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Slide 1:  CHRIS
Hello, and thank you for joining us today for Part five of the “Understanding and Addressing Challenging Behaviors of Individuals with Complex Needs” webinar series.  I am Chris Filler, the coordinator of the Lifespan Transition Center at OCALI, the Ohio Center for Autism and Low Incidence.

WENDY
And I am Wendy Szakacs, the Regional Coach for Autism and Low Incidence at OCALI in the northeast and eastern parts of Ohio. We serve families, educators and professionals working with individuals with autism, low incidence disabilities, and complex needs.

This series will teach you a systematic process for addressing and changing challenging behaviors.  We will be building your knowledge step by step through each of the webinars in this 5 part series.  Today we will focus on substitute behaviors and related skills, and also choosing interventions to support the positive behavior plan.

Slide 2:  If you chose to work through the process with your own individual, since the last webinar, you filled in the strengths form.

Slide 3:  Then you summarized the strengths in section three on the Intervention form and started thinking about what additional skills might be needed in section four.  Remember as you work through this process, what you fill out on these forms can, and probably will, change and be added to as you talk with team members and start using what you think is going to help support behavioral change and make adjustments.

Slide 4:  You also worked on a data system for your positive behavior plan.  

Slide 5:  And started on your reinforcement system.

CHRIS
Slide 6:  As we continue working on the tools you need in your toolkit, we are going to discuss interventions and replacement behaviors.

Slide 7:  Lets talk about what the interventions you select should do.  Interventions might help reduce stress by supporting things the challenges that the person may face.  This may help decrease the frequency or intensity of the behaviors.

Slide 8:  Some interventions may specifically target the setting events that make the behaviors more likely to occur. Targeting setting events can lessen the occurrence of the behavior.  So, for example, more sleep might help an individual be able to better cope with the challenges of the day.  

Slide 9:  Another goal of interventions is to teach the skills an individual needs in order to be successful in the situations where the challenging behaviors occur.  Some of those skills may include social competence, coping, self-regulation, or academics.  The skills that are needed and will work best for the person are individually determined for that person in that situation. There are generally two categories of skills to consider:  these are substitute skills and related skills.  Let’s clarify some information about the difference between these two.

Slide 10:  A substitute skill is what we teach to help the person replace the challenging behavior.  Sometimes it is referred to as the replacement behavior. For example, your FBA determines that hitting is a means to communicate: “Leave me alone!” or “Back off” or “I do not want to do that!”
The replacement or substitute behavior must provide an alternative way for the person to communicate the same message of “Leave me alone”, “Back off” or “I do not want to do that”.  This could be a word, a picture, a sign, gesture, AAC device, or any other understood communication that is selected and taught.  Additionally, when you looked at your antecedents and consequences to the hitting, you discovered that hitting caused people to leave the person alone…to back off. Basically, it was an effective communication tool.  So, your substitute communication must be equally as effective. When the person uses the desired communication, others must honor the request. Otherwise, the individual will likely return to the hitting behaviors…or worse!
This is defined as a “Functionally Equivalent” behavior to hitting.  
But this may feel like it is not a complete plan, right? There should be more. And yes, that is where related skills come in.

Slide 11:  So let’s discuss “Related Skills”.   A related skill is one that will assist the person in the targeted situation but does not get the exact results for the individual. It is not an equal exchange. Here’s an example: Sometimes instead of hitting to immediately escape a situation, we want the person to “cope” with the situation for a short time. Being able to cope is an excellent skill. One that will help any person get through life more successfully. But being able to cope for a short time is not equal to being able to communicate, “I need a break” and getting a chance to leave the classroom and walk down the hall. “Waiting quietly” is a helpful coping skill that to learn, but it does not replace a hitting behavior that the FBA determined was an “escape” or “I need a break” behavior.  I hope that at this point, you are beginning to realize that people need to be taught both substitute and related skills.  Let’s look at this a different way.

Slide 12:  So let’s say you lost your Droid smartphone! You go to the store and they offer to “replace” your Droid phone with one of these options on the right side of the slide. Would you accept that? Why not? It is a phone. You can make a call.  But, we know it really is not the same at all. While the Droid has the “phone” function, it also has Internet, Apps, Texting, Camera, etc. Most of these phones have none of these options. Now, the iPhone for example, DOES also have these functions and options. And most of us would see the iPhone as an equal tool to the Droid and accept it as a replacement for the Droid.  However, offering one of the old phones is not equivalent. It is related. They do have the phone function. But they are not able to offer all the options of the iPhone or Droid.

Slide 13: Let’s think a little further with these “real life” examples.  Say, for example, you owned the gorgeous sports car on the left, would you accept the cute little dilapidated car on the right as equivalent?  No way, right?  Even though it would function by getting you from one place to another.  OK…Maybe …but let’s pretend that it does. …Still…. it is not the same.

Slide 14:  If you want someone to accept this functionally related car you may need to add extra reinforcement.  For example, I might be willing to accept that little dilapidated car if you add a big wad of cash and a sweet motorcycle, that I could drive to maintain some of the status that I will lose driving the old car.   Here’s another example.  You want me to learn to cope or to wait for the teacher’s attention by sitting quietly for a short time.  Maybe if you give me a timer and fidget, I might be able to sit here for a while without jumping. And if you reinforce my use of the fidget and my quiet body with something I really like, that will also help convince me to use the new coping behaviors while I learn how to ask for your attention in a better way.

Slide 15: Let’s bring this back to the classroom.  If the FBA shows that hitting equals an escape from academic demands, then we want all the skills on this slide to be part of the plan.
We do not want the person to continue to escape academic demands, but they must first learn a different way to “escape”…. An acceptable way…or they will continue to hit, or worse.  Once you have their trust, a new skill and some relationship, attempt to teach additional related skills that will require teaching the person to cope with the situation rather than immediately escaping. First identify and teach the substitute skills or behavior. Then add the related skills.

Slide 16:  Here are four areas that are common to look for replacement skills:  escape, attention getting, communication, and coping. Often the needed replacement skills will fit into one of these areas. Note, however, coping skills only become replacement skills when the FBA determines that the challenging behavior is functioning as a coping mechanism for the person.

Slide 17:  Remember Molly? Let’s look at what substitute and related skills need to be taught to her in order to change the screaming behaviors. In step 4 we determined that Molly had a number of areas of skill development that needed attention. These included social, academic, coping and communications skills. Step 5 allows the focus to be narrowed to those skills that are specific to the targeted behavior. In this case, screaming. We determined in steps 1 and 2 Molly is escaping the sensory and academic demands by using the screaming as an effective communication tool. Therefore, in step 6; we will narrow our selection of skills to target first the equivalent communication skills that will allow Molly to ask for a break or to give her personal space and then secondly to the related skills of improved academic abilities that will allow her to more readily participate in the circle activities.

WENDY
Slide 18:  This quote is about students with autism, but can be generalized across disability categories.  Basically, if you have baseline data for an individual’s behavior, and you continue to keep data while an intervention is trialed and the data shows improvement, then you have an evidence base to show that the intervention works for that student.  Think about if you decided to go on a new diet.  Would you just follow the diet and not think about it?  Or would you be checking your weight, your measurements, how your clothing fits?  We need to use data to know if what we are doing is working.

Slide 19:  As we have conducted trainings 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 our individual.  Why not?”  We have identified seven factors across the literature that contribute to successful outcomes when implementing a strategy or intervention.  We are going to briefly review each factor, and then show you a tool you can use that will help you match an intervention to your individual, possibly through revision of it, as you build the positive behavior plan.

Slide 20:  The visual/tactile factor:  Research supports that many persons 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 the person needs them, and stay consistent across environments.  Strategies that include visual components are schedules, written/picture directions, and video modeling.  If an intervention or strategy doesn’t have a visual component and you believe this factor would help your individual, do you throw it out as a possibility?  Not necessarily.  We will be showing you how to think about revising a strategy to possibly include a visual/tactile factor.

Slide 21:  The sensory factor:  Sensory integration is a promising practice that supports the sensory system of an 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.

CHRIS
Slide 22:  The positive reinforcement factor:  Positive reinforcement is an evidence-based practice that can support the teaching of new skills and interventions.  During this webinar series, we have addressed this topic as part of building a positive behavior plan.  Now, we are breaking that down further to look at how it can impact each intervention.  Changing behavior is a complicated task that requires a “pay off” for the person with complex needs, and positive reinforcement can increase the chances for positive outcomes.  So, for example if you are working with a person who absolutely adores trains, then perhaps you might try a reinforcement system with tokens of train engines that earn the ability to read train books and magazines.  Maybe an ultimate goal could be a train trip.  And in school, trains can be worked into literature, history, math problems, physics, and many other topics.  At home as part of building social competence for instance, trains can be part of learning leisure skills and connecting with other peers who also like trains.  Incorporating positive reinforcement into strategies that are supporting behavior,  and being creative with what a person finds reinforcing can increase the chances of success.

Slide 23:  Individualized, motivating factor:  Similar to what we just discussed, part of positive reinforcement and the teaching of new skills involves the consideration of the individual’s strengths and interests. A successful strategy individualizes both the focus and implementation of the intervention. This means that the way the strategy 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 and 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 are working with finds it to be reinforcing. When we are 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.

Slide 24:  Teaches what to do factor:  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 needs have difficulty 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 teach what to do and can help support changing a challenging behavior.

WENDY
Slide 25:  Predictable and consistent factor:  Persons with complex needs are challenged to learn new information unless it is taught with repetition and uniformity.  Interventions need to be taught and used consistently across environments by those who are teaching them.  The strategies themselves may work better if they have a component of predictability, as in The Incredible Five Point Scale that we will examine shortly.

Slide 26:  Reliable implementation factor:  Implementation is what makes all the other factors work together.  Making sure that all steps of a strategy are being taught and used by all persons across all environments in the manner they were developed to be used 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 analyzing data show if an intervention is working for the individual.

Slide 27:  Applying these seven factors to an intervention or strategy being used or considered for an individual will lead to thoughtful systems of change.  Now, we are going to work through several examples using the first step of SART.  The strategies we are going to share today reflect discussions with parents and professionals about various interventions that were being used or considered for students.  Some of these strategies were subsequently used with success, some were revised to improve success and others were simply discarded as not likely to be useful. First we will review several examples, then we will show how to revise a strategy that might not have all of desired features.

CHRIS
Slide 28:  First let’s look at the Incredible 5-Point Scale.  This is a visual method that illustrates emotions and social behaviors.  Students rate their emotion or stages of behavior and think about possible supports for each level.

Slide 29:  Here is an example that describes what the emotion looks or sounds like and what it feels like at each level and then there is a column of things to try to do to calm down.  These scales can be represented by all words, or may be only pictures, and include a number/color system for each level.

Slide 30:  This scale is an example of what may be developed after a person has worked through and recognizes how it feels to “escalate and escape” and what action may be necessary when that occurs to avoid unfortunate endings. This scale is an example of one that only uses numbers and text. Notice the description and ideas for supports at each level.

Slide 31:  So now that you are familiar with the Incredible Five Point Scale, let’s work through the seven factors.  Visual:  yes, there are words and/or pictures plus a colored number system; sensory:  can include sensory interventions within the supports; positive reinforcement: uses desirable outcomes as part of the focus; Individualized, motivating: yes, each scale is designed for that specific person; teaches what to do:  yes, the alternatives teach skills and the method explains that the scale needs to be taught to the individual; predictable and consistent:  once developed it is 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.  As you would think through these factors for your individual, you could consider specifics for him/her.

WENDY
Slide 32:  Our next example is social narratives.  These are stories that teach about social situations in a positive way.  The narratives can use words and/or pictures; they need to be taught repetitively; and they help to gain new skills.   

Slide 33:  Here is a social narrative about pretending.  The story describes “pretend” situations and what it means to play through pretending.  This is a words only story, but narratives can have pictures to help illustrate the social behaviors.

Slide 34:  So how do social narratives measure up?  Are they visual:  yes, using words and sometimes pictures; do they address sensory:  the stories can take sensory into consideration; how about positive reinforcement:  the stories are written with positive language and can include information that is reinforcing to the individual; are they individualized and motivating: the narratives are written specifically for the individual and can include special interest areas; do they teach what to do:  yes, they are written to teach social behaviors and the method conveys the importance of teaching the stories; how about predictable and consistent:  stays the same once written; and the reliable implementation is stressed in the method to repetitively teach the skills through the narratives, especially right before the situation it’s written about happens.  For social narratives, the SART factors are all present, so it can be a successful strategy.

CHRIS
Slide 35:  How about response cost systems?  When using this strategy, there are penalties for those behaviors we’d like to change.  And sometimes, the more times the inappropriate behavior occurs the penalties will increase.  This could include loss of token, points or privileges.

Slide 36:  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; positive reinforcement:  nope, this is the opposite of positive - it’s punishment; individualized, motivating:  might be individualized, but losing privileges is not usually motivating; teaches what to do:  this focuses on what NOT to do; predictable and consistent:  it can be; reliable implementation:  should be used consistently.  When looking at response cost systems for addressing challenging behaviors for students with complex needs, it probably will not produce outcomes that are as positive as some other methods might provide.  Therefore, it should not be the intervention of choice for many students with challenging behaviors.

WENDY
Slide 37:  Our next example is exclusionary time out.  This method uses removal from a situation where the individual is acting out or causing a disruption.  It is meant to allow for time to start acting appropriately while the individual is moved away from those in the vicinity.  

Slide 38:  How does exclusionary time out measure up with SART?  Is it visual: not usually; does it have sensory considerations:  not in the method, but the individual might use time out as an escape mechanism from sensory overload; positive reinforcement: no; individualized, motivating:  not usually individualized and only motivating if the individual is using it as avoidance or escape; does it teach what to do:  no; is it predictable and consistent:  it can be; is there reliable implementation:  that is dependent on the providers.  The assessment of time out shows it is probably not going to have outcomes that are as positive as other interventions.  We will be showing you the revision component of SART shortly that discusses how to possibly adapt interventions for an individual.

CHRIS
Slide 39:  Here’s one last example:  verbal directives.  This intervention includes using speech to give directions or to correct behavior.  Verbal directives could also be prompts to urge completion of an action or a task.

Slide 40:  Here’s the assessment of SART factors for verbal directives.  Visual:  no; sensory considerations: no; positive reinforcement: the directives might have social reinforcement; individualized, motivating:  can be depending on what is said and how the individual receives it; teaches what to do:  possibly; predictable and consistent:  no; reliable implementation:  possibly.  In this case, SART shows that the use of verbal directives would need to be revised in order to produce positive outcomes.

Slide 41:  So let’s take a look at how you can apply these factors we just practiced using the SART Worksheet.  This sheet can be found in your downloadable file.  This will help you apply the seven factors to an intervention that is being used with your individual with complex needs or an intervention you are considering using.  To begin, you fill in the name of the individual, the name of the strategy or intervention, and then decide if each element is included in the strategy.  We’ll be showing you a list of guiding questions in a minute to help with this step.  So 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.  

Slide 42:  Here is a peek at the guiding questions sheet that was also included in your downloadable file.  As you go through column 2 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 3.

WENDY
Slide 43:  Let’s go through an illustration of how to use the SART worksheet.  We are going to assess and revise the strategy of hand over hand prompting.  We are describing hand over hand as a physical prompt involving an adult guiding the hand of the individual to complete an action or task.   

Slide 44:  Let’s think about this intervention in an overall sense.  The SART tells us it can be visual, but that is not typical; it does not consider sensory needs; it does not incorporate positive reinforcement; hand over hand might be motivating to the individual if they want to finish the task; it can teach what to do, if you can fade the prompt; it can be predictable and consistent if everyone does it the same every time; and reliable implementation is dependent on the caregivers.  So, hand over hand prompting receives a mixed review.

Slide 45: Now let’s apply this to an individual.  Remember Molly?  Here is the SART worksheet for hand over hand prompting with Molly as the individual, and it’s being used to teach hand washing.  Let’s see how the elements match up to what we know about her.  Is the intervention visual enough for Molly?  We think it is somewhat visual because the hand over hand prompts her and she is seeing the action, but it doesn’t really demonstrate the new skill of washing her hands.  How can we revise the visual element of hand over hand prompting to support Molly?  We can develop visual prompts to show how to wash her hands and also model the action for her.  Does hand over hand prompting address Molly’s sensory considerations?  No.  Remember, she is tactile defensive, so pressure on her hands could cause her some discomfort.  How can we revise this element?  If we used hand under hand support, we could prompt her while Molly maintains control of the pressure.  Is there enough positive reinforcement for Molly with hand over hand prompting?  No.  There is no positive reinforcement.  How can we revise this element?  We can add a reinforcement plan for completing washing her hands using items from her reinforcement inventory.  Is the hand over hand prompting individualized and motivating for Molly?  It is somewhat, because she is prompted when she needs it, but she doesn’t really like it when people touch her or move her hands.  How do we revise this element?  We are going to add a song about washing your hands that will motivate Molly and help teach the steps.  Does hand over hand teach what to do?  Yes, it moves Molly through the action to see how to do it.  Is it predictable and consistent?  Yes, in Molly’s case the staff is working on prompting in the same way.  Is there reliable implementation?  For Molly, the answer is yes, because all staff are waiting for a count of 12 (which has been determined to be her processing time) after giving her a direction to wash her hands before using the hand over hand prompting.  And now, everyone will be using hand under hand as well as visual directions to support the prompting.  Using this form can help match up an intervention or strategy to an individual and revise it for the greatest chance at positive outcomes, which will make it more likely to help support the challenging behavior you are trying to change.

CHRIS
Slide 46: We are going to return to the Intervention form for Molly and to start thinking about replacement and substitute behaviors we discussed earlier in this webinar.  The intervention plan needs to include teaching replacement and substitute skills.  For Molly, these include using social stories and social scripting to teach her skills for getting along with peers and being able to communicate her emotions and needs at circle time.   The plan also addresses adding music to Molly’s academic and social activities and teaching her how to make choices within her schedule rather than screaming to communicate her frustration.  Also, the intervention plan goes further to address the other challenges found with the FBA.  For Molly, this means teaching her how to ask for a break to leave circle time, which is an functionally equivalent skill or behavior to screaming as both allow her to leave the circle area. Teaching her how to ask someone to leave her alone or to not touch her which is equal to her hitting someone for the same result.  Also, making circle time more predictable with a schedule and making sure Molly has enough space around her to address her sensory issues supports other challenges the FBA identified.   Eventually, as Molly is more engaged with learning, the plan should be expanded to include the identification of different teaching methods to improve her academic skills. Remember, “academic skills” was identified as a related skill in this situation.

Slide 47:  One of the final steps for checking the Intervention plan is to be sure you have addressed the following issues:  are there strategies to address what was identified as antecedent behaviors; are there strategies that address the consequences that are reinforcing the behaviors; and are there interventions that address every challenge and strength listed?  Molly’s plan does answer all of these questions. Your plan may not have all of these components initially, but this is a process and that plan can evolve over time. So don’t panic!

Slide 48:  The final checkpoint is to be sure that there are strategies in sections five and six that reinforce and teach new skills to support challenges identified in the FBA.

Slide 49:  Your last step in developing the behavior plan is to identify new skills to be taught and then to select interventions for each of the areas in section six.

Slide 50:  We have included this Behavior Plan Steps Chart that takes you through each step of the plan and shows what form to use.

Slide 51: Also, there are two optional forms that may be helpful to some teams.  The first is an Action Steps form.  If you have decided on an intervention or strategy that is going to require some planning and timelines, this form can help your team stay on track.  The second from is to Review and Check if you have included strategies that change setting events, decrease stressors, and teach substitute or related skills.  

Slide 52:  Because many districts and agencies have approved behavior paper work, you may want to transfer the information you have developed to the behavior plan forms required in your district or agency.  

Slide 53:  To continue applying what you have learned in this webinar series, you want to put in as much information you and your team can think of to include in all of the forms.  Because you can’t work on everything you have discovered at the same time, select which strategies you want to work on first, use SART to assess and revise the first strategies, and then implement the first strategies.  Remember to keep data on the strategies and continue to update your plan.  This process can be applied to other challenging behaviors in the same way you have learned through this webinar series.  In the downloadable file, there are other case studies showing how this process might work for Molly with a behavior at home and how it might work for an older individual named Joe.    

Slide 54:  Thanks for learning with OCALI.