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
DSM-IV-TR
Borderline Intellectual Function
• V62.89 Borderline Intellectual Functioning
– IQ in the 71-84 range.
– Differential diagnosis between Borderline Intellectual
Functioning and Mental Retardation (IQ 70 or below)
can be difficult, especially with coexisting mental
disorders.
– Coded on Axis II
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.
Low Functioning: RM age 16 male, CSC
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Scale
Verbal
Performance
Full Scale IQ
Score Percentile Range
69
2
Extremely Low
59
.3
Extremely Low
61
.5
Extremely Low
• Low Functioning: EA age 16 female, SC
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Scale
Verbal
Performance
Working Memory
Processing Speed
Full Scale IQ
Score Percentile Range
57
.02
Extremely Low
80
18
Low Average
74
4
Borderline
70
4
Borderline
65
1
Extremely Low
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: 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
Childhood maltreatment changes brain structure
and function. Abuse/chronic trauma hx =
Left Prefrontal Cortex Damage
Effects of Left Prefrontal Damage
• Damaged left prefrontal
– Corticotrophin, epinephrine, norepinephrine released when
stressed….damaged left prefrontal cortex cannot mediate overwhelm.
– Impaired left prefrontal ability to mediate right prefrontal cortex
results in continued sympathetic response at high rate, extended time.
– Impaired brain status is exacerbated by stress, re-traumatization
(flooding) = reoccurring chemical cascade.
– Vicious cycle
• Imbalance impairs functioning in other parts of brain (pouring battery acid
over brain)
• Sleep deprivation impairs repair of brain; insomnia common
• Symptoms: shut-down/acting-out, suicidal ideation/gestures = distress
• Emotional pain drives compulsions, precipitates self-medication (alcoholsubstance abuse, neg. compulsive behaviors) = lifelong institutionalization
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
documented.
– 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, where stress responses occur.
• 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, precipitates.
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.
Neurobiology
• Trauma affects both structure & chemistry of a developing brain.
• Behavior-learning problems plague 3/4 of children in child welfare system.
– Altered stress-regulating hormone production
– Altered key neuro-transmitters: 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,
associated with rational thinking, and the hippocampus.
– 1998 study showed left cortex of the abused group underdeveloped.
– Abuse typically lowers serotonin levels, leading to depression and impulsive
aggression.
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
Striatum: grey matter volume deficit
Drug AbuseHealthy Brain
Grey Matter Deficits: Limbic, L hemisphere,
corpus collosum, cerebellar vermis,
prefrontal cortex, striatum, cerebellum
Verbal Abuse Linked to Permanent
Brain Damage
• Martin Teicher, Harvard Medical School associate professor
of psychiatry at McLean Hospital. Biological Psychiatry,
February 1, 2009.
– 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 ?
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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
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
• 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
Verbal, physical, emotional, sexual abuse effect 2ndary brain damage
2ndary brain damage is exacerbated by stress, retraumatization
• 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
L: Left temporal deficit-suicidal child
R: Worried & Rigid
Undoing Neurobiological Effects of Trauma
• Alexandra Cook, Ph.D. Trauma Center at Justice Resource Institute
– 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.
Chronic trauma affects structural &
functional changes in the brain
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.
• 2002 biopsychology: Increases vascular highways of brain; improves brain function
– 2007 study: A mouse that runs is smarter than one that doesn’t run.
• Environmental stimulus (toys/tastes), new learning, exercise compared.
• No matter how stimulating, enriching environment did not improve brain.
• New learning made task specific neurons that re-fire to task only.
• Exercise made neurons nimble, could multitask and re-fire cognitively flexibly
• Exercise doubled new neurons in hippocampi compared to sedentary animals
• Only thing that mattered in improving brain: 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 grp 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
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Daniel Amen, MD, ‘Use Your Brain to Change Your Age,’ 2012
– 1-hr aerobic exercise daily, preserves and repairs brain
– Effects wear off after 24 hr.
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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
– 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: region behind the forehead and
eyes, associated with thinking in words about emotional experiences; implicated in
inhibiting behavior and processing emotions.
– Suggests thinking in words about feelings, label 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.
Process emotions, de-intensify emotional pain:
Label feelings, verbalize feelings
Kinesthetic Intervention
• Walk through learning experience, repetitively
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Enactment: experiential approach; drama therapy; Supervise enactment.
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CSC-- Clarify rules, enact
– You do not touch others.
– You do NOT say you want to be close, or ask her to ‘do it.’
– You Can ask social questions.
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Role-play, rehearse, coach Emotion Program: I feel…because…I want….
– Empowers client to verbalize fears, upsets, resentments.
– Go from 2ndary to primary feelings.
– Client experiences verbalizing face-to-face with support.
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Win-win collaborative problem solving with client (Greene, 2001).
– Client is empowered in win-win resolution, in which they participate.
– Client experiences equality, to support assertiveness.
– Clients wants/needs are valued. Providing choice is not cps.
• Re-enactment: Coach ‘acting’ of 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
Relevant Intervention Tools
• Differences & Perception
– Acknowledge client perception regardless of cognitive distortion.
• Listen to the client. Reflect to clarify what you understand, question.
– It takes time to discover their feelings and thoughts.
• Feelings drive behaviors.
– Use collaborative problem solving (The Explosive Child, Greene).
• Submission is not assertiveness, doesn’t teach assertiveness.
• Equalize the playing field to elicit a win-win solution via verbalization
• Assist client to verbalize
– Format: ‘I feel…because…. I want….’ = assertive verbalization; respond.
– Repeat for primary feeling underlying secondary feeling.
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Process until underlying emotion is accessed, helps client discover their feeling
Helps access a genuine emotion versus reaction.
Discovery and disclosure to self is the goal.
Clients talk when they feel safe, they do not talk when they feel unsafe.
What to Do
• Capitalize on strength: Kinesthetic - Engage in physical activity
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Increases vascular networking to the brain.
Increases short-/long-term memory and brain function.
Increases/sustains endorphin levels, elevating mood.
Improves brain function and brain repair. Sleep is critical.
Relieves stress in high anxiety individuals.
Physical activity and/or laughter drops defenses.
• Target Priority: Reduce self/other harm, repair the brain
– Symptoms of a stressed brain: compulsions, suicidal ideation, aggression
– Stress is cumulative, effects are often delayed
• Low functioning
– Low Vocabulary: Keep it Simple (KIS)
– Low Information: Keep it practical
– Low Comprehension: ‘do’ desired behavior
• Experiential Learners
– Kinesthetic learners must “do” to learn
• Not visual: See to learn
• Not auditory: Hear 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.
• Nail biting, smoking, binging, restlessness, OCD behaviors
• Sleeping in class, rebellious attitude
• APA Ethic: Do no harm (Iatrogenic tx)
• Corroborate
– Seek persons w/higher education, more experience, training
– Ask questions before implementing interventions
• Consult, consult consult.
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Attend to client ‘feelings’
• Neither authoritarian nor permissive is therapeutic.
• Attending to feelings is preventive, feelings drive behavior
• Fastest way to achieve goals: ‘Motivate’ via client desired incentives.
• Supportive intervention is slower, takes longer
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Reduces compulsions, self-harm
Reduces suicidal ideation, suicide gestures, suicidal attempts
Reduces acting out, aggression, assault
Increases verbalization, assertiveness, and adaptive functioning
Insufficient Interventions
• It may be insufficient to:
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Repeat back to me, so I know you understand.
Talk more than the client: Repetitively explain ‘why’
Post the instruction on the wall, medication box.
Tell client why s/he shouldn’t feel what they feel.
• It is ineffective to:
• Threaten client: privilege removal, loss of desired event
• Punish client: item removal,
Interventions NOT for Low Functioning Individuals
• Rewards & Punishment
– ‘Incentive only’ is preferred treatment approach
– Punishment= re-victimization experience, victim stance
– Punishment stops behavior, doesn’t teach appropriate behavior;
stacked consequences
• Broad based education & experience
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Target: strengths to maximize competency; income earning
Learning takes so long, focus on high risk behaviors.
Intergenerational government dependency status perpetuated
Avoid unnecessary stress: 2ndary damage suffered when stressed
• Prioritize reducing self-harm/other harm
• Flooding
– Prolonged exposure to desensitize individual to stressful stimuli
exacerbates damage in impaired brain.
• Authoritarianism – Triggers victim-stance, domination-subordination.
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.
• Counts the number of replacement/goal behaviors.
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.
Confounding Factors
• 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
Notes
• 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.
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.
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
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– 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/