Bell | 7-14




Positive Approaches Journal - Volume 2 Title

Volume 8 ► Issue 3 ► 2019



Analyzing Positive Behavioral Support through One Individual’s Experiences

George Bell IV


Abstract

Positive Behavior Support (PBS) in conjunction with effective programming provides an effective paradigm for supporting individuals with complex needs.  The framework of PBS contains an assortment of approaches that can be implemented successfully in a community setting, while still emphasizing the concepts of individuality and Everyday Lives. This article will analyze one person’s experiences and demonstrate the effectiveness of implementing a program based on interventions grounded in the philosophy of PBS. 

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Introduction

Within the context of community-based services, the system is sometimes faced with challenges that seem unsurmountable.  Yet, experiences demonstrate that with the application of strategies grounded in the philosophy of Positive Behavior Support (PBS), in conjunction with effective programming, even the most complex situations can be effectively managed. 1

Case Study

Consider this case in which a 14-year-old male presented with pervasive medical and behavioral needs. As he aged, the family described increasing difficulty to manage his needs.  He was receiving supports through multiple systems, yet locating resources that possessed not only medical expertise, but could also support developmental and behavioral challenges, was difficult.

The response became all too familiar. Providers were unable to provide support based on the concurrence of behavioral and medical issues. With each passing day, the challenge of supporting this individual increased, eventually resulting in recommendation for Residential Treatment Facility (RTF) placement.  Referrals were made, but the team encountered similar responses.  Programs were unable to support the co-occurrence of medical and behavioral needs.  Eventually, the family became unwilling to accept discharge from an emergency room, resulting in an acute psychiatric placement. 

Upon admission to the acute psychiatric setting, the first task facing the hospital’s team was to mitigate the significant health and safety risks resulting from self-removal of the tracheostomy and G-tube.  Initially, the only feasible mechanism of prevention included frequent 4-point restraint use. Eventually, though, the team developed a modified arm brace that helped prevent removal of the medical devices.  This was a significant turning point in achieving stabilization.  Further development of interventions continued with utilization of psychotropic medications and behavioral-based techniques.  Still, the successful reduction in removing medical devices was the most significant achievement and paved a path to potential community-based placement.

Eventually, a provider agency committed to developing a program for this child. During transition, the agency initiated a comprehensive Functional Behavioral Analysis (FBA), employing a host of assessment and screening activities to better understand the function and motivating factors of his behaviors.  Thorough assessment is a cornerstone of PBS. 2 One process employed during transition was the Biographical Timeline (BT).  The BT is a critical element used to generate data on a person’s history through facilitated team discussions. The BT facilitator documents the information generated on a visual timeline.  This process enables the team to learn from the person’s history, focus in on their role as supporters, and develop empathy and understanding for the person’s experiences. 3 This process provided a comprehensive understanding of previous medical and behavioral challenges. 

Environmental design is an integral part of program development and an important aspect of PBS. 4 It is a proactive process to create a setting specifically geared towards a person’s needs. It is effective because it seeks to modify potentially hazardous or anxiety-provoking stimuli, while also incorporating characteristics to foster success. The foundation of the program developed for this individual included the provision of a 1-person home with 2:1 staffing support and 24-hour nursing care. Other adaptations included specialized padding on dangerous surfaces, Lexan to replace glass, a fenced-in yard, limited access to dangerous items, and incorporation of specialized furniture.

Another important evaluation included completion of a sensory assessment.  According to Reynolds et al., evaluating the impact of sensory integration can support professionals to understand “… how sensory experiences serve as antecedents for undesirable behaviors and identify positive sensory experiences to use as rewards for reinforcing desirable behaviors.”  By fully exploring the impact of sensory integration, it provided framework for additional modifications, including development of a sensory room.  It also led to the installation of a swing, which can have calming affects in over-stimulated children. 6 Not only was this a helpful coping mechanism, but it was found to be useful in pairing with other less preferred activities. It became a means to facilitate the completion of adaptive and self-care skills that were otherwise difficult to perform.

The team believed that communication deficits were a primary source of issues aligned with self-regulation.  The implementation of a functional communication assessment and training is another intervention grounded in the philosophy of PBS. 7  The team implemented the Verbal Behavioral Milestones Assessment and Placement Program (VB-MAPP). The purpose of this assessment is to evaluate baseline skills and design intervention strategies. 8 Using the VB-MAPP, the team developed strategies that enhanced the opportunity for communication.  Specific strategies that were developed included the use of adapted sign language and implementation of a modified version of the PECS (Picture Exchange Communication System).

Another critical component of success included implementation of a trauma informed environment with emphasis on consistency and predictability.  9,10 The agency sought to achieve this by fostering trust with supporters, describing this as a critical factor in achieving success. Efforts to provide consistency with staffing supports led to the development of trusting relationships, which in turn enhanced predictability in the child’s life.  The team believed this was a significant antecedent to reducing concerning behaviors and improving success.

Although much focus was maintained on development and learning, there was also a need to incorporate comprehensive safety planning in response to crisis.  Strategies highlighted resources to be utilized during the occurrence of challenging behaviors, such as the nursing supports to respond to the removal of medical devices.  In creating a plan to mitigate this predictable behavior, chronic emergency room visits were often avoided.  An on-site medical professional was able to provide treatment, avoiding the potential crisis that could accompany treatment from professionals unfamiliar with the individual.  Eliminating these pitfalls was a significant driver in achieving success and furthered the team’s efforts towards the development of a stable environment.  

In addition to the accomplishments of program development, it is still necessary to be flexible and willing to adapt to change.  “PBS is an approach to behavior support that includes an ongoing process of research-based assessment, intervention, and data-based decision-making ….” 11 The team placed a great deal of emphasis on data collection and analysis as a means to capture progress, identify change, and recognize new challenges.  The Antecedents, Behaviors, and Consequences (ABC) tracking tool was the primary mechanism used to collect data.  This documentation is completed in hourly intervals and used to formulate interpretations related to target behaviors. The data is gathered and closely scrutinized each month.  This ensures that significant change is quickly identified, which enables the team to update the health and safety plan within 24 hours.  A change in this plan also sparks a process for informing and training staff.  Therefore, when significant change is identified, the team can respond in a timely manner. It is through this continued emphasis on data collection that the team can respond effectively to changing needs.

Despite an assortment of barriers, this individual has not only remained in the community, but he has thrived.  This is not to suggest that challenges no longer exist, as there are still intensive needs.  Instead, the takeaway is that comprehensive assessment grounded in the philosophy of PBS can be a cornerstone in the development of effective individualized supports. Assessment helped to recognize specific needs leading to the creation of an environment that fostered success.   In understanding the holistic person and creating an individualized program based on this knowledge, it has enabled this child to achieve what we hope for everyone: an opportunity to live an Everyday Life.




References
  1. Chartier, K., (2015).  Outcome evaluation of a specialized treatment home for adults with dual diagnosis and challenging behavior.  Journal of Developmental Disabilities, 21(2).
  2. Burke, M. D., Rispoli, M., Clemens, N. H., Lee, Y. H., Sanchez, L., & Hatton, H., (2016).  Integrating universal behavioral screening within program-wide positive behavioral interventions and supports. Journal of Positive Behavior Interventions, 18(1), 5-16.
  3. Barol, B., (2001).  Learning from a person’s biography: An introduction to the biographical timeline process. Positive Approaches, 3(4).
  4. Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., & Fox, L. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions, 4, 4–16.
  5. Reynolds, S., Glennon, T. J., Ausderau, K., Bendixen, R. M., Kuhaneck, H. M., Pfeiffer, B., Watling, R., Wilkinson, K., & Bodison, S. C., (2017).  Using a multifaceted approach to working with children who have differences in sensory processing and integration.  The American Journal of Occupational Therapy, 71(2), 1-10.
  6. Davis, T., Abdo, A. L., Toole, K., Columna, L., Russo, N., & Norris, M. L., (2017).  Sensory motor activities training for families of children with autism spectrum disorders.  Palaestra, 31(3), 35-40.
  7. Kincaid, D., & Horner, R., (2017).  Changing systems to scale up an evidence-based educational interventionEvidence-Based Communication Assessment and Intervention, 11(3-4), 99-113.
  8. Barnes, C. S., Mellor, J. R., & Rehfeldt, R. A., (2014). Implementing the verbal behavior milestones assessment and placement program (VB-MAPP): Teaching assessment techniques.  Association for Behavior Analysis International, 30, 36-47. 
  9. Gentry, J. E., Baranowsky, A. B., Rhoton, R., (2017).  Trauma competency: An active ingredients approach to treating post-traumatic stress disorder.  Journal of Counseling and Development, 95, 279-287.
  10. Hodgdon, H. B., Kinniburgh, K., Gabowitz, D., Blaustein, M. E., & Spinazzola, J., (2013). Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework.  Journal of Family Violence, 28, 679-672.
  11. Kincaid, D., Dunlap, G., Kern, L., Lane, K. L., Bambara, L., M., Brown, F., Fox, L., & Knoster, T., P., (2016). Positive behavior support:  A proposal for updating and refining the definition.  Journal of Positive Behavior Interventions, 18(2), 69-73.

Biography

George Bell IV is 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 nearly five years. Prior to his current position, he worked with a private provider agency for more than 20 years supporting individuals with intellectual and developmental disabilities in community-based programs. 

Contact

George Bell IV

PA Department of Human Services

Office of Developmental Programs

Northeast Regional Office

100 Lackawanna Ave

Scranton, PA 18503

(570) 963-4982