Positive Approaches Journal, Volume 10, Issue 4

Positive Approaches Journal | 6

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Introduction

If there’s one thing we’ve learned in the past year, it’s the value of being able to pivot. Our routines have been ransacked, whether we’re providing support services in our jobs or planning a family gathering. Day by day, we evaluate the risks and benefits of any activity involving an encounter with others and make choices about social distance, masks, and using hand sanitizer. The restrictions have encouraged us to develop creative ways to take part in the world around us. Meeting in parks, virtual breakout rooms, or under patio lights by a firepit is now commonplace. Flexibility once praised primarily for people in creative endeavors, has become a survival strategy. And those who have mastered the ability to adapt quickly have thrived in spite of the obstacles.

Positive Behavioral Support, when done well, merges not only evidence-based practices but also ones that are flexible and creative. All humans use behaviors that work for them. Behavior specialists work like detectives uncovering clues and solving the puzzle to determine the functions of behavior. Each plan is unique and individualized, exploring not only observable consequences but also past trauma, environment, and genetics.

Articles in this issue encourage us to focus on merging silos of mental and physical health and incorporating biomedical and socio-environmental influences which all play into how a person behaves. No longer limited to practices like discrete trial training and aprons filled with M&M’s, Positive Behavioral Support has proven effective in a variety of messy settings where challenging behaviors are likely to be triggered, like fast-food restaurants, playgrounds, job sites, and people’s homes. We’ve learned that behavioral approaches, once thought to be effective only with specific populations of people with diagnoses like autism or intellectual disability are effective for everyone, especially when developing plans with people who require complex mental health support. Creating multidisciplinary teams with a variety of stakeholders who like and admire the person needing support helps to promote a positive outcome and ensures simplicity and ease of administering a plan that works for everyone.

If this work inspires you, check out The Home and Community Positive Behavior Support (HCPBS) Network of the Association of Positive Behavior Support. HCPBS is a nonprofit organization that is dedicated to expanding and enhancing the application of positive behavior support principles across home and community settings, contexts, and the lifespan for people with behavioral challenges (including intellectual and developmental disabilities, mental health diagnoses, and seniors who require memory care and other related services) and the systems who support them. The HCPBS website (www.hcpbs.org)  is loaded with practical resources, videos, stories of people who have been helped, and a treasure trove of evidence-based practices and research.

Positive Approaches Journal | 8-12

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For more resources and training to learn more about PBS, visit the Home and Community Positive Behavior Support Network (HCPBS) website (www.hcpbs.org/). HCBPS is a clearinghouse of resources, webinars, literature, and other information focused on the application of PBS in home and community-based settings. For more information about the web based ODP FBA training, visit: https://www.myodp.org/enrol/index.php?id=1644. For more resources about FBAs from ASERT visit: https://paautism.org/resource/functional-behavioral-assessment-student-education/.

 

References

1.     Hieneman M. Positive Behavior Support for Individuals with Behavior Challenges. Behavior Analysis in Practice. 2015;8(1):101-108. doi:10.1007/s40617-015-0051-6

2.     Horner RH, Dunlap G, Koegel RL, et al. Toward a Technology of “Nonaversive” Behavioral Support. Research and Practice for Persons with Severe Disabilities. 2005;30(1):3-10. doi:10.2511/rpsd.30.1.3

3.     Smith JD, St. George SM, Prado G. Family-Centered Positive Behavior Support Interventions in Early Childhood To Prevent Obesity. Child Development. 2017;88(2):427-435. doi:10.1111/cdev.12738

4.     Todd A, Horner HR, Vanater S, Schneider C. Working together to make change: An example of positive behavioral support for a student with traumatic brain injury. Education & treatment of children. 1997;20(4):425.

5.     Gardner RM, Bird FL, Maguire H, Carreiro R, Abenaim N. Intensive Positive Behavior Supports for Adolescents with Acquired Brain Injury. Journal of Head Trauma Rehabilitation. 2003;18(1):52-74. doi:10.1097/00001199-200301000-00007

6.     What is Positive Behavior Support? Home and Community Positive Behavior Support Network (HCPBS). Accessed February 10, 2022. https://hcpbs.org/what-is-positive-behavior-support/

7.     Shriver MD, Anderson CM, Proctor B. Evaluating the Validity of Functional Behavior Assessment. School Psychology Review. 2001;30(2):180-192. doi:10.1080/02796015.2001.12086108

Alford, Arva, Bell, Burger, Easley, Gaworski, Hollander & Treadway | 13-31

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Misconception #1: Behavioral support only works for people with autism and certainly is not effective for people with mental illness.

Research has established behavioral interventions as an effective treatment strategy for people with autism; however, that does not mean behavioral supports and interventions should be limited to those diagnosed with autism. Behavioral supports include the development and implementation of behavioral interventions that are grounded in FBA across diagnoses.

The connection between behavioral support and mental illness is often misunderstood and undervalued. Behavioral supports may be overlooked as a treatment option for people with mental illness because when we think of “behavior” we associate it with things that we can readily observe such as breaking objects, biting, or refusals to complete personal hygiene whereas mental illness is viewed as an internal or physiological state that we cannot easily observe. It is often misconstrued that there is nothing behavioral supports can do to address behavior that is attributed to an internal state. Griffiths, Gardner, and Nugent offer a comprehensive and individualized approach to functional behavioral assessment that incorporates assessment of both biomedical and socio-environmental influences.¹ Biomedical factors may play a part in explaining the occurrence of problem behavior.

Behavioral assessment can effectively be utilized to understand the interaction between physiological (biomedical) and environmental factors. For example, an individual is diagnosed with an anxiety disorder and when faced with an anxiety-provoking situation that results in physiological changes such as sweating and a pounding heart, a problem behavior such as physical aggression is triggered. An FBA can assist in identifying those situations that are associated with the physiological symptoms of anxiety so that behavioral strategies can be put in place to prevent or reduce the likelihood of physical aggression. Additionally, the role of other biomedical factors such as medications, sleep, and medical conditions may be discovered during the FBA which aids in the development of comprehensive behavioral interventions.

As the needs within our system grow so does the complexity of behavior. Factors like trauma, neurodevelopmental differences, environment, and genetics all play into how an individual behaves. It can create a confusing picture and many teams are not sure where to begin or what to address first. Utilizing a functional behavioral assessment can help to clarify that picture and to sort out the complexities. Mental health diagnoses are at their essence a collection of visible behaviors and internalized thoughts and emotions.² It is not easy for the individual to sort out and verbalize nor is it easy for the outside observer. Practicing the use of purposeful, evidence-based tools allows the individual and the support team to better define and understand what is happening. Furthermore, it can potentially be determined what other factors influence the symptoms and can be changed or adapted to improve the outcome.³ There is evidence dating back to some of the very first behavior analysts that indicates that the modification of antecedents and triggers can produce different outcomes for those living with mental illness. In fact, behavior modification rooted in functional behavior assessment was used to support things like improvements in social skills, working skills, and overall independent living over 30 years ago.³

Misconception #2: Behavioral support is the only treatment modality that will address challenging or problematic behavior.

Effective behavioral supports require a multidisciplinary approach. This is especially true when the person receiving support has complex needs. Complex needs are complex because supports require a biopsychosocial approach – it’s never one thing. ³ As mentioned above, behavioral assessment can effectively be utilized to understand the interaction between physiological (biomedical) and environmental factors. Behaviors have a suspected physiological cause. It is within the scope of behavioral support to collaborate with other professionals to develop a holistic plan that includes recommendations and instructions from a multidisciplinary team, especially when the FBA does not demonstrate a clear relationship between environmental antecedent and behavioral function.

These professionals include:

Some of these professionals may already be involved when this person becomes known to the behavioral specialist and some may be identified during the FBA process when the behavioral specialists identify needs beyond their scope of practice and seek recommendations from relevant professionals. The resulting Behavioral Support Plan (BSP) should be a document that is consistent with and informed by the treatment plans developed by all members of the multidisciplinary team and is aligned with the individual’s values and goals.

Misconception #3: The more complex a person’s needs are, the more behavioral support is required.

One of the most common yet unfitting assumptions we encounter in supporting people with complex needs (i.e., needs requiring significant attention, resources, or supports) is that increases in maladaptive behavior should be met with an equivocal increase in service. In other words, the more concerning behavior a person exhibits, the more we attribute a need to increase direct behavioral supports. However, an increase in direct support is not always the answer. Of course, there are times where the challenges a person exhibits can be mitigated by increasing direct service, but often these increases can have an inverse effect, and can even exacerbate the problem. At its core, behavioral support is about the consistent implementation of the BSP by the entire support team.

As a review, let’s provide simple explanations for these two approaches.

In order to fully understand how to effectively support behaviors, we should first consider the philosophy of “quality over quantity.” Sometimes it is not necessarily how much direct support is provided, but rather the content, quality, and implementation of these services that truly drive effectiveness. Yet, the first response by many teams often involves some form of direct service increase. Instead of providing a quantitative response characterized by increases in direct support, emphasis should first consider a review of qualitative factors often found through indirect means. The focus should incorporate a review of plan fidelity and consistency of plan implementation. Additional indirect activities should incorporate a review of data, elicited feedback from the multidisciplinary team, observation, and additional training to supporters. It’s through these activities where most factors limiting success can be identified, resulting in a more profound impact than simply increasing direct support.

In summary, if response efforts maintain focus on indirect strategies that seek to analyze data and evaluate fidelity, changes can be made to better modify the environment and best meet the person’s individualized needs. When we question the effectiveness of supports, our focus is not always best served by increasing direct service with the individual. Instead, this provides an opportunity to enhance the implementation of indirect strategies that enable us to better understand the problem and how to best support the person. This includes an emphasis on:

Adopting this approach empowers the multidisciplinary team to work collectively and ensure the application of supports is provided in a consistent manner, as they were intended, and helps to alter the practice of simply adding already ineffective direct supports as a means of better managing the person’s needs. Without these considerations, there is an increased risk of over-reliance on the behavioral specialist. After all, effective behavioral support is evidenced by empowering other members of the team to understand the function of challenging behaviors and implement individualized strategies with integrity.

Misconception #4: Behavioral support is primarily focusing on developing rewards as reinforcement for the person to decrease their challenging or problematic behavior.

When people think about behavioral support, many envision Pavlov’s dogs or Skinner’s reinforcement theory. Many think of sticker charts and token economies or tangible rewards used in discrete trials when training new skills. Though these are all components of its history, the field has grown from this simple notion of rewards and consequences to a rich tapestry of understanding and perspective rooted in the experience of the person supported.

A behavioral approach, at its core, is all about reinforcement, but the principles of reinforcement are often misunderstood. All humans engage in behavior that is functional to them. This means that our individual behavioral repertoires are developed throughout our lifetimes based on our experiences and responses to those experiences. We continue to engage in behaviors that have been successful in meeting our needs in different situations throughout our lives. Favorable consequences or outcomes make it more likely that the behavior that led to that outcome will occur in that situation in the future. This is the core of reinforcement theory, but behavioral support is so much more than a focus on decreasing challenging behavior by pairing new behaviors with rewards or privileges thought to be reinforcing.

Through the FBA process, a behavioral specialist should have a functional understanding of a person’s challenging behavior. This includes an understanding of the situations in which challenging behaviors have historically occurred as well as an understanding of WHY those situations may be challenging to the person. To understand the function is to understand the reinforcement history of that behavior. In practice, this means if the behavioral specialist has completed a quality FBA, they already know the needs of the person in specific challenging situations as well as what will likely reinforce more efficient alternative and replacement behaviors. Positive behavioral supports focus on modifying or avoiding those situations to help the person be more successful in the future. As one cannot simply suggest an environment change in isolation, one must couple that with skill-building, “...to promote performance of desired behaviors, support planners must ensure that these behaviors have been taught and that they produce adequate maintaining consequences (reinforcers) when they occur.⁴” This is accomplished in two ways. First teaching more efficiently achieves the same function when preventative strategies are not effective, and second, by teaching alternative behaviors that help the person cope with some of the challenges presented in those situations.

Behavior support in current practice takes a holistic approach to assessment and implementation.  When a problem behavior has been identified and supports are sought, the gathering of information begins. As the assessment gives shape to the behavior support plan, we see the proactive nature of behavior support emerge. It is not about responding to a crisis and stopping the behavior at that moment but rather setting up the internal and external environment to respond proactively to avoid the crisis altogether. The plan focuses on identifying alternative, adaptive responses to a given trigger or antecedent and practicing those to create a fluidity that feels natural and then becomes the default.

Interventions focus on modeling, coaching, teaching, and transferring skills to the team and individual supported. This can only be accomplished through ongoing assessment and feedback of the efficacy of interventions and their outcomes.  It is not aversive conditioning but rather reteaching the response to triggers and antecedents and building the necessary skills to do so. Carr’s discussion suggests one can be confident that positive behavior support as an approach focuses on skill-building and environmental design as the two vehicles for producing desirable change.⁵

If a person is only working for a reward when that reward is removed, the desired behavior will not likely continue. However, if you teach a person how to respond differently or adapt an environment to be more suitable, systematically fading and modifying the reward contingencies as part of the larger plan, the conditions themselves work to change the behavior and lead to long-lasting success.

Misconception #5: There is one right way to conduct an FBA.

Behavioral support is rooted in FBA and therefore functional understanding of behavior. The FBA is not a one-time thing, but an ongoing process that should be the core of any BSP. Behavioral specialists should always base their interventions on the most current and comprehensive functional hypothesis of challenging behavior.

Unlike other assessments and tools, the FBA is an individualized process to understand why someone does what they do. By collecting information, analyzing information, and making data-based recommendations, a comprehensive BSP can be developed. If all FBAs are identical, you may be missing key information needed to understand the person you are supporting. Recognizing that an FBA is an ongoing process ensures that teams have the most up-to-date information and data to understand the function of the targeted behaviors. That being said, there are best practices to the FBA process that should be considered to ensure the BSP approaches treatment and intervention comprehensively, holistically, and individualized to the person.

The first best practice of the FBA process is through indirect and direct information gathering. Record reviews are one method of indirect information gathering which offers a historical perspective of the individual and the targeted behavior, while also gathering social, medical, educational, and/or behavioral information. There are no rules around what information must be gathered during record reviews, however, the information gathered should be relevant to the targeted behavior and understanding what may be maintaining the behaviors. Interviews are another form of indirect information gathering that offers personal perspectives from the individual and people who know them well. These personal perspectives can be gathered through questionnaires, rating tools, and/or structured/unstructured conversations. Some examples of these tools are the functional Assessment Interviews (FAI), Motivation Assessment Scale (MAS), Questions About Behavioral Function (QABF), and Functional Assessment Screening Tool (FAST). The questionnaires, tools or assessments that are used during the FBA process should provide enough information to formulate a hypothesis that will drive the multi-component behavioral support plan.

Direct information gathering includes observation of the individual in their natural environment. It should include data collection of the targeted behavior to more clearly define the behavior, support or refute the interview information, determine baseline levels and current levels of skills, provide objective information on conditions surrounding behaviors, and lead to a more accurate hypothesis of the behavior. The data collection method and items collected need to be specific to the individual. It should be succinct, targeted to the behavior of the individual, and written using clear, quantitative, consistent, and targeted language. Be sure to consider other elements of data collection beyond a frequency count (e.g. duration, latency, intensity).

Once the data is collected, a thorough analysis of the information to identify patterns, form hypothesis statements, and inform the data-based recommendations should be completed. Often, Excel or other similar programs are used to create graphs, but there is great flexibility in how the information should be analyzed and presented to the person and other team members. The data-based recommendations should then be identified based upon the information gathered and analyzed as part of the FBA process.

Many think this is the end of the FBA process, but this process should be ongoing for the duration of the time the person receives behavioral support. As support is provided and ongoing data is collected and analyzed, the behavioral hypothesis may change and the strategies within the BSP must also change to reflect the most current hypothesis. The FBA must also be updated to reflect these changes.

Misconception #6: Behavioral support and therapy are the same.

The education and experience of a therapist or counselor provide an important perspective to behavioral support, but in practice it is very different from traditional therapy, counseling, or social work. Behavioral support is about more than the behavioral specialist’s “sessions” with the individual. It is more than providing access to resources and tools. Behavioral support is more about DOING than THINKING. It uses data to assess problematic behaviors and creates a team implemented plan to teach skills, express needs, and create more successful environments for the individual. Successful behavioral support relies primarily on the time outside the direct interaction with the behavioral specialist. Therapy, on the contrary, helps someone develop strategies to change the way someone thinks. Primarily, a therapist works directly with the person to process feelings and emotions without direct intent to manipulate or change the environment and others in their environment.

Sometimes we feel like people need access to certain supports and when there are seemingly barriers to accessing needed supports, like counseling or therapy, the behavior specialist jumps in and takes on a role outside their scope. This well-intentioned act can be detrimental to the individual receiving services and can cross an ethical line that should not be crossed. Programs have different service lines for a reason. If someone needs therapy, they should receive therapy (in addition to behavioral support).

References

1.     Gardner WI, Griffiths DM, Jo Anne Nugent, National Association For The Dually Diagnosed. Individual Centered Behavioral Interventions: A Multimodal Functional Approach. Nadd Press; 1998.

2.     Wong SE. Behavior Analysis of Psychotic Disorders: Scientific Dead End or Casualty of the Mental Health Political Economy? Behavior and Social Issues. 2006;15(2):152-177. doi:10.5210/bsi.v15i2.365

3.     Griffiths DM, Summers J, Chrissoula Stavrakaki. Dual Diagnosis: An Introduction to the Mental Health Needs of Persons with Developmental Disabilities. Habilitative Mental Health Resource Network; 2002.

4.     Rehabilitation Research and Training Center on Positive Behavioral Support. PBS Practice. Association for Positive Behavioral Support. https://www.apbs.org/files/competingbehav_prac.pdf. Accessed January 5, 2022.

5.     Carr EG, Dunlap G, Horner RH, et al. Positive Behavior Support: Evolution of an Applied Science. Journal of Positive Behavior Interventions. January 2002; 4:4-16.

Biographies

Amy Alford M.Ed., BCBA, is a Senior Clinical Consultant for the Bureau of Supports for Autism and Special Populations (BSASP), Office of Developmental Programs (ODP). She has been supporting children, adolescents, and adults with autism and other developmental disabilities for over 15 years in community, home, and school settings. She holds a master’s degree in Special Education and in 2011, became a Board-Certified Behavior Analyst (BCBA). Prior to joining the BSASP clinical team in 2008, Amy was a behavioral specialist for a provider in the Behavioral Health Rehabilitation Services (BHRS) system (now Intensive Behavioral Health Services (IBHS)). She spends much of her time leading training efforts across ODP and continues to apply principles of positive behavioral supports and applied behavioral analysis throughout her work.

Heidi Arva has worked as a Clinical Consultant for ODP’s- Bureau of Supports for Autism and Special Populations since the Spring of 2016. Prior to working at ODP, she spent over 15 years providing direct support to adults, children, and families within the mental health system.

George Bell IV, MA is is currently assigned as the Regional Clinical Director for the Northeast Region's Office of Developmental Programs, Bureau of Community Services. He has worked with the state office for seven years. Prior to his current position, he worked with a private provider agency for more than twenty years supporting individuals with intellectual and developmental disabilities in community-based programs.

Emily Burger MS, NCC is a Special Populations Professional in the Bureau of Supports for Autism and Special Populations. Prior to joining ODP, Emily worked with both the mental health and intellectual disability/autism community. She provided a wide variety of supports spanning from children's services, psychiatric rehabilitation, and residential community homes to most recently directing a behavioral support program. Currently she works with the Special Populations Unit focusing on complex cases with children, infant mental health and communication.

Heather Easley has worked for the Office of Developmental Programs (ODP)- Bureau of Supports for Autism and Special Populations as a Clinical consultant for 4 years. Prior to her work at ODP, Heather spent over 10 years supporting children, and adults across multiple systems.

Lindsay Gaworski joined ODP as a contractor in 2021 as a Clinical Director within the Western Region. Lindsay holds a Master of Education in Special Education from the University of Pittsburgh, with focused and intensive coursework in Applied Behavior Analysis. In addition, Lindsay has over 12 years of professional experience across multiple systems service lines including serving 2-5 year old children with ASD within a partial hospital setting, Intensive Behavioral Health Services (formerly BHRS) working with youth and families as a BSC while serving as a provider Autism Director, and most recently a Clinical leadership role within a residential provider. Lindsay is a graduate of the Capacity Building Institute, Year 3.

Jordan Hollander M.Ed., BCBA is a Senior Clinical Consultant for the Office of Developmental Programs – Bureau of Supports for Autism and Special Populations. He has been working for the past 12 years to help people on the autism spectrum identify goals, and work towards achieving them through a person-centered approach that utilizes the principles of positive behavioral supports. Jordan has worked in various Direct Support Professional roles as well as in clinical and operational management positions for various service providers throughout Southeastern PA.

Pamela Treadway, M.Ed., is a Senior Clinical Consultant for the Bureau of Supports for Autism Services and Special Populations, Office of Developmental Programs, Department of Human Services. She has been supporting individuals with disabilities for 42 years in home and community settings. She received a master's degree in special education from Lehigh University and has worked with adults and children with autism, intellectual disability, and emotional and behavioral disabilities.

Contact Information

Amy Alford M.Ed., BCBA

Office of Developmental Program – Bureau of Supports for Autism and Special Populations

Senior Clinical Consultant

c-aalford@pa.gov

Heidi Arva

Office of Developmental Program – Bureau of Supports for Autism and Special Populations

Clinical Consultant

c-harva@pa.gov

George Bell IV, MA

Office of Developmental Programs - Bureau of Community Supports

Clinical Director

c-gbelliv@pa.gov

Emily Burger MS, NCC

Office of Developmental Program – Bureau of Supports for Autism and Special Populations

Special Populations Professional

c-eburger@pa.gov

Heather Easley

Office of Developmental Program – Bureau of Supports for Autism and Special Populations

Clinical Consultant

c-heasley@pa.gov

Lindsay Gaworski

Office of Developmental Programs - Bureau of Community Supports

Clinical Director

c-lgaworsk@pa.gov

Jordan Hollander M.Ed., BCBA

Office of Developmental Program – Bureau of Supports for Autism and Special Populations

Senior Clinical Consultant

jholland@pa.gov

Pamela Treadway

Office of Developmental Programs – Bureau of Supports for Autism and Special Populations

Senior Clinical Consultant

c-ptreadwa@pa.gov

Hieneman & Fefer | 32-69

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1.     Grossi PhD L, Osborn PhD L, Joplin MME, MT-BC K, O’Conner MS B. Clinical Interventions in State Psychiatric Hospitals: Safety and Logistical Considerations. Journal of Forensic Psychology Research and Practice. 2020;21(2):152-170. doi.org/10.1080/24732850.2020.1843105

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3.     Office of Developmental Programs. Functional Behavior Assessment Training. MyODP. https://www.myodp.org/course/view.php?id=1644

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References

1.     What is Positive Behavior Support? Home and Community Positive Behavior Support Network (HCPBS). https://hcpbs.org/what-is-positive-behavior-support/

2.     Blasingame GD, Haaven J. Practical Treatment Strategies for Persons with Intellectual Disabilities: Working with Forensic Clients with Severe and Sexual Behavior Problems. Wood “N” Barnes Pub; 2006.

3.     Deci E, Ryan R. Motivation, personality, and development within embedded social contexts: An overview of self-determination theory. The Oxford Handbook of Human Motivation. 2012.

4.     Pink DH. DRIVE: The Surprising Truth about What Motivates Us. Canongate Books Ltd; 2018.

5.     Hingsburger D. Power Tools: Thoughts about Power & Control in Service to People with Developmental Disabilities. Langara College; 2007.

Biography

Stacy L. Nonnemacher received her Ph.D. from Lehigh University. She is currently the Clinical Director for the Bureau of Supports for Autism and Special Populations in the Office of Developmental Programs in Pennsylvania's Department of Human Services.  Stacy is the Editor in Chief of the Positive Approaches Journal. She has been involved in the field of disabilities for over twenty-five years supporting children, adolescents, and adults in home, community, and school settings. Dr. Nonnemacher has conducted applied research and training on Positive Behavioral Support, fostering self-determination, Functional Behavioral Assessment, and the needs of and support for individuals with autism.

Contact Information

c-snonnema@pa.gov