Living in the West 2010 19 th November 2010 Craig McIver & Debbie Lobb

Positive Behaviour Team – development and clinical application of a positive behaviour support model Living in the West 2010 19th November 2010 Craig McIver & Debbie Lobb (Positive Behaviour Service, Disability Services Commission, WA)

Development of the Service Model - Overview Context Development of the Positive Behaviour Team Implementation – Service Model Evaluation Results

Context The Positive Behaviour Framework (Disability Services Commission (DSC), 2009) - a plan for services provided to people with disabilities who sometimes exhibit challenging behaviour - recognised the place for highly skilled and dedicated tertiary teams in supporting this consumer group and their families

Client Group People with a developmental disability aged 6-25 who sometimes exhibit challenging behaviour Client group identified via qualitative analysis of pre-existing referral data Living in a family context Focus on supporting families and preventing premature out-of-home placement

Positive Behaviour Team Developed as an interdisciplinary tertiary team within the Disability Services Commission in 2007 Accessed existing resources of Clinical Psychologists, Speech Pathologists and Social Workers who are experienced in working with challenging behaviour and families

Team Mission ‘To encourage lasting, positive behaviour change and improved quality of life of the person with a disability and their family by increasing the capacity of the person, their environment and support systems’

Theoretical Underpinnings Positive Behaviour Support model (e.g. Lucyshyn, Horner, Dunlap, Albin & Ben, 2002) A Family-centred approach - dictates that interventions with families are focused on what change may be meaningful for them and emphasises a collaborative partnership between service and family Functional Assessment as a basis for intervention Behaviour viewed as serving a communicative function Quality of Life is important for individuals and their families (e.g. John O’Brien) and an important consideration in service design & outcome Family systems approaches to psychotherapy - systemic interventions and engagement with families and other key stakeholders is necessary for lasting change (e.g. Milan Group (Palazzoli, Cecchin, Boscolo, Prata)

The 3-pillars Rationale for the 3 discipline groups: Applied Behaviour Analysis (Clinical Psychology) Family Systems Approaches (Social Work) Interventions to support functionalcommunication (Speech Pathology)

Service Model Approximately 35 referral places across metropolitan Perth Interventions run for 12-18 months (aim for 12 months) 2 clinicians of different disciplines assigned to each referral, but referral viewed as ‘whole of team referral’ Two teams of 7 clinicians (North & South metro) Small case loads (6-7 referrals per full-time employee) Team supervision 3 times per month (2hr meetings) Individual supervision with Team Leader once per month, and as required

Implementation Team Members engage with families to facilitate greater awareness of why behaviour exists and what changes they can make to achieve lasting positive behaviour change The aim is to develop a ‘shared understanding’ of why problems occur and what might help

Implementation (Continued) Goal-directed and process driven approach (process checklists to guide interventions, though not manualised) ‘Introduction to Service’ meeting – focus on establishing engagement with parents and discussion of normal family expectations of a ‘fix’ for the problems they are experiencing Frequency and intensity varies based on identified needs and goals for each family Intervention moves along a continuum from assessment, through intervention, to maintenance Safety-planning and behaviour support plans prioritised as required Goals start off as ‘desired outcomes’ and are refined through process of systemic assessment Sustainability of goals is a key consideration

Research Objectives To determine the impact & effectiveness of the services provided by the PBT. To establish an evaluation framework & management tool for on-going support of the PBT To provide a framework to inform evidence-based practices in future sector-wide developments involving PBT services.

Research Activities Documentation review Development of Research Protocol with PBT Database Development Family Interviews & Surveys Staff Interviews & Surveys Local Area Coordinator Focus Group Community Teams Focus Group School & Respite Service Interviews

Family Measures Beach Center on Disability (2003). Partnership and family quality of life survey. University of Kansas. Cummins, R., & Lau, A. (2006). Personal Wellbeing Index, 4th Edition. Melbourne: Deakin University. Einfeld, S. & Tong, B (2002). Developmental Behaviour Checklist, Revised. Melbourne, Australia: Centre for Developmental Psychiatry & Psychology, Monash University. Hammer, A., & marting, M. (1987). Coping Resources Inventory. Palo Alto, CA: Consulting Psychologists Press. Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.). Sydney: Psychology Foundation Stepping Stones Positive Parenting Program (2003) Parenting Scale. Queensland, Australia: Author.

Family Interviews The Partnership Orientation Measure Garbacz, S., Woods, K., Swanger-Gagne, M., Taylor, A., Black, K., & Sheridan, S. (2008). The Effectiveness of a Partnership-Centred Approach in Conjoint Behavioral Consultation. School Psychology Quarterly, 23 (3), 313–326. Quality of Family – Professional Partnerships Summers, J., Hoffman, L., Marquis, J., Turnbull, A., Poston, D., Nelson, Louis (2005). Measuring the quality of family – professional partnerships in special education. Exceptional Children, 72 (1), 65-81. Measure of Processes of Care (MPOC-20) King, S., King. G, & Rosenbaum, P. (2004). Evaluating Health Service Delivery to Children With Chronic Conditions and Their Families: Development of a Refined Measure of Processes of Care (MPOC–20). Children’s Health Care,33(1), 35–57. Measure of Beliefs About Participation in Family-Centered Services King, G., Kertoy, M., King, S., Law, M., Rosenbaum, P., & Hurley, P. (2003). A Measure of Parents’ and Service Providers’ Beliefs About Participation in Family-Centered Services. Children’s Health Care, 33(3), 191-214.

Staff Measures King, G., Kertoy, M., King, S., Law, M., Rosenbaum, P., & Hurley, P. (2003). A Measure of Parents’ and Service Providers’ Beliefs About Participation in Family-Centered Services. Children’s Health Care, Maslach, C. & Jackson, S. (1986). Human Services Survey. Palo Alto, CA: Consulting Psychologists Press 33(3), 191-214. Osipow, S. & Spokane, A., (1998). Occupational Stress Inventory Revised Edition (OSI-R): Professional Manual. USA- Psychological Assessment Resources, Inc.

Clients of the PBT Referrals = 92 Accepted Cases = 80 Closed at June 2010 = 47 Active at June 2010 = 33 Assessment = 10 Intervention = 19 Maintenance = 4 Engagement = M 346 days (SD 226) ID = 41% ASD = 20% ID + ASD = 39% Males = 66% Mean Age = 14 (SD3.8) Range = 5 to 26 years Mode = 16 yrs (13%)

Issues for the Person with Disability Aggression = 31% Aggression & Self-Injury = 25% Non-compliance = 20% Risk-taking = 11% Residual > socially unacceptable behaviour; toileting issues;

Issues for the Family Personal Wellbeing PWI Fathers = M 6.4 / 10 (SD 1.5) PWI Mothers = M 5.75 / 10 (SD 1.3) Child’s safety School exclusion Safety of family members Impact on parent’s relationship Impact on siblings Communication Social Skills Control Independence

Preliminary Analysis Goal Attainment for PWD Met = 32% Partially Met = 45% Discontinued = 13% Unmet = 10% (3/47 clients) Family QoL Significant Improvement: M 3.2 (SD 0.58) > M 3.7 (SD 0.45) Parental Efficacy Significant Improvement: M 54.25 (SD 11.6) > M 61.88 (SD 7.9) Parental Mental Health Significant Improvement: M 33.77 (SD 23.03) > M 24.81 (SD 19.08)

Why Might it be Effective? Positive Behaviour Support Techniques Communications Strategies Multi-Systemic Family Therapy & Education Experienced Multi-disciplinary Team Trans-disciplinary framework Regulated Referrals Extended Engagement Family & networks

References Disability Services Commission (2009), Positive Behaviour Framework. Lucyshyn,J.M., Horner, R.H., Dunlap,G., Albin, R.W., Ben, K.R. (2002). Positive Behaviour Support With Families. In J.M. Lucyshyn, G. Dunlap & R.W. Albin (Eds.), Families and Positive Behaviour Support (pp.3-43). Baltimore: Paul H. Brookes. Refer also to references concerning the various measures, as noted in earlier slides

Clinical Application - Overview • Client background • Application of service model • Outcomes for client, family and community supports • Importance and result of across agency collaboration • Overall Results

Initial presentation – October 2008 • Client • Male, 14 years of age • Over 6’, approx 90kg • Living with mother and father • Autism Spectrum Disorder, Intellectual Disability • Taking Risperidone • Reported Problematic Behaviour • Hitting, scratching, kicking, ripping clothing, bending fingers of others. Has tried to strangle some caregivers. Broke a toddlers leg • Family management of beh – physical restraint on floor (wrestling to ground) for up to 45 minutes

Previous interventions • Early Intervention Programme for Autism (DTT model) • Sleep programme to sleep in own room • Stepping Stones • Individual Psychology support • Family dynamics • Mother main caregiver. Father disengaged • Two older brothers living out of home • Respite for one weekend a month out of home • School history • Exclusion due to significant injury to staff. Staff considered legal charges. • New school mid 2008. Support School. • Continued aggression at new school requiring restraint by male and multiple staff

Initial Hypotheses by Mother and PBT • Behaviour attention related • Mother queried response to loud noise and father’s voice • Inability to express what needed or difficulties due to highly echolalic and limited functional speech • Compliance issues

Service Model The Iceburg Concept Not just scratching the surface but looking at the bigger picture • Core component of intervention achieved through assessment • Family guided to explore and make explicit links between family relationships, personal beliefs and thoughts, patterns of behaviour and what the person is trying to communicate through the behaviour • Supporting the family and systems to create their own understanding of why the behaviour occurs, factors that influence and what might help

“Assessment” • 8 months of assessment/exploration • Weekly sessions at home, some at school • Exploration of how behaviours developed • Thorough exploration of specifics around attention • Tracking behaviour and relationship to mood/anxiety • Exploring family dynamics and influence on management, ability to change • Safety planning for parental safety during episodes of aggression • Passive self defence training • Sessions structured to guide mother to problem solve what triggers his anxiety and what needs to happen to prevent anxiety

Results of “assessment” • Relationship between anxiety and processing issues. Processing as distinct from comprehension. • Mo identified factors surrounding anxiety including • Changes in environment • Changes in expectations • Insufficient information to meet expectations and knowledge • Mo identified what was socially acceptable and non acceptable physical behaviours on a daily basis eg, touching her neck. • Mo identified the functions of his behaviours and how to meet these without accepting inappropriate beh. • Clear understanding of pattern to anxiety escalation and ability to control mood • Mo ‘ownership’ of knowledge and self-direction to strategies required

Mo identified the different forms of attention he received at home. • Mo had a plan to avoid/escape from escalating behaviour • Mo more confident. • Marital relationship in conflict (Mo more confident in demanding support) • Mo aware of inability to change behaviour but the need to prevent it. Mo aware that focus of intervention is to prevent anxiety.

Mother determined what needed to change • How information is presented to him • Establishing consistent messages about inappropriate behaviour • Meeting his physical/sensory needs in a proactive way • How to communicate information to him in a way that will assist his processing • Meeting his needs for social attention across day • Responding differently to different communication purposes of behaviour. • Behaviour plan commenced

Based on Managing Threatening Confrontations, Behaviour Support Plan, Paul White

Behaviour Support - Strategies Strategies emerge from parent knowledge. Strategies to support needs demonstrated through behaviour Strategies should focus on keeping anxiety at low levels, meeting someone’s needs when things are going well

For this client this included: How to… Ensurehe has enough information to make life predictable and satisfy his need for knowledge. • e.g. specially designed schedules to meet his need of knowledge of whereabouts of family members and expectations of tasks. • Present visual information to predict upcoming events and changes • Present visual information to give extended information to meet his need for knowledge and details

Communicate with him • Best communicate with him through writing and visuals • Phrase information to assist his comprehension and assist his verbal expression Relationships • Initiate physical contact on parent’s terms and to meet his needs throughout the day. • Respond to inappropriate touch when used as a sign of affection.

How to.. • Recognise early warning signs of tension/anxiety • Manage redirection and levels of attention • Communicate in a way that facilitates processing at different levels of anxiety – auditory processing shuts down with increased anxiety Read the message behind the behaviour and signs to differentiate this. • Holding paired with questioning - to seek information, comfort and reassurance (seeking assistance) • Holding not paired with questioning (seeking forced attention) • How to clearly and consistently respond to each purpose of the behaviour

How to.. React/manage emerging signs of increasing anxiety and the behaviour in which this is communicated. Adapt expectations and methods of communicating with him at increasing levels of anxiety – processing shuts down. Reflect on signs of anxiety and determine what this tells us about gaps in potential supports.

Results • Behaviour improved at home • Mother’s confidence improved • Father’s involvement challenged. Saw impact of changes being made. • Behaviour deteriorated at school

Observations at school • Inconsistent use of visual supports • Boredom • Noisy classroom • Early warning signs of anxiety not being identified • Staff fearful • Resulted in temporary exclusion

School intervention • Systemic and behavioural exploration with immediate staff daily over a two week period (most part of the day) • Planning for what supports he required to manage his anxiety • Shift in being reactive and fearful to planning for supports. Behaviour plan changed from red to green/yellow • Education Department Autism Support provided intensive visiting teacher to work with staff for remainder of term (putting in place supports and problem solving on daily basis)

School results • Finely detailed Behaviour Support Plan with emphasis on preventative supports. • Behaviour Support Plan updated weekly • Optimal supports put in place • Staff exploring what is going well and why it’s going well. What supports things going well • Staff reading and responding to early warning signs, therefore decreasing escalation of anxiety • Significant decrease in aggressive behaviour

Overall Results Goal attainment (service involved for approx 18mths) • Frequency of holding behaviour to reduce by 70% in the home environment over a monthly period. Preintervention • Nov 08 - up to 10 incidents a day of forceful, restrictive holding lasting in duration of over an hour. Holding at least once daily Post intervention • March 2010 - 3 incidents over a 4 week period up to one minute in length. • Reduction by approx 80% (when compared to pre-intervention of once daily) • Current report of family – limited occurrences at home

Frequency of aggression towards parents (scratching, hitting, ripping, kicking, forcible holding) to reduce by 50% over a 3 monthly period as evidenced by recordings and parent report. Preintervention • Oct 08 - Feb 09 5 incidences at home • Sept - Nov 09 6 or more incidences at school Post intervention • Feb - April 2010 1 incident at school, nil at home • Greater than 50% reduction in both environments • Current report of family • nil at home since April 2010 • Some continued aggression towards property at school but no staff injury

Overall results Change across three pillars in home and school environments Applied behaviour (Positive Behaviour Support) • Carers reading early warning signs effectively • Consistency in management • Strategies and supports put in place to reduce possibility of anxiety • Carers identifying potential triggers and potential influence on raising his anxiety • Carers able to reflect on triggers and identify further supports required

Family Systems Approach • Carer perspective of him has changed from avoiding and being fearful of his behaviour to planning for what support he requires • Separation of identity from behaviour • Support driven not behaviour driven • Family and school relationships challenged to work more cohesively • School supports now focussed on his gifts, what he needs and how to meet those needs in place of reacting to his behaviour. Communication • Detailed exploration of his processing needs and resultant visual supports required • Verbal skills improved

Current Issues • Acknowledgement that behaviour will not change. Proactive supports keep likelihood of behaviour low. • Referral behaviours remain low • Continued anxiety – lower levels • Expressive communication needs to be addressed • Significant resources and energy required to maintain proactive practices • Continued risk of exclusion due to staff burnout, potential risk to staff • Visionary planning of his future (person centred plan) is required to look at what environment in the short and long term will best meet his, his family and community access needs.

Living in the West 2010 19 th November 2010 Craig McIver & Debbie Lobb