PSY 4600 U7: Gerontology and Staff Management

1. Schedule Lecture: Today and Tuesday Exam: Thursday, 4/03 But before U7, a word or two about U8…. PSY 4600 U7: Gerontology andStaff Management (these are two rapidly growing areas, and while the topics don’t seem to be related, they are. Studies have been done in long term care facilities – nursing homes and facilities for those with dementia; but right now most staff mgt is being done in group homes/residential homes for developmentally disabled adults, schools/programs for autistic children)

2. Unit 8: Very Different Assignment! • Topics covered: • Certification and licensing in behavior analysis • Research and professional ethics • Unit Assignment: 2 parts • 20 pt exam over study objectives in course pack • 15 pts for completion of an on-line training program about research ethics (Behavioral and social sciences modules) • Research and professional ethics have the same overarching principles, and thus there are a lot of similarities between them

3. Unit 8: Online Training Program • You must hand in a computer print out that you have completed the on-line training on the day of U8 exam, which is Tuesday, 4/15 (no electronic copies via email) • For the computer print out – MODULES COMPLETED, which lists the score you got on the quiz for each module • Completion Criteria: • Complete all modules in the behavioral and social sciences category • 80% average on quizzes across modules • Quizzes at the end of the modules can be retaken before you move on to the next module; once you move on, then the quizzes cannot be retaken • If you have already completed this training, you only need to print off a copy of the page that indicates that you have completed it. You don’t need to do it again. • You do not have do to this all in one sitting – in fact I recommend that you not try to do that!

4. Unit 8: Online Training Program • If you do not hand this in on the day of the exam - no credit. I will not accept late assignments. • See Study objectives for grading criteria • See Study objectives for instructions on logging onto the training program (tend to update these on a regular basis) • Some of you have already completed this • Required to complete it if you were/are an RA • Some students like to hand this in early - that’s fine with me!

5. Behavioral Gerontology Linda LeBlanc, Ph.D. Allison Jay, MA Alyce Dickinson, Ph.D. Based on: LeBlanc, L. A., Raetz, P. B., & Feliciano, L. (2011)

6. SO1: Aging of America • The proportion of the population over age 65 in the U.S. increased from 4% to 13% in the 20th Century • It is predicted to be 20% of the population by 2030

7. SO2: Aging of America, Contributing Factors • Medical advances increased life expectancy about 30 years between 1900 & 2000 • 1900: 47 years • 1950: 67 years • 2000: 76 years • Aging of Baby Boomers • Born during the post-World War II baby boom • Years between 1946 and about 1953 (longer life expectancy has increased about 30 years between 1900 & 2000 - fine for exam)

8. SO3: Effects of Aging Living longer means a substantial portion of elders live with chronic illness and disability • Higher total cost of care • Greater care needs • Potentially lower quality of life (more doctor’s visits, more medication, more MRIs,, more protthestics - hearing aids, walkers, etc.)

9. Behavioral Gerontology • Application of behavioral principles to aging issues • Clinical/Rehabilitation Issues • OBM/Staff Training Issues • Small sub-field of behavior analysis that needs new interested students • Check out the Behavioral Gerontology SIG at ABAI • Different approach to aging from typical medical model of inevitable biological decline (Just because you lost it, doesn’t mean you can’t get it back; provide behavioral/environmental supports; teach people how to self-prompt)

10. SO4: Behavioral Gerontology • From a behavioral perspective, when a person ages (examples of each follow) • Fewer discriminative stimuli control behavior • Different motivating operations are likely • Contingencies of reinforcement tend to support the wrong behaviors (Go back and look at examples of each)

11. SO4: SDs become less effective • Get lost when driving to someplace you go to frequently (i.e., the grocery store) and don’t know how to get home • Faces may no longer evoke correct names - even of loved ones • Trouble with ordinary conversations; words don’t evoke typical responses, particularly with a quick change of topics • Can’t write a check anymore, and certainly cannot master web banking (how do you pay bills?) • TV/DVD/TIVO remotes: two or more remotes, each one is different (stimulus control combined with punishment), can’t figure out how to do things • Changing technology – phones used to be easy; using menus and navi keys are 2nd nature to you – not to seniors; too many buttons, too many options!

12. Stimulus Control & Punishment (buttons are all in different places, symbols v. words, not one but two navi pads, jitterbugs)

13. SO4: Different MOs • Deprivation of social contacts makes elders susceptible to telephone solicitors and scams by strangers (someone comes to the door - they let them in) • Foot pain, hip replacement, arthritic pain make a decrease in pain reinforcing and evoke behaviors that lead to decreased pain – and, inactivity, watching TV, win out over activities such as gardening, walking in the woods, needlepoint (also punishes those behaviors if engaged in) • Sleep deprivation is often present so evokes more irritable behaviors (when cut off when driving, or a relative is late for a visit, or a grandchild begins to cry/scream) Fact that not only quantity but quality of sleep changes with age

14. SO4: Reinforcement for dependent behaviors and punishment for active behavior • When do you go see Grandma? When she is not feeling well. (reinforcement for complaining and behaviors related to not feeling well) • Punishment for verbal behavior when can’t “find the right word” or “follow the conversation” • “Does it hurt to do that? Why don’t you rest and let me do it?” (reinforcement for dependent behaviors) • “Let me go to the grocery store for you” (same issue as with Fordyce, chronic pain)

15. Behavioral Gerontology • Use of behavioral procedures to solve problems related to SDs, MOs, and wrong reinforcement/punishment contingencies • No different than the approach we take in other areas of specialization

16. Enjoy Old Age, 1983 (click, animation)

17. SO5: Why behavioral gerontology is needed • Behavior problems, not health declines or medical problems are • Major cause of caregiver stress • The most common cause of institutionalization • I “can’t take it anymore” on the part of the caregiver • aggression, arguing, losing things, wandering, incontinence • 65% of individuals in nursing homes have significant behavior problems • Can lead to high staff turnover

18. NFE: Obstacles to widespread behavioral services • Practitioners are reluctant to serve elders – no training • Because of that it is hard to locate behavioral services • Older people and caregivers perceive stigma for accessing mental health services • Older adult: means “I’m crazy” • Caregiver: “a good son/daughter/wife/husband” could handle it without help (Cont. on next slide)

19. Obstacles, cont. • Medical Model Myths • Psychotropic medications are the only thing that will work - most common intervention • Once a skill is lost it cannot be regained • Cost and effort constraints • Simple and/or cheap will always be selected Which is simpler and less effortful? Medication or behavioral interventions? Elders are taking an average of 5 different meds

20. SO6: NFE: Anxiety and Depression • Anxiety and depression are not common in seniors, contrary to popular belief • Anxiety: • Only about 6% of healthy elders have clinical anxiety • Higher rates in elders with medical conditions • Depression • Only occurs in 2 - 10% of older adults • 2x more in women (as in younger population) • 40-50% of people in nursing/retirement homes • Which comes first, the chicken or the egg?

21. Behaviorally . . why depression/anxiety? • Loss of reinforcers due to changes in the environment • Including deaths of siblings, friends, and perhaps life mate • Loss of reinforcers due to physical deterioration of receptors • can’t hear or see as well • aren’t as strong • have trouble opening containers • Increased dependence but don’t want to be a burden • can’t drive anymore (can’t go shopping when you want to) • But remember, healthy seniors are not depressed or anxious • Economically stable (hopefully) • Tend to become more “forgiving” and “kinder” • Not as concerned about what other people think

22. Behavioral Gerontology Services • Typical Nursing Home • No active engagement, even in leisure activities • No social interaction or conversations • Memory problems • High rates of problem behavior Behavioral gerontologists have tackled each of these problems successfully

23. SO7: Aggression • 85% of seniors with dementia physically aggress their care providers • This is one of the most common behavioral problems that leads to placement in long-term care facilities, physical constraints, and/or medication • 75% of the aggressive behaviors have been shown to be escape behaviors from antecedent task demands (MOs) related to daily living activities • Dressing, taking the senior to the bathroom, showering/bathing, brushing teeth, shaving, etc. (moderate to severe) • Antecedent MOs include verbal prompts, physical prompts, task demands: it’s time to get up, you need a bath/shower, put on your out-door clothes, why don’t you take a walk, you shouldn’t be drinking that glass of wine (mild to moderate) • NAG, NAG, NAG all day long!

24. SO7: Aggression • Common behavioral interventions: • Care provider moves away and stops the demands • Often done to prevent the senior from “being too upset” • Care provider doesn’t want to be hurt • Time out (a punishment procedure) What’s wrong with these interventions?? (answer, next slide)

25. SO7: Aggression What’s wrong with these interventions?? MO: R Sr- Task demands, prompts Aggression No task demands In words: These interventions terminate the task demands, which negatively reinforces the aggression (This is why functional assessment, determining the cause of the behavior is so important before designing an intervention )

26. SO7: NFE, What to do instead? • Noncontingent escape • Determine interresponse time of aggression • Seconds before onset, seconds in-between • Provide escape (terminate the activity or prompt) before aggression occurs • Form of differential reinforcement Example: Elder in a nursing home aggressed against care givers during toileting. Found it was escape-maintained. It started ~30 s after toileting began, and thereafter every 25 s. Care givers prompted toileting, but stopped after 20 s, paused for 10 s, then began prompts again. Repeated this until end of toileting. Aggression decreased to near 0 levels. (extinction next) 26

27. SO7: NFE What to do instead? • Extinction is also possible if the senior will not hurt himself/herself or the care giver • There is, of course, concern about an extinction burst • Seems “cruel” but • Literature suggests that alternatives have been punishment or high doses of medication • Physical restraints • Strong verbal reprimands Food for thought: Think of respondent conditioning, what happens if strong verbal reprimands and other stimuli that elicit unpleasant emotional responses are consistently paired with the care provider? (How would you extinguish? Are these kinder? Drugs do decrease aggression, but are systemic and decrease the entire activity level of the elder. Do you want a doped up Grandpa?)

28. SO8: Bourgeois (1993), Memory Wallets • Effects of memory aids (wallet) on conversations of individuals with dementia • People with dementia appear incoherent in conversation because they (mainly intraverbals) • Substitute vague words for specifics • Don’t follow the content or topic • Cannot spontaneously generate topics • Interventions like memory wallets do result in better conversations (really like this, simple intervention; if you ask them what they did that morning, they may start complaining about the food at dinner or staff , or talk about an event that was a very long time ago)

29. My Nieces:Caroline, Courtney, Jessica

30. My favorite color is blue. My cat is Mr. Snuffles and he is a Siamese.

31. I live at 427 Bloomfield Ave

32. Bourgeois (1993) Memory Wallets • Participants: 6 individuals at adult day care centers • Two individuals talk to each other • Memory wallet for one of the two was used • Interviewed family members to develop list of facts and topics • Took corresponding pictures to include in wallet • 5 minute conversations 3 times per week • Measured • Statements related to the memory aid • On-topic statements

33. SO8: Bourgeois (1993) Memory Wallets • Research design • Reversal: BAB • Results (exception one P, most demented) • Quite a few statements directly related to the aids • More on-topic statements about the aids, but also about other areas (generalized to other topics) • More on-topic statements by the partner - it wasn’t their aid! • Social Validity • 13 Speech Staff listened to tapes and rated quality • Aided conversations rated higher on staying on topic, being less ambiguous, and in general, just being more comfortable to listen to,

34. No Aid Memory Aid

35. SO9 Intro (NFE): The Intersection of Gerontology and OBM/Staff Mgt • It’s important for behavior analysts to develop and experimentally evaluate interventions to deal with problem behaviors • However, if we want to alter/improve the behaviors of consumers permanently, we need care givers and staff to implement those interventions • This is where OBM/Staff Mgt comes in (OBM in business and industry, but typically staff mgt in human services)

36. Gerontology and OBM/Staff Mgt • Direct care staff in nursing homes • Are CNAs (Certified Nursing Assistants) • Often receive low pay and work long hours • Have many potentially unpleasant aspects to their job • Are often kind people who sincerely want to help • Often have no idea that their actions are directly contributing to an environment that • Suppresses independence and activity • Reinforces problem behavior (note medical model, nursing, rather than hiring direct care staff with behavioral background – different than in group homes and residential facilities for DD and autistic children supervisors have a psychology/behavioral background)

37. Gerontology and Staff Mgt • Staff training and performance monitoring are a critical part of providing good care in nursing home settings • Staff will often acquire knowledge of procedures in in-service then fail to use the procedures when they interact with clients • No system in place to make it worthwhile or feasible to maintain new procedures

38. SO9: Engelman, Altus & Mathews (1999),Increasing Leisure Activities • Designed to increase engagement in leisure activities • Engagement in leisure activities is believed to: • Increase the quality of life of individuals by bringing them into contact with reinforcers they enjoy • Decrease inappropriate behaviors • Often, however, elders with dementia don’t initiate activities without assistance • While staff are encouraged to facilitate this, they are not trained to help them choose or maintain leisure activities • Furthermore, staff have a lot to do and may have many competing job responsibilities (Basically, just make them happier; True of other at-risk populations as well, DD)

39. SO9: Engelman, Altus & Mathews (1999) • 5 residents in a nursing home with dementia • Intervention: • CNAs were trained to • Check-in with each of their assigned residents every 15 min • If engaged, praise activity • If not engaged, offer activity choices and assist if necessary • CNAs were observed and given written performance feedback • Measured appropriate engagement, inappropriate engagement, no engagement of residents • Research Design = MB across morning/afternoon (really cool design)

43. Engelman, Altus & Mathews (1999) • Results • All participants experienced increased appropriate engagement • over 80% of intervals in morning • over 70% of intervals in afternoon • MB design clearly shows the increase was due to the check-in procedure • Greater diversity of activities • 7 in baseline, over 20 in intervention 43 (Piano player; sometimes the problem is they just can’t get started by themselves)

44. SO10: Engelman et al. (2003), Increasing independence • Well meaning staff may increase resident dependence by doing everything for them • System of “Least to Most” Prompts ensures opportunity to perform independently • Verbal (least help/prompt, fosters most independence) • Gestural (next level of help/prompt, independence) • Physical (most help/prompt, fosters least independence) • Intervention • Interactive 30 min training on System of Least to Most Prompts (model, rehearse, feedback) • Feedback: Daily monitoring of consumer performance by CNA

45. SO10: Engelman et al. (2003),Increasing Independence • Participants: 2 CNAs; 3 elders with dementia • Measured • CNA use of Least to Most Prompts • Time it took to dress elders • Research Design = MB across elders • Results • Prompts increased for all CNAs across elders • No increase in time it took to dress elder (6.7 vs. 6.5 min) • Why is the above result very important? (during baseline, no prompts at all, they were dressing the elders)

46. Conclusions: Behavioral Gerontology • Increasing need for professionals with experience and expertise in aging • Opportunity to create new models for service delivery that allow individuals to retain independence as long as possible • Allows you to blend clinical and OBM interests

47. Interested in this area? • Southern Illinois University, Rehabilitation Institute • Dr. Jonathan Baker: jonathan.c.baker@siu.edu • University of Colorado, Colorado Springs, Clinical Psychology • Dr. Leilani Feliciano: lfelicia@uccs.edu • WMU’s Center for Gerontology • wmich.edu/hhs/centers/gerontology • minor in gerontology (relatively new)

48. Staff Management • Staff management, while similar to OBM interventions in business and industry, offers some unique challenges • One is that few professionals in human services are trained in staff management; rather they are trained to develop effective training and behavior management programs for their consumers • There has been increasing recognition over the past 10 years that staff management skills are essential for professionals in human services • Most individuals who obtain graduate degrees to work in human services, end up as supervisors or managers – they do not implement the programs with the consumers themselves, rather they supervise those that do (most of sm studies have been conducted in group homes or residential facilities for DD; however, the results of that research are clear: there is a need for individuals with expertise in staff mgt in all areas of human services. schools and programs that serve children with autism, to name a few) 48

49. SO11: Staff Management • Furthermore, many professionals manage several different units or programs within human service agencies and some have started their own human service organizations, but again they have no or little training in staff management or organizational systems analysis • Yet, it is quite clear that no matter how well designed a training or behavior management program is, unless it is implemented correctly by staff, the consumers will not benefit (answer to SO11) • Functional daily living and job skill training • Management of disruptive and inappropriate behavior • Verbal behavior training • In business and industry, it’s a given that employees need to acquire new skills and supervisors/managers need to know how to supervise their employees 49

50. Staff Management • Most business organizations hire experts in training, performance management, and organizational systems analysis, usually in the human resources dept. • Human service agencies have not done that • Human service professionals, therefore, have little or no training in staff training, performance management, and organizational systems analysis • And, there aren’t experts in the organization to help them (At WMU, over the years, no idea how many of our graduates in human services have told me that they wished they had taken all of our OBM courses while in graduate school here) 50