BEHAVIOR ASSESSMENT REPORT AND RECOMMENDED …
NOTE: This report was written by a participant in Institute for Applied Behavior Analysis’ Summer Institute () on “Assessment and Analysis of Severe and Challenging Behavior.” All identifying information has been changed. This report is presented as an example of the type of report that participants will be able to write after completing the course.
COMPREHENSIVE FUNCTIONAL ASSESSMENT REPORT
AND RECOMMENDED SUPPORT PLAN
Client Confidential
Date of Report: July 27, this year (draft)
Referral Date: July 1, this year
Period of Report: July 26 – August 4, this year
IDENTIFYING INFORMATION
Name: Jane Doe
Date of Birth: July 2, 1976
Address: Any Lane, Apartment 2
Any Town
Referral Source: Tina Timmons, Manager, Supported Employment Service
REASONS FOR REFERRAL
Jane was referred for an evaluation by Tina Timmons, manager of the Supported Employment Service, Inc (SESI) program, a behavior management day service that is a division of the Alphabet Program (ABCD). The purposes of the evaluation were to assist Jane in securing the services and programming which would enable her to develop and to use her capabilities, to get the most out of the educational opportunities that can be made available to her and to enable her to develop and to use her capabilities for more independent, normal living and more productive activity than her behavior problems presently permit. Accordingly, it was requested that the evaluation focus on these behavior problems, which were characterized as physical aggression, verbal aggression, anger management and problem solving, and the type(s) of behavioral services, support strategies, programming, professional competencies and skills, and environments required to eliminate, minimize, or manage them.
Specifically, Jane has engaged in aggressive behavior on an average of approximately once per month over the past year. In March and April this year she verbally and physically assaulted a member of her SESI-ABCD group on three separate occasions, resulting in the other client’s withdrawal from SESI as he feared future attacks. This was also followed by a period of sporadic attendance at work her subsequent resignation to avoid losing her job. She also moved from a group home setting to supported independent living in March this year and started a new job July 5, this year with a new job coach. Concern from SESI-ABCD staff seems to be that future episodes of similar behavior could jeopardize her placement in the program and her current job. Staff members supervising her supported living arrangement have not noted any instances of aggression and are not concerned with this behavior at the present time.
DESCRIPTION OF ASSESSMENT ACTIVITIES
The assessment is based on information obtained from the following sources on July 26, this year:
A. Interviews with Jane at her workplace (60 min.) and over the phone (15 min.); with Mary Whitten, Jane’s current Employment Specialist with SESI (20 min.); Charlie Quinton, Jane’s former Employment Specialist with SESI (75 min.);and Kim Chow, SESI Supervisor (90 min.);
B. Direct Observations of Jane in her place of work (Wiener's are Us) with job coach present (60 min.);
C. Review of the SESI-ABCD case file and field notebook (180 min.);
D. A Reinforcement Survey completed by Jane (obtained from SESI file);
E. Telephone Conference with Ginger Bertrulano, Manager for Help Me (15 min.);
BACKGROUND INFORMATION
I. Brief Client Description.
A. General. Jane is a 24 year-old Caucasian female with light brown hair and blue eyes. She is short (approximately 62 inches tall) and heavyset. She indicates that she wears size 20 clothing and she appears to be about 200 pounds. She was wearing her Wiener's are Us uniform at the time of the interview. It was clean and properly fastened. Her face and hair were also clean. No identifying marks or physical disabilities were visible or indicated in the files. Jane was friendly and pleasant when interviewed.
Jane was diagnosed with Post-Traumatic Stress Disorder and Mild Mental Retardation in May 1993 by Dr. William Webster, psychologist at Saturn Hall. Documents in her SESI-ABCD file indicate that she is also currently diagnosed with either Schizoaffective disorder or Schizophrenia, although no documentation was present supporting the either diagnosis. Indeed, previous reports indicate that her reality testing was not impaired and that her thinking was not disordered. A Counselor’s Report from County Regional Center for Developmentally Disabled Persons (August 20, 1984, when Jane was 8 years old) indicates that Jane also carries a diagnosis of aphasia.
B. Language and Communication Skills. Jane’s primary method of communication is the spoken English language. Her speech is clear and easily understandable. It is reported that she has a repertoire of approximately 20 signs using conventional sign language, which she learned while residing with her foster mother, Snow White. All verbal and written reports indicate that Jane’s communication skills are well developed, including the ability to emit complex sentences. The writer observed that she is able to articulate her likes and dislikes. She is also able to clearly describe her job duties. Charlie Quinton, Jane’s former Employment Specialist, told the writer that he sometimes observes Jane using complex words out of context. He was unable to give a specific example but stated a general belief that her vocabulary exceeds her level of comprehension. The writer also observed in the interview that sometimes when asked a question, Jane would fail to respond. When the question was broken down into shorter sentences and repeated, Jane would respond to the question, suggesting that she did not understand the question when it was first asked. It was also noted that Jane thought that she had responded to the question when she had not. For example, when the writer asked her why she had discontinued counseling with Dr. Anything, Jane responded “I quit”. With further verbal prompting she was able to tell the writer that she left the counseling because she did not think she needed any more help.
Jane agreed to discuss her aggressive episodes with the writer but told the story from a different point of view than staff reports. In general, staff indicate that her descriptions of emotionally charged situations are quite different from that of her peers or staff. For example, there was a situation where she assaulted another member of her SESI group. She acknowledged that she slapped him with an open hand. When asked about the sequence of events, Jane indicated that she observed this man touching her friend in “the chest area”, she told him to stop, he tried to retaliate and she hit him. She then says she left the area but heard him talking about her and returned to slap him in the shoulder. In the opinion of staff, however, no inappropriate touching had occurred.
With respect to the aggression, it should be noted that numerous messages are attributed to the cluster of aggression, tantrums, and/or verbal or physical threats. Some staff believe that the behavior is triggered by memories of childhood abuse and communicates desire for person to stop activity that is bothering her. Others hypothesize that the aggression is an expression of frustration at the inability to have her needs met: “When she has no other way out”. It should also be noted that an episode of minor self-injury (picking at scabs on back of hand) seemed to be an expression of anger towards a staff member who had refused to comply with a request made by Jane.
C. Cognitive and Academic Abilities. Formal testing conducted by Dr. William Webster in 1993 placed Jane in the mildly mentally retarded level of functioning. At the time, Jane’s Verbal IQ was 67, and her Performance and Full Scale I.Q.’s were both 66. Her impairment was most severe on subtests measuring distractibility from stimuli presented auditorily and anticipation of consequences of social behavior. A psychological summary completed by Dr. Hightower in August 1993 mentions earlier psychological testing completed by Dr. Bully (no date or affiliation noted). According to Dr. Bully, a large discrepancy was noted between Jane’s verbal IQ (50) and performance IQ (80), resulting in a full scale IQ of 63. This discrepancy was attributed to “receptive and expressive developmental language deficits”. A report written by Jennifer Tilley (Counselor) in August 1984 reports that Jane had been diagnosed with aphasia, defined as “diminished ability to correctly use and comprehend language” in the Dictionary of Developmental Disabilities Terminology (p. 20; Accardo, P.J. & Whitman, B.Y., 1996). The documentation supporting that diagnosis was not available.
Jane graduated from Pumpkin High School with her high school diploma. All available records indicate that she was in special education classes for the majority of her tenure at school. She was registered in classes at local Community College last year but attended for just a few days before dropping out. She is not currently expressing interest in further academic pursuits.
Jane can sign her name independently, address an envelope and mail a letter. She can usually complete a job application independently, but may require some verbal prompting. She can read simple recipes and instructions and has used the want ads to do a job search. Reading is not a pastime for Jane. Charlie Quinton estimated that she can read at a grade four or five level. No formal testing was available in this regard.
Verbal reports indicate that Jane can add, subtract and multiply but cannot perform division. According to Charlie Quinton, Jane has difficulty making change and relies on a calculator to assist her with most math functions. Regarding measurement skills, Jane did indicate that she has recently lost weight, suggesting that she weighs herself. The writer, however, was not able to determine how accurate she is in weighing herself. Recipes that she prepares independently would probably not involve measurement (e.g. ground beef with peppers and onions). Jane knows what time she needs to catch her bus, what time she needs to transfer, and what times she starts & finishes work. When asked to describe what she does on the weekend, however, Jane began to describe her weekly activities. She is able to differentiate between the days that she is and is not required to be at work.
D. Self Care Skills. Verbal and written reports from staff indicate that Jane is completely independent in her self-care abilities. It is worth noting that at the last reported dental examination Jane had 23 cavities, suggesting that she has or had some difficulty brushing her teeth. The residential support services manager indicated that in-home staff check to ensure that her grooming is completed but previous reports indicate that she is completely independent in this area.
E. Domestic Skills. Verbal and written reports from staff indicate that Jane can complete all indoor maintenance tasks independently. The writer was not able to verify her skill level as her home was not directly observed. Jane completes her laundry independently. There are laundry facilities at her apartment. She spontaneously informed the writer how much it costs for her to wash and dry her laundry. Jane is able to prepare her own meals. She described the SESIs to prepare a fried egg sandwich, one of her favorite quick meals to prepare. Written reports describe that she is able to prepare complex meals independently but residential support staff indicate that she requires verbal prompting to prepare a novel or complex recipe.
F. Community Skills. Jane takes the bus to work independently from her apartment. She was able to describe the routes and schedules of the two buses she takes to get to work. The bus ride takes approximately one hour each way. A progress report from Map, the agency that operated Jane’s former group home, dated February 1, this year indicated that she was using public transportation independently. However, one of the learning objectives established by Help Me was to teach her the route to work, which she successfully learned. The type of instruction used was not specified. The writer hypothesizes from this information that Jane requires some assistance to learn novel bus routes. She has walked from her job to her SESI group when her bus pass was not available.
Residential support staff accompany Jane to complete her grocery shopping. The purpose of the assistance is primarily to provide verbal prompts to ensure that Jane remains within her budget for groceries.
Jane currently completes an emergency skills checklist on a monthly basis as part of her SESI-ABCD behavior support plan, which includes ensuring that she is carrying her identification. Jane has consistently been meeting the criteria in the checklist for the last 6 months.
Money management is consistently identified as an area of difficulty for Jane. Budgeting skills were targeted by Map as an opportunity for learning for Jane and are currently targeted by the SESI-ABCD program as well. Jane consistently states that she does not require assistance in this area and no formal protocol is currently in place. Previous reports from residential care services indicate that she gives money away freely and has incurred debts of over $1000.00. Since resuming employment, she reports that she has opened a bank account. She was able to report to the writer the amount of money that is set aside from her social assistance check each month for rent ($420.00 paid by direct deposit), for groceries ($150.00) and for laundry ($20.00). She was able to report how much she had earned on her first paycheck from Wiener's are Us ($214.00) and how much she had spent from her paycheck (e.g. $25.00 to purchase a kitten). When asked by the writer how much money she had left over from her paycheck, she did not respond. When prompted she indicated that she did not know but was sure that she would have enough money. She also stated “When I go shopping, if I see something I like, I buy it”. She did not show recognition, even when prompted, that she might have to consider how much money she had left in her budget before purchasing a particular item. According to Charlie Quinton, former Employment Specialist, Jane would also ask other members of her SESI group for money, sometimes even threatening them to obtain it.
G. Recreation and Leisure Skills. Jane indicates that she enjoys shopping, going to movies, watching television, and going to church. She attends church at Rolling Hills Covenant Church every Sunday and describes this as a good opportunity to socialize with non-consumers. She also goes to swap meets to shop on the weekends. Jane also indicated that her friends Bruce Lee and Brandon Lee occasionally come to visit her on the weekends. However, none of the staff interviewed have met these friends. By her description, she spends most of her evenings and several hours on the weekend watching television. Some of her favorite television shows are “Touched by an Angel”, “The Drew Carey Show” and “Twice in a Lifetime”.
H. Social Skills. Reports about Jane’s social skills are conflicting. Her current job coach, who has worked with her for approximately three weeks, has not observed any difficulty getting along with co-workers. She described an instance when Jane talked with a co-worker spontaneously about what to do with her pet fish when she buys a kitten. The co-worker responded positively by asking her if she could help by taking the fish for Jane. The writer observed Jane saying hello to her co-workers. She smiled, made eye contact and shook hands with the writer when approached for introductions.
Topics of conversation that were not in response to direct questions were expressions of physical concerns (i.e. describing knee problems, describing surgery in February), pets, boyfriend, and favorite television programs.
Reports from her former job coach, Charlie Quinton, are quite different. He describes her as having difficulty initiating and maintaining friendships. Apparently she developed a close relationship with a same-age female co-consumer who was in the same SESI group with her. They worked together at Come-view Video and spent time socializing outside of group time, attending swap meets and movies together. When her friend moved to a different job site the frequency of contact was reduced. No one interviewed could indicate how often Jane currently has contact with this individual, if at all. Some staff interviewed had the impression that Jane emulated this individual. One example cited was that when Jane’s friend left Come-view Video, Jane wanted to leave Come-view Video within one week. Another example given was that when this individual recently became engaged, Jane started to talk about becoming engaged to her boyfriend. It should also be mentioned that the aggressive episode that Jane described to the writer involved this young woman. Jane indicated that she thought that another member of the group was touching her friend “in the chest area”. She claims that she hit this individual in an effort to protect her friend. Some staff interpreted the episode as Jane expressing jealousy at her friend spending time with someone else. Charlie Quinton described Jane as liking “to be the center of attention”.
Jane is very interested in having a boyfriend. She indicates that she currently has a boyfriend whom she sees a couple of times per week. She announced in the interview with the writer that she will be getting engaged to this individual. However, none of the staff contacted have ever met this individual. When asked for details about this individual, she indicates that they have been dating for approximately four months. She reports that she used to work with him and “just happened” to meet him again and start dating him.
Jane is not currently sexually active and reports that she has never had consensual sexual relations. Verbal and written reports indicate that Jane has recently expressed interest in becoming pregnant.
Past reports show that Jane was introduced to sex at a very early age (prior to age 8) in the form of sexual abuse, possibly ritualistic in nature. She reported that she received formal sex education in the form of a class at Pumpkin High School. A report from Map noted that she has had several appropriate relationships with men but further information about the nature of the relationships was not provided. Jane may benefit from further counseling to overcome the effects of the events of her childhood and improve her ability to relate to men.
II. Living Arrangement and Family History. Jane currently resides alone in a studio apartment in Hawthorne, CA. She has a short walk to the closest bus stop and is walking distance to a dollar store, She owns a fish and is looking forward to acquiring a kitten on the weekend. She is supported by female staff members from Help Me at a 1:1 ratio. From Monday to Friday staff are present for one hour in the morning (8:00-9:00 am) and for six hours in the evening (4:00-10:00 p.m.). On the weekends staff are present from 8:00 am until 10:00 p.m.. Sugar reported that staff prompt Jane to get out of bed, accompany her to doctor’s appointments, give her medication, provide transportation to recreational activities and provide assistance with preparation of complicated meals. Jane is able to prepare simple meals herself. Staff are expected to complete twelve hours of continuing education each year, which is primarily consists of inservice training on medical topics (Help Me’s typical population). Dr. Stuart Little, a clinical psychologist employed by Help Me trains the staff members who work with Jane in the implementation a behavior support plan that he has written. The writer was not able to review this plan or the method of training employed.
When Jane originally moved into the apartment, the case manager required that she receive overnight supervision as she had always resided in group homes and had never spent a night unsupervised. However, Help Me staff felt that this was not an efficient use of resources as she did not require this level of supervision. Overnight supervision was discontinued a couple of months ago. Sugar Cane, Help Me manager, reported that when Jane left her job at Come-view Video there was period where she was paging Sugar “constantly”. Due to the brief nature of the interaction with Sugar, the writer was unable to determine the exact frequency per night. However, Sugar noted that this behavior ceased completely when Jane started her new job at Wiener's are Us on July 5, this year. Jane reports that she is very happy with the present arrangement and gets along well with her support staff.
Prior to the move to her own apartment, Jane was residing in a group home in Lawndale, CA under the supervision of Map Residential Care. She was taken into the care of this agency in May 1994 and discharged from their care when she moved into her own apartment in March this year. Jane was not able to say why she had to move into this group home and the reason was not available in written files. Given that she was placed at age 18 after residing in a residential children’s facility, the writer hypothesizes that she could no longer be served by children’s services and the move to Map coincided with a move to adult services. Jane lived in the same house within the Map system from July 15, 1996 until March this year. Jane indicates that she moved out of that home because of a conflict with a male co-resident but no one was able to corroborate this report. It was verbally reported to the writer that Jane was well liked by staff at this group home.
Jane resided at Saturn Hall from May 3, 1993 until early 1994. It is not know whether she moved directly from Saturn to Map. Jane believes that she moved to Saturn because she “could not find a group home”. Written reports indicate that Jane was moved to Saturn when her foster mother could no longer control her violent outbursts. One incident was described wherein Jane was upset because one of her foster siblings received a present and she did not so she bit her foster mother in the eye area, resulting in a black eye.
Jane was sent to live with Snow White, foster parent, when she was removed from her family of origin in November 1983. She was seven years old at the time. It is reported that she and her siblings were the victims of severe physical and sexual abuse. It is suspected that there may have been ritualistic overtones to the abuse and that Jane may have witnessed the homicides of transient individuals in the context of this abuse. Her natural father apparently served at Concrete State Prison for the abuse perpetrated against Jane and her siblings. Her mother was implicated in the abuse but never formally charged. Jane has had absolutely no contact with her natural parents since she was removed. She did receive notification within the last couple of years that her father had passed away.
Jane indicates that she has three siblings: Mercury (age 23), Cinderella (age 22) and Grettle (age unknown). Reports completed at the time of the apprehension indicate that all children were removed from the home and that all experienced severe emotional disturbance. None of the siblings were placed in the same home. When asked about her siblings, Jane indicates that she speaks to Mercury every day by telephone and sometimes visits with him in person. She describes him as “very funny”. When asked about a previous plan to move into an apartment with Mercury, Jane indicated that Mercury had decided that he wanted to move in with her sister Cinderella. She has sporadic contact by telephone with Cinderella. Jane verbalized excitement at the possibility of going to Disneyland with Cinderella when Cinderella regains custody of her children. Jane currently has no contact with her sister Grettle but receives reports about Grettle from Cinderella.
III. Daytime Services Received and Day Service History. Jane has been served by the Service to Employ People (A division of the Alphabet Program), a behavior management day program, since March 3, 1999. She indicates that she referred herself to the program on the recommendation of a friend, a fact that is corroborated by the SESI reports. Target behaviors or goals identified in the most recent individual service plan are job tenure, aggressive behavior, verbal aggression, emergency skills, skills maintenance, budget and social skills. No current protocol is in place for budgeting as Jane has indicated that she does not require assistance in this area. Verbal reports indicate that staff plan to wait until a discrete budgeting problem arises for Jane (e.g. incurred debt) before trying to initiate another intervention. As reported earlier Jane has consistently achieved the emergency skills criteria implemented through the monthly emergency skills checklist over the last 6 months. This is maintained through verbal praise, as is the completion of the skills maintenance checklist. The writer did not have an opportunity to review the skills maintenance checklist or protocol. Social skills objective is implemented through discussion allotted with the job coach, with no reinforcement protocol.
With regard to job tenure, Jane gained employment with a local Wiener's are Us on July 5, this year. Her hours of work are Monday through Friday, 11:00 am to 3:00 p.m.. She is considered to be naturally supported in this environment at this time. Jane was able to describe all of the tasks that she is expected to complete as part of her job. Her manager verbally indicated that she thinks that Jane is very independent in her position. Observational data are consistent with this opinion. Jane was able to clock in with minor assistance from a fellow staff member, which she sought independently. She was observed to get a wet rag and wipe down all of the tables, collect and clean trays and wipe down the pop machine. She also repeated these tasks as necessary. Employment Specialist Mary Whitten, assigned to the case when Jane obtained this job, attends the job site for one hour each day, from 12:00-1:00 p.m., in order to assist Jane with the lunch rush if necessary. When Jane started in this position, she found the pace much quicker than her previous job at Come-view Video, thereby necessitating the additional assistance. There are plans to extend Ms. Jones’s contact with Jane outside of scheduled work time but time constraints do not allow for more hours at this time.
Prior to obtaining employment Jane was involved in job development activities (e.g. resume development). Jane’s daily activities included meeting in the morning at the local Community College or other appointed place (e.g. McDonald’s) to plan the day’s activities and work on job development if appropriate. Jane worked at Come-view Video with 1:3 supervision from August 16, 1999 until June 23, this year where her starting wage was $5.75 per hour. She was required to stock shelves. One of the other clients at the job site was a paid staff member (and Jane’s friend) and the other client was present simply because he required constant supervision by the Employment Specialist (Charlie Quinton). The consumer who required constant supervision was the individual with whom Jane was having repeated conflicts. He reported that Jane had been physically assaulting him outside of staff presence at the job site after he was noted to have bruising. Consequently, he no longer attended the job site with Jane. Jane’s friend, who was working with her, left that job site to go to another site. The date of these events is not exactly known but staff report that it was very difficult for Jane to suddenly be alone at the job site. In April this year Jane’s attendance at group and her job were sufficiently sporadic that her employer planned to take her off of the schedule. Jane tendered her resignation on June 23, this year, shortly before she was to be taken off the schedule. Regrettably, the writer did not obtain more detail regarding the pattern of missed days.
Verbal reports indicate that Jane had difficulty with another individual in her SESI group before the gentleman who eventually left the group joined. This woman was verbally high functioning but diagnosed with cerebral palsy. It was described to the writer that Jane and this woman were in frequent conflict. Shortly after this woman left the group, this other male consumer joined the group and seemed to become the new target of the aggressive behavior.
Jane accessed the Neptune County Social and Vocational Services for assistance with job development from August 1994 until November 1998. The writer is not familiar with the mandate of this agency but based on verbal reports from SESI staff and Jane’s description, the writer hypothesizes that the agency obtains contracts from employers and several clients go to a single job site to fulfill the contract. Jane reports that she worked at Here on Mars University and at the Airport picking up trash. She also washed dishes at Saturn Mountain University. The duration of each placement is not known. Jane’s favorite job was at HOMU where she says she made many friends. Jane indicated that she left the agency because “they weren’t respectful”. No written or verbal reports were available to confirm or deny Jane’s reason for leaving.
IV. Health, Medical and Psychiatric Status. The last full physical examination of which the writer is aware was completed July 13, 1999. Jane was considered to be in good health overall at that time. Ongoing health-related difficulties are an allergy to penicillin and obesity. Jane verbalizes interest in losing weight but indicates that she is not currently on any special diet nor does she engage in regular physical exercise.
1999 - Summary of medical contacts
|Date |Reason |
|February 25, March 9, 11, 25, 1999 |Lab tests due to discharge from breast |
|April 26, May 25, July 13, 1999 |Routine physical examinations |
|March 1999 |Antibiotics for flu |
|April 1999 |Laryngitis |
|July 28, 1999 |Skin rash |
|September 28, 1999 |Unresolved skin rash |
|October 13, 1999 |Virus/flu |
|November 4, 1999 |Fall and subsequent bruising |
|December 6, 1999 |Pap smear due to vaginal bleeding |
To summarize, Jane visited the general practitioner (Dr. Rings) 14 times during a 12-month period, outside of the annual physical examination. She also visited her dentist, Dr. Circle, on January 28, this year at which time it was determined that she has 23 cavities. It is not known whether or not these cavities have been filled. Although a summary of the year to date was not available, qualitative data indicate that Jane was hospitalized for surgery to remove a benign cyst in late February this year. She is currently complaining of pain and swelling in one knee. There were no verbal or written reports of a history of seizure activity. Historical reports queried the presence of a dissociative state but there is no further documentation available that proves or refutes this assertion. The manager of her residential support service described Jane as having a “fixation” on her physical problems. However, based on the available information, Jane’s reasons for attending the doctor were reasonable and justified. It may be that Jane is simply prone to minor health problems.
The following table lists the medications, dosages, and reason for prescription as indicated in the SESI Facesheet.
|Name |Prescribed dosage |Schedule of delivery |Reason prescribed |
|Maxzide |50 mg |1 tab am |Anti-hypertensive |
|Pepcid |20 mg |1 tab am |Gastric upset |
|Triavil |25 mg |4 at am & 2 tabs p.m. |Antidepressant |
|Mellaril |50 mg |2 at p.m. & prn |Agitation |
|Depakote |250 mg |am/p.m./noon |Behavior management |
|Lomotril |50 mg |2 prn |Birth control |
When shown a list of current medications as above, Jane noted that the Mellaril was discontinued sometime after she moved into her current living arrangement because “I was doing so well”. Although her account differs from the documentation, Jane seems to have a good understanding of her medication.
No more recent history of medication was available. It should be noted, however, that no mention of medication was made in the psychological reports completed in 1993, when Jane came to Saturn Hall.
V. Previous and Current Treatments. SESI – ABCD
In the protocol for physical, verbal aggression, and property damage (response class under the heading “aggressive behavior”), written May 11, 1999, verbal praise is being used to reinforce the absence of the target behaviors in conjunction with a Differential Reinforcement of Other Behavior (Progressive) schedule of reinforcement. She can earn a $4.00 lunch or other reinforcer up to $4.00 in value when she has gone a minimum of 8 days without the target behaviors. The longer she goes without engaging in aggressive behavior the more quickly she can earn the reinforcer. The protocol also describes positive programming procedures (teaching anger response, encouraging attendance at PET classes); ecological strategies (non-directive interactive style, increasing self-control over schedule, respecting personal space); and reactive strategies (active listening, natural barriers). This protocol has been successful in decreasing the frequency of Jane’s behavior to an average of 1.3 times per month. The goal set in the individual service plan dated January 3, this year was for Jane to maintain the frequency of this behavior on average at less than once per month. Verbal reports indicate that this behavior continues to be a concern because of the severity of the behavior when it occurs and the impact of the behavior on co-consumers. A summary of supports currently being offered by SESI is provided below:
Help Me. According to Sugar Cane, the clinical psychologist employed by Help Me (Dr. Stuart Little) completed a behavioral assessment and developed a behavior support plan. The content of the assessment and/or the plan is not known. Sugar was able to confirm that the plan did not include treatment for aggression of any kind. She also informed the writer that Jane looks forward to visits from Dr. Stuart Little.
Map. No records of a specific intervention plan carried out at Map were available.
Counseling services. Jane received counseling for her emotional and behavioral problems associated with childhood abuse starting when she was removed from her home (age 7) and ending when was approximately 18 years old. Jane states that the purpose of this counseling was to help her express her emotions. Historical records suggest that Jane became more physically violent during these years but does not indicate on what dimensions the severity of the behavior increased (i.e. frequency, duration, strength). She also saw Dr. Square Allen (Neptune-Help Me Clinic) for a couple of counseling sessions in June-July 1997 but chose to discontinue service.
FUNCTIONAL ANALYSIS OF PRESENTING PROBLEMS
A functional analysis was conducted for aggressive behavior. Accordingly, the analysis endeavored to identify the events that control the emission and non-emission of these clinically important problems. It is therefore organized around six specific subcategories of analysis: (1) Description of the Problem. The analysis attempts to describe the presenting problems in such detail that they can be objectively measured. It presents the topography of the behavior, the cycle (beginning and ending) of the behavior (if applicable), and the strength of the behavior (e.g., frequency, rate, duration, intensity). (2) History of the Problem. Three analysis presents the recent and long-term history of the problem. The purpose here is to better understand Jane's learning history, and the historical events that might have contributed to the problem(s). (3) Antecedent Analysis. The antecedent analysis attempts to identify the conditions that control the problem behaviors. Some of the specific antecedents explored include the setting, specific persons, times of the day/week/month, and specific events that may occur regularly in Jane's everyday life. (4) Consequence Analysis. The consequence analysis attempts to identify the reactions and management styles that might contribute to and/or ameliorate the presenting problems. It also focuses on the effects that the behaviors might have on the immediate social and physical environment, on the possible function(s) served by the problem behaviors and on the possible events that might serve to maintain or inhibit their occurrence. (5) Ecological Analysis . The ecological analysis attempts to identify the critical mismatches that may exist between the physical, interpersonal and programmatic environments and Jane's needs and characteristics. (6) Analysis of Meaning. The analysis of meaning is the culmination and synthesis of the above analyses and attempts to identify the functions served by the problem behaviors. The functional analysis of Jane, organized around these headings, follows:
A. Description of Behavior and Operational Definition.
1. Topography. The following definition was developed from the definition provided in the Behavior Intervention Protocol for Aggressive Behavior.
Aggressive behavior is defined as the occurrence of any or all of the following behaviors:
Verbal aggression:
This includes any of the following behaviors:
• calling other people rude or offensive names (e.g. “You handicapped bitch”, racial slurs such as “nigger”);
• threatening to harm others or their families (e.g. “I’m going to kick your ass”, “I’m going to get your sister”);
• threatening to reveal embarrassing information about others (e.g. “I’m going to tell everyone you have to wear a diaper”);
• threatening to falsify information about others (e.g. “I’m going to tell Tina you hit me”);
• directing profane language towards others or using it to describe others (e.g. “F*** you” or “She’s a bitch”).
Physical aggression:
This includes using her body or an object to make forceful contact with the body of another person, causing the person to report pain or leaving a mark on the person’s body. Any attempts that fail due to poor aim or evasion strategies are also included. Accidental contact (e.g. during the course of a game such as soccer) should not be included. Specific examples of physical aggression include:
Hitting: Making contact with any part of the body of another person with an open hand or a closed fist such that the other person reports pain or a mark is left on the person’s body.
Biting: Making contact with the flesh or clothing of another person with the teeth such that a mark is left or pain is reported.
Kicking: Making contact with any part of the body of another person with the feet such that the other person reports pain or a mark is left on the person’s body.
Pushing: Making contact with any part of the body of another person with outstretched arms and hands with sufficient force to move that person, to cause pain or to leave a mark on the person’s body.
Property destruction:
This includes any actions that render objects or property in need of repair (e.g. breaking a table leg) or unusable (e.g. tearing up a piece of paper).
2. Cycle. Onset of the behavior occurs with the onset of any one of the behaviors described above. Feedback from the former Employment Specialist, who implemented the program until approximately three weeks ago suggested that the current offset criteria (i.e. absence of any of the above behaviors for at least 15 minutes) does not capture all instances of the behavior. For instance, one instance of physical aggression consisted of three discrete attacks that occurred within a 15-minute period. Based on the description of the incident, which involved an initial physical attack and two subsequent attacks on the same individual, in conjunction with the other limited descriptions of the behavior, it is recommended that behaviors continue to be coded as episodes, consistent with the original definition.
3. Course. Starts by calling individual she is angry with a couple of names, then might kick towards individual. She may say something like “I hate you. I don’t want to be in the group” or threaten to contact higher authorities (e.g. “I’m calling Tina on you). She may engage in minor self-injury at this point (e.g. scratching the back of hands with fingernails but not with sufficient force to draw blood).The volume of her voice increases, her face becomes flushed, her pupils dilate, progresses to yelling full sentences (for example threats or accusations such as “You were talking about me”.). She then moves towards the individual and strikes with an open hand or closed fist once or twice then backs away. If target of aggressive behavior attempts to fight back physically or verbally, Jane may approach the individual again to fight or leave the area . Typically by the time she approaches the target person a second time, a staff member has intervened.
4. Strength.
a. Rate. Writer could only find evidence of four Incident Reports for the year this year on the SESI casefile to indicate the presence of aggressive events (March 24, March 31, April 12 and April 24). No recording sheets were observed. Discussion with the Employment Specialist indicates that rates of verbal conflict were higher than indicated by tracking data. Furthermore, the E.S. indicated that he found out at a later date that one individual, who had been the target of some of Jane’s documented attacks, had sustained bruising. This individual indicated that Jane had been physically aggressive toward him, resulting in the bruising.
b. Duration. Exact duration is unknown. Previous documentation indicates that the average duration of a tantrum is 10 minutes but report of the most recent incident indicates that 3 separate attacks occurred within a 15-minute period, comprising a single episode. There was not enough data available to establish an average duration.
c. Severity. The most severe physical injuries that have resulted from this class of behavior within the last year are bruises and a bloody lip. One client has left the SESI program because of Jane’s behavior towards him.
B. History of the Problem. There are reports of Jane engaging in physical aggression, verbal aggression and property damage from the time that she was taken into foster care in 1983.
Counselor’s report, completed by Jennifer Tilley, 1983: Severe attacks of self-abuse are described that were believed to be in response to attempts to impose diHOPPline. Examples of such behavior were completely removing her own toenails, attempting to remove her own eyeball. She also physically attacked her foster mother, at one time biting her with enough force around her eye to cause a black eye. She also destroyed bedsheets, bedspreads and clothes for no discernible reason. Episodes were up to 2 hours in duration.
Psychological report, completed by Dr. K. Lite Color, 1993: Refers to an escalating pattern of violence towards the foster mother including biting. The episode named as the reason that Jane left the foster home is that she bit the foster mother in the face when she was angry that one of the other children received a present when she did not. No mention of self-abusive behavior.
History of the behavior between 1993 and 1998 was not available.
1998 - Review of frequency of behaviors as recorded in SESI casefile
| |Tantrums |Verbal Abuse |Property Destruction |
|January |2 |3 |N/A |
|February |2 |3 |N/A |
|March |2 |3 |N/A |
|April |1 |3 |N/A |
|May |0 |1 |2 |
|June |0 |0 |2 |
|July |1 |5 |0 |
|August |0 |0 |0 |
|September |2 |5 |0 |
|October |4 |5 |1 |
|November |0 |1 |1 |
|December |2 |5 |0 |
|Average |1.3 |2.8 |0.75 |
There is no discernible pattern to this constellation of data.
The most recent incident reports that the writer was able to observe are summarized below:
|Date |Description |
|March 24/00 |Was playfighting in backseat with another consumer. Consumer with whom she had previously had |
| |conflict said “Watch out for the police”. Jane became verbally aggressive (racial slurs and |
| |swearing) towards this individual, escalating to attempting to strangle him with a seat belt. |
|March 30/00 |Became upset with employment specialist and verbally abused him. Swore, used racial slurs and |
| |physically attacked consumer who had previously been victim of her attack. |
|April 12/00 |Verbally aggressive towards others in the group then directed towards other patrons in the area |
| |where they were meeting |
|April 24/00 |Verbally threatened “I’m going to hit you” (unsure who this was directed towards) |
It was also indicated in the written notes that there had been an incident in April this year involving a physical altercation between Jane and the consumer with whom she was having ongoing conflict. It is not known if this occurred as part of the incidents described above.
C. Antecedent Analysis. In an antecedent analysis, one tries to identify the events, situations and circumstances that set the occasion for a higher likelihood of the behavior and those that set the occasion for a lower likelihood. Further, in both categories, one tries to identify both the more distant setting events and the more immediate triggers that influence the likelihood of the behavior. Below is firstly an analysis of those setting events and triggers, i.e., those antecedents, that increase the likelihood of aggressive behavior and their escalation and secondly an analysis of those that decrease the likelihood. Detailed examples substantiating each of these, based on actual incidents, are also included.
Setting Events. A major stressor such as suddenly being alone at job site or moving to a new home may increase the likelihood that Jane will engage in aggressive behavior. The incident reports mentioned above occurred within a couple of weeks of Jane moving into her new home.
Triggers
Location
Aggressive behavior is unlikely to occur when Jane is either alone or with her support staff from Help Me in the apartment. When asked whether aggression was included as part of the support plan for Jane written by Dr. Stuart Little, Sugar Cane indicated that this had never been a problem there nor did they anticipate the problem developing in that setting.
People. The aggressive behavior is more likely to occur if Jane is in the presence of obviously disabled clients. For example, the one individual that she repeatedly targeted was in a wheelchair and the other was challenged with cerebral palsy. She was witnessed on one occasion to back the wheelchair-bound individual into a corner and punch him.
Aggressive behavior is not likely to occur when Jane is in the presence of non-consumers only. She has not exhibited any aggressive behavior since starting her job at Wiener's are Us, where she is the only consumer, even though she had to work more quickly than at her previous job.
Physically aggressive behavior is less likely to occur in the presence of physically larger non-consumers. For example, Jane would be verbally aggressive towards her Employment Specialist (a non-consumer who is larger than her) but never directed physical aggression towards this person.
Time. There was no suggestion that time of day was related to aggressive behavior. The fact that the incident reports indicated that the behavior occurred before noon is likely significant in that the SESI group was in the morning.
Event. The following types of responses to a request for help or request to meet a need are highly likely to trigger an aggressive response:
Repeated refusal of a request to help her meet a need (e.g. getting a ride to the 99-Cent Store)
Statements such as “You’re not the only person in the group”
Challenging her beliefs or authority
Ignoring her requests
When Jane perceives that a friend is being touched sexually she is highly likely to behave in an aggressive fashion. For example, she states that she was physically aggressive towards another member of her group because she thought that that individual was touching the “chest area” of her friend.
Being offered an alternative solution to presenting problem decreases the likelihood of an occurrence of aggressive behavior. For example, when she asked her Employment Specialist to go to the dollar store she is never became aggressive if she is told “I’m sorry we can’t go today but we can go on Friday”.
D. Consequence Analysis.
Planned consequences. Jane’s current behavior support plan for aggressive behavior rewards her for the absence of aggressive behavior on a 28-box DROP (Differential Reinforcement of Other Behavior, Progressive) schedule. For consecutive days without engaging in aggressive behavior, Jane fills in progressive numbers of boxes (up to a maximum of five per day). When she has filled in 28 boxes (minimum of 8 days), she earns a $4.00 lunch (or reinforcer of equivalent value). The reactive strategies currently recommended in the support plan include active listening and natural barriers.
Unplanned consequences. Verbal reports indicate that subsequent to physically or verbally aggressive acts, Jane either leaves the situation or apologizes to the target of the behavior and the group (e.g. “I’m so sorry. I don’t know why I do these things”). The Employment Specialist utilizes active listening but describes this as a “stopgap measure” which slows the course of the behavior but has been ineffective in de-escalating the behavior. He indicates that he has not found any techniques that are effective in de-escalating the behavior once it starts except to agree with her request.
Clients that she has attacked typically fight back and others freeze. It has been necessary for the Employment Specialist has had to place a barrier between Jane and other client. In one case he described having Jane and the other client each trying to go around him to get to each other.
Jane stated that she chooses to throw objects that will break when they connect with the wall, suggesting that she enjoys the noise made by these objects.
In the long term, these outbursts seem to be related to Jane’s poor attendance at the SESI group and at work. Subsequent to the series of incidents noted in the incident reports, Jane began to miss shifts at work and time at SESI group. This eventually resulted in Jane having to submit her resignation to Come-view Video to avoid being fired from this position.
E. Ecological Analysis. There are a number of ways in which understanding the ecology surrounding and how it may conflict with Jane's needs and characteristics, may be helpful in understanding the meaning of her behavior and in understanding the ecological changes that may be necessary to provide the necessary support for her. The brief discussion addressing the ecological analysis is organized below around the physical environment, the interpersonal environment and the programmatic environment.
Physical environment. There are currently no obvious conflicts or mismatches in the physical environment.
Interpersonal environment. As identified in the Behavior Intervention Protocol for Aggressive Behavior designed by SESI, Jane is more likely to engage in aggressive behavior when she feels that she is being told what to do. Furthermore, she seems more likely to challenge people in her environment that confront her about her behavior and/or her disability. Her previous Employment Specialist stated that he felt he had to adopt a more authoritarian approach (e.g. confronting her about her behavior) with his clients in the interest of self-preservation. He stated that when he adopted this approach he began to see a “dark side” of Jane, that she was “manipulative”: “She probably fooled me the longest of any of them [consumers]”. He also described needing to be more directive in his approach at her previous job at Come-view Video, whereas she is naturally supported in her present work environment. It is the opinion of the writer that the change of Employment Specialist has occurred at a good time as her former E.S. was feeling that he no longer had the personal resources to help Jane with her behavior. Her present E.S. describes a less confrontational style, although she has not yet had to deal with one of Jane’s major outbursts. She also sees her role as facilitating Jane’s ability to complete the tasks of the job, rather than directing her activity on the job.
SESI co-consumers who Jane assaulted were both African-American, physically disabled and assertive to aggressive in approach to conflict. Based on verbal reports and observations of Jane in her work setting, it seems that more conflict arises with groups of other consumers than individually or with others who are not consumers.
Programmatic environment. The ecological strategy of “Interactive Style” as described in the Behavior Intervention Protocol was has not been consistently implemented by all staff. There is also some concern about the social validity of the approach. Former E.S. indicated that he did not perceive sufficient response to occurrences of this serious behavior by the administration. He feels that the other client who was usually the target of Jane’s aggressive behavior was not sufficiently protected by ABCD.
SESI and Help Me may be duplicating services or be able to obtain crucial information from each other if copies of behavioral assessment and support plan completed by Dr. Stuart Little may be shared with SESI and vice versa.
F. Impressions and Analysis of Meaning. In considering the functional analysis and the background information summarized above, there are a number of factors that are helpful in trying to understand the meaning of Jane's behavior.
Jane is a complex and talented individual who has done a remarkable job of overcoming many barriers in her life. When one considers the longitudinal nature of the data it is obvious that the severity and duration of aggressive behavior has decreased over the years. Given the severity of the aggressive that was modeled for her and perpetrated against her, it is a testament to the training that she has already had that she does not respond to every situation with aggressive behavior. It seems that Jane, like everyone else, wants to feel normal – be around “normal” people, do the things that “normal” people do, have the experiences that “normal” people have. There are barriers to her ability to achieve these experiences. She does not always understand what other people are saying or the complexities of their social interactions. She is confused about sex and intimacy and love. Consequently she may perceive innocuous social cues as threats to which she needs to be respond. Also she does not possess a large repertoire of coping responses to which she can control a threatening or confusing situation. She seems to be using the strongest behaviors she has in her arsenal to order the situation in the way that she wants it. Alternately (or additionally) she may seek to control those individuals over which she at least has physical control in an effort to improve her own limited sense of self-worth. Also, one cannot discount the modeling effect of the abuse she suffered as a child. It is our job then to help her make sense of this confusing world through the acquisition of skills such as discrimination of social cues and anger management training.
MOTIVATIONAL ANALYSIS
A motivational analysis was carried out to identify those events, opportunities and activities that Jane enjoys and that may be used to enhance her quality of life and provide her with incentives to improve her behavior and to enhance her academic progress. The results of the analysis showed a number of events that could be used effectively as positive reinforcement in a well designed support plan to reduce the identified behavior problems. These events include, but are not limited to money, shopping trips (especially swap meets and the 99 Cent Store), receiving beauty treatments like manicures, and watching favorite television programs (e.g. “Touched By An Angel”, “The Drew Carey Show”). Although she identified several edible reinforcers, it is recommended that these be avoided due to Jane’s desire to lose weight. She expressed a great deal of excitement for a future trip to Disneyland. These reinforcers, and others, should be used in a variety of ways, the least of which would be through the contingencies of formal reinforcement schedules.
MEDIATOR ANALYSIS
A "Mediator Analysis" was conducted for the purposes of identifying those persons who might be responsible for providing behavioral support for Jane, their abilities to carry out the recommended support plan, given the demands on time, energy, and the constraints imposed by the specific settings, and motivation and interest in implementing behavioral services as recommended. The analysis showed the following:
The primary responsibility for implementing the behavior support plan will be with Mary Whitten, Jane’s currently assigned Employment Specialist. Upon brief meeting she appears to naturally possess the interactional style recommended in the Behavior Support Plan. However, it will be necessary to prepare her for the occurrence of the target behavior. She may also require more specific training in the implementation of the plan as she has only occasionally worked with Jane in the past. She is physically smaller or the same size as Jane so she may require assistance to develop strategies other than the interpositioning strategy used by the previous Employment Specialist. Currently she is only assigned to spend one hour per day with Jane at the job site, constraining the amount of time that will be available to carry out other interventions (e.g. focused intervention strategies). Supervisor Kim Chow indicated that a new schedule is currently being developed to allow Annie to spend more time with Jane. Annie will likely require specific training in the interactive style that works best with Jane, as well as specific education about the function of the behavior.
It should also be noted that if the plan is to be very successful, training and involvement of Help Me staff in the implementation of this plan is also recommended.
RECOMMENDED SUPPORT PLAN
A. Long-Range Goal. The long-range goal for Jane is to establish enough self control over her behavior that she will be able to live and work in the least restrictive setting possible that is capable of meeting her developmental and behavioral needs. The goal of her educational plan is to provide her with the academic and other skills necessary to meet her needs, while eliminating those behaviors that tend to stigmatize and isolate her from full community and social presence and participation. Additionally, the goal is to transfer the control of Jane's behavior from external mediators (parents and staff) to internally generated controls. The plans and objectives presented in the following paragraphs are intended to increase the likelihood that the following specific outcomes will occur:
1. Jane will live in and contribute to her community at a level commensurate with her non-disabled peers. This will include living in her own apartment and being naturally supported in her work environment with the minimum support necessary to meet her developmental needs.
2. Jane will develop the full range of relationships with friends and family thereby increasing her natural supports in the community, reducing her overall reliance on staff, and enhancing her overall quality of life.
3. Jane will master a wide range of coping strategies that will help her deal with the everyday challenges faced by all of us, thereby increasing her control over her environment.
B. Operational Definition(s).
1. Aggressive behavior
a. Topography. Aggressive behavior is defined as the occurrence of any or all of the following behaviors:
Verbal aggression:
This includes any of the following behaviors:
• calling other people rude or offensive names (e.g. “You handicapped bitch”, racial slurs such as “nigger”);
• threatening to harm others or their families (e.g. “I’m going to kick your ass”, “I’m going to get your sister”);
• threatening to reveal embarrassing information about others (e.g. “I’m going to tell everyone you have to wear a diaper”);
• threatening to falsify information about others (e.g. “I’m going to tell Tina you hit me”);
• directing profane language towards others or using it to describe others (e.g. “F*** you” or “She’s a bitch”).
Physical aggression:
This includes using her body or an object to make forceful contact with the body of another person, causing the person to report pain or leaving a mark on the person’s body. Any attempts that fail due to poor aim or evasion strategies are also included. Accidental contact (e.g. during the course of a game such as soccer) should not be included. Specific examples of physical aggression include:
Hitting: Making contact with any part of the body of another person with an open hand or a closed fist such that the other person reports pain or a mark is left on the person’s body.
Biting :Making contact with the flesh or clothing of another person with the teeth such that a mark is left or pain is reported.
Kicking: Making contact with any part of the body of another person with the feet such that the other person reports pain or a mark is left on the person’s body.
Pushing: Making contact with any part of the body of another person with outstretched arms and hands with sufficient force to move that person, to cause pain or to leave a mark on the person’s body.
Property destruction:
This includes any actions that render objects or property in need of repair (e.g. breaking a table leg) or unusable (e.g. tearing up a piece of paper).
b. Cycle. The recording cycle for the response class Aggressive Behavior begins with the onset of any of the above topographies and ends when all of the behaviors have been absent for 15 minutes.
C. Short Term Measurable Objectives. The following objectives and plans are suggested on the assumption that Jane has the opportunity to continue to live in her own apartment and work in a naturally supported setting. It is unlikely that they would be realistic if she did not have these opportunities. These objectives were also selected as being most reflective of Jane's priority needs and as being the most realistic given her level of functioning at the time. Given that the recording definition of Aggressive Behavior has been altered, it is recommended that three new baselines be collected: physical aggression, verbal aggression and property damage. Objectives should then be set for each type of aggressive behavior. It is recommended that a 50% reduction in the baseline occurrence of each type of aggressive behavior by the end of a 6-month period be established as the short-term objectives. Further objectives may be established as a function of the success or failure of the recommended strategies.
D. Observation and Data Collection Procedures.
1. Methods.
a. Aggressive behavior. The writer observed four incident reports describing episodes of aggressive behavior. It is recommended that a revised version of incident-based data collection continue, in addition to a daily recording of the occurrence/non-occurrence of physical aggression, verbal aggression and property damage.
i. Daily recording
The purpose of adding formal daily recording to the data collection methods is to serve as a reminder to staff as to when they need to complete an incident recording form. Each day, staff should be assigned to record the occurrence/non-occurrence of the behavior. A sample format is shown below:
|Date |Aggressive behavior? |
| |V |P |PD |
|e.g. September 20, this year |+ / - |+ / - |+ / - |
ii. Incident recording
In addition to the daily recording described above, it is recommended that each incident of aggressive behavior be recorded, including the following information:
• Date and time of aggressive episode
• Duration of aggressive episode
• Location of aggressive episode
• Each topography that occurred (i.e. physical aggression, verbal aggression and/or property damage)
• People present at the time of the episode
• Activity at the time of the episode
• Events leading up to the episode of aggressive behavior. This should include the closest verbatim account of any interactions with Jane that occurred immediately prior to the event.
• How people reacted.
• Description of any property damage or injury that occurred as a result.
• Observer’s impressions regarding the occurrence of the aggressive episode.
• Jane’s impressions regarding the aggressive behavior (if possible to obtain)
I think that it would be helpful to develop a form that specifies each of the above as a separate field to help staff completing the form to consistently complete the same information. Having fields defined in this way will also help in the calculation of a reliability index (see below for description of same).
The frequency of the occurrence of each topography (i.e. physical aggression, verbal aggression and property damage) should be graphed in addition to the total frequency of aggressive behavior. These graphs should be available on a quarterly basis.
2. Observational Reliability.
a. Aggressive Behavior. Observational reliability will be determined using an incident-based strategy. As this behavior occurs at relatively low rates, it is unlikely for an aggressive episode to occur during a supervisory visit. Therefore, after an incident has been recorded, the supervisor should interview the client and the staff member who completed the incident report and score the presence or absence of each required piece of information. In other words, if both the supervisor and the front-line staff have recorded the same time & date, that would be recorded as an agreement (“+”). If one person indicates that the episode included physical and verbal aggression and incident report indicates that it only included verbal aggression, that would be scored as a disagreement (“-“). The following formula should be used to calculate a reliability index for the recording of aggressive episodes:
# of agreements X 100 = reliability index
-------------------------------------------
# of agreements + # of disagreements
The observational reliability index should be presented in the quarterly report.
In the case of physical aggression and property damage, permanent product reliability could be established by viewing the damage to persons or property caused by the aggressive behavior.
E. Intervention Procedures. In the following paragraphs, a summary of possible strategies to support Jane is presented. These are by no means meant to be comprehensive or exclusive of other procedures. They simply represent a set of starting points that would be elaborated and modified as services are provided. Support is organized around four primary themes: Ecological Strategies, Positive Programming Strategies, Focused Support Strategies, and Reactive Strategies.
1. Ecological Strategies. Many behavior problems are a reflection of conflicts between the individual needs of a person and the environmental or interpersonal context in which the person must live, go to work or otherwise behave. As part of the above evaluation, several possible contextual (ecological) conflicts were identified. It is possible, that by altering these contextual conflicts, that Jane's behavior may change and her progress may improve, thus eliminating the need for consequential strategies. In the following paragraphs, a number of "Ecological Manipulations" are presented with the intention of providing a better mesh between Jane's needs and the environments in which she must behave:
a. Interactive style. It was recommended in Jane’s protocol for aggressive behavior that a “non-directive” approach be used when communicating with Jane. However, it is not clear that this approach was consistently implemented. The writer noted that when Jane is challenged, refused or told what to do, she is more likely to engage in aggressive behavior. Some specific guidelines about characteristics of individuals who work with Jane follow:
• People who work Jane should be low-keyed. They should be willing to rephrase requests, find different ways of communicating a message to Jane, or even to leave and come back later.
• People who work with Jane should avoid making demands. Instead, they should attempt to elicit cooperation by asking Jane to choose from a list of choices.
• People who work with Jane should respect her as an adult. Operationally, this means dropping the “staff-client” power struggle and adopting the role of a mentor or helper. It is likely that staff who are working with or are expected to work with Jane will require role-play training in this approach.
b. Using simple clear speech. As Jane seems to have some difficulty understanding complex speech, it is recommended that communication be simple and concrete. Confusion in social situations seems to be related to the occurrence of aggressive behavior for Jane as it seems that she sometimes reacts based on her misperception of social cues. Staff should use short sentences when talking to Jane and be alert to signs that she has not understood what was said (e.g. failure to respond).
c. Group placement. When placing Jane in group settings, great care should be taken to avoid placing her in groups with consumers who have obvious physical or developmental disabilities as it seems that Jane is more likely to assault individuals with such challenges. Groups of consumers who are of similar or slightly higher level of functioning than Jane would be preferred.
d. Increased access to family and friends. Individuals with a large circle of support (i.e. important people in their life) have a better quality of life and are therefore less likely to engage in challenging behavior. Jane’s circle of support currently consists almost entirely of paid staff. Jane currently interacts with her brother frequently by telephone and has limited to zero contact with her sisters. It is recommended that staff responsible for the management of Jane’s case make every effort to contact the family members, assess the level of contact they wish to have with Jane, and provide that level of contact.
In addition, it was mentioned that Jane had a very close friend in her SESI group who moved to another job site. Jane was close to this young woman and they spent a lot of time together. It is strongly recommended that staff responsible for managing Jane’s case assist her in re-establishing contact with this woman, given that both parties are interested in maintaining the friendship. Every effort possible should be made to help Jane and her former friend stay in contact with one another, as a means of expanding Jane’s circle of support.
e. Sharing of information with residential services provider. Currently SESI has no record of the behavior support plan that has been implemented in Jane’s residential setting. It is recommended that Help Me and SESI share information about the services being offered in the interest of improving consistency between staff and increasing the predictability of Jane’s environment across settings.
f. Ecological inventory:. Currently Jane has few interests outside of her residence. She identifies watching television, shopping and attending church as her main leisure activities. Research has clearly demonstrated that low levels of activity are the context for challenging behaviors. As part of this intervention, every effort should be taken to determine Jane’s interests and activity preferences. Staff may want to use activities identified on the reinforcement inventory as very interesting to Jane as a starting point to suggest some activities. She should be given the opportunity (within reason) to participate in the activities she specified. Outings to try new activities could be scheduled into her day timer. During these activities, the following information should be formally recorded.:
• Jane’s emotional response to the activity
• Jane’s proficiency in the activity
• Related and unrelated activities that occur during and immediately after the selected activity.
Over time a list of preferred activities will be developed that can be used either contingently or noncontingently as part of a behavior support plan.
g. Re-distribution of available staffing. Currently the Employment Specialist assigned to Jane’s case, Mary Whitten, observes Jane in her work environment for one hour per day, between the hours of 12:00 and 1:00 p.m.. Initially this was necessary to ensure that Jane could keep up with the pace of the job requirements. Given Jane’s current level of job performance, it is the opinion of the writer that 1:1 staff time be maintained. Instead of helping Jane work, time would be better spent helping Jane develop some of the skills described in the section on Positive Programming.
h. Informal instruction. The strategy of “training loosely” should be used with Jane, whereby opportunities to instruct her on skills are not restricted to structured, focused training trials only. Instead, instruction should be provided whenever and wherever the opportunity presents itself. The purpose of using this strategy is to expand the learning process to the natural times and locations that the skills are required.
i. Maintenance of naturally supported working environment. It is recommended that Jane not be placed back into a SESI group. She is currently naturally supported in her work environment so there is currently no reason to place her back in that setting. Her recent problems with aggressive behavior have been in the context of the SESI group.
j. Daytimer with daily planning. In order to encourage Jane to exercise control over her daily schedule, it is recommended that she purchase a daytimer (i.e. a portable daily calendar) wherein she can keep track of scheduled appointments, work schedule and scheduled leisure activities. As Jane’s aggressive behavior sometimes seems to be her way of exercising control over her environment, the daytimer is recommended help her find other ways of exercising that control.
k. Counseling. Counseling is recommended for Jane to address lingering abuse issues. Based on her difficulty talking about sex and intimacy in addition to her reliance on romantic fantasies it is clear that Jane continues to be confused about her own sexuality. Her knowledge of sex from a sex education standpoint is also questionable. In addition, Jane’s need to assert herself over those less powerful than her with aggressive behavior, would suggest that her opinion of herself is quite low. Any counselor to whom Jane is referred should have the following characteristics: experienced in treating victims of physical/sexual abuse and/or Post-Traumatic Stress Disorder; would be willing to meet with her in a natural setting rather than in an office; and would be willing to talk to her in the style of a mentor providing guidance rather than as an authority figure giving her directions. Issues that should be addressed in this setting include past abuse, sex education, social mores surrounding sex and intimacy, and self-esteem.
2. Positive Programming. Challenging behavior frequently occurs in settings that lack the opportunities for and instruction in adaptive, age-appropriate behavior. It is our assertion that environments that provide instruction to promote the development of functional academic, domestic, vocational, recreational, and general community skills is procedurally important in our efforts to support people who have challenging behavior. To the extent that Jane exhibits a rich repertoire of appropriate behaviors that are incompatible with undesired behavior, the latter should be less likely to occur. Positive programming, therefore, should not only result in developing Jane's functional skills, but also contribute to reducing the occurrence of problematic behavior. At the very least, a context of positive programming should make it feasible to effectively and directly address Jane’s aggressive behavior. In the following paragraphs, several initial thrusts for positive programming are presented:
a. General Skills.
1) Self-Care domain
a) Rationale / Logic. The writer recognizes that skills like budgeting and toothbrushing are important functional skills that Jane could learn. However, pursuant to the goal of reducing frequency and severity of the target behavior by increasing the availability of noncontingent reinforcement, the writer suggests choosing a skill that Jane will find intrinsically enjoyable. This will also serve the purpose of developing rapport with staff as, hopefully, Jane will not so strongly associate “staff” with “telling me what to do”.
According to staff reports and the reinforcement inventory that Jane completed, she enjoys getting her nails done. Therefore, the writer recommends that Jane be taught to give herself a manicure.
b) Objective. By November 1, this year, Jane will be able follow all of the SESIs of giving herself a manicure without staff assistance and with 100% accuracy.
c) Method. Jane should be taken shopping to buy the following materials necessary to complete the task:
Clear nail polish, colored nail polish, nail clippers, emery board or nail file, nail buffer, hand cream.
Using a whole task forward chaining procedure, Jane will be taught the following SESIs of giving herself a manicure:
• Squeeze hand cream into hand.
• Rub hands together until hand cream is no longer visible
• Using nail clippers, cut nails such that they are all the same length.
• Using the nail file or emery board, file nails until they are all the same length.
• Put one coat of clear nail polish on each fingernail.
• Put two coats of colored nail polish on each fingernail.
• Let nails dry for at least fifteen minutes before starting any activity where you have to use your hands.
The reinforcer that should be used for this chaining procedure is giving verbal praise. The whole-task forward chaining procedure involves presenting the entire task then prompting Jane through each SESI except the one she is performing for reinforcement. Training sessions could be conducted on a weekly or bi-weekly basis, according to Jane’s wishes and desires. Sessions should be approached as a fun activity, not as a required part of a training program.
2) Vocational Domain
a) Rationale/Logic. Jane has repeatedly verbalized an interest in working with children. She mentioned it in the interview with the writer and has enrolled in child-care classes at the local Community College but never substantially participated. Given her comprehension difficulties, it is not unexpected for her to have difficulty in a classroom setting. She may learn better in a setting wherein she is actually required to interact with children. However, given her history of aggressive behavior, options in this area should be explored very carefully.
b) Objective. By August 1, next year, Jane will have acquired a volunteer position working with children, supervised by a responsible adult, that she will attend at least one hour per week.
c) Method. Assigned staff should complete a background check to ascertain whether Jane has physically assaulted children in the past. IF SUCH A HISTORY EXISTS, STAFF WILL HAVE TO CAREFULLY EVALUATE THE WISDOM OF PROCEEDING WITH THIS OBJECTIVE ACCORDING TO THE RECENCY AND SEVERITY OF THE INCIDENT.
Jane and assigned staff should work together to procure a list of agencies that could be contacted regarding possible volunteer positions related to childcare.
Jane should be assisted as necessary to contact these agencies, complete the necessary applications and attend interviews.
In this setting, at least initially, a 1:1 staff should supervise Jane to establish safety of the children and the skills necessary to maintain the position.
The presence of the 1:1 staff should gradually be faded such that Jane becomes naturally supported in that environment. However, Jane should remain under the supervision of a responsible adult.
If Jane wishes to pursue this goal, some difficult situations typically experienced during the course of caring for children could be incorporated into the incident-based social skills training described under the section below describing “Functionally Equivalent Skills”. This might help prepare her for the difficult and potentially frustrating scenarios she could face when dealing with children.
3) Recreational Domain
a) Rationale/Logic. Jane reports that she spends most of her time watching television, shopping, and going to church. An ecological inventory has been recommended under the heading “Ecological Strategies” to expose Jane to more leisure activities and assess her interest in and proficiency at those activities. It is important, however, not to stop at the assessment phase of this procedure. A plan needs to be implemented to ensure that not only is Jane exposed to a variety of opportunities, she should also have an opportunity to participate in those activities on a regular basis. This will serve the dual purpose of improving her quality of life and, consequently, reducing the likelihood that she will engage in aggressive behavior.
b) Objective. By January 1, next year, Jane will have incorporated at least one new activity into her weekly schedule. This excludes work, shopping, watching television and therapeutic activities (like counseling).
c) Method.
i. An ecological inventory will be completed. Jane should be given the opportunity (within reason) to participate in the activities she specified. Outings to try new activities could be scheduled into her day timer. During these activities, the following information should be formally recorded.:
• Jane’s emotional response to the activity
• Jane’s proficiency in the activity
• Related and unrelated activities that occur during and immediately after the selected activity.
ii. From a list of identified preferred activities, Jane should choose an activity that she would like to incorporate into her weekly schedule.
iii. Assigned staff should help Jane choose a location to participate in the scheduled activity.
iv. Staff should support Jane in learning how to transport herself independently to the activity (i.e. learn a novel bus route) through modeling and shaping procedures.
v. Staff should also brainstorm with Jane how she can access the resources necessary to participate in the chosen activity (e.g. money for admission, a bathing suit for swimming, etc.).
vi. On a weekly basis, Jane should be prompted to schedule a day for the activity in her daily planner. The prompts should gradually be faded over time.
At each stage of this process, gentle shaping should be used to help Jane choose the most appropriate solution.
b. Teaching Functionally Equivalent Skills. People engage in seriously challenging behaviors for perfectly legitimate reasons. They use these behaviors to communicate important messages, to assert themselves, to manage unpleasant emotions, to escape unpleasant events, and to gain access to events and activities. One important strategy for helping people overcome their challenging behaviors is to provide them with alternative ways of achieving the same objectives, alternative ways of satisfying their needs. These alternatives are defined as functionally equivalent skills because they achieve the same goal as the challenging behavior or communicate the same message. The above analysis of Jane's behavior concluded, among other things, that these aggressive episodes are related to difficulties with social problem solving.
1) Rationale / Logic. Jane seems to have a limited repertoire of behaviors that she uses to control her environment. When she cannot get her needs met or is challenged in her way of meeting those needs, she may become frustrated and lash out at those around her. Therefore it is recommended that Jane receive specific social skills training based on identifying alternative solutions to incidents that have occurred in the past or similar incidents, thereby reducing her need to rely on aggressive behavior as a way of controlling her environment.
2) Objective. By January 1, next year, Jane will be able to respond to generalization probes based on pre-scripted social situations without prompting in five out of five daily trials.
3) Method.
a. SESI incident reports should be gathered together from the time that Jane started receiving services in that setting. Any other descriptions of incidents that SESI has access to could be reviewed as well. Incidents that include any of the topographies described under the response class of “Aggressive Behavior” should be extracted.
b. Scripts should be written based on each incident that include the cues for the aggressive behavior and possible solutions. For example:
Script #1
Antecedent: You’re trying to get your Employment Specialist’s attention. Another consumer turns to you and says “Shut up! I was here first”.
Solution: “Sorry, I thought you were done”
Solution: “I feel hurt when you talk to me like that. I just wanted to get Annie’s attention.”
Script # 2
Antecedent: You see a man touching your friend in her private places.
Solution #1: Ask your friend “Are you OK?”
Solution #2: Go and tell a person in authority (your job coach, for example)
c. For each script, it should be demonstrated that Jane can describe what she would do in the described situation.
e.g., “What would you do if someone told you ‘You know, you’re not the only person in the group’?”
d. When Jane has demonstrated verbal competence (i.e. requires no prompting to come up with solution) in a situation, the script should be role-played with Jane switching parts. Her performance should be recorded as correct, prompted, or incorrect.
e. When Jane has demonstrated both verbal and analog competence with a particular script, she should be told that a staff person will approach her when she is not expecting it to practice the script. Initially the day should be announced, but the announcement should be faded over time.
These training sessions should be conducted with Jane three times per week, for approximately 15 minutes at a time. Jane’s mastery at each level of skills should be documented and presented in a quarterly report.
c. Teaching Functionally Related Skills. There are many skills that if learned by the person, may have a direct impact on the person's behavior. For example, a person who is taught the difference between demeaning criticism and well-intended feedback may start acting differently to the feedback she receives from others. The purpose of this category of strategies, again, is to empower the person; to give the person greater skills. In the following paragraphs, discriminatory skills are identified which are thought to be related to Jane's aggressive behavior.
1) Rationale / Logic. Jane’s aggressive behavior seems to be related to the misperception of innocuous social cues. In other words, due to a limited level of comprehension of social events, Jane may perceive certain events as being threatening and requiring strong action. It would not be helpful to teach Jane not to respond to any events, as certain events certainly are threatening. Therefore the intervention described here is designed to help Jane discriminate between threatening and non-threatening events. It should be noted that Jane would be learning how to respond to both types of events as described above (i.e. Functionally Equivalent Skill).
2) Objective. By January 1, next year Jane will be able to accurately classify scenarios presented to her as either threatening (i.e. requiring action) or non-threatening within 10 seconds without prompting, without error, and without exhibiting aggressive behavior ten times consecutively.
3) Method
i. In order to develop possible scenarios, generic pictures clipped from magazines or staged for this purpose should be compiled. One might picture a man standing next to a woman with hand on her arm, while another might show a picture of a woman recoiling from a man who is approaching her.
ii. Staff should brainstorm with Jane possible descriptions of these scenes. For example, staff might say,
“Jane, what do you think could be happening in this picture?”
Using this approach, a list of scenarios would be compiled. Efforts should be made to ensure that the list includes both innocuous and threatening social situations.
iii. All of the scenario descriptions should be transferred to 3x5 index cards and assembled with the pictures used to generate the scenarios.
iv. Using a discrete trial training format, each card and accompanying picture should be presented to Jane. She should be encouraged to classify the scenario as either threatening or non-threatening.
v. When Jane chooses the correct classification, she should be verbally praised and asked “So what should you do in this situation?” Through gentle shaping, staff should help Jane come up with a viable solution. Typically, a non-threatening situation would require no action on her part.
vi. On any trial that Jane does not choose the correct classification, staff should end the session, to be repeated later in the day.
vii. The next time that Jane is asked to classify the same social interaction that she classified incorrectly the first time, she should be verbally prompted immediately after staff make the request for her to classify the scenario.
viii. The correct response should then be reinforced with social praise and Jane should be asked “So what would you do in that situation?” Again, Jane should be guided to some viable solutions using gentle shaping.
It is recommended that once Jane can meet the objective described above, discrimination training be conducted using video presentation of threatening/non-threatening situations.
CAUTION
It is possible that viewing and describing threatening situations may be too difficult for Jane. If there is any indication that this procedure is increasing levels of agitation or otherwise causing Jane distress, the procedure should be discontinued and other options for teaching discrimination should be explored. A game like “Stacking the Deck”, developed by Richard Foxx and others and available from Research Press may be another option.
d. Teaching Coping and Tolerance Skills. Many of Jane's seriously challenging behaviors are a reflection of her inability to cope with aversive events such as delay in gratification, denial, the need to perform a non preferred activity, etc. While Jane can avoid some of these behaviors, aversive events are also naturally occurring. Especially if she is to lead a full life, from time to time, she will face the disappointments we all have to face, for example, not getting something that she wants, when she wants it and having to wait for it, i.e., delay; not getting something she wants, at all, i.e., denial; being told by somebody that a relationship is not possible; being criticized or reprimanded; etc. In the face of these events and the emotions they understandably arouse, Jane’s coping responses have not had the opportunity to develop much beyond the primitive responses of a young child; nor is she likely to develop much beyond this level through "natural consequences." Rather, it will be necessary to be systematic in applying sophisticated instructional technology, with the objective of teaching her these very important coping and tolerance skills. The following is a recommendation for how to proceed in the important area of skill development, with the initial focus being on Jane's ability to relax.
STAGE 1
1) Rationale / Logic. In order for any coping/tolerance strategy (e.g. desensitization) to work, it must first be ensured that Jane can adequately cue herself to relax. Although relaxation training was mentioned in written reports about Jane, no qualitative or quantitative data was available to indicate that Jane has mastered the relaxation response. The intervention described below is designed to ensure that Jane has mastered relaxation so that she may then use it in situations she finds difficult and so that staff may proceed with desensitizing her to threatening or upsetting situations. The deep breathing method was chosen as it is portable and easily modeled by staff, making it unnecessary to touch Jane to teach the correct response. A progressive muscle relaxation procedure could be introduced when Jane is familiar and comfortable with the deep breathing method.
2) Objective. By January 1, next year, Jane will be able to respond without error to the verbal cue “Relax” with the deep breathing relaxation response (described below) without further verbal or nonverbal prompting by staff in five out of five in-vivo practice sessions.
3) Method. Jane will be verbally presented with the following instructions by staff, who will also model the behavior:
a. Choose a quiet place.
b. Sit, stand or lie down in a comfortable position.
c. Take 10-15 deep breaths, breathing in through the nose and out through the mouth. (Staff should model breathing into the diaphragm as opposed to breathing into the chest)
d. Shake your arms as you are breathing in and out.
e. When you have taken all of your deep breaths, sit or stand quietly for a couple of minutes before returning to what you were doing.
Staff should start each brief session (10 minutes maximum) by saying, “When I say ‘Relax’ we are going to start the relaxation session”. After initial presentation, the SESIs of deep breathing should be taught by modeling and shaping successive approximations toward the correct response. When Jane has mastered each SESI of deep breathing as described above, the verbal cue should be faded until she can respond to the single word “Relax”. When she is able to respond to the single cue in focused practice sessions, generalization probes should be conducted using the single-word cue until the objective is met.
STAGE 2
1) Rationale/Logic. As noted in the functional analysis, there are several events that seem to cause Jane discomfort, which is then manifested in the form of frustration, anger, and/or aggression. For example, Jane describes physically attacking an individual who was, she believed, touching her friend inappropriately. One strategy for helping Jane overcome her powerful reactions to these events is pairing these events with the relaxation response, otherwise known as desensitization.
2) Objective. By December 1, next year, Jane will be able to listen to a description of the highest item on a pre-established hierarchy while simultaneously engaging in the relaxation response during five consecutive sessions.
3) Method
a. Based on the incident review (described under the heading “Functionally Equivalent Skills), development of threatening/non-threatening discrimination task (described under the heading “Functionally Related Skills”), and discussions with Jane, a hierarchy of stimuli that cause frustration and anger should be developed. The events at the bottom of the hierarchy would be those that only cause minor frustration, while the events at the other end of the hierarchy would cause significant discomfort. Events between would gradually produce more and more frustration.
b. Sessions should be scheduled with Jane to occur once per day, for a maximum of 10 minutes.
c. During each session, the relaxation should be cued, as described in Stage 1 of this procedure. While Jane is relaxing, the first item on the hierarchy should be described to her and she should again be cued to relax. The rationale for this procedure is that the relaxation response would compete with the frustration producing stimuli.
d. When Jane has successfully relaxed with the presentation of the first item on the hierarchy for five consecutive sessions, the next item on the hierarchy should be presented using the same procedure. The hierarchy should gradually be ascended in this way.
e. If Jane is unable to relax upon presentation of any of the items in the hierarchy for four consecutive sessions, the procedure should be reviewed and revised.
3. Focused Support Strategies. Some of the ecological strategies that were recommended above, depending on their complexity and/or difficulty, may take time to arrange, and positive programming will require some time before new skills and competencies are mastered. Although these ecological and positive programming strategies are necessary to produce good long-term quality of life outcomes for Jane, it is also necessary to include focused strategies for more rapid effects; hence the inclusion of these strategies in our support plans. Specific recommendations for the limited but important need for rapid effects are made below.
The focused support strategy currently employed to deal with Jane’s target behavior is a Differential Reinforcement of Other Behavior, Progressive (DROP) schedule of reinforcement. According to the schedule that she is currently on, she may earn her reinforcer of a $4.00 lunch after a minimum of 8 days. She makes X marks on a 28 box DROP chart (one on the first day, two on the second day, and so on up to a maximum of five boxes for the fifth and each consecutive day that she goes without engaging in aggressive behavior). It is hypothesized that the reinforcer is not of sufficient magnitude to preclude the occurrence of aggressive behavior when Jane is very upset. With the average occurrence of the behavior being once per month, it is recommended that the amount of time between available reinforcers also be increased. The mediating system used for the DROP schedule should also be made more meaningful. Finally, in order to provide a greater target for Jane to aim for, it is recommended that she be provided with a large reinforcer once she has repeatedly met the criteria for reinforcement according to the DROP schedule. The details of these recommendations are provided below.
Revised mediating system. Jane is currently required to make X’s in boxes on a standard DROP sheet. It is recommended that a revised DROP sheet be developed with Jane that is more colorful and interesting. In the reinforcement inventory that Jane completed, she indicated that she collects “hearts”, suggesting that hearts have some intrinsically reinforcing value to her. Also she has indicated that one of her favorite television programs is “Touched By an Angel”. Rather than using X’s, perhaps small heart and angel stickers could be used to indicate the progressive levels of reinforcement. Not only do these have some intrinsically appealing value to Jane but they also convey positive regard for Jane, perhaps facilitating her involvement in the program, thereby reducing the likelihood of the occurrence of aggressive behavior. Although revising the mediating system in this way may not be considered age-appropriate by some, it is the writer’s opinion that the endemic interest in such a revised system mitigates the concern for age-appropriateness.
Revised inter-reinforcement interval. Jane currently has to complete a 28-box DROP sheet to earn a $4.00 lunch (or equivalent). It is recommended that Jane work of a 60 box DROP sheet to delay the frequency with which she can earn the reinforcer, commensurate with the reported rate of occurrence of the behavior.
Revised reinforcers. As the amount of time Jane is required to go without earning a reinforcer has increased, the magnitude of the reinforcer should be increased accordingly. Therefore she should be reinforced as follows:
60 hearts or angels = Going to a movie with popcorn and pop (or other reinforcer of similar magnitude)
To increase interest, Jane may be able to choose from a variety of unknown pre-determined reinforcers of similar value when she completes each DROP sheet, analogous to a grab bag system. In other words, when Jane completes her DROP sheet, she would have the opportunity to reach into a box and draw out a pictorial representation of a reinforcer (e.g. movie ticket).
The number of sheets that Jane has earned should be recorded on a form that includes a table similar to the one below:
|DROP Sheet # |Date completed |
|1 |September 15, this year |
|2 |October 3, this year |
|3 |October 17, this year |
|4 |October 31, this year |
Each time a DROP sheet is completed, it is also recommended that Jane receive a Disney sticker to place in her daytimer as an ongoing reminder of her success.
When the fourth DROP sheet has been completed, Jane will have earned a trip to Disneyland. Once the trip to Disneyland has been earned, she will start to work towards the trip again.
The trip to Disneyland is suggested as a reinforcer because of Jane seemed to be excited about the possibility of going there with her sister. However, other reinforcing events of similar magnitude may be identified during the course of the ecological inventory. These may be used instead of the trip to Disneyland, in accordance with Jane’s wishes, if there are concerns about her becoming satiated on that reinforcer. One example may be a trip to the Rose Bowl Flea Market, a large version of a swap meet.
Antecedent Control Strategies
The most powerful way to prevent episodes of aggressive behavior is to use a respectful interactive style with Jane. This was described under the heading of “Ecological Strategies” but should also be considered an antecedent control strategy.
The writer noted that when Jane is challenged, refused or told what to do, she is more likely to engage in aggressive behavior. Therefore, the way you ask Jane to do things or even the way you offer assistance can affect whether or not she becomes aggressive. Examples of how to interact with Jane are offered below:
Instead of
“You know, you aren’t the only person I have to help.”
Say
“I can see that you want my help right now Jane. I’m sorry, but I don’t have time to take you to the store right now. Can we go tomorrow?”
Instead of
“Jane, we have to go to your appointment right now!”
Say
“Jane, it’s going to take a little while for us to get to your appointment. You know how traffic can be! How long will it be until you are ready?”
Another antecedent control strategy for Jane is to avoid having her placed in groups with obviously disabled consumers as she is more likely to be assaultive towards individuals with obvious disabilities.
4. Reactive Strategies. Efforts to manage the antecedents to Jane's aggressive behavior are likely to have a considerable impact on the rate of their occurrence, as will the focused support and positive programming strategies recommended above. However, these behaviors are still likely to occur, at least to some degree, especially during the initial stages of the implementation of the support plan, as the necessary adjustments to the plan are identified and made. Therefore, staff may need measures for dealing with these behaviors when they occur. Such reactive strategies have an even more limited role than the focused strategies recommended above. Specifically, reactive strategies are designed to produce the most rapid control over the situation, in a manner that keeps both Jane and staff as free from risks to injury as possible and that keep Jane free from risks of exclusion and devaluation as much as possible. Accordingly, reactive strategies are not intended to produce any change in the future occurrence of Jane's challenging behavior. Both rapid and durable changes, instead, are being sought by the Ecological Strategies, Positive Programming Strategies, and Focused Support Strategies described in the preceding sections. These proactive strategies are also expected to prevent any counter therapeutic effects that might accrue from the nonaversive reactive strategies being recommended here. The following procedures are suggested as initial strategies that fit within ABCD's "Emergency Management Guidelines." They, along with other strategies that fall within the guidelines which may be considered in the future, are expected to preclude the need for the physical management of Jane's behavior, including the need for physical restraint.
Active listening. When Jane is becoming angry, every effort should be made to attempt to see the situation from her point of view. She needs to hear that you understand how she is feeling and where she might be coming from. For example:
“Jane, I can see that you are feeling really frustrated with me right now.”
This should be reflected at approximately the same level of emotion that Jane is expressing at the time.
In conjunction with this active listening strategy, every effort should be made to elicit communication from Jane when she is starting to become angry. For example,
“Jane, tell me about what’s bothering you”.
Positive program reminders. Before Jane has escalated to the point of physical aggression, she may also be reminded of the skills that she is working on as part of her positive program training (e.g. relaxation response).
Stimulus change. It may be possible to interrupt the chain of Jane’s behavior once she has started an aggressive episode with a novel event. For example, staff could put on Mickey Mouse ears and start singing the Mickey Mouse Club song, also serving the purpose of reminding Jane of the large reinforcer she is trying to earn. It will be important to come up with a list of possible stimulus change procedures, depending on the level of comfort/discomfort staff working with Jane would have implementing such a procedure.
Geographical containment. Geographical containment should be used particularly if staff are afraid of imminent physical harm to themselves or another person. Essentially this strategy involves finding a natural barrier in the environment that can be placed between Jane and the target of her aggressive behavior. The goal of geographical containment is to eliminate the need for physical contact, thereby reducing the risk of injury. Active listening and facilitated communication as described above should continue to be employed when using this strategy. If necessary, staff should call for assistance.
5. Staff Development and Management Systems. Key elements that will determine the degree of success of this support plan are staff competence and management systems that assures staff consistency in providing services to Jane. The following is recommended:
a. Procedural Protocols. Each strategy and procedure described above should be broken down into teachable SESIs.
b. Three tiered Training.
1) Each staff person would be required to show "verbal competence" for each procedure. That is, they would need to describe each and every SESI in the specific procedure. Each staff would be scored using a "+/O" system for each SESI of the procedure. A 90% criterion is considered passing.
2) Each person would be required to show "role play competence" for each procedure. That is, they would need to demonstrate each SESI of a procedure to another member of Jane's support team. The scoring system would be the same as for "verbal competence," as described above.
3) Finally, each staff person would need to demonstrate "in-vivo" procedural reliability; that is, the ability to carry out each program component of Jane's support plan for which they are responsible. This would require the designated person to observe each staff person as they provide services and to see the degree to which what they do agrees with the written protocols. The scoring procedure described above would be used again, and 90% consistency should be considered as minimally acceptable. For those procedures that do not occur frequently, such as the need to react to Jane’s infrequent aggressive behavior, role-play competence should be reconfirmed on a regular schedule.
c. Periodic Service Review. Jane's entire support plan should be operationalized into a series of performance standards to be met by the support team and integrated into a Periodic Service Review. Monthly (initially, weekly) monitoring should be carried out by the designated coordinator and the status of the support plan's implementation should be quantified as a percentage score. Three score should be summarized on a graph and kept visible to staff as an incentive to achieve and maintain a score of 85% or better. Three should be reviewed regularly by management and feedback should be provided. More information on how to develop and implement a Periodic Service Review system can be provided on request.
COMMENTS AND RECOMMENDATIONS
The intervention strategies recommended to help Jane get control over her aggressive behavior are summarized below:
Ecological Strategies
Interpersonal: Interactive style; Using simple clear speech; Group placement; Increased access to family; Increased access to friends
Programmatic: Sharing of information with residential services provider; Ecological inventory; Re-distribution of available staffing; Training loosely; Maintenance of naturally supported working environment; Daytimer with daily planning
Other: Counseling
Positive Programming
General Skill: Giving self a manicure, Child care volunteer options, increased leisure involvement.
Functionally Equivalent Skill: Incident-based social skills training
Functionally Related Skill: Threat/No threat discrimination training
Coping/Tolerance Skill: Relaxation and desensitization
Focused Support Strategy: DRO and DROP schedule combined
Reactive Strategy: Active listening, Stimulus change, geographical containment
Staff Development and Training: Procedural protocols, three-tiered training, periodic service review.
1. Revisions are certain to be necessary during the initial stages of implementation and as Jane's responsiveness to the new support plan are observed. Early revisions and fine-tuning are necessary in the initial implementation of any support plan, especially one as comprehensive as this one attempts to be.
2. It is recommended that Jane receive a thorough psychological evaluation specifically to evaluate her current level of expressive and receptive language skills. In the opinion of the writer, she may have some difficulty processing information, based on observations and reviews of previous reports. Knowledge of the extent of this deficit would be very useful in designing future intervention strategies or in modifying the strategies recommended above.
3. Counseling is recommended for Jane to address lingering abuse issues. Based on her difficulty talking about sex and intimacy in addition to her reliance on romantic fantasies it is clear that Jane continues to be confused about her own sexuality. Her knowledge of sex from a sex education standpoint is also questionable. In addition, Jane’s need to assert herself over those less powerful than her with aggressive behavior, would suggest that her opinion of herself is quite low. Any counselor to whom Jane is referred should have the following characteristics: experienced in treating victims of physical/sexual abuse and/or Post-Traumatic Stress Disorder; would be willing to meet with her in a natural setting rather than in an office; and would be willing to talk to her in the style of a mentor providing guidance rather than as an authority figure giving her directions. Issues that should be addressed in this setting include past abuse, sex education, social mores surrounding sex and intimacy, and self-esteem.
Thank you for the opportunity to help Jane gain control over her challenging behavior. I hope this information has been helpful. If you have any questions about this report, do not hesitate to contact Dr. Howard Stern or Dr. John London.
_______________________________________
writer
_______________________________________
Clinical Director
_______________________________________
Associate Director
Client Confidential
Positive Programming Protocol
Consumer’s name: Jane Doe
Protocol name: Incident-based social skills training
Date of implementation: TBA
Revision date(s): New protocol
Definition of Skill:
Identification and practice of possible solutions to prepared scripts of social situations.
Purpose of Protocol:
Teach Jane alternative methods of solving difficult social situations.
METHOD – PREPARATION
Materials required
3x5 index cards
Responsible person
Assigned specialist
Steps
f. STEP incident reports should be gathered together from the time that Jane started receiving services from STEP. Any other descriptions of incidents that STEP has access to could be reviewed as well. Incidents that include any of the topographies described under the response class of “Aggressive Behavior” should be extracted.
g. A set of scripts for staff and corresponding scripts for Jane should be prepared. Scripts should be written based on each incident that include the cues for the aggressive behavior and possible solutions. Scripts of similar situations may also be developed. For example:
EXAMPLE A
Script #1 – Staff
Setup: Jane is trying to get the Employment Specialist’s attention. Another consumer is already talking to the Employment Specialist.
Staff (playing the other consumer): “Would you shut up! I was here first!”
Script #1a – Jane
Look at the person
Say “ I feel hurt when you talk to me like that. I just wanted to get Annie’s attention”
Don’t say anything else
Script #1b – Jane
Look at the person
Say “I’m sorry. I thought you were done”
Don’t say anything else
EXAMPLE B
Script #2 – Staff
Setup: Jane sees her friend being touched in the chest area.
Script # 2a – Jane
Look at your friend
Ask your friend “Are you OK?”
She says “Yes”
Script #2b – Jane
Look at your friend
Ask your friend, “Are you OK?”
If she says no,
Go and tell a person in authority (your job coach, for example)
When all of the scenarios have been developed, they should be transferred to 3x5 index cards. A suggested order of presentation should be established starting with the easiest social situations and ascending a hierarchy to more complex scenarios.
Method -- Implementation
Schedule
Two to three times per week, 15 minute sessions
Location
Jane’s home or other non-work/office setting
Materials required for training session
3x5 index cards with scenarios written on them
Can of Coca-Cola or other small edible
Steps
a. At the beginning of each session, approach Jane and say “Hey Jane. Why don’t we have a Coke [or whatever edible is available] and do a little play-acting”. Variations: Variations are permitted as long as the style of approach is light-hearted, non-confrontational and accompanied by a tangible reinforcer.
b. Starting with the least difficult scenario in the hierarchy:
Verbal competence: For each scenario, review the setup and possible solutions with Jane until she can tell the story without prompting. When she can tell the story twice without prompting, move on to the development of role-play competence.
Analog competence: Role-play the scenario with Jane. Start with staff playing the part of Jane (modeling) and Jane setting up the situation. Then switch roles and have Jane play herself in the situation, prompting her as necessary. The prompts should gradually be faded until Jane is able to role-play the scenario without prompting. When she is able to role-play the scenario twice without prompting, move on to generalization trials.
h. Generalization probes: Jane should be told that a staff person will approach her when she is not expecting it to practice the script. Initially the day should be announced and Jane should be prompted through the exercise. Then the prompts should be gradually faded, then the announcement of the day of the trials should be gradually faded.
Each session should be ended with Jane being verbally praised for her efforts in that session. Data should be recorded immediately after the session.
Pass: Pass to next scenario when Jane has successfully responded to 3 consecutive generalization probes without prompting.
Fail: If Jane does not move up the scoring matrix on a particular script for 3 consecutive sessions, the protocol should be reviewed and revised.
Data Collection Methods
The results of each session should be recorded in a log book created for this purpose. Each entry should include the following information:
a. A description of the scenario employed.
b. Indication of what instructional step(s) was worked on.
c. Highest level of competence achieved (see scoring matrix below)
d. Staff comments (optional)
e. Indication of whether Jane is ready to move to the next level
Scoring matrix
|Verbal |Analog (Role-play) |In-vivo |
|Incorrect |Correct |Incorrect |Correct |Incorrect |Correct |
|Prompt |No prompt | |Prompt |No prompt | |Prompt |No prompt | |1 |2 |3 |4 |5 |6 |7 |8 |9 | |
Data Summary Methods
Information should be transferred to the data summary sheet on a weekly basis, indicating the date of each session, which scenario(s) was introduced in that session, and the highest level of competence achieved according to the scoring matrix.
Script # |1 |2 |3 |4 |5 |6 |7 |8 |9 |10 | |Sept. 10 |4 | | | | | | | | | | |Sept.12 |6 | | | | | | | | | | |Sept. 20 |9 |4 | | | | | | | | | |Sept. 23 | |9 |1 | | | | | | | | |Sept. 25 | | |3 | | | | | | | | |Sept. 27 | | |6 | | | | | | | | |
The percentage of total scenarios mastered (i.e. Level 9) should be indicated in the quarterly report. Any problems with the procedure should also be noted at at that time.
Procedural Reliability
Supervisor should observe one initial training session then one session per month to ensure that the procedure is being followed as outlined above. Procedural reliability checklist for this procedure should be used for this purpose. Each step should be scored as “+” (completed) or “-“ (not completed). Feedback should then be given to assigned staff based on the results of the checklist.
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