ADULTS WITH COMPLEX BEHAVIORAL SUPPORT NEEDS. Betsey Benson, Ph.D. Vanessa Rodriguez, Ph.D., BCBA-D Nisonger Institute 2015

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1 ADULTS WITH COMPLEX BEHAVIORAL SUPPORT NEEDS Betsey Benson, Ph.D. Vanessa Rodriguez, Ph.D., BCBA-D Nisonger Institute 2015

2 Transitions School to Work or Other Guardianship Home Mental Health Physical Health

3 Guardianship Decision making around whether guardian is needed, and if so, who? Dignity of Risk and Choice making vs. Protection from Harm Protection of community

4 School to Work or Other Employment First initiative Eligibility requirements of adult options Education needs- job skills, daily living skills, social skills Loss of routine, structure, and peers provided in school environment

5 Residential Issues May move from family residence New role for family members Challenges in a Staffed residence: Living with peers Staff personalities and staff turnover Different expectations than family home How is structure and routine established?

6 Physical Health Physical growth and development size impacts ability to manage behavior Chronic Health conditions and emerging issues Obtaining health services for adults

7 Mental Health Emergence of new psychiatric illness Supports for pre-existing conditions Obtaining psychiatric services for adults w DD Availability of counselors

8 Composition of Adult Team Individual with DD Guardian (may be family member) Day program or worksite representative Residential staff Transportation staff Counselor Psychiatrist Physicians in primary care, specialty care Probation, CIT officer, other law enforcement MH crisis services (Netcare)

9 Case Examples Co-occurring Mental health needs Lack of appropriate adult services Complex needs in a shared environment

10 Co-occurring Mental Health disorders Estimates of 10-40% of people with DD have a mental illness People with developmental disabilities experience the full range of mental illness Mental illness occurs at all levels of functioning of DD

11 Monitoring of Behavior With appropriate consent, behavior data can be shared with other professionals Can be useful in tracking response to interventions Can be useful in signaling changes in mental status Can promote integration of treatments

12 Integration of Psychiatric and Behavioral Interventions Index Behavior Medication

13 Coordination of Psychiatric and Behavioral Interventions - Jo Diagnosis: Williams syndrome and bipolar disorder Observation: Swearing increases in manic phase Behavior monitoring tracks swearing as well as other behaviors addressed in behavior plan Share monthly data with psychiatrist who adjusts psychotropic medication when needed Swearing frequency is index behavior

14 Coordination of Psychiatric and Behavioral Interventions-Steven Diagnosis: Psychotic disorder Hoarding of undesirable item- unhealthy Room searches one part of behavior plan Monthly behavior data is shared with psychiatrist

15 Integration of Mental Health and Behavioral Interventions Behavior Plan incorporates interventions to manage symptoms and behavior

16 Coordination of Psychiatric and Behavioral Interventions - Chris Diagnosis: Bipolar Disorder 25-yr. old woman, mild ID Periods of intense hostility and assaults Delusions of cat living in her stomach Auditory and visual hallucinations Multiple psychiatric hospitalizations

17 Behavior Plan- Elements for Chris Procedures Set daily schedule, choose activity the day before so there is something to get up for Make daily menu with her input Do not ignore when agitated, remind of consequences and suggest alternatives

18 Behavior Plan - Chris Behaviors to Increase Speak respectfully to staff (absence of verbal agg.) Follow Menu and recommended portions Chore schedule, 2-3 each day in home Reinforcement If met criteria 3 days per week, then got wrapped present, surprise Criteria for earning reward was increased as progress was made

19 Staff Interventions - Chris Target behavior of verbal aggression has both internal and external antecedents. Address sleep with schedule and change staff response Encourage to go to bed by midnight Wake up in morning in time for an activity Staff Response to Verbal Aggression When verbal aggression occurred, staff first tried to talk to her. If she threatened, then staff backed off and re-engaged in 10 minutes

20 Behavior Plan supports other interventions

21 Coordination of Psychiatric and Behavioral Interventions-Jess Young woman with mild ID Dx. Borderline Personality Disorder Target behaviors include: self-injury, property destruction, running away Frequent hospitalizations Received mental health and behavior support services

22 Behavior Plan and Borderline Personality Disorder Educate staff and family on BPD Staff provides supports Coping skills, keep safe, monitor Behavior monitoring shared with MH counselor and psychiatrist

23 Behavior Plan and Borderline Personality Disorder Reward program to increase frequency of: weekly schedule work attendance medication compliance daily emotion talk with staff writing in emotion diary (reviewed with counselor) writing in journal

24 Staff Supported Interventions at home: Practice coping skills and relaxation Focus on here and now Make plans Keep busy Be productive Encourage use of emotion journal Discuss feelings with staff daily

25 Antecedents/Precursors Behavior: Reports auditory hallucinations, increase in depressive statements, poor eye contact, withdrawal Interventions: Prompt coping strategies Make calls for support (supervisor or other) Move to a quiet area

26 Coordination of Psychiatric, Psychotherapeutic, and Behavioral Interventions Staff and family education on psychiatric diagnosis, DD syndromes, medical issues, etc. Tracking of target behaviors and symptoms Appropriate interventions based on assessment Routine communication among team members Effective intervention comes from unified approach and timely response to changes in mental status and behavior

27 Case Examples Lack of appropriate adult services Complex needs in a shared environment

28 Lack of appropriate adult services Sam- 37-year-old male with moderate to severe ID Diagnoses of Autism, Mood Disorder, and Insomnia Target Behaviors include food seeking (will binge eat) and vomiting Height 6 2 Lost approx. 150 lbs over 18 month period.

29 Functional Assessment & Behavioral Hypotheses History of vomiting Increase in vomiting following significant changes in environment Eating Disorder Food is comforting. Vomiting provides sense of control. Desire to return to family home

30 Medical Concerns Significant drop in weight following move to supported living (107 lbs). Risks of dehydration (electrolyte imbalance), and GI complications Two hospitalizations

31 Barriers to Service Age ID Non-verbal

32 Recommendations Collaboration with psychiatrist and physician Frequent nursing visits Locked food sources Frequent Meals Post-Meal Enrichment Program Consistency & Daily Routine (short-term limit on overnight visits home) Medical Contingencies

33 Data Graphs /1/2014 2/1/2014 3/1/2014 4/1/2014 5/1/2014 6/1/2014 7/1/2014 8/1/2014 9/1/ /1/ /1/ /1/2014 1/1/2015 2/1/2015 3/1/2015 4/1/2015 5/1/2015 Scale Weight (pounds) Medication Change Baseline Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Vomiting Food Seeking Responses per Shift

34 Complex needs in a shared environment Doug mid 50s male diagnosed with Profound Intellectual Disability with a remote history of selfinjurious behavior and recent history of aggression to others General Intervention for Aggression & Dropping to floor during transitions (Home Only) Self-injury infrequent (historically linked to illness and pain, e.g., ear infections) Discontinued to success under 1 year

35 Functional Assessment Referral following high intensity self-injury Staff interview & observations Rule out medical conditions Day program staff attributed SIB to new housemate ( Doug doesn t like his new housemate) Home staff acknowledged that housemate s behavior may be irritating Doug

36 Behavior Function Hypotheses Sleep deprivation as establishing operation SIB to escape or avoid demands and interaction with others SIB to maintain access to protective equipment and self-restraint items 3 intensities of SIB Self-injury 1- hitting self that is low intensity, low audible (unlikely to be heard from across room), causes no redness Self-injury 2- hitting self that causes redness and is audible from across room Self-injury 3- high intensity, loud, forceful self-hitting that results in tissue damage

37 Behavioral Recommendations Response Interruption & redirect to incompatible behavior (SIB 1) Contingent protective equipment for SIB 2 & 3 Enriched environment with competing items Escape extinction

38 Post-Intervention Data (initial) BASELINE 3/1/2011 4/1/2011 5/1/2011 6/1/2011 7/1/2011 8/1/2011 9/1/ /1/ /1/ /1/2011 1/1/2012 2/1/2012 3/1/2012 4/1/2012 5/1/2012 6/1/2012 FREQUENCY 7/1/2012 Baseline SIB1(home) SIB2(home) SIB3(home) SIB1(day program) SIB2(day program) SIB3(day program) Combined SIB 8/1/2012 9/1/2012

39 Sleep Data # Hours Asleep /1/2011 1/31/2011 3/2/2011 4/1/2011 5/1/2011 5/31/2011 6/30/2011 7/30/2011 8/29/2011 9/28/ /28/ /27/ /27/2011 1/26/2012 2/25/2012 3/26/2012 4/25/2012 5/25/2012 6/24/2012 7/24/2012 8/23/2012 9/22/ /22/ /21/ /21/2012 1/20/2013 2/19/2013 3/21/2013 4/20/2013 Date

40 Housemate Two Joe- early 40s male diagnosed with Severe Intellectual Disability; Psychotic Disorder NOS with history of self-injury with yelling Transition BSP (authored by different agency). General Intervention Case transferred to NBSS Data revealed decrease in Joe s sleep preceding Doug s increase in SIB

41 Data at Referral Total Intervals Awake Overnight Total Intervals Awake Overnight 7 per. Mov. Avg. (Total Intervals Awake Overnight) 1/1/2011 1/15/2011 1/29/2011 2/12/2011 2/26/2011 3/12/2011 3/26/2011 4/9/2011 4/23/2011 5/7/2011 5/21/2011 6/4/2011 6/18/2011 7/2/2011 7/16/2011 7/30/2011 8/13/2011 8/27/2011 9/10/2011 9/24/ /8/ /22/ /5/ /19/ /3/ /17/ /31/2011 1/14/2012 1/28/2012 2/11/2012 2/25/2012 3/10/2012 3/24/2012 4/7/2012 4/21/2012 5/5/2012 5/19/2012 6/2/2012 6/16/2012 6/30/ Average Mood Overnight Average Mood Overnight 1/1/2011 1/15/2011 1/29/2011 2/12/2011 2/26/2011 3/12/2011 3/26/2011 4/9/2011 4/23/2011 5/7/2011 5/21/2011 6/4/2011 6/18/2011 7/2/2011 7/16/2011 7/30/2011 8/13/2011 8/27/2011 9/10/2011 9/24/ /8/ /22/ /5/ /19/ /3/ /17/ /31/2011 1/14/2012 1/28/2012 2/11/2012 2/25/2012 3/10/2012 3/24/2012 4/7/2012 4/21/2012 5/5/2012 5/19/2012 6/2/2012 6/16/2012 6/30/2012

42 Assessment & Recommendations Functional Assessment Behavioral hypotheses Decreased sleep associated with increased yelling and increases in SIB Secondary Socially-mediated Function: Attention seeking Preventative procedures discourage day sleep, night time is for sleeping not playing Environmental modifications Medication to address sleep disturbance Response Interruption and redirection to ongoing activity

43 Post-Intervention Data Data (Joe) Total Intervals Awake Overnight Total Intervals Awake Overnight 7 per. Mov. Avg. (Total Intervals Awake Overnight) /1/2011 2/1/2011 3/4/2011 4/4/2011 5/4/2011 6/4/2011 7/4/2011 8/4/2011 9/4/ /4/ /4/ /4/2011 1/4/2012 2/4/2012 3/4/2012 4/4/2012 5/4/2012 6/4/2012 7/4/2012 8/4/2012 9/4/ /4/ /4/ /4/2012 1/4/ Average Mood Overnight Average Mood Overnight Serzone added Increase Serzone 1/1/2011 2/1/2011 3/4/2011 4/4/2011 5/4/2011 6/4/2011 7/4/2011 8/4/2011 9/4/ /4/ /4/ /4/2011 1/4/2012 2/4/2012 3/4/2012 4/4/2012 5/4/2012 6/4/2012 7/4/2012 8/4/2012 9/4/ /4/ /4/ /4/2012 1/4/2013

44 Post-Intervention Data (Doug) 500 FREQUENCY Baseline SIB1(home) SIB2(home) SIB3(home) SIB1(day program) SIB2(day program) SIB3(day program) Combined SIB BASELINE 3/1/2011 4/1/2011 5/1/2011 6/1/2011 7/1/2011 8/1/2011 9/1/ /1/ /1/ /1/2011 1/1/2012 2/1/2012 3/1/2012 4/1/2012 5/1/2012 6/1/2012 7/1/2012 8/1/2012 9/1/ /1/ /1/ /1/2012 1/1/2013 2/1/2013

45 Joe (top panels)and Doug (bottom panel) Average Mood Overnight /1/11 2/1/11 3/1/11 4/1/11 5/1/11 6/1/11 7/1/11 8/1/11 9/1/11 10/1/11 11/1/11 12/1/11 1/1/12 2/1/12 3/1/12 4/1/12 1/1/11 5/1/12 2/1/11 6/1/12 3/1/11 7/1/12 4/1/11 8/1/12 9/1/12 10/1/12 11/1/12 12/1/12 1/1/13 2/1/ /1/11 2/1/11 3/1/11 4/1/11 5/1/11 6/1/11 7/1/11 8/1/11 9/1/11 10/1/11 11/1/11 12/1/11 1/1/12 2/1/12 3/1/12 4/1/12 5/1/12 6/1/12 7/1/12 5/1/11 8/1/12 9/1/12 6/1/11 10/1/12 7/1/11 11/1/12 8/1/11 12/1/12 9/1/11 1/1/13 10/1/ 2/1/13 11/1/ 12/1/ 1/1/12 2/1/12 3/1/12 4/1/12 5/1/12 6/1/12 7/1/12 8/1/12 9/1/12 10/1/ 11/1/ 12/1/ 1/1/13 2/1/13 # Awake Intervals # Sleep Intervals

46 Complex needs in a shared environment Housemate behavior can impact others Potential cumulative effect of Joe s behavior deterioration on Doug s sleep and SIB Objective data interpretation Team collaboration Avoided either individual moving out of the home

47 Contact Information:

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