Conjoint Behavioral Consultation

1. Conjoint Behavioral Consultation

2. Different settings Emphasis on PartnershipsDifferent settings Emphasis on Partnerships

4. Process Goals of CBC Improve communication and knowledge about child and family. Increase commitments to educational goals. Address problems across, rather than within, settings. Promote shared ownership for need identification and solution. Promote greater conceptualization of a need. Increase the diversity of expertise and resources available.

5. Process Goals of CBC (continued) Establish and strengthen home-school partnerships; enhance the family-school relationship. Refers to a mutual effort toward a shared goal. Contains the philosophy, attitude, and belief that both families and educators are essential for children�s progress in school. Working together to promote the academic and social development of students.

6. Outcomes Goals of CBC Obtain comprehensive and functional data over extended temporal and contextual bases. Identify potential setting events that are temporally or contextually distal to target. Improve skills and knowledge of all parties. Establish consistent programming across settings. Monitor behavioral contrast and side effects systematically via cross-setting treatment agents. Develop skills and competencies for future conjoint problem solving. Enhance generalization and maintenance of treatment effects.

7. Preconsultation Conjoint Needs Identification Conjoint Needs Analysis Conjoint Plan Implementation Conjoint Needs Evaluation See PC Handout 3 Stages of CBC

8. Preconsultation Important process of communication, relationship building, cohesion begins well before formal consultation stages and continues throughout! Opportunities for inviting participation and sharing information should be seized whenever possible Use initial contacts to ensure that participants know what to expect (and what not to expect) in consultation See Pre-CBC Handouts 1 - 3

9. Conjoint Needs Identification: Initiating Formal Consultation Standard consultation forms outline specific objectives of the CNII Use agenda for participants to keep them informed of the process and meeting objectives (see CNII Handout 1) See CNII Handouts 2 and 3 for structured CNII forms

10. CNII: Child�s Strengths/Assets Strengths, abilities, or other positive features of the client Can also include things that the client likes, which can be used in reinforcement programs Examples: �What are some of Jamie�s strengths?� �What are some things Kevin does well?�

11. CNII: Behavior Specification/Needs Identification Elicit behavioral descriptions of client functioning Focus is on specific behaviors of the client in terms that can be understood by an independent observer Ask for as many examples of the problem behavior as possible Careful specification is essential to identify the precise problem, direct the focus of an intervention, and monitor progress Assist consultee focus on a specific target problem by asking for a priority For example, �What is causing you the most concern?� or �Which of these behaviors is most problematic for Joey?�

12. Guidelines for Target Selection Focus on building a client�s skill repertoire, rather than simply extinguishing behaviors Prioritize urgent or dangerous behaviors if they pose serious risk or invoke serious consequences Select a target that leads to the best treatment outcome (treatment validity, generalization) -- HOW??

13. Identifying a response chain and target first behavior of the chain Selecting behaviors that will likely generalize to other behaviors (e.g., work completion with generalization to on-task or accuracy) Organizing behaviors in terms of their topographical or functional properties Prioritizing behaviors that have general utility and that the environment will likely maintain (e.g., social skills) Changing the �easiest� behavior to encourage further treatment efforts Changing behaviors that are most irritating to or preferred by the consultees Guidelines for Target Selection

14. Operationalizing the Target Behavior Operational Definition: A precise description of the behavior of concern to the consultee Criteria Objective: observable characteristics of behavior; must be countable and measurable Clear: unambiguous, specific, reliable; should be explainable to others & should not require interpretation on the part of an observer Complete: describes what is included and excluded; leaves little to judgement of observer It is often helpful to include information about situations/conditions where/when the behavior occurs SUMMARIZE & VALIDATE TARGET BEHAVIOR -- WRITE IT DOWN!!!

15. Case Example: Prioritizing &Operationalizing Target Behaviors Parent and teacher describe the following concerns about 8 year old Pedro: talks out/talks back fights, argues, complains fails to complete assignments/tasks uses obscene language doesn�t get along with other kids/siblings doesn�t pay attention to lectures or instructions tardy for school As a consultant, how would you go about helping consultees prioritize and operationalize a target behavior in the case of Pedro??

16. CNII: Behavior Setting A precise description of the specific settings in which the problem behavior occurs at home and at school Specific within-school and within-home settings important to prioritize Ask for as many examples of problem settings as possible In academic areas, this may include subject areas and not just physical environment Assist consultees prioritize problem settings by asking which setting is causing the most difficult

17. CNII: Antecedent Conditions A tentative delineation of events that precede the client�s behavior Ask for information regarding what happens before the problem behavior occurs Setting events: Antecedents that are removed in time or place from the target behavior, but that bear a functional relationship to its occurrence

18. CNII: Sequential Conditions Situational /ecological variables or events occurring when the behavior occurs Environmental (contextual) conditions in operation when the problem behavior occurs Pattern or trend of antecedent and/or consequent conditions across a series of occasions Examples: Time of day Day of week Class period or common situations Expectations of child (e.g., task demands) Sequence of events Curricular or instructional variables

19. Ecological Assessment & Existing Conditions Curricular assessment: What is taught Instructional assessment: How it is taught Variables to assess include materials, teaching format, assignments, daily routine, student grouping, evaluation and feedback procedures, homework

20. CNII: Consequent Conditions A tentative delineation of events that follow the client�s behavior Ask for information regarding what happens after the problem behavior occurs Setting events: Consequences that are removed in time or place from the target behavior, but which are related to its occurrence Examples: Being removed from the class, staying in from recess SUMMARIZE & VALIDATE CONDITIONS SURROUNDING BEHAVIOR

21. CNII: Behavior Strength Attain a tentative estimate of the frequency or duration of a problem behavior Level of incidence that is to be focused on Examples: Frequency Duration Latency Intensity SUMMARIZE & VALIDATE BEHAVIOR & BEHAVIOR STRENGTH

22. CNII: Goal Statement Assist consultee generate an acceptable or appropriate level of the behavior Examples �How often would Patrick have to turn in his work in order to get along OK?� �How much time could Sally take to respond to your request?� �What would be an acceptable amount of talking out in class?�

23. CNII: Existing Procedures Procedures or rules in force which are external to the child and behavior Questions regarding approach to teaching or parenting Examples: �How long are Stacy and the others doing seatwork?� �What are the playground rules?� �How do you currently handle Paul�s talking back?� �How are instructions/directions given to Anna?�

24. CNII: Data Collection Rationale provided to set the stage for data collection (why) Examples: �It would be very helpful to observe Sam in the lunchroom and see exactly how often he throws his food. This will help us understand... make comparisons later...� Specific data collection procedures discussed Common observation procedures include event, duration, interval, momentary time sample, latency Permanent product measures easy, useful Procedures must be appropriate for the target behavior, and continued throughout consultation Provide a form on which consultees can collect data, if possible See CNII Handout 4 for example

25. Data collected must have high treatment utility and be relevant to treatment Direct assessments will lead to meaningful treatments if they promote greater understanding of a behavior On-going and repeated measurement, rather than pre/post assessment only, is required Multi-source, multi-method multi-setting assessment strategies are used along the direct >>> indirect continuum Multi-source: Collect information from teacher, parent(s), peers, self, others Multi-method: Collect information using different methods, such as rating scales, interviews, observations Multi-setting: Collect information across settings of home and school, and other relevant settings as appropriate (e.g., classroom, playground, lunchroom, library, etc.) Behavioral Assessment

26. Tips for Data Collection Keep it simple! Clearly define what is to be recorded Match the data collection procedure to the target behavior Consider retrospective baseline data when applicable Graph the data to monitor progress Record data that have a range (i.e., not simply �yes/no�

27. Practical, Direct Data Collection Procedures Permanent Products Direct Observation Performance-Based Assessment Curriculum-Based Measurement Self-Monitoring

28. Permanent Product Concrete evidence of a student�s behavior taken from an existing source Examples: Percent of homework assignments completed Number of worksheets completed in a subject area Number of pages read Number of problems attempted/completed/accurate Organization of work on a page

29. Direct Observation Measurement of discrete behaviors while they are occurring Examples: On task/off task Disruptive behavior Out of seat Talking out Initiating conversations Compliance with commands

30. Direct Observations How to� Low frequency behaviors: Frequency counts using golf counter, pennies, tallies on wristband How to� High frequency behaviors: Identify intervals that are easy to monitor Consider momentary time sampling procedure

31. Performance-Based Assessment Use of rating scales to record behaviors over time periods, based on a Likert scale Examples: Aggression Oppositional behavior Active participation in activities

32. Curriculum-Based Measurement The use of standardized short-duration fluency measures of basic, any testing strategy that uses a student�s curriculum to monitor progress and as the basis for decision-making Examples: Reading fluency and accuracy Math digits correct Spelling correct words

33. Self-Monitoring An observation technique wherein students are responsible for recording their own behaviors Examples: On-task behaviors Following instructions Beginning work on time Completing chores/tasks Cognitive events such as using self-control, problem solving, experiencing depressive symptomotology

34. Goal Attainment Scaling A rating on a 5-point scale (from -2 to +2) based on the degree to which a student�s performance is approximating a predetermined goal Somewhere between a direct and subjective measurement system Examples: Work completion Accuracy on academic tasks Compliance Using self control Social skill development

35. Specify the target response to record, the kind of measure, and procedures for recording (what, when, where, how) SUMMARIZE & VALIDATE RECORDING PROCEDURES Establish date to begin data collection CNII: Data Collection

36. CNII: Closing Establish date of next appointment Date, time, place Closing Salutation: �Bye! Good luck!� �I�ll check back in a few days to see how things are going.� �Call me if you have questions or problems!�

37. Conjoint Needs Analysis Interview: Opening the Interview Use agenda for participants to keep them informed of the process and meeting objectives (See CNAI Handout 1) General Statement re: Data and Problem Make a general statement to orient consultee toward data Questions or Statement about Behavior Strength Questions and statements about specific data, behaviors, and patterns Statement determining representativeness of the data

39. CNAI: Conditions/Functional Analysis Adequate functional analysis may highlight important functions of a behavior (i.e., lead to functional hypotheses) or pinpoint environmental events (i.e., lead to contextual hypotheses) that impact or maintain the target behavior �Functions� refer to the function that a behavior serves for an individual, and are often related to environmental conditions that reinforce its occurrence (i.e., motivate a person to engage in the behavior) Examples include attention, escape, avoidance, others It is critically important to conduct a careful conditions/functional analysis to accurately generate hypotheses and develop meaningful interventions

40. Primary Outcomes of the Functional Assessment Process A clear description of the problem behaviors, including classes or sequences of behaviors that frequently occur together Identification of events, times, and situations that predict when the problem behaviors will and will not occur Identification of the consequences that maintain the problem behaviors (i.e., what functions the behaviors appear to serve for the person)

41. Development of one or more summary statements or hypotheses that describe specific behaviors, a specific type of situation in which they occur, and the outcomes or reinforcers maintaining them in that situation Collection of direct observation data that support the summary statements that have been developed Primary Outcomes of the Functional Assessment Process

42. CNAI: Conditions/Contextual Analysis Antecedents, Consequences, Sequential/Ecological conditions are explored in relation to the specific data collected by consultees What happened before, after, and during the occurrence of the target behavior? What things may have triggered or maintained a behavior? What patterns were present that may be related to the occurrence of a target behavior? Trends across settings (e.g., home and school) are investigated; cross-setting conditions and setting events are highlighted when appropriate Are there common things that happen across settings that trigger or maintain a behavior? Do events occurring in one setting precipitate, trigger, or predict a behavior in another setting?

43. Environmental variables can function as discriminative stimuli for behaviors, as consequences that maintain behavior, and as stimuli that elicit behavior Environment covariation can reflect a causal relationship, so it is important to identify environmental sources of behavioral variance Ask: �to what extent do target behaviors demonstrate covariation with environmental events, and can these controlling environmental stimuli be targeted for modification?� Conditions Analysis: Summary

44. CNAI: Skills Analysis Often what appears to be �behavior� problems are in reality related to skill (vs. performance) deficits Can�t do vs. won�t do (i.e., skill vs. will) Skills analyses are important when the target behavior concerns skills to be mastered Steps of skills analyses: Identify target skill that should be present Break the skill down into component parts Assess the client�s ability to perform each component Determine the uppermost level at which the client can perform Develop an intervention starting at this point

45. CNAI: Hypothesis Generation Can be based on the function, context, or skills/deficits surrounding the behavior Hypotheses addressing function are based on an examination of the consequences that are presumed to maintain the behavior Contextual hypotheses are based on an analysis of the settings or events wherein a behavior is likely to occur Skills hypotheses are based on the identification of deficits in the child�s behavioral repertoire

46. CNAI: Interpretation/Hypothesis Statement Consultant elicits consultee�s perception regarding the purpose, function, or �causes� of the behavior Careful (strategic) questioning and summaries prior to this point in the process should assist consultees in forming appropriate hypotheses More appropriate interpretations should be provided by the consultant when necessary Interpretation should be based on the conditions/skills/functional analyses (behaviorally- or environmentally-based, rather than following a medical model) Provides an important link between assessment and intervention!

47. Case Example During independent work time, Servio daydreams and fails to complete any math worksheet problems. When his teacher tells him to get to work, he argues that he is working, and sometimes writes down random answers. The teacher requires students to bring uncompleted or incorrect work home. At home, Servio�s mother works the night shift and leaves the house at 7:00. She tries to get him to do his homework before leaving, but he spends his time watching TV, fighting with his younger brother, and arguing with his mother. Servio leaves to catch the bus before his mother gets home from work. Upon returning to school, he doesn�t turn in his worksheet and gets a �0� in the gradebook. What are some possible target behaviors in this case? What are some possible antecedents, consequences, and sequential conditions in this case? (Contextual analysis) What are some possible functions of his behaviors? (Functional analysis) What are some important areas to explore during the conditions analysis?

48. CNAI: Plan Strategies Focus on identifying: Ways to change the context Ways to prevent the problem behavior Ways to increase expected behavior or teach a replacement behavior What should happen when the problem behavior occurs What should happen when the desired behavior or replacement behavior occurs

49. CNAI: Plan Strategies Consultant and consultee establish general strategies and specific tactics that might be used in treatment implementation Strategies should be related to the hypothesis/interpretation statement May use brainstorming techniques SUMMARIZE & VALIDATE PLAN Use form and write it down! See CNAI Handouts 4 - 7

50. Other Considerations When Designing Intervention Programs Diagnosis Target Behavior Characteristics Intervention Variables Consultee Variables Intervention History

51. Interventions That Influence Antecedents of Problem Behavior Alter schedule of activities; Adapt curriculum or task-specific aspects of instruction; Vary size of instructional groupings; Provide special directions regarding instruction; Introduce pre-corrective strategies before problems occur; Teach students rules.

52. Factors That Influence Success of Consequence Components of a Behavioral Intervention Plan Length of reinforcement interval; Program reinforcers; Reinforcement variables.

53. Factors Influencing Acceptability of Intervention Consistent with teacher and parent beliefs and values Does not require too much effort or time Does not exceed the skill level of the teacher or parent (with support) Is unobtrusive Holds promise of effectiveness!

54. Escape-Motivated Behavior Description: Student need to escape from an aversive situation. Examples: difficult, irrelevant lengthy or ambiguous assignment; undesirable group placement; negative peer or adult interaction. Intervention Options: Instruction in signal responses Safety Signal for Escape-Motivated Behaviors When the function of a behavior is to escape a situation, it may be necessary to teach the student how to appropriately �leave the situation� when they feel they must escape. For example, if a student becomes anxious when asked to do long division you might initiate the use of a signal that they student could use when they need to leave the situation. This safety signal would be used in place of an outburst or some other inappropriate behavior. This signal could be verbal or physical, much like the signals coaches use in baseball. Safety Signal for Escape-Motivated Behaviors When the function of a behavior is to escape a situation, it may be necessary to teach the student how to appropriately �leave the situation� when they feel they must escape. For example, if a student becomes anxious when asked to do long division you might initiate the use of a signal that they student could use when they need to leave the situation. This safety signal would be used in place of an outburst or some other inappropriate behavior. This signal could be verbal or physical, much like the signals coaches use in baseball.

55. Attention-Seeking Behavior Description: Unmet student need for attention, coupled with perception that attention is unlikely to occur. Examples: call outs, swearing, yelling at classmate or teacher; tantrum or noncompliance with adult request. Intervention Options: Non-contingent attention

56. Strategies to Support Positive Behavior Changes Social/environmental re-engineering; Cognitive mediation and self-management; Periodic �booster� training; Advocacy training; Accept �just noticeable difference.�

57. CNAI: Closing Continue data collection procedures Important that data collection continue in the same manner (time, setting, procedure) as collected during baseline! Establish next appointment Closing salutation

58. Conjoint Plan Evaluation Interview

59. Treatment Evaluation The data gathering activity that allows the consultant to determine: What progress the client is making The overall success of an intervention The overall success of services

60. Treatment Evaluation as Feedback Feedback is provided to consultant and consultees throughout the course of consultation Evaluation allows for immediate modification of the treatment plan, if necessary Evaluation/feedback can suggest information about the adequacy of treatment implementation (integrity and strength)

61. Requirements of �Best Practices� in Treatment Evaluation Take systematic, relevant, and repeated measures of the target behavior Specify treatments in such a way that they can be replicated Determine whether treatments are actually benefiting the client Use appropriate design elements (time-series methodology) to demonstrate and replicate meaningful outcomes/effects

62. Evaluating the Intervention Remember: Techniques making up the intervention must be completely identified and described Written summaries/manuals are helpful Specification enhances treatment integrity and allows for empirical investigation of the treatment program Careful specification is critical for replication purposes

63. Establishing the Degree of Variability Sources of Variability: Measurement procedures/measurement error Extraneous variables/outside influences Treatment program (the good kind of variability!) Remember: The influences of measurement error and extraneous variables must be sufficiently limited or clear to enable a reasonable statement about the effects of the treatment

64. What to Do if Data are Excessively Variable Wait and see if patterns become clearer; variability may be temporary Analyze the sources of variability Explore possible effects due to measurement error Identify possible extraneous variables Attempt to control all possible extraneous variables Examine the temporal unit of analysis (e.g., daily vs. weekly data sets). Some detail may be lost, but �Part of good clinical skill seems to involve knowing when to ignore individual trees in order to see the forest� (Hayes & Nelson, 1986, p. 439).

65. Improving Consultation Cases Use objective (e.g., frequency counts), rather than subjective data Collect data continuously throughout all phases of case study (baseline, treatment, follow up) Collect historical data; effects of treatment are more convincing if problems are chronic and intractable

66. Improving Consultation Cases Consider repeating procedures over a number of cases to replicate the effects Include diverse subjects in replication attempts to assess breadth of intervention Standardize assessment and treatment procedures, including consultation procedures For example, by using structured interview forms and standard intervention programs, the details of �what� was done (and �how�) becomes clear

67. Improving Consultation Cases Assess treatment integrity to ensure that the intervention was implemented correctly This allows for immediate revisions or attention Only when interventions are implemented appropriately can effects of the intervention be determined Assess clinical meaningfulness of outcomes through social validation procedures Treatment acceptability Perceptions of effectiveness of interventions Subjective measures of outcomes Degree to which consultation goals were met Assess generalization and follow up

68. Improving Consultation Cases Formalize procedures for analyzing case data Level changes from baseline to treatment Immediacy effects Overlap in data points across phases Within phase variability Trend in baseline and treatment (see Tawney & Gast) Use formal design structure when possible: ABAB (reversal design) A/B/B+C/A (multi-element design with reversal) Multiple baseline designs

69. Assessing Client Outcomes Direct Observations Consultees can collect data daily, but keep procedures simple! (see consultation record) Use permanent product data if appropriate Include independent observations when possible (e.g., weekly) Include procedures for improving case studies (Galloway & Sheridan, 1994; Kratochwill, 1985)

70. Assessing Client Outcomes Goal Attainment Scaling Provides a method for quantifying parents� and teachers� reports of treatment progress with regard to a target behavior and consultation goal Ratings are made on a 5-point scale from +2 to -2 (+2=behavioral goal fully met; +1=behavioral goal partially met; 0=no progress toward goal; -1=behavior somewhat worse; -2=behavior significantly worse) Assess periodically (e.g., weekly) throughout treatment

71. Assessing Client Outcomes Rating Scales & Questionnaires Include pre- and post- standardized checklists as they relate to your case (e.g., SSRS, Conners� Questionnaires, etc.) Include Problem Behavior Questionnaire during problem identification/analysis to obtain information about the function of the target behavior

72. Problem Behavior Questionnaire 15-item scale completed by teachers Responses based on the degree to which an event is likely to be observed relative to a problem behavior Five functional areas assessed: access to peer attention, access to teacher attention, escape/avoidance of peer attention, escape/avoidance of teacher attention, setting events

73. Problem Behavior Questionnaire Scores plotted on the PBQ Profile Items marked 3 or above are considered potential hypotheses for the problem behavior; if 2 or more items within one area are rated 3 or above, a primary hypothesis is suggested Authors suggest that interventions should focus on teaching the student an alternative behavior that serves the same function as the problem behavior

74. Assessing Client Outcomes Social Validity Include social comparison and subjective evaluation data (Kazdin, 1977) Treatment Acceptability Include Child Intervention Rating Profile (Witt & Elliott)