Addressing Challenging Behavior - Part 11

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Well, welcome to the final webcast of the Understanding and Addressing Challenging Behavior of Individuals with Complex Needs series. Both Chris and I are here to finish up with you together. You're going to learn about the strategy assessment and revision tool, or SART, today. This is a tool that can help the team decide if a strategy from the intervention plan will have positive outcomes or how to revise one if it isn't working.

SART can also be used as a standalone tool to help with other individuals as you try to assess and revise a strategy. If you're working on the process with an individual, since the last webcast you've completed the reinforcement chart and you've filled out your replacement and related behavior intervention plans.

As we've conducted trainings on how to address challenging behaviors of individuals with complex needs across Ohio, some discussions that kept coming up were how can we know if an intervention will work for an individual before we try it? Or we tried this evidence-based practice, but it didn't work for an individual. Why not?

Some people shared that they had a strategy that worked for almost every student, except this one. Or that they had tried everything, but nothing was working. Sometimes we had person share a strategy that was helping with the challenging behavior, but maybe they couldn't explain what was right about it.

As we repeatedly heard similar comments from professionals and family members, the question became how can we help them figure out why? Why might a strategy work? Or why isn't it working? Or how can we revise the strategy to help it work without changing the fidelity of the strategy? From our research to answer these questions came the strategy assessment and revision tool or SART.

So determine if the strategy is successful, we need to use data to track progress. First, we start with the baseline data of the behavior an individual exhibits, and then continue to gather data as a new strategy or intervention is implemented. The resulting data will show if the strategy is successfully teaching desired behaviors and decreasing behaviors of concern.

In other words, the data will show if the strategy is evidence-based for a given individual. Through research we have identified seven factors across the literature that are likely to contribute to successful outcomes when implementing a strategy or intervention that you've selected. We are going to briefly review each factor. And then show you a tool you can use that will help match an intervention to an individual, possibly through revising the strategy, as you build a positive behavior plan.

So, let's look at the first factor. The first factor is the visual tactile factor. Research supports that many people with complex needs, especially those on the autism spectrum, learn skills and routines best with visual or tactile supports. Visual components for strategies remain constant, are available when a person needs them, and stay consistent across the environments.

Strategies that include visual components are schedules, written picture directions, video modeling. You may have heard of some of them. If an intervention or strategy doesn't have a visual component, and you believe this factor would help the situation, do you just eliminate the strategy as a possibility? No, not necessarily.

That is the revision part of SART. A team can revise a strategy that is not complete. We will be showing you how to think about revising a strategy to possibly include a visual tactile factor. Let's take a look at some examples of strategies that already include the visual tactile factor.

This interactive word wall is one example of a strategy that includes the visual tactile factor. The vocabulary is in ABC order using picture word cards and is able to be taken from the wall to the individual's work area for use with the task associated with the student's grade-level content standards. Next, a word or photo schedule is a strategy that you want to consider. It can be used across many settings, including the vocational setting.

These elements are not just for children or for school, and you'll see that throughout. Each transition for the day is represented by a photo to tell the individual what comes next.

Timers are an intervention that help individuals know how long an activity will be taking place. There are timers that are very visual such as the time timer, with a red area that disappears at the time goes by. Stoplight Clock app, that moves from red to yellow to green at times you set. Or Sharing Timer app, that sets up times for individuals needing to work or play with others in an activity.

Thanks, Chris. Well, the next factor is sensory. So addressing the sensory processing needs of a person is a promising practice that supports the individual with complex needs. This could include persons with neurological disorders, autism spectrum disorders, deafness, blindness, and other multiple disabilities. Addressing an individual's sensory needs can bring regulation and an optimum learning state.

Assessing a strategy to see how it impacts an individual's sensory needs can help it be more successful. Keep in mind an occupational therapist should always oversee a sensory program. Let's take a look at some strategies that include the sensory factor.

The pictures on this slide show examples of self-assessment scales. So these may help individuals to begin to identify the level of the distress they're feeling, based on the sensory input that's occurring in their environment. The example on the right also provides suggestions for sensory activities that may help a person feel better.

The behavior sensory choice board on the left is loosely based on the How Does Your Engine Run program by Williams and Shellenberger. The child is asked to identify if they are just right, or if their engine is running too low, or too high. It then provides some sensory activities under each area to help adjust that engine to just right again. Using these as interventions considers the sensory factor.

Physical movement and exercise helps everyone. Having movement built into an individual's day or especially right before a challenging activity can help make a strategy more successful. Physical movement as a strategy addresses the sensory factor.

Having a place to regroup can be a benefit to some individuals. This is not timeout, but rather a place to calm the sensory system using ideas from the occupational therapist. A calming area, as an intervention, takes the sensory factor into account.

The next factor is the positive reinforcement factor. Positive reinforcement is a practice that is supported by a strong evidence in research and in every day use, as well. It is often associated with teaching of new skills and interventions. Positive reinforcement is basically rewarding a desired behavior in a way that the person will want to use that desired behavior again and again and again. Another way to explain it is to say that positive reinforcement is providing a person with something he desires after he engages in the behavior you are teaching, in order that same behavior will occur again in the future.

The idea is that even when a person is able to earn a favorite outcome or reward after using a specific behavior, that particular behavior will increase over time. For example, if every time I wear a particular dress my husband tells me I look beautiful, I will likely choose that dress to wear over many other choices. Or if a student is allowed to be first in line to get a snack when she sits quietly, we are not surprised to learn that she tries to quietly sit and stop talking when it's close to snack time.

Another example might focus on the token system, where the person who absolutely adores trains earns tokens that add up to the reward of reading train books and magazines. Maybe even an ultimate goal could be that train trip. So you can see why positive reinforcement can increase the chances for positive outcomes. Let's take a look at a few examples of positive reinforcement as part of a strategy.

Some interventions include positive reinforcement as part of the approach. Discrete trial training or DTT is an intervention that includes positive reinforcement as a step in the process. OCALI has a resource available called Autism Internet Modules or AIM. This includes further information about DTT. AIM is a system of adult online learning modules that are available for use free of charge, with options for purchasing professional development credits, or taking them for college credit.

Here's an example of building positive reinforcement into a challenging situation. If a student is crazy about using technology, then using all of the avenues available throughout the school day can be reinforcing to the student and increase the chance of a strategy to be successful. For instance, Jonathan's class is split into groups of four students, each that will be responsible for developing a product about their science unit on natural disasters.

Jonathan's group chooses tornadoes. Mr. Rhodes, the teacher, knows that working in a group can be challenging for Jonathan. So he makes sure that Jonathan, who is very techy, gets the job of making a slide presentation with the group's research using a laptop. Jonathan also gets assigned to look for images and videos of tornadoes using a notebook they can take home for the weekend. By building in the use of technology, Jonathan is reinforced while doing this group work.

Here we have a token system that is used to earn music. Fred had a way of cleaning his nose frequently and did not always bother to use the tissue, not even when it was easily available. So the team decided to try this strategy.

When Fred used a tissue to clean his, nose instead of his hand or his sleeve, he received a star to put on the token board. When the board is filled, he earned the chance to go listen to a special CD of music. It is a favorite and only available through the token system. The token system has positive reinforcement built right in.

Well, next we're going to talk about individualized and the motivating factor. Similar to positive reinforcement, teaching of new skills involves the consideration of the individual strengths and interests. A successful strategy individualizes both the focus and implementation of the intervention. So this means that the way the strategies is presented, paced, taught, reinforced, and generalized is specifically designed for that one individual.

The person must feel motivated to change based on the reinforcement we use in the way we structure the intervention. Remember, reinforcement is in the eye of the beholder. A strategy or reinforcement is only reinforcing if the individual we're working with finds it to be that way.

While we're trying to transform deeply ingrained patterns of behavior, making the positive behavior plan and each strategy as saturated as possible with individualized topics, items, and passions increases the opportunity for successful outcomes. Let's think about how strategies can have the individualized motivating factor.

Here's an activity for an individual who loves sports. Using a special interest as part of the task only increases interest, engagement, and the possibility for more positive outcomes. For instance, let's look at this one. If the use of an AAC device is being considered, making sure that language and topics are individualized and motivating can make it more likely to have positive outcomes.

Let's take the Tango as an example. The father of an individual with a disability developed the Tango. Well, this father was well aware of what would be motivating for his 11-year-old son and his friends when he included a fart noise button on the device. Both his son and friends were motivated to communicate using that button.

Here's an example of an individual who's highly motivated by anything gardening. How can a teacher raise that interest level of the student in various school subjects? By including gardening and flowers in the actual work being done.

Most people get excited when they get to make a choice and exercise some kind of control over what's happening. We could motivate those with challenging behaviors and complex needs by giving choices within what needs to happen across a day. This holds true at home, at school, in the community, or at a job. Chris?

Yes, the next factor discusses teaching what to do. Direct instruction is an evidence-based practice for individuals with complex needs. New interventions or changes in strategies must have a teaching component. And this instruction must teach what to do, and not what not to do.

Persons with intricate need have difficulty with just picking up on something new. They need to receive repeated instruction, positive feedback, and opportunities to practice the new skills. For example, using social narratives to teach how to ask for a break, or teaching how to use a speech device to communicate, or demonstrating how to use a visual support to follow a deep breathing sequence for anxiety reduction. All of these teach what to do and can help support changing a challenging behavior.

So, let's take a look at a few other examples. Using a self-monitoring tracking system teaches a student how to track their own behavior. The system would need to be taught to the person, and the progress needs to be reinforced. The self-monitoring teaches what to do and reminds the individual to practice that skill.

And then there's the hidden curriculum. The hidden curriculum teaches what to do and what is expected in social situations. The hidden curriculum may include things like knocking on the door of your neighbor's house and waiting for a response before just walking in, or refraining from telling your employer that her new haircut is ugly. Some things need to be just staying in that thought bubble.

Unfortunately, many behavior support plans forget the element of teaching new skills. Teams may be so focused on stopping an unwanted behavior that they forget to teach a new or desired behavior. Sometimes we just assume that the person knows what to do and is just choosing what not to do. Regardless of whether either of these situations is true, we now know that intentionally teaching a person what to do through the use of a variety of strategies and supports enhances the long term success of the support plan.

That's a really important factor, Chris. I know we've talked about that being probably the most important one, when we're dealing with the behavior plans.

Often times it is.

Well, the next one is predictable and consistent. Persons with complex needs are challenged to learn new information unless it's taught with repetition and uniformity. Therefore, the format and presentation of the strategy or support must be easily recognizable and easily understood by the person that it's intended to support.

The predictability and consistency of the intervention allows the person to follow through more successfully as they expend their energy working on changing the behavior, and not trying to understand how to use or respond to the support. We see this component of predictability and the Incredible 5-Point Scale. We're going to examine that shortly.

Let's check out a few other examples of strategies that are predictable and consistent. Power cards, we mentioned that earlier as being individualized a motivating, and they also foster predictability and consistency. Power cards utilize an individual's special interest and teach specific behaviors. And this is an example of the slide.

If an individual is enamoured with Will Smith, then they may be more likely to listen to what Will says in a social situation about how to stay calm. There's a story that precedes the use of the power card and explains how Will sometimes makes mistakes when filming. And he has to stay calm when the director yells cut and Will has to repeat the scene. The power card stays the same once it's created. Consistency comes from all people who support the individual using it as directed.

This slide shows an example of a visual support for anxiety. This visual support uses pictures and text in order to help the child relax. Each step of the sequence would need to be taught, practiced, and reinforced for it to become a habit an individual can remember in the time of anxiety. Because the visual stays the same, it is predictable.

The next factor is about reliable implementation. Implementation is what makes all the other factors work together. Making sure that all the steps of the strategy are being taught and used similarly by all persons, across all environments, as intended. And this is called fidelity.

When evidence-based interventions and promising practices are used with fidelity, positive outcomes are more likely to happen. Implementation requires ongoing monitoring of progress. So collecting and then analyzing the data to show it's an intervention is working for the individual is very important.

Some methods to support implementation are shown on the slide. Keeping data and graphing, it gives teams a visual to see how the plan is progressing. Implementation checklists that list the steps to be followed for strategy can be used by a team member to be sure they are using the strategy as it was studied, or someone who is evaluating the use of the strategy could use it to give the feedback to the team.

Having an action plan in place with the time frames and the persons assigned to design specific steps of the strategy, helps keep the implementation moving ahead and assures that all steps are achieved. Reliable implementation requires that all persons using the strategy or intervention with an individual truly understand how it is supposed to be used. This can only happen with training and ongoing monitoring of how staff are doing with implementation.

Applying these seven factors to an intervention or strategy being used or considered for an individual, will lead to thoughtful systems of change. So now, we're going to work through several examples using SART. The strategies we're going to share today reflect discussions that we've had with parents and professionals about various interventions that were being or considered for use, for individuals with complex needs.

Some of these strategies were subsequently used with success. Some, we helped them revise so they could improve the success. And a couple were discarded. Although, mostly, we were able to help people work through and use the different strategies for a particular individual.

So our first case study is Josh. He's a sophomore in high school. He's verbal and in a full inclusion situation. The functional behavior assessment process found that he's having anxiety reactions in class and has a difficulty recognizing his internal emotions. So his team decided to put the Incredible 5-Point Scale in his intervention plan.

Let's take a look at the Incredible 5-Point Scale. This is a visual method that illustrates emotions and social behaviors. Individuals write their emotion or stages of behavior and think about possible supports for each level. This is the Incredible 5-Point Scale that Josh's team developed with him.

You can see that Josh was able to describe how his anxiety starts and builds in the description column, with a two being like a buzzing in his upper arms, up to a five that he's got to leave the room because he's hit the fight, flight, or freeze level of anxiety. In column three, there are things for him to do in reaction to each anxious feeling. The team would teach each of these what to try supports when Josh is not anxious and have visuals to help him remember, in times of anxiety.

So, let's work through the seven factors of SART. Is it visual? Yep, there are works and or pictures plus a colored number system. Sensory? It can include sensory interventions within the supports.

Positive reinforcement? It uses desirable outcomes as part of the focus. Individualized, motivating? Yes, each scale is designed for that specific person.

Does it teach what to do? For sure. Those alternatives teach skills and the method explains that the scale needs to be taught to the individual. Predictable and consistent? Once it's developed, it's familiar and unchanging.

Implemented consistently? The method encourages needing to teach it and use it the same across persons and environments. So the SART shows the Incredible 5-Point Scale to be a worthwhile strategy to consider.

Let's see if there are any modifications for Josh. This is a chart included in your downloadable packet that allows you to document, in column two, if the strategy includes each element with the response of yes, no, or somewhat. In column three, you'll describe why you responded with a yes/no or maybe, which is what we just did in the previous slide.

And in the last column, if you put no or somewhat there's a space to include how you might revise that element for the individual, while keeping within the fidelity of the strategy. You can see that for Josh and the Incredible 5-Point Scale all elements are addressed and answered with a yes. So there are no revisions.

The scale is a visual representation. The what to try column includes sensory-based activities. Positive reinforcement has been built into his fidget items and his imagery. It's individualized for Josh.

Positive strategies will be taught directly to Josh. His team is trained in the strategy and supports, and is using data to keep it predictable, consistent, and used with reliable implementation. Can the team expect good outcomes with the strategy? Yes, they can.

Here is another example with Molly, who is a kindergarten student and who has some spoken words. She is in a full-inclusion classroom, but is having difficulty completing tasks. Her functional behavior assessment or FBA showed the function of her behavior is to communicate through yelling, kicking, biting, and escaping the situation.

It is not clear, however, if Molly is communicating that she does not understand what to do, does not know how to do it, or if there is something about the task that is uncomfortable. So Molly's team decided to try Hand Over Hand prompting to help Molly learn to wash your hands, that she was having difficulty with this.

Let's see how that works out with SART. The SART tells us that hand over hand can be visual, but is not static. It can change, so that may be an issue. It does not consider sensory needs, if someone is tactfully defensive that could be a problem.

It does not incorporate positive reinforcement. That's not part of hand over hand, generally. Hand over hand might be motivating to the individual if they want to finish that task and be done. It can teach what to do, absolutely. And if you convey the prompt, it can be predictable and consistent, if everyone does it the same way, every time.

And reliable implementation is dependent on the caregivers, but it is possible. So, hand over hand prompting receives a mixed review. When we look at this chart, Molly's team has added some revisions to a few of the elements. For visual tactile the team is going to also add visual prompts to show how to wash their hands, and have her watch others as a model. This would make this more consistent.

With sensory, since the team knows that Molly is tactfully defensive, the team will use a hand under hand so that she can pull away if the touch seems uncomfortable. To build in some positive reinforcement, the team will use favorite items from her reinforcement survey to reinforce completion of hand washing. And to make this individualized and motivating, the team is going to add music, one of her favorites, by singing a wash your hands song to the task.

The other factors that were already included such as teaching what to do it through the action, being predictable through the staff doing and the prompting of each of the staff items each time, and being done with reliable implementation through the staff using the same process and waiting for a 12 second interval. All of this is already part of the strategy.

Can Molly's team expect positive outcomes from this strategy with these added revisions? Yes, I think so. I think they can.

Our next example is a seventh grader named Carlos. He is nonverbal and attends a public school in a self-contained classroom for now. His FBA identified that he is not participating in small group activities because of avoidance. He runs from the room, or sometimes hides under table, or behind a divider when he sees the small group picture card on his schedule.

Carlos's team also realized, through the FBA process, he does not have a functional communication system which would allow him to have the opportunity to participate in the small group activities, and would allow him to use a more appropriate and universally understood way to say that he does not want to participate, if that might be the case. They completed an assistive technology assessment on Carlos and explored the features of some possible communication systems coming to the conclusion, through feature matching, that the Proloquo2Go app was a good match to try with him.

If assistive technology or feature matching are unfamiliar terms to you, OCALI also has assistive technology modules, or ATIMs available at www.atinternetmodules.org that will help you learn about these terms and processes. SART tells us that this app on the iPad has the visual tactile factor through the pictures with each word or phrase, and with swiping the icons. The sensory factor is addressed through the adjustment of colors and sound levels, and also with the choices or options that appear on the device, such as asking for a break, or other type of sensory related intervention, instead of bolting from the group.

For positive reinforcement you can build in preferred topics. And hopefully the ability to communicate would be a positive for him. This is individualized by being built for the user, and hopefully being able to interact would be motivating. When thinking about teaches what to do, we had some good discussion around this, didn't we, Chris?

Yes. You know, the app itself, if you set the iPad down with the app going, does it teach what to do? No, it really doesn't. We had to come to conclusions with that.

But what happens is you have to teach that vocabulary. But once the options for asking for break, or giving a way to participate are placed on the device, it could be a part of the plan then to teach Carlos what to do when he wants to escape instead of bolting or how to participate in the actual activities. Since the app stays the same once it's designed, it can be predictable and consistent. And the reliable implementation would be dependent upon staff training and consistency of use.

This communication app on an iPad has mixed results with SART. How could Carlos's team revise it? As you can see, the positive reinforcement factor can be revised by including food choices, free-time choices, and some icons from Nickelodeon, which are things that he loves. The factor teaches what to do could be revised by making sure Carlos and all staff are trained on how to use the iPad app and the vocabulary.

And the reliable implementation factor could be revised by ensuring that Carlos will have access to app at all times, that he receives an immediate response to all initiated communication, and he'll be taught how to use it. So with revisions, it appears that the Proloquo2Go app can be a successful strategy for Carlos.

So, Wendy, the let's take a look at the use of a response cost system with Suyin. She is a fourth grader who is conversational and attends public school in a partial inclusion situation that includes one period a day in a resource room and the rest of her classes are mainstream. Her FBA shows that she is having difficulty with talking out in class, due to impulse control. And she is presently earning tokens for raising her hand.

How about response cost systems? Well, with this system there are penalties for those behaviors we'd like to change. And sometimes the more times the inappropriate behavior occurs the penalties will actually increase. This could include loss of points or loss of privileges.

So, in her class response cost is a strategy used with everyone. Her team decided she is to lose five minutes of computer time each time she talks out without raising her hand and waiting to be called on. They're going to implement this with her specifically. So, let's take a look at response cost systems using SART.

Is it visual? This is not a required element, although it could be added in. Sensory? Not typically considered, not really. Positive reinforcement? Nope, that is really not at all. This is considered more on the punishment end.

Individualized and motivating? Might be individualized, but losing privileges is usually not motivating. Does it teach what to do? This strategy focuses on what not to do, not what to do.

Predictable and consistent? It can be, yes. Reliably implemented? It should be use consistently, so that is a possibility. Yes, it could be reliably implemented.

When looking at response cost Systems for addressing challenging behaviours for students with complex needs, it probably will not produce outcomes there are as positive as some of the other methods that we've either looked at or that might be available. Are there ways to revise the response cost to meet Suyin's needs? For the visual factor, the team could use visuals and maybe a self monitoring chart as an additional strategy. Not really part of the response cost, but you might help teach a skill by adding that.

For the sensory piece, losing computer time really can't meet sensory needs, not really. Positive reinforcement also can't be addressed by losing computer time, although Suyin is simultaneously earning tokens for raising our hand appropriately, which is positive reinforcement. It may not always be included as part of a typical response cost system though.

In this case, the response cost is part of the classroom system for Suyin's room. So this isn't individualized for her. Does response cost teach what to do? Not as designed, not really. Suyin needs direct instruction and visual supports to learn about this skill. But that is a different or additional intervention, not response cost.

For individuals with complex needs, the skills needed to understand a response cost system may not, typically, be a part of that individual's toolkit. You have take that into consideration, absolutely. The person needs to understand and recall the behavioral expectation at the time, still remembering what will be lost while remaining on task and making sure to do what you are thinking about, in regards to your behavior. Lots going on there.

This can be very difficult for individuals with complex needs. And it doesn't teach missing skills, very important piece. So response cost does not pass the SART test. And actually needs so much modification that it may not even end up being a response cost system at the end. So because of that, Suyin's team decided to try a different approach for her talking out behaviors.

Those are the individualized examples showing how you can use the SART system. Some feedback from people who are using SART have made several uses apparent. SART can help a team decide if an intervention might work for an individual, as these examples have demonstrated. SART can also help a team revise an intervention that just isn't working so well before deciding to throw out the baby with the bathwater and discontinue that usage.

SART has been used to guide discussions with family members and with staff who are implementing an intervention, to help everyone get on the same page and understand how an intervention matches up with an individual, especially if there are difficulties with some relationships on the team, possibly. It takes that power struggle away and allows for a focus on the individual and the work.

A discussion using SART can also help teams process what might be missing from implementation or what revisions might be helpful in making the strategy successful. We had one teacher tell us that she just pinned it on a bulletin board so that when she was working with a student and it wasn't going well, she'd kind of glance up and see am I doing everything that I want to be doing? So it can be helpful in a lot of ways.

Let's take a look at one more example, which involves looking at a strategy across the whole classroom. Bucket Fillers is a character development program that uses a story to explain how you can do nice things and fill someone's bucket, or do mean things and dip from someone's bucket. For more info on the program, see the website on this slide.

But anyway, Mrs. Lee decided to read up on Bucket Fillers over the summer and was considering using it for her whole class. She chose SART to see if it had possibility for success. For the visual factor, Bucket Fillers has a story with pictures. But she could revise it further by adding visuals in her classroom, such as buckets, and dippers, and even pictures to remind the students of the program. And they could have them on their desk.

For sensory, she could build in examples during discussions for possible sensory sensitivities of her students, so if someone is sensitive to sound, everybody pushes their chairs in quietly and then we're filling that bucket. For positive reinforcement, Filling Buckets is exactly that.

Since it would be a class-wide system, if anyone needed further individualisation, she could use small group or individual instruction about the program, and also make some of the games listed on the website, and practice those. Bucket Fillers teaches what to do through the story and modeling by the teacher and other students.

The processes is consistent and predictable, once learned. And the reliable implementation could happen through the teacher being a good model for the program. So after completing SART, Mrs. Lee felt Bucket Fillers would be a good program and decided to try it.

So, let's do a quick review of the SART worksheet that can be found in your downloadable file. You fill in the name of the individual, the name of the strategy or intervention you're going to look at, and then decide if each element is included in the strategy. If the element is included, check yes. If it is marginally included, check somewhat, or if it is not included at all, check no.

In the third column, you describe how you determined that answer. And if the answer is somewhat or no, you can use column four to write ideas about how to revise the intervention for your individual, so you don't have to just throw it all away.

Here's a peek at the guiding question sheet that was also included in your downloadable file. As you go through column two of the SART worksheet these questions can help you determine your yes, no, or somewhat answers and can help answer how it is or isn't included in column three. SART can help your team examine a strategy from the intervention plan and see if it has a good chance of a positive outcome, or if some revisions are needed to get it there. If the strategy is still is not as successful as it needs to be, come back to the SART and see what's missing that can be further revised.

Now, you did it. You made it through the whole process. We hope that you rediscovered some concepts that will help build behavior plans and that you learned some new ideas to continue building your skill set, as you support individuals with complex needs.

Explore the Strategy, Assessment, and Revision Tool (SART). As the final step in this process, build on the intervention and reinforcement plan that has been developed, using the SART to assist in matching the appropriate intervention to the needs of the individual. Step-by-step instruction is provided complete with case examples to guide you through the SART process.

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