A Perspective on Inhome Behavioral Services Mark Levine
A Perspective on “In-home Behavioral Services” Mark Levine MS BCBA LMHC LPC Behavioral Counseling and Research Center LLC
(Listener take note) • My conception of service …only mine Service Recipients? © Behavioral Counseling and Research Center LLC 2009
Behavioral Services By Statute (Mainly)
Behavioral Services Via Class Action Lawsuit
Behavioral Health = Mental Health “Behavioral” in Behavioral Health ≠ “Behavioral” as in Behavioral Interventions “Behavior Management” My Preference: Behavior Analysis © Behavioral Counseling and Research Center LLC 2009
The science in which procedures derived from [learning] principles are systematically applied to improve socially significant behavior to a meaningful degree and to demonstrate [empirically] that the procedures employed were responsible for the improvement in behavior. Thanks to (Cooper, Heron & Howard. Applied Behavior Analysis. Columbus OH. Merrill. p. 14) and Behavior Analyst Certification Board
• Driven by behavior than diagnosis • More challenging behaviors • Can be diagnostic clusters • Often dual diagnoses Based on significance of single factor: e. g. severity) or sum of 2 or more dimensions: e. g. severity + frequency (or duration) severity + frequency + duration © Behavioral Counseling and Research Center LLC 2009
Sire, May I suggest an Applied Behavior Analysis consultant
What kinds of behavior? • Lack of cooperation • Verbal abuse • Destroying property • Aggression • Arson • Sexually inappropriate • Theft • AWOL • VERBS © Behavioral Counseling and Research Center LLC 2009
Behavior problems are maintained by environmental/antecedent conditions, learning history and skill absences Behaviors happen within contexts. They do not happen in vacuums or spontaneously © Behavioral Counseling and Research Center LLC 2009
Committed to established principles of behavior Focus on observable behavior. Data Driven © Behavioral Counseling and Research Center LLC 2009
Behavior plans are created when social significance justifies. © Behavioral Counseling and Research Center LLC 2009
Medical and other inherent conditions that can affect behavior and learning are considered. © Behavioral Counseling and Research Center LLC 2009
Create behavior plans that are based on the function of the person’s behavior Antecedent and reinforcement interventions are used but not aversives © Behavioral Counseling and Research Center LLC 2009
Skills and other youth assets are building material for intervention strategies Absent skills are acquired and inappropriate skills are altered through the teaching of replacement skills © Behavioral Counseling and Research Center LLC 2009
A well-chosen, well-trained and well-supervised staff that does it the behavioral way Collaborate with other parties in the youth’s life © Behavioral Counseling and Research Center LLC 2009
(Bring your CANS) © Behavioral Counseling and Research Center LLC 2009
Antecedent is a stimulus that is present when a behavior occurs. It does not necessarily produce the behavior But can develop control Behavior – interaction with the environment Consequence – an environmental change following the behavior that alters the probability of future occurrences of that behavior • Added • Removed © Behavioral Counseling and Research Center LLC 2009
Antecedent Behavior Consequence Asked to pick Pulled own hair Had him sit to up sweater for 5 min calm down Steve entered Making loud room noises Told repeatedly to stop until he did © Behavioral Counseling and Research Center LLC 2009
Lately, I’ve discovered that I’m my own worst antecedent
ECOLOGICAL • Cold/Hot Places • Crowded/Noisy environments • Novel places INTERPERSONAL Corrective feedback Denial of a request Following reinforcement Peer receives attention Presence of specific adult/peer ACTIVITY RELATED • Activity transition time • After making an error • Given an initiating instruction • Given a terminating instruction • No structured activity SCHEDULE RELATED Particular activity Particular hour Particular day © Behavioral Counseling and Research Center LLC 2009
INTRAPERSONAL Engagement in other misbehavior Fearful stimuli Following administration of medication Need cannot be made known Negative verbalizations © Behavioral Counseling and Research Center LLC 2009
What Occurs Next? Positive Reinforcement Negative Reinforcement aka Escape Extinction Punishment © Behavioral Counseling and Research Center LLC 2009
Positive Reinforcement Obtain Attention • Praise • Acknowledgement • Criticism Obtain Tangible • Money • Objects • Food Obtain Activity © Behavioral Counseling and Research Center LLC 2009
Escape/Delay • Demands • Activity • Person or Behavior a Person • Anxious situation ESCAPE IS BIG!! © Behavioral Counseling and Research Center LLC 2009
Harold, Makes A Communicative Statement
© Behavioral Counseling and Research Center LLC 2009
Current Behavior Function(s) Antecedents Consequences Skill Deficits Replacement Behavior(s) Thanks to Maag, J. Behavior Management. Singular. 1999
Hypothesize from Correlation Interventions Derive from Antecedents, Consequences, Functions. © Behavioral Counseling and Research Center LLC 2009
PROACTIVE VS REACTIVE Eliminate Alter Interrupt Chain Control (SC) Compete © Behavioral Counseling and Research Center LLC 2009
I’ll have an ounce of prevention.
Example of altering the impact of an antecedent: response to initiating instruction • Reduce complexity of the instruction or the number of steps to follow. • Provide a verbal reminder of the reinforcer that will follow cooperation. • Give choices regarding when to follow the direction (now or at a specific other time) and how to follow the instruction. • -Start the activity with the person. Or do the first parts of it. • Use proximity cues if needed. Stand close when giving the direction rather than across the room. • The less instructions given the better. The less given verbally the better © Behavioral Counseling and Research Center LLC 2009
response to initiating instruction –Initiating instructions are more likely to be followed if they are part of a routine or schedule. Developing an event-based schedule helps the individual to predict when demands will be made and what they will be. The schedule can include visual along with written cues. –Correspondence Training. This involves getting a person to commit verbally something. If cooperation is subsequently achieved the cooperation is reinforced socially as well as completion of the task. -Don’t give the instruction Is there a method of escape? © Behavioral Counseling and Research Center LLC 2009
Joe creates a sense of predictability through scheduling
Replace the behavior with an appropriate one, preserving the function. • Most common choice: communicative Independence skills Choice Making Cooperation Vocational skills ($) Leisure skills Social skills (Heavy interaction with sexual behaviors) © Behavioral Counseling and Research Center LLC 2009
Reinforce: • alternative behavior • less behavior • other behavior • any behavior • Incompatibility ________ • Interrupt/extinguish reinforcement of undesired behavior © Behavioral Counseling and Research Center LLC 2009
Just try to reinforce him when he isn’t hitting you.
NOT A LEARNING MOMENT © Behavioral Counseling and Research Center LLC 2009
Who implements? Typically… • Family Members • Behavior(al) Management Monitor • Other paraprofessionals in the youth’s life ***Monitored by data collection** © Behavioral Counseling and Research Center LLC 2009
HIRING TRAINING QUALITY CONTROL Task/Data Driven © Behavioral Counseling and Research Center LLC 2009
Someone who has done the above Direct experience working with youth as well as from directed training mentoring personnel in the relevant methods to successfully reach objectives Professional performance in program design and in understanding exactly how change happens Academic and clinical problem solving along with an ability to use feedback constructively. Experience gleaned from “being there and trying that” over multiple trials with a wide range of populations. © Behavioral Counseling and Research Center LLC 2009
• • • Developing and drafting of functional assessments and plans Supervising paraprofessionals Overseeing implementation of plans (Dealing with non-clinical factors) Collection and analysis of data Evaluation and monitoring of outcomes Collaboration with teams © Behavioral Counseling and Research Center LLC 2009
Experience as directly related as possible w/population Experience with anticipated behaviors Experience as directly related as possible w/para tasks Smarts SOCIALLY REINFORCING / ENGAGING Proactive Career oriented Positive models Agree behaviors to be addressed scientifically, not in own way Will not take behaviors personally © Behavioral Counseling and Research Center LLC 2009
• Eliminating or altering antecedents to create behavior change • Employing positive reinforcement to increase replacement target behaviors and reduce challenging behavior • As instructed, not being reactive to unwanted behaviors • Observing and defining, with the help of a supervisor, target behaviors to alter • Collecting data on target behaviors • Collecting data on skill deficits • Defining and obtaining data on “replacement behaviors”, under the guidance of a supervisor • Implementing plans as written © Behavioral Counseling and Research Center LLC 2009
• Providing prompts and cues to trigger appropriate behavior • Repeating skill training across the day and in multiple environments • Employing “Functional Communication Training” • Reporting plan obstacles immediately • Handling emergencies as directed and reporting ASAP • Assisting in a problem solving approach with new behaviors until an effective plan is formulated © Behavioral Counseling and Research Center LLC 2009
BEHAVIOR ANALYSIS THEORY – PERTINENT to the job e. g. • Building skills in communication, compliance, and cooperation • Interpreting Functional Behavioral Assessments • Behavioral Strategies (Shaping, Chaining, Task Analysis) • Social Skills, Circles of Support • Precision Teaching • Sexuality • Data Collection and Analysis • Engaging and working with families © Behavioral Counseling and Research Center LLC 2009
• Working in the community • Professional boundaries • Normal child development • Inclusion strategies • Specific Dual Diagnoses (ADHD; Asperger’s…) TRAIN TO THE SPECIFICS OF THE YOUTH’S PROGRAM CONFIDENTIALITY IN HOME AND COMMUNITY SETTINGS CRISIS MANAGEMENT TRAINING © Behavioral Counseling and Research Center LLC 2009
In ABA supervision at all levels—including peer supervision—is expected Direct professional supervision of paraprofessionals Task driven supervision. Checklists Ample literature © Behavioral Counseling and Research Center LLC 2009
• Parents and Caregivers are people too • Plan for them as well • Personnel. Absences. No shows. Substitutes • Place a system into action ahead of time • Practice of skills with caregivers and paras • Paperwork • System to meet the standards without interfering with services © Behavioral Counseling and Research Center LLC 2009
• Protection from Harm/Safety – Various environs • Training and supervision; follow-thru on plans • Prudence • Presence of family member/caregiver (or other) Privacy and Confidentiality in Homes and Community • Persistent training with scenarios • Physicians. Med Changes • Provide Data • Please Don’t Go • Plan Ahead. Data-base. • Possible Conflict with Other Services • Be the first to collaborate and… © Behavioral Counseling and Research Center LLC 2009
• Are based on established principles of behavior • Are linked to the data of the youth’s behavior • Develop and implement behavior plans that are based on the function of the person’s behavior • Focus on teaching replacement behaviors (skills) that displace unwanted behaviors but preserve function • Use antecedent interventions and reinforcement but not aversives © Behavioral Counseling and Research Center LLC 2009
PREVENT TEACH REINFORCE © Behavioral Counseling and Research Center LLC 2009
Functional Assessment and Program Development for Problem Behavior: A Practical Handbook (Paperback) by Robert E. O'Neill, Robert H. Horner, Richard W. Albin, Keith Storey, Jeffrey R. Sprague. Cengage
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