Positive Behavior Intervention

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Positive Behavior Intervention Common Sense
Supports for Individuals with Challenging Behavior
Tim Feeney, Ph.D. New York State Neurobehavioral
Resource Project Southern Tier Independence
Center Binghamton, NY School and Community
Support, Inc. 17 British American Blvd. Latham,
NY 12110 USA tfeeney_at_scssconsulting.com 518-782-71
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• Our Tasks
• Me
• Present a framework for supporting
• individuals with a variety of needs
• to regulate themselves to the greatest extent
• possible while recognizing and being respectful
• of your knowledge and expertise in this area.
• Leave everyone with a least 3 strategies
• to use upon return to their jobs.
• You
• Listen
• Ask questions
• Make plans

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www.scssconsulting.org
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In many ways good intervention really based on
the systematic application of common-sense. Unfo
rtunately. . . Common sense is terribly
uncommon!
-
Mark Twain
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Communication
Cognition
Behavior
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COGNITION Organizatio
n Memory Info Processing Planning Procedural
vs. Declarative Non-strategic Self
Monitoring Implicit vs. Explicit Reviewing Self-
evaluating
BEHAVIOR Excesses Impulsiveness Aggressiveness Su
bstance Abuse Deficits Initiation
Impairments Insight Impairments
COMMUNICATION Efficiency Fluency/Articulation Dis
course Effectiveness Functional Apparent
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Behavioral Control

Academic Vocational Growth
Social Competence
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Fluctuations in behavior are expected, the goal
of behavioral support is to make those
fluctuations manageable
High Risk/Unsafe/Unmanageable
Manageable Risk
Behavior
Low Risk
Manageable Risk
High Risk/Unsafe/Unmanageable
Time
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Fluctuations in behavior are expected, the goal
of behavioral support is to make those
fluctuations manageable
High Risk/Unsafe/Unmanageable
Manageable Risk
Behavior
Low Risk
Manageable Risk
High Risk/Unsafe/Unmanageable
Time
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Behavioral Control

Academic Vocational Growth
Social Competence
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• In many (most?) situations, it is the quality of
  the relationship that you have with the
  individual which will have the greatest effect on
  the success of the intervention.

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You can make people do things that they just
dont want to do but the price for doing so will
be high
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Three Beliefs That Will Affect the Likelihood
That Youll Be Successful

• Optimism Hope. Evident in the problems that are
  targeted and the language that is used when
  describing the individual and when interacting
  with the individual.
• Appreciating the Influences of Contextual Factors
  on Behavior. Requiring an understanding of the
  setting events (the distant events on an
  individuals behavior).
• Applied Pragmatism. Recognizing that there is no
  single right solution moving away from the
  notion of consistent use of a prescribed
  intervention strategy to concordance on the
  part of all involved.

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Success via Learning from Consequences Presuppose
s
Reasonable intactness of the neural networks
responsible for connecting Memory for the
factual aspects of past behavior and/or Memory
for the Somatic Markers, or the feeling states
associated with the consequences of those
behaviors
Without these connections in memory, past
rewards and punishments lack the power to drive
future behavior
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Problem Behavior
Primary Symptomatic - Organic Neurophysiological
Limbic Kindling Perceptual Disturbances Electrop
hysiological Seizure Disorders Psychiatric Mood
Disturbances PTSD and/or Postconcussive
Syndrome Perseveration and Obsessive-Complusive
Disorder Anxiety Disorders Physiological Metaboli
c Tolerance Pain
Secondary Functional - Learned Escape/Avoid Att
ention Qualitative Aspects Acquisition Sensation
Automatic SR Control
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RECIPROCAL INFLUENCES OF BEHAVIOR
Interventionist Behavior
Individual Behavior
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Potential Influences on Behavior
Environmental Vulnerability Behavior
Problems Communication Problems
Life Events
Neurological/ Psychiatric Impairments Cognitive/A
cademic/Vocational Failure Physical/Health
Problems
Setting Events
Environmental Rigidity Decontextualized
Intervention Focus on External Control
Us
WE MAKE PEOPLE CRAZY!
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• Introduction to
• Intervention Ideas
• Conceptually Simple,
• Procedurally Difficult

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Alternative Behavioral Paradigms
A B C
Tradition Behavior is a function of its
consequences
A B C
Positive Behavior Support Alternative Satisfying
behavior chains are created with everyday
antecedent supports
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GOAL OF INTERVENTION

• The individual not only behaves in ways that are
  acceptable, but CHOOSES to behave in ways that
  are acceptable
• Thus cognitive and executive self-regulatory
  functions are inevitably part of behavioral
  interventions
• The intervention is accomplished with as little
  failure as possible

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Context Relevancy How does this stuff apply
to the bigger world? adapted from Sailor, 1999
Useful Do the outcomes that were targeting
produce something useful to the individual in
long run? Desirable Does the individual
choose the outcomes for him/herself when given
the choice? Is the individual given the choice
of outcome? Social Do the outcomes result
in behaviors that will increase interactions
with persons other than paid staff? Practical
Will the behavior be used in real contexts
without staff support? Adaptable Is there
a focus on developing skills that can/will be
used in a number of situations and without staff?
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Meaningful Engagement

• In the absence of meaningful engagement in
  CHOSEN (not impulsed) life activities, all
  interventions will ultimately fail
• Meaningful Engagement
• Job
• Volunteer activity
• Personal betterment
• Recovery
• Personal relationships
• Avocational pursuits
• Contributory projects
• Group affiliation (eg, church)

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Narrative Therapy

• In striving to make sense of life, persons face
  the task of arranging their experiences across
  time in such a way as to arrive at a coherent
  account of themselves and the world around them
  .. The account can be referred to as a story or
  self-narrative.
• White, M., Epstein, D. (1990). Narrative means
  to therapeutic ends. New York W.W. Norton and
  Company.

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An impulse is not a choice
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• When choice is offered, of course, it is
  essential that the person being offered the
  choice have the information necessary for making
  a meaningful decision . . . without such
  information, being given a choice will feel more
  like a burden than a support for autonomy.
• Edward Deci, 1995
• Why We Do What We Do

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Choice

• (Noun)
• 1 The act of choosing selection 2 the right,
  power, or chance to choose option 3 a person or
  thing chosen 4 the best or most preferable part 5
  a variety from which to choose 6 a supply that is
  well chosen 7 an alternative 8 purposive
  discernment.

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Impulse

• (Noun)
• 1 a) an impelling or driving forward with sudden
  force b) an impelling force sudden, driving
  force push thrust impetus 2 a) incitement to
  action arising from a state of mind or external
  stimulus b) a sudden inclination to act, usually
  without premeditation 3 sudden involuntary
  inclination prompting action.

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Functional Conceptions of Choice Free
choice Fixed choice Forced
choice Feeling the natural and logical
results of actions in the environment
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• So, we can and should honor
• choices (even some of those
• choices that we consider not-so-
• hot) but, we should not (cannot?)
• accept impulsive behaviors as
• choices.

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• For behavior-outcome linkages to serve as
  motivators, people must understand them, see them
  as relevant to their lives, and have the
  capabilities for utilizing them.
• Edward Deci, 1995
• Why We Do What We Do
• In other words People need to have the
  strategies, the tactics, and the capacities for
  attaining desired outcomes!

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The Three Big Things
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When we think of your future the next 10 years
we need to think about the 3 most
important things to work on the things that, if
you achieve, youll have a meaningful life.
The 3 Things tend to cluster around these
areas Behavioral regulation/self-regulation
Friendships/social-interaction Vocational
skills/meaningful engagement Self-help skills
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• Being intrinsically motivated has to do with
  being wholly involved in the activity itself and
  not with reaching a goal.
• -Edward Deci, 1995
• Why We Do What We Do

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Making the Big Things Real

• Creating personal maps or steps to attaining the
  personally meaningful goals.
• Articulated by the individual (with some help
  from staff, friends, family)
• Organized in a visual manner to assure clarity

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Step 55. Me the _______
Im good at I need to
Step 3.
Step 2.
Step 1. Me Now
Im good at I need to
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KEEPING A HOTTIE BOYFRIEND
EULAS STEPS TO SUCCESS
BEING A GOOD PERSON WITHOUT THINKING ABOUT IT
HANDLING MYSELF OUT OF CLASSES
DEALING WITH PROBLEMS /BEING IN CONTROL
HANDLING MYSELF IN CLASSES
LISTENING TO GOOD ADVICE/IGNORING BAD
IN THE RESOURCE ROOM
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HAVING A JOB, LIVING IN MY APARTMENT
PETERS STEPS TO SUCCESS
DONT FORCE IT
GET OUT OF IT BEFORE I GET INTO IT
FOLLOW MY PLAN WHEN IM OUT IN THEWORLD People,
Places, Things
MAKING PLANS BEFORE GOING OUT IN THE WORLD
DEALING WITH ASSHOLES POSITIVELY
MAKING MEETINGS PARTICIPATING IN THEM
MAKING MY PLAN TO STAY CLEAN EVERYDAY LETTING
PEOPLE KNOW
IN A TREATMENT PROGRAM
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A doctor
Toms Plan Toms Reality
An EMT
Be a helping person
In rehab
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The Importance of Community in Establishing an
Identity

• Communities help us to accomplish things.
• Communities are change agents.
• Communities are sources of meaning and belonging.
• Need to Belong (Baumeister Leary, 1995)
• The need to belong is a powerful, fundamental,
  and extremely pervasive motivation.
• A lack of belongingness constitutes severe
  deprivation and causes a variety of ill effects.
• The Belongingness Hypothesis A drive to form and
  maintain at least a minimum number of lasting,
  positive, and significant interpersonal
  relationships.

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• Alone.... Uh, Im alone! I'm a lonely,
  insignificant speck on a has-been planet orbited
  by a cold, indifferent sun.
• -Homer Simpson

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Social Identity Theory

• People have an innate and strong tendency to
  mentally organize things and people into
  categories
• To the extent that we associate ourselves with
  communities (i.e. categorize ourselves), we have
  social identities
• Social identities (via our community memberships)
  are important aspects of how we define ourselves
• To the extent that we identify with communities
  that are valued (e.g., powerful, prestigious,
  high status, popular), well feel good about
  ourselves.

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A Community
Shared purpose
Recognition of individual needs
Ongoing articulation of purpose Identity(ies)/Role
s/ Places/Jobs
Procedures for managing situations when
participants are out of roles
Procedures for feedback from community members
Shared Projects
Community Meetings Staff Roles Leader,
supporter Participant Roles Leader, supporter,
facilitator
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• Some Thoughts About Assessment

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The Danger of Traditional Diagnostic Assessments

• Used predominantly for the purpose of meeting
  eligibility criteria often the result of a need
  for a primary diagnosis.
• Standardized assessment of needs is often
  invalid.
• Many issues resemble psychiatric disorders, so
  there is an increased risk of incorrect diagnosis
  and treatment decisions that often result in a
  lack of collaboration on the part of the
  individual.

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A FRAMEWORK FOR ASSESSMENT
ONGOING CONTEXT-SENSITIVE COLLABORATIVE HYPOTHESIS
-TESTING
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A Non-Functional Assessment Question

• How much of this is brain injury anyway?
• A euphemism for
• Whos problem is it?

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A Functional Assessment Question

• What is the problem that the person wants us to
  help with?
• assumes that
• THE PERSON WANTS HELP!

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Contextualized Collaborative Hypothesis-Testing
Whats the problem? (Using the two strangers in
the doorway rule)
Hypothesis Formulation (Why is s/he doing this?)
Hypothesis Selection (Begin with easiest to test
or most obvious)
Hypothesis Testing (Protocol for
experimentation Plan A - Plan B - Plan C Testing
time line)
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WHY TEST HYPOTHESES?

• Failure on any complex task is multiply
  interpretable
• Complex students can be supported in a variety of
  ways
• Test results do not necessarily indicate how best
  to achieve success on specific tasks

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WHY COLLABORATE?

• Increase observations and experiments
• Increase compliance
• Educate family, staff, others
• EF training for student
• Show respect

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WHY IN REAL CONTEXTS?

• Inconsistency
• Validity problems of standardized testing
• Impact of setting, person, activity
• Impact of stress
• Observe real-world initiation, inhibition,
  self-monitoring, problem solving
• Observe effects of real-world supports and
  routines
• Observe support behaviors of others

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• Intervention Ideas
• Conceptually Simple,
• Procedurally Difficult

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PERSON
Language
Emotion
Volition
Behavior
MentalHealth
Cognition
Human beings are a collection of relatively
independent structures, processes, and systems
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Johns Cognition
Attention
Perception
Memory
Organization
Reasoning
EF
Sequence Categorize Associate Analyze Synthesize
Arousal Select Direct/ Filter Maintain Divide
Shift
Encode/Store/Retrieve Episodic/Semantic Explicit/I
mplicit Declarative/Procedural Involuntary/Strateg
ic Working Memory/ Knowledge
Base Remote/Recent Pro/retrospective Iconic
Inductive Deductive Analogical Divergent Convergen
t

• Goals for John - John will
• Increase duration of maintained attention
• Increase prospective memory from 3 to 5 minutes
• Increase category naming from 3 to 5 members per
  category

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Johns Mental Health
Axis I
Axis III
Axis II
Axis IV
Axis V
Personality Disorders Mental Retardation
General Medical Conditions
Global Assessment of Functioning
Clinical Disorders Other Conditions
Psychosocial And Environmental Problems

• Goals for John John will
• Participate in psychotherapy sessions without
  falling asleep
• Comply with his medication regimen as directed
• Follow the recommendations of the clinical staff
  to assure his safety
• Seek community services for his disorder and for
  his living
• arrangements

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Johns Behavior
John is the totality of his behaviors and the
systematic relationships among them
John
b1 b3 b12 b4 b1 b7 b62 b17 b17 b17 b4 b6 b9 b17
b12 b3 b8 b8 b5 b6 b17

• Goals for John John will
• Increase frequency of b3 and b12
• Decrease frequency of b17

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Alternative Understanding of Human Beings
Sarah
Pursuing personally meaningful goals
While participating in culturally valued
activities
In social, cultural, and historical contexts
Mediated as necessary by individuals with
greater expertise in that domain
Using cultural tools, such as language, category
schemes, mathematics, organizational supports,
domain-specific strategies
In the presence of varied context facilitators
and barriers
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Intervention Goals

• Sarah will successfully complete ___ meaningful
  task, with ___ supports, possibly using ___
  tools/strategies, in ___ context (setting,
  people, activities), in order to achieve ___
  goal.
• Possibly focusing intervention attention on some
  specific aspects of cognition, communication,
  social skills, behavioral self-regulation, or
  educational/vocational skills aspects that are
  either particularly weak or particularly
  important for Sarah.

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• The way cognition is distributed throughout the
  cortex is graduated and continuous, not modular
  and encapsulated.
• Elkhonon Goldberg
• The Executive Brain

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• Steps to Organize Routines of Everyday Life
• 1. Identify successful and unsuccessful routines
• of everyday life. Whats working, whats not
• working?
• 2. Identify changes that have the potential to
• transform unsuccessful routines into
• successful routines (including changes in the
• environment and the behaviors of others.)
• 3. Identify how changes in routines include
• activities that are motivating to the individual
  
• and everyday people.

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Steps to Organize Routines of Everyday Life

• 4. Implement needed supports to organize
• routines so that the individual experiences
• success and receives intensive practice in
• context.
• 5. Systematically withdraw supports and
• expand contexts as much as possible.

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Goal
Plan
Predict/Obstacle
Do
Review
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ROUTINES Repetition
creating temporal structure to improve memory
about relevant past events Cognitive
predictions about what happens next Natural
occasions for promoting cognitive growth An
impetus for improvisation when trying to avoid
a negative outcome
are a necessary prerequisite for Planning
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• Routine is despairs sly assassin.

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• Much of our cognitive life may be the product of
  highly automated routines.
• - Gerald Edelman

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Concrete Routines Picture Routines Written
Routines
Interaction Routines Language Routines
Activity Sequencing
Routines to Deal with Changes in Routines
What I do when what I expected to happen
doesnt happen
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Key Executive System Concepts That Help
Individuals Learn Self-Regulation
Hard - Easy Big Deal - Little Deal Ready -
Not Ready Scary - Not Scary Like - Dont
Like Choice - No Choice
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Interaction Scripts for Routines
Making Decisions About the
Goal Whatre you going to do? What are
we here for? How will we know were
done? Well know were done when it looks
like this . . .
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Making Plans OK, so whats the
plan? Whatll you need to get this
done? How will you and I know youll need
help? What will help look like? Dont
tell me what you dont want, tell me what you do
want. OK, so what do you want me to do?
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Making Decisions About Ease or Difficulty
Before Beginning Do you think this will be
hard or easy? If its hard, then whatll you
need? Have you ever done this before? What
happened? I dont think I could do this! How
do you know that you can? Whaddaya think?
Big deal or little deal?
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Coaching Through Problems You look upset, is
there anything I can do? OK, youre not
ready. No problem just let me know when youre
ready. Ill know youre ready when you look
like this . . . Ill wait. You know
weve gotta figure this out, lets try . . .
I know its hard, but weve got to do
this.
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Coaching in Context So, hows it
going? Is that helping you? Not
helping? Is there anything else you can
do? Is there anything I can do to help
you? So when are you going to start?
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Review What Occurred So howd it
go? Howd you do? Tell me exactly what
happened . . . and then what? What do you
think other people thought? What were you
thinking when you . . . Next time you do
this, whatll you do differently? The
same? What helped? What didnt help?
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An Important Goal of Intervention Learning to
Recognize Internal States

• Using some commonly understood method of
  communicating my mood/
• feelings/health, etc.
• - Red Yellow Green
• - A thermometer
• - Rating Scales

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Recognizing and Communicating My Internal State
Im feeling great
Im feeling really lousy
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AARONS RATING SCALE
Prior to, and following, each activity Aaron and
his staff will evaluate his general mood using
this scale. In addition, the scale can and
should be used during activities as a way of
helping Aaron recognize his mood changes, and the
causes for those changes.
Aarons Indicators
Red in the face Staring Lips clenched
Following directions Making eye contact
Quiet
Swearing
PERSEVERATION
Destructive Past the Red Line
Peaceful
Cool Zone Blue Zone
Yellow Zone
Red Zone
Use your strategies - take a break and move
away - talk about what your feeling - listen to
music
Stop and breathe

• Clear the deck
• Get somewhere else quiet

Staff Scripts

• Use the Hard Easy Script
• Aaron is this hard or easy?
• OK, if its hard, no problem
• Ill give you some help.

• Use the Ready Not Ready Script
• Aaron youre not ready to do this.
• Ill know youre ready when you look
• like ________.

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• Each waking day is a stage dominated for the good
  or ill, in comedy, farce, or tragedy, by a
  dramatis persona, the self. And so it will be
  until the curtain drops . . . Although multiple
  aspects characterize the conscious self, this
  self is a unity.
• - Charles Sherrington, 1946
• The Integrative Action of the Nervous System

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THATS WHAT I AM! THATS WHO I AM! RIGHT OR
WRONG, I CANT CHANGE THAT CARLITO (AL PACINO),
CARLITOS WAY
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The self is not something ready made but
something in continuous formation through choice
of action. - John Dewey
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New Person, New Story Reality combined with
hope, resolve, plans, strategies Meaningful Enga
gement!
Construction Of Meaning
Synthesis Integration
Angry Opposer Reactive Out of control
Sick/ victim Changed forever Helpless Hopeless
Thesis Force 1
Anti-thesis Force 2
Apparently irresolvable conflict
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New Person, New Story Reality combined with
hope, resolve, plans Meaningful Engagement!
Synthesis Integration
Construction Of Meaning
I am a victim Helpless Self-pitying
I am my old self Talented Successful Popular
Thesis Force 1
Anti-thesis Force 2
Apparently irresolvable conflict
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Ive lived a very dysfunctional life, and I know
that that life has shaped and molded me into
the person I am today. I want to reshape
myself.
-
Lloyd K.
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Self-Awareness Intervention

• Range of options highly confrontational to non-
  confrontational. The degree of confrontation that
  is appropriate depends on
• length of time post injury
• seriousness of the consequences of unawareness
• severity of anosagnosia/potential for change
• emotional fragility
• age/maturity
• available resources and support
• environment

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• Constructing an identity that is meaningful and
  sustainable is a primary goal of intervention

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Identity (construed broadly)

• Sense/definition of self
• I am a
• Occupation eg, teacher, business man
• Social relationships eg, husband/wife, friend
• Biological relationships eg, brother/sister
  son/daughter
• Quasi-occupation eg, helper/volunteer
• Avocation eg, athlete, musician, artist,
  collector, etc
• Affiliation eg, Shriner, Yankee fan
• Ability/disability eg, smart person, person with
  a disability, patient
• Salient attribute eg, reliable, dishonest
• Spirituality eg, child of God, Catholic

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Identity

• We all have multiple identities senses of self
• Most identities are dynamic/ in flux
• Identities are often imposed by environmental or
  cultural forces
• Construction of identity is rarely a
  deliberate, self-conscious process
• Identities are generally housed as metaphoric,
  gut-level meanings
• Identities are generally judged as
  comfortable/uncomfortable not true/false

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Identity and Occupation

• It is a commonly used cultural standard in
  Western society that we tend to frame opinions
  about people add including ourselves based
  largely on what they do for a living. When ones
  living has been removed or changed by external
  forces, facing that reality is hard and often
  avoided. p. 202
• Baptiste, S. (2003). Spirituality at work. In
  M.A. McColl (ed.), Spirituality and occupational
  therapy (pp. 193-206). Ottowa, ON CAOT
  Publications ACE

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Identity and Culture

• Identities that are culturally valued
  associated with competence, status, success,
  talent, interest, etc. are more likely to be
  sustained as self-defining identities.
• Identities can be associated with
• Freedom/constraint
• Conformity/nonconformity

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Identity and Disability

• Disability can easily become an identity
• Every interaction with a person with a disability
  contributes in one way or another to that
  persons identity construction
• sick role
• Learned helplessness
• Defiant oppositional role
• One cannot NOT contribute to identity
  construction in people with disability with whom
  one interacts

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Somatic Effects
Negative Feedback in the Environment
Somatic Markers
Negative Schematic Models (Implicational)
Problem Behaviors
(Potentially perseveratively recycled)
Negative Feedback in the Environment
Negative Specific Meanings (Propositional)
Learned Effects
(Adapted from Teasdale Barnard, 1997)
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Interacting Cognitive Subsystems

• Propositional Code Semantic meanings knowing
  that
• Implicational Code Generic, holistic, emotional
  meaning
• Not true/false, but rather motivating vs
  disheartening inspiring vs. boring etc
• Communicated by narrative, symbol, metaphor,
  image, etc
• Includes sense of self
• Connected to ones gut

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IDENTITY MAPPING

• Identification of goals
• Identification of image, hero, metaphor
• Organization of identity description
• Creation of identity map
• Supported practice
• Modification of others support behavior
• Possibly meaningful project

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Reconstructing/Constructing Identity
An Identity Map
FEELINGS
How does this person feel?
FACTS
APPEARANCE
What has this person done?
What does this person look like?
POSITIVE IDENTITY METAPHOR
GOALS
PROCEDURES
What am I trying to accomplish?
What will I need to do?
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IDENTITY CONSTRUCTION

• Helping individuals with disability construct a
  sense of personal identity that is
• Satisfying/compelling
• Organized
• Adequately realistic
• AND that includes the hard strategic effort
  needed to be successful with a disability

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IDENTITY MAPPING

• Identification of goals
• Identification of image, hero, metaphor
• Organization of identity description
• Creation of identity map
• Supported practice
• Modification of others support behavior
• Possibly meaningful project

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Identity Mapping Cautions

• Professional competence
• Emotional fragility
• Professional imposition
• Cognitive prerequisites
• Meaningful language

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Identity Mapping Cautions

• Dangerous metaphors
• Negative use (e.g., nagging)
• Getting stuck flexibility
• Heroes and victims
• Time post injury