BEHAVIOR ASSESSMENT REPORT AND INTERVENTION PLAN
Client Confidential
Date of Report: July 3, 1998
Referral Date: May 13, 1998
IDENTIFYING INFORMATION
Name: Edna Carry
Date of Birth: March 14, 1980
Age: 18
SSN#: 571-69-4339
Address:
Bendigo Development Center
Bendigo, Australia
Referral Source:
Judy Smith
REASONS FOR REFERRAL
Edna Carry was referred to the Institute for Applied Behavior Analysis
(IABA) by Judy Smith, a staff attorney from Self Advocacy, Inc. (SAI). According
to Ms. Smith, Edna has a long history of self injury and physical aggression and
has been a resident of Melbourne and Bendigo Development Centers for the last
several years. Concerns were expressed that she was being physically
restrained several times each week and had not been off the grounds of the
Development Centers for several years because of her behavior.
It was
requested that this assessment focus on devising a plan to re-integrate Edna into
the community. Accordingly, this devaluation focused on the behavior problems
that apparently prevent her from being in the community, the type(s) of treatment
services, treatment techniques, programming, professional competencies and
skills, and environments required to help Edna to gain control over her behavior
and to live, work, and play in the least restrictive environment necessary to meet
her needs.
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DESCRIPTION OF ASSESSMENT ACTIVITIES
This assessment is based on information obtained from the following sources:
A.
Observations of Edna on Baker Unit and in her adult education classroom
at Bendigo Development Center;
B.
Interviews with Edna on Baker Unit;
C.
Interviews with Key Staff who have worked with Edna since her arrival
and some who knew her when she resided at Melbourne Development
Center, including the following:
Name
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
Position
Unit Social Worker
Unit Psychologist
Classroom Aide
Substitute Teacher
Psych. Tech
Evening Supervisor
D.
A review of background information, program materials, and treatment
data provided by Self Advocacy;
E.
A review of background information, program materials, and treatment
data maintained on Baker Unit.
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BACKGROUND INFORMATION
I.
Brief Client Description.
A.
General. Edna is a 18-year-old young woman of Aboriginal decent who
carries the following diagnoses based on a Psychological Assessment
dated March 10, 1998:
Axis I
Oppositional Defiant Disorder
Dysthymic Disorder, Early Onset
r/o Major Depressive Disorder, Recurrent
Axis II
Borderline Intellectual Functioning
Borderline Personality Disorder
Axis III
Motor vehicle accident at age 2 with loss of consciousness
for 16 days
History of meningitis
Abnormal EEG
Obesity
Axis IV
Multiple psychiatric hospitalizations, anticipated change in
living situation, academic problems, history of abuse and
neglect, inadequate social support
Axis V
GAF - 10 to 20 (current)
Records reveal that Edna has had a number of other diagnoses
over the last few years, including Conduct Disorder-Childhood Onset,
Learning Disorder, NOS, PTSD, Borderline Personality Disorder, possible
Organic Brain Damage Syndrome, and History of Liver Damage.
Edna is a nice-looking girl with curly, black hair and brown eyes.
She stands approximately 5’1” tall and weighs about 180 lbs. There is no
question but that she is significantly overweight for her height - perhaps as
much as 60lbs overweight.
She is fully ambulatory and walks, runs,
jumps without difficulty. She has full and unrestricted use of her hands
and arms and does not appear to have any obvious or reported physical
disabilities. She has scars on both forearms as a result of self-injurious
arm scratching episodes.
During the times Edna was observed and interviewed she was
nicely dressed in fashionable clothing. On one occasion, she was wearing
a red blouse, overalls, and tennis shoes. Her hair was jelled fashionably
and held back with a bandanna. She was dressed neatly and seemed
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to take pride in her appearance. During interviews, she was friendly and
talkative. She freely and willingly answered questions and joked. She
easily conversed, her speech was clear and easily understood, but her
speech seemed to miss grammatical pieces (e.g., “What this say?”), as if
English might be her second language (but it is not). She willingly
described her experiences at Bendigo Development Center, her
experiences at Melbourne Development Center, her behavior, and the
things that get her angry. She also described her wishes for the future,
where she would like to live, who she would like to live with, etc. She
described her earliest memory as being in a car accident when she was 2
years old. She seemed to remember unusual events at a very early age.
She described current problems as being due to being abused by a man
at a young age. It is not clear whether these were true memories or things
she had been told by others. Generally speaking, Edna was a true
pleasure during all of our interactions.
B.
Language and Communication Skills. Edna has well developed
language skills. She uses sentences to communicate her needs, to
describe her surroundings, and to negotiate with others. During my
interactions with her, she carried out rather complex conversation,
seemed to understand my questions related to her behavior, emotions,
and future. She asked meaningful questions related to my role and how it
might impact her future. Her speech was well articulated and clearly
understood; but had a nasal quality.
C.
Cognitive and Academic Abilities.
Edna has had numerous
psychological evaluations since her first contact with the Mental Health
System in California.
An Intake Assessment and Individualized
Treatment Plan Dated August 6, 1987 when Edna was 7 years old
reported that “Previous testing reflects she is a very bright youngster with
a full scale IQ of 114.”
A Psychological Assessment Annual Update
dated August 26, 1992 summarized WISC-R results from 1986 through
1990. The results of this summary are presented in the table below:
Date
2/13/86
1/9/88
7/2/90
PIQ
118
86
85
VIQ
109
74
90
FSIQ
114
78
86
The author concluded “The most recent administrations suggest
that Edna performed in the low average to borderline range of general
intellectual functioning. The variance between these administrations has
not been accounted for but is most likely situational to her psychiatric
condition.”
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In the same report, the authors described the results of a
Neuropsychological Assessment administered on July 2, 1990.
The
authors concluded that the Neuropsychological Assessment
•
showed signs of problem-solving, planning, and evaluation deficits
indicative of frontal lobe dysfunction;
•
showed that her performance was more consistent with severe
learning disabilities rather than underlying brain damage.
•
showed that deficits were primarily on tasks requiring complex,
higher level cortical function or sustained attention and
concentration.
A Psychological Assessment Report dated August 24, 1993 (Edna
was 13 years old)
was available for my review.
The types of
evaluation instruments and individual scatter or results were not reported.
The authors concluded the following:
•
Edna “has difficulty with most cognitive skills.”
•
Edna “performed significantly worse than on past testing. This
drop may be a result of her consistently drowsy state, or due to
current cognitive delays.”
•
Edna’s “strongest performance was in her receptive vocabulary
(English). Unfortunately, she did significantly worse in expressive
vocabulary.”
•
“Processing speed was Edna’s weakest skills, although she also
had difficulty with visual-motor integration.”
In this same report, the authors concluded that Edna should be
presented material (for learning) in a multi-modal manner to increase the
likelihood of maintaining her attention. The author recommended that
visual information should be presented with verbal prompts whenever
possible.
The authors also recommended that a Neuropsychological
Assessment be conducted to assist in determining the reason for and / or
the extent of her current cognitive difficulties.
Edna’s most recent psychological evaluation was conducted in
March 1998 (See Psychological Assessment dated 3/10/98).
On
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Weschler Adult Intelligence Scale - Revised (WAIS-R), Edna reported
achieved a Full Scale IQ Score of 72, which placed her in the Borderline
Range of intellectual functioning. Her Performance Scale IQ Score was
75 and her Verbal Scale IQ Score was 71. The difference between the
two was not significant according to the author.
The author noted the
differences between the current results and the results of previous testing.
It was concluded that “It is suspected that the current IQ score
underestimates the patient’s true cognitive ability.” The author described
that motivation appeared to improve Edna’s performance during testing.
Unfortunately, the report did not describe Edna’s specific strengths or
weaknesses and how they might impact her behavior or the development
of a support plan to meet her needs. What is clear is that there has been
a steady decline in Edna’s performance on tests of intellectual functioning
over time.
The reasons behind Edna’s declining performance on standardized
intelligence tests have not been sufficiently explained. The decline has
been explained as being due possibly to behavior or psychiatric problems.
A previous Evaluation recommended that
a Neuropsychological
Assessment be carried out.
A report of such an Evaluation was not
contained within the documents available.
Given Edna’s long history of self injurious head banging, given her
history of meningitis, and given that her records contain an early report of
an abnormal EEG, it seems only logical to proceed with a complete
Neuropsychological Battery. It should be noted that a Neuropsychological
Assessment was referenced in a Psychological Assessment Annual
Update dated August 26, 1992. In that report reference was made to a
Neuropsychological Assessment conducted in July 1990. However, the
referenced report was not available at the time of this evaluation. I
recommend that a qualified Psychologist review the previous
Neuropsychological Assessment for the following purposes:
1.
to identify better ways to teach / instruct Edna;
2.
to understand some of the reasons behind Edna’s behavior;
3.
to determine or clarify the reasons behind her loss of cognitive
ability.
If the Neuropsychological Assessment does not provide this type
of information, then I recommend that a new Neuropsychological Battery
be completed.
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The available reports did not describe very clearly Edna’s academic
proficiencies. A Biopsychosocial Data Base dated 6/20/97 described that
“Edna functions at a second grade level.” The same report described that
her reading and math grade-level scores were 1.3 and 1.1 respectively.
II.
D.
Self Care Skills. Staff at Bendigo Development Center described that
Edna cares for her hygiene and grooming independently. A Rehabilitation
report dated 1/20/98 described that she cares for her grooming and
hygiene “fair.”
E.
Domestic Skills. The same report described that Edna takes care of her
personal space neatly and conscientiously and seems to have some
ability to manage her finances with the help of the trust office. However,
because of the long period during which she has been institutionalized,
those who work with Edna could not describe her abilities to do such
things as shop, do laundry, vacuum, make purchases, etc.
F.
Community Skills. Since Edna has not been off the grounds of a
Development Center for approximately 10 years, and since the staff at
Bendigo Development Center have not had the experience of being with
her in the community, knowledge of her recent skills levels cannot be
assessed.
G.
Recreation and Leisure Skills. Much of the time, while on the unit, Edna
listens to her music. She will play board games with the other residents
and watches television in her spare time. She indicates an interest in
riding her bicycle, but does not have the opportunity. Again, because of
limited opportunities (She has not really been off the unit for several
years), staff could not describe what Edna would do to occupy herself off a
locked unit.
H.
Social Skills. Edna has fair social skills. She does describe a number of
girls on the unit as friends. Reports indicate that much of her interaction is
inappropriate and involves arguing and fighting. During my observations,
she seemed to carry on normal conversations with her peers, laughed,
teased, etc. The reports available to me did not describe the range of her
social skills.
Living Arrangement and Family History.
Edna arrived at Bendigo
Development Center from Melbourne Development Center on June 9, 1997.
The move was precipitated by the closure of MelbourneDevelopment Center.
At Bendigo Development Center , Edna resides on Baker Unit; this is a
locked unit. According to staff, this unit is authorized to serve 20 adolescents.
Currently, 18 girls ranging from 13 to 18 years of age reside on the unit. The
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girls have been placed for a number of reasons, including physical and sexual
abuse, failed community placements, and behavior challenges (e.g., physical
aggression, self injury, AWOL, etc.).
Baker Unit is a large unit organized around a central corridor. Along the
main corridor are resident rooms, linen rooms, tub and shower rooms, group
therapy room, day room, janitor’s room, social worker’s office, physician’s office,
laundry, staff lounge, bathrooms and the nurses station. Next to the nurses
station, along a small corridor that runs perpendicular to the main corridor, are
located the restraint / seclusion room and time out room, examination room, and
female staff bathroom.
The day room is the primary focus of client activities on the unit. This
room sits across from the nurses station and has windows along the main
corridor for monitoring purposes. The room measures approximately 45 by 25
feet. It contains chairs and couches, 2 TVs a video player, game table, meeting
table, empty bookcase, a bookcase with books, two artificial trees, a broken
stationary bike, and storage cabinets. A double door leads to a large, enclosed,
cemented courtyard. In the middle of the courtyard, there is a large patio cover
under which there are picnic tables and bar-b-ques. A punching bag hangs from
the patio cover. At one end of the courtyard is a basketball hoop and what
appeared to be a volleyball court. A number of bicycles were located at the other
end of the courtyard. With the exception a planter along the side of the building
and a flower area in the middle of the courtyard, there was very little pleasant to
look at in the courtyard. The entire courtyard was surrounded by buildings.
Along the roof line surrounding the courtyard, chainlink fencing was angled at
about 45 degrees toward the courtyard area. Clearly, the courtyard was
designed to prevent escape.
During the day, 5 staff members are in attendance; during the PM shift
there are 4 staff present and there are 3 at night. It was explained that on each
shift, there is one person who is designated as the shift supervisor, one person
who is designated to monitor medication, and the remaining staff are on the floor
providing service. As a rule, there are three staff providing monitoring,
supervision and services to the 18 girls who live on the unit; thus there is a 1:6
ratio at this time. With the capacity of 20 girls, the staffing ratio would be 1:6.7.
However, it was explained to me that the real staffing ratio is 1:8.
According to an Intake Assessment and Individualized Treatment Plan
dated August 6, 1987, Edna is the third of five children born to Barbara Carry.
Edna’s two older siblings were removed from the home due to Barbara’s inability
to care for the children. They were subsequently adopted prior to Edna birth by
acquaintances of Edna’s mother.
In 1979, Barbara became involved with
__________________ and became pregnant with his child. That same year,
____ was shot and killed during a fight. Barbara, now 8 months pregnant, was
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taken in by a friend of _____, Mr. _____. On March 14, 1980, Edna was born.
The relationship between Barbara and ___________ resulted in the birth of Patty
on April 8, 1981 and Lester, Jr. on November 19, 1993. The children were
removed from the home in March 1984. Reportedly, Barbara had a long history
of alcoholism, which was a primary reason for the removal. All three children
were removed and released into the custody of __________ ex-wife. The
children were subsequently removed from this home after it had been
determined that Edna had been physically abused by a boyfriend of the foster
parent, in addition to the sexual abuse by her stepfather, __________. The
children were subsequently placed in protective services on July 24, 1984.
Patty, Edna’s sister, visits once every three months with her social worker.
Apparently, Patty is in a treatment center located in Bethesda, Maryland, and is
in the process of being adopted by her foster mother. Freddy, Edna’s brother,
reportedly lives in a Residential Treatment Facility. He has visited Edna once at
Bendigo Development Center.
The earliest report available from a previous placement is an Intake
Assessment and Individualized Treatment Plan Dated August 6, 1987 when
Edna was 7 years old. The origin of this report is not clear, although it could
have been from Marysville. In that report, the author (____________, MSSW,
Cottage Social Worker) described that reports from previous placements
described a history of defiance, temper tantrums, scratching, hitting and biting
peers and staff.
The author further described that her behavior resulted in
being ostracized by her peers which only intensified her acting out and poor self
esteem. The report described a history of harming herself by biting and banging
her head. She also made self-abusing statements i.e., I’m Bad.”
A BioPsychoSocial Data Base Update - Addendum dated August 6, 1997
described that Edna has a long history of mental illness with hospital admissions
beginning at the age of five. In that report the following placements and
hospitalizations were outlined:
Location
Various foster homes after she was
removed from her family home
Marysville
Alabama Psychiatric Hospital
Alabama Medical Center
Marysville
Melbourne Development Center
Gatekeepers Hospital
Melbourne Development Center
Length of Stay
From 1982 to 1985
1/85 to 4/86
2/86 to 3/86
8/86 to 7/86
7/86 to 11/86
8/89 >> 4 1/2 years
4/94 to 6/97
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She was originally admitted to Melbourne Development Center in 1989,
for treatment of major depression with severe psychosis, organic personality
disorder with organic brain disorder. She also experienced auditory and visual
hallucinations along with being a danger to self and a danger to others.
She was admitted to Melbourne Development Center for the second time
on April 5, 1994. She was admitted for intense depression, physically assaultive
behavior and self abusive behavior.
She left Melbourne in June 1998 as a
result of the closing of the hospital.
In summary, Edna has a long history of living and going to school within
the Development Center System. She currently resides on Baker Unit which has
a distinct prison-like feel about it. With it’s locked doors, locked seclusion room,
locked nurses station, windowed day hall, linoleum floors, dorm-like living areas,
and inescapable courtyard, there is very little to distinguish it from a minimum
security prison. There is no question that this is not a place to raise or treat
children and adolescents. The atmosphere, the impersonal ecology surely
cannot enhance a person’s quality of life or the effects of treatment strategies.
There is no reason why Edna cannot be treated in a community-based living
arrangement, providing that she has the level of support she needs. Every effort
needs to be taken to provide Edna with the opportunity to live in the community.
While there may be considerable controversy and argument over this statement,
in my estimation it is simply THE RIGHT THING TO DO.
C.
Daytime Services Received and day Service History.
This information provided regarding Edna’s educational program was
obtained through direct observation and interviews with the classroom aide and a
substitute teacher. The regular classroom teacher was ill on both days that I was
present at MSH. Edna attends an adult education program on a daily basis. The
program is located in Rolling Stones Building located in an old, two-story building
across the campus from the living area.
The classroom is very small. It
contains perhaps 8-9 desks a computer several tables, storage and filing
cabinets, a desk and has an adjoining bathroom. The room seems cluttered.
Two students are currently enrolled in the class. The other student was not
present during either of my visits.
Edna has 1:1 support the entire time she is at school. Reportedly, the role
of the 1:1 is to take notes, to observe, and to support the teaching staff when
Edna has a behavior problem. The 1:1 aide is not actively engaged in teaching,
education, etc.
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Edna’s typical classroom schedule is described in the table below:
Time Period
9:00 to 9:20
9:20 to 10:00
10:00 to 10:15
10:15 to 11:00
11:00 to 11:15
11:15 to 12:00
12:00 to 1:00
1:00 to 2:15
Activity
Journal / Calendar
Computer Game
Break
Math 45
Break
Reading
Lunch
Period 5
Computer / Extra Assignments
Computer Lab out of classroom
Wednesdays - Library
The classroom aide reported property destruction is essentially absent in
the school setting. She could remember only one incident of marking on a desk,
which Edna cleaned up and apologized for.
She reported that there have been no incidents of physical aggression,
AWOL, self injury or tantrums in the school setting. Edna has said to her that
she doesn’t explode because she will lose her privileges. Cursing has been
observed on 1 or two occasions. The aide did say that they may not experience
many behavior problems in the classroom because staff keep her on the unit
when Edna is having difficulty.
Incidents of ANGER have occurred. These
typically involve Edna putting her head down on the desk, and raising her voice
while complaining that she is tired
Edna participates in a point program in the classroom.
organized as follows:
Behaviors
Remains in seat / area - no horseplay
Uses appropriate language - no
profanity
Follows directions / rules without
talking back
Treats others with consideration - no
manipulation
1
2
The point sheet is
Periods
Break 3 Break
4
5
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Cares for class / school materials /
returns homework
Arrives / starts work on time each
period
Works quietly without disturbing others
Completes assignments - stays on
task
Accepts criticism / comments without
arguing
Turns in acceptable work / good effort
No drug / gang activity - talk or writing
Respects property / material of others /
no stealing / no gambling
Accepts not getting her way without
leaving the room
Verbalize angry feelings without
screaming / yelling
Gets permission to speak before
speaking out (Raises Hand)
During each period, Edna receives a point for each of the identified target
performances.
At this time, Edna can achieve a maximum of 95 points in a
schoolday.
Review of “Point Sheet / Contract” sheets from 3/20/98 through
5/22/98 (A total of daily point sheets were available for this time period.) showed
that Edna met criteria for reinforcement (Between 91 and 95 points) on 62
percent of the occasions.
At this time, Edna can earn a maximum of 95 points. This has been
gradually escalated as new targets and rules have been added. If she has
between 91 and 95 points at the end of the day, she has the opportunity to
choose a reinforcing item from a cabinet in the classroom.
On Mondays, the
points for the previous week are totaled to determine who in the class has
achieved the “Student of the Week Award” (a certificate). When Edna showed
me her room, she proudly pointed to several “certificates” displayed over her
bed. Each month, there is a determination of who has achieved “Student of the
Month.” Edna has achieved this on one occasion. When this happens, a special
meal (of the student’s choice) is brought into the classroom. The classroom aide
reported very clearly that “We have found that incentives work.”
At the end of each day, the teacher comments regarding Edna’s
behavioral and academic performance. There were no references to physical
aggression, self injury, or AWOL
in the 29 point sheets I reviewed. The
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behaviors mentioned were relatively minor and included the following: fail to
follow directions, disturb others, argue, anger, go back to unit, cursing, crying,
illness, fidgety, complaining, moaning, and allergies.
Edna was observed during her morning class. When she entered the
classroom, myself, the classroom aide and the 1:1 aide were present. When she
entered the class, she began working on her journal. She then went to the board
and wrote the day, date and temperature. After the journal, the classroom aide
began working on a math assignment with Edna. The room was very quiet with
few distracters. Edna yawned from time to time, but she participated. Once the
aide finished instructing Edna in the assignment, she (Edna) worked for the next
16 minutes independently with only one small interruption. At that point, she
stated “I’m done.” The aide immediately approached to correct the paper. As
the aide approached, Edna said “I want my treat.” The aide responded with “I
haven’t checked it yet.” The both of them then checked the work. Subsequently,
the aide said “You did it. Remember how much easier it is than when you first
did it.” The entire discussion was supportive and gentle.
The available reports, did not describe very clearly Edna’s academic /
functional academic skills.
Neither did they describe her learning strengths /
weaknesses.
Given her very apparent learning difficulties over the years, it
seems only logical that she have the benefit of a complete Psychoeducational
Evaluation.
IV.
Health, Medical and Psychiatric Status.
At the time of my interviews with Edna, she appeared to be in good health.
However, upon review of her records, it appears that she has a long history of
physical complaints. For example, according to a psychiatric evaluation dated
4/3/97 from Melbourne Development Center (See BioPsychoSocial Data Base
Update - Addendum dated 8/6/97) Edna suffers from obesity, menstrual cramps,
constipation, anemia, airborne allergies, high serum iron, and high cortisone
level. It was recommended that Cushing’s Syndrome be ruled out.
A Social
Work Evaluation and Recommendations Report dated 4/3/97 (Melbourne
Development Center)
described that Edna’s problems include obesity,
hypothyroidism and airborne allergies. The same report described that Edna
was being treated for obesity with a calorie-restricted diet and that there “are no
other physical problems that would prevent her from being discharged to a less
restrictive setting. It was suggested that the problem of hypothyroidism be
further assessed and monitored (As far as I could determine, the last thyroid test
- hTSH__2 was conducted on June 10, 1997. The results were within normal
limits.).
The same report noted that Edna has a history of lab tests indicating
liver damage. A physicians note from MSH suggested that the damage may
have been a function of Thorazine poisoning. In my review of Physician’s
Orders (83 pages) from June 97 through April 98, there were several references
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to the need to repeat Liver Function Tests (LFT). A note on 3/31/98 suggested
that an elevated ALT (Alanine Aminotransferase) -106 was likely due to
Risperidol. Given Edna’s history of liver damage and the nature of the
medications designed to support her, it will continue to be important to monitor
Edna’s liver status regularly and frequently.
A Psychological Assessment dated 3/10/98 described that Edna sustained
a head injury as a result of being hit by a car at two-years old. Reportedly, she
was unconscious for 16 days. This report described that “other significant
medical history includes meningitis, “hepatic damage” secondary to Thorazine,
and abnormal EEG in 1989 with bi-temporal dysfunction.”
The same report
described Edna’s current medical problems as of the date of the report (3/10/98)
as including “obesity, constipation, tinea pedis, dry skin, and dental Pain. Prior
medical problems at this facility were allergic rhinitis, epitaxis (nosebleed), and
varicella vaccination (to prevent chicken pox). “ Edna was described as being
on a regular lite diet.
Neurologically, the impact of Edna’s early car accident and subsequent
meningitis are unclear. According to the above cited psychological evaluation,
Edna has a history of abnormal EEG (1989) “...with bi-temporal dysfunction.”
However, EEG reports dated 7/25/97 and 11/17/97 both concluded that the EEG
results were within normal limits for chronological age. At this point, there is no
evidence that Edna’s behavior is influenced by seizure activity.
However, it is possible that the differences between the abnormal EEG in
1989 and those carried out in 1997 are a function of the medication she was
taking (i.e., Depakote) at the time. (Note: She is not currently taking Depakote.)
Daily Care Flow sheets from June 1997 through February 1998 were
reviewed. It appears that Edna has regular menstruation. I then compared the
menses records with a record of Edna behavior over the same time period.
There was no conclusive relationship between her menstruation cycle and the
occurrence of her behavior given the data available to me.
Edna’s records both at Melbourne Development Center and Bendigo
Development Center describe her as obese.
Since arriving at Bendigo
Development Center, Edna’s weight has varied from a low of 178 to a high of
188. Her weight on 4/1/98 was 180, down 8 pounds from 1/1/98. While at
Melbourne Development Center (See report dated 4/3/97) Edna was on a
Regular, slim diet with a recommendation for no concentrated sweets. This
target was opened at Melbourne on 4/5/94 and appears to have been an ongoing
problem. In August 1998, Edna was receiving a 1500 calorie diet. Nutritional
Assessment Updates dated 11/26/97 and 1/26/98 suggested an 1800 calorie
diet to reduce weight to a goal of 178 lbs.
It should be noted that many
incidents of self injury and physical aggression (described below) centered
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around Edna’s unsuccessful attempts to get food, snacks, etc. from staff and
peers.
Reportedly, Edna has an allergy to Thorazine. It has been suggested that
Thorazine resulted in liver damage. Numerous reports describe that Edna is
being treated for airborne allergies.
Edna has been seen on numerous occasions for medical problems since
her arrival at Bendigo Development Center. I reviewed physician reports from
September 1997 through April 1998. A summary of reasons for the medical visit
or comments by the physician is presented below. Many are not presented
because of poor copy or illegibility.
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9/25/97
9/26/97
9/31/97
10/6/97
10/7/97
10/9/97
10/21/97
10/22/97
10/23/97
10/27/97
10/30/97
11/4/97
11/10/97
11/13/97
12/8/97
12/9/97
12/10/97
12/12/97
1/12/98
1/13/98
1/28/98
2/10/98
2/18/98
3/5/98
3/6/98
3/6/98
Reports emesis 5 times today, throat worsening when lying down or
bending forward, abdominal pain.
Complains of abdominal Pain.
Blood sugar is high. Will obtain fasting blood sugar tomorrow.
Complains of sore throat, stomach Pain and chest Pain, abdomen
distended.
Complains of coughing with production of greenish phlegm.
Sprain right ankle.
Reports diarrhea. Blood possible. Complains of abdominal Pain earlier
in evening.
Complains of right sided abdominal pain. Patient has history of hepatic
failure in the past - presumably due to Thorazine. Examination showed
abdomen slightly distended, liver was enlarged over the right subcostal
margin with marked tenderness.
Right elbow and left knee pain (x-ray, Tylenol).
Knee Pain, walking with limp (Tylenol).
Vague abdominal yesterday coinciding with menstrual cycle
Complains of abdominal discomfort after meal (Gaseous Distention Maelox)
Diarrhea, knee pain
Reports emesis several times (Place on clear liquid diet)
Nasal congestion
Examined for cold / cough
Dry skin / itching - lotion recommended
High GGTP (Gamma-glutamyl transpeptidase) most likely due to
Valproate – Insignificant
Complains of anal bleeding (Has external hemorrhoid, anal fissure,
recommend Anusol suppositories)
Abrasions to forearm
Complains of rectal bleeding
Complains of rectal bleeding from external hemorrhoids (Recommend
medication tid and Anusol suppositories)
Sore throat.
Complains of chest pain, weakness, parasthesia,
hyperactivity, syncope (loss of consciousness, light headedness)
Injury to left hand, right wrist, right foot and leg secondary to restraint
(Recommended x-ray, raise right leg, Tylenol)
Nausea and abdominal pain, burning on urination
Complains of pain/ emesis x 2 and diarrhea (Most likely due to loxitane).
Assessment and Intervention Plan
Re: Edna Carry
Page 17
3/10/98
3/23/98
3/25/98
4/1/98
Complains of sore throat, post nasal drip, infection, and elEvated LFT.
Complains of ______ Pain after eating (Reflux Esophagitis - recommend
Maelox and another medication).
Complains of cold
Continues to show evaluated ALT (Alanine aminotransferase).Repeat
Liver Function Test (LFT)
Edna is currently receiving the following medications (Per June / July 1998
Orders) :
Name of Medication
Hydroxizine (Ativan)
Loxitane
Cogentin
Dosage / Schedule
50 mg Q 6 hours
10 mg bid
1 mg Q 4 hours PRN
Paxil
Milk of Magnesia
Carmol - 10 Lotion
Tylenol
Orthonovum
Ducosate Calcium
20 mg / day
30 mg day
650 mg Q 4 hours PRN
1 tab
240 mg per day.
Reason
Agitation
Anti-psychotic
Extra-Pyramidial
Symptoms
Antidepressant
Constipation
Dry Skin
Pain
Birth Control
Edna has received a number of other medications since her arrival at
Bendigo Development Center, including Buspar (d/c 7/24/97) , Depakote (d/c
2/98), Risperidol (d/c 9/1/97), Dexedrine (start 7/22/97, d/c/8/1/97), Ritalin (start
9/12/97, d/c 9/29/97). A number of medications have been used PRN for
agitation including Vistaril, Ativan, Loxitane, Risperidol, and Benadryl.
Records reveal a wide variety of other medications have been given for
physical problems including antibiotics, Lotrimin (Feet), Tinactin (Feet), Mallox
(Stomach), Caramal - 10 (Dry Skin), White Rose Soap (Skin), Cepacol (Sore
Throat), Cortisporin (Ears), Robitussin (Cough), Surfak, Anusol Suppositories
(Hemorrhoids), Motrin, Dimetapp (Cough), Calamine Lotion (Skin).
Edna has been treated for obesity for several years, as far as could be
determined. Indeed, restrictions of food have been antecedents for conflict and
anger on Edna’s part. At this point, one must question the efficacy of a restrictive
diet in Edna’s life given the absence of one of the most important parts of a good
diet; namely, exercise. Currently in Edna’s life there are few activities available
to “burn off calories.” It seems that in addition to restricting her diet, several
Assessment and Intervention Plan
Re: Edna Carry
Page 18
additional thrusts must be implemented, including an exercise plan, and a plan
to help Edna learn to manage her own diet.
Edna has a wide range of physical complaints. Indeed, the antecedent
analysis suggests that medical issues may serve as “setting events” effecting
Edna’s behavior. Given this relationship it will be important that Edna’s medical
condition be monitored very closely; especially rectal bleeding, stomach Pains,
diarrhea, constipation, and liver damage related complications.
V.
Previous and Current Treatments. Edna has a long history of treatments for
her behavioral challenges. Unfortunately, records were not available to fully
describe the nature and types of treatments Edna has experienced over the
years. A Social Work Evaluation and Recommendations Report dated 4/3/97,
when Edna resided at Melbourne Development Center, described the following
treatment plan for Edna:
Target Behavior
Assaultive Behavior: Hitting, biting,
kicking, scratching, throwing objects,
or destroying property.
Intervention Plan
4/7/94 Medications per physicians
orders;
4/7/94 Care plan for assualtive
behavior: Encourage expression of
feelings
11/15/95 Evening Leisure Skills; To
find appropriate outlet for frustrations
and develop appropriate leisure skills.
•
•
•
•
•
Individual therapy
Daily Living Skills Increase self
control and reduce frustration,
(Daily 2 hours)
Family issues and discharge
planning; to discuss family
issues and behaviors which
prevent discharge. (1 x per
month)
Socialization Skills Group; To
improve self esteem and
develop appropriate outlets for
anger (1X per week - 2 hours)
Leisure Skills; To improve
leisure skills and find an
appropriate outlet for frustration
(2 hours daily)
Assessment and Intervention Plan
Re: Edna Carry
Page 19
•
Interaction Skills; To enhance
self-esteem and social skills (2
hours per week).
Target Behavior
Intervention Plan
AWOL - Reduce incidence of AWOL
10/23/97 Care Plan for AWOL;
from 4 X per month to 2 X per month in Reduce self endangering and
three months.
impulsive behavior
10/23/97 Individual Psychotherapy (1x
per week)
Target Behavior
Self Abusive Behavior: Hitting self,
scratching, and poking self to make
skin bleed. Reduce to one or less
incidents or SIB or threats per month
Intervention Plan
4/11/95 Care Plan.....
4/11/95 Medications as per physicians
orders
11/15/95 Individual Therapy
11/15/95 Current Events; decrease
self abuse by stimulating an interest in
the world around her.
11/15/95 Patient Government /
Community Meeting: Increase positive
interactions with her environment.
11/15/95 Family issues and discharge
planning.
Assessment and Intervention Plan
Re: Edna Carry
Page 20
At Bendigo Development Center, a Social Service Assessment Update dated
8/26/97 summarized the major components of Edna’s treatment, which are presented
below:
Intervention / Service
Frequency
Anger Management Group
1 time per week - 60 minutes
Focus on coping skills and expression
3/6/98
of anger.
Nutrition and Medication Management
1 time per week - 60 minute session
Group
Focus on nutritional and medication
3/6/98 reported at every other week
needs
Health Group / Art Therapy Group
Alternating weeks meeting 60 minutes
Focus on expression and working out
every other week.
issues related to placement at MSH
and the health group works on issues
relating to patient’s health
Social Skills Group
1 time per week - 60 minutes
Focuses on developing appropriate
social skills
Relaxation Group
1 time per week - 60 minutes
Focuses on stress relieving techniques
A Treatment Plan dated 3/6/98 also summarized the major components of
Edna’s treatment. They are as follows:
Intervention / Service
Individual Therapy
Art Therapy
Leisure Education
Individual Art Therapy
Self Esteem Group Therapy
Life Skills Discharge Planning Group
Dance Movement Therapy
Nursing Teaching Component of
Teaching Patient Coping Skills
for Dealing with Angry Behavior
Frequency
2 times per week
1 X per week
2 X per week
1 X per week
1 X per week
1 X per week
1 X per week
As Needed
On Baker Unit, Edna participates in a Unit Wide point and level system. The
program is designed generally for all of the residents of the program. It is not generally
Assessment and Intervention Plan
Re: Edna Carry
Page 21
individualized. It was explained to me that residents earn points for completing daily
living skills, participation and generally following the rules. Points are exchanged once
a day at the Incentive Store. It is only at the end of the day that residents are provided
feedback regarding the points they have earned.
As part of Edna’s treatment plan, she participates in a “Level System.” “The
purpose of the level system is to determine which activities are appropriate for each
child. Higher levels represent less restrictive settings” (Bendigo Development Center
Child Adolescent Treatment Center Program 1 - November 14, 1997). There are five
levels and a freeze status. As the child meets criteria, the child earns higher Levels.
Each level is associated with progressively greater and wider array of privileges. For
example, on Level 1 the child is allowed to attend activities only on the premises of
Program 1. This is the most restrictive level. The child is moved to Level 2 if NONE of
the following criteria exist: AWOL risk / precaution; one-to-one for psychiatric /
behavioral reasons; observational status for psychiatric / behavioral reasons; danger to
others, homicidal, or suicidal precaution). The child is moved to Level 3 if the following
criteria are met: on Level 2 for at least 2 consecutive weeks; received at least 60
percent of their points for 2 consecutive weeks; has not exhibited any recent significant
behavioral problems. The child is moved to Level 4 if the following criteria are met: on
Level 3 for at least 3 consecutive weeks; received at least 80 percent of their points for
3 consecutive weeks; has not exhibited any recent significant behavioral problems.
A “Freeze” status is also part of this level system. “A child who is placed on a
‘freeze’ is prohibited from attending on-grounds and community activities until the freeze
is lifted.” A freeze may be invoked by the treatment team is a child exhibits “a problem
behavior which significantly increases the potential risk of harm for the child and / or
others...”
The behaviors that can result in a freeze include assaults, self-injury,
property destruction, threats, contraband, sexually inappropriate acts, theft, arson, etc.
While the length of a freeze may vary depending on the situation, the usual length of the
freeze is 24 hours (minor incident), 48 hours (moderate incident), or 72 hours (severe
incident).
Freezes can be extended depending on the child’s behavior from the
initiation of the original freeze status. If a child is placed on 1:1 supervision or
observational status for psychiatric / behavioral reasons, then the child is placed on
Level 1; but this may be at the discretion of the treatment team.
Restraint logs and ID Notes from June 10, 1997 through 4/16/98 (4/5/98 in the
case of the restraint logs) were reviewed. This review looked for reference to “Freeze”
recommendations. Based on reading the description of the Level System, a it appears
that the “freeze” status could be implemented for any one or combination of the
behaviors presented by Edna. According to the description, a “freeze” may be initiated
as a result of assaults, self-injury, property destruction, threats, contraband, sexually
inappropriate acts, theft, arson, etc.
It is logical to assume, therefore, that Edna has spent a majority of her time at
Bendigo Development Center on Freeze status.
A comment in an ID Note dated
Assessment and Intervention Plan
Re: Edna Carry
Page 22
7/28/97 suggests that this might be the case. But if my reading of the Level System is
correct, being on Level 1 is equivalent to being on a Freeze, since on Level 1 “Children
...are only eligible to attend program-wide activities (i.e., within the Program 1 area).” “A
child who is placed on a ‘freeze’ is prohibited from attending on-grounds and community
activities until the freeze is lifted.”
My review of ID Notes and Restraint Logs showed that “Freeze” status was
specifically referenced on numerous occasions. The following table shows the number
of references to “Freeze” and the number of days that the referenced “Freezes” were in
place:
Month
July 97
August 97
September 97
October 97
November 97
December 97
January 98
February 98
March 98
April 98
Number of
Freezes
Referenced
4
1
3
3
4
5
6
7
1
1
Number of Days
on
Freeze
9
Not Specified
9
8
7
12
12
13
3
1
As part of Edna’s treatment, Restraint and Seclusion (R/S) are used to manage
serious behavioral challenges. The following table reflects the number of occurrences
of R/S as well as the average duration of R/S by month:
Assessment and Intervention Plan
Re: Edna Carry
Page 23
Month
June 97
July 97
August 97
September 97
October 97
November 97
December 97
January 98
February 98
March 98
April 98
May 98
Number of
Reported
Incidents of
Restraint
4
11
9
8
6
1
2
9
3
6
7
3
Average # of
Minutes in
Restraint Per
Episode
78.5
118
125
131
104
30
90
145
98
120
138
190
The number and duration of restraints are based on the records made available
by Self Advocacy Inc. and records that were reviewed while on the unit. Since there
were records that were not legible due to poor copy and illegible writing, the real
numbers may differ. However, the table does reflect that Edna has spent a significant
amount of time in restraint since her arrival at Bendigo Development Center.
Edna has a long history of treatment for relatively severe behavior challenges.
However, it is unclear whether any of her behavioral treatment plans were guided by a
comprehensive Behavioral Assessment, or at least a Functional Analysis. Without
such analyses, it would be difficult if not impossible to design a behavior treatment plan
to meet Edna’s needs. Staff who know Edna at Melbourne and were familiar with her
behavior plan described it as a general Level System applied to all the residents. This
is also the case at Bendigo Development Center.
In other words, the behavioral
treatment plans have not been individualized to meet Edna’s needs.
At this point in Edna’s life, it is absolutely necessary that treatment, support
plans, be designed around what we know about Edna. Her support plans need to be
individualized. Failure to do so may mean that Edna will spend the next 10 years in a
Development Center, continuing to fail to meet her behavioral goals.
FUNCTIONAL ANALYSIS OF PRESENTING PROBLEMS
Assessment and Intervention Plan
Re: Edna Carry
Page 24
A functional analysis was conducted for the following behaviors: Physical
aggression, property destruction and self-injurious behavior.
These were grouped
together under the label of “Anger Outburst.” This label reflects a conclusion that the
topographies presented below represent a behavioral response class that
independently and together serve the same functions.
The Functional Analysis endeavors to identify the events that control the
emission and non-emission of clinically important problems. This evaluation is divided
into five specific levels of analysis: (1) Description of the Problem. This analysis
attempts to describe the presenting problem in such detail that it can be objectively
measured. It presents the topography of the behavior, the cycle (beginning and ending)
of the behavior (if applicable), and the strength of the behavior (i.e., frequency, rate,
duration, intensity). (2) History of the problem. This analysis presents the recent and
long-term history of the problem. The purpose here is to better understand the client'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 behavior. 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 the client'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) Analysis of
Meaning. The analysis of meaning is the culmination of the above analyses and
attempts to identify the functions served by the problem behaviors.
A.
Description of Problem Behaviors and Operational Definition.
1.
Topography.
a.
Property Destruction. This category of behavior involves actions
that (i) render objects in need of repair, (ii) render objects unusable,
(iii) have the potential of causing damage to objects, and (iv)
throwing object not meant to be thrown (e.g., tables, chairs, etc.).
Some specific actions that fall in this category include the following:
•
•
•
•
•
•
•
•
throwing chairs
throw tray of glasses
throw glasses
throw cup of juice and snacks onto the floor
throw bottle of lotion breaking it
kick trash can, walls, furniture
take apart beds
turn over tables / furniture
Assessment and Intervention Plan
Re: Edna Carry
Page 25
•
•
•
•
•
•
•
•
•
•
•
•
•
•
b.
overturn plants
banging on windows and tables with objects or hands
pound on walls
hit television with hand
banging on telephone
pulling down curtains
break windows
break open display case
tearing paper
tear pictures from walls
pulled drinking fountain from the wall
break public phone
break movies
pull apart alarm box
Self Injury. This category of behavior involves actions (i) that result
in visible injury, damage, (ii) that have the potential for causing
damage, (iii) and that result in bruising or bleeding.
•
Head Banging. Contact of head to surfaces such as walls,
windows, floor, such that the contact is clearly audible at a
distance of 10 feet.
•
Head Hit. With an open hand or closed fist, makes contact
with her head such that the contact is audible at any
distance or results in movement of her head. This does not
include simply touching her face or head. If the contact
results in bleeding, the contact will be recorded. Typically,
Edna will strike her nose with her hand or fist, or will strike
her nose to her forearm (which usually results in
nosebleeding.
•
Picking Nose. Insertion of finger into nose such that
bleeding occurs.
•
Scratching / Cutting Self. Edna will use her fingernails or
objects to scratch or cut her body. Typically this target is her
arms. This behavior is recorded if her nails or object come
into contact with her arm such that a mark remains or blood
is drawn.
•
Other. Any other action that results in self-inflicted injury
would fall in this category, e.g., swallowing or putting
dangerous substances in mouth, wrapping straps, ropes,
etc. around neck
Assessment and Intervention Plan
Re: Edna Carry
Page 26
Some specific actions derived from Edna’s records that fall
in this category include the following:
•
•
•
•
•
•
•
•
•
•
•
bang head on window
bang head on wall
bang head on door
stab pencil into hand
strike self in nose with fist
scratch arm with metal object
bang head on office window
pick nose
scratch arms with thumb tac
swallow hair spray
put strap around neck in attempt to choke self
Edna described that she bangs her head on walls and
window and tries to make her nose bleed by hitting her nose with
her fist of arm. She also described that she uses nails and sharp
objects (e.g., staples, pieces of plastic and pens) to hurt herself.
She showed me a number of healed scars on her arms from this
form of self injury. She said that she doesn’t want to do this, and
has stopped. She said that the only problem she is having now is
banging her head, but “I’m doing better.”
c.
Verbal and Physical Threats Toward Others (THO). This
category of behavior includes (i) statements that suggest an intent
to cause injury to another, or to engage in a physically assaultive
act , or (ii) physical gestures that similarly indicate an intent to injure
another (e.g., raising a hand and shaking it at another). Some
specific actions that fall into this category described in Edna’s
records include the following:
•
•
•
•
•
•
•
•
•
•
•
“I’m going to scratch your eyes out if you come near me.”
“I’m going to fuck you up.” “I’m going to get you.”
“I’m going to go off and hurt someone.”
“I’ll run you over with my wheelchair.”
“I’m going to kick your ass bitch.”
“I’m going to beat you up.”
“I’m going to bash you in the eye.”
“I can throw this bag at you.”
“I can kick your ass.”
“If you touch me, I’ll bite your fucking face off.”
“I don’t care if I go to jail, I want to rip her head off.”
Assessment and Intervention Plan
Re: Edna Carry
Page 27
•
d.
“She gives me an attitude. If she watches me I’m going to
bite her.”
Physical Aggression. This class of behavior involves the following
discrete topographies / actions:
•
Hitting.
This topography is defined as striking another
person with a closed fist (or open hand) with a force that the
blow is clearly audible at a distance of at least five feet,
results in the person's body being deflected in a direction
away from the blow; or the person who is the recipient
reports, Pain / discomfort / injury.
•
Kicking. This topography involves any contact of the foot to
the body of another that is not part of an organized game or
accidental.
•
Biting. This topography is defined as any contact of her
mouth to the body of another. If bite marks remain or injury
has occurred, biting is recorded.
•
Head Butting. This topography is defined as contact of the
head with the body of another with a force that the blow is
clearly audible at a distance of at least five feet, results in the
person's body being deflected in a direction away from the
blow; or the person who is the recipient reports, Pain /
discomfort / injury.
•
Grabbing. This topography is defined as grasping the
clothing or body of another person with a force that the
person's movement of a body part is impeded (e.g., can't
move an arm, can't back up); the person’s body is deflected
in space (e.g., body part pulled closer to Edna; direction of
body is changed).
•
Scratching. This topography is defined as contact of
fingernails to the flesh of another such that a depression is
observed at the moment, a white mark is evident as a result
of the contact, there is swelling or bleeding.
•
Pulling Hair. This topography is defined as grasping the hair
of another such that the person’s head movement is
restricted, the pulling motion results in movement of the
person’s head, or the person reports Pain. Simple touching
another person’s hair is not included in this actions.
Assessment and Intervention Plan
Re: Edna Carry
Page 28
•
Spitting. This topography involves the projection of saliva in
the direction of another such that the saliva makes contact
with another, or lands within 3 feet of a person. This
category would also be recorded if contact is avoided
through good Evasion.
•
Directed Throwing. This topography involves tossing objects
in the direction of another such that contact is made or the
object lands within 3 feet. This category would also be
recorded if contact is avoided through good Evasion.
Some specific actions that fall into these categories
described in Edna’s records include the following:
•
•
•
•
•
•
•
•
•
•
•
•
•
2.
hit staff member on shoulder and in ribcage
attempt to scratch while being restrained
kicked female staff in her face
scratches to arm and hand area
kicking, biting, spitting while being brought back to unit
“I scratched him and bit a staff.”
came out of time out and attacked a peer
hit 1:1 with clipboard and fist
scratches to staff fingers and broken fingernail
bit one staff and scratched another on their backs
spitting at staff
grabbed staff by left wrist
pushed staff
Measurement Criteria.
a.
Occurrence Measure (Cycle: Onset / Offset). An episode
begins with the first emission of any one or combination of the
above topographies, and ends when the topographies have been
absent for five minutes. For the purposes of recording, an interval
recording strategy will be used.
Thus, the end of an the
topographies will occur when the recording interval times out.
b.
Episodic Severity Measures.
1)
Severity Level
1
Anger Outburst. The episodic severity of the entire class of
behaviors subsumed under the label is presented below:
Severity Code Criteria
Screaming Loudly and Cursing
Assessment and Intervention Plan
Re: Edna Carry
Page 29
2
3
4
5
6
Verbal and Physical Threats Toward Others
Property Destruction – No Damage Results
Physical Destruction – Damage Results
Physical Aggression / Self Injury – No Damage
Physical Aggression / Self Injury – With Injury
2)
Physical Aggression: The episodic severity of physical
aggression will be measured using the four-point scale
presented below:
Severity Level
Severity Code Criteria
1
Physically aggressive acts that do not require first aid and do
not threaten severe injury (e.g. hair pulling (without pulling hair
out), finger poking (except when directed at eyes), pinching,
grabbing, throwing small or light objects, pushing without body
deflecting more than a foot.)
Injury requires first aid (e.g., scratching, blows that cause
bruising, biting without breaking skin etc.
Injury requires professional emergency care with immediate
medical release, worker’s compensation or threatens
significant injury (e.g. choking without asphyxiation, charging
and shoving so that body deflects against an objects or person
falls down, shaking another person, attempting to hit with
heavy objects such as chairs, biting and breaking skin
Injury causes need for overnight stay in hospital or more than
one professional medical follow-up.
2
3
4
The average severity should be reported and graphed on a
weekly basis
3)
Self Injury: The episodic severity of self-injury should be
measured using the following rating scale:
Severity Level
Severity Code Criteria
1
2
3
4
Self Injurious Threats
Self Injurious Actions that do not require first aid
Self Injurious Actions that require first aid
Self Injurious Actions that result in medical attention other than first
aid (e.g., emergency room)
Self Injurious Actions that result in permanent injury or
disfigurement.
5
The average severity should be reported and graphed on a
weekly basis
Assessment and Intervention Plan
Re: Edna Carry
Page 30
4)
Severity Level
1
2
3
4
5
6
Property Destruction: The episodic severity of property
destruction should be measured using the following rating
scale:
Severity Code Criteria
No damage to environment
Cost of repair or replacement less than $10
Cost of repair or replacement between $11 and $20
Cost of repair or replacement between $21 and $50
Cost of repair or replacement between $51 and $100
Cost of repair or replacement more than $100
The average severity should be reported and graphed on a
weekly basis.
3.
Course. Interviews with staff gave a fairly consistent picture of how
Edna’s Angry Outbursts develop.
Unfortunately, ID Notes, as well as
other records, failed to consistently describe the development or course
of episodes. Descriptions would typically begin with the emission of a
major target behavior.
One staff who has known Edna for a number of years, could only
remember one incident that did not involve escalation of the type
described below.
Generally, staff described that an episode usually
begins with the denial of one of Edna’s requests, of a request directed
toward Edna.
An episode may begin whining and then escalate into screaming
loudly while cursing at those around her. She may tell people to get away.
During this phase, she may lay on the floor while whining and screaming.
If Edna’s needs are not met by this stage, she will either begin to
destroy property or she will injure herself. One staff member who has
known Edna for several years described that she seems to cycle through
these two behavioral categories. There are periods where she seems to
select property destruction and other periods during which she seems to
select self injury. But it was generally agreed that property destruction
and / or self injury precede physical aggression.
The next phase involves physical aggression. If staff get too close
to her when she is angry, or lay hands on her in an attempt to restrain or
control her, Edna will surely be physically assaultive.
Assessment and Intervention Plan
Re: Edna Carry
Page 31
Episodes do not always follow a gradual escalation.
In some
instances, any one or combination of topographies may occur so close
together as to be described as simultaneous.
Here are some examples of episodes as they were reported in BDS
ID Notes”
January 23, 1998 “Patient became hostile when wash room could
not be opened at her request. She began to threaten staff to “kick your
ass bitch.” Patient then began to bang her head, hitting the wall, and
banging on the washer. She was then put in 5 point restraint. Attempted
to harm self then was placed in 6 point restraint.”
September 17, 1997. “Patient was in hallway banging on nurses
station window. Then she went to the dayhall and proceeded to bang on
the dayhall windows. Patient broke dayhall window and was escorted to
side room for staff conference. Patient attempted to hit her nose with her
fist. Patient not placed in locked seclusion; patient placed in 5 point
leather belts and cuffs at this time with the help of clinical staff from sister
unit.”
November 28, 1997. “Is whining and starting to bang her forehead
on the ‘glass’ wall of the dayroom. Was redirected to talk to this writer.
Became loud, upset. Offered use of Time Out room. Loud, stated a peer
told her she is fat. Given reassurance that she does not have to have a
peer ‘ruin’ her day. Pounded on the screen of the window on the Time
Out room. Allowed to express anger. Later came out of the room and
continued to elicit staff’s attention. “
November 2, 1997. “Patient has been agitated. Flipped her bed
over. Was redirected several times to participate in group. Patient
refused. Offered time out and refused. Patient went down hallway
banging on wall/ window and door of group room. Patient was placed in
restraint for banging head on wall/ Patient screaming and yelling. “
4.
Strength.
•
Anger Outburst.
a.
Rate. It is estimated that an anger outburst is initiated a
approximately 6 times a month.
b.
Episodic Severity. It is estimated that an severity of an
anger out averaged between 5 and 6 on the scale presented
above.
Assessment and Intervention Plan
Re: Edna Carry
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•
Threatening Others.
a.
•
Rate. ID Notes and Restraint Logs from June 97 through
May 98 showed a total of 36 (mean 3 per month)
references to Threats. The monthly references ranged from
1 to 8 per month.
Self Injury.
a.
Rate. One staff reported that self injury is not nearly as
frequent as when Edna first arrived. She estimated that at
that time, self injury occurred daily. One staff member
asserted that self injury occurs one time a week on her shift.
ID Notes and Restraint Logs showed a total of 69 (mean
5.75 per month) references to self injury from June 97
through May 98. Monthly references ranged from 1 to 10
per month. Fifty-nine percent of the incidents involved head
banging. Eighteen percent involved striking her nose.
b.
Episodic Severity.
Episodic severity has not been
measured in the past using the scale described above.
However, interviews as well as records revealed the
following:
1)
Duration. An episode of self injury varies from a
single blow or contact to several that may go on for
several minutes. One staff member indicated that she
had experienced an episode that continued for 20
minutes. The average duration was estimated at 8
minutes.
2)
Severity. A staff member was so concerned that she
concluded that “if she (referring to Edna) doesn’t get
attention she will do damage.” Reports indicate that
Edna has drawn blood on numerous occasions and
observation reveals that she has scarring over her
forearms as a result of SIB. Edna has opened
wounds on her head on numerous occasions and as
a result there has been some discussion of putting
Edna into a helmet to protect her. The average
severity was estimated to be a “2” on the above
described scale, with 18% of the episodes
requiring first aid (“3”).
Assessment and Intervention Plan
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•
•
Property Destruction.
a.
Rate. Staff reported that property destruction occurs about
one time per week. ID Notes and Restraint Logs from June
97 through May 98 showed a total of 39 (mean 3.25 per
month) references to property destruction. The monthly
references ranged from 0 to 8 per month.
b.
Episodic Severity. Episodic severity has not been
measured in the past using the scale described above.
However, interviews as well as records revealed the
following:
1)
Duration. Staff reported that property destruction
may involve one contact, but may continue for up to
10 minutes. The length of an episode is determined
by the speed with which staff intervene. The longest
episode reported lasted 20 minutes. This was during
an extinction procedure. It was felt that the behavior
was designed to get attention, so staff decided to
ignore the behavior.
However, the destruction
became so severe that staff could not continue to
ignore. The average duration was estimated to be
between 4 and 5 minutes.
2)
Severity. The amount of damage from property
damage is a primary measure of severity. As a rule,
property damage has a minimal impact on the
environment. The furniture is sturdy and is not easily
broken. Edna has broken windows, and has caused
damage at an estimated cost of $500. The major
impact of this behavior is that those who are
responsible for her do not feel that Edna can live in
the community as long as she continues to engage in
this behavior.
The average severity of property
destruction is estimated to a level “3.”
Physical Aggression.
a.
Rate. Staff estimated that physical aggression may occur
between 1-2 times per week. ID Notes and Restraint Logs
from June 97 through May 98 showed a total of 28
references (mean 2.33 per month) to physical aggression.
The monthly references ranged from 0 to 6 per month.
Assessment and Intervention Plan
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b.
B.
Episodic Severity. Episodic severity has not been
measured in the past using the scale described above.
However, interviews as well as records revealed the
following:
1)
Duration. An episode of physical aggression varies
from a single blow or contact to several that may go
on for several minutes. One staff member indicated
that she had experienced an episode that continued
for 20 minutes. The average duration an episode
was estimated to be between 5 and 10 minutes
2)
Severity. Reportedly, Edna has injured some staff as
a result of her assaults. She kicked staff in the face,
and recently, bit a staff member, breaking the skin,
thus necessitating medical intervention.
During
physical aggression episodes, Edna has broken
glasses, and several staff have experienced back
injuries in their attempts to manage Edna during crisis
periods.
The unit psychologist and social worker
described that Edna broke the rib of one staff
member, has inflicted deep scratches on other staff.
They noted that staff injuries have resulted in loss of
work days for some injured staff. It is estimated that
the average severity of lan episode of physical
aggression is between a 1 and 2 on the scale
presented above.
History of The Problem(s). Edna has a long history of serious behavior
challenges.
An Intake Assessment and Individualized Treatment Plan dated
8/6/87 (Edna was 7 years old and residing at Melbourne Development Center)
described “Previous placements report she has a history of defiance, temper
tantrums, scratching, hitting and biting peers and staff. Due to her behavior, she
is often ostracized by her peers which intensifies her acting out and poor self
esteem. She also has a history of harming herself by biting and banging her
head. She has often made self-abusing statements i.e., I’m Bad.”
Social Work Evaluation and Recommendations Dated 4/3/97 described
that Edna was admitted to Melbourne Development Center for the second time
on April 5, 1994. She has history of intense depression, physically assaultive
behavior, and self abusive behavior. The report also described that Edna had
been in “7 five-point restraints due to her physically assaultive behavior” during
the previous quarter.
Assessment and Intervention Plan
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Staff who knew Edna when she was at Melbourne Development Center
described that in those days, she would spontaneously stab someone with a
pencil for no apparent reason. During that time, her nose hitting was so severe,
that just a sharp movement of her head would result in bleeding. Consequently,
her nose had to be cauterized. “She had self injurious and assaultive episodes
at least daily when she was younger. Those were rough times for her.”
Reportedly, Edna’s behavior seemed to escalate during her 13th, and 16th
birthdays. After an initial escalation after her sixteenth birthday, her behavior
seemed to improve “when she became an older girl. “ Staff described that while
Edna has a long history of self injury, she never attempted to harm herself with
objects while she was at Melbourne. It was not until she was around girls at
Bendigo Development Center who had these type of behaviors that she began to
use objects to injure herself.
The staff I interviewed seemed to feel that there had been some
improvement since Edna’s arrival at Bendigo Development Center.
There
seemed to be some agreement that there was improvement after Edna’s 18th
birthday and the subsequent implementation of the 1:1 services. However,
analysis of ID Notes and Restraint Logs failed to show a clear trend toward fewer
restraints or behaviors leading to restraint.
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 the above identified behaviors and their escalation and secondly an
analysis of those that decrease the likelihood. Detailed examples substantiating
each of these, based on actual incidents, are also included.
1.
Setting Events. Setting events are antecedents that may occur hours,
days, weeks, months before the occurrence of a behavior. They are
antecedents that when they occur impact a person’s response to
everyday, more immediate antecedents; examples include mood,
psychiatric state, emotional event, etc.
Staff described a number of
setting events that may have a negative impact on Edna’s daily behavior.
•
Visits from Edna’s sister appear to be difficult for her. While she
loves her sister dearly, the stress seems to increase her likelihood
of becoming angry with others.
Assessment and Intervention Plan
Re: Edna Carry
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•
Staff reported that holidays are difficult for Edna. Staff who have
known her from Melbourne described that holidays such as
Christmas, Thanksgiving and Birthdays traditionally have been
difficult for Edna. One staff member suggested that Edna’s 13th,
16th, and 18th year old birthdays were both difficult and good for
her. While she was more likely to become angry around her
birthdays, her behavior after these times may have improved
because Edna viewed her self as having achieved some special
state of maturity.
•
It was reported that there are days where you just know it is going
to be difficult. Edna “seems to get up in a mood.” She won’t brush
her hair, may say that she is not feeling well. It may be something
as small as a stuffy nose. This will literally “ruin her day.” Her
mood, however, may change quickly. Staff reported that any little
thing is likely to put her into a bad mood, which may result in an
increased likelihood of an anger outburst. In contrast, Edna is
less likely to engage in anger outbursts when she is feeling
well and when she is in what staff describe as a good mood.
During these times, she seems to be able to tolerate more
disappointment.
•
A Treatment Plan dated 3/6/98 described that Edna is more likely
to act out aggressively during times of frustration, such as
birthdays, and anticipation of discharge.
•
It was suggested that Edna is more likely to act up during her
menses. However, comparison of monthly menses records with
occurrences of her behavior did not bear out this belief. However,
the available data may not have been complete.
As a
consequence, staff perceptions may be more correct than the
available data. Therefore, Ecological Strategies need to address
menses as a setting event.
•
Staff suggested that Edna is more likely to become angry and
engage in an emotional outburst when it is “hectic on the unit.”
Getting ready for school in the morning, where there are a number
of things to be done in a short period of time, was described as
one such example. In contrast, she is reported to be less likely
to engage in emotional outbursts when it is calm on the unit
and when the schedule is leisurely.
•
Edna is less likely to engage in the challenging behaviors
when she is feeling well, when she she is taking her
prescribed medications, and when she appears to be in a
Assessment and Intervention Plan
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“good mood. She is less likely to engage in the challenging
behaivors when she experiences high levels of non-contingent
reinforcement (i.e., is having a day of lots of fun), and when
she is highly motivated to achieve a particular goal.
2.
Triggers.
a.
Location. The classroom aide could not remember an incident in
which Edna was physically assaultive or self injurious in the school
setting.
She felt that might be due to staff keeping Edna on the
unit when she is “having a bad day.” But, the aide described that
Edna does become angry at school. As far as I could determine,
there are no locations where Edna does not have anger outbursts.
Reports indicate self injury, physical aggression, and tantrums have
been a significant part of Edna’s repertoire in all settings.
b.
People. While Edna is likely to focus her anger outbursts on a
wide variety of people, there are some people characteristics that
might set the stage for greater or lesser likelihood of these
behaviors.
•
Staff described that Edna does not like strangers or new
people , particularly “floats” (1:1 staff who are temporarily
assigned to watch Edna).
These are people in whose
presence she is more likely to engage in emotional
outbursts. But once she gets to know people, “it is OK.”
•
Edna is more likely to physically aggression males. Staff
reported that her behavior is likely to escalate is she is with
males who are strangers, or with a male 1:1 who is not
familiar with her. Staff reported that she is more likely to
target males who are authoritarian, and males who have
been called to assist during an emergency (i.e., escorting or
placing in restraint).
•
Staff reported that Edna does not usually aggress toward her
peers. But, there have been a few fights and altercations.
For the most part, physical aggression has been directed at
staff.
•
Staff suggested that Edna is less likely to aggress toward
people she likes. In some instances this tendency may be
reflected in Edna’s statement to people “Ok, it’s not you I
want to hurt.”
Assessment and Intervention Plan
Re: Edna Carry
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•
Staff generally agreed that people who take on an
authoritarian approach are more likely to initiate an
emotional outburst, even people she has known for a long
period and likes.
•
Some staff believed that the 1:1 is half the problem. It was
reported that since she is required to inform the 1:1 of her
every movement, there is more conflict. However, available
data did not shed any light in support of this belief.
c.
Time. Staff could not define any specific times of the day during
which Edna is more or less likely to engage in emotional outbursts.
Hectic times were described as highly likely times, however.
The
chart below shows the distribution of times of incidents derived from
Restraint Logs and ID Notes.
Staff suggested that anger
outbursts seemed to be more likely in the afternoons.
This
impression may be fostered by the fact that Edna spends mornings
and early afternoons at school.
The time analysis presented
below partially supports this impression. Analysis showed that 10
percent occurred between the hours of 6 and 9 AM, 16 percent
occurred between the hours of 9 AM and Noon, 15 percent
occurred between the hours of Noon and 3 PM,
21 percent
occurred between the hours of 3 and 6 PM, 26 percent occurred
between the hours of 6 and 9 PM, and 14 percent occurred
between the hours of 9 PM and 12 Midnight.
d.
Specific Events and Activities.
Staff described a number of events that are likely (and have)
to initiate an “Anger Outburst.” Staff described that Edna is likely
to become angry if she is told “no,” if staff deny her request for
something that is totally inappropriate (e.g., Visit someone on
another unit when she is on Freeze), refuse to do what she has
asked or requested (e.g., take her to get candy, take her to shower
when it is not time), deny her sweets when she asks.
Staff described that simple events that occur throughout the
day may “set her off.” For example, she may become angry if she
is given only one sausage at breakfast instead of two, she is given
light syrup instead of regular syrup at a meal, and if staff open the
door too slowly when she requests. Staff described that if she is
shown a package and told that she can’t open it now, she is likely
to become angry and escalate. She is also likely to become angry
and begin to escalate if she observes other kids going on a walk or
leaving the unit when she is not able to do so because of a Freeze
Assessment and Intervention Plan
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of her Level. Staff also described that she is likely to become angry
if her peers tease her or take her things.
Regarding physical aggression specifically, staff generally,
could not remember of an incident in which she assaulted for “no
apparent reason.” They described that there is “always a reason.”
Physical aggression usually happens when there are attempts to
control Edna’s self injury. Staff reported that if she knows she is
going to be restrained, “she will fight all the way.” They described
that it is almost a guarantee that if staff lay hands on her, she will
engage in physical aggression. The Unit Psychologist and Social
Worker estimated that fully 90 percent of the assaults occur during
attempts to restrain Edna. Another staff member estimated that 50
percent of physical assaults are precipitated by staff physically
intervening to redirect or restrain Edna. This same staff person felt,
however, based on her experience, that there are incidents that
occur as a function of simply redirecting her verbally (e.g., get back
in line during mealtime, put shoes on for dinner).
Staff described that Edna has assaulted her peers for
teasing and making fun of her, when horseplay has gotten out of
control, when a peer has taken her belongings, and when peers
have called her “retarded.”
The review of Restraint Logs and ID Notes, focused of
specific events that may have contributed to the occurrence of the
identified problem behaviors. Unfortunately, these sources did not
consistently describe the events such that antecedents could be
identified clearly. Additionally, it was difficult to tie one antecedent
event to a specific behavior within the Anger Outburst. Below, a list
of possible antecedents extracted from ID Notes and Restraint
Logs is presented. They are very consistent with those reported by
staff. It would have been nice, however, if an association between
specific antecedents and physical aggression or self injury could
have been identified. At the very least, the events presented below
may be a starting point for Antecedent Control Strategies and for
teaching Coping Strategies.
•
•
•
•
•
•
Unit crisis on going
Agitation throughout the entire shift
Agitated all morning
Sister said she is no longer visiting her
Ill, loose stool and bowel problems.
Complaining of chest Pain
Assessment and Intervention Plan
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•
•
Learned that she would be on Level 1
Give a 72 hour freeze and not allowed to attend unit events
•
•
•
•
Angry at peer
Peer told her to get out of her face
Hit by peer in face
Upset with peer who was doing her laundry and refused to
remove her clothes
Upset because peer would not give her soup
Peer calls her names
Horseplay with peer but got out of hand
Verbal altercation with roommate
Peers making comments about her
Peer threatened to get her on the PM shift
Peer told her that she was fat
Peer talking about her on the phone with another patient
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Attempt to remove piece of metal from her being used to self
injure
Told to give up scissors with which she was injuring herself
Redirected to participate in group several times
Asked to put doll away during community meeting
Told to pick up trash can
Told to make her bed
In her room without permission during unit contraband
search. Told to leave.
Told to leave room where she was interrupting a session
Told to leave the doorway of the R/S room
Repeated directions from staff
Asked to take her medication
Asked to go to the dining room
•
•
•
•
•
•
(Denied) Told that washroom could not be opened
(Denied) Request for extra food not granted
(Denied) Upset because was not allowed to have a snack
(Denied) Wanted a cookie in staff’s office
(Denied) request to go to Unit 106
(Denied) Wanted to go on patio to lie in the sun. Told “No”
by staff.
•
1:1 watching her.
Edna described a number of events that cause her to hurt herself.
She said that hearing “no” makes her feel angry and hurt and that she
Assessment and Intervention Plan
Re: Edna Carry
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feels like she has done something wrong. Some of the “no’s” she
mentioned were “No, you can’t go for a walk.” “No, you can’t go outside to
play.” “No, you can’t be in your room.” She described that when people
threaten her with time out or restraint she gets angry. When asked what
would help her be less angry, Edna responded with “If I had a CD, it would
get me off my anger. I like listening to music; classical, opera, etc. Once I
listen to music, it calms me down. Music helps. When they say ‘no’ I
have nothing to do here. Everyone else has a music player; but I don’t.”
Edna described what causes her to physically attack staff. She
said “If they grab me, I start scratching, kicking, and biting. I’m scared
they might hurt me. When I was a child I was abused. I scared of getting
hurt. Sometimes in restraint it hurts.” She described that “If they hurt me,
I hurt them. I fight back.”
Edna described what causes her to hit her peers. She will hit them
when they say “What’s up Bitch” of when they “push me.” She said that
she learned to fight back watching television.
She also noted that she
doesn’t do this now because she will go to jail for hitting minors.
3.
Specific Incident Example.
One staff who really likes Edna described an incident that occurred
on April 3, 1998. Edna had returned from on-campus school program with
her 1:1 aide. After about 30 minutes of relaxing, the other young girls
started returning from their programs. It was time for the girls to exchange
their points (tokens) for afternoon privileges. Many of the girls chose
riding bikes, others chose to go the canteen where there is music and they
can purchase snacks. When it came to Edna, she did not have enouigh
points to leave the unit (This is usually the case). She was told that she
did not have enough points. Edna began screaming “It’s not fair.
Everyone else gets to go.” Staff reiterated that she needs to control her
behavior to get enough points to leave the unit. She continued screaming.
She started pushing furniture around. The staff ignored her. She turned
over the couch, but they are big and indestruc tible. Staff continued to
ignore her. Edna approached the nursing station and began banging on
lthe plexiglas window. But the staff inside had their backs toward Edna
and continued to ignore. Edna began banging her face on the plexiglas.
Blood immediately started gushing from her nose. The staff in the nursing
station signaled a “code” and other staff began arriving. They encircled
Edna and began to approach her. Edna took a menacing stance and said
“You want some of me. Come on down. I’ll scratch your eyes out.” She
was screaming at the top of her lungs, cursing, and holding her hands in a
claw-like fashion. The staff that surrounded Edna, lunged at here and
took her down to the floor in a prone position. They then escorted her to
Assessment and Intervention Plan
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the “Seclusion and Restraint” room where she was tied to the table using
5 points. At this point the staff left. It took Edna 90 minutes to stop
yelling, at which point she fell asleep. She was released and remained
calm.
D.
Consequence Analysis. Staff generally agreed that there is NO formal, multilevel program in place for Edna. Rather, each staff described what they found
had worked for them; as well as those that have not worked. Staff described a
number of reactions and strategies that have been used when Edna has an
“anger Outburst.” These strategies and their impact are described below.
1.
Ignoring. Sometimes staff ignore Edna’s whining and crying (Note:
These are early parts of the escalation toward more severe behaviors.) It
was generally agreed when she is ignored, she will escalate to the point
that someone must DO SOMETHING.
“You can only ignore so long
before you have to do something.” Reportedly, when she is ignored, she
is likely to escalate to head banging or property destruction. It was further
reported that ignoring almost never works. But one staff said that every so
often if you say “I’m not going to talk.”, she may stop.
2.
Determine The Nature Of The Problem. When ignoring doesn’t work,
staff will attempt to “determine the problem.” Staff reported that this
sometimes effective. They may be able to talk her down once they know
the problem.
3.
Reassurance / Touching. One staff has found that sometimes by putting
her arm around Edna when she is upset, while saying “You don’t have to
do that.” she may calm down. Other times, it simply doesn’t work.
4.
Argue. Some staff will get into arguments with Edna. But it was also
noted that if you get into an argument with Edna, “You are dead.” She
will surely escalate.
5.
Joking. One staff member described that sometimes she can stop her
from escalating by getting her to laugh. So this staff member will “Joke”
with Edna. Her advocate reported to me on example in which she was
able to stop Edna in the midst of a major episode by asking her “Have you
heard any dirty jokes recently?” Not only did this stop the episode, but
stopped staff from placing Edna in 5-point restraint.
6.
Voluntary Time. Frequently, staff will ask Edna if she would like to take
a time out. If she uses time out, she may gain control and calm down.
However, if she refuses to go to time out, she is usually physically taken to
another room and placed in restraint so that she can calm down.
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7.
Formal Treatment Plan. Edna’s treatment plans for her behavior were
summarized above. In addition, the following strategies were described in
a Treatment Plan dated 5/29/98.
•
During the first stage of escalation when patient is whining or
crying, patient should use coping skills such as writing or drawing
out feelings, counting to ten, requesting time out on the patio, using
password that she uses with certain staff, including “I need help!”
•
Monitor level of distress.
•
Ignore negative behavior and attention seeking behaviors and
reinforce and prompt coping skills.
•
When whining and crying and if the request can be met - OK.
•
If she does not choose a coping skill, provide her with one.
Level Program / Freezes. As mentioned above, Edna participates
in a unit-wide Level Program through which she earns progressively more
privileges on and off grounds.
As part of the Level Program, for
misbehaviors her privileges can be frozen (Freeze) so that her privileges
are limited to Baker Unit.
The chart presented above showed that
Freezes have been used extensively as a consequence for her behavior.
But given that she seldom achieves higher than Level 1, she truly is on a
Freeze Status a majority of the time. In the antecedent analysis, it was
noted that being placed on a Freeze, or knowledge that she was being
returned to Level 1 was sufficient to set her off.
Physical Restraint. Physical restraint is used quite often to
manage Edna’s behavior. Based on review of available information,
during the period from June 97 through May 98, Edna spent 141 hours in
physical restraint (i.e., Equivalent to 5.88 complete, 24 hour days).
Staff described that when Edna is aggressive, she must be
restrained. “She hates it.” Since she doesn’t like being placed in
restraints, she seldom walks to the restraint / seclusion room. Usually she
must be physically escorted. During this time, Edna will aggress toward
most anyone who gets close enough to put hands on her. Staff reported
that it sometimes takes 6 to 10 people to effectively get her into restraints.
Frequently, Edna and / or staff are injured as she is placed in restraints.
Staff who knew Edna at Melbourne described that restraint was also used
in that setting. However, it may have been easier because she was younger
and smaller.
The impact and difficulties with restraint are not known.
Assessment and Intervention Plan
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Reportedly, Edna participated in a Level Program while she was a resident of
Melbourne. In that setting, she never got to a level where she had the privilege
of leaving campus. Given that her last placement began in April 94, it looks as if
Edna has not been off the campus of a Development Center for at least 4 years.
But, it is likely that Edna has not been off the Campus of a Development Center
since her first admission to Melbourne in 1989.
The unit social worker reported that attempts have been made to
implement individualized reinforcement plans for Edna on the unit. Unfortunately,
attempts at individualized programs based on staff delivery of reinforcers were
not effective because they were not carried out. The unit social worker described
a program that she and Edna had worked on. It was a self control program in
which Edna would give herself “Stars” for select performances. However, it is
unclear that this program ever really got off the ground.
It is my impression that Edna’s behavior management programs have
been generally ineffective. There may be a number of reasons, but the primary
ones seem to be lack of individualization, reinforcement programs based on “too
many target performances,” reinforcement of insufficient power to motivate
participation or change, and an over-reliance on negative consequences and
emergency management strategies.
The exception to the statement above may be the school program at
Bendigo Development Center (Described above in Program Placement Section).
Reportedly, the more severe behaviors of self injury and physical aggression are
absent. This may be due to staff keeping Edna on the unit of “rough days.”
While the program is not based on a comprehensive behavioral assessment, is
not individualized based on an such an assessment, it is a small classroom in
which Edna receives considerable individual support. She receives frequent
feedback for assignments that lead to reinforcement at the end of the day. Most
importantly, when Edna is upset, staff have established a number of
“individualized” ways to help Edna “survive” and “cope” with upsetting events.
E.
Ecological Analysis.
The purpose of the Ecological Analysis is to identify
aspects of a person’s living, working, playing, and learning environment that
might be in conflict with their needs. Information for this analysis may come
from any part of a Behavioral Assessment. This Analysis will set the stage for
Ecological Recommendations designed to provide a better fit between the
person’s needs and the environment.
The areas of the ecology addressed in
this analysis include the following:
physical environment, interpersonal
environment, programmatic / instructional environment, and training / supervision
/ support environment.
1.
Physical Environment. Edna has lived much of her life in large,
congregate settings with other children who manifest behavior challenges.
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It is my impression that this history has contributed to Edna’s continuing
behavioral challenges in a number of ways. In the first place, those
around her very likely have been models for her behavior. For example,
staff reported that while Edna has a long history of self injurious behavior,
she did not begin using objects to injure herself until she arrived at
Bendigo Development Center and was in the presence of children who
engaged in these behaviors. This “negative modeling” is not surprising.
The work of Albert Bandura in the 1960s and 1970s clearly demonstrated
that children will imitate the behaviors of their peers, including physically
aggressive acts.
Edna reported that she has difficulty with noise. She reported that
when things get too noisy and hectic, she gets “scared,” and that she
doesn’t want to feel this way. It is very likely that the congestion that
exists on the unit, the noise, also contribute to Edna’s ongoing behavior by
acting as a “setting event” that reduces her tolerance to everyday
environmental stressors.
As noted above, generally speaking Edna has been served in the
context of a 1:8 staffing ratio.
Given this ratio, it is difficult to imagine
staff carrying out an effective individualized behavior plan for Edna. While
she has been provided with 1:1 staffing for the last several months, the
purpose of the extra support has not been for treatment purposes, but for
legal / logistical reasons.
The lack of sufficient staffing resources
prevents clearly prevents the adoption and implementation of an
individualized support plan. It is my impression that Edna’s individual
needs cannot be met within the context of a 1:8 ratio. It is also my
impression that she needs and deserves 1:1 support to effectively meet
her needs.
2.
Interpersonal Environment. Edna has lived a majority of her life in a
“professional” environment; an environment of practitioners, teachers,
aides, staff, etc. While some of these people may have had feelings for
Edna, they have been said to control, to manage, to make, to ________ .
As far as could be determined, Edna has nobody who truly cares; nobody
who continues to love and care about her in spite of her actions.
Professionals and staff go home at night and leave Edna on the unit.
This lack of a truly personal commitment in Edna’s environment itself may
have a negative impact on her behavior.
Edna reported that she was abused as a youngster. Her records
are replete with references to sexual and physical abuse. Given this
history, then it should not be surprising that she is more likely to “go off”
(using her words) around men, around strangers, around male strangers,
around people who take on a very authoritarian, demanding approach with
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her. Edna was very clear when she said that people like this, people who
are mean to her, make her fearful.
If treatment is to be successful, it must take into consideration
these interpersonal characteristics. First of all, a treatment plan needs to
be designed around fostering a relationship with Edna, a relationship of a
close friend or a mentor, one in which the people see Edna first. Second,
since Edna is fearful of men and strangers, her treatment team needs to
be made up of caring women who treat her in a manner consistent with
the following terms:
dignifying, respectful, asking not demanding,
negotiating, etc.
3.
Programmatic / Instructional Environment. For people with severe
behavioral challenges to be successful their treatment (i.e., support plan)
needs to be guided by a Comprehensive Behavioral Assessment, of a indepth Functional Analysis. As far as could be determined, neither of these
has been done for Edna. It is on the basis of such analyses that an
appropriate, individualized support plan can be designed. In should be
noted that Functional Assessment is the foundation of recent legislation
both at the State and Federal Levels (See Hughes Bill and IDEA).
To illustrate what is meant by individualization and its importance,
Edna has participated in Level Programs both at Melbourne and Bendigo
Development Centers. In these programs, Edna was and is able (but
seldom did) to earn progressively more privileges as a function her
following rules and controlling her behavior.
At Bendigo Development
Center, for example, for Edna to move to Level Three, she would have to
be on Level Two for two consecutive weeks; and to be on Level Two she
would need to meet the following criteria: NO AWOL risk / precaution;
NO one-to-one for psychiatric / behavioral reasons; NO danger to others,
NO homicidal, or suicidal precaution. In other words, she would have to
be BEHAVIOR FREE for several weeks in a row. Perhaps Edna has not
been successful thus far because the rules that guide the Level System
were not designed around individual knowledge about or reference to the
extant rates of her behavior. Given what is known about Edna’s behavior,
it is unlikely that she would be able to meet the criteria for Level 2, let
alone Level 3.
When children manifest severe challenging behaviors, the tendency
is to make the child earn everything and to increase the discipline around
occurrences of the problem behaviors.
To say it another way, the
tendency is to make the child’s entire environment CONTINGENT. This
seems to be the way Edna’s life has been for several years. She has had
to earn what other kids might take for granted (e.g., going to the store,
going to a show, browsing in the community). Very little does Edna get
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FOR FREE, or for JUST BEING A KID. For example, Edna has been on
Level 1 for a majority of the time she has been at Bendigo Development
Center. This means that her privileges are localized to the things that can
be done within the confines of Baker Unit. We might conclude, therefore,
that Edna’s life is best characterized as having a LOW DENSITY of
noncontingent reinforcement, which in and of itself can contribute to
behavioral challenges. In other words, given that there is nothing to look
forward to, why should Edna make the effort to manage or change her
behavior.
If a behavioral support plan is to be effective for Edna, it must be
based on a Comprehensive Behavioral Assessment, must be
individualized based on information derived from the assessment, and
must insure a HIGH DENSITY of noncontingent reinforcement.
F.
Impressions and Analysis of Meaning. The functions of Edna’s behavior need
to be considered closely. The effectiveness of the support plan designed to help
her with her behaviors will depend to a great extent on the ability of those around
Edna to teach her more effective ways of meeting the needs satisfied by these
behaviors.
1.
Communication. Some staff at Bendigo Development Center believe
rather firmly that Edna engages in self injury as a way of getting attention;
and it makes no difference whether the attention is positive or negative.
It is my impression, that Edna uses her self injury, property destruction,
physical aggression to communicate a variety of messages, one of which
is a need for attention at the moment. Although Edna has excellent
communication skills, at one level, she uses her behavior as a form of
“personalized sign language,” with which she communicates messages
such as “I want to talk to you.” “I want _______ __________.” “Leave
me alone.” “I want to eat _________.” It is my impression that in many
instances, people around Edna have not listened to what she has said.
They have ignored, they have said “no,” they have forced her. In a
sense, Edna has adopted the behavioral repertoire above as a form of
“behavioral shout.”
Given this powerful function, a total support plan must encourage
less forceful, more appropriate communication strategies. In the first
place, Edna must be given permission to send messages verbally. Then
the environment must be willing to listen and to validate the verbal
messages she sends.
2.
Learned Response to Anxiety / Anger. Edna has said that many things
make her afraid or angry. Men make her afraid. When people put hands
on her and try to restrain her, this makes her mad. When peers tease her
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or take her things, she becomes angry (See Antecedent Analysis for more
examples). It is my impression that Edna has learned self injury and
physical aggression (i.e., anger outbursts) as a way of managing or
reducing negative emotions. On the other side, we might also say that
Edna has failed to learn alternative ways of managing her negative
emotions.
Given this potential function of Edna’s behavior, it is imperative that
she learn better ways of managing her emotions. Relaxation is one
response that might be helpful for her. But in addition, Edna should be
taught to cope with specific events that tend to set off the negative
emotions that might culminate in her problem behaviors.
3.
Escape From Unpleasant Activities / Events. Edna seems to use her
behavior to escape or avoid what she seems to perceive as unpleasant at
the time. These might be demands to pick up trash, leave the room, take
medication, participate in group, etc. That is, by engaging in self injury,
property destruction, or physical aggression, Edna may be able to escape
or avoid these events as a result of being placed in time out or physical
restraint. It is even possible that even a short delay the requested activity
might continue to reinforce the problem behaviors.
Given this possible function, at least two thrusts must be
considered. First, the many events that set off Edna’s behavior initially
should be avoided (i.e., Antecedent Control Strategies). Second, a
motivation must be created to GET EDNA TO WANT TO PARTICIPATE,
TO FOLLOW DIRECTIONS, ETC. Traditionally, this has been done
through the use of negative consequences.
We suggest that positive
reinforcement be used in this endeavor.
4.
Lack of Appropriate Peers / Models. Edna has been and continues to
be surrounded by negative models. This may be one very powerful event
that has contributed to the initiation and development of new problem
behaviors.
What has been missing in Edna’s life are PEERS WHO DON’T
HAVE PROBLEMS. Most children learn by watching their friends and age
mates.
The literature is replete with studies pointing to the powerful
impact of modeling. If Edna is to be successful, she must be taken out of
the environment where everyone around her is challenged by a multiplicity
of behavioral and emotional challenges. She needs to be around other
kids and adults who do not have problem behaviors. This may only be
achieved through an INCLUSIVE LIFE MODEL in which Edna’s entire
support structure is conducted within a non-handicapped, non-behaviorally
challenged milieu.
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5.
Boredom. Looking at Edna’s schedule and given that her privileges are
usually restricted to the residential setting, one word that might best
characterize her life is “BORING.”
Edna candidly described her life as
there is NOTHING TO DO. Since Edna has nothing better to do, since
there is nothing fun to occupy her mind and day, we need to entertain the
possibility that her ongoing behavioral challenges are partially supported
by the low density of non-contingent reinforcement in her life. Sadly, if she
remains on the Level Program as it currently exists, there is very little
chance that things will change. It hasn’t, it won’t!
A comprehensive program to meet Edna’s needs MUST change
the status quo in this area. Instead of a totally contingent model of life
(which is not normalizing at all since most of what people do in the natural
world in the way of fun is noncontingent) every effort must be taken to
increase Edna opportunities and range for exciting, meaningful, and fun
activities in the community.
6.
Other Controlled. Edna’s life can best be characterized as “other”
controlled. She has few choices. She must follow a schedule dictated
by others, she can’t eat when she wants, she can’t shower when she
wants, she cannot choose to participate or not to participate in her day
program, she cannot choose. In other words, she has no control over her
life, which in and of itself may create some significant negative emotions
and subsequently the manifestation of challenging behaviors.
Some people may say that Edna has a choice to behave or not and
therefore has control over the things she can do. Given the programs
that have operated in Edna’s life to this point in time, she truly has not had
choices.
A major thrust of Edna’s support plan, therefore, must
“empower” Edna; i.e., must give her greater control over her life. This can
be done by giving Edna choices over what she does or does not do
throughout the day, and by providing Edna with the opportunities to do or
not do based on her choices.
9.
Lack of Individualized Programs and Lack of Motivation. We need to
ask, why Edna’s behavior has continued essentially unabated over the
past 10 years in spite of the presence of “treatment plans.” It seems that
something should have clicked for her.
It is easy to write a child like
Edna off as willful, unmotivated, emotionally disturbed, organic brain
syndrome, or as a personality disorder. However, before we do this we
need to go back and ask whether the behavioral support plan’s were
sufficient to meet her needs. It is my impression that Edna’s lack of
success over the years may be partially explained by the absence of an
Individualized Treatment Plan; i.e., one based on a comprehensive
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behavioral assessment and designed around individually determined
behavior rates and motivators.
Along the same lines, there is no evidence in Edna’s records that
her behavior management plan was designed around individually
determined motivators. The questions that need to be answered here
include “What will it take to motivate Edna to show greater self control?”
What will motivate Edna to get through the day, two days, a week, a
month, etc.?”
As mentioned several times above, Edna needs to have an
Individualized Treatment Plan that is based on a Comprehensive
Behavioral Assessment (This is the purpose of this evaluation.). All stops
motivationally need to be pulled out in an effort to motivate Edna to WANT
TO SHOW SELF CONTROL. Finally, a hallmark of behavior is change.
Edna Individualized Treatment Plan must be fluid and capable of being
change based on Edna’s needs.
10.
Response to Physical Stressors.. Edna has a whole host of physical
problems (See Health / Medication Section).
It is important to
understand just how such events might impact a person’s behavior.
Medical, physical, psychiatric problems can act as “setting events.” A
setting event is an antecedent that may occur an hour before, a day
before, a week before, or a month before the occurrence of a behavior. It
acts to alter the everyday three-part contingencies that control a person’s
behavior. This concept may be best understood by the answers to these
questions: “Have you ever been in a bad mood?” “Does your mood
have an impact on your behavior?” “Have you been ill recently?” “Is your
behavior influenced by your state of health?” Most of us would answer
these questions with a hearty “yes!” This is also the case for Edna, but
perhaps at a more profound and severe level. There is every reason to
believe that Edna’s mood, her physical status, have an impact on her
behavior at the moment and the rest of the day. Staff reported that there
are days during which you just know it is going to be rough; “She is in a
mood.”
Edna’s behavior is partially a function of the environmental
demands and reactions in the presence of certain setting events.
For the most part, when Edna experiences changes in her mood, or
minor changes in her physical well-being, people are understanding, but
Edna must continue to “follow the plan.” If Edna support plan is to work
for her then these “setting events” must be taken into consideration. Her
day, what she is asked to do at the moment, how staff react at the
moment need to change depending on her mood, physical complaints,
etc.
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11.
Emotional Response. to Previous Abuse and Physical Restraint. Edna
reportedly has a history of physical and sexual abuse as a youngster.
She reported that she is afraid of males because they abused her. It is
difficult to determine objectively the impact of this abuse on Edna’s current
behavior, but the potential cannot be discounted. Using the concept of
“Least Dangerous Assumption” we must assume that these experiences
have an impact on Edna’s current behavior. Consequently, Edna’s
treatment plan needs to provide individual therapy to deal with issues
related to her abuse.
MOTIVATIONAL ANALYSIS.
A "Motivational Analysis" was conducted for the purposes of identifying the
events that might be used effectively as positive reinforcement in a well designed
behavior modification program designed to ameliorate the identified behavior problems,
and to develop functional, age-appropriate, adaptive skills.
As part of this analysis,
Edna was interviewed. The results of this interview are presented below:
1.
Foods. Edna described that she really likes Aboriginal Food. But she also likes
Thai and Chinese Food. She described that she likes gummies, lolly pops,
pecan ice cream, hot peppers, and soft drinks. She described that the last coke
she had was nearly “four weeks ago.”
2.
Activities. Edna described that she likes gymnastics, ballet, hiking, skating, and
possibly roller blading. She demonstrated how she could do a front roll. Many
of these things she did while she was at Melbourne Development Center. She
had never been roller blading, but would like to try. She was especially “high” on
hiking and described hiking through the hills of Melbourne. She said that she
really likes swimming and can dive. She said with some sadness that they don’t
have a pool at MSH. She said that she went horseback riding when she was a
young child; about 4 years old. She said that this is something she would like to
try again.
3.
Excursions. Edna described that there are other places she would like to visit,
including Disneyland, Universal Studios, Raging Waters, Six Flags. When asked
how she knew about these, she described that she has seen them on television
and other kids have told her about them.
But she has never been given the
opportunity. She said that she would like going to parks and the beach. But
when asked the last time she had done these things, she said that she had never
been to the beach; but really wants to go.”
4.
Toys, Playthings, Tangible Objects. Edna gave a list of the things she would like
to have. These included a radio with CD play. She said that she really wanted to
go shopping for clothes, shoes, makeup, and jewelry.
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5.
Entertainment. Edna described that she enjoys watching television, especially
cartoons and Disney videos. She would like an entire collection of Disney
videos.
Edna said that she likes listening to music, especially Madonna,
Michael Crawford and the soundtrack from Cats. She also likes drawing, and
dancing.
6.
People. Edna said that she likes people; if they are nice to her. She likes talking
to them and going on outings with others. She said that she likes playing with
kids.
7.
School. Edna described that she likes recess, math and reading. She noted that
she is “really good in math,” and is still learning to read better. She
demonstrated her reading ability and was proud to have been successful.
A number of events of interest for Edna were described in her records (See
BioPsychoSocial Data Base Update - Addendum dated 8/6/97; and Rehabilitation
Therapy Assessment dated 1/20/98). Some of these interests and wishes included the
following:
1.
being reunited with her family including her sister Loke and brother Lester;
2.
being a masseuse when she grows up, in addition to a baby sitter;
3.
drawing, helping out her friends, playing board games, cleaning, ice skating,
roller blading, swimming and gymnastics;
4.
keeping things neat, which she remains extremely proud of;
5.
selling things, beading, making key chains, listening to opera (She was very
impressed with Phantom of the Opera), classical music, Cats (The musical);
MEDIATOR ANALYSIS.
A "Mediator Analysis" was conducted for the purposes of identifying and
specifying the people supports Edna will need if she is going to be successful.
This
analysis addresses the staffing ratio that will be necessary to carry out the plan
presented here, as well as the level of training and supervisory support that will be
needed.
1.
Staffing Ratio. Edna’s current treatment staffing ratio is 1 staff member to 8
consumers (1:8). The plan described in this document simply cannot be carried
out with these staffing constraints.
To carry out the plan described in this
document, Edna will require 1:1 staffing support.
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The purpose of those who provide the 1:1 support will not be observation,
self and reaction as has been the case in the past. Rather, the 1:1 support
member will be active in the implementation of every phase of Edna’s support
plan. With this level of support, a majority of behavioral episodes may be
prevented because the staff will have nothing better to do than to Mentor Edna
through each day. They will not have to “make her” because the schedule calls
for it; they will not need to ignore her behavior because they have other things to
do; they will not need to demand that she do it now, because there will be time to
do it later.
2.
Staff Characteristics. This analysis suggests that Edna has greater difficulties
and is more likely to physically agggress towards males when they are involved
in her management. This is not surprising given her history of aggression. It
was also noted that she has greater difficulty with staff who take on an
“authoritarian” role with Edna.
Given these issues, and given the needs for
personal dignity, staff who work with Edna should be women. The women who
work with her should be hired specifically for their ability NOT TO TAKE Edna’s
behavior personally. They need to be tolerant, understanding and supportive.
They need to be able to take “NO” for what it is worth and go on with life. Using
the words of Mark Gold, if they want Edna to do something, the (staff) need to
“TRY ANOTHER WAY.”
3.
Staff Training and Supervision. The staff who work with Edna will require a
level of training and supervision that is not currently available at Bendigo
Development Center. The support plan described below is comprehensive and
complex. For staff to be successful in its implementation, training will need to be
just as comprehensive, and clinical supervision will need to be available on a 24hour on-call basis.
The training of staff, in order to be effective, should be characterized by a
three-tiered training model that incorporates the following steps:
a.
Protocol Development. All programs should be detailed in a step-by-step
fashion, outlining the actions taken by staff, including verbal interactions.
b.
Verbal Competence. After reading these protocols, staff should be able to
verbalize each program to a specified level of accuracy.
c.
Analog / Role-Play Competence. Each staff member should be able to
role play each component of the support plan to a specified level of
accuracy.
d.
In-Vivo Competence. Each staff member should be able to carry out each
program under supervision to a specified level of accuracy.
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In other words, each staff member should be trained to a pre-specified
criterion on each program across three dimensions of competence: Verbal,
Analog, and In-Vivo. Additionally, to insure that programs continue to be carried
out consistently over time, Procedural Reliability Checks should be conducted
weekly for selected programs.
RECOMMENDED INTERVENTION PLAN
A.
B.
Long-Range Goal. The long-term goal for Edna is to help her establish sufficient
self-control over her behavior problems so that she is increasingly able to live
and to work in the least restrictive setting possible that is capable of meeting her
needs. Some preliminary goals for Edna would be
1.
to eliminate of restraint and aversive measures to manage her behavior,
2.
to greatly reduce or eliminate Edna’s assaultive behavior and self
injurious behaviors;
3.
to transition Edna into a full-time, community-based residential program;
4.
to transition Edna into a community-based educational program;
5.
to help Edna achieve a wide range of friendships and acquaintances.
Operational Definitions. Each performance or behavior for which data are
collected needs to be “operationally defined.” An operational definition can be
defined as a “description of behavior in reliably observable terms.” The following
behavioral categories are defined for the purpose of data collection:
1.
Topographies.
a.
Property Destruction. This category of behavior involves actions
that (i) render objects in need of repair, (ii) render objects unusable,
(iii) have the potential of causing damage, and (iv) throwing object
not meant to be thrown (e.g., tables, chairs, etc.). Some specific
actions that fall in this category include the following:
•
•
•
•
•
•
throwing chairs
throw tray of glasses
throw glasses
throw cup of juice and snacks onto the floor
throw bottle of lotion breaking it
kick trash can, walls, furniture
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
b.
take apart beds
turn over tables / furniture
overturn plants
banging on windows and tables with objects or hands
pound on walls
hit television with hand
banging on telephone
pulling down curtains
break windows
break open display case
tearing paper
tear pictures from walls
pulled drinking fountain from the wall
break public phone
break movies
pull apart alarm box
Self Injury. This category of behavior involves actions (i) that
result in visible injury, damage, (ii) that have the potential for
causing damage, (iii) and that result in bruising or bleeding.
•
Head Banding. Contact of head to surfaces such as walls,
windows, floor, such that the contact is clearly audible at a
distance of 10 feet.
•
Head Hit. With an open hand or closed fist, makes contact
with her head. Typically, Edna will strike her nose with her
hand or fist, or will strike her nose to her forearm.
•
Scratching / Cutting Self. Edna will use her fingernails or
objects to scratch or cut her body. Typically this target is her
arms.
This is recorded if her nails or object come into
contact with her arm such that a mark remains or blood is
drawn.
•
Other. Any other action that results in self-inflicted injury
would fall in this category, e.g., swallowing or putting
dangerous substances in mouth, wrapping straps, ropes,
etc. around neck
Some specific actions derived from Edna’s records that fall
in this category include the following:
•
•
bang head on window
bang head on wall
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•
•
•
•
•
•
•
•
•
c.
Verbal and Physical Threats Toward Others (THO). This
category of behavior includes (i) statements that suggest an intent
to cause injury to another, or to engage in a physically assaultive
act , or (ii) physical gestures that similarly indicate an intent to injure
another (e.g., raising a hand and shaking it at another). Some
specific actions that fall into this category described in Edna’s
records include the following:
•
•
•
•
•
•
•
•
•
•
•
•
d.
bang head on door
stab pencil into hand
strike self in nose with fist
scratch arm with metal object
bang head on office window
pick nose
scratch arms with thumb tac
swallow hair spray
put strap around neck in attempt to choke self
“I’m going to scratch your eyes out if you come near me.”
“I’m going to fuck you up.” “I’m going to get you.”
“I’m going to go off and hurt someone.”
“I’ll run you over with my wheelchair.”
“I’m going to kick your ass bitch.”
“I’m going to beat you up.”
“I’m going to bash you in the eye.”
“I can throw this bag at you.”
“I can kick your ass.”
“If you touch me, I’ll bite your fucking face off.”
“I don’t care if I go to jail, I want to rip her head off.”
“She gives me an attitude. If she watches me I’m going to
bite her.”
Physical Aggression. This class of behavior involves the
following discrete topographies / actions:
•
Hitting.
This topography is defined as striking another
person with a closed fist (or open hand) with a force that the
blow is clearly audible at a distance of at least five feet,
results in the person's body being deflected in a direction
away from the blow; or the person who is the recipient
reports, pain / discomfort / injury.
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•
Kicking. This topography involves any contact of the foot to
the body of another that is not part of an organized game or
accidental.
•
Biting. This topography is defined as any contact of her
mouth to the body of another. If bite marks remain or injury
has occurred, biting is recorded.
•
Head Butting. This topography is defined as contact of the
head with the body of another with a force that the blow is
clearly audible at a distance of at least five feet, results in the
person's body being deflected in a direction away from the
blow; or the person who is the recipient reports, pain /
discomfort / injury.
•
Grabbing. This topography is defined as grasping the
clothing or body of another person with a force that the
person's movement of a body part is impeded (e.g., can't
move an arm, can't back up); the person’s body is deflected
in space (e.g., body part pulled closer to Edna; direction of
body is changed).
•
Scratching. This topography is defined as contact of
fingernails to the flesh of another such that a depression is
observed at the moment, a white mark is evident as a result
of the contact, there is swelling or bleeding.
•
Pulling Hair. This topography is defined as grasping the hair
of another such that the person’s head movement is
restricted, the pulling motion results in movement of the
person’s head, or the person reports pain. Simple touching
another person’s hair is not included in this actions.
•
Spitting. This topography involves the projection of saliva in
the direction of another such that the saliva makes contact
with another, or lands within 3 feet of a person. This
category would also be recorded if contact is avoided
through good evasion.
•
Directed Throwing. This topography involves tossing objects
in the direction of another such that contact is made or the
object lands within 3 feet. This category would also be
recorded if contact is avoided through good evasion.
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Some specific actions that fall into these categories
described in Edna’s records include the following:
•
•
•
•
•
•
•
•
•
•
•
•
•
2.
hit staff member on shoulder and in ribcage
attempt to scratch while being restrained
kicked female staff in her face
scratches to arm and hand area
kicking, biting, spitting while being brought back to unit
“I scratched him and bit a staff.”
came out of time out and attacked a peer
hit 1:1 with clipboard and fist
scratches to staff fingers and broken fingernail
bit one staff and scratched another on their backs
spitting at staff
grabbed staff by left wrist
pushed staff
Measurement Criteria.
a.
Occurrence Measure (Cycle: Onset / Offset). An episode
begins with the first emission of any one or combination of the
above topographies, and ends when the topographies have been
absent for five minutes. For the purposes of recording, an interval
recording strategy will be used.
Thus, the end of an the
topographies will occur when the recording interval times out.
b.
Episodic Severity Measures.
1)
Severity Level
Anger Outburst. The episodic severity of the entire class of
behaviors subsumed under the label is presented below:
Severity Code Criteria
1
2
3
4
5
6
Screaming Loudly and Cursing
Verbal and Physical Threats Toward Others
Property Destruction – No Damage Results
Physical Destruction – Damage Results
Physical Aggression / Self Injury – No Damage
Physical Aggression / Self Injury – With Injury
2)
Physical Aggression: The episodic severity of physical
aggression will be measured using the four-point scale
presented below:
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Severity Level
Severity Code Criteria
1
Physically aggressive acts that do not require first aid and do
not threaten severe injury (e.g. hair pulling (without pulling hair
out), finger poking (except when directed at eyes), pinching,
grabbing, throwing small or light objects, pushing without body
deflecting more than a foot.)
Injury requires first aid or threatens the need for first aid (e.g.,
scratching, blows that cause bruising, biting without breaking
skin etc.
Injury requires professional emergency care with immediate
medical release, worker’s compensation or threatens
significant injury (e.g. choking without asphyxiation, charging
and shoving so that body deflects against an objects or person
falls down, shaking another person, attempting to hit with
heavy objects such as chairs, biting and breaking skin
Injury causes need for overnight stay in hospital or more than
one professional medical follow-up.
2
3
4
The average severity should be reported and graphed on a
weekly basis
3)
Self Injury: The severity of self-injury should be measured
using the following rating scale:
Severity Level
Severity Code Criteria
1
2
3
4
Self Injurious Threats
Self Injurious Actions that do not require first aid
Self Injurious Actions that require first aid
Self Injurious Actions that result in medical attention other than first
aid (e.g., emergency room)
Self Injurious Actions that result in permanent injury or
disfigurement.
5
The average severity should be reported and graphed on a
weekly basis
C.
Short-Term Measurable Objectives.
The following objectives were selected as being most reflective of Edna's
priority needs and as being the most realistic given Edna’s disabilities, and her
history of placement in the California Development Center System
Further
objectives will need to be established as a function of the success or failure of
the recommended support strategies presented below.
1.
Anger Outburst
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2.
3.
4.
D.
a.
Rate. To reduce the rate of this class of behaviors from an
estimated average of 6 times a month to 1 time a month within 1
year of the full implementation of this support plan.
b.
Episodic Severity. To reduce the average severity of this class of
actions from an estimated severity off 5.5 to 2 within 1 year of the
full implementation of this support plan.
Physical Aggression (Pa).
a.
Reduction Of Rate Over Time. To reduce the rate of physical
aggression from an average of 2.33 times per month to 1 time a
month within the 12 months of full implementation of this plan.
b.
Episodic Severity. To reduce the average severity of an episode
from 1.5 to 1 within 12 months of full implementation of this plan.
Self Injurious Behavior (SIB)
a.
Reduction Of Rate Over Time. To reduce the rate of this behavior
from an average of 5.75 times a month to 1 time a month within the
12 months of full implementation of this plan.
b.
Episodic Severity. To reduce the average severity of an episode
from an estimated level of “2” to “1” within 12 months of full
implementation of this plan.
Property Destruction. To reduce the average severity of this behavior
from 3 to 1 within 12 months of full implementation of this plan.
Observation and Data Collection.
The purpose of data collection is to facilitate treatment decisions. It
should provide a maximum amount of information, but should not require
extraordinary amounts of staff time. A comprehensive program to meet Edna's
needs would be incomplete without a comparable method of verifying the effects
of treatment. In the following paragraphs, some possible data collection
strategies are presented.
1.
Fifteen Minute Interval Sampling. Each 15-minute period throughout
the program day, staff should indicate the presence of the target behaviors
on a sheet like that presented below. The overall low frequency of the
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behaviors would lead me to believe that an interval-sampling strategy
would provide a maximum amount of information and would approximate
a true frequency count. In addition to recording the presence / absence of
the target behaviors, the use of physical restraint, PRN medication, and
the overall severity of each assaultive episode should be noted. The
severity of an episode refers to the effects on those around Edna.
Severity may be measured along a number of dimensions. One such
scale would rate each incident on a 0 to 5 scale, with "1" indicating no
physical damage, and "5" indicating that the person required
hospitalization and major tissue trauma was evident.
2.
ABC Incident Analysis.. Initially, any incident of physical aggression that
involves physical contact between Edna and another person, and any
incident of self-injurious behavior should culminate in the completion of an
ABC Incident Analysis. Each event should be recorded on a prepared
form indicating the following:
a.
b.
c.
d.
e.
6.
7.
The time of occurrence,
The activity in which the behavior occurs,
The setting in which the behavior occurs,
The immediate antecedents of the behavior,
The consequences applied to the behavior (reactions)
The specific actions involved in the episode (e.g., hit, kick)
Severity Level
3.
Data Summary and Graphing. The daily number of intervals during
which the target behaviors occurred; as well as the use of physical
intervention and PRN medication should be summarized separately on a
"Daily Data Summary,” and the weekly numer of intervals during which the
behaviors occurred should be summarized on a "Weekly Graph." At this
point, it is assumed that the interval data collection method will indeed
approximate the frequency of occurrence of the Edna’s behaviors.
However, at the same time, those who review Edna's data should be
aware that the proper method of reducing these data is by reporting the
percentage of intervals in which the behavior occurs. Additionally, for
each occurrence of the target behaviors, the highest severity level during
a recording should be recorded. On a weekly basis, the average “episodic
severity” should be calculated.
4.
Reliability Check. A secondary observer should be assigned to
determine the reliability of observer data. At least once a week, this
calibrating observer should observe Edna at the same time as assigned
staff. Each occurrence of the target behavior should be entered on an
independently maintained data sheet. Reliability should be determined
quarterly by calculating the degree of agreement between the primary and
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secondary observers over all the observations. Each event should be
compared item by item, by time of occurrence. The following formula
should be used in calculating each quarter's index of reliability for this
behavior.
# of agreements
____________________________________ X 100 = index
of reliability
# of agreements + # of disagreements
5.
Reinforcement Tracking Chart. To evaluate Edna's reinforcement
programs effectively, staff should indicate whether or not reinforcement
was delivered throughout the day. Staff should place a "Y" in the
appropriate cell if Edna met the criteria for reinforcement according to the
prescribed schedule (e.g., DRO, DRL) and reinforcement was delivered.
An "N" should be indicated if the criteria for reinforcement were not met.
At the end of the day, the percentage of successful (i.e., intervals in which
reinforcement was delivered) intervals should be calculated:
Total Number of "Yes"
X 100
Total Number "Yes" Plus "No"
E.
Recommended Strategies. In the following paragraphs, a summary of possible
intervention strategies to ameliorate the target behaviors is presented. These
are by no means meant to be comprehensive or exclusive of other procedures.
They simply represent a set of preliminary idea statements that would be
elaborated and modified as the intervention takes place. Intervention is
organized around several themes: Ecological Strategies, Positive Programming,
Direct Treatment Strategies, and Reactive Strategies.
1.
Ecological Strategies. Research supports the notion that behavior
problems very often are a reflection of problems in a person's physical or
interpersonal environment.
Ecological strategies involve planned
environmental changes designed to improve the match between the
person and his environment, thus changing the behavior. My review of
Edna's history suggests a number of areas where "Ecological
Manipulations" should be considered.
a.
Physical Characteristics of The Living Environment.
(1)
Residential Setting. Edna currently lives in a large
residential unit on the grounds of Bendigo Development
Center. As mentioned above, this is no place to raise or
treat any child, especially given that there is no reason why
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Edna could not live and be treated in the community
provided the necessary supports are in place. There are
several residential models that might meet Edna’s needs.
In addition, research points out rather clearly that for
best results, treatment should be carried out in the settings
and under the conditions where the effects are desired and
skills are expected to be used.
A community-based
residential program partially fulfills these guidelines.
Foster Family Agency. Edna has expressed an
interest in living with a family. Foster family agencies are
entrusted with the responsibility of locating and certifying
foster families to provide services for needy children. This
model might work very well providing the family members
are well trained, have additional support, and have access to
intense clinical service and crisis management services.
Level IV Group Home. Level IV group homes are
vendored to provide services to Developmentally Disabled
persons in the state of California. As a rule, they are
authorized to provide services at a 1:2 staff to client ratio.
This might meet Edna needs providing that Edna has
designated 1:1 support.
Supported Living Arrangement. Perhaps the best
strategy would be to design a program around Edna, in her
own apartment or in her own home. The concept of
supported living is that people have the right to live
anywhere they can afford to live with the support necessary
to insure their success.
(2).
Reduce Congestion. There is every reason to believe that
the more congested the living environment, the greater
likelihood she will have “anger outbursts.” An environment
should be selected that minimizes congestion. If a group
home is selected, there should be no more than 3 or 4
consumers living there. Perhaps the best alternatives that
would fit this need are the foster family arrangement and
supported living. In my estimation, supported living offers
the ideal mesh for meeting Edna’s needs.
(3)
Reduce Opportunities for Negative Modeling. Clearly,
Edna should not live with other children or adults who have
challenging behaviors. She has had this experience most of
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her life and probably has learned quite well how to
misbehave to meet her needs. Given this recommendation,
perhaps a Level IV program would not be the best solution
for Edna.
Again, the Foster Family and Supported Living
Arrangements seem to be better alternatives to meet Edna’s
needs.
(4)
Transition Services. Given Edna’s long history of living in a
Development Center setting care needs to be taken not to
overwhelm Edna by the experience of moving into the
community. During my interview with Edna, she expressed
delightful anticipation about moving into the community,
along with fearfulness.
In an effort to prevent Edna from being overwhelmed
and to prevent a subsequent escalation in her behaviors that
could accompany intense feelings of anxiety, the move to
the community will need to be gradual and based on Edna’s
ability to cope with each step. The major steps of this
transfer toward the community might involve the following:
•
gradual increase in amount of time spent off of the
unit;
•
gradual introduction to activities and events in the
community;
•
gradual integration of Edna into the activities of young
people her age beginning with leisure activities (e.g.,
YMCA);
•
meeting and spending time with foster parents,
supported living roommates and mentors;
•
gradual increase in amount of time involved in
activities at the living site to a point where Edna’s only
activity at Bendigo Development Center is sleeping;
•
Gradual introduction of Edna to “sleeping” over at the
foster home or her own apartment, to a point where
she sleeps at her place of residence 7-nights-a-week.
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The length of transition should depend on Edna and
available data. I estimate that it might require from 6 to 12
months to achieve complete transition (This is based on our
experiences under similar circumstances.).
b.
Day Program Services. Edna currently participates in an adult
education program on the campus of Bendigo Development Center.
For the most part, she has 1:1 teaching services in this setting. At
this point it may not be in Edna’s best interest to attempt to
integrate her into a special education environment in the
community. By the time transition has been completed, educational
plans developed and implemented, behavioral plans implemented,
it would be time to leave for adult services anyway. It seems
logical, therefore, to focus on services as they might be provided for
an adult.
Edna, therefore, should have the opportunity to
participate in a community-based supported-work service with oneto-one support from a mentor. As part of the service, Edna should
also have the opportunity to attend adult education classes (if this is
something she wants to do) at a local high school or college again with the support of her mentor.
b.
Interpersonal Characteristics.
(1)
One-To-One Services / The Mentor; Model of Service.
The above analysis points out that teaching methods that
are direct, forceful, authoritarian, and that leave little or no
choice (e.g., “Do it now!”) are conditions that are likely to
result in increased Anger Outbursts. Interactions that force,
cajole and involve physical interactions are likely to result in
similar behavioral patterns.
There is no question that Edna will require the support
1:1 support if her treatment plan is to be carried out
effectively (This applies to both the Foster Family and
Supported Living Arrangements). But given the above
analysis, it seems logical that every effort be made to reduce
the characteristics of person-to-person interaction that might
act as cues for serious behavior problems.
The staff / client dichotomy is a model of service that
is likely to result in conflict with Edna. In this model,
interactions are essentially “one way” e.g., "I am staff and
you are client, and you should do what I said. " As we
know, this authoritarian, no choice approach is likely to result
in conflict with Edna.
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One way of reducing the potential for conflict is to
eliminate the staff / client dichotomy.
This can be
accomplished by reframing the role of the 1:1 as a mentor, a
helper, a friend, or a buddy who does things with Edna, NOT
TO EDNA. Instead of demanding that Edna do _______, the
mentor approach would mean that activities designed as part
of Edna’s program would be carried out “jointly.” Edna and
her mentor, her friend would get ready to go together,
problem solve together, eat together, do laundry together,
wash dishes together, etc. Instead of saying “You need to
_____.” the message would be “Let’s _____”; “What do we
want to do next?”
(2)
Female Mentors. As mentioned above, Edna reported that
she is fearful of men because of her history of abuse. She
reported that she might not mind working with “nice” men,
but not at first.
I strongly recommend that her team be
made of women. While Edna hopefully will get to a point
where she can trust men, it does not seem logical to have
men attending to the needs of this young women.
(3)
Style of Interaction. The interactions between Edna and
those who work with her will play a major part in the success
of a support plan. It is rather clear that she is more likely to
escalate, to engage in an angry outburst, and aggress
towards people who demand rather than request, people
who say "no" and fail to give explanations, people who do
not respect Edna’s assertions (e.g., "no"), and people who
are authoritarian. In the following paragraphs, some specific
characteristics of those who may work with Edna are
presented:
(4)
Mentors. As noted above, a Mentor view of the relationship
between Edna and those who work with her would be
conveyed.
Those who work with her should view
themselves as "friends," as "life tutors" who are there to
"help" her rather than "make her." This view of the
relationship, itself, will require specific staff training.
(5)
Avoid Demands. Demands should be avoided. Consistent
with the "mentor" view of the relationship, Edna should be
asked. She should be given a range of choices at all times
(unless it is a life or death situation). If she doesn't make a
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choice, then the mentor should suggest that they do the
activity together (The “help me” approach).
c.
(6)
Respecting the Message. Edna can communicate her
needs verbally without difficulty. When she doesn’t want
something, she will say “no.” When she wants something,
she will ask. Unfortunately, her verbal messages frequently
do not work. They are ignored, she is told she “must,” and
she is told “no, you can’t.” Those who work with Edna must
be willing to “listen to Edna,” to respect the intent of her
messages.
Of course, the typical concern is that she will
refuse to do anything and will demand everything.
However, an effective treatment plan should be capable of
motivating Edna to participate and to cope with the fact that
she sometimes cannot have what she wants.
(7)
Low-Keyed People. People who work with Edna should be
low-keyed. Given a potentially confrontational situation, they
should be able and willing to rephrase a request, to find
"another way" to communicate the same message to
achieve the same goal. They should be willing to leave and
come back later, when the conditions are better for such
interactions.
Programmatic / Instructional Characteristics.
(1)
Ecological Inventory. Edna expressed interests in
community events far beyond her level of experience. I am
not sure that she really knows what to expect from the things
she has expressed an interest.
To get a better view of
Edna’s real interests and preferences an In-Vivo Ecological
Inventory Approach is suggested. This inventory might
involve the following steps:
a)
Initially, Edna and her mentors should determine the
places she would like to visit, events and activities
that she might like to participate in. This might be
done initially by browsing through the Calendar
Section of the morning newspaper. The activities and
events should include recreational / leisure activities
(e.g., bowling, swimming), shopping areas, eating
places, theaters, nature activities (e.g., nature walks
and trails) , amusement areas, sporting events, etc.
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(2)
b)
Next, Edna should be given the opportunity to
sample each of these activities.
Placed on a
schedule for the day and week, Edna and her
mentors should select the NEW THINGS they are
going to do TODAY. (Note: These activities would be
made available non-contingently).
c)
During these activities, the following information
should be recorded:
•
Edna’s emotional response to the activity;
•
Edna’s proficiency in the activity;
•
The length of time spent in the activity before
leaving or asking to leave;
•
whether Edna expressed a desire to leave or
remained until the activity was completed.
•
related and unrelated activities that occur
during and immediately after the selected
activity.
Weekly Planner. The analysis showed that at best, Edna’s
life can best be characterized as “other” controlled.
She
has few choices. She must follow a schedule dictated by
others, she can’t eat when she wants, she can’t shower
when she wants, she cannot choose to participate or not to
participate in her day program, she cannot choose. In other
words, she has no control over her life, which in and of itself
may create some significant negative emotions and
subsequently the manifestation of challenging behaviors.
A weekly planner which Edna and her mentor prepare
together, should go along way toward giving Edna control
over her life.
•
I suggest that a weekly planner concept be utilized;
one in which Edna can view not only this week, but
also all of the weeks of the month.
•
At the beginning of each week, fixed appointments
should be placed into the schedule. Edna should be
encouraged to write the “appointments” but if she has
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difficulty, her mentor should assist.
The fixed
appointments might include things such as doctor’s
appointments, work schedules, meetings, laundry,
vacuuming, preparing meals, depositing check, etc.
Also events should be selected from the Ecological
Inventory so that Edna can plan and positively
anticipate the week.
•
At the beginning of each day, Edna and her mentor
should review the schedule and insert new and
optional events. Events should be selected from the
Ecological Inventory. They should talk about the
schedule, agree on the events, and change what they
wish to change. Flexibility must be the focus.
•
Each night, Edna and her mentor should review the
schedule to determine what was done. The things
that were not done or were unfinished should be
crossed out and rescheduled for some other time
during the week.
At the same time, new events
should be placed into the schedule.
(3)
Eliminate Aversive Strategies. Edna has a long history of
being disciplined for her behavior, a long history of being
consequated with aversives for her so called misbehaviors.
They haven’t worked yet (18 years) and Edna just doesn’t
have enough time for the environment to continue scaling up
aversive consequences. As a result of the aversive /
disciplinary thrust Edna’s support plan, she has not been off
the campus of a Development Center for years, and has
spent hundreds of hours in physical restraint. Additionally,
the analysis showed that the onset of an aversive event
frequently is a stimulus for more severe behavior. It is time
to consider a different approach. Discipline, aversives
should be avoided.
A completely non-aversive approach
needs to be adopted in which Edna is proactively motivated
NOT TO ENGAGE IN THE IDENTIFIED PROBLEM
BEHAVIORS.
(4)
Noncontingent Reinforcement. The analysis suggested
that the low density of non-contingent reinforcement in
Edna’s life may contribute to the occurrence of her problem
behaviors.
In other words, being “bored” with life, having
nothing to look forward to, may reduce the likelihood that she
will be motivated to SHOW SELF CONTROL.
It is
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recommended therefore, that those events that the average
person has in their life FOR FREE, events that they TAKE
FOR GRANTED such as going to the show, going shopping,
staying up late, having an ice cream, visiting a friend, making
a telephone call, etc. be made freely available to Edna.
Indeed, it might be a good idea to make a comprehensive list
of RIGHTS for those who work with Edna, so that they do
not make the mistake of making contingent what should be
FREE.
For more information on the impact of noncontingent
reinforcement in people’s lives and the impact on behavior
problems, the reader is referred to the following article:
Gregory P. Hanley, Cathleen C. Piazza, and Wayne W.
Fisher.
Noncontingent Presentation of Attention and
Alternative Stimuli in the Treatment of Attention-Maintained
Destructive Behavior.
Journal of Applied Behavior
Analysis, 1997, 30, 229-237.
(5)
Processing Time. It has been suggested that Edna
processes information slowly. Given this tendency, those
who work with Edna need to show patience, need to be
willing to repeat the information / request, need to be willing
to rephrase it until Edna understands.
(6)
Multi-Modal Presentation of Material To Be Learned. It
has been suggested that Edna may lose her attention to
educational material quickly.
One psychological report
suggested that material to be learned should be presented in
a
multi-modal manner to increase the likelihood of
maintaining her attention. The report recommended that
visual information be presented with verbal prompts
whenever possible.
(7)
Response Priming. Edna has been described as
noncompliant. Indeed, placing pressure on her to do
something has been indicated as one antecedent for “Anger
Outbursts.” The question is what can be done to increase
her interest in participating. One strategy that can be very
successful is called “Response Priming.”
Using this
strategy requests to participate in highly preferred activities
are presented first. This is followed by a request to do
something that is less preferred. Research has shown that
the introduction of the instruction for the more highly
preferred activity may act as a setting event increasing the
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likelihood of cooperation to requests to do things that are
less preferable.
(8).
4.
Choice. Edna has had very few opportunities to make
choices in her life. Her behavior seems to have screamed
out over the years “I want a choice.” The only choice she
has been given is the choice to misbehave or not. At this
point, the opportunity to choose must become a major part of
Edna’s life. She must be given the opportunity to make
choices about her life, her schedule, and her momentary
actions.
Other Support Services.
a.
Individual Counseling. Given Edna’s history of sexual
victimization, and physical abuse, individual and group
counseling needs to be available to her.
b.
Medical Support. Edna has a wide range of physical
complaints. Indeed, the antecedent analysis suggests that
medical issues may serve as “setting events” effecting
Edna’s behavior. Given this relationship it will be important
that Edna’s medical condition be monitored very closely;
especially the problems of rectal bleeding, stomach pains,
diarrhea, constipation, and liver damage related
complications.
Additionally, one report referred to a
problem of “hypothyroidism.” However, it was unclear
whether the problem was evaluated or ruled out. This
should be followed up by Edna’s attending physician.
c.
Nutritional Consultation. It should be noted that many
incidents of self injury and physical aggression have
centered around Edna’s unsuccessful attempts to get food,
snacks, etc. from staff and peers.
While nutritional
consultations have been provided at Bendigo Development
Center, and Edna is on a special diet to help her lose weight,
it seems that a very important component of a weight loss
program was missing; exercise. If Edna is to successfully
live in the community, and if she is to lose weight, something
more than restricting her food will need to be done. I
recommend that regular consultation from a qualified
nutritionist be part of her support plan. It needs to be
remembered that if Edna lives in her own apartment as part
of a supported living arrangement, blanket restrictions of
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food will not be possible. She will need to learn skills to
manage her diet / weight herself.
c.
Additional Evaluations.
Neuropsychological Evaluation. The records were
unclear regarding whether Edna has had a comprehensive
Neuropsychological evaluation.
Given her history of
meningitis, apparently explosive behavior, and an abnormal
EEG at one time, it seems logical that such an evaluation be
completed, especially given Edna’s learning problems and
declining intelligence quotients. If one has been completed,
and it is sufficiently comprehensive, it should be reviewed by
a qualified psychologist for appropriate recommendations. If
it has not been completed, then a comprehensive
Neuropsychological evaluation is clearly warranted.
Psychoeducational Evaluation.
The available
reports, did not describe very clearly Edna’s academic /
functional academic skills.
Neither did they describe her
learning strengths / weaknesses. Given her very apparent
learning difficulties over the years, it seems only logical that
she have the benefit of a complete Psychoeducational
evaluation.
Personal Futures Plan. Before Edna moves into the
community, Edna should have the benefit of a Positive
Futures Plan. This process produces a series of MAPS
which give a picture of the person (Edna) in her
environment. The process also leads to a vision of the
person’s future, a set of goals and objectives and methods
for actualizing these life goals. The reader is referred to the
work of Beth Mount and John O’Brien and colleagues (Beth
Mount - 1987 - Personal Futures Planning:
Finding
Directions for Change. Available From Graphic Futures,
Inc.; O’Brien, John, and Lyle, Connie - 1987 - Design for
Accomplishment.
Available from Responsive Systems
Associates.)
2.
Positive Programming. Behavior problems frequently occur in settings
that lack the opportunities for and instruction in adaptive, age-appropriate
behavior. It is our assertion that environments that provide programs to
promote the development of functional, domestic, vocational, recreational,
and general community skills is procedurally important in our efforts to
ameliorate problematic behaviors. To the extent that Edna exhibits a rich
Assessment and Intervention Plan
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repertoire of appropriate behaviors that are incompatible with the
undesired behavior, the latter should be less likely to occur. Positive
programming, therefore, should be effective not only in developing Edna’s
functional skills, but also in reducing the occurrence of the problematic
behaviors. At the very least, a context of positive programming should
make it feasible to design effective interventions for effectively managing
Edna’s behavior problems. In the following paragraphs, several initial
thrusts for positive programming are presented:
a.
General Skills Training.
1)
2)
Putting On Make-up.
a)
Rational / Logic.
Edna is very proud of her
appearance and enjoys putting on make-up.
However, my obserevation was that she does not
have this skill well developed. To help her with her
own self-image and to improve her appearance to
others, it will be important that she develop this skill.
b)
Objective. Within 6 months of the full-implementation
of this support plan, Edna will put on her make-up;
including eye liner and shadow independently.
c)
Method. First of all, an assessment of Edna’s
proficience in this area should be determined. The
steps of putting on make up will be listed in a Task
Analysis. Using modeling and verbal support, a
whole-task presentation strategy should be used to
teach this skill.
Preparing a Meal.
a)
Rationale / Logic. It is doubtful that Edna has ever
had the opportunity to prepare a meal for herself and /
or a friend. Having this skill will contribute to her
independence as well as improve her social skills.
b)
Objective. Within 90 days of the initiation of this
plan, Edna will prepare a cooked meal for herself and
a friend (initially staff) one time a week with no more
than verbal assistance.
c)
Method.
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b.
•
Task Analysis. Edna in conjunction with her
staff will select a meal to prepare. The steps
to pepare the meal will be written in step-wise
fashion beginning with preparing a menu of
ingredients, shopping for the ingredients,
preparing the worksite, and cooking the meal.
•
Assessment.
Under natural conditions,
Edna’s abilities in these areas will be
determined. That is, for each step of the task
analysis staff will note the level of support that
she requires (e.g., independent, verbal
directions, gestural prompts, etc.).
•
Teaching the Task. Under natural conditions
Edna will prepare the identified meal at least
once a week.
A whole-task presentation
should be used with prompts being provided
when and where necessary. Prompts should
be faded. The maximum level of assistance
provided by staff on each step, should be
recorded.
Teaching Functionally Equivalent Skills.
1)
Communicaton Skills.
a)
Rationale / Logic. This is truly an Ecological
Approach, but it fits nicely at this point in Edna’s Plan.
She has the skill to say “No!” ; to say that she wants
to do it later, to say that she is bored, to say leave me
alone, to say she doesn’t want to do it. For this
support plan to be successful, Edna must be GIVEN
PERMISSION to refuse, to assert herself USING HER
WORDS. But, since she has been engaging in self
injury and physical aggression as a form of
communication most of her life it may take some time
for her to figure out that she doesn’t have to hurt
herself or others.
b)
Objective.
(1)
Given 10 scripted vignettes Edna will correctly
verbalize the solution to the problem 10 of 10
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trials within 3 months of the initiation of
services.
(2)
c)
Given 10 scripted vignettes Edna will correctly
role-play the solution to the problem 10 of 10
within 6 months of the initiation of services.
Method. Teaching Edna to verbalize he needs (e.g.,
denial) may involve the following steps:
•
Make a list of activities that Edna would
typically refuse.
•
Select one of these for training.
•
Talk to Edna and discuss how, when she
doesn't want to engage in the activity, she can
say "no," "later," "wait," "I’m busy," etc.
•
A dialog should be developed in which there is
a script describing the specific action
requested of Edna, and Edna’s verbal and nonverbal response. For example:
Staff. "Edna. It’s time to do the laundry."
Edna.
"I don't want to do the laundry now.
How about later?" Edna gestures to the
mentor “away.”
•
Edna and staff should role-play the identified
scripts. If Edna has difficulty with the “session”
like condition of role-play, she can be asked to
assist practice some strategies that are to be
used with other consumers.
•
The roles should be reversed so that Edna has
the opportunity to see (modeling) the mentor
engage in critical elements of the message
(e.g., facial characteristics, verbal intonation,
body carry).
•
Once Edna has shown competence with the
scripts, probes should be conducted at other
times. Initially the time that the probes should
Assessment and Intervention Plan
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be conveyed to Edna.
should be unannounced.
c.
Later, the probes
Teaching Functionally Related Skills.
1)
Incident Based Social Skills Training.
a)
Rationals / Logic. Anger management groups as
well as many other forms of social skills training are
designed to teach a broad range of skills that can be
used by most people in social situations. Incidentbased social skills training, on the other hand, is
specifically designed to teach social problem solving
skills that are idiosyncratic to the person.
b)
Objective(s).
c)
(1)
Given 10 identified antecedents for Edna’s
behavior challenges, Edna will correctly
verbalize the solution (i.e., appropriate
response) 10 of 10 trials within six months of
the initiation of services.
(2)
Given 10 identified antecedents for Edna’s
behavior challenges, Edna will correctly role
play the solution (i.e., appropriate response) 10
of 10 presentations within 12 months of the
initiation of services.
Method.
Step 1. Edna’s special incidents reports, ID Notes,
and Restraint Logs contain descriptions of a whole
array of social situations in which she has had
difficulty. An intensive review of incident reports over
the past five years should be conducted. From these,
incidents that include cursing, property destruction,
physical aggression and self-injurious behavior (i.e.,
Anger Outbursts) should be extracted.
Step 2. For each incident, a script should be written
that includes the antecedent (i.e., cues) and a series
of solutions.
Assessment and Intervention Plan
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Antecedent #1:
"Edna, you can’t have
something to eat right now."
Solution #1: "That's not fair, I'm an adult. I
have the right to eat if I want.”
Antecedent #2: "Edna you need to do this right
now."
Solution #1: "I can't do it now.
middle of something."
I'm in the
Solution #2. "As soon as this program is over."
Step 3. Verbal Competence. For each of these
scripts, it must be determined that Edna can verbalize
the solutions for each antecedent. For example,
"Edna, what could you do if someone told you that
you couldn't have something to eat?"
The
correctness, or lack thereof, on each vignette should
be recorded.
Step 4. Role Playing Competence. Once Edna has
demonstrated verbal competence, the vignette (i.e.,
script) should be "role-played" with Edna switching
parts so that she "has a view from both positions".
Her performance on each vignette should be recorded
as correct, prompted or incorrect.
Step 5. Generalization Probes. Once Edna has
shown proficiency in Steps 3 and 4, she should be
told that periodically her mentor will approach her for
an unscheduled practice vignette. Initially, the day of
the practice should be announced.
Teaching sessions should be conducted for
one or two 15-minute sessions each day. The results
should be recorded as described above. In addition,
reinforcement should be provided for participating in
the practice.
d.
Teaching Coping Skills.
1)
Relaxation Training.
Assessment and Intervention Plan
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a)
Rationale / Logic. The purpose of this type of
training would be to teach Edna relaxation as an
alternative, self-controlling strategy to be used when
she is agitated, tense, angry or upset.
b)
Objective. Within 6 months of the full implementation
of this plan, given the instruction “Let’s practice
relaxing,” Edna will be able to carry out the relaxation
procedure 10 of 10 trials without assistance.
c)
Method.
(1)
Initially, it will be important for Edna to practice
relaxation exercises when she is likely to be
most successful. Allow Edna to help identify
what times she is likely to be most calm
when practicing this skill. Some advisable
times to practice are prior to meals, prior to
making phone calls, prior to or immediately
after being read to, prior to transitions from one
activity to another.
(2)
When it is time to practice relaxation, Edna
should be asked, “What do we need to relax.
She should say,
•
•
•
•
(3)
Calm
Quiet
Relaxed Body
Relaxed Breathing
If Edna is unable to say these steps, say them
yourself then begin to model relaxation
techniques. Edna may follow your lead: Which
consists of:
•
Choose 5 different muscles. Then each
one at a time tense for two seconds
then focuses on relaxing the muscle.
•
Take 5 slows deep breathes through
your nose. Hold each breathes at least
one second then slowly let the air out
your mouth. While letting the air out,
slowly say the word, “R E L A X”.
Assessment and Intervention Plan
Re: Edna Carry
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•
(4)
When finished talk about how much
better you feel.
Once Edna has completed the three steps indicated
above: Verbally indicated what is needed to relax,
(calm, quiet, relaxed body, relaxed breathing),
Practiced tensing and relaxing five different muscles,
and Taken five slow deep breaths with pause then
slow exhale; Staff will:
1. Compliment Edna about how great her coping
skills are and talk about how much better they feel
after practicing their relaxation skills.
2. Immediately give her $2 of monopoly money per
the Daily Responsibilities protocol.
2)
Teaching Edna to Cope with Specific Antecedents.
(Planned Counterconditioning).
a)
Rationale / Logic. This strategy is quite similar to
Incident Based Social Skills training. The primary
difference is that the training will be taken beyond
incidents she has experienced in the past.
b)
Objective. Edna will complete a coping hierarchy
(presented below) for 2 identified antecedents within
12 months of the initiation of services.
c)
Method. As noted in the antecedent analysis, there
are several events that appear to cause Edna
considerable discomfort. This discomfort may be
experienced in the form of frustration, anxiety, or
anger. Her reaction to these emotions is one of
anger, upset, and if allowed to go unchecked, are
likely to culminate in property destruction, selfinjurious behavior or physical aggression. Some of
the events that may cause Edna to become angry
include telling her “no,” “criticizing her,” “a noisy,
hectic environment, etc. One way of helping Edna
overcome her reactions to these antecedent events is
to pair these events with the occurrence of powerful
positive events.
The following steps presents
Assessment and Intervention Plan
Re: Edna Carry
Page 80
general guidelines for the development
implementation of this therapeutic procedure:
and
•
Antecedent Stimulus. Select an event from the
above array for training (e.g., the word “You
can’t do that!”).
•
Competing Stimulus. Select an event that
Edna shows obvious signs of enjoying (e.g.,
eating specific foods or listening to her favorite
music).
•
Hierarchy. Arrange the events that cause
Edna emotional discomfort (i.e., anxiety, anger)
in a hierarchy.
The idea of the hierarchy, is
that events at one end (i.e., the bottom) cause
only minor frustration or anxiety, events at the
other end (i.e., the top) cause significant
discomfort, and events in between increase in
the level of anxiety that they produce as they
ascend the hierarchy.
An example of such a hierarchy for
being told “You can’t do that!” is shown below.
Level of Distress
10
5
1
Hierarchy Items
Person standing in front of Edna yelling at her saying “You
can’t go to the show unless you shape up. Your behavior
is so bad that you may never get to go to the show!!!”
Person standing in front of Edna saying in an very
assertive tone (but not yelling) “You will not be able to go to
the show because you haven’t earned it.”
Person standing at a distance from Edna, in a calm manner
saying, “We can’t go to the show tonight, but we can go
tomorrow.”
•
Response Scenario. For each item on the
hierarchy, Edna and her mentor should devise
a verbal and / or non-verbal response for her.
This should be in the form of a script that
describes what she should say and how she
should conduct herself as the antecedent is
presented.
Assessment and Intervention Plan
Re: Edna Carry
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•
Sessions.
Sessions should planned and
scheduled. They should be relatively short, not
exceeding about 20 minutes. They may need
to be extremely brief at the beginning.
Sessions should be conducted at least 3 times
a week.
•
Sharing. The session should begin by picking
a small, low-calorie snack that will be available
during the session. As the session continues,
the snacks will be freely available to Edna; that
is, she and her mentor can freely snack as they
practice. The conceptual framework driving
this procedure would suggest that the pleasant
feelings associated with eating would
neutralize feelings of anxiety and would
transfer the scenarios presented to her.
•
Criteria. If Edna completes 5 sessions in a row
without showing signs of being upset, then next
session should begin with the next higher item
on the hierarchy.
•
Data Collection. For each session, Edna’s
level of agitation should be scored using a
“pass” / “fail” system.
•
This process should be continued until all of
the items on the hierarchy have been
addressed.
Once the response to the “first antecedent”
has been counterconditioned, then a new antecedent
(See Antecedent Analysis) should be selected for
treatment.
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 Edna, 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.
Assessment and Intervention Plan
Re: Edna Carry
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a.
b.
Antecedent Control Strategies. By knowing the antecedent
conditions where behavior is more likely or less likely, seriously
challenging behaviors may be either eliminated or significantly
reduced.
Some beginning antecedent control strategies are
presented below.
•
Do not have men responsible for Edna. Her team, initially,
should be made up of women.
•
Do not have people who work with Edna who are
authoritative, demanding, or who are likely to take her
behavior personally.
•
Do not touch Edna in an attempt to force her to carry out an
activity. If she says “No!” respect the message.
•
Eliminate the use of aversive consequences, since these are
likely to escalate her behavior. Privilege “freezes,” time out
from positive reinforcement, and physical restraint should be
eliminated. Physical intervention should only be used under
conditions in which Edna is in imminent danger of injuring
herself or others (not for refusal, or screaming, or for
threatening verbally, or for property destruction).
•
Do not demand.
way.
•
Do not verbally nag Edna with the idea of verbally “making
her.” If she says no, respect the message. Let her support
plan encourage her to do the things that are important to her
future.
•
Do not ignore Edna. When she attempts to get attention,
respond immediately. With time, she will learn to cope with
“waiting,” “denial,” etc.
Request, ask nicely, negotiate another
Differential Reinforcement of Alternative Behavior (Alt-R).
1)
Chores and Responsibilities.. Edna and her mentor should
develop a list of chores and responsibilities that need to be
completed daily and weekly. These might include the
following:
•
completing daily hygiene / grooming activities
Assessment and Intervention Plan
Re: Edna Carry
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•
•
•
•
•
•
•
following the daily schedule
participating in relaxation training
participating in counterconditioning sessions
preparing evening meal
setting the table
after-dinner cleanup
Etc.
To enhance the likelihood that Edna will participate,
where appropriate Edna and her mentor will do the daily
activities together. In some instances (e.g., hygiene) it will
be completely Edna’s responsibility.
2)
Self Control Checksheet.
A checksheet should be
developed that lists the responsibilities and WHO has been
assigned to that responsibility.
At the completion of each
item listed on the checksheet, Edna and mentor will COSIGN to indicate that the activity / event was completed to
the desired level. A space where both have signed (i.e.,
COSIGNED) will be considered a point or a token. An
example of such a checksheet is presented below:
Daily Responsibility Checksheet
Responsibilities
M
T
W
Completes Daily Hygiene / Grooming
Th
F
Sat
Sun
(Note: This area might be made more
specific
per each hygiene / grooming activity)
Follow Daily Schedule
Participate in Relaxation Training
Participate in Counterconditioning
Prepare Evening Meal
Clean Up After Dinner
Total Signatures
3)
Shaping. The list of responsibilities should be limited to
begin with. As Edna develops a tolerance, more items
should be added to the list of chores and responsibilities.
4)
Backup Reinforcement. At the end of the day, the number
of TOKENS earned for that day should be counted.
A
Assessment and Intervention Plan
Re: Edna Carry
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menu of potential reinforcers should be developed (e.g.,
money, special magazine, one piece of special makeup,
etc.).
The opportunity to make a choice from the menu
should be based on the percentage of tokens earned for the
day beginning at 50 percent. That is as Edna has earned a
greater percentage of tokens (e.g., 50, 60, 70, 80, 90, 100
percent) more powerful reinforcement can be earned.
Each day that Edna earns at least 80 percent of the
available tokens, she should receive a “certificate.” Once
she has accumulated four “certificates” she should have the
opportunity to pick another reward that is worth 4 days of
work.
c.
Differential
Reinforcement
of
Other
Behavior
with
Progressively Increasing Reinforcement (DROP) for
Self
Injury, and Physical Aggression. (Note: This recommendation
is based on the assumption that Edna has the numerical skills to
understand “hundreds.”
Records did not elaborate on the
presence or absence of this ability. If she does not have the
numerical skills, then the procedure will need to be adapted to meet
her numerical abilities. For example, it may be necessary to divide
all of the numbers by ten. Or it may be necessary to convert the
entire system to a visual display in which the accumulation is
represented visually, thus not requiring advanced numerical skills).
1)
Using a DROP, the person is reinforced for the absence of
the target behaviors. For each consecutive interval without
the occurrence of the behavior, the amount of reinforcement
increases.
2)
Initially, Edna should be reinforced for the absence of the
most severe topographies of her “Anger Outbursts;” namely,
physical aggression and self injury.
3)
Edna should be reinforced for every 4 hours without these
behaviors. The chart below reflects the number of points
Edna should be given for the absence of these behaviors.
•
For the first interval without these behaviors, Edna
should be given 30 points.
•
For the second consecutive interval without these
behaviors, Edna should be given 40 points.
Assessment and Intervention Plan
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•
For the third consecutive interval without these
behaviors, Edna should be given 50 points.
•
For the fourth consecutive interval without these
behaviors, Edna should be given 60 points.
•
For the fifth consecutive interval without these
behaviors, Edna should be given 140 points.
4)
If Edna goes through the entire day without physical
aggression she would earn 320 points. Similarly, if she goes
through the entire day without self injury, she would earn 320
points. Initially, she would have the capacity to earn 640
points per day. The table below shows the escalation. Two
other behavioral topographies are shaded out. These would
be added to the token system at a later date.
5)
When Edna engages in a physically aggressive or self
injurious act, no points would be earned. For the next
successful interval without the behaviors, she would begin
back a the beginning of the escalation (30 points).
Behaviors
DROP
Escalation
Physical Aggression
Self Injury
Property Destruction
Verbal Aggression
Toward Others
10
10
5
2
Totals By Shift
10 PM 6 AM 10 AM
to
to
to
6 AM 10 AM 2 PM
30
40
50
30
40
50
5
10
15
4
6
8
60
6)
80
100
2 PM
to
6 PM
60
60
20
10
6 PM
to
10 PM
140
140
50
12
Total
120
280
640
320
320
100
40
Edna can earn a maximum of 640 points each day. The
points can be exchanged for money according to the
schedule presented in the table below:
Assessment and Intervention Plan
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Percentage of
Points Earned
Daily
Points
100 %
90%
80%
70%
60%
50%
40%
30%
20%
10%
640
576
512
448
384
320
256
192
128
64
7)
Dollar
Conversion
2/23/97
$6.50
$5.75
$2.00
$1.75
$1.50
$1.25
$1.00
$.75
$.50
$.25
The following scenario shows the impact of one physical
aggression on Edna’s potential earning for the day. In this
scenario, one physical aggression occurred during the 6 to
10 AM interval. No points were earned for that interval, and
the earning was recycled back to the beginning of the
escalation. As a consequence, Edna would have earned
470 points by the end of the day, which would be exchanged
for $1.75
Example Scenario #1
Behaviors
DROP
Escalation
Physical Aggression
Self Injury
Property Destruction
Verbal Aggression
Toward Others
10
10
5
2
Totals By Shift
10 PM 6 AM 10 AM
to
to
to
6 AM 10 AM 2 PM
30
0
30
30
40
50
5
10
15
4
6
8
60
40
80
2 PM
to
6 PM
40
60
20
10
6 PM
to
10 PM
50
140
50
12
Total
100
190
470
150
320
100
40
Assessment and Intervention Plan
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Edna’s Point Chart
Behaviors
DROP
Escalation
Physical Aggression
Self Injury
Property Destruction
Verbal Aggression
Toward Others
10
10
5
2
Date: ________________
10 PM 6 AM 10 AM 2 PM 6 PM Total
to
to
to
to
to
6 AM 10 AM 2 PM 6 PM 10 PM
Totals By Shift
d.
Differential Reinforcement of Other Behavior (Layered).
Physical aggression and self injury have kept Edna out of the
community most of her life. Given the impact of her behavior it is
logical to make every effort to create motivation that is so powerful
that Edna would have difficult not participating. Therefore, a
second, source of motivation is recommended around these two
behaviors.
1)
General. Using this strategy, the person is reinforced for the
absence of specified behaviors for fixed periods of time.
2)
Time Interval. The method suggested for Edna initially is a
Fixed-Time DRO which has as its base a 24 hour day.
3)
Daily Procedure. For each day without the occurrence of
self injury or physical aggression, a signature will be placed
on a 3 by 5 inch card that has been segmented into four
parts.
4)
Level One Reinforcement. Once a card is filled with
signatures, Edna should have the opportunity to select from
the Level One Menu. The items on this menu should be
worth working approximately four days.
5)
Long-Term Procedure. The completed signature cards
should be saved.
Once Edna has accumulated 20 cards,
she should have the opportunity to select from the Level Two
Menu. The items on this menu should be worth working
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approximately 20 days. Items on this menu might include
trip to Disneyland or Magic Mountain, visiting a water park,
etc. (Note: While these may seem expensive, they do not
compare to the impact of Edna’s behavior.)
4.
Reactive Strategies.. Efforts to manage the antecedents to Edna’s
behavior are likely to have considerable benefit. However, these behaviors
are likely to continue in spite of such efforts. Staff / Mentor will need
measures for dealing with these behaviors when they occur. The
following procedures are suggested as initial reactive strategies. These
procedures and others are explained in more detail in the "Emergency
Management Guidelines” published by IABA.
a.
Don’t Ignore. If Edna is upset, it will do no good to ignore her.
There is good evidence that ignoring will only exacerbate the
problem Without some response, Edna is likely to continue to
escalate.
b.
Help Her Communicate The Problem. When Edna escalates,
there is usually a good reason in her mind.
•
Use Active Listening to help Edna express the nature of the
problem. Active Listening itself may help de-escalate the
problem by just providing an “understanding ear.”
•
Ask strategic questions to help Edna express the problem.
Indeed, you may know the problem. Ask her what is
bothering her. Ask her if she has a problem.
c.
Help Her Solve The Problem. Once the problem is identified,
discuss with Edna some ways to solve the problem.
d.
Negotiate.
Edna may feel that what is being asked is
unreasonable. Discuss with her the problem and negotiate a
solution (e.g., “One more and we are all done.” “Why not stop and
come back to it later.”
e.
Facilitate Communication and Relaxation. Prior to engaging in
physically assaultive, property destruction or self injury, Edna may
appear to be agitated or angry. Intervention at the time she
manifests these precursors may reduce the likelihood of more
severe behaviors appearing. Thus, the following approach is
suggested.
Assessment and Intervention Plan
Re: Edna Carry
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When Edna initially displays agitated actions or appears to
be angry, staff should encourage her to verbalize or in some way
communicate her problem. Every effort should be made to actively
listen to messages that she is sending at the moment (e.g., "Leave
me alone." "I don't want to do this.").
If Edna continues to be agitated, staff should use the "Cued
Relaxation" procedures described above. Basically, she should be
encouraged to relax her hands and arms, and to breath deeply and
slowly. These instructions should be presented slowly and in a low
voice, and with gestures that are consistent with directions to calm
down.
Edna should be encouraged to move to a quiet area where
she can better gain control. Her mentor might say to her “C’mon
Edna. Let’s go to your room where we can talk privately.” Once
there Edna should be encouraged to turn on her favorite “calming
music.” Calmly, quietly, using active listening along with gentle
suggestions, the mentor should help Edna discuss the problem she
is having and help her to gain control.
f.
Stimulus Change Strategies. At the time of an incident, or as
Edna is escalating, the introduction of a novel stimulus may
interrupt the course of or terminate aggressive and self injurious
actions. For example, a loud noise, a flick of the lights, a staff
member doing something entirely unexpected (e.g., singing and
dancing) might stop the occurrence of the behaviors. For example,
I had a recent experience with a potentially dangerous behavior
where stimulus change saved the moment. While I was consulting
at a group home, one of the young residents (about 10 years old)
was exploring how he could part a cat’s head from the rest of his
body. The cat was showing signs of being noticeably upset. A staff
member was attempting to disengage the child from the cat, but
gently because a forceful action could be dangerous to the cat’s
ninth life and would surely result in a serious physical altercation
between the staff member and the child. At that instant, I jumped
up and went running through the house and outside screaming that
someone was taking my surfboard. Not three seconds later, the
boy who was hurting the cat came to the door and said "Tom, what
happened?" Importantly, he did not have the cat in his hands - but I
saw it heading for open fields in the back yard. This is an example
of stimulus change.
g.
Instructional Control. Providing an instruction that evokes a
competing behavior might stop an aggressive, property destructive
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or self injurious episode (e.g., "Give me the ." "Get me the ."
"Help me ."). Asking a question may evoke a response that also
competes with such behavior (e.g., “What did you do at
?"
"Where is your ?" "Where is your radio?"). Indeed, asking Edna
to help may interfere with her escalation or the ongoing occurrence
of the behavior.
h.
Geographical Containment.
(See 4.1 through 4.4 in the
Emergency Management Guidelines). I would like to suggest just
a couple of examples of this treatment strategy that may apply
particularly to Edna. For example, when Edna is coming toward
staff to be aggressive, they should not stand there in the open with
hands and body bared, prepared for physical contact. Rather,
unobtrusively staff should move themselves behind a table, a
couch, a large tree, a bush, etc., and keep the object between them
and Edna. At the same time, the de-escalating verbalizations
described above should be used. This is an example of judiciously
using the environment to reduce the likelihood of physical contact.
If Edna is approaching another person (e.g., child or adult), it may
be necessary for staff to place their body between Edna and her
target. This can be done in a "bumping" fashion as staff might be
using a range of stimulus change and instructional control
strategies.
i.
Physical Containment. (See through 5.10 in the Emergency
Management Guidelines). As noted previously there is a likelihood
that staff will be assaulted. Physical containment should be the
last resort considered as a method of management. There is no
reason where a single blow or contact needs to be contained
physically. Physical containment should only be used when a an
assaultive or property destructive act involves several blows, and
physical intervention is "the only way to stop the blows." However,
if it is determined that it is needed, it should only be carried out by
persons who have been certified in the use approved strategies
(e.g.,).
I suggest that everyone who works with Edna be "overtrained" on methods of managing physical aggression specifically.
j.
The Edna Carry Almanac. Prior to beginning services, and as an
ongoing process, a document should be developed that contains
methods of solving everyday problems / issues that might arise
when working with Edna. The term we use to describe such a
document is an Almanac of Solutions.
Topics that might be
contained in this Almanac include the following:
•
refuses to go to school
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5.
•
wants to leave the apartment at midnight
•
not feeling well, but it is shopping day
•
goes AWOL and is missing
Staffing Resources, Staff Development and Management
Systems.
a.
Organizational Structure of Treatment Resources. Edna has
not had the opportunity to participate in a comprehensive program
designed to meet her needs. It is important to understand that if
Edna is going to be successful in the community the organizational
structure of her service will need to be clearly specified. Some
tentative roles and responsibilities of Edna’s team are described
below:
1)
Residential and Day Program Providers. The service that
takes
responsibility
for
implementing
these
recommendations must have a commitment to Edna as a
person first, and to the non-aversive clinical management of
her behaviors. Without this philosophical commitment, I am
sure that these recommendations will not be carried out to
their fullest, and that little effort would be taken to modify and
expand them creatively.
2)
Clinical Supervisor. This person should be a licensed
psychologist, or Ph.D. level Behavior Analyst, who has
extensive (at least 5 years) experience designing, and
supervising non-aversive treatment packages for persons
with severe challenging behavior. This person would have
the overall clinical responsibility for the integrity and ethical
conduct of Edna’s support plan. In addition to providing
behavioral expertise, this person should be able to provide
non-behavioral clinical insights into Edna’s service. The
clinical supervisor should review Edna’s overall program at
least weekly. The clinical supervisor should have the
experience and skills to re-assess on a regular basis, to
troubleshoot programs, and to design and to modify
programs based on objective data and staff reports.
3)
Program Supervisor. It will be critical that a person be
appointed who will have the primary responsibility for
insuring the day-to-day and moment-to-moment operation of
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Edna’s program. This person’s role would include consulting
with direct service providers (i.e., mentors), conducting
competency-based and three-tiered training, conducting
reliability checks and Periodic Service Reviews, and acting
as back-up for Edna’s mentor. The Program Supervisor
should have at least a Bachelor’s Degree, should have two
years experience using non-aversive strategies with people
who manifest challenging behaviors, and should have basic
training in the field of Applied Behavior Analysis. I estimate
that the Program Supervisor will need to be available about
16 hours a week in the beginning; but no less that 4 hours a
week over time.
4)
b.
Direct Service Provider (i.e., Mentor). The concept of a
mentor was discussed above. Edna will require one to one
support if the above recommendations are to be carried out.
The person(s) who provide this service should have at least
one year experience implementing behavioral support to
people with behavioral challenges. They also should have
the ability and motivation to carry out the non-aversive
supports described above.
Staff Training. Edna will require good, supportive, structured
support throughout her waking day. Those who work with her will
need a great deal of sophistication to be successful with her and for
Edna to be successful.
A key element that will determine the
degree of success of Edna’s support plan is staff competence. In
order to insure that each staff person is “competent,” the following
guidelines are suggested:
1)
General Competency Based Training. Those who work
with Edna should have a good understanding of the basic
concepts that underly Applied Behavior Analysis and more
specifically, non-aversive approaches to solving behavioral
challenges. I suggest that each staff member (i.e., mentor),
and program supervisor participate in a training program
similar to the Competency Based Training Program provided
by IABA. This program is a self-instructional training course
that certifies staff who work with people who have
challenging behaviors. To demonstrate competence, staff
must meet specific criteria on objective tests, during field
assignments, and / or during role plays. Some topics
addressed in this training include the following:
•
Orientation
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
2)
Administrative Requirements
Full Inclusion
Ethical Issues
Public Relations
Managing Client Records
Basic Principles of Behavior
Instructional Strategies
Positive Reinforcement
Data Recording
Behavior Assessment Report and Recommended
Support Plan
Positive Programming
Reducing Behavior Problems
Evaluation and Troubleshooting
Generalization and Maintenance
Three-Tiered Training. The purpose of this training
is to insure that each person who works with Edna
has competency at the verbal level, role playing level
and real life implementation level.
a)
Procedural Protocol Development. Each
therapeutic procedure should be broken into
teachable steps. For example, every action a
staff person would be required to make in order
to operate Edna’s DROP program would be
listed in order, including tone of voice and
content of communication.
b)
Verbal Competence. Each staff person should
be required to show “verbal competence” in
each procedure. That is, they should be able
to describe each and every step of the specific
procedure. Each staff should be scored using
a “+” / “-” system for each step of the
procedure.
An 85% criterion should be
considered passing.
c)
Analog Competence.
Each staff person
should be required to show “role-play
competence” in each procedure with the
Program Supervisor. That is, they should be
able to demonstrate each step of a procedure
to the program supervisor. The scoring system
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would be identical to that described in “b”
above.
3)
d)
In-Vivo Competence. Finally, each staff
person should be able to demonstrate “in-vivo”
procedural reliability; that is, the ability to carry
out each program component in the
environment where will be used. This would
require the Program Supervisor to observe
each staff person as they carry out Edna’s
support plan to see the degree to which what
they do agree with the written protocols. The
scoring procedure described above should be
used here also. Again, 85% agreement would
be considered minimal program efficiency.
e)
Procedural Reliability. Procedural Reliability
should be checked on a monthly basis as part
of regular supervision. Staff should maintain
an 85% Level.
Emergency Management Training. While we
indicate that physical intervention should be the last
resort with Edna, those who work with her must be
prepared for a possible aggression. Given that the
possibility of aggression exists, staff need to be
trained to protect themselves and others. Those who
work with Edna should have two forms of training:
a)
Emergency / Crisis Management within a
Non-Aversive Framework. Those who work
with Edna should have intensive training
around the many ways that they can react in
emergencies without using physical methods.
Such a course is provided by IABA and is
contained in the Emergency Management
Guidelines published by IABA.
b)
State Certified Training. Since there is some
likelihood that staff will be physically assaulted,
those who work with Edna should receive
certification in one of a variety of Emergency
Management Courses - e.g., PART, CPI, MAB,
Mandt, etc.
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c.
Periodic Service Review (PSR).
All of the major
components of Edna’s support plan should be checked for
implementation consistency at least monthly. The Periodic
Service Review has demonstrated effectiveness in this area
(See Gary W. LaVigna, Thomas J. Willis, Julia F. Shaull,
Maryam Abedi, Melissa Sweitzer. Periodic Service Review:
A Total Quality Assurance System For Human Services and
Education.).
COMMENTS AND RECOMMENDATIONS
1.
Edna has a long history of severe behavior problems. The nature, frequency,
and intensity are such that Edna has not lived in the community most of her life
and has not been off the grounds of a Development Center for perhaps 10 years.
It is my opinion, that the failures of previous efforts to manage Edna’s behavior
cannot be attributed to Edna. Rather, the lack of a comprehensive behavioral
assessment to guide her services as well as the lack of an individualized
behavior plan and over reliance on aversive methods may have contributed in
some way. While treatment services have been provided in the past, they have
lacked the comprehensives necessary to meet Edna’s needs. To this point in
time, she has not had the benefit of a comprehensive behavioral support plan. It
is time!
2.
There is nothing endemic to Edna’s behavior that would prevent her from
participating in community-based services. However, for Edna’s behavioral
needs to be met effectively, she will require the intensive delivery of behavioral
support services throughout her entire waking day (i.e., The Mentor Delivery
System).
Without this level of services, it is unlikely that the above
recommendations can be carried out with sufficient consistency to be effective.
_______________________________
Thomas J. Willis, Ph.D.
Associate Director
_____________________
Date
_______________________________
Gary W. LaVigna
Clinical Director
_____________________
Date
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