Best Practices Dealing With Problem Behaviour of Children and Adolescents with ASD

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Best Practices Dealing With Problem Behaviour of
Children and Adolescents with ASDs

• Sponsored by
• Childrens Mental Health Ontario
• Dr. Joel Hundert Dr. Nicole Walton-Allen
• Behaviour Institute

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Welcome Sites
Burlington London Sault Ste. Marie
Chatham Markham Sudbury
Dryden Mississauga Thunder Bay
Kapuskasing Ottawa Timmins
Kingston Parry Sound Windsor
Kitchener Peterborough
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Schedule For the Workshop

• 130 - 230 Joel Hundert Understanding and
  assessing problem behaviours
• 230 - 245 Questions
• 245 - 355 Break
• 255 - 355 Nicole Walton-Allen Interventions
• 355 - 410 Questions
• 410 - 430 Application to school families

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What is the Behaviour Institute?

• The Behaviour Institute is a private agency
  providing intensive behavioural intervention for
  young children with autism. Home-based services
  are provided out of Hamilton and Toronto offices
  centre-based IBI services out of Toronto office
• Training organization for the Ontario Autism
  Initiative

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• Sponsor of part-time Masters degree program in
  Behaviour Analysis offered in Toronto by the
  University of Nevada, Reno (42 students)
• Directors are Dr. Joel Hundert Dr. Nicole
  Walton-Allen, psychologists and Board Certified
  Behaviour Analysts

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Goals of the Workshop

• Understanding of the unique behaviour / emotional
  needs of children with ASDs
• Knowledge of the conceptual and research
  foundations of PBS
• Knowledge and skills in conducting a functional
  behavioural assessment
• Knowledge and skills of PBS strategies to
  anticipate and prevent problem behaviours

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Goalscontd

• Knowledge and skills of PBS strategies to teach
  functional skill alternatives
• Knowledge and skills of how to use PBS with
  families
• Knowledge and skills of how to use PBS with
  schools

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How to Get Materials

• http//www.behaviourinstitute.com

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AGENDA

• Autism
• Positive Behaviour Support
• How to Implement PBS
• Forming a team
• Functional assessment
• Develop a hypothesis

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AgendaContd

• Behaviour support plan
• Anticipate and prevent
• Teach positive alternatives
• No longer let the problem behaviour be effective
• Implement evaluate
• Promote generalization of positive behaviours
• Application to schools
• Application to families

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Assumptions

• You are experienced childrens mental health
  clinicians
• Less experienced in working with children and
  youth with ASDs and their families
• Have read Best Practices document
• Have attended or have knowledge of introductory
  and advanced training provided by Geneva Centre

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CMHO Training Plan

• Introductory training (1-day)
• Advanced training (2-days)
• Specialized training
• Best Practices for Dealing with Problem
  Behaviours of Children and Youth with Autism
  Spectrum Disorders
• Best Practices for Children and Youth with
  Aspergers Disorder

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AUTISM SPECTRUM DISORDERS
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What We Know About Autism Spectrum Disorders

• Is a neurodevelopmental disorder with no clearly
  understood cause, although there evidence that it
  runs in families and has a genetic component
• Is not caused by poor parenting
• Prevalence is about 1/300 (Yeargin-Allsopp et
  al., 2003) and increasing

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What We Knowcontd

• Can identify by 24 months (Stone et al., 1999)
• More common in boys (41)
• No prevention or cure
• There is a treatment that works (Early Intensive
  Behavioural Intervention)

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Growth Trajectory
Typically-developing children
Developmental Age
Chronological Age
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Growth Trajectory
Typically-developing children
Children with autism
Developmental Age
Chronological Age
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Growth Trajectory
Typically-developing children
Goal of IBI
Children with autism
Developmental Age
Chronological Age
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Summary of Research on IBI

• 20 - 40 hours/week of IBI can produce significant
  and long-lasting gains in young children with
  autism to a point where about half achieve
  average IQ and do not need special help in school
• The success of IBI depends on staff being trained
  and supervised by competent behavioural
  consultants

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Critical Componentscontd

• A large proportion of the childs waking hours
  should involve active engagement in learning

20 hours
100 waking hours
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Challenges Of CMH Agencies Serving This Population

• Problems are chronic and episodic
• Motivational and skill deficits

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Challengescontd

• Compared to families of typically-developing
  children and children with other forms of
  developmental disabilities, levels of stress and
  depression is the highest in families of children
  with ASDs
• Lack of cross-sectorial service coordination
  (e.g., medical, educational, developmental
  services, etc.) is common

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Problem Behaviours and Children / Adolescents
with ASDs

• About 50 have significant problem behaviours
  including aggression, tantrums, stereotypic
  behaviours, and self-injurious behaviours
• No evidence of spontaneous improvement
• More frequent and severe problem behaviours are
  associated with children / adolescents who have
  more severe symptoms of autism
• Problem-behaviours crytallize and become more
  entrenched as children get older

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POSITIVE BEHAVIOUR SUPPORT

• Origins were to provide an alternative to the use
  of aversives
• Early researchers Glen Dunlap, Ted Carr, Mark
  Durand, Rob Horner, Robert Koegel
• Journal of Positive Behavior Interventions
• Association and annual meeting

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POSITIVE BEHAVIOUR SUPPORT

• Origins were to provide an alternative to the use
  of aversives
• Early researchers Glen Dunlap, Ted Carr, Mark
  Durand, Rob Horner, Robert Koegel
• Journal of Positive Behavior Support
  Interventions
• Association and annual meeting

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PBScontd

• Since 1997, amendment to Individuals with
  Disabilities Act (IDEA) requires
• a) PBS and,
• b) functional behavioural assessment

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Carr Durand (1985)

• Problem behaviours have a function
• Understanding the function of behaviours lead to
  more effective treatment

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ABA, IBI, and Autism
Psychology
ABA
Autism
IBI
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ABA, IBI, PBS and Autism
PBS is ABA
PBS
Psychology
ABA
Autism
IBI
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Core Features of PBS Interventions

• Driven by functional assessment
• Result in outcomes that are acceptable to the
  individual, family and the supportive community
• Fit the contexts within which the behaviour
  occurs

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Core Features of PBS

• Consistent with values of those who will
  implement the procedures
• Consistent with the skills of the people who will
  implement the procedures
• Consistent with the resources available to the
  people who will implement the procedures and
  matched by administrative support (Horner, 2000)

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Core Features of PBS InterventionsContd

• Operate from a person-centred values base
  (Anderson Freeman, 2000)
• Blend multiple, empirically-based procedures
  (Horner, 2000),
• Focus on large unit of analysis and intervention

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PBS is ABA Dressed-Up and Ready to Go Out
ABA
PBS
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HOW TO DELIVER PBS
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Case Example

• Cameron is a six year old boy who has been
  receiving IBI for the past 1.5 years. He attends
  a community school with support from a PDD class
  in the school. Major areas of need
• Social pragmatics (e.g., conversation)
• Peer interaction
• Compliance

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CAMERON IN IBI
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CAMERON IN PLAY
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STEPS

• Form a team around the child or youth
• Complete a functional assessment
• Develop a hypothesis of the triggers and
  maintaining factors
• Develop a Behaviour Support Plan
• Implement and evaluate
• Generalize

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STEP 1

• Form a team around the child of individuals who
  can help or hinder the childs adjustment
• Like Wrap-Around, Person-Centred Planning

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• Identify strengths and needs

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STEP 2

• Complete a functional assessment

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• Problem behaviours do not occur at random. They
  occur to meet a need of the child

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Functions of Behaviour

• Obtain Objects
•  Activities
•  Attention
•  Sensory
• Escape

If positive
If negative
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Form Function

• Different forms of problem behaviours may serve
  the same function (e.g., kicking, crying to get a
  desired object)
• Same form problem behaviours may serve different
  functions (e.g., crying at home to escape, crying
  at school for attention)

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Identify the Problem Behaviour, Its Form and
Possible Functions

• David is a 14 year old boy with autism who is
  fascinated by brightly coloured string, shoe
  laces, and other long fabric. He takes the
  string between two cupped hands, rocks while
  making humming noises.

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Identify the Problem Behaviour, Its Form and
Possible Function(s)

• Jane is late from work and rushing at the grocery
  store with her son, Andy. At the check out, Andy
  spots the chocolate bars. Andy asked for a candy
  bar. His mother, Jane, said, You cant have
  candy now, its almost dinner time. Andy asked
  for it again and again, began to whine and cry.
  Jane was embarrassed and said, OK, but you
  better eat your dinner tonight.

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Identify the Problem Behaviour, Its Form and
Possible Function(s)

• Emily is a four-year with autism and hates to
  have her hair washed. Sometimes when her dad,
  Ron, bathes her, she kicks and screams. When
  this happens, Ron decides to wait for his wife to
  come home to wash Emilys hair that day.

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Identify The Possible Functions

• 1. David, a 13-year old is given seat work to do
  at the back of the room which he does not like.
  Periodically, David will run out of the room.
• a escape situation b obtain attention
• c escape attention d obtain internal
  stimulation e obtain object or activity

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Identify The Possible Functions

• 2. Tommy is a 5 year old who hovers nears other
  children at outdoor play but does not play with
  them. Periodically, he will run by and hit a
  child who is playing in a group.
• a escape situation b obtain attention
• c escape attention d obtain internal
  stimulation e obtain object or activity

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The Importance of Functions

• Before you develop an intervention for behaviour
  problems, you must understand the function(s) of
  the behaviour and develop an intervention based
  on that understanding. Interventions built on an
  understanding of functions are more effective
  (Carr et al., 1999)

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Functional Assessment

• Indirect method
• interview
• Direct method
• Functional Assessment Checklist
• Functional Assessment Cards (Carr and Durand,
  1985)
• Scatter Plot
• Functional Assessment Observation Form

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Functional Assessment Checklist
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ABC Record

• Is not enough

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Functional Assessment Cards(takes about 5 min to
complete)

• Identifies factors that trigger the behaviour
• Identifies the form(s) of the problem
  behaviour(s)
• Identify factors that may maintain the behaviour
• Identifies possible function(s) of the problem
  behaviours

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Functional Assessment Cardscontd
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Functional Assessment Cardscontd
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Functional Assessment Cardscontd

• Hand out 5 - 10 Functional Assessment Cards,
  preferably to different staff
• Staff complete a card after each incident
• Once all cards are completed, cards are sorted
  into piles by function (preferably as a group)

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ExerciseComplete a FAC for Throwing Stones
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(No Transcript)
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SCATTER PLOT

• Paul Touchette

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Scatter Plot(takes about 7 min to complete a day)

• Method of recording occurrence and non-occurrence
  of behaviours across activities and time periods
• Suggests patterns that may help to identify
  triggers and functions of problem behaviour

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Example
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Away
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How To Do Scatter Plots

• Pick the target behaviour
• Operationally define the target behaviour
• Record when the behaviour occurs by time
  intervals or by activity

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Functional Assessment Observation Form (ONeill
et al., 1997)
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FAO How to Complete
Fill in behaviours

• Fill in time and activities

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FAO How To Complete

• Enter for each episode

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Interpret
Problem seems to be escape-motivated
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STEP 3

• Hypothesize what factors trigger and maintain the
  problem behaviour

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The Competing Behaviour Model(ONeil, et al.,
1990)
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Setting Events
Setting events are events that have occurred
earlier that alters the effectiveness of the
consequence e.g. sleep loss, long car ride
A B C
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Learning Behaviour

• Setting Event

Triggering Antecedent
Problem Behaviour
Maintaining Consequence
Hitting
Avoid task
Ear infection
Asked to clean up
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Example

• Jane is late from work and rushing at the grocery
  store with her son, Andy. At the check out, Andy
  spots the chocolate bars. Andy asked for a candy
  bar. His mother, Jane, said, You cant have
  candy now, its almost dinner time. Andy asked
  for it again and again, began to whine and cry.
  Jane was embarrassed and said, OK, but you
  better eat your dinner tonight.

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Learning Behaviour

• Setting Event

Triggering Antecedent
Problem Behaviour
Maintaining Consequence
Crying
Gets candy
Many hours since last eaten
Sees chocolate bar
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Exercise

• It is late in the day. Ron, is rushing to get
  his seven year old daughters, (Emily) ready for
  bed. Emily hates to have her hair washed. When
  her dad, Ron, was bathing her, she kicks and
  screams. When this happens, Ron decides not to
  wash her hair that day.

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Learning Behaviour

• Setting Event

Triggering Antecedent
Problem Behaviour
Maintaining Consequence
Kicks and screams
Avoid task
Tired, rushed
Wash hair
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STEP 4

• Formulate a Behaviour Support Plan

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Rob Horner

• Make the problem behaviour irrelevant
• Make the problem behaviour inefficient
• Make the problem behaviour ineffective

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Making the Problem Behaviour IrrelevantANTICIPAT
E AND PREVENT
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Neutralizing Routines for Setting Events(Horner,
1997)
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Horner, Day Day (1997)

• 3 adolescents with autism and developmental
  disabilities who were self-injurious or
  aggressive
• Setting events delay in favourite event, lack
  of sleep
• Neutralizing routines drawing pictures, looking
  through photos, nap

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SETTING EVENT
IMMEDIATE TRIGGER
AGGRESSION SIB
ESCAPE
NEUTRALIZING ROUTINE

• Showed that aggression / SIB occurred only when
  setting event occurred before the immediate
  trigger
• Then showed that the addition of a neutralizing
  routine reduced the problem behaviour to near zero

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Other Examples of Neutralizing Routines

• Looking through a favourite book
• Looking through a picture album
• Watching a video
• Eating a favourite snack

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Delay, Reduce, or Remove Triggers

• Make activities and materials easier,
• Add aids to learning
• Make activities more fun, build in reinforcement
  (e.g., computer-assisted learning)
• Break activities into small steps

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Add Visual Information

• Used to show the sequence of pending activities.
  Typically, child turns over picture at the end of
  one activity and looks at the next activity
  coming.

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Visual Schedule
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Play Picture Activity ScheduleMcClannahan
Krantz (1993)
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How PAS Differs From Picture Schedules

• Focuses on the steps of performing an activity
• Goal is for the child to perform an activity
  without adult prompts
• Picture schedules have had very little research,
  PAS have had extensive research

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High-P Requests

• Give 4 or more high probability requests
• Return to original request

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Priming

• Problem behaviour is more likely to occur in
  unpredictable than predictable environments
  (Flannery Horner, 1994)
• Consists of child previewing future events (no
  practice)
• Originally used for children with autism to
  preview a story at home that was read the next
  day in school (Wilde et al., 1992)
• Video priming (Schriebman, Whalen, Stahmer,
  2000)
• Cutting hair

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Making The Problem Behaviour Inefficient

• Teach Positive Skills That Involve Less Effort

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Behaviour and Communication

• There is a direct relationship between problem
  behaviour and communication deficits in children
  with autism
• Not all behaviour is communication (e.g.,
  echolia)

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Functional Communication Trainingby Durand (1990)

• Select a response modality that would be
  successful for the child (e.g., signs, PECS,
  micro-switch voice generators)
• Select a response form that the child can learn
  rapidly (e.g., break card) and involves less
  effort than the problem behaviour
• Maximize natural opportunities for the child to
  learn this communicative response
• The communicative response is taught during
  teachable opportunities

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Functional Communication Training Contdby
Durand (1990)

• Deliver instruction for the child to use a
  communicative response (e.g. "What do you want?")
• Deliver physical prompt (e.g., The therapist
  gives the child a picture depicting break" and
  puts out his or her hand)
• Delivers a verbal prompt as the child uses a
  communication response (e.g. "I want a break")
• The child receives the requested object or
  activity.
• Prompt to assist the child in responding are
  systematically faded.
• Generalization of the learned response is
  promoted across people and setting

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Making the Problem Behaviour Ineffective

• The problem behaviour is no longer effective in
  meeting the childs needs

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Match Strategies to Function

• FIRST STRATGEGY FOR ATTENTION-MAINTAINED
  BEHAVIOURS
• Give effective instructions
• Differential reinforcement
• Planned ignoring of the small stuff
• SECOND STRATEGY FOR DESIRED OBJECT/ACTIVITY
• Response cost

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Match Strategies to Function

• THIRD STRATEGY FOR SENSATION MAINTAINED
  BEHAVIOURS
• Interrupt, Redirect, Reinforce
• FOURTH STRATEGY FOR ESCAPED-MOTIVATED BEHAVIOURS
• Proceed with caution

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The First Strategy

• For problem behaviours maintained by attention

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Give Effective Instructions

• Be sure that the child is paying attention
• State what you want the child to do, rather than
  not do
• Give only one instruction at a time
• Be brief and simple
• Do not repeat your instruction

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Exercise Identify the Errors

• Gregory was having a great time at outdoor play
  in the sandbox, but was throwing sand. His
  teacher said, Okay Gregory, stop throwing sand.
  . GREGORY, I SAID STOP THROWING SAND!!!
• Jean wanted Melissa to clean up the dress-up
  centre. Jean said, Melissa how about you
  picking up the brown shoes and put them over by
  the wall, then gather up the necklaces and place
  then in a bin. Then, put all of the hats on the
  hat rack.

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Reinforce Compliance

• Reinforce positive alternative behaviours
• Use descriptive praise (describe what the child
  did), (e.g., I like the way you stopped what you
  were doing and looked at me.)
• If praise is not important to the child, pair the
  praise with a tangible reinforcer that is
  effective for the child.

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Ignore The Small Stuff

• Dont ignore behaviours that are harmful,
  dangerous or highly disruptive
• Only ignore behaviours that are maintained by
  attention (e.g., whining)
• Discuss with the care givers what behaviours can
  and cannot be ignored
• Biting another child
• Whining
• Jumping up and down
• Screaming

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Planned Ignoring (Extinction)contd

• Act in all ways as if the annoying behaviour is
  not occurring
• Reinforce the alternative behaviour
• Expect an extinction burst

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SECOND STRATEGY

• For problem behaviours maintained by getting
  desired object

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Removal of Object or Activity(Response Cost)

• Cameron and his sister, Amy, were playing with a
  truck, pushing it back and forth. Amy decided to
  stop the game and push the truck by herself.
  Cameron wanted a turn too and tried to pull the
  truck away. They began to struggle and cry over
  the truck when their father walked in. He took
  the truck away and said, You need to share your
  toys. After a few minutes he returned the truck
  and reminded them to share.

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Response Cost

• Only use for problem behaviours that occur
  occasionally
• Use for problem behaviour that are motivated to
  get desired object or activity
• The object or privilege that is removed should be
  naturally connected to the problem behaviour
• The consequence should be immediate
• Always reinforce the desired behaviour

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Exercise How would you use Response Cost?

• Jason loves to watch the videotape of Lion King,
  particularly one scene that he rewinds and
  replays continuously. In the past he has broken
  VCRs and videos from the constant rewinding.

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THIRD STRATEGY

• For problem behaviours maintained by sensations

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Interrupt, Redirect, Reinforce
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Stereotypy

• What is it?
• Routinized and repetitive actions (may be verbal
  and/or motoric) that occurs often with no
  function
• Why does it occur?
• Feels good
• How does it impact children?
• Interferes with learning
• How do you treat it?

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Treatment of Stereotypy

• Have functional activities for the child to do
  that keeps him/her busy (e.g.,carry objects
  during a transition, place hands in pockets)
• When stereotypy occurs
• Interrupt (e.g., gentle touch)
• Redirect (e.g., give item to carry)
• Reinforce (e.g., give reinforcement for carrying
  item)

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(No Transcript)
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Also Can Be Used for Aggression To Get
Objects/Activities

• Brian is beside James at the water table and
  starts to pinch him because he wants the pail.
  The aide then redirects Brian to the vehicle play
  area and reinforces him when he begins to play
  with trucks.

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Redirection Should Not Be Used for
Escape-Motivated Problem Behaviours

• Why?

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FOURTH STRATEGY PROCEED WITH CAUTION
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Match Intervention to Function of Behaviour

1. Get attention
2. Escape request
3. Get desired object or activity
4. Sensory

1. Planned ignoring
2. Interrupt-redirect- reinforce
3. Get professional consultation
4. Response cost

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Review

• Make the problem behaviour irrelevant
• Neutralizing routines
• Make activities and materials easier,
• Add aids to learning (e.g., visual schedules)
• Make activities more fun, build in reinforcement
• Break activities into small steps
• Make the problem behaviour inefficient
• Functional communication training

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Summary

• Make the problem behaviour ineffective
• Planned ignoring and differential reinforcement
• Response cost
• Interrupt, redirect, reinforce
• For escape-motivated behaviour proceed with
  caution