NOTE: This report was written by a participant in Institute for Applied
Behavior Analysis’ Summer Institute (http://www.iaba.com) on
“Assessment and Analysis of Severe and Challenging Behavior.” All
identifying information has been changed. This report is presented as an
example of the type of report that participants will be able to write after
completing the course.
COMPREHENSIVE FUNCTIONAL ASSESSMENT REPORT
AND RECOMMENDED SUPPORT PLAN
Client Confidential
Date of Report: July 27, this year (draft)
Referral Date: July 1, this year
Period of Report: July 26 – August 4, this year
IDENTIFYING INFORMATION
Name: Jane Doe
Date of Birth: July 2, 1976
Address: Any Lane, Apartment 2
Any Town
Referral Source:
Tina Timmons, Manager, Supported Employment Service
REASONS FOR REFERRAL
Jane was referred for an evaluation by Tina Timmons, manager of the
Supported Employment Service, Inc (SESI) program, a behavior management
day service that is a division of the Alphabet Program (ABCD). The purposes
of the evaluation were to assist Jane in securing the services and programming
which would enable her to develop and to use her capabilities, to get the most
out of the educational opportunities that can be made available to her and to
enable her to develop and to use her capabilities for more independent, normal
living and more productive activity than her behavior problems presently
permit. Accordingly, it was requested that the evaluation focus on these
behavior problems, which were characterized as physical aggression, verbal
aggression, anger management and problem solving, and the type(s) of
behavioral services, support strategies, programming, professional
competencies and skills, and environments required to eliminate, minimize, or
manage them.
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Specifically, Jane has engaged in aggressive behavior on an average of
approximately once per month over the past year. In March and April this year
she verbally and physically assaulted a member of her SESI-ABCD group on
three separate occasions, resulting in the other client’s withdrawal from SESI
as he feared future attacks. This was also followed by a period of sporadic
attendance at work her subsequent resignation to avoid losing her job. She
also moved from a group home setting to supported independent living in
March this year and started a new job July 5, this year with a new job coach.
Concern from SESI-ABCD staff seems to be that future episodes of similar
behavior could jeopardize her placement in the program and her current job.
Staff members supervising her supported living arrangement have not noted
any instances of aggression and are not concerned with this behavior at the
present time.
DESCRIPTION OF ASSESSMENT ACTIVITIES
The assessment is based on information obtained from the following
sources on July 26, this year:
A.
Interviews with Jane at her workplace (60 min.) and over the
phone (15 min.); with Mary Whitten, Jane’s current Employment
Specialist with SESI (20 min.); Charlie Quinton, Jane’s former
Employment Specialist with SESI (75 min.);and Kim Chow, SESI
Supervisor (90 min.);
B.
Direct Observations of Jane in her place of work (Wiener's are
Us) with job coach present (60 min.);
C.
Review of the SESI-ABCD case file and field notebook (180
min.);
D.
A Reinforcement Survey completed by Jane (obtained from SESI
file);
E.
Telephone Conference with Ginger Bertrulano, Manager for Help
Me (15 min.);
BACKGROUND INFORMATION
I.
Brief Client Description.
A.
General. Jane is a 24 year-old Caucasian female with light
brown hair and blue eyes. She is short (approximately 62 inches
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tall) and heavyset. She indicates that she wears size 20 clothing
and she appears to be about 200 pounds. She was wearing her
Wiener's are Us uniform at the time of the interview. It was clean
and properly fastened. Her face and hair were also clean. No
identifying marks or physical disabilities were visible or indicated
in the files. Jane was friendly and pleasant when interviewed.
Jane was diagnosed with Post-Traumatic Stress Disorder and
Mild Mental Retardation in May 1993 by Dr. William Webster,
psychologist at Saturn Hall. Documents in her SESI-ABCD file
indicate that she is also currently diagnosed with either
Schizoaffective disorder or Schizophrenia, although no
documentation was present supporting the either diagnosis.
Indeed, previous reports indicate that her reality testing was not
impaired and that her thinking was not disordered. A Counselor’s
Report from County Regional Center for Developmentally
Disabled Persons (August 20, 1984, when Jane was 8 years old)
indicates that Jane also carries a diagnosis of aphasia.
B.
Language and Communication Skills. Jane’s primary method of
communication is the spoken English language. Her speech is
clear and easily understandable. It is reported that she has a
repertoire of approximately 20 signs using conventional sign
language, which she learned while residing with her foster
mother, Snow White. All verbal and written reports indicate that
Jane’s communication skills are well developed, including the
ability to emit complex sentences. The writer observed that she is
able to articulate her likes and dislikes. She is also able to clearly
describe her job duties. Charlie Quinton, Jane’s former
Employment Specialist, told the writer that he sometimes
observes Jane using complex words out of context. He was
unable to give a specific example but stated a general belief that
her vocabulary exceeds her level of comprehension. The writer
also observed in the interview that sometimes when asked a
question, Jane would fail to respond. When the question was
broken down into shorter sentences and repeated, Jane would
respond to the question, suggesting that she did not understand
the question when it was first asked. It was also noted that Jane
thought that she had responded to the question when she had
not. For example, when the writer asked her why she had
discontinued counseling with Dr. Anything, Jane responded “I
quit”. With further verbal prompting she was able to tell the writer
that she left the counseling because she did not think she needed
any more help.
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Jane agreed to discuss her aggressive episodes with the writer
but told the story from a different point of view than staff reports.
In general, staff indicate that her descriptions of emotionally
charged situations are quite different from that of her peers or
staff. For example, there was a situation where she assaulted
another member of her SESI group. She acknowledged that she
slapped him with an open hand. When asked about the sequence
of events, Jane indicated that she observed this man touching
her friend in “the chest area”, she told him to stop, he tried to
retaliate and she hit him. She then says she left the area but
heard him talking about her and returned to slap him in the
shoulder. In the opinion of staff, however, no inappropriate
touching had occurred.
With respect to the aggression, it should be noted that numerous
messages are attributed to the cluster of aggression, tantrums,
and/or verbal or physical threats. Some staff believe that the
behavior is triggered by memories of childhood abuse and
communicates desire for person to stop activity that is bothering
her. Others hypothesize that the aggression is an expression of
frustration at the inability to have her needs met: “When she has
no other way out”. It should also be noted that an episode of
minor self-injury (picking at scabs on back of hand) seemed to be
an expression of anger towards a staff member who had refused
to comply with a request made by Jane.
C.
Cognitive and Academic Abilities. Formal testing conducted by
Dr. William Webster in 1993 placed Jane in the mildly mentally
retarded level of functioning. At the time, Jane’s Verbal IQ was
67, and her Performance and Full Scale I.Q.’s were both 66. Her
impairment was most severe on subtests measuring distractibility
from stimuli presented auditorily and anticipation of
consequences of social behavior. A psychological summary
completed by Dr. Hightower in August 1993 mentions earlier
psychological testing completed by Dr. Bully (no date or affiliation
noted). According to Dr. Bully, a large discrepancy was noted
between Jane’s verbal IQ (50) and performance IQ (80), resulting
in a full scale IQ of 63. This discrepancy was attributed to
“receptive and expressive developmental language deficits”. A
report written by Jennifer Tilley (Counselor) in August 1984
reports that Jane had been diagnosed with aphasia, defined as
“diminished ability to correctly use and comprehend language” in
the Dictionary of Developmental Disabilities Terminology (p. 20;
Accardo, P.J. & Whitman, B.Y., 1996). The documentation
supporting that diagnosis was not available.
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Jane graduated from Pumpkin High School with her high school
diploma. All available records indicate that she was in special
education classes for the majority of her tenure at school. She
was registered in classes at local Community College last year
but attended for just a few days before dropping out. She is not
currently expressing interest in further academic pursuits.
Jane can sign her name independently, address an envelope and
mail a letter. She can usually complete a job application
independently, but may require some verbal prompting. She can
read simple recipes and instructions and has used the want ads
to do a job search. Reading is not a pastime for Jane. Charlie
Quinton estimated that she can read at a grade four or five level.
No formal testing was available in this regard.
Verbal reports indicate that Jane can add, subtract and multiply
but cannot perform division. According to Charlie Quinton, Jane
has difficulty making change and relies on a calculator to assist
her with most math functions. Regarding measurement skills,
Jane did indicate that she has recently lost weight, suggesting
that she weighs herself. The writer, however, was not able to
determine how accurate she is in weighing herself. Recipes that
she prepares independently would probably not involve
measurement (e.g. ground beef with peppers and onions). Jane
knows what time she needs to catch her bus, what time she
needs to transfer, and what times she starts & finishes work.
When asked to describe what she does on the weekend,
however, Jane began to describe her weekly activities. She is
able to differentiate between the days that she is and is not
required to be at work.
D.
Self Care Skills. Verbal and written reports from staff indicate
that Jane is completely independent in her self-care abilities. It is
worth noting that at the last reported dental examination Jane had
23 cavities, suggesting that she has or had some difficulty
brushing her teeth. The residential support services manager
indicated that in-home staff check to ensure that her grooming is
completed but previous reports indicate that she is completely
independent in this area.
E.
Domestic Skills. Verbal and written reports from staff indicate
that Jane can complete all indoor maintenance tasks
independently. The writer was not able to verify her skill level as
her home was not directly observed. Jane completes her laundry
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independently. There are laundry facilities at her apartment. She
spontaneously informed the writer how much it costs for her to
wash and dry her laundry. Jane is able to prepare her own meals.
She described the SESIs to prepare a fried egg sandwich, one of
her favorite quick meals to prepare. Written reports describe that
she is able to prepare complex meals independently but
residential support staff indicate that she requires verbal
prompting to prepare a novel or complex recipe.
F.
Community Skills. Jane takes the bus to work independently
from her apartment. She was able to describe the routes and
schedules of the two buses she takes to get to work. The bus ride
takes approximately one hour each way. A progress report from
Map, the agency that operated Jane’s former group home, dated
February 1, this year indicated that she was using public
transportation independently. However, one of the learning
objectives established by Help Me was to teach her the route to
work, which she successfully learned. The type of instruction
used was not specified. The writer hypothesizes from this
information that Jane requires some assistance to learn novel
bus routes. She has walked from her job to her SESI group when
her bus pass was not available.
Residential support staff accompany Jane to complete her
grocery shopping. The purpose of the assistance is primarily to
provide verbal prompts to ensure that Jane remains within her
budget for groceries.
Jane currently completes an emergency skills checklist on a
monthly basis as part of her SESI-ABCD behavior support plan,
which includes ensuring that she is carrying her identification.
Jane has consistently been meeting the criteria in the checklist
for the last 6 months.
Money management is consistently identified as an area of
difficulty for Jane. Budgeting skills were targeted by Map as an
opportunity for learning for Jane and are currently targeted by the
SESI-ABCD program as well. Jane consistently states that she
does not require assistance in this area and no formal protocol is
currently in place. Previous reports from residential care services
indicate that she gives money away freely and has incurred debts
of over $1000.00. Since resuming employment, she reports that
she has opened a bank account. She was able to report to the
writer the amount of money that is set aside from her social
assistance check each month for rent ($420.00 paid by direct
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deposit), for groceries ($150.00) and for laundry ($20.00). She
was able to report how much she had earned on her first
paycheck from Wiener's are Us ($214.00) and how much she had
spent from her paycheck (e.g. $25.00 to purchase a kitten). When
asked by the writer how much money she had left over from her
paycheck, she did not respond. When prompted she indicated
that she did not know but was sure that she would have enough
money. She also stated “When I go shopping, if I see something I
like, I buy it”. She did not show recognition, even when prompted,
that she might have to consider how much money she had left in
her budget before purchasing a particular item. According to
Charlie Quinton, former Employment Specialist, Jane would also
ask other members of her SESI group for money, sometimes
even threatening them to obtain it.
G.
Recreation and Leisure Skills. Jane indicates that she enjoys
shopping, going to movies, watching television, and going to
church. She attends church at Rolling Hills Covenant Church
every Sunday and describes this as a good opportunity to
socialize with non-consumers. She also goes to swap meets to
shop on the weekends. Jane also indicated that her friends Bruce
Lee and Brandon Lee occasionally come to visit her on the
weekends. However, none of the staff interviewed have met
these friends. By her description, she spends most of her
evenings and several hours on the weekend watching television.
Some of her favorite television shows are “Touched by an Angel”,
“The Drew Carey Show” and “Twice in a Lifetime”.
H.
Social Skills. Reports about Jane’s social skills are conflicting.
Her current job coach, who has worked with her for approximately
three weeks, has not observed any difficulty getting along with
co-workers. She described an instance when Jane talked with a
co-worker spontaneously about what to do with her pet fish when
she buys a kitten. The co-worker responded positively by asking
her if she could help by taking the fish for Jane. The writer
observed Jane saying hello to her co-workers. She smiled, made
eye contact and shook hands with the writer when approached
for introductions.
Topics of conversation that were not in response to direct
questions were expressions of physical concerns (i.e. describing
knee problems, describing surgery in February), pets, boyfriend,
and favorite television programs.
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Reports from her former job coach, Charlie Quinton, are quite
different. He describes her as having difficulty initiating and
maintaining friendships. Apparently she developed a close
relationship with a same-age female co-consumer who was in the
same SESI group with her. They worked together at Come-view
Video and spent time socializing outside of group time, attending
swap meets and movies together. When her friend moved to a
different job site the frequency of contact was reduced. No one
interviewed could indicate how often Jane currently has contact
with this individual, if at all. Some staff interviewed had the
impression that Jane emulated this individual. One example cited
was that when Jane’s friend left Come-view Video, Jane wanted
to leave Come-view Video within one week. Another example
given was that when this individual recently became engaged,
Jane started to talk about becoming engaged to her boyfriend. It
should also be mentioned that the aggressive episode that Jane
described to the writer involved this young woman. Jane
indicated that she thought that another member of the group was
touching her friend “in the chest area”. She claims that she hit this
individual in an effort to protect her friend. Some staff interpreted
the episode as Jane expressing jealousy at her friend spending
time with someone else. Charlie Quinton described Jane as liking
“to be the center of attention”.
Jane is very interested in having a boyfriend. She indicates that
she currently has a boyfriend whom she sees a couple of times
per week. She announced in the interview with the writer that she
will be getting engaged to this individual. However, none of the
staff contacted have ever met this individual. When asked for
details about this individual, she indicates that they have been
dating for approximately four months. She reports that she used
to work with him and “just happened” to meet him again and start
dating him.
Jane is not currently sexually active and reports that she has
never had consensual sexual relations. Verbal and written reports
indicate that Jane has recently expressed interest in becoming
pregnant.
Past reports show that Jane was introduced to sex at a very early
age (prior to age 8) in the form of sexual abuse, possibly
ritualistic in nature. She reported that she received formal sex
education in the form of a class at Pumpkin High School. A report
from Map noted that she has had several appropriate
relationships with men but further information about the nature of
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the relationships was not provided. Jane may benefit from further
counseling to overcome the effects of the events of her childhood
and improve her ability to relate to men.
II.
Living Arrangement and Family History. Jane currently resides alone in
a studio apartment in Hawthorne, CA. She has a short walk to the
closest bus stop and is walking distance to a dollar store, She owns a
fish and is looking forward to acquiring a kitten on the weekend. She is
supported by female staff members from Help Me at a 1:1 ratio. From
Monday to Friday staff are present for one hour in the morning (8:009:00 am) and for six hours in the evening (4:00-10:00 p.m.). On the
weekends staff are present from 8:00 am until 10:00 p.m.. Sugar
reported that staff prompt Jane to get out of bed, accompany her to
doctor’s appointments, give her medication, provide transportation to
recreational activities and provide assistance with preparation of
complicated meals. Jane is able to prepare simple meals herself. Staff
are expected to complete twelve hours of continuing education each
year, which is primarily consists of inservice training on medical topics
(Help Me’s typical population). Dr. Stuart Little, a clinical psychologist
employed by Help Me trains the staff members who work with Jane in
the implementation a behavior support plan that he has written. The
writer was not able to review this plan or the method of training
employed.
When Jane originally moved into the apartment, the case manager
required that she receive overnight supervision as she had always
resided in group homes and had never spent a night unsupervised.
However, Help Me staff felt that this was not an efficient use of
resources as she did not require this level of supervision. Overnight
supervision was discontinued a couple of months ago. Sugar Cane,
Help Me manager, reported that when Jane left her job at Come-view
Video there was period where she was paging Sugar “constantly”. Due
to the brief nature of the interaction with Sugar, the writer was unable to
determine the exact frequency per night. However, Sugar noted that this
behavior ceased completely when Jane started her new job at Wiener's
are Us on July 5, this year. Jane reports that she is very happy with the
present arrangement and gets along well with her support staff.
Prior to the move to her own apartment, Jane was residing in a group
home in Lawndale, CA under the supervision of Map Residential Care.
She was taken into the care of this agency in May 1994 and discharged
from their care when she moved into her own apartment in March this
year. Jane was not able to say why she had to move into this group
home and the reason was not available in written files. Given that she
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was placed at age 18 after residing in a residential children’s facility, the
writer hypothesizes that she could no longer be served by children’s
services and the move to Map coincided with a move to adult services.
Jane lived in the same house within the Map system from July 15, 1996
until March this year. Jane indicates that she moved out of that home
because of a conflict with a male co-resident but no one was able to
corroborate this report. It was verbally reported to the writer that Jane
was well liked by staff at this group home.
Jane resided at Saturn Hall from May 3, 1993 until early 1994. It is not
know whether she moved directly from Saturn to Map. Jane believes
that she moved to Saturn because she “could not find a group home”.
Written reports indicate that Jane was moved to Saturn when her foster
mother could no longer control her violent outbursts. One incident was
described wherein Jane was upset because one of her foster siblings
received a present and she did not so she bit her foster mother in the
eye area, resulting in a black eye.
Jane was sent to live with Snow White, foster parent, when she was
removed from her family of origin in November 1983. She was seven
years old at the time. It is reported that she and her siblings were the
victims of severe physical and sexual abuse. It is suspected that there
may have been ritualistic overtones to the abuse and that Jane may
have witnessed the homicides of transient individuals in the context of
this abuse. Her natural father apparently served at Concrete State
Prison for the abuse perpetrated against Jane and her siblings. Her
mother was implicated in the abuse but never formally charged. Jane
has had absolutely no contact with her natural parents since she was
removed. She did receive notification within the last couple of years that
her father had passed away.
Jane indicates that she has three siblings: Mercury (age 23), Cinderella
(age 22) and Grettle (age unknown). Reports completed at the time of
the apprehension indicate that all children were removed from the home
and that all experienced severe emotional disturbance. None of the
siblings were placed in the same home. When asked about her siblings,
Jane indicates that she speaks to Mercury every day by telephone and
sometimes visits with him in person. She describes him as “very funny”.
When asked about a previous plan to move into an apartment with
Mercury, Jane indicated that Mercury had decided that he wanted to
move in with her sister Cinderella. She has sporadic contact by
telephone with Cinderella. Jane verbalized excitement at the possibility
of going to Disneyland with Cinderella when Cinderella regains custody
of her children. Jane currently has no contact with her sister Grettle but
receives reports about Grettle from Cinderella.
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III.
Daytime Services Received and Day Service History. Jane has been
served by the Service to Employ People (A division of the Alphabet
Program), a behavior management day program, since March 3, 1999.
She indicates that she referred herself to the program on the
recommendation of a friend, a fact that is corroborated by the SESI
reports. Target behaviors or goals identified in the most recent individual
service plan are job tenure, aggressive behavior, verbal aggression,
emergency skills, skills maintenance, budget and social skills. No
current protocol is in place for budgeting as Jane has indicated that she
does not require assistance in this area. Verbal reports indicate that staff
plan to wait until a discrete budgeting problem arises for Jane (e.g.
incurred debt) before trying to initiate another intervention. As reported
earlier Jane has consistently achieved the emergency skills criteria
implemented through the monthly emergency skills checklist over the
last 6 months. This is maintained through verbal praise, as is the
completion of the skills maintenance checklist. The writer did not have
an opportunity to review the skills maintenance checklist or protocol.
Social skills objective is implemented through discussion allotted with
the job coach, with no reinforcement protocol.
With regard to job tenure, Jane gained employment with a local Wiener's
are Us on July 5, this year. Her hours of work are Monday through
Friday, 11:00 am to 3:00 p.m.. She is considered to be naturally
supported in this environment at this time. Jane was able to describe all
of the tasks that she is expected to complete as part of her job. Her
manager verbally indicated that she thinks that Jane is very independent
in her position. Observational data are consistent with this opinion. Jane
was able to clock in with minor assistance from a fellow staff member,
which she sought independently. She was observed to get a wet rag
and wipe down all of the tables, collect and clean trays and wipe down
the pop machine. She also repeated these tasks as necessary.
Employment Specialist Mary Whitten, assigned to the case when Jane
obtained this job, attends the job site for one hour each day, from 12:001:00 p.m., in order to assist Jane with the lunch rush if necessary. When
Jane started in this position, she found the pace much quicker than her
previous job at Come-view Video, thereby necessitating the additional
assistance. There are plans to extend Ms. Jones’s contact with Jane
outside of scheduled work time but time constraints do not allow for
more hours at this time.
Prior to obtaining employment Jane was involved in job development
activities (e.g. resume development). Jane’s daily activities included
meeting in the morning at the local Community College or other
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appointed place (e.g. McDonald’s) to plan the day’s activities and work
on job development if appropriate. Jane worked at Come-view Video
with 1:3 supervision from August 16, 1999 until June 23, this year where
her starting wage was $5.75 per hour. She was required to stock
shelves. One of the other clients at the job site was a paid staff member
(and Jane’s friend) and the other client was present simply because he
required constant supervision by the Employment Specialist (Charlie
Quinton). The consumer who required constant supervision was the
individual with whom Jane was having repeated conflicts. He reported
that Jane had been physically assaulting him outside of staff presence
at the job site after he was noted to have bruising. Consequently, he no
longer attended the job site with Jane. Jane’s friend, who was working
with her, left that job site to go to another site. The date of these events
is not exactly known but staff report that it was very difficult for Jane to
suddenly be alone at the job site. In April this year Jane’s attendance at
group and her job were sufficiently sporadic that her employer planned
to take her off of the schedule. Jane tendered her resignation on June
23, this year, shortly before she was to be taken off the schedule.
Regrettably, the writer did not obtain more detail regarding the pattern of
missed days.
Verbal reports indicate that Jane had difficulty with another individual in
her SESI group before the gentleman who eventually left the group
joined. This woman was verbally high functioning but diagnosed with
cerebral palsy. It was described to the writer that Jane and this woman
were in frequent conflict. Shortly after this woman left the group, this
other male consumer joined the group and seemed to become the new
target of the aggressive behavior.
Jane accessed the Neptune County Social and Vocational Services for
assistance with job development from August 1994 until November
1998. The writer is not familiar with the mandate of this agency but
based on verbal reports from SESI staff and Jane’s description, the
writer hypothesizes that the agency obtains contracts from employers
and several clients go to a single job site to fulfill the contract. Jane
reports that she worked at Here on Mars University and at the Airport
picking up trash. She also washed dishes at Saturn Mountain University.
The duration of each placement is not known. Jane’s favorite job was at
HOMU where she says she made many friends. Jane indicated that she
left the agency because “they weren’t respectful”. No written or verbal
reports were available to confirm or deny Jane’s reason for leaving.
IV.
Health, Medical and Psychiatric Status.
The last full physical
examination of which the writer is aware was completed July 13, 1999.
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Jane was considered to be in good health overall at that time. Ongoing
health-related difficulties are an allergy to penicillin and obesity. Jane
verbalizes interest in losing weight but indicates that she is not currently
on any special diet nor does she engage in regular physical exercise.
1999 - Summary of medical contacts
Date
Reason
February 25, March 9, 11, 25, 1999
April 26, May 25, July 13, 1999
March 1999
April 1999
July 28, 1999
September 28, 1999
October 13, 1999
November 4, 1999
December 6, 1999
Lab tests due to discharge from breast
Routine physical examinations
Antibiotics for flu
Laryngitis
Skin rash
Unresolved skin rash
Virus/flu
Fall and subsequent bruising
Pap smear due to vaginal bleeding
To summarize, Jane visited the general practitioner (Dr. Rings) 14 times
during a 12-month period, outside of the annual physical examination.
She also visited her dentist, Dr. Circle, on January 28, this year at which
time it was determined that she has 23 cavities. It is not known whether
or not these cavities have been filled. Although a summary of the year to
date was not available, qualitative data indicate that Jane was
hospitalized for surgery to remove a benign cyst in late February this
year. She is currently complaining of pain and swelling in one knee.
There were no verbal or written reports of a history of seizure activity.
Historical reports queried the presence of a dissociative state but there
is no further documentation available that proves or refutes this
assertion. The manager of her residential support service described
Jane as having a “fixation” on her physical problems. However, based
on the available information, Jane’s reasons for attending the doctor
were reasonable and justified. It may be that Jane is simply prone to
minor health problems.
The following table lists the medications, dosages, and reason for
prescription as indicated in the SESI Facesheet.
Name
Maxzide
Pepcid
Prescribed
dosage
50 mg
20 mg
Schedule of
delivery
1 tab am
1 tab am
Reason prescribed
Anti-hypertensive
Gastric upset
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Triavil
Mellaril
Depakote
Lomotril
25 mg
50 mg
250 mg
50 mg
4 at am & 2 tabs p.m.
2 at p.m. & prn
am/p.m./noon
2 prn
Antidepressant
Agitation
Behavior management
Birth control
When shown a list of current medications as above, Jane noted that the
Mellaril was discontinued sometime after she moved into her current
living arrangement because “I was doing so well”. Although her account
differs from the documentation, Jane seems to have a good
understanding of her medication.
No more recent history of medication was available. It should be noted,
however, that no mention of medication was made in the psychological
reports completed in 1993, when Jane came to Saturn Hall.
V.
Previous and Current Treatments. SESI – ABCD
In the protocol for physical, verbal aggression, and property damage
(response class under the heading “aggressive behavior”), written May
11, 1999, verbal praise is being used to reinforce the absence of the
target behaviors in conjunction with a Differential Reinforcement of
Other Behavior (Progressive) schedule of reinforcement. She can earn a
$4.00 lunch or other reinforcer up to $4.00 in value when she has gone
a minimum of 8 days without the target behaviors. The longer she goes
without engaging in aggressive behavior the more quickly she can earn
the reinforcer. The protocol also describes positive programming
procedures (teaching anger response, encouraging attendance at PET
classes); ecological strategies (non-directive interactive style, increasing
self-control over schedule, respecting personal space); and reactive
strategies (active listening, natural barriers). This protocol has been
successful in decreasing the frequency of Jane’s behavior to an average
of 1.3 times per month. The goal set in the individual service plan dated
January 3, this year was for Jane to maintain the frequency of this
behavior on average at less than once per month. Verbal reports
indicate that this behavior continues to be a concern because of the
severity of the behavior when it occurs and the impact of the behavior
on co-consumers. A summary of supports currently being offered by
SESI is provided below:
Help Me. According to Sugar Cane, the clinical psychologist employed
by Help Me (Dr. Stuart Little) completed a behavioral assessment and
developed a behavior support plan. The content of the assessment
and/or the plan is not known. Sugar was able to confirm that the plan did
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© 2002 Institute for Applied Behavior Analysis, All Rights Reserved.
not include treatment for aggression of any kind. She also informed the
writer that Jane looks forward to visits from Dr. Stuart Little.
Map. No records of a specific intervention plan carried out at Map were
available.
Counseling services. Jane received counseling for her emotional and
behavioral problems associated with childhood abuse starting when she
was removed from her home (age 7) and ending when was
approximately 18 years old. Jane states that the purpose of this
counseling was to help her express her emotions. Historical records
suggest that Jane became more physically violent during these years
but does not indicate on what dimensions the severity of the behavior
increased (i.e. frequency, duration, strength). She also saw Dr. Square
Allen (Neptune-Help Me Clinic) for a couple of counseling sessions in
June-July 1997 but chose to discontinue service.
FUNCTIONAL ANALYSIS OF PRESENTING PROBLEMS
A functional analysis was conducted for aggressive behavior.
Accordingly, the analysis endeavored to identify the events that control the
emission and non-emission of these clinically important problems. It is
therefore organized around six specific subcategories of analysis:
(1)
Description of the Problem. The analysis attempts to describe the presenting
problems in such detail that they 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 (e.g., frequency, rate, duration,
intensity). (2) History of the Problem. Three analysis presents the recent and
long-term history of the problem. The purpose here is to better understand
Jane's learning history, and the historical events that might have contributed to
the problem(s). (3) Antecedent Analysis. The antecedent analysis attempts to
identify the conditions that control the problem behaviors. Some of the specific
antecedents explored include the setting, specific persons, times of the
day/week/month, and specific events that may occur regularly in Jane's
everyday life. (4) Consequence Analysis. The consequence analysis attempts
to identify the reactions and management styles that might contribute to and/or
ameliorate the presenting problems. It also focuses on the effects that the
behaviors might have on the immediate social and physical environment, on
the possible function(s) served by the problem behaviors and on the possible
events that might serve to maintain or inhibit their occurrence. (5) Ecological
Analysis . The ecological analysis attempts to identify the critical mismatches
that may exist between the physical, interpersonal and programmatic
environments and Jane's needs and characteristics. (6) Analysis of Meaning.
The analysis of meaning is the culmination and synthesis of the above
analyses and attempts to identify the functions served by the problem
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© 2002 Institute for Applied Behavior Analysis, All Rights Reserved.
behaviors. The functional analysis of Jane, organized around these headings,
follows:
A.
Description of Behavior and Operational Definition.
1.
Topography. The following definition was developed from the
definition provided in the Behavior Intervention Protocol for
Aggressive Behavior.
Aggressive behavior is defined as the occurrence of any or all of
the following behaviors:
Verbal aggression:
This includes any of the following behaviors:





calling other people rude or offensive names (e.g.
“You handicapped bitch”, racial slurs such as
“nigger”);
threatening to harm others or their families (e.g. “I’m
going to kick your ass”, “I’m going to get your
sister”);
threatening to reveal embarrassing information
about others (e.g. “I’m going to tell everyone you
have to wear a diaper”);
threatening to falsify information about others (e.g.
“I’m going to tell Tina you hit me”);
directing profane language towards others or using
it to describe others (e.g. “F*** you” or “She’s a
bitch”).
Physical aggression:
This includes using her body or an object to make forceful
contact with the body of another person, causing the
person to report pain or leaving a mark on the person’s
body. Any attempts that fail due to poor aim or evasion
strategies are also included. Accidental contact (e.g.
during the course of a game such as soccer) should not be
included. Specific examples of physical aggression
include:
Hitting:
Making contact with any part of the body of
another person with an open hand or a
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closed fist such that the other person reports
pain or a mark is left on the person’s body.
Biting:
Making contact with the flesh or clothing of
another person with the teeth such that a
mark is left or pain is reported.
Kicking:
Making contact with any part of the body of
another person with the feet such that the
other person reports pain or a mark is left on
the person’s body.
Pushing:
Making contact with any part of the body of
another person with outstretched arms and
hands with sufficient force to move that
person, to cause pain or to leave a mark on
the person’s body.
Property destruction:
This includes any actions that render objects or property in
need of repair (e.g. breaking a table leg) or unusable (e.g.
tearing up a piece of paper).
2.
Cycle. Onset of the behavior occurs with the onset of any one of
the behaviors described above. Feedback from the former
Employment Specialist, who implemented the program until
approximately three weeks ago suggested that the current offset
criteria (i.e. absence of any of the above behaviors for at least 15
minutes) does not capture all instances of the behavior. For
instance, one instance of physical aggression consisted of three
discrete attacks that occurred within a 15-minute period. Based
on the description of the incident, which involved an initial
physical attack and two subsequent attacks on the same
individual, in conjunction with the other limited descriptions of the
behavior, it is recommended that behaviors continue to be coded
as episodes, consistent with the original definition.
3.
Course. Starts by calling individual she is angry with a couple of
names, then might kick towards individual. She may say
something like “I hate you. I don’t want to be in the group” or
threaten to contact higher authorities (e.g. “I’m calling Tina on
you). She may engage in minor self-injury at this point (e.g.
scratching the back of hands with fingernails but not with
sufficient force to draw blood).The volume of her voice increases,
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her face becomes flushed, her pupils dilate, progresses to yelling
full sentences (for example threats or accusations such as “You
were talking about me”.). She then moves towards the individual
and strikes with an open hand or closed fist once or twice then
backs away. If target of aggressive behavior attempts to fight
back physically or verbally, Jane may approach the individual
again to fight or leave the area . Typically by the time she
approaches the target person a second time, a staff member has
intervened.
4.
B.
Strength.
a.
Rate. Writer could only find evidence of four Incident
Reports for the year this year on the SESI casefile to
indicate the presence of aggressive events (March 24,
March 31, April 12 and April 24). No recording sheets were
observed. Discussion with the Employment Specialist
indicates that rates of verbal conflict were higher than
indicated by tracking data. Furthermore, the E.S. indicated
that he found out at a later date that one individual, who
had been the target of some of Jane’s documented
attacks, had sustained bruising. This individual indicated
that Jane had been physically aggressive toward him,
resulting in the bruising.
b.
Duration. Exact duration is unknown. Previous
documentation indicates that the average duration of a
tantrum is 10 minutes but report of the most recent
incident indicates that 3 separate attacks occurred within a
15-minute period, comprising a single episode. There was
not enough data available to establish an average
duration.
c.
Severity. The most severe physical injuries that have
resulted from this class of behavior within the last year are
bruises and a bloody lip. One client has left the SESI
program because of Jane’s behavior towards him.
History of the Problem. There are reports of Jane engaging in physical
aggression, verbal aggression and property damage from the time that
she was taken into foster care in 1983.
Counselor’s report, completed by Jennifer Tilley, 1983: Severe attacks
of self-abuse are described that were believed to be in response to
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attempts to impose diHOPPline. Examples of such behavior were
completely removing her own toenails, attempting to remove her own
eyeball. She also physically attacked her foster mother, at one time
biting her with enough force around her eye to cause a black eye. She
also destroyed bedsheets, bedspreads and clothes for no discernible
reason. Episodes were up to 2 hours in duration.
Psychological report, completed by Dr. K. Lite Color, 1993: Refers to an
escalating pattern of violence towards the foster mother including biting.
The episode named as the reason that Jane left the foster home is that
she bit the foster mother in the face when she was angry that one of the
other children received a present when she did not. No mention of selfabusive behavior.
History of the behavior between 1993 and 1998 was not available.
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1998 - Review of frequency of behaviors as recorded in SESI casefile
January
February
March
April
May
June
July
August
September
October
November
December
Average
Tantrums
Verbal Abuse
Property Destruction
2
2
2
1
0
0
1
0
2
4
0
2
3
3
3
3
1
0
5
0
5
5
1
5
N/A
N/A
N/A
N/A
2
2
0
0
0
1
1
0
1.3
2.8
0.75
There is no discernible pattern to this constellation of data.
The most recent incident reports that the writer was able to observe are
summarized below:
Date
Description
March 24/00
Was playfighting in backseat with another consumer.
Consumer with whom she had previously had conflict said
“Watch out for the police”. Jane became verbally aggressive
(racial slurs and swearing) towards this individual, escalating
to attempting to strangle him with a seat belt.
Became upset with employment specialist and verbally
abused him. Swore, used racial slurs and physically attacked
consumer who had previously been victim of her attack.
Verbally aggressive towards others in the group then directed
towards other patrons in the area where they were meeting
Verbally threatened “I’m going to hit you” (unsure who this
was directed towards)
March 30/00
April 12/00
April 24/00
It was also indicated in the written notes that there had been an incident
in April this year involving a physical altercation between Jane and the
consumer with whom she was having ongoing conflict. It is not known if
this occurred as part of the incidents described above.
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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 aggressive behavior 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.
Setting Events. A major stressor such as suddenly being alone
at job site or moving to a new home may increase the likelihood
that Jane will engage in aggressive behavior. The incident reports
mentioned above occurred within a couple of weeks of Jane
moving into her new home.
Triggers
Location
Aggressive behavior is unlikely to occur when Jane is either
alone or with her support staff from Help Me in the apartment.
When asked whether aggression was included as part of the
support plan for Jane written by Dr. Stuart Little, Sugar Cane
indicated that this had never been a problem there nor did they
anticipate the problem developing in that setting.
People. The aggressive behavior is more likely to occur if Jane is
in the presence of obviously disabled clients. For example, the
one individual that she repeatedly targeted was in a wheelchair
and the other was challenged with cerebral palsy. She was
witnessed on one occasion to back the wheelchair-bound
individual into a corner and punch him.
Aggressive behavior is not likely to occur when Jane is in the
presence of non-consumers only. She has not exhibited any
aggressive behavior since starting her job at Wiener's are Us,
where she is the only consumer, even though she had to work
more quickly than at her previous job.
Physically aggressive behavior is less likely to occur in the
presence of physically larger non-consumers. For example, Jane
would be verbally aggressive towards her Employment Specialist
(a non-consumer who is larger than her) but never directed
physical aggression towards this person.
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Time. There was no suggestion that time of day was related to
aggressive behavior. The fact that the incident reports indicated
that the behavior occurred before noon is likely significant in that
the SESI group was in the morning.
Event. The following types of responses to a request for help or
request to meet a need are highly likely to trigger an aggressive
response:
Repeated refusal of a request to help her meet a need (e.g.
getting a ride to the 99-Cent Store)
Statements such as “You’re not the only person in the group”
Challenging her beliefs or authority
Ignoring her requests
When Jane perceives that a friend is being touched sexually she
is highly likely to behave in an aggressive fashion. For example,
she states that she was physically aggressive towards another
member of her group because she thought that that individual
was touching the “chest area” of her friend.
Being offered an alternative solution to presenting problem
decreases the likelihood of an occurrence of aggressive behavior.
For example, when she asked her Employment Specialist to go to
the dollar store she is never became aggressive if she is told “I’m
sorry we can’t go today but we can go on Friday”.
D.
Consequence Analysis.
Planned consequences. Jane’s current behavior support plan for
aggressive behavior rewards her for the absence of aggressive behavior
on a 28-box DROP (Differential Reinforcement of Other Behavior,
Progressive) schedule. For consecutive days without engaging in
aggressive behavior, Jane fills in progressive numbers of boxes (up to a
maximum of five per day). When she has filled in 28 boxes (minimum of
8 days), she earns a $4.00 lunch (or reinforcer of equivalent value). The
reactive strategies currently recommended in the support plan include
active listening and natural barriers.
Unplanned consequences. Verbal reports indicate that subsequent to
physically or verbally aggressive acts, Jane either leaves the situation or
apologizes to the target of the behavior and the group (e.g. “I’m so sorry.
I don’t know why I do these things”). The Employment Specialist utilizes
active listening but describes this as a “stopgap measure” which slows
the course of the behavior but has been ineffective in de-escalating the
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© 2002 Institute for Applied Behavior Analysis, All Rights Reserved.
behavior. He indicates that he has not found any techniques that are
effective in de-escalating the behavior once it starts except to agree with
her request.
Clients that she has attacked typically fight back and others freeze. It
has been necessary for the Employment Specialist has had to place a
barrier between Jane and other client. In one case he described having
Jane and the other client each trying to go around him to get to each
other.
Jane stated that she chooses to throw objects that will break when they
connect with the wall, suggesting that she enjoys the noise made by
these objects.
In the long term, these outbursts seem to be related to Jane’s poor
attendance at the SESI group and at work. Subsequent to the series of
incidents noted in the incident reports, Jane began to miss shifts at work
and time at SESI group. This eventually resulted in Jane having to
submit her resignation to Come-view Video to avoid being fired from this
position.
E.
Ecological Analysis.
There are a number of ways in which
understanding the ecology surrounding and how it may conflict with
Jane's needs and characteristics, may be helpful in understanding the
meaning of her behavior and in understanding the ecological changes
that may be necessary to provide the necessary support for her. The
brief discussion addressing the ecological analysis is organized below
around the physical environment, the interpersonal environment and the
programmatic environment.
Physical environment. There are currently no obvious conflicts or
mismatches in the physical environment.
Interpersonal environment.
As identified in the Behavior
Intervention Protocol for Aggressive Behavior designed by SESI,
Jane is more likely to engage in aggressive behavior when she
feels that she is being told what to do. Furthermore, she seems
more likely to challenge people in her environment that confront
her about her behavior and/or her disability. Her previous
Employment Specialist stated that he felt he had to adopt a more
authoritarian approach (e.g. confronting her about her behavior)
with his clients in the interest of self-preservation. He stated that
when he adopted this approach he began to see a “dark side” of
Jane, that she was “manipulative”: “She probably fooled me the
longest of any of them [consumers]”. He also described needing
to be more directive in his approach at her previous job at Come-
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© 2002 Institute for Applied Behavior Analysis, All Rights Reserved.
view Video, whereas she is naturally supported in her present
work environment. It is the opinion of the writer that the change of
Employment Specialist has occurred at a good time as her former
E.S. was feeling that he no longer had the personal resources to
help Jane with her behavior. Her present E.S. describes a less
confrontational style, although she has not yet had to deal with
one of Jane’s major outbursts. She also sees her role as
facilitating Jane’s ability to complete the tasks of the job, rather
than directing her activity on the job.
SESI co-consumers who Jane assaulted were both AfricanAmerican, physically disabled and assertive to aggressive in
approach to conflict. Based on verbal reports and observations of
Jane in her work setting, it seems that more conflict arises with
groups of other consumers than individually or with others who
are not consumers.
Programmatic
environment.
The ecological strategy of
“Interactive Style” as described in the Behavior Intervention
Protocol was has not been consistently implemented by all staff.
There is also some concern about the social validity of the
approach. Former E.S. indicated that he did not perceive
sufficient response to occurrences of this serious behavior by the
administration. He feels that the other client who was usually the
target of Jane’s aggressive behavior was not sufficiently
protected by ABCD.
SESI and Help Me may be duplicating services or be able to
obtain crucial information from each other if copies of behavioral
assessment and support plan completed by Dr. Stuart Little may
be shared with SESI and vice versa.
F.
Impressions and Analysis of Meaning. In considering the functional
analysis and the background information summarized above, there are a
number of factors that are helpful in trying to understand the meaning of
Jane's behavior.
Jane is a complex and talented individual who has done a remarkable
job of overcoming many barriers in her life. When one considers the
longitudinal nature of the data it is obvious that the severity and duration
of aggressive behavior has decreased over the years. Given the severity
of the aggressive that was modeled for her and perpetrated against her,
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© 2002 Institute for Applied Behavior Analysis, All Rights Reserved.
it is a testament to the training that she has already had that she does
not respond to every situation with aggressive behavior. It seems that
Jane, like everyone else, wants to feel normal – be around “normal”
people, do the things that “normal” people do, have the experiences that
“normal” people have. There are barriers to her ability to achieve these
experiences. She does not always understand what other people are
saying or the complexities of their social interactions. She is confused
about sex and intimacy and love. Consequently she may perceive
innocuous social cues as threats to which she needs to be respond.
Also she does not possess a large repertoire of coping responses to
which she can control a threatening or confusing situation. She seems
to be using the strongest behaviors she has in her arsenal to order the
situation in the way that she wants it. Alternately (or additionally) she
may seek to control those individuals over which she at least has
physical control in an effort to improve her own limited sense of selfworth. Also, one cannot discount the modeling effect of the abuse she
suffered as a child. It is our job then to help her make sense of this
confusing world through the acquisition of skills such as discrimination of
social cues and anger management training.
MOTIVATIONAL ANALYSIS
A motivational analysis was carried out to identify those events,
opportunities and activities that Jane enjoys and that may be used to enhance
her quality of life and provide her with incentives to improve her behavior and
to enhance her academic progress. The results of the analysis showed a
number of events that could be used effectively as positive reinforcement in a
well designed support plan to reduce the identified behavior problems. These
events include, but are not limited to money, shopping trips (especially swap
meets and the 99 Cent Store), receiving beauty treatments like manicures, and
watching favorite television programs (e.g. “Touched By An Angel”, “The Drew
Carey Show”). Although she identified several edible reinforcers, it is
recommended that these be avoided due to Jane’s desire to lose weight. She
expressed a great deal of excitement for a future trip to Disneyland. These
reinforcers, and others, should be used in a variety of ways, the least of which
would be through the contingencies of formal reinforcement schedules.
MEDIATOR ANALYSIS
A "Mediator Analysis" was conducted for the purposes of identifying
those persons who might be responsible for providing behavioral support for
Jane, their abilities to carry out the recommended support plan, given the
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demands on time, energy, and the constraints imposed by the specific settings,
and motivation and interest in implementing behavioral services as
recommended. The analysis showed the following:
The primary responsibility for implementing the behavior support plan
will be with Mary Whitten, Jane’s currently assigned Employment Specialist.
Upon brief meeting she appears to naturally possess the interactional style
recommended in the Behavior Support Plan. However, it will be necessary to
prepare her for the occurrence of the target behavior. She may also require
more specific training in the implementation of the plan as she has only
occasionally worked with Jane in the past. She is physically smaller or the
same size as Jane so she may require assistance to develop strategies other
than the interpositioning strategy used by the previous Employment Specialist.
Currently she is only assigned to spend one hour per day with Jane at the job
site, constraining the amount of time that will be available to carry out other
interventions (e.g. focused intervention strategies). Supervisor Kim Chow
indicated that a new schedule is currently being developed to allow Annie to
spend more time with Jane. Annie will likely require specific training in the
interactive style that works best with Jane, as well as specific education about
the function of the behavior.
It should also be noted that if the plan is to be very successful, training
and involvement of Help Me staff in the implementation of this plan is also
recommended.
RECOMMENDED SUPPORT PLAN
A.
Long-Range Goal. The long-range goal for Jane is to establish enough
self control over her behavior that she will be able to live and work in the
least restrictive setting possible that is capable of meeting her
developmental and behavioral needs. The goal of her educational plan
is to provide her with the academic and other skills necessary to meet
her needs, while eliminating those behaviors that tend to stigmatize and
isolate her from full community and social presence and participation.
Additionally, the goal is to transfer the control of Jane's behavior from
external mediators (parents and staff) to internally generated controls.
The plans and objectives presented in the following paragraphs are
intended to increase the likelihood that the following specific outcomes
will occur:
1.
Jane will live in and contribute to her community at a level
commensurate with her non-disabled peers. This will include
living in her own apartment and being naturally supported in her
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work environment with the minimum support necessary to meet
her developmental needs.
B.
2.
Jane will develop the full range of relationships with friends and
family thereby increasing her natural supports in the community,
reducing her overall reliance on staff, and enhancing her overall
quality of life.
3.
Jane will master a wide range of coping strategies that will help
her deal with the everyday challenges faced by all of us, thereby
increasing her control over her environment.
Operational Definition(s).
1.
Aggressive behavior
a.
Topography.
Aggressive behavior is defined as the
occurrence of any or all of the following behaviors:
Verbal aggression:
This includes any of the following behaviors:





calling other people rude or offensive names (e.g.
“You handicapped bitch”, racial slurs such as
“nigger”);
threatening to harm others or their families (e.g. “I’m
going to kick your ass”, “I’m going to get your
sister”);
threatening to reveal embarrassing information
about others (e.g. “I’m going to tell everyone you
have to wear a diaper”);
threatening to falsify information about others (e.g.
“I’m going to tell Tina you hit me”);
directing profane language towards others or using
it to describe others (e.g. “F*** you” or “She’s a
bitch”).
Physical aggression:
This includes using her body or an object to make forceful
contact with the body of another person, causing the
person to report pain or leaving a mark on the person’s
body. Any attempts that fail due to poor aim or evasion
strategies are also included. Accidental contact (e.g.
during the course of a game such as soccer) should not be
Comprehensive Functional Behavior Assessment Report and Support Plan
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© 2002 Institute for Applied Behavior Analysis, All Rights Reserved.
included.
include:
Specific examples
of
physical aggression
Hitting:
Making contact with any part of the body of
another person with an open hand or a
closed fist such that the other person reports
pain or a mark is left on the person’s body.
Biting
:Making contact with the flesh or clothing of
another person with the teeth such that a
mark is left or pain is reported.
Kicking:
Making contact with any part of the body of
another person with the feet such that the
other person reports pain or a mark is left on
the person’s body.
Pushing:
Making contact with any part of the body of
another person with outstretched arms and
hands with sufficient force to move that
person, to cause pain or to leave a mark on
the person’s body.
Property destruction:
This includes any actions that render objects or property in
need of repair (e.g. breaking a table leg) or unusable (e.g.
tearing up a piece of paper).
b.
C.
Cycle.
The recording cycle for the response class
Aggressive Behavior begins with the onset of any of the
above topographies and ends when all of the behaviors
have been absent for 15 minutes.
Short Term Measurable Objectives. The following objectives and plans
are suggested on the assumption that Jane has the opportunity to
continue to live in her own apartment and work in a naturally supported
setting. It is unlikely that they would be realistic if she did not have
these opportunities. These objectives were also selected as being most
reflective of Jane's priority needs and as being the most realistic given
her level of functioning at the time. Given that the recording definition of
Aggressive Behavior has been altered, it is recommended that three
new baselines be collected: physical aggression, verbal aggression and
property damage. Objectives should then be set for each type of
aggressive behavior. It is recommended that a 50% reduction in the
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baseline occurrence of each type of aggressive behavior by the end of a
6-month period be established as the short-term objectives. Further
objectives may be established as a function of the success or failure of
the recommended strategies.
D.
Observation and Data Collection Procedures.
1.
Methods.
a.
Aggressive behavior. The writer observed four incident
reports describing episodes of aggressive behavior. It is
recommended that a revised version of incident-based
data collection continue, in addition to a daily recording of
the occurrence/non-occurrence of physical aggression,
verbal aggression and property damage.
i.
Daily recording
The purpose of adding formal daily recording to the
data collection methods is to serve as a reminder to
staff as to when they need to complete an incident
recording form. Each day, staff should be assigned
to record the occurrence/non-occurrence of the
behavior. A sample format is shown below:
Date
e.g. September 20, this
year
ii.
Aggressive behavior?
V
P
PD
+/+/+/-
Incident recording
In addition to the daily recording described above, it
is recommended that each incident of aggressive
behavior be recorded, including the following
information:






Date and time of aggressive episode
Duration of aggressive episode
Location of aggressive episode
Each topography that occurred (i.e. physical
aggression, verbal aggression and/or
property damage)
People present at the time of the episode
Activity at the time of the episode
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




Events leading up to the episode of
aggressive behavior. This should include the
closest verbatim account of any interactions
with Jane that occurred immediately prior to
the event.
How people reacted.
Description of any property damage or injury
that occurred as a result.
Observer’s impressions regarding the
occurrence of the aggressive episode.
Jane’s impressions regarding the aggressive
behavior (if possible to obtain)
I think that it would be helpful to develop a form that
specifies each of the above as a separate field to help staff
completing the form to consistently complete the same
information. Having fields defined in this way will also help
in the calculation of a reliability index (see below for
description of same).
The frequency of the occurrence of each topography (i.e.
physical aggression, verbal aggression and property
damage) should be graphed in addition to the total
frequency of aggressive behavior. These graphs should be
available on a quarterly basis.
2.
Observational Reliability.
a.
Aggressive Behavior. Observational reliability will be
determined using an incident-based strategy. As this
behavior occurs at relatively low rates, it is unlikely for an
aggressive episode to occur during a supervisory visit.
Therefore, after an incident has been recorded, the
supervisor should interview the client and the staff member
who completed the incident report and score the presence
or absence of each required piece of information. In other
words, if both the supervisor and the front-line staff have
recorded the same time & date, that would be recorded as
an agreement (“+”). If one person indicates that the
episode included physical and verbal aggression and
incident report indicates that it only included verbal
aggression, that would be scored as a disagreement (“-“).
The following formula should be used to calculate a
reliability index for the recording of aggressive episodes:
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# of agreements
X 100 = reliability index
------------------------------------------# of agreements + # of disagreements
The observational reliability index should be presented in
the quarterly report.
In the case of physical aggression and property damage,
permanent product reliability could be established by
viewing the damage to persons or property caused by the
aggressive behavior.
E.
Intervention Procedures. In the following paragraphs, a summary of
possible strategies to support Jane is presented. These are by no
means meant to be comprehensive or exclusive of other procedures.
They simply represent a set of starting points that would be elaborated
and modified as services are provided. Support is organized around
four primary themes: Ecological Strategies, Positive Programming
Strategies, Focused Support Strategies, and Reactive Strategies.
1.
Ecological Strategies. Many behavior problems are a reflection
of conflicts between the individual needs of a person and the
environmental or interpersonal context in which the person must
live, go to work or otherwise behave. As part of the above
evaluation, several possible contextual (ecological) conflicts were
identified. It is possible, that by altering these contextual
conflicts, that Jane's behavior may change and her progress may
improve, thus eliminating the need for consequential strategies.
In the following paragraphs, a number of "Ecological
Manipulations" are presented with the intention of providing a
better mesh between Jane's needs and the environments in
which she must behave:
a.
Interactive style. It was recommended in Jane’s protocol
for aggressive behavior that a “non-directive” approach be
used when communicating with Jane. However, it is not
clear that this approach was consistently implemented.
The writer noted that when Jane is challenged, refused or
told what to do, she is more likely to engage in aggressive
behavior. Some specific guidelines about characteristics of
individuals who work with Jane follow:

People who work Jane should be low-keyed. They
should be willing to rephrase requests, find different
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ways of communicating a message to Jane, or even
to leave and come back later.

People who work with Jane should avoid making
demands. Instead, they should attempt to elicit
cooperation by asking Jane to choose from a list of
choices.

People who work with Jane should respect her as
an adult. Operationally, this means dropping the
“staff-client” power struggle and adopting the role of
a mentor or helper. It is likely that staff who are
working with or are expected to work with Jane will
require role-play training in this approach.
b.
Using simple clear speech. As Jane seems to have some
difficulty
understanding
complex
speech,
it
is
recommended that communication be simple and
concrete. Confusion in social situations seems to be
related to the occurrence of aggressive behavior for Jane
as it seems that she sometimes reacts based on her
misperception of social cues. Staff should use short
sentences when talking to Jane and be alert to signs that
she has not understood what was said (e.g. failure to
respond).
c.
Group placement. When placing Jane in group settings,
great care should be taken to avoid placing her in groups
with consumers who have obvious physical or
developmental disabilities as it seems that Jane is more
likely to assault individuals with such challenges. Groups
of consumers who are of similar or slightly higher level of
functioning than Jane would be preferred.
d.
Increased access to family and friends. Individuals with a
large circle of support (i.e. important people in their life)
have a better quality of life and are therefore less likely to
engage in challenging behavior. Jane’s circle of support
currently consists almost entirely of paid staff. Jane
currently interacts with her brother frequently by telephone
and has limited to zero contact with her sisters. It is
recommended that staff responsible for the management
of Jane’s case make every effort to contact the family
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members, assess the level of contact they wish to have
with Jane, and provide that level of contact.
In addition, it was mentioned that Jane had a very close
friend in her SESI group who moved to another job site.
Jane was close to this young woman and they spent a lot
of time together. It is strongly recommended that staff
responsible for managing Jane’s case assist her in reestablishing contact with this woman, given that both
parties are interested in maintaining the friendship. Every
effort possible should be made to help Jane and her
former friend stay in contact with one another, as a means
of expanding Jane’s circle of support.
e.
Sharing of information with residential services provider.
Currently SESI has no record of the behavior support plan
that has been implemented in Jane’s residential setting. It
is recommended that Help Me and SESI share information
about the services being offered in the interest of
improving consistency between staff and increasing the
predictability of Jane’s environment across settings.
f.
Ecological inventory:. Currently Jane has few interests
outside of her residence. She identifies watching
television, shopping and attending church as her main
leisure activities. Research has clearly demonstrated that
low levels of activity are the context for challenging
behaviors. As part of this intervention, every effort should
be taken to determine Jane’s interests and activity
preferences. Staff may want to use activities identified on
the reinforcement inventory as very interesting to Jane as
a starting point to suggest some activities. She should be
given the opportunity (within reason) to participate in the
activities she specified. Outings to try new activities could
be scheduled into her day timer. During these activities,
the following information should be formally recorded.:



Jane’s emotional response to the activity
Jane’s proficiency in the activity
Related and unrelated activities that occur during
and immediately after the selected activity.
Over time a list of preferred activities will be developed
that can be used either contingently or noncontingently as
part of a behavior support plan.
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g.
Re-distribution of available staffing.
Currently the
Employment Specialist assigned to Jane’s case, Mary
Whitten, observes Jane in her work environment for one
hour per day, between the hours of 12:00 and 1:00 p.m..
Initially this was necessary to ensure that Jane could keep
up with the pace of the job requirements. Given Jane’s
current level of job performance, it is the opinion of the
writer that 1:1 staff time be maintained. Instead of helping
Jane work, time would be better spent helping Jane
develop some of the skills described in the section on
Positive Programming.
h.
Informal instruction. The strategy of “training loosely”
should be used with Jane, whereby opportunities to
instruct her on skills are not restricted to structured,
focused training trials only. Instead, instruction should be
provided whenever and wherever the opportunity presents
itself. The purpose of using this strategy is to expand the
learning process to the natural times and locations that the
skills are required.
i.
Maintenance of naturally supported working environment.
It is recommended that Jane not be placed back into a
SESI group. She is currently naturally supported in her
work environment so there is currently no reason to place
her back in that setting. Her recent problems with
aggressive behavior have been in the context of the SESI
group.
j.
Daytimer with daily planning. In order to encourage Jane
to exercise control over her daily schedule, it is
recommended that she purchase a daytimer (i.e. a
portable daily calendar) wherein she can keep track of
scheduled appointments, work schedule and scheduled
leisure activities. As Jane’s aggressive behavior
sometimes seems to be her way of exercising control over
her environment, the daytimer is recommended help her
find other ways of exercising that control.
k.
Counseling. Counseling is recommended for Jane to
address lingering abuse issues. Based on her difficulty
talking about sex and intimacy in addition to her reliance
on romantic fantasies it is clear that Jane continues to be
confused about her own sexuality. Her knowledge of sex
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from a sex education standpoint is also questionable. In
addition, Jane’s need to assert herself over those less
powerful than her with aggressive behavior, would suggest
that her opinion of herself is quite low. Any counselor to
whom Jane is referred should have the following
characteristics: experienced in treating victims of
physical/sexual abuse and/or Post-Traumatic Stress
Disorder; would be willing to meet with her in a natural
setting rather than in an office; and would be willing to talk
to her in the style of a mentor providing guidance rather
than as an authority figure giving her directions. Issues
that should be addressed in this setting include past
abuse, sex education, social mores surrounding sex and
intimacy, and self-esteem.
2.
Positive Programming. Challenging behavior frequently occurs in
settings that lack the opportunities for and instruction in adaptive,
age-appropriate behavior. It is our assertion that environments
that provide instruction to promote the development of functional
academic, domestic, vocational, recreational, and general
community skills is procedurally important in our efforts to support
people who have challenging behavior. To the extent that Jane
exhibits a rich repertoire of appropriate behaviors that are
incompatible with undesired behavior, the latter should be less
likely to occur. Positive programming, therefore, should not only
result in developing Jane's functional skills, but also contribute to
reducing the occurrence of problematic behavior. At the very
least, a context of positive programming should make it feasible
to effectively and directly address Jane’s aggressive behavior. In
the following paragraphs, several initial thrusts for positive
programming are presented:
a.
General Skills.
1)
Self-Care domain
a)
Rationale / Logic. The writer recognizes that
skills like budgeting and toothbrushing are
important functional skills that Jane could
learn. However, pursuant to the goal of
reducing frequency and severity of the target
behavior by increasing the availability of
noncontingent reinforcement, the writer
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suggests choosing a skill that Jane will find
intrinsically enjoyable. This will also serve the
purpose of developing rapport with staff as,
hopefully, Jane will not so strongly associate
“staff” with “telling me what to do”.
According to staff reports and the
reinforcement inventory that Jane completed,
she enjoys getting her nails done. Therefore,
the writer recommends that Jane be taught
to give herself a manicure.
b)
Objective. By November 1, this year, Jane
will be able follow all of the SESIs of giving
herself a manicure without staff assistance
and with 100% accuracy.
c)
Method. Jane should be taken shopping to
buy the following materials necessary to
complete the task:
Clear nail polish, colored nail polish, nail
clippers, emery board or nail file, nail buffer,
hand cream.
Using a whole task forward chaining
procedure, Jane will be taught the following
SESIs of giving herself a manicure:







Squeeze hand cream into hand.
Rub hands together until hand cream
is no longer visible
Using nail clippers, cut nails such that
they are all the same length.
Using the nail file or emery board, file
nails until they are all the same length.
Put one coat of clear nail polish on
each fingernail.
Put two coats of colored nail polish on
each fingernail.
Let nails dry for at least fifteen
minutes before starting any activity
where you have to use your hands.
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The reinforcer that should be used for this chaining
procedure is giving verbal praise. The whole-task
forward chaining procedure involves presenting the
entire task then prompting Jane through each SESI
except the one she is performing for reinforcement.
Training sessions could be conducted on a weekly
or bi-weekly basis, according to Jane’s wishes and
desires. Sessions should be approached as a fun
activity, not as a required part of a training program.
2)
Vocational Domain
a)
Rationale/Logic. Jane has repeatedly verbalized an
interest in working with children. She mentioned it in
the interview with the writer and has enrolled in
child-care classes at the local Community College
but never substantially participated. Given her
comprehension difficulties, it is not unexpected for
her to have difficulty in a classroom setting. She
may learn better in a setting wherein she is actually
required to interact with children. However, given
her history of aggressive behavior, options in this
area should be explored very carefully.
b)
Objective. By August 1, next year, Jane will have
acquired a volunteer position working with children,
supervised by a responsible adult, that she will
attend at least one hour per week.
c)
Method.
Assigned staff should complete a
background check to ascertain whether Jane has
physically assaulted children in the past. IF SUCH A
HISTORY EXISTS, STAFF WILL HAVE TO
CAREFULLY EVALUATE THE WISDOM OF
PROCEEDING
WITH
THIS
OBJECTIVE
ACCORDING TO THE RECENCY AND SEVERITY
OF THE INCIDENT.
Jane and assigned staff should work together to
procure a list of agencies that could be contacted
regarding possible volunteer positions related to
childcare.
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Jane should be assisted as necessary to contact
these
agencies,
complete
the
necessary
applications and attend interviews.
In this setting, at least initially, a 1:1 staff should
supervise Jane to establish safety of the children
and the skills necessary to maintain the position.
The presence of the 1:1 staff should gradually be
faded such that Jane becomes naturally supported
in that environment. However, Jane should remain
under the supervision of a responsible adult.
If Jane wishes to pursue this goal, some difficult situations
typically experienced during the course of caring for
children could be incorporated into the incident-based
social skills training described under the section below
describing “Functionally Equivalent Skills”. This might help
prepare her for the difficult and potentially frustrating
scenarios she could face when dealing with children.
3)
Recreational Domain
a)
Rationale/Logic. Jane reports that she spends most
of her time watching television, shopping, and going
to church. An ecological inventory has been
recommended under the heading “Ecological
Strategies” to expose Jane to more leisure activities
and assess her interest in and proficiency at those
activities. It is important, however, not to stop at the
assessment phase of this procedure. A plan needs
to be implemented to ensure that not only is Jane
exposed to a variety of opportunities, she should
also have an opportunity to participate in those
activities on a regular basis. This will serve the dual
purpose of improving her quality of life and,
consequently, reducing the likelihood that she will
engage in aggressive behavior.
b)
Objective. By January 1, next year, Jane will have
incorporated at least one new activity into her
weekly schedule. This excludes work, shopping,
watching television and therapeutic activities (like
counseling).
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c)
Method.
i.
An ecological inventory will be completed.
Jane should be given the opportunity (within
reason) to participate in the activities she
specified. Outings to try new activities could
be scheduled into her day timer. During
these activities, the following information
should be formally recorded.:



ii.
iii.
iv.
v.
vi.
Jane’s emotional response to the
activity
Jane’s proficiency in the activity
Related and unrelated activities that
occur during and immediately after the
selected activity.
From a list of identified preferred activities,
Jane should choose an activity that she
would like to incorporate into her weekly
schedule.
Assigned staff should help Jane choose a
location to participate in the scheduled
activity.
Staff should support Jane in learning how to
transport herself independently to the activity
(i.e. learn a novel bus route) through
modeling and shaping procedures.
Staff should also brainstorm with Jane how
she can access the resources necessary to
participate in the chosen activity (e.g. money
for admission, a bathing suit for swimming,
etc.).
On a weekly basis, Jane should be prompted
to schedule a day for the activity in her daily
planner. The prompts should gradually be
faded over time.
At each stage of this process, gentle shaping
should be used to help Jane choose the most
appropriate solution.
b.
Teaching Functionally Equivalent Skills. People engage in
seriously challenging behaviors for perfectly legitimate
reasons. They use these behaviors to communicate
important messages, to assert themselves, to manage
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unpleasant emotions, to escape unpleasant events, and to
gain access to events and activities. One important
strategy for helping people overcome their challenging
behaviors is to provide them with alternative ways of
achieving the same objectives, alternative ways of
satisfying their needs. These alternatives are defined as
functionally equivalent skills because they achieve the
same goal as the challenging behavior or communicate
the same message.
The above analysis of Jane's
behavior concluded, among other things, that these
aggressive episodes are related to difficulties with social
problem solving.
1)
Rationale / Logic. Jane seems to have a limited
repertoire of behaviors that she uses to control her
environment. When she cannot get her needs met
or is challenged in her way of meeting those needs,
she may become frustrated and lash out at those
around her. Therefore it is recommended that Jane
receive specific social skills training based on
identifying alternative solutions to incidents that
have occurred in the past or similar incidents,
thereby reducing her need to rely on aggressive
behavior as a way of controlling her environment.
2)
Objective.
By January 1, next year, Jane will be
able to respond to generalization probes based on
pre-scripted social situations without prompting in
five out of five daily trials.
3)
Method.
a.
SESI incident reports should be gathered
together from the time that Jane started
receiving services in that setting. Any other
descriptions of incidents that SESI has
access to could be reviewed as well.
Incidents that include any of the
topographies described under the response
class of “Aggressive Behavior” should be
extracted.
b.
Scripts should be written based on each
incident that include the cues for the
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aggressive behavior and possible solutions.
For example:
Script #1
Antecedent: You’re trying to get your
Employment Specialist’s attention.
Another consumer turns to you and
says “Shut up! I was here first”.
Solution: “Sorry, I thought you were
done”
Solution: “I feel hurt when you talk to
me like that. I just wanted to get
Annie’s attention.”
Script # 2
Antecedent: You see a man touching
your friend in her private places.
Solution #1: Ask your friend “Are you
OK?”
Solution #2: Go and tell a person in
authority (your job coach, for example)
c.
For each script, it should be demonstrated
that Jane can describe what she would do in
the described situation.
e.g., “What would you do if someone
told you ‘You know, you’re not the
only person in the group’?”
d.
When Jane has demonstrated verbal
competence (i.e. requires no prompting to
come up with solution) in a situation, the
script should be role-played with Jane
switching parts. Her performance should be
recorded as correct, prompted, or incorrect.
e.
When Jane has demonstrated both verbal
and analog competence with a particular
script, she should be told that a staff person
will approach her when she is not expecting
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it to practice the script. Initially the day
should be announced, but the announcement
should be faded over time.
These training sessions should be conducted with Jane
three times per week, for approximately 15 minutes at a
time. Jane’s mastery at each level of skills should be
documented and presented in a quarterly report.
c.
Teaching Functionally Related Skills. There are many
skills that if learned by the person, may have a direct
impact on the person's behavior. For example, a person
who is taught the difference between demeaning criticism
and well-intended feedback may start acting differently to
the feedback she receives from others. The purpose of
this category of strategies, again, is to empower the
person; to give the person greater skills. In the following
paragraphs, discriminatory skills are identified which are
thought to be related to Jane's aggressive behavior.
1)
Rationale / Logic. Jane’s aggressive behavior
seems to be related to the misperception of
innocuous social cues. In other words, due to a
limited level of comprehension of social events,
Jane may perceive certain events as being
threatening and requiring strong action. It would not
be helpful to teach Jane not to respond to any
events, as certain events certainly are threatening.
Therefore the intervention described here is
designed to help Jane discriminate between
threatening and non-threatening events. It should
be noted that Jane would be learning how to
respond to both types of events as described above
(i.e. Functionally Equivalent Skill).
2)
Objective. By January 1, next year Jane will be
able to accurately classify scenarios presented to
her as either threatening (i.e. requiring action) or
non-threatening within 10 seconds without
prompting, without error, and without exhibiting
aggressive behavior ten times consecutively.
3)
Method
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i.
In order to develop possible scenarios,
generic pictures clipped from magazines or
staged for this purpose should be compiled.
One might picture a man standing next to a
woman with hand on her arm, while another
might show a picture of a woman recoiling
from a man who is approaching her.
ii.
Staff should brainstorm with Jane possible
descriptions of these scenes. For example,
staff might say,
“Jane, what do you think could be happening
in this picture?”
Using this approach, a list of scenarios would
be compiled. Efforts should be made to
ensure that the list includes both innocuous
and threatening social situations.
iii.
All of the scenario descriptions should be
transferred to 3x5 index cards and
assembled with the pictures used to
generate the scenarios.
iv.
Using a discrete trial training format, each
card and accompanying picture should be
presented to Jane. She should be
encouraged to classify the scenario as either
threatening or non-threatening.
v.
When
Jane
chooses
the
correct
classification, she should be verbally praised
and asked “So what should you do in this
situation?” Through gentle shaping, staff
should help Jane come up with a viable
solution.
Typically,
a
non-threatening
situation would require no action on her part.
vi.
On any trial that Jane does not choose the
correct classification, staff should end the
session, to be repeated later in the day.
vii.
The next time that Jane is asked to classify
the same social interaction that she classified
incorrectly the first time, she should be
verbally prompted immediately after staff
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make the request for her to classify the
scenario.
viii.
The correct response should then be
reinforced with social praise and Jane should
be asked “So what would you do in that
situation?” Again, Jane should be guided to
some viable solutions using gentle shaping.
It is recommended that once Jane can meet the objective
described above, discrimination training be conducted
using video presentation of threatening/non-threatening
situations.
CAUTION
It is possible that viewing and describing threatening
situations may be too difficult for Jane. If there is any
indication that this procedure is increasing levels of
agitation or otherwise causing Jane distress, the
procedure should be discontinued and other options for
teaching discrimination should be explored. A game like
“Stacking the Deck”, developed by Richard Foxx and
others and available from Research Press may be another
option.
d.
Teaching Coping and Tolerance Skills. Many of Jane's
seriously challenging behaviors are a reflection of her
inability to cope with aversive events such as delay in
gratification, denial, the need to perform a non preferred
activity, etc. While Jane can avoid some of these
behaviors, aversive events are also naturally occurring.
Especially if she is to lead a full life, from time to time, she
will face the disappointments we all have to face, for
example, not getting something that she wants, when she
wants it and having to wait for it, i.e., delay; not getting
something she wants, at all, i.e., denial; being told by
somebody that a relationship is not possible; being
criticized or reprimanded; etc. In the face of these events
and the emotions they understandably arouse, Jane’s
coping responses have not had the opportunity to develop
much beyond the primitive responses of a young child; nor
is she likely to develop much beyond this level through
"natural consequences." Rather, it will be necessary to be
systematic in applying sophisticated instructional
technology, with the objective of teaching her these very
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important coping and tolerance skills. The following is a
recommendation for how to proceed in the important area
of skill development, with the initial focus being on Jane's
ability to relax.
STAGE 1
1)
Rationale / Logic. In order for any coping/tolerance
strategy (e.g. desensitization) to work, it must first
be ensured that Jane can adequately cue herself to
relax. Although relaxation training was mentioned in
written reports about Jane, no qualitative or
quantitative data was available to indicate that Jane
has mastered the relaxation response. The
intervention described below is designed to ensure
that Jane has mastered relaxation so that she may
then use it in situations she finds difficult and so that
staff may proceed with desensitizing her to
threatening or upsetting situations. The deep
breathing method was chosen as it is portable and
easily modeled by staff, making it unnecessary to
touch Jane to teach the correct response. A
progressive muscle relaxation procedure could be
introduced when Jane is familiar and comfortable
with the deep breathing method.
2)
Objective. By January 1, next year, Jane will be
able to respond without error to the verbal cue
“Relax” with the deep breathing relaxation response
(described below) without further verbal or
nonverbal prompting by staff in five out of five invivo practice sessions.
3)
Method.
Jane will be verbally presented with
the following instructions by staff, who will also
model the behavior:
a.
b.
c.
Choose a quiet place.
Sit, stand or lie down in a comfortable
position.
Take 10-15 deep breaths, breathing in
through the nose and out through the mouth.
(Staff should model breathing into the
diaphragm as opposed to breathing into the
chest)
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d.
e.
Shake your arms as you are breathing in and
out.
When you have taken all of your deep
breaths, sit or stand quietly for a couple of
minutes before returning to what you were
doing.
Staff should start each brief session (10 minutes
maximum) by saying, “When I say ‘Relax’ we are
going to start the relaxation session”. After initial
presentation, the SESIs of deep breathing should
be taught by modeling and shaping successive
approximations toward the correct response. When
Jane has mastered each SESI of deep breathing as
described above, the verbal cue should be faded
until she can respond to the single word “Relax”.
When she is able to respond to the single cue in
focused practice sessions, generalization probes
should be conducted using the single-word cue until
the objective is met.
STAGE 2
1)
Rationale/Logic.
As noted in the functional
analysis, there are several events that seem to
cause Jane discomfort, which is then manifested in
the form of frustration, anger, and/or aggression.
For example, Jane describes physically attacking
an individual who was, she believed, touching her
friend inappropriately. One strategy for helping Jane
overcome her powerful reactions to these events is
pairing these events with the relaxation response,
otherwise known as desensitization.
2)
Objective. By December 1, next year, Jane will be
able to listen to a description of the highest item on
a pre-established hierarchy while simultaneously
engaging in the relaxation response during five
consecutive sessions.
3)
Method
a.
Based on the incident review (described
under the heading “Functionally Equivalent
Skills), development of threatening/non-
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threatening discrimination task (described
under the heading “Functionally Related
Skills”), and discussions with Jane, a
hierarchy of stimuli that cause frustration and
anger should be developed. The events at
the bottom of the hierarchy would be those
that only cause minor frustration, while the
events at the other end of the hierarchy
would cause significant discomfort. Events
between would gradually produce more and
more frustration.
3.
b.
Sessions should be scheduled with Jane to
occur once per day, for a maximum of 10
minutes.
c.
During each session, the relaxation should
be cued, as described in Stage 1 of this
procedure. While Jane is relaxing, the first
item on the hierarchy should be described to
her and she should again be cued to relax.
The rationale for this procedure is that the
relaxation response would compete with the
frustration producing stimuli.
d.
When Jane has successfully relaxed with the
presentation of the first item on the hierarchy
for five consecutive sessions, the next item
on the hierarchy should be presented using
the same procedure. The hierarchy should
gradually be ascended in this way.
e.
If Jane is unable to relax upon presentation
of any of the items in the hierarchy for four
consecutive sessions, the procedure should
be reviewed and revised.
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 Jane, it is also necessary to
include focused strategies for more rapid effects; hence the
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inclusion of these strategies in our support plans. Specific
recommendations for the limited but important need for rapid
effects are made below.
The focused support strategy currently employed to deal with
Jane’s target behavior is a Differential Reinforcement of Other
Behavior, Progressive (DROP) schedule of reinforcement.
According to the schedule that she is currently on, she may earn
her reinforcer of a $4.00 lunch after a minimum of 8 days. She
makes X marks on a 28 box DROP chart (one on the first day,
two on the second day, and so on up to a maximum of five boxes
for the fifth and each consecutive day that she goes without
engaging in aggressive behavior). It is hypothesized that the
reinforcer is not of sufficient magnitude to preclude the
occurrence of aggressive behavior when Jane is very upset. With
the average occurrence of the behavior being once per month, it
is recommended that the amount of time between available
reinforcers also be increased. The mediating system used for the
DROP schedule should also be made more meaningful. Finally,
in order to provide a greater target for Jane to aim for, it is
recommended that she be provided with a large reinforcer once
she has repeatedly met the criteria for reinforcement according to
the DROP schedule. The details of these recommendations are
provided below.
Revised mediating system. Jane is currently required to
make X’s in boxes on a standard DROP sheet. It is
recommended that a revised DROP sheet be developed
with Jane that is more colorful and interesting. In the
reinforcement inventory that Jane completed, she
indicated that she collects “hearts”, suggesting that hearts
have some intrinsically reinforcing value to her. Also she
has indicated that one of her favorite television programs
is “Touched By an Angel”. Rather than using X’s, perhaps
small heart and angel stickers could be used to indicate
the progressive levels of reinforcement. Not only do these
have some intrinsically appealing value to Jane but they
also convey positive regard for Jane, perhaps facilitating
her involvement in the program, thereby reducing the
likelihood of the occurrence of aggressive behavior.
Although revising the mediating system in this way may
not be considered age-appropriate by some, it is the
writer’s opinion that the endemic interest in such a revised
system mitigates the concern for age-appropriateness.
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Revised inter-reinforcement interval. Jane currently has to
complete a 28-box DROP sheet to earn a $4.00 lunch (or
equivalent). It is recommended that Jane work of a 60 box
DROP sheet to delay the frequency with which she can
earn the reinforcer, commensurate with the reported rate
of occurrence of the behavior.
Revised reinforcers. As the amount of time Jane is
required to go without earning a reinforcer has increased,
the magnitude of the reinforcer should be increased
accordingly. Therefore she should be reinforced as
follows:
60 hearts or angels =
Going to a movie with popcorn
and pop (or other reinforcer of similar
magnitude)
To increase interest, Jane may be able to choose from a variety
of unknown pre-determined reinforcers of similar value when she
completes each DROP sheet, analogous to a grab bag system. In
other words, when Jane completes her DROP sheet, she would
have the opportunity to reach into a box and draw out a pictorial
representation of a reinforcer (e.g. movie ticket).
The number of sheets that Jane has earned should be recorded
on a form that includes a table similar to the one below:
DROP Sheet #
Date completed
1
September 15, this
year
October 3, this year
October 17, this
year
October 31, this
year
2
3
4
Each time a DROP sheet is completed, it is also recommended
that Jane receive a Disney sticker to place in her daytimer as an
ongoing reminder of her success.
When the fourth DROP sheet has been completed, Jane will
have earned a trip to Disneyland. Once the trip to Disneyland has
been earned, she will start to work towards the trip again.
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The trip to Disneyland is suggested as a reinforcer because of
Jane seemed to be excited about the possibility of going there
with her sister. However, other reinforcing events of similar
magnitude may be identified during the course of the ecological
inventory. These may be used instead of the trip to Disneyland, in
accordance with Jane’s wishes, if there are concerns about her
becoming satiated on that reinforcer. One example may be a trip
to the Rose Bowl Flea Market, a large version of a swap meet.
Antecedent Control Strategies
The most powerful way to prevent episodes of aggressive
behavior is to use a respectful interactive style with Jane. This
was described under the heading of “Ecological Strategies” but
should also be considered an antecedent control strategy.
The writer noted that when Jane is challenged, refused or told
what to do, she is more likely to engage in aggressive behavior.
Therefore, the way you ask Jane to do things or even the way
you offer assistance can affect whether or not she becomes
aggressive. Examples of how to interact with Jane are offered
below:
Instead of
“You know, you aren’t the only person I have to help.”
Say
“I can see that you want my help right now Jane. I’m sorry, but I
don’t have time to take you to the store right now. Can we go
tomorrow?”
Instead of
“Jane, we have to go to your appointment right now!”
Say
“Jane, it’s going to take a little while for us to get to your
appointment. You know how traffic can be! How long will it be
until you are ready?”
Another antecedent control strategy for Jane is to avoid having
her placed in groups with obviously disabled consumers as she is
more likely to be assaultive towards individuals with obvious
disabilities.
4.
Reactive Strategies. Efforts to manage the antecedents to Jane's
aggressive behavior are likely to have a considerable impact on
the rate of their occurrence, as will the focused support and
positive programming strategies recommended above. However,
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these behaviors are still likely to occur, at least to some degree,
especially during the initial stages of the implementation of the
support plan, as the necessary adjustments to the plan are
identified and made. Therefore, staff may need measures for
dealing with these behaviors when they occur. Such reactive
strategies have an even more limited role than the focused
strategies recommended above. Specifically, reactive strategies
are designed to produce the most rapid control over the situation,
in a manner that keeps both Jane and staff as free from risks to
injury as possible and that keep Jane free from risks of exclusion
and devaluation as much as possible. Accordingly, reactive
strategies are not intended to produce any change in the future
occurrence of Jane's challenging behavior. Both rapid and
durable changes, instead, are being sought by the Ecological
Strategies, Positive Programming Strategies, and Focused
Support Strategies described in the preceding sections. These
proactive strategies are also expected to prevent any counter
therapeutic effects that might accrue from the nonaversive
reactive strategies being recommended here. The following
procedures are suggested as initial strategies that fit within
ABCD's "Emergency Management Guidelines." They, along with
other strategies that fall within the guidelines which may be
considered in the future, are expected to preclude the need for
the physical management of Jane's behavior, including the need
for physical restraint.
Active listening. When Jane is becoming angry, every
effort should be made to attempt to see the situation from
her point of view. She needs to hear that you understand
how she is feeling and where she might be coming from.
For example:
“Jane, I can see that you are feeling really frustrated with me
right now.”
This should be reflected at approximately the same level of
emotion that Jane is expressing at the time.
In conjunction with this active listening strategy, every effort
should be made to elicit communication from Jane when she is
starting to become angry. For example,
“Jane, tell me about what’s bothering you”.
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Positive program reminders. Before Jane has escalated to
the point of physical aggression, she may also be
reminded of the skills that she is working on as part of her
positive program training (e.g. relaxation response).
Stimulus change. It may be possible to interrupt the chain
of Jane’s behavior once she has started an aggressive
episode with a novel event. For example, staff could put on
Mickey Mouse ears and start singing the Mickey Mouse
Club song, also serving the purpose of reminding Jane of
the large reinforcer she is trying to earn. It will be important
to come up with a list of possible stimulus change
procedures, depending on the level of comfort/discomfort
staff working with Jane would have implementing such a
procedure.
Geographical containment.
Geographical containment
should be used particularly if staff are afraid of imminent
physical harm to themselves or another person.
Essentially this strategy involves finding a natural barrier in
the environment that can be placed between Jane and the
target of her aggressive behavior. The goal of
geographical containment is to eliminate the need for
physical contact, thereby reducing the risk of injury. Active
listening and facilitated communication as described above
should continue to be employed when using this strategy.
If necessary, staff should call for assistance.
5.
Staff Development and Management Systems. Key elements
that will determine the degree of success of this support plan are
staff competence and management systems that assures staff
consistency in providing services to Jane. The following is
recommended:
a.
Procedural Protocols.
Each strategy and procedure
described above should be broken down into teachable
SESIs.
b.
Three tiered Training.
1)
Each staff person would be required to show "verbal
competence" for each procedure. That is, they
would need to describe each and every SESI in the
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specific procedure. Each staff would be scored
using a "+/O" system for each SESI of the
procedure. A 90% criterion is considered passing.
c.
2)
Each person would be required to show "role play
competence" for each procedure. That is, they
would need to demonstrate each SESI of a
procedure to another member of Jane's support
team. The scoring system would be the same as
for "verbal competence," as described above.
3)
Finally, each staff person would need to
demonstrate "in-vivo" procedural reliability; that is,
the ability to carry out each program component of
Jane's support plan for which they are responsible.
This would require the designated person to
observe each staff person as they provide services
and to see the degree to which what they do agrees
with the written protocols. The scoring procedure
described above would be used again, and 90%
consistency should be considered as minimally
acceptable. For those procedures that do not occur
frequently, such as the need to react to Jane’s
infrequent
aggressive
behavior,
role-play
competence should be reconfirmed on a regular
schedule.
Periodic Service Review. Jane's entire support plan
should be operationalized into a series of performance
standards to be met by the support team and integrated
into a Periodic Service Review. Monthly (initially, weekly)
monitoring should be carried out by the designated
coordinator and the status of the support plan's
implementation should be quantified as a percentage
score. Three score should be summarized on a graph and
kept visible to staff as an incentive to achieve and maintain
a score of 85% or better. Three should be reviewed
regularly by management and feedback should be
provided. More information on how to develop and
implement a Periodic Service Review system can be
provided on request.
COMMENTS AND RECOMMENDATIONS
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The intervention strategies recommended to help Jane get control over
her aggressive behavior are summarized below:
Ecological Strategies
Interpersonal: Interactive style; Using simple clear speech; Group
placement; Increased access to family; Increased access to
friends
Programmatic: Sharing of information with residential services
provider; Ecological inventory; Re-distribution of available
staffing; Training loosely; Maintenance of naturally supported
working environment; Daytimer with daily planning
Other: Counseling
Positive Programming
General Skill: Giving self a manicure, Child care volunteer
options, increased leisure involvement.
Functionally Equivalent Skill: Incident-based social skills training
Functionally Related Skill: Threat/No threat discrimination training
Coping/Tolerance Skill: Relaxation and desensitization
Focused Support Strategy: DRO and DROP schedule combined
Reactive Strategy: Active listening, Stimulus change, geographical
containment
Staff Development and Training: Procedural protocols, three-tiered
training, periodic service review.
1.
Revisions are certain to be necessary during the initial stages of
implementation and as Jane's responsiveness to the new support plan
are observed. Early revisions and fine-tuning are necessary in the initial
implementation of any support plan, especially one as comprehensive
as this one attempts to be.
2.
It is recommended that Jane receive a thorough psychological
evaluation specifically to evaluate her current level of expressive and
receptive language skills. In the opinion of the writer, she may have
some difficulty processing information, based on observations and
reviews of previous reports. Knowledge of the extent of this deficit would
be very useful in designing future intervention strategies or in modifying
the strategies recommended above.
3.
Counseling is recommended for Jane to address lingering abuse issues.
Based on her difficulty talking about sex and intimacy in addition to her
reliance on romantic fantasies it is clear that Jane continues to be
confused about her own sexuality. Her knowledge of sex from a sex
education standpoint is also questionable. In addition, Jane’s need to
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assert herself over those less powerful than her with aggressive
behavior, would suggest that her opinion of herself is quite low. Any
counselor to whom Jane is referred should have the following
characteristics: experienced in treating victims of physical/sexual abuse
and/or Post-Traumatic Stress Disorder; would be willing to meet with her
in a natural setting rather than in an office; and would be willing to talk to
her in the style of a mentor providing guidance rather than as an
authority figure giving her directions. Issues that should be addressed in
this setting include past abuse, sex education, social mores surrounding
sex and intimacy, and self-esteem.
Thank you for the opportunity to help Jane gain control over her
challenging behavior. I hope this information has been helpful. If you
have any questions about this report, do not hesitate to contact Dr.
Howard Stern or Dr. John London.
_______________________________________
writer
_______________________________________
Clinical Director
_______________________________________
Associate Director
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Client Confidential
Positive Programming Protocol
Consumer’s name: Jane Doe
Protocol name: Incident-based social skills training
Date of implementation: TBA
Revision date(s): New protocol
Definition of Skill:
Identification and practice of possible solutions to prepared scripts of social
situations.
Purpose of Protocol:
Teach Jane alternative methods of solving difficult social situations.
METHOD – PREPARATION
Materials required
3x5 index cards
Responsible person
Assigned specialist
Steps
f.
STEP incident reports should be gathered together from the time
that Jane started receiving services from STEP. Any other descriptions
of incidents that STEP has access to could be reviewed as well.
Incidents that include any of the topographies described under the
response class of “Aggressive Behavior” should be extracted.
g.
A set of scripts for staff and corresponding scripts for Jane should
be prepared. Scripts should be written based on each incident that
include the cues for the aggressive behavior and possible solutions.
Scripts of similar situations may also be developed. For example:
EXAMPLE A
Script #1 – Staff
Setup: Jane is trying to get the Employment Specialist’s attention.
Another consumer is already talking to the Employment
Specialist.
Staff (playing the other consumer): “Would you shut up! I was here first!”
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Script #1a – Jane
Look at the person
Say “ I feel hurt when you talk to me like that. I just wanted to get
Annie’s attention”
Don’t say anything else
Script #1b – Jane
Look at the person
Say “I’m sorry. I thought you were done”
Don’t say anything else
EXAMPLE B
Script #2 – Staff
Setup: Jane sees her friend being touched in the chest area.
Script # 2a – Jane
Look at your friend
Ask your friend “Are you OK?”
She says “Yes”
Script #2b – Jane
Look at your friend
Ask your friend, “Are you OK?”
If she says no,
Go and tell a person in authority (your job coach, for example)
When all of the scenarios have been developed, they should be transferred to
3x5 index cards. A suggested order of presentation should be established
starting with the easiest social situations and ascending a hierarchy to more
complex scenarios.
METHOD -- IMPLEMENTATION
Schedule
Two to three times per week, 15 minute sessions
Location
Jane’s home or other non-work/office setting
Materials required for training session
3x5 index cards with scenarios written on them
Can of Coca-Cola or other small edible
Steps
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a.
At the beginning of each session, approach Jane and say “Hey Jane.
Why don’t we have a Coke [or whatever edible is available] and do a
little play-acting”. Variations: Variations are permitted as long as the
style of approach is light-hearted, non-confrontational and accompanied
by a tangible reinforcer.
b.
Starting with the least difficult scenario in the hierarchy:
Verbal competence: For each scenario, review the setup and possible
solutions with Jane until she can tell the story without prompting. When
she can tell the story twice without prompting, move on to the
development of role-play competence.
Analog competence: Role-play the scenario with Jane. Start with staff
playing the part of Jane (modeling) and Jane setting up the situation.
Then switch roles and have Jane play herself in the situation, prompting
her as necessary. The prompts should gradually be faded until Jane is
able to role-play the scenario without prompting. When she is able to
role-play the scenario twice without prompting, move on to
generalization trials.
h.
Generalization probes: Jane should be told that a staff person will
approach her when she is not expecting it to practice the script. Initially
the day should be announced and Jane should be prompted through the
exercise. Then the prompts should be gradually faded, then the
announcement of the day of the trials should be gradually faded.
Each session should be ended with Jane being verbally praised for her efforts
in that session. Data should be recorded immediately after the session.
Pass: Pass to next scenario when Jane has successfully responded to 3
consecutive generalization probes without prompting.
Fail: If Jane does not move up the scoring matrix on a particular script for 3
consecutive sessions, the protocol should be reviewed and revised.
Data Collection Methods
The results of each session should be recorded in a log book created for this
purpose. Each entry should include the following information:
a.
A description of the scenario employed.
b.
Indication of what instructional step(s) was worked on.
c.
Highest level of competence achieved (see scoring matrix below)
d.
Staff comments (optional)
e.
Indication of whether Jane is ready to move to the next level
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Scoring matrix
Verbal
Analog (Role-play)
In-vivo
Incorre
Correct
Incorre
Correct
Incorre
Correct
ct
ct
ct
Promp
No
Promp
No
Promp
No
t
prompt
t
prompt
t
prompt
1
2
3
4
5
6
7
8
9
Data Summary Methods
Information should be transferred to the data summary sheet on a weekly
basis, indicating the date of each session, which scenario(s) was introduced in
that session, and the highest level of competence achieved according to the
scoring matrix.
Script #
1
Sept.
10
Sept.12
Sept.
20
Sept.
23
Sept.
25
Sept.
27
4
6
9
2
3
4
5
6
7
8
9
10
4
9
1
3
6
The percentage of total scenarios mastered (i.e. Level 9) should be indicated in
the quarterly report. Any problems with the procedure should also be noted at
at that time.
Procedural Reliability
Supervisor should observe one initial training session then one session per
month to ensure that the procedure is being followed as outlined above.
Procedural reliability checklist for this procedure should be used for this
purpose. Each step should be scored as “+” (completed) or “-“ (not completed).
Feedback should then be given to assigned staff based on the results of the
checklist.