Working with Low Functioning Clients
& Sexual Perpetrators
Definition of Low Functioning
Abuse & Brain Damage
Behavioral Interventions
Preface
• Psychiatrist
– Medical doctor
– Trained in medicine, labs, NOT trained in psychometrics or behavior
– Following medical school, training in specializations (residency):
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Neurosurgery, Oncology, pediatrics
Obstetrics & Gynecology, psychiatry
Podiatry, Ophthalmology, cardiology
Allergy, Dermatology, anaesthesiology
– In-field exposure (residency) to CBT
• Psychologist
– Ph.D. or Psy.D.: Cognitively (CBT) trained
– Trained in psych testing, behavior mod/mgt NOT trained in medicine
– Specialization in pre-/post-doc internship
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Child, Gerontology, Sports, Diversity, sex-abuse psychologists
Forensic, Clinical, Counseling, School, Research psychologists
Disabilities: LD/MR, low functioning, developmental disabilities
Neuro-psychologist: neurological assessment, PET scan
– 1-class in psychopharmacology
Foreword
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Nonverbal Therapeutic interventions to work with lower functioning individuals:
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Neuro-Linguistic Programming (mid 1980s)
Educational-Kinesiology (70 yr)
Sand-play, Cognitive-behavioral play therapy
EEG neuro-feedback, bio-feedback
Eye Movement Desensitization and Reprocessing, EMDR
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American Psychiatric Association (2004). Practice Guideline for the Treatment of
Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. Arlington, VA:
American Psychiatric Association Practice Guidelines. * EMDR was determined to be
an effective treatment of trauma.
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Department of Veterans Affairs and Department of Defense (2004, 2010). VA Clinical
Practice Guideline for the Management of Post-Traumatic Stress. Washington,
DC. * EMDR was placed in the "A" category as “strongly recommended” for the
treatment of trauma.
• Associate Professor 5 yr
– University of Hawaii; Chaminade University; Heald College
• Behavioral Consultant to Hawaii School System 10 yr
– Autism/disabilities Specialist
– Applied Behavioral Analysis
[Felix Waihee Consent Decree 1999-2005]
• Lovass’ 1987 landmark Young Autism Study
• Wikipedia: Preferred treatment for individuals with disabilities
• 2 courses integrated into MFT program at U of G
Low Functioning: RC, age 16, CSC
Scale
Verbal, VCI
Performance , PRI
Working Memory, WMI
Processing Speed, PSI
Full Scale IQ
Score
67
67
94
80
70
Percentile
1
1
34
9
2
Range
Extremely Low
Extremely Low
Average
Low Average
Borderline
DSM-IV-TR: Mental Retardation
• Essential Feature
– Significantly sub-average general intellectual functioning:
IQ of about 70 or below (range 55-75)
– Exhibits significant deficits in adaptive behavior: social blindness.
– Not diagnosed MR w/o significant adaptive behavior deficits.
• General Intellectual Functioning: Intelligence Quotient (IQ)
– “1” or more standardized assessments, individually administered
intelligence tests: WISC-IV, Kaufman, Stanford-Binet, TONI-4
• Adaptive Functioning
– How effectively the individual copes with common life demands
– Determined by presenting symptoms versus low IQ
– Problems in adaptation can improve with repetition, but cognitive IQ
tends to remain relatively stable.
Low Functioning: AC age 14 female CSC
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Scale
Verbal, VCI
Perceptual, PRI
Working Memory, WMI
Processing Speed, PSI
Full Scale IQ
Score Percentile Range
55
Extremely Low
82
Low Average
77
Borderline
85
Low Average
68
Extremely Low
DSM-IV-TR:
317 Mild Mental Retardation
• IQ level 50-55 to approximately 70
– Educable, 85% of population.
– Typically develop social/communication skills during preschool,
have minimum sensory-motor impairment.
– Not distinguishable from children w/o MR until later age.
– Adolescents: Can acquire academic skills up to 6th grade level.
– Adults: Usually achieve social/vocational skills adequate for
minimum self-support; may need supervision.
– Can usually live successfully in community, independently or in
supervised settings.
DSM-IV-TR:
318 Moderate Mental Retardation
• IQ level 35-40 to 50-55
– Trainable; 10% of population.
– Acquire communication skills during early childhood.
– Can attend to personal care.
– Can benefit from social/occupational skills training.
– Unlikely to progress beyond 2nd grade level academics.
– Adolescents: difficulties recognizing social conventions interfere with peer
relations. Can profit from vocational training.
– Adults: Can perform unskilled/semi-skilled work, supervised, in sheltered
workshops/workforce.
– Adapt well to life in community, usually in supervised settings.
Moderate MR: DC age 14 male CSC
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Scale
Verbal
Performance
Working Memory
Processing Speed
Full Scale IQ
Score
50
71
50
59
49
Percentile Range
<.1
Extremely Low
3
Borderline
<.1
Extremely Low
.3
Extremely Low
<1
Extremely Low
How is Level of Functioning Determined?
• IQ tests
• Wechsler Intelligence Scale for Children, fourth edition, WISC-IV
• Wechsler Adult Intelligence Scale, fourth edition, WAIS-IV
• Test of Nonverbal Intelligence, fourth edition, TONI-4
Myth of IQ tests
• True IQ
– No true IQ from birth to death: Genetics can be enhanced or impeded.*
– IQ is a measure in one point in time.
– IQ is less stable in childhood & adolescence than in adults.
• Factors affecting IQ
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Heavy metal/toxin exposure, TBI, prenatal alcohol/drug use, birth trauma
Physical/emotional traumas: violence, child/sex abuse, abandonment.
Nutrition, digestion (McBride, 2010), exercise
Early training: music, sign, (whole brain learning age 0-5)
– IQ is most flexible throughout childhood
Experiential/Kinesthetic/Tactile Learners
• Learning style: Learning takes place by actually carrying out a
physical activity, versus listening (lecture) or watching a
demonstration. Classroom = visual-auditory NOT kinesthetic
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Aka tactile learner, doers, physically oriented.
Realizations occur through doing versus thinking.
It helps them to move while learning, movt increases understanding.
They do well with lab experiments, sports, art, acting, dancing.
They remember things by recalling what their body was doing.
Short and long-term memory is strengthened by body movement.
They NEED to move, may seem restless, impatient, or bored.
• Various types of learning styles:
– Visual
– Auditory
– Kinesthetic
“Myths” of ‘Low Functioning’
• There are obvious indicators: False
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Speech-impaired: good articulation is deceptive
Thought processes impaired: limited, not impaired
Physically recognizable: attractiveness is deceptive
Their feelings are like my feelings: hypersensitive
• False assumptions:
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If he talks then he understands me: limited comprehension
He needs counseling: CBT is insufficient.
Since he talks, he can say what’s bothering him: no
He is choosing not to talk: not necessarily
• Conflicting emotions confuse/block concept formation
• Emotions impede verbalization
• Unable to conceptualize response
Abuse
Affects the Brain and Functioning
• R:
• L:
Alcohol Abuse
Head Trauma, Drug Abuse
• Arlene Gadia, CPS supervisor: 1200 referrals/yr child abuse; KUAM
• Lyndia Tenorio, CPS supervisor: 2000 referrals/yr child abuse; KUAM
Scans Show Brain Damage in Abused Teens
• University of Pennsylvania School of Medicine, 2011
– study on effects of childhood maltreatment on neuroimaging of
gray matter volume in adolescents
– childhood maltreatment affects subsequent psychopathology.
• Adolescents reporting a history of abuse (even
nonphysical) had deficits in gray-matter brain volume in the
prefrontal cortex, striatum, amygdala, cerebellum.
– Grey matter is made up of neuronal cell bodies. The grey matter
includes regions of the brain involved in muscle control, sensory
perception: seeing, hearing, memory, emotions, speech.
– Girls: atrophy in regions associated w/emotional regulation
– Boys: deficits concentrated in regions related to impulse control.
• At risk for development of
– mood disorders
– addictive disorders
– other psychiatric disorders
Prefrontal cortex, striatum, amygdala,
cerebellum: grey matter volume deficit
Effects of Left Prefrontal Damage
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SW Anderson, A Bechara, H Damasio (2002). Impairment of social/moral behavior
related to early damage to prefrontal cortex. Foundations in Social Neuroscience
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SW Anderson, D Tranel, H Damasio (1996). Failure to respond autonomically to
anticipated future outcomes following damage to prefrontal cortex. Cerebral
Cortex.
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A Bechara, AR Damasio, H Damasio (1994) . Insensitivity to Future Consequences
following damage to L prefrontal cortex. Cognition
– Corticotrophin, epinephrine, norepinephrine release unmediated = negative emotion
overdrive.
– Right Temporal sexual passion is unmediated by impaired L prefrontal cortex.
– Impaired brain status is exacerbated by stress (flooding) = chemical cascade.
– Vicious cycle
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Imbalance impairs functioning (pouring battery acid over brain)
Sleep deprivation impairs brain repair; insomnia common
Symptoms: shut-down/acting-out, suicidal ideation/gestures = distress
Emotional pain drives compulsions. compulsions precipitates selfmedication/addictions (alcohol-substance abuse, neg. compulsive behaviors).
Childhood maltreatment changes brain structure
and function. Abuse/chronic trauma hx =
Left Prefrontal Cortex Damage
Dr. JD Bremner: Incest
• Yale Psychiatric Institute. April 1999, Biological Psychiatry
• The problem is not that incest survivors want to stay miserable—
– Research: childhood sexual trauma causes actual shrinkage, damage to the
hippocampus of the brain. Hippocampal loss of neurons related to stress.
– Hippocampus: associated with learning, memory. PTSD from Vietnam war and
childhood abuse have neuropsychological deficits in hippocampal functioning.
• Symptoms associated with shrinkage of the hippocampus resemble Post
Traumatic Stress Disorder, PTSD
– Mind plays tricks on survivors: flashbacks, feeling uneasy and "on edge,” on
guard constantly, nightmares, problems associated with memory.
– Gaps in memory occur, a few minutes to a few days; abuse memories
suddenly "pop up” in a survivor's life.
– The hippocampus affects the prefrontal cortex, stress responses.
• Incest survivors have a far more serious response to stress than those who
have not experienced severe childhood abuse.
– All survivors need to watch and monitor their stress carefully; brain damage is
a side effect of sexual abuse.
Childhood Sexual Abuse Causes Physical Brain
Damage: An Alarming New Study
Frontal Temporal BeforeAfter Tx
Frontal-Temporal Rotated
McLean Researchers Document Brain Damage
linked to Child Abuse & Neglect
• Harvard Medical School Affiliate. December 2000, Cerebrum. Early
damage to developing brain causes anxiety & depression in adulthood.
• 4 types of permanent abnormalities caused by abuse/neglect:
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Limbic irritability: emotion; EEG abnormalities are associated with more selfdestructive behavior and aggression.
– Arrested L hemisphere development: language, perception/expression of
negative affect; contributes to depression, memory impairment.
– Corpus Collosum deficiency: 24-42% size reduction = neglect, 18-30% size
reduction = sex abuse; effects dramatic mood/personality shifts.
– Increased Cerebellar Vermis activity: emotion, limbic activity, trauma impairs
ability to maintain emotional balance. Brain is wired to experience fear,
anxiety, stress.
Irritable Limbic System: more selfdestructive behaviors & aggression
Corpus Collosum: deficit in size of 24-42% in neglect,
18-30% in sex abuse, affects dramatic mood &
personality shifts.
Hyperactive Cerebellar Vermis:
Impaired ability to maintain emotional balance
Brain wired for fear, anxiety, stress
Daniel Amen, M.D.: Magnificent Mind at Any Age (2008)
Treat Anxiety, Depression, Memory Problems, ADD, and Insomnia
• Cerebellum: 10 % of brain volume, 50% of brain’s neurons.
– Functions:
• Involved with processing speed, how quickly you can make cognitive/emotional
adjustments in stressful/new situations
• Motor control, posture, gait
• Executive function, connect to prefrontal cortex, speed of cognitive integration
– Problems in the cerebellum = easily confused.
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Slowed thinking
Slowed speech
Trouble learning routines
Disorganization
Sensitivity to noise, touch; light sensitivity
Tendency to be accident prone
– Found low in activity in autism, ADD, learning disabilities
• Major coordination center in the brain
– Major strategies to optimize: coordination exercises as sports and music,
dancing or table tennis
– Healthy diet, targeted behavioral exercises, mental exercises, supplements
(multiple, fish oil, vit D, medications).
Drug AbuseHealthy Brain
Grey matter volume reduced: prefrontal cortex,
striatum, cerebellum, amygdala per child abuse
Grey Matter Deficits: Limbic, L hemisphere,
corpus collosum, cerebellar vermis,
prefrontal cortex, striatum, cerebellum
“Magnificent Mind at Any Age” Daniel Amen, M.D., 2008
• People who experience extreme, uncontrollable early life stress
(physical/sexual abuse) are more vulnerable to anxiety, depression, effects
of stress later in life. To become resilient, strengthen the brain’s ability to
resist stress.
– The sense of control is one of the most important factors in managing stress.
– Blame = signals feeling out of control, victim-stance.
• Poor control of prefrontal cortex function has been associated with
depression and impulsivity.
• Long-term exposure to stress hormones has been found to kill cells in the
hippocampus. Smaller hippocampal volumes are found in people with
depression and chronic stress disorders.
• Early abuse/stress can cause long standing changes in brain circuits
associated with resilience and learning.
• When children w/o abuse are exposed to more manageable forms of
stress, these stresses aid in building resilience; stress inoculation develops
immunity. i.e. Family moves, parental illness, loss of friendship, learning to
deal with teasing. (Kibbutz study)
Neurobiology
• Behavior-learning problems plague 3/4 of children in child welfare system.
– stress-regulating hormone production altered
– key neuro-transmitters altered: epinephrine, dopamine and serotonin,
chemical messengers in the brain affecting mood and behavior.
• 1993 Dr. Martin Teicher linked abuse to brain wave abnormalities. The
Journal of Neuropsychiatry and Clinical Neurosciences.
– Greater the severity of the abuse, the greater the impact on brain function.
– ''Sex abuse by a family member is worse than abuse by a priest or a babysitter.'’
– Several studies document, abuse damages key brain structures: the cortex,
and the hippocampus.
– 1998 study showed left cortex of the abused group underdeveloped.
– Abuse typically lowers serotonin levels, leading to depression and impulsive
aggression.
Verbal Abuse Linked to Permanent Brain
Damage
• Martin Teicher, Harvard Medical School associate professor
of psychiatry at McLean Hospital. Biological Psychiatry,
February 1, 2009 (neuroimaging).
– damage to neural pathways cause medical and physical
problems when the children grow to adulthood such as
depression, language processing issues and anxiety.
– verbal abuse of children may be just as damaging as other forms
of abuse such as physical or sexual abuse.
– Witnessing the abuse of others is also very damaging
• multiple cases of victims who have all the symptoms of physical abuse
but were never physically abused
What Characterizes Low Functioning ?
• Characteristics of ‘Low Functioning’
– Don’t know what they’re feeling, difficulty identifying their
feeling, difficulty verbalizing their feeling(s), act on feelings,
overwhelmed by feelings.
– Low vocabulary/comprehension (Receptive auditory)*
• Interpretation of experiences may be simplistic, limited
• Responses may be brief, off-subject, vague, distorted.
• Common responses: No response, stare, walk-away, ‘I don’t know,’
child-like responses.
• Counseling/explanations may be limited in effectiveness.
– Need to do, multi-sensory to learn.
• Low vocabulary/low communication (Expressive auditory)*
• Communication is simple, limited; inability to describe
events/feelings.
• Unable to express compounded feelings, At risk for cumulative anxiety
– Non-directive inquiry to assist thinking process.
Speech & Comprehension are different
parts of the brain
Low Functioning Characteristics
• Weak to absent problem solving ability*
• Low vocabulary (limited expression) + low information + low
comprehension (distorted cognition) = weak problem solving.
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Teach collaborative problem solving, use inquiry to elicit thinking
• Choice is insufficient
• Weak coping skills*
– Ineffective ability to deal with negative emotions
– Explosions: physical, verbal, emotional aggression
– Implosion: compulsions, self-harm, suicide
• Teach emotion vocabulary, verbalizing format
• Social blindness*
– Unaware of social convention
– Social initiative, reciprocal conversing, social inquiry are absent
• Teach looking into faces (visual cues), social questions
Label feelings, verbalize feelings
Process emotions, de-intensify emotional pain
Low Functioning Characteristics
• Weak ability to implement learning*
• Low information transfer from concept to ‘doing’.
– Signs contract but repeats offenses
– Repeats what you said then fails to follow through
• Need for kinesthetic versus conceptual learning
• Difficulty learning in group format
• Difficulty with sedentary learning, need to move, to do, experience.
• Weak to absent assertiveness skills
• Authoritarian parenting = aggress or submit
• Suppression is not respectfulness
• Misunderstood disabilities elicit abuse in uneducated families
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Low receptive auditory interpreted as Not Listening
Low information implementation interpreted as disobedience
Repeat offenses interpreted as defiance
No response, blank stare, walking away, interpreted as disrespect
Disciplinary stress affects 2ndary brain damage
L: Left temporal deficit-suicidal child
R: Worried & Rigid
Undoing Neurobiological Effects of Trauma
• Alexandra Cook, Ph.D. Trauma Center at Justice Resource Institute, MA
– Positive experiences that contradict a traumatized child's negative
expectations are critical to helping the brain to readjust.
– Just saying to a child that you are sorry the event happened changes brain
chemistry.
– Temper tantrums = amygdala can’t stop firing.
– Constructive ways to discharge overwhelming emotions (running, emotionally
expressive activities)
– Estimated 1 million children abused/yr; less than 10% receive appropriate
interventions.
– The more time that elapses between the abuse and appropriate treatment,
the more entrenched the neurological abnormalities.
– Address sensorimotor dysregulation at the body level w/a new array of
movement strategies to the standard mental health therapy repertoire to
support children to become more organized, interpersonally available, and
accessible for mental health treatments.
NY Times Magazine, April 2012: Evidence-based Interventions
• Aerobic Exercise
– 1990s research: Exercise jump-starts neuro-genesis
• Mice/rats that ran a few weeks had twice as many new neurons in hippocampi as
sedentary animals. *All animal studies involve running/aerobic activities.
• By age 20: approx 1% human hippocampus lost annually
• Exercise slows, reverses brains’ physical decay, as w/muscles.
– 2007 study: Comparison of environmental stimulus, learning tasks, aerobic exercise.
• 1) Environmental stimulus (toys/tastes), 2) new learning, 3) exercise compared.
• 1) No matter how stimulating, enriching environment did not improve brain.
• 2) New learning generated task specific neurons that re-fire to task only.
• 3) Exercise doubled new neurons in hippocampi compared to sedentary animals.
• Exercise made neurons nimble, could multitask and re-fire cognitively flexibly
• Only thing that mattered in improving the brain: aerobic exercise.
– Aerobic exercise increased Brain-derived neurotropic factor, BDNF
– BDNF sparks neuro-genesis, strengthens cells, axons, neural connections.
– After work-out = higher BDNF in blood stream.
– 2011 Study: 1-year walking or stretching program w/age group over 60
• Walkers had larger hippcampi after a year
• Walkers regained 2+ yr of hippocampal youth (65yr -->63yr)
• Stretchers lost volume to normal atrophy
Interventions
•
Daniel Amen, MD, ‘Use Your Brain to Change Your Age,’ 2012
– 1-hr aerobic exercise daily; Effects wear off after 24 hr.
– Magnificent Mind at Any Age, 2008: ANT & ANT eaters
• 9 types Anxiety & Negative Thoughts: 1) Overgeneralization, 2) Negative focus,
3) Negative predictions, 4) Mind reading, 5) Believing negative feelings, 6) Guilt
words, 7) Negative labeling, 8) Personalization, 9) Blame.
• Challenge your thoughts: talk back to ANTs. You don’t have to believe your
thoughts.
• When stuck, distract yourself by jumping up and down, dancing, singing, etc.
Repetitive thoughts worsen control, but lose control over time when blocked.
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Journal of Child Psychology & Psychiatry, January 2000, vol 41, 97-116
– Secure attachment buffers the effects of the stress response.
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Medical News Today, June 2007, Mathew Lieberman, UCLA psychologist (neuroimaging)
– Verbalizing Feelings Makes Sadness, Anger And Pain Less Intense
– Amygdala is less active when an individual labeled a feeling (anger) (brain imaging)
– Right ventrolateral prefrontal cortex is more active: thinking in words about emotional
experiences inhibits behavior and processes emotions.
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Enactment
– Trauma therapy: Enactment is a form of therapy that facilitates trauma repair. Until
expressed, the energy remains in the form of symptoms of depression and anxiety.
– Journal of Marital & Family Therapy, July 2004: Enacting relationships in Marriage &
Family Therapy is a medium for mediating relationships.
– Handbook of Family Therapy, April 2012, Al Gurman, Ph.D. Enactments bring
maladaptive interactional sequences into the therapy session and thus available for
directed change.
Kinesthetic Intervention
• Walk through learning experience, repetitively
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Enactment: pre-experience drama therapy.
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CSC-- Clarify rules, enact
– Touching others is off limits.
– Telling strangers you want to be close to them is off limits.
– Asking girls to ‘do it’ with you is off limits.
– Social questions are okay. Let’s practice social questions.
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Role-play, rehearse, then coach Emotion Program: I feel…because…I want….
– Empowers client to verbalize fears, upsets, resentments.
– Go from 2ndary to primary feelings.
– Experientially learn assertive verbalization with support.
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Win-win collaborative problem solving with client (Greene, 2001).
– Client participates in win-win resolution.
– Assertiveness is elicited and supported.
– Clients wants/needs are valued. Providing choice is not cps.
• Re-enactment: Post-conflict ‘acting’ desired behavior
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Rehearse then re-enact drama while coaching appropriate behavior, words.
Heal the brain: Exercise, verbalize feelings, laughter,
secure attachment, nurture, enactment, diet
What to Do
• Capitalize on strength: Kinesthetic
– Engage in kinesthetic vocational training early
– Aerobic exercise
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Increases brain’s vascular networking, oxygen/nutrients to neurons
Improves short-/long-term memory, brain repair/function w/sleep.
Increases endorphin levels, elevating mood.
Relieves stress in high anxiety individuals.
And laughter drops defenses.
• Target Priority: Repair the brain; Reduce self/other harm
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Symptoms of a stressed brain: compulsions, suicidal ideation, aggression
Neural plasticity during development maximizes exercise’s effect on brain
Nonverbal therapies can reduce/eliminate PTSD, lifelong anger, historic angst
Stress is cumulative, has delayed effects
• Autonomy in adulthood exacerbates seemingly innocuous compulsions into
addictions.
• Pharmaceutically managed depression requires lifelong medication.
• Brain sustains impairments throughout lifespan without appropriate treatment.
• Low functioning
– Low Vocabulary: Keep it Simple (KIS)
– Low Information: Keep it practical
– Low Comprehension: ‘do’ desired behavior, kinesthetic: must “do” to learn.
Intervention
• Know the function the behavior serves.
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Target the function not the behavior
Behaviors are symptoms; function is the purpose it serves.
• Symptoms: Nail biting, binge eating, restlessness, OCD behaviors, compulsive
masturbation, trichotillimania, skin/scab picking, cutting
• Function: anxiety/stress release, auto-stimulus
Behaviors may look different but serve the same function: e.g. stress release
– Nail-biting, masturbating, skin picking, hair pulling
– Cigarette smoking, alcoholism, drug use, promiscuity
• Behavior may look the same but serve multiple functions: attention,
escape, tangible
– Disruptive behavior for attention + escape
– To reduce the behavior, discontinue reinforcement
– Reinforce desired behavior intermittently
• Rehabilitative intervention takes longer, achieves more
– Reduces compulsions, self-harm, reduces suicidal ideation, suicide gestures/attempts
– Reduces acting out, aggression, assault
– Increases verbalization, assertiveness, and adaptive functioning
Insufficient Interventions
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APA Ethic: Do no harm (Iatrogenic treatment)
• Corroborate
– Seek persons w/higher education, more experience, training
– Ask questions before implementing interventions
• Consult, consult consult.
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Authoritarian approach
• Neither authoritarian nor permissive is therapeutic. Assertive is therapeutic
• Attend to (nonverbal) feelings to prevent behaviors, feelings drive behavior
• Fastest way to achieve goals: ‘Motivate’ via client desired incentives.
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Cognitive therapy
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Repeat back to me, so I know you understand. They don’t.
Explaining ‘why,’ providing logic, providing rational, providing consequences.
Posting instructions, providing written instruction, contracting.
Expecting follow through of responsibilities: provide checklist.
Coercion:
• Privilege removal, item removal
• Stacked consequences
• Choice
*Interventions NOT for Low Functioning Individuals*
• Rewards & Punishment
– ‘Incentive only’ is preferred treatment approach
– Punishment, stacked consequences provoke anxiety, victim stance
– Punishment stops behavior, doesn’t teach appropriate behavior;
• Broad based education & experience
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Learning takes so long, focus on high risk behaviors.
Prioritize reducing self-harm/other harm, heal the brain.
Target: strengths to maximize competency; income earning
Intergenerational government dependency status perpetuated.
Avoid unnecessary stress: 2ndary damage suffered when stressed
• Flooding
– Prolonged exposure to desensitize individual to stressful stimuli
exacerbates damage in an impaired brain.
• Any Stress: impaired brain is fragile, more vulnerable to stress,
anxiety, depression in adulthood.
Notes
• Animals that exercise aerobically generate double the new neurons
compared to sedentary animals. These neurons refire to any need in the
brain. Exercise is the only thing that mattered in improving the brain.
• Research has established, both desirable and undesirable behaviors are
learned, through interactions with the social and physical environment.
• The function of a behavior can be thought of as the purpose a behavior
serves for a person.
– All behaviors serve a purpose.
– All behavior is communication.
• Applied Behavior Analysis-based interventions are best known for treating
people with developmental disabilities.
Track Progress, Why?
• Objective Comparison with Baseline Behaviors
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Quarterly outcome data
Retain focus on original primary goals until achieved
Provides client a measure by which to chart progress
Progress is measured in quarters and years
• Tracking Monitors
– Intervention effectiveness
• Ineffective: self-harm/other harm continues or escalates
• Needs adjustment: intervention is quasi successful
• Effective: target behavior reduces as intervention is mastered.
– Advance intervention
• Client succeeds 90%, is ready to advance intervention
• From 1 emotion program daily, increase to 3-5/daily on negative feelings
• From 1 collaborative problem solving daily to 2 daily on differences.
Performance Measures
• 2 Types of data
– Behavioral
• ABC: Antecedent, Behavior, Consequence
– To seek purpose of behavior
1) seek attention, 2) escape, 3) tangibles, 4) auto-reinforce
– To know 1) setting event, 2) behavior, 3) reinforcer
• Monitors interventions, client behaviors, staff performance
– Are interventions implemented as intended?
– Do client behaviors reflect increased competency to
intervention?
– Is staff behavior therapeutic to client?
• Data must be monitored for validity
– Preferably by ABA trained therapist
– Frequency
• Counts the number of times a behavior occurs.
Behavior data collection
Frequency data collection
Setting up Goals
• Chart the frequency of behaviors
– Baseline: per month.
– Quarterly: comparison
– Provides progress report, monitors intervention, staff
• Behaviors & goals
– Name behavior + frequency
• Ignores staff 3x daily
• Shuts down when he disagrees with staff 1x daily
– Name goal in objective measurable terms
• He states his feeling, the cause, and what he wants 3x daily.
• He participates in collaborative problem solving 1x daily.
Scott Miller, PhD
Evidenced based: working with Difficult Clients
• Listen to the Client
– They will tell you what they need
– They will tell you what works for them and what doesn’t
– They will tell you how you can motivate them
• Follow the Client’s motivation
– It is the strongest drive to facilitate goals
– Innate drive harnesses the client’s own energies
• Support the Client toward their motivation
– The client’s goals are paramount
– Client drive toward their goal is your goal.
Chronic trauma affects structural & functional
changes in the brain
Resources
• Amen, Daniel MD www.amenclinics.net/brain-science
– Child & Adult psychiatrist, medical director of Amen Clinics
– World’s largest database of functional brain scans:
70,000 Single Photon Emission Computerized Tomography (SPECT)
– 30+ books translated into 24 languages.
– 1 of the world’s experts brain imaging use in psychiatry.
– 4x New York Times bestselling author
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Use Your Brain to Change Your Age (2012)
Change your Brain, change your Body*
Change your Brain, Change Your Life*
Magnificent Mind at Any Age (2008)*
The Amen Solution*
Healing ADD
Making a Good Brain Great
Healing the Hardware of the Soul
The Brain in Love
Comprehensive Textbook of Psychiatry
Co-author: Unchain Your Brain, Healing Anxiety & Depression, Preventing
Alzheimer’s
– 49+ published research articles
Resources
• Bremner, J.D. (April 1999). Does stress damage the brain? Biological
psychiatry, Vol 47, 7, p797-801. (Yale Psychiatric Institute)
• Campbell-McBride MD, N. (2010). Gut and psychology syndrome.
Cambridge, MA: Medinform Publishing
• Cook, A. (2010). Sensory Motor Arousal Regulation Treatment (SMART):
Bottom-up Interventions for Childhood Trauma
• Greene, R. (2001). The explosive child. New York, NY: Harper-Collins
Publishers
• Johnson, Toni Cavanagh. (2011). Chairperson on California Professional
Society on Abuse of Children task force. Developed guidelines for
monitored visits. Sex abuse psychologist of 31 years, 5 books, 2 booklets,
3 therapeutic games. tcavjohn.com
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Understanding Children’s Sexual Behaviors.
Helping children with Sexual Behavior Problems
Treatment Exercises for Child Abuse Victims
Sexuality Curriculum
Space Invaders: game about boundaries
Resources
• Kahn, T. (1999). Roadmaps to recovery. Brandon, VT: SaferSocietyPress*
Bibliography of workbooks with interventions for sex offenders and
victims of sex offenses written in 3rd grade language.
• McLean Hospital, a Harvard Medical School Affiliate (December 2000).
McLean researchers document brain damage linked to child abuse,
neglect. Cerebrum, Fall 2000
• Miller, Scott, PhD. Coauthored:
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Feedback Informed Treatment Manuals (6)
The Heart & Soul of Change: What Works in Therapy
Psychotherapy with Impossible Cases
Staying on Top & Keeping the Sand Out of Your Pants
• Teicher, Martin (1993). Abuse linked to brain wave abnormalities. The
Journal of Neuropsychiatry and Clinical Neuroscience. Harvard psychiatry
associate professor, Biopsychiatry Research program director at McLean
Hospital.
American Psychological Association: Evidence-Based
• Robert Rosenthal and Lenore Jacobson (1966). Published results of a
powerful study later known as the Pygmalion Effect. According to Tauber
(1998), the Pygmalion Effect asserts that "one's expectations about a
person can eventually lead that person to behave and achieve in ways that
confirm those expectations.”
– Blind, double-blind studies are gold standard in psychology research
•
Evidence-Based Guidelines for Diagnosis of Learning Disabilities:
Response to Proposed DSM-5 Criteria for Learning Disabilities[PDF]
Psychology has embraced evidence-based practice as a basis for serving
children and adults. The purpose of evidence-based practice has been to
make available to clinicians the best evidence to guide their assessment
practices and treatment recommendations.
• 79 accredited Applied Behavioral Analysis programs for certification
– the preferred treatment for individuals with disabilities
– www.gradschools.com/search-programs/applied-behavior-analysis
– www.bacb.com/
Eligibility to sit for the BCaBA certification examination:
Board Certified Assistant Behavior Analysis
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A. Degree Requirement:
– Possession of a minimum of a bachelor's degree that was conferred in behavior analysis or
other natural science, education, human services, engineering, medicine or a field related to
behavior analysis and approved by the BACB.
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B. Coursework and Experience Requirements
– Coursework: The applicant must complete 135 classroom hours of instruction (see Definition
of Terms below) in the following content areas and for the number of hours specified:
– Ethical considerations – 10 hours
– Definition & characteristics and Principles, processes & concepts - 40 hours
– Behavioral assessment and Selecting intervention outcomes & strategies - 25 hours
– Experimental evaluation of interventions, & Measurement of behavior and Displaying &
interpreting behavioral data - 20 hours
– Behavioral change procedures and Systems support 40 hours
– Acceptable Coursework: College or university courses in behavior analysis, that are taken from
an institution that meets the requirements specified in Section A.
– www.bacb.com/