Comprehensive Functional Behavior Assessment Report and Support Plan

NOTE: This report was written by a participant in Institute for Applied Behavior Analysis’ Summer Institute (http://www.iaba.com) on “Assessment and Analysis of Severe and Challenging Behavior.” All identifying information has been changed. This report is presented as an example of the type of report that participants will be able to write after completing the course.

COMPREHENSIVE FUNCTIONAL ASSESSMENT REPORT AND RECOMMENDED SUPPORT PLAN

Client Confidential

Date of Report: July 26, Referral Date: July 25, Period of Report: July 25– August 4

IDENTIFYING INFORMATION

Name: David Doe Date of Birth: February 30, 1969 Address: Any Street Any City

Referral Source: Supported Living Service, Inc. (SLSI)

REASONS FOR REFERRAL

David was referred by Sue James, Program Manager of Supported Living Service, Inc. for an evaluation. The purposes of the evaluation were to assist David in securing the services and programming which would enable him to develop and to use his capabilities, to get the most out of the educational opportunities that can be made available to him and to enable him to develop and to use his capabilities for more independent, normal living and more productive activity than his behavior problems presently permit. Accordingly, it was requested that the evaluation focus on these behavior problems, which were characterized as self-injurious behaviors, and the type(s) of behavioral services, support strategies, programming, professional competencies and skills, and environments required to eliminate, minimize, or manage them.

Specifically, David was referred due to the potential severity of his self- injurious behaviors (face slapping and head snapping) which although greatly reduced still remain life threatening. As David gets older and stronger, the Comprehensive Functional Behavior Assessment Report and Support Plan Page 2 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. severity of the behavior although already life-threatening will increase and the staffing implications are endless. It is important that his behavior continues to reduce and that David is taught an alternative form of getting his needs met. Decreasing David's dependence upon staff in order to reduce burn out are also an important issue and this means working on various areas of life-skills.

DESCRIPTION OF ASSESSMENT ACTIVITIES

This assessment is based on information obtained from the following sources:

A. Interviews with SLSI staff including D. Doe (Senior), Mr. Miller (In School Behavioral Specialist), and Ms. Sue James, (Manager); (interviews carried out on 07/26/00 and 07/27/00 each lasting between 30 - 90 minutes)

B. Direct Observations of David in the following settings; his own house, the occupational therapy center, local eating establishment and day camp activities at the beach (Observations occurred on 07/26/00 for 5 hours);

C. Review of the following records provided by the Regional Center, School District’s Individualized Education Program, Psychological Evaluation by Timmons Neuropsychiatric Hospital, old psychiatric evaluations and reviews; (07/25/00 - 07/27/00)

D. A Reinforcement Survey completed by Sue James, Program Manager;

E. Telephone Conferences; Sue James, Program Manager (10 minutes on the 07/27/00);

F. Interacting with David (07/26/00 - 1 hour)

BACKGROUND INFORMATION

I. Brief Client Description.

A. General. David is an attractive 15-year old Caucasian boy with blue eyes, blonde hair, and a slight build. He is 4 feet 9 inches and weighs 83 pounds. On the day we met, David was dressed in age- appropriate clothing, which suited his day’s activities and gave me the impression of a normal teenage boy - including trendy sunglasses. He has an endearing face and is an engaging person Comprehensive Functional Behavior Assessment Report and Support Plan Page 3 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

to work with. He seemed very curious but comfortable in my presence and started interacting with me after a few hours. He has no obvious physical disabilities although he is currently awaiting further assessment to rule out the possibility of cerebral palsy (mild). David has been diagnosed with Autism and profound Mental Retardation. He is fully ambulatory and has use of all his extremities. His posture is good but he has a slightly awkward upper body movement when walking. He needs to wear arm restraints and a neck brace when exhibiting self-injurious behavior over a certain level.

B. Language and Communication Skills. David understands simple instruction or communication. His understanding increases within familiar context or when accompanied by gestures. He can follow some one-step directions. He has poor listening skills. He is non- verbal and uses various forms of communication to get his needs met. His main forms of communication are his use of the voice communicators, gestures, and eye contact. He currently uses 6 symbols (eat, drink, music, go upstairs and go downstairs) on his voice communicators although staff report that David does not differentiate between symbols nor does he understand the direct relationship between pressing the button and communicating his need for that symbol. Within familiar contexts, it is generally easy to understand what David wants. David’s use of sign language is restricted to ‘more’. He will initiate communication through use of several gestures, which may or may not be combined with eye contact. He does recognize three-dimensional objects. David will now try to communicate his needs using alternative forms of communication before resorting to his self-injurious behaviors

C. Cognitive and Academic Abilities. Psychological evaluation carried out in March 2000 found David to have a current Global Assessment of Functioning of 20. This is based on a scale of 0 to 100 listed in the diagnostic manual (Diagnostic Statistical Manual IV, 1994). Analysis using the Mullen Scales of Early Learning alongside the Vineland Adaptive Behavior Scale also indicated that David is significantly impaired in all areas of functioning (working at an age equivalent of 14 - 22 months). He has no reading or writing skills. Other academic skills such as math, measurement, and use of calendar were also not present. Staff interviewed noted that David’s memory was fair if relevant issues were being discussed. He also remembered where staff had placed items of interest to him - even after 10 minutes. Probes used to investigate David's matching skills proved unsuccessful. This is thought to be more due to lack of interest or inattentiveness rather than actual cognitive skill. David also showed a delayed response to many instructions Comprehensive Functional Behavior Assessment Report and Support Plan Page 4 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

given throughout the day which required staff to repeat the instructions on more than one occasion

D. Self Care Skills. David can feed himself using a fork or spoon. He needs occasional gestural assistance from staff to prevent him from overfilling his mouth. David's dressing skills are limited and he generally requires hand-over-hand assistance to dress and undress himself. He can pull his pants up or down with minimal prompting. His toileting skills are also limited and currently being worked on. At present David wears a diaper 24 hours a day and needs encouragement to sit on the toilet. His doctor has asked that he be taken to the toilet hourly. He requires full staff support in the areas of bathing, oral and nasal hygiene, and grooming.

E. Domestic Skills. Due to the severity of his self-injurious behavior, David has not had the opportunity to work in this area apart from a few skills such as bussing and emptying the garbage, which he carries out with verbal reminders. He also puts his dirty clothes into the laundry basket with verbal reminders. Some skills such as making his bed or washing dishes are carried out with hand over hand assistance and attention has focused on skills needed in the bedroom and kitchen (most applicable to David).

F. Community Skills. Due to his communication and cognitive abilities, David requires full staff support in all community activities. Areas such as telephone and personal identification are not applicable to David. He has no sense of danger and requires constant supervision whilst out in the community. With familiar staff, he will happily participate in simple shopping skills but the items need to be of interest to him.

G. Recreation and Leisure Skills. David enjoys a variety of outdoor activities such as riding his bicycle, hiking and using his Jacuzzi. These activities are all carried out at the minimum on a weekly basis. He will communicate his desire to participate in an outdoor activity by going to the door. David visits the community on a daily basis and frequently attends parties. He enjoys listening to music - 'Phantom of the Opera' being his current favorite'. He also has music therapy sessions on a weekly basis, which he thoroughly enjoys. David enjoys clapping and spends a large percentage of his leisure time either clapping by himself or with staff. He also seems to enjoy watching other people especially small children. When provided with free time, leisure activities that David will independently initiate are swinging and clapping and he spends most of his free time on these activities. Comprehensive Functional Behavior Assessment Report and Support Plan Page 5 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

H. Social Skills. Although David enjoys watching other people, he will generally interact only with people he knows or feels comfortable with. Staff reports that he can sense whether people like him and uses this knowledge as a guide. His interactions are generally limited to clapping. He has a very good relationship with his parents whom he clearly adores. He has 2 friends outside works (both from school) and likes animals (mainly staff pets). David finds it difficult to initiate friendships and needs staff assistance in this area as would be expected for someone with his level of developmental delay. His happy and engaging personality is one of his strengths and this enables him to build up and maintain friendships with staff support. Increasing his independence in self- care skills is one of his biggest weaknesses in this area. Staff interviewed all enjoyed working with David (although it could be tiring at times).

II. Living Arrangement and Family History. David lives next door to his mother and stepfather. The two separate apartments have been joined so that David has access to both sides of the house. David lives in his side of the house with 24-hour staff support, which is necessary due to the potential severity of his self-injurious behavior. His home was clean and welcoming and a large amount of effort had been made to make it suitable and comfortable for David. This included a swing type chair in the middle of the lounge area in which he spent a lot of his free time. The rooms were all spacious and cheery and David had easy access to a toilet both upstairs and downstairs. Both his weekday and weekend schedule were kept as normal and flexible as possible whilst still providing him with an obvious routine. David has constant 1:1 staffing unless his behavioral needs require a larger staff presence. His support staff looks after David's needs as well as provide him with opportunities to access the recreational and leisure activities, which he enjoys. They support and teach him basic self-care skills mainly through repetition and help him access important therapeutic programs such as his occupational therapy sessions (occur twice weekly) and his music therapy sessions (weekly). All staff working with David undergoes a 3-day training process specific to David's needs and strictly adheres to the SLSI philosophy. Another source has suggested that this period of time is insufficient due to David's complex needs and that more time should be allocated to training. David has lived with his mother for most of his life and only spent a short time in respite care mainly due to a combination of his sleeping problems and the separation. Throughout this period, Mrs. Doe had regular contact with David. David's living arrangement is stable and unthreathened at present. Staffing issues will need to be reviewed as David gets older and stronger. At present David's parents form part of the 'team' approach and will help when greater staff intervention is necessary. David's parents have contact with him on a daily basis, which both parties enjoy. Comprehensive Functional Behavior Assessment Report and Support Plan Page 6 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

III. Daytime Services Received and Day Service History. David has recently transitioned to High school where he is supposed to attend sessions, which were thought to be of relevance to him. These focus on general life skills such as shopping and cooking however David's timetable has still not been finalized. He is supported by an SLSI aide throughout his day and is currently allocated to a multiple handicapped group, which has 16 students in it. Due to the diversity of the class members, the teacher has been catering to the average student, which means David's needs are not being met. So far, David's teacher has not supervised his educational program and has left this responsibility with David's aide. Neither David's teacher not the teaching assistants work with him during school time. This has resulted in David not completing his educational objectives. At present, David has had one member of staff working with him Monday to Friday throughout his school sessions. This has resulted in staff burn out and it is hoped that the introduction of two familiar staff will improve this situation both in terms of following educational objectives and programs and preventing staff burn out. David has attended a number of educational establishments. Before High School, he attended Middle School, which generally seemed to have a better understanding of his needs. David has had similar difficulties with all his educational placements mainly due to his challenging behaviors (which teaching staff was unable to deal with) but also due to his special educational needs. The most severe of these was the Educational Center, which he attended at a much younger age.

IV. Health, Medical and Psychiatric Status. David's last medical evaluation was in 1988 and his current health is reported as good. David has a rotating, shortened colon, slow peristalsis, false rectum, and anus. He had re-constructive surgery between the ages of one and two and until recently required enemas for constipation on a regular basis due to his bowel problems. In the last couple of weeks, his enemas have been stopped (on request of his gastro-enterologist that was concerned about the accumulation of saline in his body) and he is now on a daily dose of milk of magnesia, which seems to be working well. Dosage for this medication is still being explored at present. Further assessment to rule out the possibility of David having mild cerebral palsy is planned as recommended at David's most recent neurophysiological examination in March 2000. David is allergic to wheat, gluten, dairy products, and white grapes. Due to his bowel difficulties, he must also be careful that his diet does not cause constipation or gas. He has a hole in his tympanic membrane in his right year for which he sees an ear specialist. Frequency of ear infections has also reduced. He does not have seizures.

He visits his psychiatrist on a monthly basis. David is currently taking Risperdal 3mg for agitation and behavioral control and Trazodone 150mg Comprehensive Functional Behavior Assessment Report and Support Plan Page 7 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

to help his sleep problems. Both these tablets are taken at bedtime. David also takes Thorazine 50 mg up to twice daily as a PRN for pain and/or agitation. Staff has noted that now that a liquid dose is being used, it seems to relieve David's pain quicker. He is also on a 200mg PRN dose of Advil/Motrin for pain and is currently taking a homeopathic medicine for the same reason. The only side effect caused by his medication noted as of this report was David's drooling but his psychiatrist is aware of this.

David was originally prescribed a combination of Melleril and Clonidine for his agitation and behavioral control however; the Melleril made him very drowsy. He had a short spell of using Thorazine on a daily basis before being introduced to Risperdal in April 1998 which had fewer side-effects and a good success rate with the autistic population. David was diagnosed with developmental delay at the age of one. At the age of three he was diagnosed as having profound mental retardation on both cognitive and communication tests.

V. Previous and Current Treatments. David's behavioral problems have been treated in a variety of manners before his inclusion to the SLSI support team. He has been on various medication and has had day placements which ignored his self-injurious behaviors (instead waiting until he stopped himself) or tried to restrain him through use of furniture. He used to wear a helmet to prevent head injury but this was removed due to greater injury caused by David hitting it. Despite reading through several of his earlier reviews, I have not been able to find much detail on treatment before the SLSI program. Since David has been introduced to the SLSI program, his program has remained based on the SLSI philosophy of non-aversive policies and positive programs. David has been using both arm restraints and a neck brace (following a thorough protocol) which minimizes injury to his head. When David first arrived at the SLSI program, he required use of the restraints throughout the day. Using a combination of strategies such as a gentle touch program, the chain interrupt method of teaching combined with shadowing and a number of positive programs that have focused on communication, this has now been reduced to the need for restraint only as a reactive strategy (required less than daily at present), or for use in certain situations e.g. whilst in the car as a precautionary measure. The use of restraint when needed and the barrier method as a final resort have been found to be very effective when working with David.

FUNCTIONAL ANALYSIS OF PRESENTING PROBLEMS

A functional analysis was conducted for Self-injurious behavior, which consists of face slapping and head snapping. In David's case, this is potentially life threatening due to the severity of the behavior and the possibility that this may Comprehensive Functional Behavior Assessment Report and Support Plan Page 8 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. increase due to David's probable increase in strength and size as he gets older. Accordingly, this analysis endeavored to identify the events that control the emission and non-emission of these clinically important problems. It is therefore organized around six specific subcategories of analysis: (1) Description of the Problem. This analysis attempts to describe the presenting problems in such detail that they can be objectively measured. It presents the topography of the behavior, the cycle (beginning and ending) of the behavior (if applicable), and the strength of the behavior (e.g., frequency, rate, duration, intensity). (2) History of the Problem. This analysis presents the recent and long-term history of the problem. The purpose here is to better understand David's learning history, and the historical events that might have contributed to the problem(s). (3) Antecedent Analysis. The antecedent analysis attempts to identify the conditions that control the problem behaviors. Some of the specific antecedents explored include the setting, specific persons, times of the day/week/month, and specific events that may occur regularly in David's everyday life. (4) Consequence Analysis. The consequence analysis attempts to identify the reactions and management styles that might contribute to and/or ameliorate the presenting problems. It also focuses on the effects that the behaviors might have on the immediate social and physical environment, on the possible function(s) served by the problem behaviors and on the possible events that might serve to maintain or inhibit their occurrence. (5) Ecological Analysis. The ecological analysis attempts to identify the critical mismatches that may exist between the physical, interpersonal and programmatic environments and David's needs and characteristics. (6) Analysis of Meaning. The analysis of meaning is the culmination and synthesis of the above analyses and attempts to identify the functions served by the problem behaviors. The functional analysis of his self- injurious behaviors, organized around these headings, follows:

A. Description of Behavior and Operational Definition. David's self-injurious behavior consists of two separate behaviors: head snapping and faces slapping. Incidents involving self-injurious behavior may involve either one or both behaviors and no patterns have been noted. Although their topography and cycle differ, other measurements and descriptions are the same for both behaviors, which are being recorded using the same rating scale.

1. Topography of Head Snapping. David's chin comes down to meet his chest with an exaggerated and forceful movement, which is loud enough to be heard. This behavior can occur as either a single or multiple unit behaviors.

Topography of Face Slapping David's hands (either one or both) come into contact with his face, generally the upper cheekbone with an open palm resulting in a noise that can be heard in the next room and/or causing enough impact to result in a head movement. Comprehensive Functional Behavior Assessment Report and Support Plan Page 9 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

2. Cycle of Head Snapping. The cycle begins when his chin touches his chest and ends when the behavior (including attempts) has been absent for five minutes

Cycle of Face Slapping The cycle begins when his palm(s) come(s) into contact with his face and ends when the behavior (including attempts) has been absent for 5 minutes.

3. Course. Both behaviors have an immediate onset. As duration of the behavior increases the frequency of the behaviors will both also increase but generally, the level of the force appears to remain the same. Precursors to this behavior include whining, screaming, pacing, and throwing himself to the mat and other signs of agitation as well as signs of pain such as groaning or heavy breathing.

4. Strength.

a) Rate. The current average rate of both behaviors was two every hour with a frequency range of 0-80 behaviors per hour. David's self-injury behavior is estimated to comprise of approximately 98% head snapping and 2% face slapping.

b) Duration. The average length of episode was taken to be around 10 minutes with the shortest episodes only taking a few seconds and the longest incident taking 40 minutes.

c) Severity. The severity of the behavior remains potentially life threatening despite the amazing reductions in frequency and duration when compared to data taken from 1997/8 which showed an average rate of over 200 behaviors per hour. This problem becomes more severe considering the likelihood of David increasing in size and strength in the near future.

B. History of The Problem. David's self-injurious behaviors have been reported from as early on as age two years. His behavior has decreased greatly when compared with data before 1998. Over the last year, the reduction in self-injurious behavior has continued but become more gradual. His behavior continues to show a decrease at present. Staff interviewed agreed that the major contributing factor to David's self- injurious behavior was physical discomfort especially pain and his inability to easily communicate this need. David has had cycles of self-injurious behavior relating to physical problems in the past. An example of this was the increase of his self-injurious behaviors everytime he had an ear infection. David's grandfather with whom he had a very close relationship died one month ago. His grandparents used to visit David on a weekly Comprehensive Functional Behavior Assessment Report and Support Plan Page 10 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

basis. This caused an increase in self-injurious behavior but staff report that David coped very well once the situation was explained to him. Recent medical changes consist of the change from use of enemas to a laxative but this transition only occurred recently and is still being closely monitored.

C. Antecedent Analysis. In an antecedent analysis, one tries to identify the events, situations and circumstances that set the occasion for a higher likelihood of the behavior and those that set the occasion for a lower likelihood. Further, in both categories, one tries to identify both the more distant setting events and the immediate triggers that influence the likelihood of the behavior. Below is firstly an analysis of those setting events and triggers, i.e., those antecedents, that increase the likelihood of David's self-injurious behaviors and their escalation and secondly an analysis of those that decrease the likelihood. Detailed examples substantiating each of these, based on actual incidents, are also included.

Setting Events: Setting events that increase the likelihood of these behaviors include lack of sleep, physical discomfort such as pain, constipation, presence of gas, ear infection, being hungry, environments that cause overstimulation and crowded places especially when they contain people talking loudly. Being in a mellow mood also decreases the likelihood of an incident whereas being agitated or anxious increases it. At present, staff interviewed reported physical discomfort as the main trigger for his self-injury. Just before the behavior occurs, David is often noted to be groaning or breathing heavily. This is not surprising considering the large amount of physiological evidence showing the pain suppressing effect resulting from self-injury.

People: David's behaviors occur regardless of staff/person working with him. The likelihood of his behaviors occurring increases with people who do not make the effort to interact with him. He is also more likely to test out new staff. A forceful approach is more likely to lead to self-injury whereas a gentle approach works well with David and provides a low likelihood of self-injury.

Time: Although his behavior can occur throughout the day, it is least likely to occur in the early morning or late at night which is when David is mellower.

Activities/Events: Although staff reported that the behavior is thought to occur equally whether at home or school, another source suggested that this discrepancy may be more due to recording errors. Events associated with low likelihood self-injury include being in the bath or swinging (during which he will sit on his hands) as well as when interacting (clapping) with Comprehensive Functional Behavior Assessment Report and Support Plan Page 11 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

people he is comfortable with. David is also less likely to self-injure while eating or when being restrained.

During the day that I observed David, no incidents of self-injurious behavior occurred in the morning as David was in a mellow mood (having woken up late), was scheduled to participate in activities that he enjoyed; occupational therapy, visit to Burger King, visiting the beach and listening to music. He was also supported throughout the morning by a member of staff whose company it was obvious he enjoyed thoroughly and who obviously felt the same way about David. On interviewing staff, I was also told about an incident that had occurred on the previous Saturday evening (07/22/00) which involved 6-10 self-injurious behaviors and was given a rating of 2 out of a range of 0 (no SIB's per half hour interval) t0 5 (most severe and involving more than 41 SIB's during the half hour interval). A quick scan of available data at David's house (probably the last month and a half) resulted in ratings of 2 as the most severe incidents David had had. This particular incident was brought on by physical discomfort - an upset stomach and ended about half an hour after medication for pain relief had been given which is the time it takes for the medication to occur. In this incident, David had required use of his restraints for over 30 minutes.

D. Consequence Analysis. Staff adheres to a strict protocol when reacting to David's behaviors and therefore unplanned reactions are non-existent since introduction of his protocol. There were no records of previous management methods however these were unsuccessful in that David's level of self -injury was not reduced until his involvement with the SLSI program. At present, the only people working with David are either SLSI staff (or supported by SLSI staff during behavioral incidents in the case of his therapists' etc). His parents are the only other people that work with him and they too follow the protocols.

His restraints have had to be used all day in the past and he had use of a helmet, which was removed as it increased injury to David. The effect on others is severe both physically (resulting in staff burnout and therefore high staff turnover) and mentally as staff have become extremely frustrated and discouraged.

Giving David attention using both eye contact and speech whilst providing empathy and pain relief where applicable were all thought to improve the behavior when it occurred. The only solution to the behavior in staff opinion was to relieve the pain either through use of medication or in some case tea.

E. Ecological Analysis. There are a number of ways in which understanding the ecology surrounding and how it may conflict with David's needs and Comprehensive Functional Behavior Assessment Report and Support Plan Page 12 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. characteristics, may be helpful in understanding the meaning of his behavior and in understanding the ecological changes that may be necessary to provide the necessary support for him. The brief discussion addressing this ecological analysis is organized below around the physical environment, the interpersonal environment, and the programmatic environment.

Physical Environment: This could only be described as extremely well thought out and suited to his needs. It was obvious that David enjoyed living in his home and found it easy to access all areas of the house when he needed to. In my observation, the use of symbols on David's communicators provided an ecological conflict due to his inability to understand these symbols. The use of three-dimensional symbols would increase his understanding as staff reports that he does recognize and understand three-dimensional objects. Three-dimensional objects could also be used to provide an activity sequence schedule, which would provide a visual reminder and method of predicting the day's activities. Unfortunately, I was unable to visit David's school environment, which is programmatically less well suited to his needs based on staff interviews. However, a visit to the school and classrooms would be necessary to establish what specific areas required work.

Interpersonal Environment: David has constant 1:1 staffing and all staff working with him provided him with a high quantity and quality of attention whilst allowing him space and time to relax when he wanted it. Staff working with David did continuously try to increase his independence by encouraging him to complete tasks or parts of tasks with minimal prompting and without nagging. David has no relationship with his schoolteacher and teaching assistants who do not work with him which staff found very frustrating. Staff noted that this was probably due to his behaviors and perhaps some form of basic training for some if not all of the teaching assistants about David would help in this area. Expectations of staff for David were to increase his independence in areas of life that would result in an increase in quality of life such as personal care and domestic or community skills. They also would like to see further reductions in his behavior. David was observed interacting with his father on more than one occasion and it was obvious how much both parties enjoyed this relationship. An opportunity to see David interact with his mother did not occur due to busy schedules, however staff reports all indicated that the same close relationship existed between David and his mother.

Programmatic Environment: David's home environment was suited to increasing his self-help skills and he already possessed a fair amount of materials designed to further increase stimulation and instruction such as well adapted computer technology. Work is continuing in this area to try to Comprehensive Functional Behavior Assessment Report and Support Plan Page 13 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

make the materials even more suitable to David. As previously mentioned staff reported the lack of suitable materials in the school environment to suit David's needs and limited abilities. A member of staff interviewed felt that there was not enough motivation provided in the form of stimulation to maintain David's interests. It was also the consensus that David required a more functional curriculum, which would enable him to work on his personal care and community, or domestic skills, which would increase his overall quality of life.

F. Impressions and Analysis of Meaning. In considering this functional analysis and the background information summarized above, there are a number of factors that are helpful in trying to understand the meaning of David's behavior. Currently David's self-injurious behavior seems to occur mainly when David is trying to communicate his need for pain relief. Due to his significant bowel problems, even with his limited diet and medication, David appears to regularly undergo an intolerable level of pain. Staff reports that David does try to communicate his need without using his self-injurious behaviors but will use them as a last resort. An alternative easily recognizable (and user friendly) form of communication is needed to help David get his needs met.

Due to David showing severe self-injury since the age of two years, he has not had the opportunity to work on many areas of personal care and other important life-skills. This would greatly reduce his dependence upon staff. Since the almost miraculous reduction of his self-injury over the last year or so, it is crucial that David is now given every opportunity to extend the quality of his life and improve his independence in order to enable him to live as independent and normal a life as possible as an adult.

MOTIVATIONAL ANALYSIS

A motivational analysis was carried out to identify those events, opportunities and activities that David enjoys and that may be used to enhance his quality of life and provide him with incentives to improve his behavior and to enhance his academic progress. The results of the analysis showed a number of events that could be used effectively as positive reinforcement in a well designed support plan to reduce the identified behavior problems. These events include, but are not limited to the use of food (ensuring it was suited to his limited diet and healthy), the use of music, increasing access to the swings, and using his love for clapping with staff. David enjoys a variety of finger foods such as tomatoes, potato tots, and corn chips and has a large but healthy appetite. These reinforcers, and others, should be used in a variety of ways, the least of which would be through the contingencies of formal reinforcement schedules. Information for this section was gathered through use of staff interviews and completion of a reinforcement inventory. Comprehensive Functional Behavior Assessment Report and Support Plan Page 14 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

David already has access to all these potential reinforcers but increasing access to these reinforcers would increase his motivation to participate in areas of his life that need improving such as personal care skills and have already been used to achieve some success in this area. Using a form of reinforcement might also improve his communication skills when seeking pain relief as staff has already noticed attempts to communicate his need without resorting to self-injurious behavior. Increasing access to the community may also be used to motivate David into learning community skills as he obviously enjoys being out in the community and it provides him with an opportunity to observe other people who he also enjoys.

MEDIATOR ANALYSIS

A "Mediator Analysis" was conducted for the purposes of identifying those persons who might be responsible for providing behavioral support for David, their abilities to carry out the recommended support plan, given the demands on time, energy, and the constraints imposed by the specific settings, and motivation and interest in implementing behavioral services as recommended. This analysis showed the following:

In this situation, the mediators were the SLSI staff providing 24-hour support to David and his parents. Staff working with David was happy with the way the current program was running as far as the reduction on behavior and the quality of life provided for him at home. It was felt that David needed to work on a variety of skills in order to increase this quality of life. They felt that a lot of this work needed to be achieved within the school environment. Due to present staffing issues, supervision in this area has not been readily available due to the need for supervisors to work 'on a hands-on basis. The use of only one member of staff as David's 'school staff' has also resulted in burn out and has prevented education objectives being completed on a regular basis. Working with David can be emotionally draining but all staff interviewed enjoyed working with him and was more than positive and motivated. Staff were very concerned about the severity of his behavior increasing as he gets older and larger/stronger and the implications of greater staffing or use of more male staff were frequently brought up. Attitudes of the school to David's educational needs and the provision of a teaching aide by SLSI also need working on, but this situation may be improved by the introduction of two staff to fill this position. Throughout the behavior assessment, staff working with David has been extremely co-operative and motivated to improve his quality of life and increase his independence. They seemed quite happy to make any changes to the program or environment that were in David's best interests and also pointed out that David's parent were just as eager to cooperate. The only constraint they believed could affect the Comprehensive Functional Behavior Assessment Report and Support Plan Page 15 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. program were physical constraints and current limited staffing resources should David require more than1: 1 staffing.

RECOMMENDED SUPPORT PLAN

A. Long-Range Goal. The long-range goal for David is to establish enough self control over his behavior that he will be able to live and work in the least restrictive setting possible that is capable of meeting his developmental and behavioral needs. The goal of his educational plan is to provide him with the academic and other skills necessary to meet his needs, while eliminating those behaviors that tend to stigmatize and isolate him from full community and social presence and participation. Additionally, the goal is to transfer the control of David's behavior from external mediators (parents and staff) to internally generated controls. The plans and objectives presented in the following paragraphs are intended to increase the likelihood that the following specific outcomes will occur:

1. That David will be able to communicate his needs (especially for pain relief) without needing to rely on his self-injurious behavior. 2. That David will become less dependent upon staff members in the areas of personal care, domestic skills and community skills all of that will result in an increase in the quality of his life.

B. Operational Definition of Self-injurious behavior(s). David's self-injurious behavior consists of two separate behaviors: heads snapping and face slapping. Incidents involving self-injurious behavior may involve either one or both behaviors and no patterns have been noted.

1. Topography of Head Snapping David's chin comes down to meet his chest with an exaggerated and forceful movement, which is loud enough to be heard. This behavior can occur as either a single or multiple unit behavior.

a. Cycle of head snapping. The cycle begins when his chin touches his chest and ends when the behavior (including attempts) has been absent for five minute.

2. Topography of Face Slapping David's hands (either one or both) come into contact with his face, generally the upper cheekbone with an open palm resulting in a noise that can be heard in the next room and/or causing enough impact to cause head movement. Comprehensive Functional Behavior Assessment Report and Support Plan Page 16 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

a. Cycle of Face Slapping The cycle begins when his palm(s) come(s) into contact with his face and ends when the behavior (including attempts) has been absent for 5 minutes.

C. Short Term Measurable Objectives. The following objectives and plans are suggested on the assumption that David has the opportunity to remain in a supported living environment with 24 hour support in order that David is always provided with at least 1:1 staffing and that he has access to a suitable educational environment. It is unlikely that they would be realistic if he did not have these opportunities. These objectives were also selected as being most reflective of David's priority needs and as being the most realistic given his level of functioning at this time. Further objectives may be established as a function of the success or failure of the recommended strategies.

1. Self-injurious behavior (Head snapping & Face slapping).To reduce the rate of self-injury from the current average of 0.5 an hour to 0.25 an hour within a period of 12 months from the initiation of intervention services

2. Self-injurious behavior (Head snapping & Face slapping) To reduce the percentage of time spent in restraints from the current percentage of 5% by one quarter within a period of 12 months of the initiation of intervention services and by a half within a period of 2 years.

D. Observation and Data Collection Procedures.

1. Methods. - Self-injurious behavior (Head snapping and Face slapping): Due to the previous high frequency of this behavior, a rating scale was developed which was used to measure self- injurious behavior based on frequency markers. The current recording chart already records all necessary data in an extremely efficient and clear way (number of incidents per half hour session, time spent in restraints as well as other data relevant to David's other behaviors), and should be continued.

2. Observational Reliability. Randomly scheduled observational reliability checks will be carried out in both home and school on a monthly basis and document reliability indices of 85% or better

E. Intervention Procedures. In the following paragraphs, a summary of possible strategies to support David is presented. These are by no means meant to be comprehensive or exclusive of other procedures. They Comprehensive Functional Behavior Assessment Report and Support Plan Page 17 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. simply represent a set of starting points that would be elaborated and modified as services are provided. Support is organized around four primary themes: Ecological Strategies, Positive Programming Strategies, Focused Support Strategies, and Reactive Strategies.

1. Ecological Strategies. Many behavior problems are a reflection of conflicts between the individual needs of a person and the environmental or interpersonal context, in which the person must live, go to work or otherwise behave. As part of the above evaluation, several possible contextual (ecological) conflicts were identified. It is possible, that by altering these contextual conflicts, that David's behavior may change and his progress may improve, thus eliminating the need for consequential strategies. In the following paragraphs, a number of "Ecological Manipulations" are presented with the intention of providing a better mesh between David's needs and the environments in which he must behave:

a) Physical environment Communication: David's inability to discriminate between the symbols used on his communicators prevents him from communicating his needs easily and means he has to rely on staff interpretation. The use of three-dimensional objects will increase his understanding as he finds these much easier to understand. This use of three-dimensional objects may be shaped into photographs at a later stage (through use of slicing the objects into half so as to make raised or textured photographs). As his preferred use of communication is based on either use of eye contact or gestures this will also give him something specific that he easily recognizes upon which to focus. It is suggested that small examples of representational items e.g. a fork to represent eating should be attached to the communicator. It is also suggested that similar three-dimensional objects are used to help David locate important items or useful items in the house, e.g. a glass attached to the cupboard containing glasses. The use of these three dimensional objects to aid communication should also be carried out in the school environment as far as possible to provide David with consistency.

b) Programmatic Environment Daily Activity Schedule: At present David has no concrete way of predicting the next activity involves apart from when staff tell him, usually before his transition to the new activity or location. It is suggested that an Activity sequence using three-dimensional objects to give David a visual reminder of what is happening next may help reduce his anxiety levels and therefore reduce the Comprehensive Functional Behavior Assessment Report and Support Plan Page 18 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

likelihood of self-injurious behavior. This schedule can then be used to visually remind David of the next activity as well as what activities are occurring on that day.

Education Timetable: David's educational timetable does not appear to meet all his needs at present as some of his educational objectives appear to demand cognitive skill areas that he does not possess or require e.g. use of a telephone. Due to his limited abilities, it is suggested that David concentrates on more functional activities that interest him and that will be more relevant to him. An example of this would be additional shopping and cooking sessions during the week as staff has already reported that these are among his favorite sessions. The additional sessions would also benefit David's learning abilities as staff report that he learns best through repetition.

c) Stimulation/Reinforcement: The use of more stimulating materials to reinforce attention is also suggested as staff report that David is easily distracted by lack of stimulation when participating in activities such as using the computer. Use of a program that provides David with more audio or musical feedback may be used to reinforce participation as he enjoys music. An example of this would be to use some of the Dorling Kindersley CD-Rom packages, which have very good audiovisual feedback.

2. Interpersonal Environment

a) Staff Hours. Staff who work with David at present are frequently expected to work long hours. This can lead to staff inconsistency and decreased motivation when following David's extensive protocols. For this reason, it has been suggested that staff supports David for shorter periods and that a larger range of staff supports David during school hours.

b) Staff Training. Another source suggested that training time is increased form the current three day level to a minimum of a week due to the large number of training procedures and protocols that must be understood when dealing with David. This will enable staff to build up a greater knowledge of David' specific needs. Teaching Assistants at school could also undergo a basic training to help them understand Comprehensive Functional Behavior Assessment Report and Support Plan Page 19 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

David's educational needs This would provide SLSI staff with some help in completing his education objects and providing him with stimulating activities in which to participate. Providing David's 'school' staff with teaching skills in the form of inservice training (video or handbook) would also help as at present they have no training in this area. This would increase their self-sufficiency in the classroom situation if the educational staff (teacher and teaching assistants) were unable to work with David.

c) Supervision. Staff supervising David's support staff and program should also be provided with sufficient supervision opportunity, as it is important that data is being recorded reliably and that all protocols are being correctly implemented. At present, supervisory staff have to use this time to work hands on due to present staff shortages.

3. Positive Programming. Challenging behavior frequently occurs in settings that lack the opportunities for and instruction in adaptive, age-appropriate behavior. It is our assertion that environments that provide instruction to promote the development of functional academic, domestic, vocational, recreational, and general community skills is procedurally important in our efforts to support people who have challenging behavior. To the extent that David exhibits a rich repertoire of appropriate behaviors that are incompatible with undesired behavior, the latter should be less likely to occur. Positive programming, therefore, should not only result in developing David's functional skills, but also contribute to reducing the occurrence of problematic behavior. At the very least, a context of positive programming should make it feasible too effectively and directly address David's self-injurious behaviors. In the following paragraphs, several initial thrusts for positive programming are presented:

a. General Skills. This evaluation indicates that due to David's severe behavioral problems, he now has very limited skills in the majority of skill areas investigated. By increasing his independence in the areas selected, it is hoped to decrease David's dependence upon staff and therefore the quality of his life.

a) Rationale / Logic. David enjoys eating with his parents but at this early stage of the program, asking him to cook a meal for them is probably too large a demand to place upon him. Setting the table for a meal with them will be a much easier starting point. Having a fun meal with his parents (favorite foods and music) should be sufficient reward for task participation especially if he is also rewarded with lots of verbal praise for completing the task. Once David is able to do this, this weekly responsibility will be one of the ways he contributes to the shared household on a continuing basis as a teenager who is learning to take responsibilities as an adult.

b) Objective. By September 1st next year,David will be able to set the dinner table in order to have a meal with his parents on a weekly basis requiring only verbal assistance from staff and without error. Setting the table will involve setting places for the family meal so that each person has a knife, fork, spoon, plate, glass and table mat.

c) Method. The task is to be taught by whole task presentation using backward chaining. A clear/simple written sequence (in order to maintain consistency) should be used alongside prompt fading starting at the physical prompt level. This will increase David's motivation to learn this task. The use of his favorite foods and background music during the meal should also help make the meal as pleasurable an experience as possible. This will add to the overall reinforcement value, which should improve task participation. It is important that this meal should be a 'fun' experience and therefore prompting related to eating and other behaviors during the meal should be kept to a minimum. For this reason, finger foods or other easily accessible foods should be used.

a) Rationale/Logic David enjoys shopping providing the items he is buying are relevant to him. David will be provided with the opportunity to select a minimum of two choices of fruit that he can then use as part of the desert for his weekly family meal. His participation will not include any money/payment responsibilities. These will be left up to the member of staff working with him due to his limited cognitive abilities.

b) Objective. By September 1, next year, David will be able to go to a named shopping facility and select a minimum of two types of fruit to put into his shopping basket. He will then carry the basket to the shopping till and place it upon the counter. He will complete this task with verbal assistance from staff and without error.

c) Method. This task is to be taught using whole task presentation with forward chaining due to the sequential nature of the task. The use of prompt fading starting at the physical prompt level should also be used. b) Teaching Functionally Equivalent Skills. People engage in seriously challenging behaviors for perfectly legitimate reasons. They use these behaviors to communicate important messages, to assert themselves, to manage unpleasant emotions, to escape unpleasant events, and to gain access to events and activities. One important strategy for helping people overcome their challenging behaviors is to provide them with alternative ways of achieving the same objectives, alternative ways of satisfying their needs. These alternatives are defined as functionally equivalent skills because they achieve the same goal as the challenging behavior or communicate the same message. The above analysis of David's behavior concluded, among other things, that his self-injury was used to communicate his needs.

1) Rationale / Logic. Staff has noted that David will generally try to communicate his needs using other forms of communication such as eye contact or gestural communication. He will only resort to self- injurious behavior when staff cannot correctly interpret his eye contact or gestures and therefore cannot meet Comprehensive Functional Behavior Assessment Report and Support Plan Page 22 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

his needs. By using three dimensional objectives that have already been discussed in the ecological strategies, David will be able to communicate his needs at first through use of his preferred forms of communication (eye contact and gestures as opposed) using a method of representation that is accessible to him (three dimensional objects as opposed to pictorial symbols that he cannot distinguish). These three-dimensional objects should be linked to the relevant communicators (i.e. removing the symbol from the communicator and replacing it with an appropriate three-dimensional object) and will make discrimination of these much easier for David. An example of this would be during mealtimes, David will be able to distinguish between the drink and eating communicator due to the presence of 2 completely different objects (e.g. a fork and a cup) as opposed to symbols, which he finds difficult to discriminate.

2) Objective - Stage 1: By 1st December this year, David to use the relevant three-dimensional object to communicate his need for food by pointing to it with verbal assistance from staff and without error. Objective - Stage 2: By 1st March next year, David to use the relevant three-dimensional object to communicate his need for drink by pointing to it with verbal assistance from staff and without error. Objective - Stage 3: By 1st June next year, David to use the relevant three-dimensional object to communicate his need for music by pointing to it with verbal assistance from staff and without error.

Objective stages to continue so as to introduce a new object to David at three monthly intervals.

3) Method. Small objects will be positioned at strategic and relevant areas of the house and school environment. David's use of the three-dimensional objects should be shaped into pointing to the object or touching the communicator as relevant. This should be carried out on a daily basis within the normal setting of David's day to provide a real life situation in which David can learn these skills. The strategy of 'training loosely' (i.e. where instruction occurs wherever and whenever the opportunity occurs) Comprehensive Functional Behavior Assessment Report and Support Plan Page 23 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

should be employed. David should be reinforced with verbal praise and clapping to increase motivation. c) Teaching Functionally Equivalent Skills (continued). This section of the program has been included in this section because of its teaching nature but also in the Reactive Strategies section because of its need for salience.

1) Rationale / Logic. At present, David communicates his physical discomfort and need for pain relief through a combination of signs such as groans, heavy breathing, appearance of pain and agitation and through use of eye contact. Both of these forms of communication require correct staff interpretation if David is to get his needs met. It is hypothesized that by providing David with an object (to focus his eye contact or gestures) that he associates with pain relief, it will be easier for him to communicate this need to staff. As David finds it much easier to recognize three-dimensional objects, this section of the program will work on his ability to associate a predetermined object with pain relief. It is suggested that this object be an exaggerated, easily recognizable version of a medicine bottle, which visually represents David's current form of medication as closely as possible. Due to David's low cognitive abilities and the length of time it takes for the medication to work, this method of teaching will have to occur during naturally occurring events so as to increase the salience of the association to a level that may be understandable to David. It is suggested that all David's pain relief medication be provided in similar bottles for the same reason, i.e. increase salience of the association

2) Objective. By 1st September next year, David to associate this three-dimensional object symbolizing his pain relief with pain relief. This will occur with verbal assistance from staff on 5/5 naturally occurring occasions.

3) Method As mentioned in the previous section, David's form of communication whether eye contact or gestural should be shaped into him touching the three-dimensional object, in this case the bottle. Staff should then reinforce David with verbal praise for Comprehensive Functional Behavior Assessment Report and Support Plan Page 24 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

communicating his need and provide him with his medication following relevant protocols. Initially, teaching David how to communicate his need for pain relief will require staff interpretation of his signs of communication but it is hoped that through repetition, David will be able to learn this association in time. This strategy of 'training loosely' (i.e. where instruction occurs wherever and whenever the opportunity occurs) needs to be used in order to increase the strength of the association therefore making it easier for David to associate. d) Teaching Coping and Tolerance Skills. Much of David's serious self-injurious behavior is a reflection of his inability to cope with aversive events such as not getting his needs met, delay in gratification, denial, the need to perform a non preferred activity, etc. While some of these behaviors can be avoided by improving his communication skills, aversive events are also naturally occurring. Especially if he is to lead a full life, from time to time, he will face the disappointments we all have to face, for example, not getting something that he wants, when he wants it and having to wait for it, i.e., delay; not getting something he wants, at all, i.e., denial; being told by somebody that a relationship is not possible; being criticized or reprimanded; etc. In the face of these events and the emotions they understandably arouse, David's coping responses have not had the opportunity to develop much beyond the primitive responses of a young child; nor is he likely to develop much beyond this level through "natural consequences." Rather, it will be necessary to be systematic in applying sophisticated instructional technology, with the objective of teaching him these very important coping and tolerance skills. The following is a recommendation for how to proceed in this important area of skill development, with the initial focus being on teaching him an alternative relaxation method.

1) Relaxation Training

a) Rationale / Logic. David enjoys having a bath and staff report this is an area where the likelihood of self-injury is very low to non- existent. By providing David with access to the bath - a reinforcing event, he may be distracted from his self-injury and because he enjoys is baths, this process will relax him as well. As Comprehensive Functional Behavior Assessment Report and Support Plan Page 25 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

baths may also reduce some of his pain/ physical discomfort, the use of a bath may be doubly reinforcing. David will also be working on his communication skills, as he will need to point to the three-dimensional bath. This will be David's initial step in communicating a need to take part in a soothing activity. It is important that staff use this strategy as a pleasurable activity that may help David relax but does not place the emphasis on getting him to relax at least for the initial stages of the program. Making his bath environment as soothing as possible through use of music and maybe using an Aromatherapy oil such as Lavendar (needs to be confirmed suitable for use by David) is suggested. This program can also be carried out using the jacuzzi but will need a different symbol so that David will be able to differentiate between the two activities at a later date.

2) Objective. By 1st September next year, David to communicate bath by pointing to the three- dimensional object representing the bath and to have a relaxing bath with staff support. David should communicate the desire to have a bath by pointing to the object with verbal assistance from staff.

3) Method This training should occur at least once a week although staff should encourage David to communicate his desire to have a bath by pointing to the object during all naturally occurring situations. Staff should shape David's form of communication into pointing to the bath and reinforce this with verbal praise for good communication and immediate provision of the bath (reinforcing event). The bath should be made as enjoyable an experience as possible for David through use of preferred relaxing music and other sensory changes such as use of aroma, bubble bath, use of texture etc.

Future Goal: The use of a picture/object sequence book should also be looked into at a much later stage of this program, as it would provide staff with a way of discussing/showing David the alternatives open to him and the effects they may have. Use of Comprehensive Functional Behavior Assessment Report and Support Plan Page 26 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

photographs and objects may help his understanding of the available options and their consequences regarding himself. Staff reports suggest he like being read to. Once his communication skills improve this may also provide him with an opportunity to choose between the various options e.g. bath, back rub, cup of tea and an opportunity of communicating this to staff.

3. Focused Support Strategies. Some of the ecological strategies that were recommended above, depending on their complexity and/or difficulty, may take time to arrange, and positive programming will require some time before new skills and competencies are mastered. Although these ecological and positive programming strategies are necessary to produce good long-term quality of life outcomes for David, it is also necessary to include focused strategies for more rapid effects; hence the inclusion of these strategies in our support plans. Specific recommendations for the limited but important need for rapid effects are made below.

a) Antecedent Control: There are a number of antecedent control strategies that may act to preclude the occurrence of the targeted behavior problems. These are provided in the following paragraphs. Eventually, perhaps after at least a year of success, gradual fading of some of these antecedents can occur. The fading process should be initiated very carefully. In addition to going a long period of time without self-injury, the most important indicator that fading can begin will be when the goals and objectives of the positive programs described above have been met.

Antecedent conditions that increase the likelihood of David's self-injurious behavior and that should therefore be avoided include: Forceful approach - David must not be forced to participate in activities or programs such as toilet training as a forceful approach will only result in him self-injuring. Instead using a gentle approach, encouragement and reinforcement such as praise will increase the chances of participation. Foods that cause gas - It is imperative that all staff follows David's limited diet guidelines as due to his bowel problems, he finds it difficult to cope with gas. If despite following the guidelines, David has a build-up of gas, he has already been taught to lie on the mat with his bottom raised and allow staff Comprehensive Functional Behavior Assessment Report and Support Plan Page 27 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

to give him a back-rub to help speed up the removal of the gas. Encourage this behavior if applicable. Being hungry/thirsty - Staff should always ensure David has a readily available supply of food and drink especially when out in the community as due to his limited diet - suitable food may not be available.

Antecedent conditions that increase the likelihood of David's self-injurious behavior but cannot be prevented easily include: Lack of sleep/Agitated mood In both these situations, staff should ensure that large demands are not place on David and that he has adequate time in one of his preferred activities (see below). Staff should also ensure that all David's other needs are being met in order to reduce likelihood of self-injury.

Antecedent conditions that decrease the likelihood of David's self-injurious behavior include: Eating/Having a bath/Swinging/Clapping - These are all activities that David likes participating in and may even reduce the likelihood of him self-injuring.

4. Reactive Strategies. Efforts to manage the antecedents to David's self-injurious behavior are likely to have a considerable impact on the rate of their occurrence, as will improving his ability to communicate. However, these behaviors are still likely to occur, at least somewhat, especially during the initial stages of the implementation of this support plan, as the necessary adjustments to the plan are identified and made. Therefore, staff may need measures for dealing with these behaviors when they occur. Such reactive strategies have an even more limited role than the focused strategies recommended above. Specifically, reactive strategies are designed to produce the most rapid control over the situation, in a manner that keeps both David and staff as free from risks to injury as possible and that keep David free from risks of exclusion and devaluation as much as possible. Accordingly, reactive strategies are not intended to produce any change in the future occurrence of David's challenging behavior. Both rapid and durable changes, instead, are being sought by the Ecological Strategies, Positive Programming Strategies, and Focused Support Strategies described in the preceding sections. These proactive strategies are also expected to prevent any counter therapeutic effects that might accrue from the nonaversive reactive strategies being recommended here. The following procedures are suggested as Comprehensive Functional Behavior Assessment Report and Support Plan Page 28 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. initial strategies that fit within SLSI's "Emergency Management Guidelines." They, along with other strategies that fall within the guidelines, which may be considered in the future, are expected to preclude the need for the physical management of David's behavior, including the need for physical restraint. a) Active 'Listening' (Understanding): Actively listening (or recognizing depending upon medium of communication) to David as a basic interactional style for staff when they are working with David should be another very effective strategy for avoiding incidents of self-injurious behavior. In addition, reflecting his feelings to David so that he knows he is being understood, as a strategy for when he exhibits precursor behavior, should be effective in preventing an escalation to full-blown episode of self-injury. Active Listening is also recommended as a way of de-escalating an actual episode of self-injury. Guidelines for developing a detailed protocol for active listening, which can be used for staff training and ongoing procedural reliability checks are to be developed. When the staff member has reached a point where transition can occur, David should be encouraged to relax as described under relaxation training (See Coping Strategies) before moving on to the regularly scheduled activities. b) Facilitated Communication: This section of the program has been included in this section because of its reactive nature but is also included in the Teaching Functionally Equivalent Skills due to it's teaching nature. Prior to engaging in self- injurious behavior David may appear to be agitated as his needs are not being met. Intervention at the time that David manifests these precursors (whining or screaming, pacing, throwing himself on the mat as well as general agitation) may reduce the likelihood of a more severe incident occurring due to the communicative function of David's behaviors. Thus, the following approach is suggested: When David initially displays agitated actions, staff should encourage him to communicate his need through eye pointing, gestures or actual pointing to the three-dimensional objects offered. In order to keep demand low; offer him a choice of two objects based on knowledge of his current situation. Every effort should be made to actively listen to and understand this message. If his communication is for pain relief or as in the initial stages of the program he appears to be in pain, shape this communication into a communicative gesture i.e. pointing to the painkiller and Comprehensive Functional Behavior Assessment Report and Support Plan Page 29 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

follow protocols for administering of painkiller whilst reinforcing David verbally for his good communication.

c) Facilitated Relaxation: If David continues to be agitated, staff should use the "Cued Relaxation" procedures described in Coping Skills. This strategy should be used at the first sign of David's antecedent behaviors such as signs of physical discomfort. Basically they will be encouraging David either to lie on the mat in order to get his back rubbed (to speed up the removal of gas) which he has already been taught how to do - or if the incident is caught at an early enough stage, David may be supported through one of the newer strategies such as use of a bath. Whichever choice, David makes, staff should facilitate communication by shaping his communication to a pointing to the relevant object and then reinforce this by verbal praise and immediate provision of his choice of relaxing activity. At the initial stages of the program, David's choice of relaxation will depend largely on staff interpretation of his needs.

d) Stimulus Change: This strategy may be used at the time of an incident and involves the introduction of a novel stimulus, which may interrupt the course of or terminate self-injurious behavior. This should provide an opportunity for facilitated communication and facilitated relaxation to occur. Activities and stimuli suggested for this distraction include use of loud music or clapping.

e) Use of Restraint: David is currently following a behavior protocol stating that his restraints must be used after three single units of self-injurious behavior. These restraints (an arm restraint for each arm and a neck brace) are the kept on David until the end of the cycle (i.e. when self-injurious behavior or attempts of have been absent for 5 minutes). If the behavior continues to escalate after the restraints have been used and all possible communicative reasons for David's self-injurious behavior ruled out, the barrier method must be used as a last resort in order to prevent severe injury to David. Specific details of the protocol have been attached. If in doubt as to the procedure, please contact David's SCIP senior for future clarification, as it is essential that these protocols are correctly followed.

5. Staff Development and Management Systems. Key elements that will determine the degree of success of this support plan are staff competence Comprehensive Functional Behavior Assessment Report and Support Plan Page 30 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved. and management systems that assures staff consistency in providing services to David. The following is recommended: a. Procedural Protocols. Each strategy and procedure described above should be broken down into teachable steps. Sample guidelines for developing such protocols are attached for one of the procedures - Active Listening. b. Three tiered Training.

1) Each staff person would be required to show "verbal competence" for each procedure. That is, they would need to describe each and every step in the specific procedure. Each staff would be scored using a "+/O" system for each step of the procedure. A 90% criterion is considered passing.

2) Each person would be required to show "role play competence" for each procedure. That is, they would need to demonstrate each step of a procedure to another member of David's support team. The scoring system would be the same as for "verbal competence," as described above.

3) Finally, each staff person would need to demonstrate "in- vivo" procedural reliability; that is, the ability to carry out each program component of David's support plan for which they are responsible. This would require the designated person to observe each staff person as they provide services and to see the degree to which what they do agrees with the written protocols. The scoring procedure described above would be used again, and 90% consistency should be considered as minimally acceptable. For those procedures that do not occur frequently, such as the need to react to infrequent behavior, role-play competence should be reconfirmed on a regular schedule.

As previously mentioned, training time needs to be increased from the current three day level to a minimum of a week due to the large number of training procedures and protocols that must be understood when dealing with David. This will enable staff to build up a greater knowledge of David' specific needs. c. Periodic Service Review. David's entire support plan should be operationalized into a series of performance standards to be met by the support team and integrated into a Periodic Service Review. Comprehensive Functional Behavior Assessment Report and Support Plan Page 31 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

Monthly (initially, weekly) monitoring should be carried out by the designated coorD.tor and the status of the support plan's implementation should be quantified as a percentage score. This score should be summarized on a graph and kept visible to staff as an incentive to achieve and maintain a score of 85% or better. This should be reviewed regularly by management and feedback should be provided. More information on how to develop and implement a Periodic Service Review system can be provided on request.

COMMENTS AND RECOMMENDATIONS

1. Revisions are certain to be necessary during the initial stages of implementation and as David's responsiveness to this new support plan are observed. Early revisions and fine tuning are necessary in the initial implementation of any support plan, especially one as comprehensive as this one attempts to be.

2. Analysis of David's self-injurious behavior has found it to be communicative in nature. By providing him with an alternative form of communication that he can easily recognize, it is hypothesizes that his greatly reduced rate of self-injury will decrease further as staff report that he only uses this behavior to communicate his needs when his alternative forms of communication are not understood. Due to David's bowel difficulties, a large part of the program has been focused on teaching him to communicate his need for painkillers as this appears to be the area of communication that he finds most difficult. Although I realize it will take a long time for David to achieve this level of communication, I feel it is critical that the communication program is carried out if David is to have any chance of getting his needs met in a consistent manner. Through decreasing his dependence upon staff, this will enable him to improve his quality of life. This will also help staff understand David's needs before he has to resort to self-injury, which is already becoming more of a problem as he gets older (and larger/stronger).

3. David has 24 hour staff support provided by SLSI which provides him with at least 1:1 staffing ratios. Staff interviewed was found to be extremely positive and co-operative and no mediator difficulties are anticipated as far as staff willingness to implement new programs is anticipated. It is crucial that senior staff is provided with sufficient opportunity to carry out their supervisory roles especially in the initial stages of the program. This will be crucial in order to provide a consistent approach when teaching David this new communication strategy. Issues of extending training and reliability checks also need to be discussed as these will ensure consistency and also help provide new staff with a better understanding of David's needs and protocols. This will be vital as the number of vacancies Comprehensive Functional Behavior Assessment Report and Support Plan Page 32 © 2002 Institute for Applied Behavior Analysis, All Rights Reserved.

for staff in David's team means that a large number of new staff are likely to be working with him.

4 Due to timing constraints I was unable to observe David's school environment and his behaviors during school sessions. I would recommend further assessment in this area to ensure that David's educational needs are being met in a suitably stimulating environment through use of suitable teaching methods and that the educational timetable focuses on teaching David functional life-skills that will increase his independence and therefore quality of life. Some form of in-service training in teaching skills for David's SLSI 'school' staff as well as training for teaching assistants at David's school is recommended as this will improve the quality of his educational program and help to ensure that his objectives are being carried out.

______writer

______Clinical Director

______Associate Director