The contribution of ABA and psychiatry to the emerging model of positive behaviour support

Transcription

1 The contribution of ABA and psychiatry to the emerging model of positive behaviour support Royal College of Psychiatrists Faculty of Intellectual Disability Psychiatry Annual Conference 2016 Dr Ashok Roy & Dr Sandy Toogood Cardiff September 29 th 2016

2 Introduction PBS emerging as the approach of choice. RCP endorsed (2007 / 2015). Questions about the definition of PBS and contribution of stakeholder and professional groups.

3 Overview Review definitions of PBS. Review contributions from psychiatry and behaviour analysis. Review two case studies. Discuss in small groups for 20 minutes. Feedback and review to full group for 20 minutes.

4 Defining PBS Comprehensive lifestyle change and quality of life. Lifespan perspectives. Ecological validity. Stakeholder participation. Social validity. Systems change and multi-component intervention. Emphasis on prevention. Flexibility with respect to scientific practices. Multiple theoretical perspectives. (Carr et al. 2002)

5 Defining PBS Values: Prevention and reduction of challenging behaviour occurs within the context of increased quality of life.. Constructional approaches... build stakeholder skills and avoid aversive and restrictive practices. Stakeholder participation. (Gore et al. 2013)

6 Defining PBS Theory: Challenging behaviour develops to serve important functions for people. Use of applied behaviour analysis to assess and support behaviour change. Use of other complementary, evidence-based approaches to support behaviour change at multiple levels of a system. (Gore et al. 2013)

7 Defining PBS Process: A data-driven approach to decision making. Functional assessment to inform function-based intervention. Multicomponent interventions to change behaviour (proactively) and manage behaviour (reactively). Implementation support, monitoring and evaluation of interventions over the long term. (Gore et al. 2013)

8 Defining PBS This definition includes both preferred labels for PBS: approach and framework. PBS is not inclusive of all approaches to behavioral support, but rather is restricted to only those approaches that share the qualities contained in the definition. PBS is inclusive of strategies and approaches from an array of disciplines and from evidence-based procedures that may currently exist in other fields or may emerge in the future. Defines a PBS approach as dynamic and continually evaluating and incorporating relevant technology and knowledge. It also promotes the critical analysis of strategies that are evidence-based or have emerging evidence. (Kincaid et al. 2015)

9 Defining PBS A tiered approach

10 Contribution of ABA the Four term contingency The four term contingency Motivative Discriminative Behaviour Consequences Learning History Rule governed behaviour Verbal rules that control behaviour. Describe and override contingencies of reinforcement and punishment. Rule-following is reinforced by contingencies.

11 Biopsychosocial perspectives from Psychiatry High prevalence of comorbid conditions Multiaxial diagnosis and formulation Psychiatric Intellectual (level of functioning) Developmental (ASD, ADHD) Physical Psychosocial ( environment, family)

12 Tom 32yr with SLD & autism Poor physical state Increase Meds Increase SIB 1,893 instances of CB in 9 days Increase SIB Increase Meds

13 Challenging behaviour Self-injury Head-hitting, head-banging, kicking, Skin-picking Physical aggression Damage to property Negative vocalisation

14 Tom s learning history: selfinjury and aggression reliably evoke a response from staff and remove demands. Staff learning history: responding to an instance of selfinjury and aggression reliably terminates the behaviour. Making few demands minimises risk of self-injury and aggression. Side effects of medication amplify attention deprivation and aversive task demand Attention deprivation or threat of attention deprivation Aversive task demand or threat of aversive task demand Equilibrium: Continuous staff attention & low task demand maintains low level aggression & self-injury And establishes low stimulus conditions that evoke skin picking Staff presence & actual or potential absence signals attention is available / not available. Activity materials & staff instruction signal likely oncoming demand. Evokes an instance or episode of self-injury or aggression or disruption Staff experience self-injury as aversive and are motivated to stop it Tom receives attention or demand is removed Staff deliver attention or moderate, delay or remove task demand Attention deprivation or aversive task demand is abolished. Aggression & selfinjury cease Sensory

15 Intervention Directly managed programme in 3 phases Withdrawal medication (PBS) FCT (PBS) Skills teaching (AS) Direct intervention (PBS) Enrichment home & community (AS) Personal routines (AS) Hobby (AS) Relationships (AS)

16 60 Intervention data % 10m intervals Retrospective incident & ABC records st 2nd 3rd 4th 5th 6th 7th 8th // 1st 2nd 3rd 4th 5th 6th 7th 8th 13 week periods Aggression SIB Damage Vocalise

17 Tim 14 years at commencement Diagnosis of autism and severe ID High rate and high impact SIB and aggression since early childhood. Excluded from all services and communities. Entered a university sponsored residential school.

18 Elevated mood Working Hypothesis Establishing operations, task demand, social avoidance & access to tangibles. Stable mood 3 4 Environmental EO comes into effect Internal mood state determines the threshold at which environmental establishing operations come into effect 5 Dynamically related system Low mood 6

19 Design A B 1 B 2 C D = No treatment = Lo-Risperidone = Hi-Risperidone = Fluoxetine = Lithium Carbonate Baseline (A) Brief Experimental Functional Analysis Treatment Phase B 1 & B 2 Treatment 1 Functional Analysis Treatment 2 Functional Analysis Withdrawal Functional Analysis Reinstatement or Treatment Phase C Treatment Functional Analysis Withdrawal Functional Analysis Reinstatement or Treatment Phase D Functional Analysis Withdrawal Functional Analysis Reinstatement or review Descriptive Analysis Continuous measurement in the natural environment of operationally defined Hi-SIB (PIR 15m). Continuous measurement of operationally defined mood (hourly on a 7-point anchored scale).

20 Measurement Hi-SIB EFA Hi-SIB Descriptive Mood Descriptive Setting Classroom All natural settings All natural settings Procedure Iwata et al. (1982) + social avoidance & tangible 4 x assessments Operationally defined. Continuous direct observation Operationally defined Continuous direct observation Measures Partial Interval 6s Partial Interval 15m Hourly rating. 7-point anchored scale. Analysis & presentation Multi-element Daily records inspected & transformed to give % intervals per week with Hi-SIB, plotted across treatment phases over time. Colour map of mood with Hi-SIB superimposed. Conditional probabilities of Hi-SIB by mood rating. Phi correlation Yule s Q

21 Pre-Baseline Mood Rating: Colour Map Pre-baseline: Conditional probabilities: Hi-SIB loaded heavily onto low mood (.69) Hi-SIB and low mood: (Phi =.609 p <.000). Yule s Q Hi-SIB & mood: Distressed v Happy =.91 Distressed v Steady =.91 Steady v Happy =.04

22 Results (3a) Brief Experimental Analysis Number of 6s intervals with Hi-SIB 0 Social escape Task Demand Alone Social Attention Social Ambiguity Control Baseline 1 (A) Baseline 2 (A) * * * 25 Lo-Risperidone 1 (B 1) Baseline 3 (A)

23 Results (3b) Brief Experimental Analysis Number of 6s intervals with Hi-SIB Social escape Task Demand Alone Social Attention Social Ambiguity Control 25 Baseline 4 (A) * * Fluoxetine 1 (C) Fluoxetine 2 (C) Fluoxetine 3 (C)

24 Natural environment

25 Comments Behavioural intervention or medication change alone would not have delivered these outcomes. Systematic and evidence-based approach to selecting intervention components. Intervention effects evaluated in detail with robust data.

26 Discussion PBS an integrated approach 20 minutes small group 20 minutes feedback and comment Suggested topic areas - Feasibility Desirability Opportunities Barriers