How to Baffle and then Appreciate a Psychiatrist

How to Baffle and then Appreciate a Psychiatrist: A Look at Complex Needs and Setting Event Strategies for Individuals with Intellectual Disabilities Presenters: Dr. John C. C. Chan, M. Sc. , M. D. , FRCPC John Kosmopoulos, B. A. , BST, MA(c) March 25 th, 2011 Kingston, ON

Objectives § Applied Behavior Analysis & Behaviour Consultation o o o Setting Events: Definitions & Types Traditional & Expanded Models of Behaviour Analysis Biopsychosocial & Setting Events Assessment Models Assessment of Setting Events Setting Event Intervention Model § Psychiatry & How The Two Disciplines Shall Meet o Interdisciplinary Support Flowchart o Complex Cases: Interactive Vignettes o Setting Events & Biopsychosocial Intervention Models

Applied Behavior Analysis & Behaviour Consultation SETTING EVENTS

Setting Events • Setting events are often referred as “slow triggers” or “setting the stage” for the likelihood of behaviour. • Setting events are types of antecedents that can precede or occur at the same time as a problem behaviour. • In specific terms, setting events may be defined as broad, complex and distant antecedent events or conditions that may occur days before or simultaneously with immediate antecedents across different settings and temporarily alter the effectiveness and value of reinforcers (Alberto and Troutman, 2006).

Setting Events • Setting events strategies address the specific events that increase the likelihood that immediate antecedent events will evoke a problem behaviour • Setting event strategies make the behaviour less likely.

Setting Events Example: • few hours of sleep or is tired (presence of setting events / slow trigger) • less likely to fulfill a request to do a task at work (immediate antecedent / fast trigger) or any other setting • Would normally be cooperative with the same request because they got a good night’s sleep (absence of setting events / slow trigger).

Traditional & Expanded Model of Behaviour Analysis (Adapted From: Sprague & Horner, 1999) Antecedent • Setting Event • Includes Motivation • Momentary Effect of SE (and motivation) on Value of Consequences • Antecedent Behaviour • Behaviour Consequence • Consequence

Types of Setting Events • Physiological • Environmental • Social • Motivational

Physiological / Biomedical Setting Events • Not enough exercise • Agitation due to emotions, • Physiological conditions • Sleep disturbance • Illness • Pain • Allergies • Infections • Injury Mood • Mental illness • • • Hunger/Thirst Hypothyroidism Menses Medication changes Mediation dosage and administration problems Medication side effects Difficulty sleeping Constipation Headache Stomach problem Lethargy

Environmental Setting Events • • Crowded conditions Barren environment Noise level Heat/Cold Time of day Music Physical lay out of environment Group instruction Independent seatwork Curriculum Being late for school Staffing patterns Moving to new school/home • Transitions • • •

Social Setting Events • Major life changes • Fight with peers • Negative social interactions • Family divorce/Discord • Certain individuals • Losing a game • Changes in teacher or classmates • Fight on the bus or playground • Loss of a loved one • Expectations • Lack of rapport

Motivational Setting Events • To escape aversive situations • To obtain attention or tangible • To escape / remedy / decrease anxiety, medical events, discomfort, pain, etc. • To relieve boredom • To increase or decrease stimulation • Deprivation of biological reinforcers (e. g. , hunger, thirst, etc. ), environmental and social reinforcers (e. g. , quiet environment, adequate support and resources) • To make things easier (less effortful)

Examples Of The Traditional ABA Models Antecedent Asked To Do Task (Demand) Behaviour Yelled & Hit Consequence Ignored & Redirected Behaviour • Why did the task, that the person is able to do and would normally comply with, provoke problem behaviour?

Example of Expanded Model of Behaviour Analysis Setting Events (SE) SE Effects on Consequences • Lack of sleep • Hungry • Increase motivation to escape task • Antecedent (A) • Asked to do Task Behaviour (B) • Yell & Hit Consequence (C) • Ignored & redirected behaviour back to task • The setting event (slow trigger) “sets the stage” and “increase the likelihood and motivation” for problem behaviour when a demand is placed.

The Synergy Of Setting Events • Notice how each of these potential setting events may be available at the same time for the challenging behaviour of hitting: ╬ Physiological Setting Event = cold / flu ╬ Environmental Setting Events = high noise level & density of people ╬ Social Setting Event = aversive demand situation(s) ╬ Motivational Setting Event = to escape (by hitting) / deprivation or satiation states / to be left alone / to enter a peaceful environment / to help her cold / flu symptoms • Psychiatric symptoms (e. g. , negative affect) may be a synergy or cumulative impact of setting events (Carr et al. , 2003; Durand & Mapstone, 1998).

Biopsychosocial Model (BPS) • Biological o Medical conditions, medication side effects, syndromes, developmental, etc. • Psychological o Mental / emotional health, psychiatric, cognitive abilities, coping with stressors • Social o Social and physical environments (interactions and supports), stimulation, choices, motivation

Biopsychosocial & Setting Events Assessment Models • Both are compatible and complimentary • Both are forms of comprehensive assessment o BPS: used as an overall assessment of a clinical problem or problem behaviour for possible diagnosis and biological, behavioural, psychological remediation o SE: used as an overall assessment specific to the likelihood, context and function of problem behaviour • Both are “holistic” (they consider the whole person) • Both are best practice and evidence-based • Psychiatrists and behaviour consultants use both models but conceptualization is different based on each discipline

Setting Events: Assessment Methods • Example assessment procedures & tools o Interviews o Functional Assessment Interview (O’Neill et al. , 1990) o Scales o Setting Events Checklist (Gardner et al. , 1986) o Problem Behavior Questionnaire (Lewis et al. , 1994) o Contextual Assessment Inventory (Mc. Atee et al. , 2004) o Analysis of Setting Events Questionnaire (Kosmopoulos, 2006)

Analysis of Setting Events Questionnaire (ASEQ) (Kosmopoulos, 2006) o Comprehensive, multi-itemed (117) rating scale. o Single or Inter-observer administrations. o Likert-type scale (0 -3) to determine the degree of relationship or the level of association between the specific target behaviour and various setting events (currently or within the last month). o 2 -1 Scale (setting events & function of behaviour). o Reviewed and supported by psychologists. o Data analysis section and graph o Good overall psychometric properties o Other scales limited in scope, diagnoses, settings and psychometric properties (based on research)

ASEQ – 4 SETTING EVENT CATEGORIES PHYSIOLOGICAL ENVIRONMENTAL ASEQ SOCIAL MOTIVATIONAL

ASEQ VARIABLES – TRADITIONAL & “UNIQUE” SE Physiological Environmental Social Motivational Traditional: medical illness, medication change, moods, allergies, constipation, diet, etc. Unique: family history, syndromal features, brain injury or dementia, licit / illicit drug use Traditional: time of day, physical environment, routines, seasons Unique: stressful family environment, access to transportation, professional assistance, medical / dental appointments Traditional: demands, lack of choices, critical incident, disappointments, proximity, level of attention, etc. Unique: specific treatments provided, language barrier, limited coping abilities, inconsistent implementation of strategies Traditional: to access attention, to escape or avoid an aversive situation, to relive boredom, to access tangibles, communicate wants and needs, etc. Unique: as a category in SE assessment tools; to satisfy a biological need or deprivation state (e. g. , hunger, thirst, sleep); response effort

ASEQ – Who can benefit? • User-friendly and versatile in its breadth as it was designed to be utilized across: ages (i. e. , children, adolescents, adults) behaviours (e. g. , tantrums, SIB, property destruction) diagnoses (e. g. , autism, DD, dual diagnosis, syndromes, mental health, etc. ) settings (i. e. , home, school, treatment centre, group home, community, etc. ) • Comments section after each category of setting events

ASEQ-FS (Function Subscale) • Specific items from each of the setting event categories are itemized according to functions similar to the QABF: Attention Escape Tangible Sensory I (Physical) Sensory II (Alone / Non-Social) • On The ASEQ Scale, there are red tags to correspond to items found in the ASEQ-FS data analysis table.

ASEQ – SAMPLE PAGE On The ASEQ Scale, there are red tags to correspond to items found in the ASEQ-FS data analysis table.

SETTING EVENT INTERVENTION MODEL • Behaviour support plans that include the setting events treatment model for individuals that present with complex needs compliment interdisciplinary investigations and multimodal treatments. • The setting events strategy models emphasize a reduction of specific behavioural challenges and behavioural health problems and an enhancement of adaptive alternative and coping behaviours. • Several setting event intervention models have demonstrated effectiveness and success in their use.

Setting Event Intervention Model (Adapted: Gardener et al. , 1986, Carr & Owen-De. Schryver, 2006) 1. Eliminate or minimize the setting events 2. Neutralize setting events 3. Redesign the physical environment 4. Increase positive interactions and positive reinforcers 5. Teach coping and communication skills

Setting Events Intervention Model 1. Eliminate or Minimize the Setting Event – Modify or minimize the likely occurrence of the setting event for problem behaviour • Medical and behavioural advice for illness, pain, sleep problems, overwhelming anxiety, etc. • Decrease crowding, change fluorescent lights to prevent seizures, decrease noise level, consider visuals within a class, etc. • Decrease or eliminate demands when tired, reinforce cooperation and communication around setting events, etc. • Use of communication for seeking medical and emotional support • Provide greater 1: 1 attention if required, etc. – Early intervention for warning signs of behavioural agitation or possible health symptoms

Setting Events Intervention Model 2. Neutralize the Setting Event – Intervene after the setting event occurs but before the antecedent for problem behaviour o Decrease demands and aversive events o Increase preferred activities and routines o Directly change the individual's response to the setting event (e. g. , instead of fighting, prompt use of negotiation or relaxation)

Setting Events Intervention Model • 3. Redesign the Physical Environment • Is the physical environment stressful or unpleasant to the individual? o o o o o Change the physical layout of the environment Create opportunities to respond in socially appropriate ways Availability of social interactions Availability of stimulating activities Consider lighting, noise levels, density of people, proximity to others Minimize distractions Increase visual systems Adaptations for mobility, navigation, easy entrance and exit safety

Setting Events Intervention Model 4. Increase Positive Interactions & Positive Reinforcers – Does the person have access to a sufficient variety of preferred stimulating activities? – Does the person have the skills and opportunities to engage in preferred stimulating activities? – Does the person have sufficient access and choice of foods? – Does the person have sufficient access to items and activities that are reinforcing to that person? – Is the activity boring or monotonous to the person? – Are the expectations unclear due to a lack of routine? – Are the established routines inappropriate for that person (i. e. doing homework before bedtime when they are too tired to think; setting a chore to be done during their weekly TV program; or having a schedule that does not include chosen activities)? – Is the person’s daily schedule so flexible that the environment seems unpredictable? – Are there recent changes in caregivers, teachers, staff or peers?

Setting Events Intervention Model 4. Increase Positive Interactions & Positive Reinforcers (continued) o Increase motivation for appropriate responses o Decrease effort for appropriate responses o Increase preferred activities o Encourage choices o Etc.

Setting Events Intervention Model 5. Teach Coping & Communication Skills o Teach tolerance for waiting, lack of attention, etc. o Teach specific coping skills (e. g. , what to do if it’s noisy, crowded, the bus is late or takes a different route, etc. ). o Teach communication skills re: illness, mood states, discomfort, etc. o Reinforce all functional communication around the need for support.

PSYCHIATRIC SUPPORT & APPLIED BEHAVIOR ANALYSIS: A COMPLIMENTARY PERSPECTIVE FOR INDIVIDUALS WITH COMPLEX NEEDS CASE VIGNETTES TO BAFFLE & APPRECIATE

Objectives • Interdisciplinary Flowchart • Clinical case vignettes • Evidence & observation-informed treatment rationale • Discussion

Interdisciplinary Support: Flowchart Behavioural Assessment Psychiatric Assessment (Biopsychosocial and Expanded Behaviour Analysis models) (Biopsychosocial model – may include Behavioural model) Biomedical? Behavioural? Both? Function? Ethics? Data? Referral for Biomedical Assessment Behavioural Suggestions & Training Monitoring & Evaluation Collaborations with Psychiatrist and other Professionals Possible Diagnosis & Medications Additional setting event and behavioural strategies Monitoring & Evaluation Additional referrals Collaborations with Behaviour Consultant and other Professionals

Vignette 1 16 yo female Non-verbal No History of Violence One wk history of sleep, frustration tolerance, obsession • On Prozac for anxiety • Family members worry about his sleep • •

Changes • Few days graduate from school with months of transition • Pt uncle passed away a week ago

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Physical Observation • • • Rocking Back and forth Slightly febrile and increase pulses Physical examination grossly normal OTITIS MEDIA on the Left Ear Rx - Amoxicillin

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Discussion • Environmental Changes (Consider setting event and other behavioural strategies) • Biological Organic Medical difficulties • Sleep issue • Non-verbal is an issue • Physical exam by medics is very important • Cold? Allergies? Constipation? Dental Caries? Etc…

Vignette 2 • • • 13 yo male Short phrase and single words Some ADL but not all IQ = 65 Just started a new school

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Vignette 2 • • • Decrease speech except for a few words Sleep disruption at night & nap during the day Enuresis & Smearing feces after BM (new) Irritable, isolated and oppositional (worsen) Agitation while waiting at the ER

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Medical Exam • ‘Normal’ • ER MD referral to Beh. Neurologist or C&A psychiatrist.

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Significant Behavioural Regression • Physical abuse • Sexual abuse • Emotional abuse

Significant Behavioural Regression Sleep problem + language regression + ADL regression ® New onset of seizure? ® Bimodal onset: < 5 yo & onset of puberty

Vignette 3 • • • 14 yo male Autism and Sever MR agitation and aggression Recent move to new group home Difficulties in adjustment

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Clinical Rationale • • • WHY NOW? Victimized in new environment? Significant difference in routine? Puberty Mood disorder ‘equivalents’ New seizure disorder? Medical Biological Organic?

Vignette 3 • Behavioural specialist working with group home staff to address increase pacing, anger outburst and minor physical aggression • He struck a staff member • Certified for involuntary Psychiatric assessment in 72 hours at Schedule 1 facility

Vignette 3 Recently adjusted medication… • Paroxetine (Paxil) 20 mg po qam (NEW) • Divalproex Sodium (Epival) 250 mg po bid • Quetiapine (Seroquel) 50 mg po bid

Medication • New agents added or removed chronologically related to behaviour?

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Vignette 4 • • • 21 year old mild/borderline DD young female Recent ER visit for slashing wrist Three prior overdoses on medication Recent breakup with boyfriend – feeling hopeless She hoped to “just get his attention” Impulsive Brief & intense relationships Abusive relationships Criminal record for mischief missed social cues

BPS & SE? Medical Organic Biological Psychiatric Psychological Social Environmental Motivational

Clinical picture Lack of awareness Blame other people for their problems Cannot cope adequately with stress Tend to responds in ways that are stereotypical (not tailored to the situation) • Their inflexibility – vicious cycles of consequences • •

Personality disorder • A set of inflexible, maladaptive character traits • Functional impairment • May cause significant subjective distress to the person • Affect 2 or more of these areas – – cognition emotion interpersonal relationship impulse control

Healthy Personality • Enable a person to adapt to stressful situations Personality Disorder • They tend to have trouble with relationship, employment or the law

Because personality traits are so ingrained, it is difficult to help people with personality disorders to develop healthier coping styles

Not all annoying personality traits are symptoms of a personality disorder!

Borderline Personality Disorder (BPD) • • Unstable self-image Unstable emotion Chronic feeling of emptiness & fear of abandonment Intense & inappropriate anger Recurrent thoughts of self-harm Impulsive Unstable & intense relationships Idealize or devalue other person

Approach to clients • • Inherent difficulty with relationship Chronic problem Coexisting mental disorder Often idealize and devalue staff

Approach to clients • Crystal clear professional boundary • Clear, consistent interaction style • Avoid manipulation – help clients to adjust their expectation (reality check) • Validate the clients’ subjective reality of crises • Encourage clients’ problem-solving skills

Treatment • No Pill can Cure Borderline Personality Disorder! • Dialectic Behavioral Therapy • Cognitive Behavioral Therapy • Intervention for substance abuse • Family or Group therapy • Treat coexisting mental disorder

Pearls of Wisdom for Staff • Always remember the bio-psycho-social and setting event models • NEVER underestimate the environmental, social, psychological and motivational factors • Medical ailments can contribute to challenging behaviours in DD population

Pearls of Wisdom for Staff • Medication can help but can BACKFIRE!!! • DD population is exquisitely sensitive to psychotropic medication • Limited evidence for psychotropic usages

THANK YOU!!! • For further information on the ASEQ or future presentations, please contact: John Kosmopoulos johnkos@rogers. com