NOTE: This report was written by a participant in Institute for Applied Behavior Analysis’ Summer Institute (http://www.iaba.com) 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.
Referral Source: Sims and Sims Services, Inc. – Corie Brown
REASONS FOR REFERRAL
Mike was referred by Sims and Sims Services, Inc. (SSS) – Corie Brown for an evaluation. The purposes of the evaluation were to assist Mike in securing the services and programming which would enable him to develop and to use his capabilities, to get the most out of the educational opportunities that can be made available to him and to enable him to develop and to use his capabilities for more independent, normal living and more productive activity than his behavior problems presently permit. Accordingly, it was requested that the evaluation focus on these behavior problems, which were characterized as Physical Aggression, and the type(s) of behavioral services, support strategies, programming, professional competencies and skills, and environments required eliminating, minimizing, or managing them.
Specifically, Mike has engaged in hitting his peer at the work site with a broom and has tried to hit his peer in the face by engaging in the action of “snapping” a cloth at his peer’s face.
DESCRIPTION OF ASSESSMENT ACTIVITIES
This assessment is based on information obtained from the following sources:
A. Interviews with Mike Jones (consumer) July 26, (20 min.). Micki Smith (SSS Job Coach) July 26, (1.5 hours.), and Missy Allen (Sr. Employment Specialist.) July 26, (45 minutes);
B. Direct Observations of Mike (consumer) in the following settings; The Steamer Restaurant, work site July 26, (1.75 hours);
C. Review of the following records provided by SSS;
i.) Local Area Cooperative Education Program, Case Study Summary, 1985.
ii.) DEF Regional Center - I.P.P. Person Centered Plan, 1999
iii.) Developmental Disabilities Center – Assessment, 1986
iv.) SSS Individual Service Plan, 1999
D. A Reinforcement Survey completed by the writer through information obtained through interviews and records review.
E. Telephone Conferences; Cathy Jones (Mother) July 26, (30 minutes)
I. Brief Client Description.
A. General. Mike is a 33 year old Caucasian male of medium, stocky build. He weighs approximately 210lbs and is 5 foot 9 inches in height. Upon meeting Mike I noticed that he was clean shaven and his hair was neatly combed. He has been diagnosed as having a mild level of learning disability with Autistic like tendencies and possible emotional deficits. Mike has blue eyes and blond hair and has no apparent physical disabilities. His gross motor skills appear to be within normal range and he is fully ambulatory, and walks slowly moving side to side. Mike has difficulties with tasks that require fine motor skills such as tying his shoes.
B. Language and Communication Skills. Mike communicates through use of verbal English language although at times is difficult to understand as he often speaks quickly and has difficulties with articulation of some sounds. Mike at times stutters and exhibits echolalia and preservative speech. Mike is spontaneous in his use of speech and uses sentences with up to 7 words in them. He can initiate conversation with others although does not do this consistently. He participates in simple conversations and can relate personal experiences through “I” statements. Mike can understand basic to moderate conversations and can follow 2 step directions.
Cognitive and Academic Abilities. At the age of nineteen, Mike was the given the Weschler Adult Intelligence Scale, with results as follows:
Verbal Subtests Performance Subtests
Information -1 Picture Completion -3
Digit Span -1 Picture Arrangement -4
Vocabulary -2 Block Design -4
Arithmetic - -2 Object Assembly -3
Comprehension -3 Digit Symbol -1
Verbal IQ=59 Performance IQ=59
Full Scale IQ=57
Mike can read his name and some safety words. He can print single letters and his name legibly, although is inconsistent with printing his name at times. Mike can recognize coins and bills and knows that money is needed to purchase items, but cannot typically make change or count out right amount to make a purchase. Mike does not appear to have a solid concept of measurement at this time. Mike can distinguish between day and night and his concept of time is based upon the consistency of his daily schedule. Mike can name the present day of the week and can differentiate between today and tomorrow. He can state his own birthday and knows the birthdays of those important to him. Mike can also state the present year.
D. Self Care Skills. Mike can eat with all eating utensils i.e.: spoon, fork, knife although at times requires prompting to do so. He drinks with ease from a glass and uses a napkin to wipe his hands and face. Mike can independently dress himself and is unable at this time to tie his shoelaces. Mike is independent at toileting himself and washing up after elimination. Mike urinates frequently at times, with the average being approximately 2x an hour. Mike is independent with washing with soap and applying deodorant with respect to his bathing skills and requires assistance with regulating water temperature. He requires verbal reminders to wash and comb his hair. Mike can independently complete all steps in oral hygiene routine. He requires verbal prompting to blow his nose with a tissue and requires physical hand over hand assistance to shave using a razor and shaving crème.
E. Domestic Skills. Mike is able to do many household chores with varying degrees of assistance. He empties the garbage, sweeps the floor and wipes the counters with verbal prompting to begin task. He rinses his dishes and places them in the sink after meals. He does not load the dishwasher or wash dishes. With verbal prompting Mike can make his bed, hang up clothes and place clothes in drawers. Mike is also capable of vacuuming floor, dusting and polishing, and cleaning windows with prompting. With varying degrees of assistance, Mike is capable of cleaning the bathroom and doing his laundry. Mike participates in some outdoor maintenance tasks such as watering the lawn and plants with hose and taking the trash out. He does not mow the lawn or trim the hedges and shrubs. Mike participates in meal prep such as peeling carrots and potatoes and can prepare simple snacks and meals independently. He requires assistance with following recipes and using the oven.
F. Community Skills. In the community skill domain, Mike will use the telephone to take a social call however he does not ask to use the phone to place a call nor does he answer the phone when it rings. He does not know his phone number and requires someone to dial the phone for him. Mike carries his identification card and bus pass with him at all times. He takes the bus independently but has, on occasion, became confused and was unable to locate the correct bus. There was limited records pertaining to Mike’s community mobility skills. Mike enjoys shopping and requires assistance with the shopping process of picking out items and paying for them. While he can identify bills and coins and understands that money is needed to purchase items, he does not posses the skill to count out the correct amount of money.
G. Recreation and Leisure Skills. Mike spends his indoor rec. and leisure time watching TV shows and movies. He enjoys listening to music and playing his Nintendo 64. He also enjoys participating with the preparation of meals. Mike enjoys going out to a show at the movie theatre and has gone to see professional sporting events at community arenas ex: NHL hockey. He attends the community center approximately once a week to access exercises facility and enjoys going shopping.
H. Social Skills. Mike’s interaction with others, although limited, is usually friendly, respectful and focuses around his great sense of humor and ability to make people laugh. He has a positive and caring relationship with his parents and older sister, Micki. Mike is well known by local firemen and city workers and he will exchange greetings with these acquaintances. Mike has 2 friends, Marnie and Jason that join him at his work sites. Mike has many assets and/or talents in the area of socialization that include his comedic nature and ability to make people laugh with his imitations of characters from TV shows. He likes to joke around and tends to be a “newscaster” of sorts. He does experience difficulties with initiating and maintaining friendships due to his lack of conversation and undesirable social skills such as: inappropriate humor – name calling, and phrases like “I’m going to kill you” and also inappropriate sounds – passing gas and loudness in tone of voice.
II. Living Arrangement and Family History. Mike lives with his mom and dad in a nice neighborhood in Ennytown, CA. The house is a two-story house and Mike has his own room. They have a family pet, a Himalayan cat that resides with them as well. Mike has lived with his parents his entire life and has an older sister, Micki that he maintains regular contact with. Micki is married and has a child and Mike’s mother stated that Mike enjoyed being an uncle. Mike maintains a very positive, caring relationship with his parents and sister. At the time of this assessment, a home visit was scheduled but was canceled by Mrs. Jones. It was not rescheduled.
III. Daytime Services Received and Day Service History. Presently, Mike is attending the SSS – behavioral day management program with the focus being on job training and community skills. He attends from Monday – Friday from 0800-1350. He entered this program on December 6, 1993 and receives a 3:1 staffing ratio. There are 3 participants in his program, himself included. Mike is employed at The Steamer Bar and Grill and makes $5.25 hr. His mode of transportation to and from the work site is by city bus. Areas of concern noted at the day program are off task behavior, dumping of items ex: salt, pepper and sugar, loud vocalizations and inappropriate name-calling. At present Mike’s schedule at the day program is as follows
MONDAY: 800-1100 The Steamer Bar and Grill – duties include setting up chairs, windows, set tables i.e.: silverware, sugar, menus, wiping chairs and booths. 1200-1330 Community Training: activity in community
TUESDAY: 800-1100 The Steamer Bar and Grill – duties same as above 1200-1330 Community Training: department store
WEDNESDAY: 800-1100 The Steamer Bar and Grill – duties same as above 1200-1330 Community Training: Borders Bookstore
THURSDAY: 800-1100 The Steamer Bar and Grill – duties same as above 1200-1330 Bi-weekly – banking 1200-1330 Bi-weekly – Community Center – workout
FRIDAY: 800-1000 Community Training: Border Bookstore 1030-1115 Lunch Out 1130-1330 Community Training: Movie at theatre
Mike graduated from school in 1988 and attended the Career Assessment and Placement Center in Whittier. He received vocational and mobility training and worked at Rockview Dairy. Due to funding issues, in 1993 Mike was referred to other programs. Since December of 1993, Mike has been supported by SSS.
III. Health, Medical and Psychiatric Status. Mike is generally in good health. He has high blood pressure but monitors his diet as a way of keeping it under control. He takes no medication at this time and has no known allergies. Mike’s hearing is within the normal range and he has mild impairment with his vision. Mike does not appear to have any physical disabilities although is overweight and this appears to have bearing on the physical exercise that he is willing to participate in. Mike’s last medical examination was in 1999 however which month was unclear. Mike does not appear to have any cardiovascular or respiratory problems at this time, nor were any genito-urinary or musculo-skeletal concerns noted. Although there is no recorded problems with gastrointestinal, it was noted that Mike eats very quickly at times and this can cause vomiting after a meal. There have been no recent hospitalizations with the last one occurring when Mike was a child to have his tonsils removed. Mike had been on various medications to control hyperactivity but has not taken medication for behavior control in over 15 years. Psychological testing indicates congenital maldevelopment of the brain manifesting in extreme hyperactivity, delay in speech, mental retardation with possible emotional deficits. Autistic mannerisms noted were namely self-stimulatory behaviors, difficulties in pragmatic use of language and the tendency to remain aloof and alone. It is unknown as to whether Mike is receiving psychiatric services at this time.
IV. Previous and Current Treatments. There was no available data on previous treatments for the target behavior of aggression before May 1999. Currently Mike is on a Differential Reinforcement of Other Behavior (DRO) for aggression and property defacement with the objective being 2 or less incidents a work shift. For each shift during which less than 2 incidents occur, Mike earns a certificate. Certificates can be exchanged as follows: One certificate for a gum ball, Two certificates for a $0.25 pop at Ralph’s, Three certificates for a hamburger. At this time, Mike is successfully meeting the objectives of the DRO reinforcement schedule. Prior to August 31, 1999, the Focused Support Strategy was a DROP schedule and it was not deemed appropriate after changing the focus of the target behavior during Mike’s work shifts.
FUNCTIONAL ANALYSIS OF PRESENTING PROBLEMS
A functional analysis was conducted for Physical Aggression. The behavior of Property Defacement is also a concern however due to time constraints it was not possible to address this behavior and it is recommended that it is addressed in the future. Accordingly, this 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. This 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. This analysis presents the recent and long-term history of the problem. The purpose here is to better understand Mike'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 Mike'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 Mike'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 Aggression, organized around these headings, follows.
A. Description of Behavior and Operational Definition.
1. Topography. The hitting or attempted hitting of others with an object ex.: broom, and the “snapping” of cloths at others bodies with in a 3-foot radius.
2. Cycle. The cycle of the behavior starts with the swinging of the object and the snapping of a cloth at another person’s body with the intent to hit and the cycle stops when there has been a period of two minutes without an occurrence of the above behaviors.
3. Course. The course of the above behaviors begins gradually with precursor behaviors noted. The precursor behaviors noted are rapid physical movement, walking away from peers, verbalizing that he is upset and loud, inappropriate name-calling and property defacement. Property defacement includes throwing rocks at vehicles, pulling at flowers or plants, pulling the cord on the bus and kicking dirt. There may be one cycle of precursor behaviors or there may be several cycles of precursor behaviors with a period of calm in between. Mike then engages in one or more of the target behaviors and is remorseful after, vocalizing to self “ Why did I do that” “ I shouldn’t of done that”.
a. Rate. The rate of behavior occurs approximately 2 or less times a year.
b. Duration. The duration of the episode in which the target behavior is occurring is short and fast, lasting approximately 5 sec. The precursor behavior period can go on for long periods of time, up to several hours.
c. Severity. The severity of the target behaviors is that the object comes in contact with the body and leaves a red mark or bruise lasting longer than 5 seconds. For Mike the severity of the target behavior is that he has internal feelings of remorse and is regretful for actions. At this time the external or physical damage is minimal as there has been no physical injuries incurred from the target behavior. The internal injuries experienced by the recipient of the target behavior are emotional trauma and are believed to be severe.
B. History of the Problem. The first appearance of the target behavior is believed to have occurred in 1994, and the first reported incident found was in June 1998. There have been only a few incidents of the target behavior. The target behavior has been under the control of a daily DRO schedule until the recent Job Coach gave her notice for termination of employment and an increase in precursor behaviors have been noted.
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 Physical Aggression 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.
The setting events that may occur before the behavior that might impact Mike’s daily behavior are events that Mike finds upsetting that are happening on the news ex: plane crashes, the death of JFK Jr. and motor vehicle accidents. A sudden change in his daily schedule for ex: the city bus being late to pick him up and take him to work and the moods of his peers at the work site are also setting events for Mike. His perception that his peers are upset with him or if his peers, in Mike’s mind, are not doing their share of or a good enough job at the work site also effect his daily behavior. Non-occurring setting events that affect Mike’s behavior are that one of his peers is absent from the work site or did not greet him in the morning when they arrived at work. The target behavior is more likely to occur at the work site, as there have been no incidents at home of the target behavior. The target behavior is more likely to occur when Marnie, his peer at the job site is present as she appears to be targeted during the behavior episode. The target behavior is more likely to occur during the morning hours 0800-1130, between Tues.- Thurs as this is when Mike is at his work site with Marnie. Activities or events that are more likely to increase the likelihood of the target behavior occurring include a news cast that Mike finds upsetting, his peers moods and behaviors at the work site and witnessing an accident on the way to work. Activities or events that are more likely to decrease the likelihood of the target behavior are positive interaction and communication with Marnie.
D. Consequence Analysis. When the target behavior occurs, staff removes the object from Mike and asks him to “Stop”. They redirect him away from the area and outside to calm down. They use the phrases “Why are you mad”; “Who are you mad at” “ Are you mad at Marnie, Jason, staff”. The staff try to encourage Mike to calm down and to open up and discuss what is upsetting him. On one occasion when the target behavior occurred, staff needed to call in a second staff to talk with Mike as she was upset with the nature of the incident. Staff notifies Mike’s parents of any incidents of the target behavior and his parents will talk with him about staying in control. Marnie, who is Mike’s friend and is also targeted when the aggressive behavior is occurring, becomes upset emotionally when the behavior occurs and thus Mike feels very remorseful and bad for engaging in the target behavior. The target behavior may be maintained by the lack of communication and self control skills that Mike has.
E. Ecological Analysis. There are a number of ways in which understanding the ecology surrounding and how it may conflict with Mike's needs and characteristics, may be helpful in understanding the meaning of his behavior and in understanding the ecological changes that may be necessary to provide the necessary support for him. The brief discussion addressing this ecological analysis is organized below around the physical environment, the interpersonal environment and the programmatic environment.
When Mike is at the work site, which is where the target behavior occurs most often, he is easily distracted by settings and activities that are going on around him. While working at The Steamer Bar and Grill, there are several TV’s that are on throughout the establishment and I noted that Mike was easily distracted by the TV’s and would frequently stop working and watch. I also noted that when he was engaging in a job duty that was near a window he would often become distracted by the traffic and would stop working.
At this job site Mike is joined by two of his peers and at times is distracted by their activities and what they are doing. As Mike’s mood is directly affected by their moods, I noted that Mike, at times, would cease working to seek them out. The Steamer Bar and Grill is closed while Mike and his peers are working there as it is in the morning. Mike does have an opportunity to interact with the manager and other employees as others are in the environment doing their daily prep work.
Mike’s routine at the job site consists of work, break, work, and break which aides him in completing the various tasks that he has at this site. I did observe that Mike would try to move on to the next task before the current task at hand was completed.
Impressions and Analysis of Meaning. In considering this functional analysis and the background information summarized above, there are a number of factors that are helpful in trying to understand the meaning of Mike's behavior. It is my impression that Mike engages in the target behaviors as a way to communicate his feelings of anger and frustration. This is evident by the precursor behavior “name calling” that he does when he becomes upset and when the precursor behavior is not addressed he continues to try and express that anger and frustration. Mike is very sensitive in regards to others perception of him and of others behavior that are occurring around him. He becomes upset and frustrated when he perceives his peers may be mad at him and the target behavior is directed towards his friend Marnie. While Marnie is targeted with the aggressive behaviors, she is also the one who is able to calm him down when he becomes upset and frustrated.
Another function of the target behavior is that he is unable to maintain self-control. After Mike becomes upset and engages in the target behavior, he is remorseful and talks to himself stating “Why did I do that” and “I shouldn’t have done that”. He is unable to maintain self-control over his feelings and the target behavior is, I feel, is a way of expressing that inability to self regulate.
A motivational analysis was carried out to identify those events, opportunities and activities that Mike enjoys and that may be used to enhance his quality of life and provide him with incentives to improve his behavior and to enhance his 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 wrestling, baseball, miniature golf, and football. Other potential reinforcers include fire station, police stations, planes and watching TV and movies. Mike’s favorite foods are burgers, fries, hot dogs, cake, popcorn and tacos. He also enjoys shopping. 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.
A "Mediator Analysis" was conducted for the purposes of identifying those persons who might be responsible for providing behavioral support for Mike, 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. This analysis showed the following:
Mike’s parents and SSS staff are those who will be responsible for carrying out the recommended support plan. While I was unable to assess the level of motivation or cooperation directly with Mike’s parents, staff advised me that his parents are very involved with Mike and his program and that SSS staff have received high levels of cooperation and motivation from them before. The support staff at SSS has positive interactions with Mike and I feel that this interaction could promote an atmosphere and conditions under which a recommended support plan could be implemented. Factors addressed that may constrain staff’s ability to carry out the recommended support plan are lack of training in area of the recommended support strategies. It is my observation that the staff at SSS are motivated to carry out a recommended support plan.
RECOMMENDED SUPPORT PLAN
A. Long-Range Goal. The long-range goal for Mike is to establish enough self control over his behavior that he will be able to live and work in the least restrictive setting possible that is capable of meeting his developmental and behavioral needs. The goal of his educational plan is to provide him with the academic and other skills necessary to meet his needs, while eliminating those behaviors that tend to stigmatize and isolate him from full community and social presence and participation. Additionally, the goal is to transfer the control of Mike'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: Mike would like to move out of his parents and into his own apartment with people he is familiar with. Mike would also like to continue to maintain employment in the
field of his interest.
B. Operational Definition(s). Physical Aggression.
1. Topography. – The hitting or attempted hitting of others with an object ex. Broom, and the snapping of cloths at others bodies within a 3-foot radius.
2. Cycle. The cycle of the behavior starts with the swinging of the object and the snapping of a cloth at another person’s body with the intent to hit and the cycle stops when there has been a period of two minutes without an occurrence of the above behaviors.
C. Short Term Measurable Objectives. The following objectives and plans are suggested on the assumption that Mike has the opportunity to continue to attend the SSS behavioral day management program. It is unlikely that they would be realistic if he did not have these opportunities. These objectives were also selected as being most reflective of Mike's priority needs and as being the most realistic given his level of functioning at this time. Further objectives may be established as a function of the success or failure of the recommended strategies.
1. By November 1, Mike will reduce the incidents of Physical Aggression from baseline rate of 1 or less a month to 0 incidents a month.
2. By August 1 next year Mike will have maintained a rate for Physical Aggression at 0.
D. Observation and Data Collection Procedures.
Behavior – Physical Aggression the SSS job coach will observe Mike for each hour of the program day. Each incident of the target behavior as defined in topography shall be recorded on an A.B.C form (See A.B.C. Form) indicating the following:
1.) Date of incident
2.) Start and stop time of incident (Duration)
3.) Setting and activity at time of incident
4.) Immediately preceding antecedent events
5.) Description of actual behavioral topography
6.) Description of consequences or actions taken by staff
The following information should be summarized on an “Individual Data Summary “ form (See Individual Data Summary Form).
2. Observational Reliability.
Behavior – Physical Aggression
Once a week, at weekly contact meeting, the SSS manager will do a Records Check to make sure that all occurring incidents have been recorded on all required forms i.e.: A.B.C. form, Daily Progress Notes, and if applicable Incident Report. If Observational reliability is less than 100% then action should be taken to review the Plan and method of data collection.
E. Intervention Procedures. In the following paragraphs, a summary of possible strategies to support Mike 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.
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 Mike's behavior may change and his 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 Mike's needs and the environments in which he must behave:
To reduce the number of distractions at the work site by turning the televisions off in the work site so that Mike can focus on the task at hand. As Mike can become distracted by the TV’s being on, and was observed engaging in off task behavior to watch the TV, it would be a better fit between Mike and the work site if that distraction were eliminated.
Mike should also increase his level of exercise to aid him in relaxation. Exercising tends to result in greater reduction or displacement of anxiety. I feel that if Mike increased his exercise level it would assist him in increasing his feeling of well being and will, in hopes, decrease his feelings of anxiety and frustration.
Implementing a scheduled interaction time each morning with his peers will benefit Mike in that it will start the day of with positive interaction and promote a positive work environment. As Mike’s mood and behavior is directly affected by the moods and behaviors of others, establishing a positive interaction time to check in establish that no one is angry with each other would benefit Mike.
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 Mike 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 Mike'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 too effectively and directly address Mike's physical aggression. In the following paragraphs, several initial thrusts for positive programming are presented:
a. General Skills.
1) Rationale/Logic. – Making independent purchase of choice. I feel that Mike would enjoy going to the store and purchasing items that he enjoys ex. CD or movie with his money that he has earned. I feel that this would give Mike a feeling of independence, choice and control over his life.
Objective. – By Feb. 1 next year the objective is for Mike to independently, without staff assistance and upon being given a $20.00, go into a store, choose the item of his choice, take the item to the till, and complete purchasing transaction of paying for and waiting for change, and leaving store.
3) Method. – To teach Mike this skill, whole task presentation should be used.
a) Take Mike to the store of his choice
b) Assist Mike in picking out the item of his choice
c) Assist Mike in paying for the item
d) Leave the store
e) Praise Mike for a job well done
f) Fade staff out as Mike’s independence and confidence in the steps of the skill increase
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 Mike's behavior concluded, among other things, that Mike needs another way to express his feelings.
1) Rationale / Logic . – Derived from the Functional Analysis of the target behavior, it is felt that the function of Mike’s behavior is a means of communicating his feelings. I feel that a program to assist Mike in finding more appropriate ways of expressing his feelings will empower Mike in feeling more in control of his feelings and social environment.
2) Objective. By Nov. 1, , Mike will be able to, without staff prompting, initiate and express his feelings using the statement: “I am feeling (angry, happy etc.). I am (angry, happy etc.) because…..”
3) Method. – Implement a social story describing how to appropriately express our feelings.
a) Create social script detailing how to express our feelings.
b) Staff is to sit with Mike and role-play the social script, aiding him in understanding and using the social script.
c) To be done 2x a week for 10-15min a session. Staff should also take advantage of any incidental opportunity to engage in this script.
Carol Gray has written books on “Social Stories” that may be of some use. 1-800-489-0727
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 he 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, skills are identified which are thought to be related to Mike's aggression.
Identifying Feelings 1) Rationale / Logic. – In order for Mike to express his feelings, he needs to be able to identify them correctly. If Mike were able to correctly identify his feelings, it would make expressing his feelings easier thus reducing his level of anxiety and frustration around communicating his feelings.
2) Objective. By Nov. 1, , Mike will be able to, without staff assistance, identify the 3 feelings of anger, frustrated and sad, 3 out of 3 trials. After this objective has been met, the 3 additional feelings of happy, confused and embarrassed can be implemented to increase Mike’s repertoire of feelings.
Method – To use a card system, with 3x5 flash cards.
a) Have the word of each objective feeling on separate flash cards.
b) Have the definition and picture of each objective feeling on flash cards.
c) Have Mike pair the picture/definition cards with the word feeling cards.
d) Complete this trial at least 3x a week for 10-15 min a session.
d. Teaching Coping and Tolerance Skills. Many of Mike's seriously challenging behaviors are a reflection of his inability to cope with aversive events such as delay in gratification, denial, the need to perform a non preferred activity, etc. While some of these behaviors can be avoided by positive programming, aversive events are also naturally occurring. Especially if he is to lead a full life, from time to time, he will face the disappointments we all have to face, for example, not getting something that he wants, when he wants it and having to wait for it, i.e., delay; not getting something he 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, Mike's coping responses have not had the opportunity to develop much beyond the primitive responses of a young child; nor is he 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 him these very important coping and tolerance skills. The following is a recommendation for how to proceed in this important area of skill development, with the initial focus being on Mike's establish boundaries.
1) Rationale / Logic. – As Mike’s mood and behavior is directly affected by the behaviors and moods of those around him and by those events that are happening in the news that he perceives as distressing, helping him establish and understand boundaries between his feelings and others feelings would be beneficial. I feel that this would be beneficial in that it would assist Mike in decreasing his feelings of responsibility and anxiety.
2) Objective. – By Nov 1, , Mike will be able to, with confidence and independence identify the boundaries between his feelings and those of others.
3) Method – Use a comic strip conversation script to help Mike establish boundaries between his feelings and those of others.
a) Explain to Mike about the comic strip
b) Show him the feeling comic strip
c) Identify the people and the feeling circles
d) Visually show Mike how his feeling and those of others over lap but do not control or consume.
Praise Mike for a job well done
Carol Gray has written articles in the Morning News on Comic strip conversations that will be informative. 1-800-489-0727.
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 Mike, 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.
Implement an “interaction time” at the beginning of each day between Mike and his peers at the work site. This interaction time will allow Mike and his peers to exchange positive interaction and create a positive work environment in hopes of increasing Mike’s social skills and decreasing his feelings of anxiety and sense of responsibility of others moods.
The “interaction time” will be facilitated by the SSS job coach and will maintain a positive tone. All topics of conversation MUST be positive and interactive between all 3 peers. Some examples of positive conversation are:
- how nice the weather is
- pay a compliment on what the other is wearing
- pay a compliment on the great work the other did yesterday at the job site.
- Talk about a desired activity that all 3 individuals will be participating in
- Talk about that days activities
At present, Mike is on a daily DRO schedule for the target behavior, which is at this time, meeting the objective of the reinforcement schedule. I suggest that Mike continue on this schedule as long as it proves effective in maintaining the objective of 2 or less occurrences of the target behavior a day.
I would also suggest that a time based, non-contingent reinforcement schedule be implemented where once an hour, every hour Mike receives verbal praise for being at the work site. This may assist Mike with increasing his self-esteem and promotes a positive work environment.
4. Reactive Strategies. Efforts to manage the antecedents to Mike's physical aggression are likely to have a considerable impact on the rate of their occurrence, as will a daily DRO schedule. However, these behaviors are still likely to occur, at least to some degree, especially during the initial stages of the implementation of this 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 Mike and staff as free from risks to injury as possible and that keep Mike 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 Mike'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 SSS'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 Mike's behavior, including the need for physical restraint.
a.) At the first sign of the topography, staff should provide undivided attention to Mike and proceed to implement the current reactive management plan that is in place for the above target behavior which is as follows:
b.) If Mike becomes hurtful or engages in the topography of aggression toward another person, ask him to please stop and encourage the other person to move out of his way. Use active listening to reflect his feelings until he is somewhat calmer. Once he is calm, help him develop a solution to his problem. Remind him that you are there to help him be successful at his job.
c.) In addition to the above strategy, redirect Mike to his identifying and expressing feelings program. Encourage him to express his feelings and praise him for any attempts at the appropriate expression of such feelings.
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 Mike. The following is recommended:
a. Procedural Protocols. Each strategy and procedure described above should be broken down into teachable steps.
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 step in the specific procedure. Each staff would be scored using a "+/O" system for each step 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 step of a procedure to another member of Mike'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 Mike'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 infrequent behavior, role-play competence should be reconfirmed on a regular schedule.
c. Periodic Service Review. Mike'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. This 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. This 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
1. Revisions are certain to be necessary during the initial stages of implementation and as Mike's responsiveness to this 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 Mike remain in SSS program and continue to work at current job placement, The Steamer Bar and Grill in Ennytown with a 3:1 ratio. Mike appears to have to have adjusted well to this job placement and appears to enjoy being there.
3. It is recommended that Mike participate in an expressing feelings program to assist Mike in becoming more confident and fluent in expressing his feelings and emotions in a calm and appropriate manner.
4. It is recommended that Mike participate in an identifying feelings and emotions program to assist Mike in being able to identify his feelings and to feel more in control of his feelings
5. It is recommended that the positive programming strategies presented above be provided at least 1.0 hours a week at the SSS program. Given the nature of Mike’s behavior difficulties, it is felt that this level of service delivery will be needed to improve Mike’s social and self-control skills.
IDENTIFYING FEELINGS PROTOCOL MIKE JONES
Initial Implementation Date: August 3,
1. Step by Step Method:
Create three 3x5 flash cards with the words “angry, frustrated, sad”, with one of these feelings on each card.
Create three 3x5 flash cards with a face picture depicting the above 3 feelings and accompanying definitions on separate cards. That is, on a 3x5 card is a picture of what the feeling looks likes and the definition of that one feeling.
Choose a quiet area with little to no environmental distractions ex: no TV’s on or in view of open windows/blinds and obtain Mike’s attention.
Present the 3x5 flash cards that have the faces of and definitions of the feelings on them to Mike. Discuss with Mike the 3 pictures and definitions of each feeling.
Ask Mike to show you each feeling face. Use the verbatim “ Show me the angry face” “Show me the sad face” “Show me the frustrated face”.
Allow Mike the opportunity to chose on his own. Give him 10-15 seconds then move the right feeling card closer to him and ask him again to “ Show me the anger card”.
Praise Mike for a job well done.
Show Mike the 3 feeling cards with the word of each feeling on them.
Explain the definitions for each feeling. Use verbatim “ Anger is when you feel ….” Give examples that pertain to Mike.
Ask Mike to show you the different feeling word cards. Use verbatim “ Show me the angry card” “Show me the frustrated card” “Show me the sad card”.
Allow Mike the opportunity to chose on his own. Give him 10-15 seconds then move the right feeling word card closer to him and ask him again to “ Show me the sad card”.
Praise Mike for a job well done.
Place one face feeling cards in front of Mike and the 3 word feeling cards directly above the face card. Ask Mike to place the face feeling card on top of the matching word card.
Allow Mike the opportunity to match on his own. Give him 10-15 seconds the move the correct word card closer to the face card and ask him again to place the face card on the correct word card.
Praise Mike for a job well done. Keep the session positive, upbeat and fun!
Complete one full trial 3x a week for approximately 15 minutes each session.
2. Once a month, a management staff from SSS will go out and observe the Job Coach carrying out this trial and will document on a Procedural Reliability form whether or not it is being carried out according to the protocol.
3. If the Procedural Reliability is less than 85% then action should be taken to review the protocol and the method of deliver.
4. Bi – weekly observations by the management staff from SSS will occur until the Procedural Reliability of 85 % or greater has been reached.
5. Each trial will be recorded on an “Identifying Feeling Chart” and at the end of each week, all information from that week’s chart will be summarized on an Individual summary chart.
6. Once a week, during weekly contact meeting, the SSS manager will review the records of the “Identifying Feeling Chart” and the Individual summary chart
7. Once a month, a management staff from SSS will go out and observe the Job Coach carrying out this trial and will document on an “Identifying Feeling Chart” what is observed.
8. If the Observational Reliability is less that 85% then action should be taken to review the protocol and scoring criteria.
9. Bi weekly observations by the management staff at SSS will occur until the Observational Reliability of 85% or greater has been reached.
10. A Pass criteria is scored when Mike can identify and match 3 out of 3 feeling cards for 3 consecutive trials/sessions. Once the Pass criteria has been meet, the next step is to add more “feelings” one at a time.
11. A Fail criteria is when the Pass criteria has not been met within 3 months. If a Fail criteria has been met, then review method and decrease the number of feeling cards in the trial to two.
12. Variations to these protocol requirements should either be because of non- applicability or explained and documented on the appropriate PSR Variations Form.
Protocol prepared by: Approved by:
MIKE JONES IDENTIFYING FEELINGS CHART
SCORING CRITERIA –
Score a ‘+’ for independently, with no prompting or staff assistance