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Prof. Peter Sturmey: Assessing the functions of problems behavior in people with multiple disabilities

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Intervento del Prof. Peter Sturmey - Queens College City University of New York - alla Lectio Magistralis tenuta a Roma sabato 15 ottobre 2016 presso l'Università Pontificia Salesiana. L'evento è stato organizzato dalla Lega del Filo d'Oro in collaborazione con l'Università Pontificia Salesiana, il Politecnico delle Marche e l'Istituto Walden.

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Prof. Peter Sturmey: Assessing the functions of problems behavior in people with multiple disabilities

  1. 1. Professor Peter Sturmey, Ph.D. The Graduate Center and Queens College City University of New York and ABACNJ psturmey@gmail.com 1
  2. 2. Overview  1. Behavioral characteristics  2. Skills Teaching  Preference assessments  Teaching  3. Challenging Behavior  Functional assessment and analysis  Behavioral intervention  Management of caregivres 2
  3. 3. I Behavioral Characteristics  Fewer, low rates of behavior  Interfering behavior  Restricted range of reinforcers  Interfering medical issues 3
  4. 4. Appropriate Goals  Skills  Functional Motor skills  Reaching, grasping, using wheelchair, walking etc.  Choice making  Social behavior  Eye contact, smiling, hugs, high fives etc.  Communication  Vocal  Augmented communication  Cards, books, ipads, etc  Assisting in self-help  Spoon feeding, Hands up when dressing  Components of bathing etc. 4
  5. 5. Skills Teaching Motor skills: Correa et al. (1985) Reaching - grasping  N= 3, 2-4 year old  Severe / profound ID  blind  Developmental Quotients = 1-4 months  Used a noisy toy placed at mid-line 5
  6. 6. Conditions  Baseline:  Experimenter sounded one of the toys, placed it in one of the three positions on the lap tray, and waited up to 10 seconds for a reach-grasp  If the child did not respond, another criterion trial was presented with a different toy.  Intervention  Graduated prompting  Fading from physical  verbal  no prompt 6
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  8. 8. Nabeyama & Sturmey (2010)  2 Physical Therapy aides  3 students with multiple disabilities  None walked independently  All had wheelchairs / complex braces  Special education setting 8
  9. 9. Baseline  Experimenter instructed staff to take the student either from his classroom doorway to a specified location  Stated the six required response components for correct posture and guarding  Said, ‘‘Safely walk him to the [location],please.’’  The experimenter said nothing else 9
  10. 10. Behavioral Skills Training Experimenter gave staff self-recording checklist and explained the six response components  Instructed him/her to walk the student safely to a specified location, and complete the self- recording checklist  provided performance feedback, including positive statements on correct response components and corrective statements on errors and reviewed correspondence and non-correspondence between their respective checklists and explained the physical therapy  If the staff member performed fewer than six correct responses, the experimenter modeled the correct response and instructed the staff to rehearse that correct response.  During modeling, the experimenter described the incorrectly implemented components and instructed the staff member to observe as he demonstrated those correct responses and instructed the staff member to guard the student during ambulation for one trial.  The experimenter then provided vocal or physical prompts for correct responses as he or she guarded the student.  The experimenter provided descriptive feedback based on the preceding trial.  Modeling and rehearsal were terminated when the staff member completed two consecutive trials with all six responses correct.  Sessions were terminated when the student completed the required distance or lost his balance 10
  11. 11. Six-Step Task Analysis: The staff member …  (a) sat on a rolling stool;  (b) directly in front of Jacquel or to the right side of Cole and Steve  (c) lower back was aligned erect with the upper back and was vertical;  (d) left hand was on the right side of Jaquel’s pelvis and hip orthosis or Cole’s and Steve’s backs;  (e) right hand held the left side of Jaquel’s trunk, the right side  of Cole’s walker, or Steve’s right hand; and  (f) provided behavior-descriptive praise within 3 s of the student’s completion of ambulation. 11
  12. 12. Other features Generalization probes to novel students Second dependent variable = distance child walked Ratings of social validity 4-month follow-up 12
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  15. 15. Houwen et al. (2014): Systematic review of teaching motor skills  Studies published 1982-2012 (MEDLINE, PsycINFO, ERIC, and CINAHL).  Coded study aim, design, sample characteristics, theoretical framework, intervention, measurement tools and outcomes.  46/295 articles met inclusion criteria  40 single-subject designs  5 used a group design.  Behavioural techniques with (n = 21) or without (n = 15) assistive technology.  Outcomes  38 reported improvement in basic motor skills  8 reported improvement in recreational / other motor skills.  No negative effects 15
  16. 16. Stimulus Preferences and Happiness Rationales Quality of life Need reinforcers to teach Methods Stimulus preference assessments, not interviews / surveys alone Observe approach / avoidnace, engagement and affective behavior (happy / sad behavior) 16
  17. 17. Preference Assessments Methods  Why not use opinion?  Single  Multiple  Multiple without replacement  Trial-based  All use approach and avoidance responses 17
  18. 18. Greene et al. (2000): Trial based N=3 individuals with multiple disabilities Person-centered planning v. single stimulus preference methods Stimuli presented 1-2 times per day in natural environment 18
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  20. 20. Preference Assessments: Not (Person-Centered)Guesses  Reid et al. (1999): compared preferences from person centered planning and stimulus preferences  N = 4 adults with multiple and profound IDs.  Non-ambulatory, limited upper body movement  Physical disabilities, uncontrolled seizures  Considerable assistance with all activities of daily living 20
  21. 21. Two preference assessment methods  Person-Centered Planning  Highly experiences professional staff, trained in PCP  All team members familiar with individual for extensive periods of time  Identified preferred leisure activities  11 systematic questions  “tell me a story when s/he was happy recently”  Stimulus Preference Assessment  Single-item preference assessment (Pace et al., 1985)  Record approach and avoidance responses 21
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  23. 23. Replicates earlier Green et al.  23
  24. 24. Does it matter? Yes! 24
  25. 25. Reid’s Studies on Happiness  Green & Reid (1996)  Observed happy and unhappy behaviors in 5 adults with profound ID  Conducted preferences assessments  Observed strong association between presence of preferred and non- preferred activities and mood-related behavior  Replicated by several studies  Staff and multi-disciplinary team members are poor at identifying stimuli associated with happy behavior 25
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  28. 28. Reid & Green “Fun time”  Three participants with profound ID  Identify situations correlated with unhappy behavior  Conduct stimulus preference assessment  Introduce preferred stimuli  Evaluate & modify if needed 28
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  30. 30. III. Challenging Behavior  Goals  Identify priorities  Identify the function  Translate into a treatment plan  Implement and evaluate it 30
  31. 31. Methods Indirect Interviews & questionaires Direct Descriptive Unstructured / structured observations ABC charts scatterplots Direct experimental 31
  32. 32. Functional Assessment and Analysis  The major contribution of ABA to SIB  Carr (late 1970’s)  Easy v. difficult tasks  Low v. High attention  Iwata et al. (1982, 1984)  Understanding environmental control of SIB  Developing idiographic, effective, function-based treatments  Avoiding harmful treatments 32
  33. 33. Schaefer (1970)  2 rhesus monkeys  Expt. 1: Shaped up “head banging”  Successive approximation  Reinforced with food  Brought under stimulus control of different person  Experimenter v. other person  Expt. 2  Shaped up head to cage  Took only 20 reinforcements 33
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  36. 36. Functional Analysis: Iwata et al. (1992) 36
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  38. 38. Functional analysis predicts treatment Iwata et al. (1994)  N=152 consecutive functional analyses of self-injury  Setting  Natural home (N=49)  Group home (N=20)  Institution (N= 83)  Demographics  57% male  51% age <21 years  91% severe / profound intellectual disabilities  47% cerebral palsy  Various genetic syndromes (Rett, Lesch-Nyhan, etc.) 38
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  41. 41. Conclusion  Self-injury is strongly environmentally determined  Function can readily be detected in most cases using functional analysis  Most predictive for socially-mediated SIB  Least predictive for non-socially mediated SIB  Function predicts  Effective treatments  Harmful treatments 41
  42. 42. Common critiques of experimental functional analyses Take too long Risks of injuries Requires specialized skills Typical Previous Practitioner Solutions Use descriptive methods Tolerate ambiguity Sacrifice accuracy to an unknown extent 42
  43. 43. Functional analysis takes place on the natural environment Brief control and test conditions Therapist presents trials that mimic Functional Assessment conditions Tangible. During control condition the therapist sits with the subject, who was playing with a preferred leisure item. Problem behavior produced no consequences. During test condition the therapist removed the item from the subject’s possession and kept it out of reach for 2 min. If problem behavior occurred, the therapist gave the item back to the subject immediately. If the subject leaves the seat the therapist followed him or her to maintain physical proximity but did not interact with the subject in doing so 43
  44. 44. Bloom et al. (2011) • Investigated the convergent validity of trial-based and experimental functional analyses •N = 6 •Target behavior = aggression 44
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  46. 46. Rispoli et al. (2014) Systematic Review of trial-based functional analysis • Systematic searches of electronic databases, journals, citations of a seminal study, and reference lists • Resulted in 13 studies • 36 full trial-based functional analyses • N = 47 participants • Mean age = 10 years (3-29 years) • 62% autism • 14 topographies of challenging behavior (47% aggression) • classroom and home settings • Implemented by teachers, service providers, or researchers. • Functions identified in 35/36 cases • 3 modifications needed • A promising method 46
  47. 47. Interview-Informed Contingency Analyses (Hanley) • Goal: To identify functions rapidly, accurately for use in practice • Extensive training materials available here: • https://practicalfunctionalassessment.com/about-2/ • Valutazione del sonno e intervento • https://practicalfunctionalassessment.com/implementation-materials/ • Intervista a domande aperte per l’analisi funzionale • https://practicalfunctionalassessment.com/implementation-materials/ 47
  48. 48. General Strategy (Hanley et al. 2014) • Interview (40 minutes) • Gail showed problem behavior when her mother divided attention and removed toys • Generate hypothesis • Gail’s problem behavior was positively reinforced by mother’s attention and access to toys • Design synthesized test and control conditions • Control: Continuous attention and toys, no demands • Test: No attention or toys, except immediately after problem behavior • Brief Reversal in 5 minute sessions 48
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  50. 50. Jessel et al. (2016) 50  30 (!) systematic replications
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  52. 52. Conclusions • Approach highly robust across many individuals • Efficient • Interview (40 min) + IISCA (30 min in many cases • May lead to effective treatment quickly • Teach tolerance of delay to reinforcer • Include requirement for more complex / effortful adaptive behavior, not just waiting 52
  53. 53. Critique  Very practical, easy technology to use  Applicable to persons with severe / profound ID  Limited external validity  Non-clinical population  No participants with mild / moderate MR 53
  54. 54. DeLeon et al. (2003): Idiosyncratic function  Grady, 14 year old boy w PID, visual impariments  Non-verbal, limited comprehension in wheel chair  Variety of problem behaviors  SIB, and disruption  Current analysis was aggression  hitting, pinching, scratching, pushing, or grabbing others.  Access to movement as reinforcer for aggression 54
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  56. 56. Function-based Treatment: DRA + Extinction  Functional communication training (FCT)  Grady requested to be pushed using a battery-operated, press-activated, voice-output device  Extinction phase 10, 1-min trials during which the therapist prompted Grady to communicate to be pushed.  Aberrant behaviors were ignored  Pressing the voice-output device so that the recorded phrase (‘‘Push, please.’’) was audible 56
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  58. 58. EVIDENCE-BASED PRACTICE: Sigafoos et al. (2014)  Search  3 databases  Self-injury terms x disability terms  Inclusion  1. English  2. evaluated at least 1 SIB treatment  Excluded psychotropic medication  3. Objective data  Observational data  Standardized psychometric data  Treatment classification  ABA  Behavior Modification  CBT  Other treatments  Sensory etc. 58
  59. 59. Evidence Standards  Effective  3 independent studies  Ineffective  3 studies showing ineffective  Inconclusive  3 studies, conflicting results  Lacks sufficient evidence  < 3 studies 59
  60. 60. Summary  Effective  ABA  Functional Communication Training, Non-Contingent Reinforcement, Function- based extinction  Behavior Modification  Differential reinforcement, Punishment, contingent restraint  Lacks sufficient evidence  Cognitive Behavior Therapy, vests, gentle teaching, ECT, Snoezelen, TENS, Exercise, room management  Ineffective  Auditory Integration Training, Sensory Integration Training 60
  61. 61. Kahng et al. (2002)  Quantitative analysis of behavioral research  35 years is provided 1964 to 2000  396 articles (706 participants)  Most participants  Male  severe/profound intellectual disability.  Trends  Reinforcement-based interventions has increased during the past decade  Punishment-based interventions has decreased slightly  Increased use of functional assessments.  Most behavioral treatments  highly effective  greater emphasis should be placed on prevention. 61
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  68. 68. Conclusion Problem behavior is highly environmentally influenced Functions differ from person to person Funtion predicts effective, ineffective and harmful treatment 68
  69. 69. IV. Management of Caregivers  Essential part of intervention  SIB is often a long-term, chronic problem  Often associated issues  Training  Must use behavioral skills training  Prevention  Skills training  Feedback  Implementation  Individual outcome 69
  70. 70. Caregiver Training  ABA interventions depend crucially upon caregiver behavior  Large numbers of staff are employed  turnover is high  Many family members, supervisors and professionals are  Limited skill repertoire  Untrained  Inappropriately trained 70
  71. 71. Behavioral Skills Training  Components  Task analyze skill  Brief instruction  Model  Rehearse  Feedback  Teach to mastery  Maintenance  Spot checks  Feedback 71
  72. 72. Madzharova, Yoo and Sturmey (in review) 72
  73. 73. Important Clinical Issues  Use local policies / stated values to leverage implementation  PBS commitment  Time management  Have clear priorities  Don’t waste time on irrelevancies  Conducting an adequate FBA  Indirect methods are insufficient  Don’t spend time collecting irrelevant information  Conducting FBAs efficiently  Identify foolish barriers / excuses and move on to help the client  If you know the function, stop and write the treatment plan  If the plan is OK, don’t do an FBA, train the staff/ family  Identifying the real problem  Adequate FBA? Adequate plan?  Adequate training  Organizational issues? 73
  74. 74. Conclusions  ABA  Readily applicable to individuals with multiple disabilities  Skills  Taught using general principles  Happiness  A quality of life approach  A great prevention strategy  Challenging Behavior  Function based assessment and treatment  Train and support staff / family members 74
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