2002: To escape a demand situation or gain access to a
preferred item.
October 8, 2001: Remaining in the same activity; avoid transition (i.e.,
escape behavior); or obtain a desired item.
However, as discussed in the Impressions and Analysis of Meaning section
below, I believe his Tantrum behavior require a deeper and more complex
understanding.
D.
Ecological Analysis. There are a number of ways in which understanding the
surrounding ecology, and how it may conflict with Mike's needs and characteristics,
may be helpful in understanding the meaning of his behavior and in understanding
the ecological changes that may be necessary to provide the necessary support for
him. The brief discussion addressing this ecological analysis is presented below.
First and foremost is the absence of a well informed, well designed,
consistently implemented, positive behavioral support plan, coordinated across his
home, school and community settings. Mike needs such a support plan. Among
other things, such a plan would emphasize a positive approach, with the role of
reactive strategies explicitly being aimed at reducing episodic severity, while the
proactive strategies, especially focused support strategies, would be aimed at
reducing future occurrences. Further, more attention should be paid to the specific
definitions of the target behaviors that are being addressed and the accuracy and
reliability of the data being collected and summarized with regards to those target
behaviors, specifically regarding target behavior occurrence and episodic severity.
While one reason for the current misfit may be that the professionals capable of
designing such a plan have not been identified (note the poorly designed
reinforcement strategies described above), another lack may be the need for a
“single-team” approach facilitated by a single qualified team coordinator.
In addition to the need for a well designed, positive behavioral support plan,
there is need for a formal plan specifying the objectives of the inclusion
opportunities he has, and the specific methods to achieve those objectives. For
example, the Math classroom, which is one of the inclusion possibilities that Mike
has, involves him, at least on the day that I observed, in an activity, isolated from the
other students. Mike’s biggest need is to have the opportunity to develop his social
and communication skills. While academic skills can be developed through other
modes, e.g., computer assisted instruction, tutoring, etc., the inclusion opportunities
he has in the school should emphasize the teaching of interaction, cooperation, and
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communication skills. If a proper inclusion plan cannot be developed without it,
outside consultation should be sought.
While these environmental conflicts need to be addressed, there are a
number of aspects of the current ecology that should be pointed to as being
particularly matched to Mike’s needs and characteristics. These include Jerry
Pitman, his instructional aide of long standing, who has a strong and positive
relationship with him and who seems open to following whatever changes in Mike’s
IEP may be made. Second, the PECS (Picture Exchange Communication System)
is well suited to Mike’s strengths in the visual modality. Its beneficial influence was
mentioned by virtually every body I talked with, including his parents, who have
received formal PECS training, his in-home staff from PEAK, and, most notably, his
instructional aide and teacher from school. Finally, the use of discrete trial teaching
procedures has been used at both home and school and to the extent that it is used,
helps Mike focus on the relevant information concerned with the particular lesson
plan being implemented at any given time.
E.
Impressions and Analysis of Meaning. In considering this functional analysis
and the background information summarized above, there are a number of factors
that are helpful in trying to understand the meaning of Mike's behavior. Firstly is the
very obvious movement disturbance that makes so much of his behavior largely
non-volitional. This also explains his dependency on the close proximity of Mr.
Pitman, his instructional aide in the classroom. Mike’s non-performance of the
assigned task and the increased likelihood of his Tantrums and other problem
behaviors when Mr. Pitman moves away, appears to be a spoiled child’s demands
for constant attention. Rather, with an impaired ability to be in control of his own
behavior, due to his movement disturbance, he is quite literally dependent on Mr.
Pitman to mediate his behavior. Accordingly, he in all likelihood becomes highly
anxious, leading to Tantrum behavior. Being more a function of the neurological
influence of his movement disturbance than of his volitional intent to acquire
something or avoid something, such behaviors are more easily influenced by the
introduction of a stimulus that can is capable of intruding and, in a sense, trumping
the neurological imperative that is driving the behavior. This may be why removing
him from the classroom at certain times and wiping his face with a wet washcloth
may act to resolve a Tantrum. The stimulus conditions that activated the movement
disturbance are replaced by alternative stimulus conditions that set the occasion for
alternative responses. Further, while for many children, such “consequences” may
have aversive qualities, leading to a reduction in future responding due to a
punishing effect and to an escalation in episodic severity as a result of escape and
avoidance behaviors, for Mike, these types of events tend to resolve the situation.
The same effect is seen when his Tantrum behavior is disrupted by introducing
Game Boy or other preferred events. In either case, Mike is probably happy that
someone has controlled his behavior as he is not able to at those times.
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This is not to say that at times Tantrum behavior, as with any child, may not
be influence by Mike’s motivation to acquire or escape something, such as when
you don’t stop when he is in the car and tells you he needs to go to the bathroom,
but I do not believe such motivations are typically independent of the movement
disturbance influence described above. Similarly, while frustration and failure can
trigger Tantrum behavior in the typically developing child, in Mike’s case, they often
conflict with the behavioral sequencing and patterns set in motion by his movement
disturbance, as are his “rituals,” that, when he is unable complete them lead to the
anxiety that underlies his behavior.
MOTIVATIONAL ANALYSIS
A motivational analysis was carried out to identify those events, opportunities
and activities that Mike enjoys and that may be used to enhance his quality of life
and provide him with incentives to improve his behavior and to enhance his
academic progress. The results of the analysis showed a number of events that
could be used effectively as positive reinforcement in a well designed support plan
to reduce the identified behavior problems. These events include, but are not
limited to certain food and drink treats (such as fruit roll-ups, apple juice, with a juicy
juice straw, and yogurt), being on the computer and playing computer games,
playing game boy, watching Barney on TV, riding his tricycle, going for car rides,
going to the water park, riding the roller coaster (at Disneyland and Knottsberry
Farm), and keeping things tidy. These reinforcers, and others, should be used in a
variety of ways, the least of which would be through the contingencies of formal
reinforcement schedules.
MEDIATOR ANALYSIS
A "Mediator Analysis" was conducted for the purposes of identifying those
persons who might be responsible for providing behavioral support for Mike, their
abilities to carry out the recommended support plan, given the demands on time,
energy, and the constraints imposed by the specific settings, and motivation and
interest in implementing behavioral services as recommended. This analysis
showed that there are a number of significant mediator issues that may prevent a
successful attempt to address Mike’s challenging behavior and to maximize the
benefit he can receive from his education. The first is an apparent lack of expertise
and leadership, in the design of positive behavioral support plans, in setting up the
systems required for their consistent implementation and in coordinating a plan
across settings. Examples of the basis for this conclusion include the poor and
sometimes counter-productive design of reinforcement procedures and the use of
preferred events to motivate and influence change; the lack of concordance
between the identified target behaviors in the formal plans and the data that are
being collected; and the lack of any systems to assure and document that the
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Mike Chow
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procedures recommended in a plan are, in fact, being implemented consistently and
are coordinated across settings.
The second barrier is the adversarial relationship between Mike’s parents and
school district personnel. The adversarial nature of this relationship is only partly
evidenced by the inches of back and forth correspondence between the two.
However, in my interviews with the school, I felt that they had some points of
concern that they felt the parents were not acknowledging. For example, I found
that school district staff were in support of maximizing inclusion opportunities for
Mike but felt that he wasn’t benefiting from them and that a different approach was
necessary. As described above, I feel this is a legitimate concern, as, from what I
observed, he wasn’t benefiting, either academically nor in terms of socialization and
developing language and communication skills, in his inclusive math class.
I also got the sense that school district personnel felt that the parents were
unending in their demands for ever more assessment and the expansion of services
for Mike. It is understandable that parents would want everything possible for their
child. Further, I believe that if the following plan is adopted by the school district,
everybody, including Mike’s parent would put 100% of their effort into its
implementation and the need for further assessments and the inclusion of additional
services could be considered as part of a formal annual review facilitated by the
agreed upon coordinator of the team, with the input of the various team members,
including Mike’s parents. For Mike to benefit, it is necessary for the adversarial
conflicts between the parents and the school to stop and for everybody to work in a
coordinated approach to his education and behavioral support.
RECOMMENDED SUPPORT PLAN
A.
Long-Range Goal. The long-range goal for Mike is to establish enough self
control over his behavior that he will be able to live and work in the least restrictive
setting possible that is capable of meeting his developmental and behavioral needs.
The goal of his educational plan is to provide him with the academic and other skills
necessary to meet his needs, while eliminating those behaviors that tend to
stigmatize and isolate him from full community and social presence and
participation. Additionally, the goal is to transfer the control of Mike's behavior from
external mediators (parents and staff) to internally generated controls. The plans
and objectives presented in the following paragraphs are intended to increase the
likelihood that the following specific outcomes will occur:
1.
That Mike will learn the appropriate social rules of home, school and
society, to the extent that his behavioral excesses and deficits will not be a barrier to
his full participation in life and the enjoyment of life that every child should have, as
a valuable member of his school and of his wider community.
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2.
That Mike will have friends whom he enjoys and with whom he enjoys
doing things.
3.
That Mike will learn to fully communicate his wants, needs, thoughts
and feelings.
4.
That Mike will be able to live out his childhood with his family, as the
loved son he is now, until such time that as an adult he is ready to venture forth in
life as an adult, ready to live in his own home and ready to earn money in a real job.
B.
Operational Definition(s).
1.
Tantrums:
a.
Topography. Tantrum include yelling, screaming and/or crying;
throwing himself on the floor; while on the floor, physical aggression, i.e., kicking,
grabbing, scratching, biting, choking and/or hitting at people or pulling their hair;
banging his own head with his hands or against a hard surface, and/or knocking
objects off table and/or throwing them.
b.
Measurement Criteria.
1)
Occurrence Measure (Cycle: Onset/Offset). A Tantrum
is considered to have begun with the occurrence of any of the above topographies
and is considered over with their absence for 15 consecutive minutes.
2)
Episodic Severity Measure(s).
The severity of an
episode of Tantrum behavior can be quantified in two ways. The first is by the
duration of the event. The second is through the use of a severity scale, as follows:
Level 1 – The Tantrum includes one or more of the
above topographies, excluding physical aggression.
Level 2 - The Tantrum includes two or more of the above
topographies, including physical aggression towards and adult.
Level 3 - The Tantrum includes two or more of the above
topographies, including physical aggression towards another child.
Level 4 - The Tantrum results in someone being injured
requiring first aide or medical attention.
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2.
Physical Aggression: Physical Aggression can and sometimes does
occur independent of a Tantrum as described above.
a.
Topography. This includes kicking, grabbing, scratching, biting,
choking and/or hitting at people or pulling their hair.
b.
Measurement Criteria.
1. Occurrence Measure (Cycle: Onset/Offset). An episode of
Physical Aggression, alone, is considered to have begun upon the appearance of
kicking, grabbing, scratching, biting, choking and/or hitting at people or pulling their
hair, separated by at least 15-minutes, from the other topographies included in the
definition of Tantrums above.
2.
Episodic Severity Measure(s).
Level 1 - Physical aggression towards and adult.
Level 2 - Physical aggression towards another child.
Level 3 - The Physical Aggression results in the need for
first aide.
Level 4 – The Physical Aggression results in the need for
medical attention.
C.
Short Term Measurable Objectives. The following objectives and plans are
suggested on the assumption that Mike has the opportunity to have a
comprehensive plan of support, fully coordinated across home, school and
community settings. It is unlikely that they would be realistic if he did not have this
opportunity. These objectives were also selected as being most reflective of Mike's
priority needs and as being the most realistic given his level of functioning at this
time. Further objectives may be established as a function of the success or failure
of the recommended strategies.
1.
Tantrums.
a.
Reductions in Behavior Over time. To reduce the occurrence of
Tantrums from the current estimated rate of five a day, with a range of from one to
ten Tantrums a day, across all settings, to a rate of three a day, with a range of one
to five a day, within three months of the full and consistent implementation of the
focus support strategies below, and to rate of one a month within twelve months.
b.
Reductions in Episodic Severity.
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1)
To reduce the duration of a Tantrum from the current
estimated average of 20-minutes, with a range of from 5-minutes to 45-minutes, to
an average of less than 5-minutes with a range of from one to 10-minutes, upon the
full and consistent implementation of the reactive strategies recommended below,
and to a maximum of two minutes within a year.
2)
To reduce the average severity rating of Tantrums from
the current estimated level of 2, with a range of from 1 to 3, to no more than 1, upon
the full and consistent implementation of the focused support and reactive strategies
recommended below.
2.
Physical Aggression.
a.
Reductions in Behavior Over Time. To carry out a formal
baseline for Physical Aggression to determine how often it occurs independent of a
Tantrum and to reduce its occurrence by 50%, within three months of the full and
consistent implementation of the focus support strategies below, and to rate of no
more than once every three months within a year.
b.
Reductions in Episodic Severity. To carry out a formal baseline
for Physical Aggression to determine its Episodic Severity when it occurs
independent of a Tantrum and to reduce the average severity rating of Physical
Aggression from the current estimated level of more than 1 to no more than 1, upon
the full and consistent implementation of the focused support and reactive strategies
recommended below.
D.
Observation and Data Collection Procedures.
1.
Methods.
a.
Tantrums. A formal data sheet should be available for each
day. It should include the formal definition of Tantrums, as defined above, and a
place to enter the start and stop time of each Tantrum that occurs, the total duration,
and the Level of episodic severity. A Primary Observer should be assigned for each
hour of the day, whether at home, school or in the community. When a Tantrum
occurs, the details regarding time and severity should be entered on the form, within
15-minutes of its resolution. Rate and episodic severity data should be summarized
on a weekly graph by the appointed Team Coordinator.
In addition, using a revolving hour method in both the home and
school, a full “ABC” sheet should be filled out for the first Tantrum, if any, that occurs
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for the identified hour for the day. For example, if the hour for Monday in school is
from 9 to 10 AM, then the first Tantrum that occurs during that hour, if any, would be
detailed with the information listed below. On Tuesday, the identified hour would be
from 10 to 11 AM and so on, until the last hour of the school day is the identified
hour. On the following day, the first hour of the school day would be the identified
hour.
If a Tantrum occurs during the identified hour, the Primary Observer
should record the following on a prepared form:
1)
Date of occurrence.
2)
Time of episode start and stop and total duration.
3)
Each topography that occurred, specifically coding the individual
topographies and sub-topographies observed during the
episode, including crying and screaming, physical aggression,
self-injurious behavior and knocking over or throwing items.
Other significant behaviors that occurred during the Tantrum
should also be recorded.
4)
The people present and/or involved in the incident.
5)
The activity at the time of occurrence.
6)
The setting in which the behavior occurred.
7)
The events (antecedents) immediately preceding each
occurrence. This should include environmental events and the
closest verbatim record possible of the conversation leading up
to the event, including an assessment of the tone and content
of the conversation.
8)
The consequences or reactions of people, following the
behavior, including the use of physical management.
9)
For each Tantrum, the assigned person should score it on a
four point scale of severity, as described above
10)
If property damage occurred, the nature and extent of the
damage, with a $ estimate of repair and replacement.
11)
Impressions regarding the behavior and its occurrence. For
those events that required physical restraint, this information
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should be based on a debriefing session held within 24-hours
following the event, attended by everybody present during any
of the episode or during the time leading up to the episode.
b.
Physical Aggression. For each and every occurrence of
Physical Aggression that occurs, independent of a Tantrum a similar “ABC” sheet
should be filled out, with the exception of item “10” above, which would qualify it as a
Tantrum. Rate and episodic severity data should be summarized on a weekly graph
by the appointed Team Coordinator.
2.
Observational Reliability.
a.
Tantrums. In school, secondary observer should also be
assigned and that person should independently record observed tantrums on the
prepared form, excluding the use of the “ABC” sheet described above. The Team
Coordinator should carry out weekly phone interviews with parents and in-home
staff and note their solicited reports concerning the occurrence of Tantrums.
Monthly, secondary records and interview reports should be compared to the
primary data sheets to determine the degree of agreement. That is, an index of
reliability should be calculated by dividing the number of agreements by the number
of agreements plus disagreements and multiplying by 100. This monthly calculation
should be documented in a formal log and if the index of reliability is less than .80 a
plan of corrective action should be indicated and taken.
b.
Physical Aggression. Same as above.
E.
Recommended Strategies. In the following paragraphs, a summary of
possible strategies to support Mike is presented. These are by no means meant to
be comprehensive or exclusive of other procedures. They simply represent a set of
starting points that would be elaborated and modified as services are provided.
Support is organized around four primary themes: Ecological Strategies, Positive
Programming Strategies, Focused Support Strategies, and Reactive Strategies.
1.
Ecological Strategies. Many behavior problems are a reflection of
conflicts between the individual needs of a person and the environmental or
interpersonal context in which the person must live, go to work or otherwise behave.
As part of the above evaluation, several possible contextual (ecological) conflicts
were identified. It is possible, that by altering these contextual conflicts, that Mike's
behavior may change and his progress may improve, thus eliminating the need for
consequential strategies. In the following paragraphs, a number "Ecological
Manipulations" are presented with the intention of providing a better mesh between
Mike's needs and the environments in which he must behave:
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a.
There are a number of things that are important for Mike’s
success that are already in place and these should be continued. The include the
use of PECS as part of his two-way communication systems with those around him,
the use of discrete trial teaching techniques in both the school and home and the
presence of in home services, currently being provided by PEAK.
b.
Word/picture sequences should be used as much as possible to
communicate expectations to Mike. This should go beyond merely portraying his
daily schedule through a sequence of word/pictures, to which he should be oriented
at the beginning of each day and at each transition. They should also be used to
orient him to the content of each new activity in which he is going to engage. For
example, before going to his inclusion session for math, he can be shown a
sequence of word pictures that show him where he is going, who will be present,
where he and everybody else will be, or how they might move around, what is going
to happen, what he is going to do, etc. Social stories should also be used to show
him, in imagery, what interpersonal conflicts he might encounter and how he should
behave under these circumstances. Social stories should be used as part of the
discrete trial methodology, as described below under Positive Programming.
c.
As indicated above, one of the most glaring things missing from
Mike’s life is the support of a collaborating, cooperative, coordinated support team to
work with him in school, at home and in the community. If Mike is to succeed in life,
the development of such a coordinated approach in imperative. Therefore, I
recommend that a Team Coordinator be appointed. This person should have the
confidence and pledge of support from parents, school and the external agencies
currently providing support to Mike and home and in school. Among other things,
this person should have the ability to take the leadership responsibility for
implementing all of the aspects of this recommended plan of support. If such a
person cannot be identified among current staff and professionals, an external
consultant should be hired to fill this role. My recommendation for the person to fit
that role would be Jackie Leigh, M.A., a psychologist with the Whittier School
District. Ms. Leigh is an outstanding professional who is more than competent in
developing and implementing positive behavioral support plans. I believe she would
be acceptable to Mr. and Mrs. Chow and, in fact, the Mid-County School District in
fact recommended her to the family as someone who might have performed the
functional assessment.
d.
Both parents and school expressed a desire for a more
productive inclusion plan for Mike. Toward this end, I would recommend that the
school seek an outside consultant to develop a formal inclusion plan, based on input
from both school and parents. The emphasis, of the inclusion plan, as part of
Mike’s IEP, should be on social opportunities and development rather than on
passive presence in an inclusion setting. Perhaps it is fortuitous that arguably the
nation’s pre-eminent expert on inclusion, Dr. Mary Falvey, a professor at California
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State University, Los Angeles. I recommend that the school district contract with Dr.
Falvey to consult on the development of a proper inclusion plan for Mike that would
maximize the opportunities he has for inclusion, both in terms of the percentage of
the day in which he is in inclusive classroom and in terms of maximizing Mike’s
educational outcomes, especially with regards to social and communication skills.
Ms. Leigh is also qualified to fill this role and can seek consultation from Dr. Falvey,
if necessary.
e.
Academic growth can be emphasized elsewhere on the IEP,
and for that matter, at home. For example, Mike is very comfortable and enjoys
working on the computer. As an instructional medium, the computer should be
maximized. His IEP, home plan, and inclusion plan can focus on generalization of
these academic skills and social interaction with peers who are not disabled.
f.
At school, staff should discontinue the current schedules of
reinforcement in which reinforcement density is a function of the frequency of
problem behavior, in which a higher rate of problem behavior produces a higher
density of reinforcement. Rather, a time-based schedule of preferred event should
be developed which provides for a preferred event, such as five- minutes with Game
Boy, having a Juicy Juice, etc., on the average of every half-hour, regardless of
behavior. To just stop the current schedules would lead to a overall reduction in
reinforcement density that could increase problems behavior. Further, research has
shown that time-based delivery of preferred events is associated with lower rates of
problem behavior.
2.
Positive Programming. Challenging behavior frequently occurs in
settings that lack the opportunities for and instruction in adaptive, age-appropriate
behavior. It is our assertion that environments that provide instruction to promote
the development of functional academic, domestic, vocational, recreational, and
general community skills is procedurally important in our efforts to support people
who have challenging behavior. To the extent that Mike exhibits a rich repertoire of
appropriate behaviors that are incompatible with undesired behavior, the latter
should be less likely to occur. Positive programming, therefore, should not only
result in developing Mike's functional skills, but also contribute to reducing the
occurrence of problematic behavior. At the very least, a context of positive
programming should make it feasible to effectively and directly address Mike's
Tantrum behavior and Physical Aggression. In the following paragraphs, several
initial thrusts for positive programming are presented:
a.
General Skills
a.1.
Recreational Domain.
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1)
Rationale/Logic. While not intended to replace the
instructional objectives established for him in his IEP or in his in-home program, the
recommendation that follows is being made because it addresses a particular need
that Mike has, i.e., how to socialize appropriately with his non-disabled peers, within
the context of an activity that he enjoys.
2)
Objective. Given the proximity of a familiar, non-disabled
peer in a known free-time/recreational and leisure time area, with the Candy Land
game visible and available on a table top, Mike will, within 5-minutes of entering the
area and being told to relax and enjoy himself, address his peer by name, ask him
to play a game of Candy Land with him, play the game from beginning to end,
appropriately taking turns and following the rules, and thank him for playing with him
when they finish, saying “good game,” whether he wins or loses. Mike will be able to
do all of this without prompting and without exhibiting Tantrum behavior or Physical
Aggression, five out of five times, by December, 2004. (A similar objective should
be established for his home program in which he invites a cousin or neighborhood
friend to play “Game Boy” with him.
3)
Method. Discrete trial teaching procedures should be
employed, with each game considered to be a trial. Global chaining, whole task
presentation should be used, with prompt/prompt fading being used throughout.
Each trial should be prepped with a “social story,” which shows the conditions being
established, Mike asking his friend to play, the children playing, the game ending,
Mike saying “good game,” and then his enjoying a Juicy Juice or a yogurt in the
presence of his one-to-one aide. This conclusion should be way every successful
trial ends. Prompt fading should occur in phases. In the first phase, the necessary
verbal, gestural, model or physical prompts should be used and then faded to
assure that Mike can play the game while taking turns and following the rules in
response to natural cues only. In the second phase, the verbal prompting for him to
ask his friend to play and to say “good game” at the end, should be faded to assure
that Mike can say these things given the natural cues only. In the third phase, Staff
should gradually move their proximity until they are able to remain in but at the
opposite end of the room from the children, as they play successfully, in response to
the natural cues only. In the final phase, the Social Story set up should be faded
back in time, initially in five-minute increments, until it is not longer necessary.
a.2.
Community Domain.
1)
Rationale/Logic. The following is recommended for
the reasons described above and to give him greater control and autonomy over
accessing his own reinforcers.
2)
Objective. By June 30, 2004, when brought to a
convenience store during a slow time of day, given a one dollar bill and invited to
go in to buy himself a Juicy Juice, Mike will enter the store, find the Juicy Juice,
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take it to the checkout counter, pay for the item and leave the store with both the
item and the correct change, without error, without problem behavior and with
staff or parent simply waiting for him outside, within five-minutes of the request.
3)
Method. I recommend that this skill be taught using a
discrete trial, whole task, global chaining methodology, with the opportunity to eat
the drink the Juicy Juice being the operative positive reinforcement for the correct
response
b.
Teaching Functionally Equivalent Skills. People engage in
seriously challenging behaviors for perfectly legitimate reasons. They use these
behaviors to communicate important messages, to assert themselves, to manage
unpleasant emotions, to escape unpleasant events, and to gain access to events
and activities. One important strategy for helping people overcome their challenging
behaviors is to provide them with alternative ways of achieving the same objectives,
alternative ways of satisfying their needs. These alternatives are defined as
functionally equivalent skills because they achieve the same goal as the challenging
behavior or communicate the same message.
1)
Rationale/Logic. The above analysis of Mike's Tantrum
behavior concluded, among other things, that it is a strong emotional reaction to
having one of his rote routines interrupted. This goes beyond his simply being
disappointed. Rather, the underlying autism and its associated movement disorder
compels him to engage in these “rituals” and when they are interrupted, his universe
can feel like it is falling apart. One example of this is his “need” to answer the
telephone when it wrings at home. Rather than engage in Tantrum behavior when
this occurs, the objective established here is to teach to respond in a different, more
socially acceptable way.
2)
Objective. Given ten phone calls at home, and with five
being answered by someone other than Mike, he will get the “Barney” tape kept on a
shelf within five feet of the phone, put it into the tape player, and watch the tape,
without prompting and without Tantrum behavior or Physical Aggression, five out of
five times, by August, 2004.
c.
Method. A similar method should be employed here,
with a Social Story set up for each trial and the use of prompt/prompt fading
strategies. However, difficulty should initially be kept at a minimum and only
gradually increased to the terminal objective. For example, the first four steps of the
program might look as follows, keeping in mind that teaching trials should be
interspersed with trials in which Mike is allowed to answer the phone when it rings:
1)
immediately hands it to Mike.
The phone rings, someone else picks it up and
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2)
The phone rings, someone else picks it up, says
hello, and immediately hands it to Mike.
3)
The phone rings, someone else picks it up, says
hello, clicks on Barney and immediately hands the phone to Mike.
4)
The phone rings, someone else picks it up, says
hello, someone prompts Mike to click on Barney and then the person who answered
the phone hands it to Mike.
5)
The Barney tape plays for longer and longer time
periods, just seconds at a time, before Mike is handed the phone, and so on, until
objective is met.
The “pass” criterion for this program should be five correct trials
in a row. The “fail” criterion should be ten trial in a row without a “pass.” In such a
case, smaller steps for moving forward should be used. Watching the Barney tape
should act as a natural reinforcer for this program, and as such, should be renewed
at least once a week, and then alternated randomly with the growing library of tapes.
c.
Teaching Functionally Related Skills. There are many skills that
if learned by the person, may have a direct impact on the person's behavior. For
example, a person who is taught the difference between demeaning criticism and
well intended feedback, may start acting differently to the feedback he receives from
others. The purpose of this category of strategies, again, is to empower the person;
to give the person greater skills. In the following paragraphs, key communication
skills are identified which are thought to be related to Mike's Tantrum behavior and
Physical Aggression.
1)
Rationale/Logic. Mike’s most notable skills deficits are in
the areas of communication and socialization. In particular, he rarely initiates formal
communication, other than to make concrete requests for something he wants. The
following is an initial objective aimed at the ultimate goal of Mike spontaneously
asking “what,” “when,” “where,” “who” and “why” questions under the appropriate
circumstances.
Accordingly, this instructional program may very well be
implemented by Mike’s speech and language therapist.
2)
Objective. When with an adult who has a bag, and when
the adult looks into the bag, within 5-seconds, Mike will ask “what’s that?” without
prompting, five out of five times, by June 30, 2004.
3)
Method. Simple discrete trial, prompt/prompt fading
should be used. Initially, verbal prompts should be used, but they should be faded
to visual prompts, i.e., the printed words “what’s that,” printed on the bag and then
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gradually faded, letter by letter or by the size of the letters. Towards the end, the
size of the bags should be varied and bags and boxes randomly used and
alternated. Appropriate pass/fail criteria should be established as a part of the
formal lesson plan/protocol.
d.
Teaching Coping and Tolerance Skills.
Many of Mike's
seriously challenging behaviors are a reflection of his inability to cope with aversive
events such as delay in gratification, denial, the need to perform a non preferred
activity, etc. While some of these behaviors can be avoided by some of the
ecological and focused support strategies described above, aversive events are also
naturally occurring. Especially if he is to lead a full life, from time to time, he will
face the disappointments we all have to face, for example, not getting something
that he wants, when he wants it and having to wait for it, i.e., delay; not getting
something he wants, at all, i.e., denial; being told by somebody that a relationship is
not possible; being criticized or reprimanded; etc. In the face of these events and
the emotions they understandably arouse, Mike's coping responses have not had
the opportunity to develop much beyond the primitive responses of a young child;
nor is he likely to develop much beyond this level through "natural consequences."
Rather, it will be necessary to be systematic in applying sophisticated instructional
technology, with the objective of teaching him these very important coping and
tolerance skills. The following is a recommendation for how to proceed in this
important area of skill development, with the initial focus being on Mike's ability to
cope with and tolerate having his time on the computer interrupted; waiting for
Game Boy, once he has asked for it; and being in the presence of a young girl with
long hair, with her back turned toward him, without pulling her hair. (For this last
area, with her parent’s approval, training can begin with his sister using a wig.)
1)
Rationale/Logic. These three situations are known
problems for Mike. Teaching him how to cope with them in more socially acceptable
ways will be important in their own right. Further, with success, parents and staff will
be empowered to address additional area for which Mike needs to develop more
socially acceptable coping and tolerance skills.
2)
Objectives.
a)
Given that Mike has been playing on his computer
for from five to six minutes without interruption, and given that he has not come to
natural end of his computer based activity, when staff or parent interrupts by saying
“Mike, may I interrupt please. Would you please (some task that will take less than
a minute to perform, over which Mike has known mastery), Mike will, within 30seconds, stop, do what he was asked to do, and return to the computer, without
prompting and without Tantrum Behavior or Physical Aggression, five out of five
times, by September 30, 2004, at both home and school.
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b)
Given the game boy in view and he says he wants
to play with it when asked, When asked to please wait while “I finish this up,” Mike
will wait for 5-minutes, while the adult finishes their task, without Tantrum Behavior
or Physical Aggression, without repeated asking again, and without prompting, five
out of five times, by June 30, 2004..
c)
Given his engagement in a preferred activity, and
with a young girl with long hair standing within 3 feet standing with her back to him
for 1-minute, Mike will not reach, grab for or pull her hair, five out of five times by
June 30, 2004.
3)
Method. The general idea for each of these would be to
start small and move slow, with explicit pass/fail criteria established. For example,
in teaching him to wait for Game Boy, the initial criteria should only be one second
and increased in two second increments when the pass criteria is met, until a whole
minute is reached. These program can be based on 5 discrete trials a day, with
each trial utilizing a “social story set-up,” and reinforcement being immediately
delivered for a correct trial, either natural, e.g., access to Game Box, or extrinsic,
e.g., the use of exchangeable tokens for not pulling hair.
3.
Focused Support Strategies. Some of the ecological strategies that
were recommended above, depending on their complexity and/or difficulty, may take
time to arrange, and positive programming will require some time before new skills
and competencies are mastered.
Although these ecological and positive
programming strategies are necessary to produce good long term quality of life
outcomes for Mike, it is also necessary to include focused strategies for more rapid
effects; hence the inclusion of these strategies in our support plans. Specific
recommendations for the limited but important need for rapid effects are made
below.
a.
Differential Reinforcement of Low Rates of Responding, Shifting
to Differential Reinforcement of Other Behavior with Progressively Increased
Reinforcement (DRL/OP). A progressive schedule of reinforcement should be
introduced in an effort to rapid control over Tantrum Behavior and Physical
Aggression. Specifically:
1)
An exchangeable token should be provided to Mike for
each day in which there is less than five occurrences of Tantrum Behavior and
Physical Aggression (as defined above), combined.
2)
Mike should earn 1-5 exchangeable tokens per day
depending on the number of consecutive days he meets the criterion.
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3)
Tokens should be accumulated on a concrete, visual
device that clearly shows progress to an accumulated 70 tokens.
4)
grab out of the grab bag.
When 70 tokens have been accumulated, Mike get a
5)
The grab bag should have five nicely rapped "surprises"
in it, including gift certificates for a trip to the water park, Disneyland, or comparable
“payoff.”
d.
Failure should be responded to with encouragement and
an expectation of success the following day. Reprimands should be avoided.
e.
The pass criterion for moving from a criterion of less than
five to a criterion of less than four, and than less than three and so on down to less
than one (making it technically a DRO schedule of reinforcement should be five
days in a row of meeting the existing criterion for receiving tokens. The fail criterion
should be based on a monthly review of the summary graph and be considered to
have been met if the behavior is not in a downward trend and a pass criterion has
not been met within the prior 30-days.
f.
This schedule should address Mike’s behavior in both
home and school and therefore will require careful and accurate communication and
cooperation across settings.
i.
Distraction Menu and Scripts. With the help of Mr.
and Mrs. Chow and his one to one aide at school, who has four years experience
working with Mike, his team, with the guidance of the Team Coordinator, should
develop a distraction menu that can be used to get Mike back on track if he should
start to engage in precursor behavior and scripts for how to manage these
situations. For example, currently identified precursors include darting around the
room, often away from the supervising adult, grinding his teeth, engaging in
stereotypic, repetitive actions, or communicating an unfulfilled need or desire. His
darting around the room is likely influenced by his movement disorder. What could
be placed on the distraction menu has been suggested by his aide, when he said he
often deals with such behavior by guiding Mike outside to go for a walk. While in
traditional terms, this may have been done both to remove the distraction from the
classroom and to provide what was perhaps looked at as a mild “time-out,” it
typically worked effectively as a way of interrupting the behavior without escalating it
to a Tantrum or to Physical Aggression. More such strategies can be identified by
the team for responding to darting, grinding his teeth, engaging in stereotypic
behavior and other identified precursors.
Similarly, when he is communicating an unfilled desire or unmet need,
or is otherwise expressing frustration, Mr. Chow has found that helping him
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Mike Chow
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communicate what the problem is and problem solving it with him, typically
precludes escalation to Tantrum behavior or Physical Aggression. Accordingly, as
above, a formal protocol in the form of a script should be developed for all of his
staff for them to follow under these and similar circumstances.
ii.
Avoid or Minimize Triggers. As identified in the
analysis above, there are some predictable triggers for Tantrum Behavior. Some of
these include transitions, placing demands on him to do things he doesn’t want to
do, requiring him to stop certain activities before he is finished and ready to do so,
especially those that have a compulsive quality to them, such as playing with water,
and so on. A protocol should be developed that clearly identifies these triggers and
those that can be identified through continued assessment. The protocol should
provide explicit instructions to staff on how to deal with these triggers. For example,
in non-critical circumstances, the procedure might be not to interrupt an activity but
rather to wait for him to reach a natural finish, such as when he is playing a game on
the computer. Another example is that if he must be interrupted because of an
urgent need to move on to another activity or to leave, keeping his movement
disorder in mind, a formalized script my be necessary to ease him out of the activity.
This may be necessary for a behavior like water play. For example, if it was
necessary to leave the house to go to school and Mike is engaged in water play, we
might distract him from water play with the game boy, distract him from game boy
with Juicy Juice, and then after he has the Juicy Juice, use this to transition to the
car to leave. A final example is that all transitions may need to be preceded with a
picture sequence that allow him to rehearse in imagery where he is going, what will
happen, who he’ll see, etc. I believe that the use of such scripts and picture
sequences will dramatically reduce the occurrence of Tantrum behavior and
Physical Aggression.
4.
Reactive Strategies. Efforts to manage the antecedents to Mike's
Tantrum behavior, as described immediately above, are likely to have a
considerable impact on the rate of its occurrence, as will the described schedule of
reinforcement. However, these behaviors and Physical Aggression are still likely to
occur, at least to some degree, especially during the initial stages of the
implementation of this support plan, as the necessary adjustments to the plan are
identified and made. Therefore, staff and parents may need measures for dealing
with these behaviors when they occur. Such reactive strategies have an even more
limited role than the focused strategies recommended above. Specifically, reactive
strategies are designed to produce the most rapid control over the situation, in a
manner that keeps both Mike and staff as free from risks to injury as possible and
that keep Mike free from risks of exclusion and devaluation as much as possible.
That is, the role of reactive strategy is to rapidly and safely resolve the situation and
reduce episodic severity. Accordingly, reactive strategies are not intended to
produce any change in the future occurrence of Mike's challenging behavior. Both
Comprehensive Functional Behavior Assessment Report and Support Plan
Mike Chow
Page 40
rapid and durable changes, instead, are being sought by the Ecological Strategies,
Positive Programming Strategies, and Focused Support Strategies described in the
preceding sections. These proactive strategies are also expected to prevent any
counter therapeutic effects that might accrue from the nonaversive reactive
strategies being recommended here. The following procedures are suggested as
initial strategies that fit within IABA's "Emergency Management Guidelines." They,
along with other strategies that fall within the guidelines that may be considered in
the future, are expected to preclude the need for the physical management of Mike's
behavior, including the need for physical restraint or the need to send him home
from school.
a.
Problem Solving ProtocolFor Tantrum behavior, the primary strategy
recommended here is to engage Mike in a process of problem solving. This formal
protocol should include the following elements.
1.
Active listening to identify the problem;
2.
When transition out of active listening in appropriate, engaging
Mike in a process of problem solving for dealing with the situation;
3.
Throughout, encourage communication, including the use of
4.
Help Mike meet the need, if appropriate and possible.
PECS; and
b.
Stimulus Change and Redirection/Distraction. If the Tantrum includes
or if Mike separately exhibits Physical Aggression, the immediate agenda should be
to interrupt the behavior. Fortunately, this is where his obsession with certain
objects and activities can be used to advantage. For example, if he is being
physically aggressive, it is likely that we can interrupt him by introducing an activity
that is totally out of context and that has a powerful attraction to him. Example here
might be to say something like:
“…you are clearly upset, why don’t we (you) go and play with Game Boy and
calm down,” or “play in the sink” “go for a walk” or “watch Barney.”
This takes advantage of Mike responsiveness to the environment around him.
Distractibility can be used here as a very effective strategy for getting control over a
Tantrum or Physical Aggression. For this purpose, Mike's family and staff should
brainstorm on what activities/or invitations are most likely to distract him. If the
proactive parts of this support plan have been implemented, it should even be
possible to distract him with a preferred activity, without producing any countertherapeutic effects, i.e., without reinforcing the problem behavior.
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Mike Chow
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5.
Staff Development and Management Systems. Key elements that will
determine the degree of success of this support plan are staff competence and
management systems that assures staff consistency in providing services to Mike.
The following is recommended:
a.
Procedural Protocols. Each strategy and procedure described
above should be broken down into teachable steps.
b.
Three tiered Training.
1)
Each staff person would be required to show "verbal
competence" for each procedure. That is, they would need to describe each and
every step in the specific procedure. Each staff would be scored using a "+/O"
system for each step of the procedure. A 90% criterion is considered passing.
2)
Each person would be required to show "role play
competence" for each procedure. That is, they would need to demonstrate each
step of a procedure to another member of Mike's support team. The scoring system
would be the same as for "verbal competence," as described above.
3)
Finally, each staff person would need to demonstrate "invivo" procedural reliability; that is, the ability to carry out each program component of
Mike's support plan for which they are responsible.. This would require the
designated person to observe each staff person as they provide services and to see
the degree to which what they do agrees with the written protocols. The scoring
procedure described above would be used again, and 90% consistency should be
considered as minimally acceptable. For those procedures that do not occur
frequently, such as the need to react to infrequent behavior, role play competence
should be reconfirmed on a regular schedule.
c.
Periodic Service Review. Mike's entire support plan should be
operationalized into a series of performance standards to be met by the support
team and integrated into a Periodic Service Review. Monthly (initially, weekly)
monitoring should be carried out by the designated coordinator and the status of the
support plan's implementation should be quantified as a percentage score. This
score should be summarized on a graph and kept visible to staff as an incentive to
achieve and maintain a score of 85% or better. This should be reviewed regularly
by management and feedback should be provided. More information on how to
develop and implement a Periodic Service Review system can be provided on
request.
COMMENTS AND RECOMMENDATIONS
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Mike Chow
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1.
Revisions are certain to be necessary during the initial stages of
implementation and as Mike's responsiveness to this new support plan are
observed. Early revisions and fine tuning are necessary in the initial implementation
of any support plan, especially one as comprehensive as this one attempts to be.
2.
I recommend that Jacki Leigh be considered as both the behavioral and
inclusion consultant and act as the facilitator for purposes of forging a coordinated
team approach for Mike across all settings and across all services. She would help
the team sort out who should take responsibility for all of the above
recommendations and be responsible for form quarterly progress reports. A format
for quarterly progress reports for comprehensive plans such as this is available on
request. Among the areas addressed would be the possible need of further
consultations, assessments or services.
3.
I remain available to provide assistance and guidance to the school district
that clearly holds Mike’s education as a high priority and to his family in there
determination to see Mike receive the best education possible.
_______________________________________
Gary W. LaVigna, Ph.D., Clinical Director