Descriptive & Informant Based Functional Assessment Methodologies. Peter Baker

Transcription

1 Descriptive & Informant Based Functional Assessment Methodologies Peter Baker 2018

2 Positive Behavioural Support as a Whole Service System Social Role Valorisation Applied Behaviour + + Analysis Person Centred Approaches Functional Behavioural Assessment Functional Behavioural Assessment Behaviour Change Strategies (environmental change, antecedent change, skill teaching, active support) Behaviour Management Strategies (secondary prevention & ethical reactive strategies) Mediator variables (mediator analysis, competence building, emotional needs) Implementation and management process (goodness of fit, quality assurance of inputs and outcomes) Achieve Behavioural Change + Improve Quality of Life + Reduce use of Restrictive Practices

3 Functional Assessment Behavioural is functional (or purposeful) Functional assessment is about identifying this function It is about discovering the meaning behind behaviour, why it occurs and what it achieves It improves intervention effectiveness by a factor of 2-3

4 Functional assessment must produce: O Neill et al (1997): A clear description of the challenging behaviours, including classes or sequences of behaviour that frequently occur together The identification of events, times, and situations that predict when the challenging behaviours will and will not happen across the full typical range of daily routines Identification of the consequences that maintain the problem behaviours (that is, the function that the behaviour serves for the person) The development of one or more summary statements or hypotheses that describe specific behaviours, a specific type of situations in which they occur, and the outcomes or reinforcers that maintain them in those situations The collection of direct observational data that verify the summary statements that have been produced

5 Methods of Data Collection Reliability Intrusiveness Experimental analysis Direct Observations ABC Charts Structured Interview Interview Checklists Records Review Clinical Intuition

6 Methods of Data Collection Reliability Intrusiveness Experimental Analysis Descriptive Analysis Informant based methods

7 Pre-considerations to conducting a functional assessment Is there a person-centred plan in place for the service user? How extensive are the person s activities and social networks? Are then any unresolved medical of psychological issues that may be underlying the challenging behaviour?

8 Brief vs. Comprehensive Functional Assessment Identify the challenging behaviour Describe how often it occurs, how long it lasts and the risks it poses Identify the time of day when it is most likely to occur Identify common predictors and setting events Identify common consequences Crone & Horner (2003)

9 Triggers for more comprehensive functional assessment Challenging behaviour persists despite the consistent implementation of intervention plans based on simpler analyses The behaviour poses a high level of risk More intrusive, aversive interventions are being considered There is a threat of placement breakdown (based on Willis & LaVigna)

10 Informant Tools I: The Functional Assessment Interview (O Neill et al 1977) Ten Different Sections minutes to complete-but can take considerably longer depending on complexity of person Response classes-a warning!

11 FAI Sections Describe the behaviours Define potential ecological/setting events Define the immediate antecedent events (predictors) for occurrences and non-occurrences of the challenging behaviour Identify the consequences or outcomes of the challenging behaviour that may maintain them Define the efficiency of the challenging behaviours What functional alternative behaviours does the person already know how to do?

12 FAI Sections What are the primary ways the person communicates with other people? What are the things you should do and avoid in working with this person? What are the things the person likes and are reinforcing for him or her? What do you know about the history of the challenging behaviours, the interventions that have been attempted to decrease or eliminate them, and the effects of those interventions?

13 Informant Tools II: Contextual Assessment Inventory (McAtee, Carr & Schlute, 2004) Designed to assess setting events and specific antecedents 93 items Five point scale with three anchors ( Never, Half the time or Always ) 25 minutes to complete Not scored as such, but any item rated as 4 or 5 merits further analysis

14 Informant Tools III: Motivation Assessment Scale (Durand & Crimmins, 1983) Designed to assess the function of challenging behaviour The likelihood of the behaviour occurring in 16 antecedent conditions is rated on 7 point scales (whose anchors range from behaviour never occurring to behaviour always occurring) Antecedents are arranged into the four classes of: attention, tangible, escape & sensory) with four questions for each class The more specific the behaviour, the more reliable the results More reliable with higher rate behaviours

15 Scoring the MAS Number circled for each question in entered into blank cell next to question number on rear of form Each totalled separately and a mean score (total/4) is calculated The consequence with the highest mean score is taken as the key maintaining variable If the highest score is tied, or if the top two consequences are within.25 points, then both are considered as possible maintaining variables

16 Formulation & Summary Statements Formulation is best regarded as a hypothesis (or set of interconnected hypotheses) about the nature of the challenging behaviour and its development. It usually contains informed guesses about causal about causal or functional relationships between variables/events and the behaviours of concern. It has two main functions: a. it tells you what to do i.e. guides your clinical actions with an explicit rationale, and b. it helps you set up criteria for evaluating your intervention. (Based on BPS, 2004)

17 Formulation & Summary Statements Should therefore include an understanding of the onset and reasons for the development of the behaviour Should identify the personal, environmental and interpersonal factors which have increased or maintained the behaviour, and also factors which prevent 0r reduce its occurrence. Should present a hypothesis, which can be tested through interventions or further assessment, about the function or meaning of the behaviour for the person in his or her environment

18 Basic Summary Statement Motivating Operation: Discriminative Stimulus: Challenging Behaviour: Maintaining Consequence: Sleep disrupted previous night School day starts with a physical activity Screaming, throwing self to the floor Removed from class

19 Setting Events / MO s Ear Infection Hungry Discriminative Stimuli Asked to sit at table to do work task Behaviour Hits out at others Consequences Told to sit on own and calm down (hard to concentrate) Function Hitting = Demand Avoided Setting Events / MO s Mornings Group activities Discriminative Stimuli Teaching assistant arrives to do paperwork Behaviour Bites own hand Consequences Told stop doing that (deprived of 1:1 attention) Function Biting self = Attention Gained

20 Observational Methods II: Scatter Plots A Scatter Plot is a very simple way or recording the pattern of behavioural incidents and specifically whether behaviour occurs around specific times Recordings are made on a simple grid with columns covering a week or longer Each day is divided into hour or half-hour cells Each time the target behaviours occur, the relevant cell is filled in (with a simple tick mark if one behaviour is being recorded or with behavioural codes if more than one behaviour is being tracked)

21 Scatter Plots Scatter plots record only the time slots in the day during which specific behaviours occur They don t normally provide any data on frequency or severity They essentially suggest whether behaviours are under particular stimulus control They also helpful identify the stimuli under which behaviours do not occur

22 Example Scatter Plot Person s Name: Peter McGill Start Date: Target Behaviours SIB=self-injury P=physical aggression Time/Day Sun Mon Tues Weds Thurs Fri Sat am am am am am SIB SIB/P SIB P am am am am SIB P SIB P am am P pm pm pm pm pm SIB pm pm pm SIB pm pm pm pm pm SIB pm SIB P SIB pm SIB SIB SIB pm SIB SIB pm SIB SIB SIB pm pm pm pm pm

23 Scatter plot SIB P

24 Observational Methods II: ABC Recordings ABC stand for Antecedents, Behaviour and Consequences, the three key elements in the behavioural model Antecedents are factors which appear to set off or trigger a person s behavioural challenges. Consequences are things that happen as a result of the behaviour (for example, does it result in the person gaining something that they want or avoiding something that they do not?). ABC forms provide a simple way of trying to identify these factors and are of two basic types: continuous and narrative

25 Narrative ABCs Narrative ABC forms are only completed when an incident of challenging behaviour occurs and in that recording is usually open-ended (thereby allowing respondents to potentially consider a less restrictive range of antecedents and consequences than may be contained in a continuous recording form). This method may be less resource-intensive than continuous ABC recordings (given that they are only completed once an incident takes place), but this may be countered by the fact that the tick-box methodology of the former is more user-friendly than having to produce written statements. Because of the method of data collection, it is also possible that such recording may suggest false ABC relationships (in that setting events, triggers and consequences identified may occur just as often without the challenging behaviour appearing).

26 Example of an ABC Chart Date Time Describe behaviour Where did it occur What happened just before What did you do in response How did they react Comments Angry noises removed shoes and socks threw them around and cried Garden I had been humouring her for half an hour running up & down the garden path being dragged by the hand then she wanted my boots and I said no. I left her in the garden and went in and observed her She carried on Angry protests, crying, throwing things around. Slapping her head & punching her face Lounge Wanted my boots I wanted to see Holby City so I gave them to her, she then wanted my socks. I refused my feet would have been cold I told her off when she hurled my sewing basket across the room She got even more cross when reprimanded She got bundled off to bed & I missed Holby City

27 Continuous ABCs The idea of a continuous ABC recording chart is that all potential influences on a person s behaviour that occur within a particular period of time are recorded using pre-determined codes for particular triggers, behaviours and outcomes (as in the example below) These codes are worked out from prior functional assessment interviews or the use of narrative ABC charts and have been identified as being potentially important in terms of explaining the person s behaviour. Importantly, using this method, the identified triggers and outcomes are recorded whether or not challenging behaviour occurs when they are present. This potentially helps to identify the likelihood of a behaviour occurring under the specified conditions.

28 Example of a Continuous ABC Form Person s Name Liz Gregory Date 2/9/14 Start Time: 10.15am Stop Time: 11.45am Observer: Mo Farmer Triggers Behaviour Outcomes Left alone Self-injury Social attention Activity Cancelled Activity started Asked to do task Physical Aggression Task removed Others receiving attention Seizure Left alone Self-injury Social Attention Activity Cancelled Activity started Asked to do task Physical Aggression Task removed Others receiving attention Seizure Left alone Self-injury Social attention Activity Cancelled Activity started Asked to do task Physical Aggression Task removed Others receiving attention Seizure Left alone Self-injury Social attention Activity Cancelled Activity started Asked to do task Physical Aggression Task removed Others receiving attention Seizure

29 Analysing ABC Charts There is obviously no point in collecting data if you do not then go on to analyse it! ABC charts allow you to do a number of different things: 1. You can calculate a measure of behavioural frequency by counting up the number of times the behaviour occurs over the number of days that you collected data. From this, you can calculate an average rate (number of times behaviour happened/number of days recorded) and describe the frequency range (the lowest and highest daily rate). 2. You need to look for patterns in your data. Look at your recorded antecedents and see if there are similarities in these (for example, did the behaviour tend to happen when the person was asked to do something, when they were left alone, or in a noisy place and so on?) 3. Do the same for the outcomes of the behaviour (for example, were any requests that the person did something were withdrawn, were they given attention, was the noise switched off or the person supported to move to a quieter location?)

30 Analysing ABC Charts 4. Look for links between antecedents and outcomes (for example, when the person was faced with demands as an antecedent, did the removal of those demands often appear to be an outcome?) 5. If you have collected continuous ABC data, you can look at the probability of the behaviour occurring when key antecedents and outcomes are or are NOT present. 6. Collect your findings into a summary statement which describes the specific antecedents that appear to produce the behaviour and the outcomes that the behaviour achieves for the person. Check that this makes sense to you and to other people who are supporting the person.

31 Analysis Strategies Antecedent analysis What happened just before Consequence analysis What happened just after Remember you don t always get what you intend every time

32 Analysis of ABC Charts Antecedent analysis Self stimulation look for clues that not enough or the wrong sort of stimulation is on offer little happening things happening but not of interest to the individual nothing novel occurred

33 Analysis of ABC Charts Antecedent analysis Escape from demand look for clues that the individual might suspect a demand is to be made upon him/her. asked to do something people appear who may be associated with demand equipment associated with demands somebody else asked to do something the time of day demands are made

34 Analysis of ABC Charts Antecedent analysis Attention look for clues that would indicate the individual was in need of attention alone for a period of time person stops giving attention person giving attention to somebody else person arrives

35 Analysis of ABC Charts Antecedent analysis Tangible reinforcement look for clues that the individual might want something period without something they usually have regularly something in the environment but not accessible presence of person associated with giving/getting things for the individual being made to wait being told no/stop

36 Analysis of ABC Charts Further questions When doesn t it occur? How could I stop it?

37 Analysis of ABC Charts Consequence analysis Self stimulation look for the behaviour continuing unless the level/type of stimulation changes

38 Analysis of ABC Charts Consequence analysis Escape from demand look for evidence that the demand is either withdrawn, not presented or presented less frequently

39 Analysis of ABC Charts Consequence analysis Attention look for evidence that the individual receives some form of social/physical contact

40 Analysis of ABC Charts Consequence analysis Tangible reinforcement look for evidence that the person gets something they like

41 Improving the quality of ABCs Train carers in use Are structured rather than open-created once an initial idea of setting events, antecedents and consequences have been obtained from the FAI) Ensure recording focuses only on actions that are seen or heard (thus limiting inferences or interpretations) Ensure focus on events immediately before and after the behaviour occurs Also allow some scope for recording setting events as well as specific antecedents Are collected for a specific period of time (e.g., once key variables reliably identified, may only need to record event frequency; ABCs can then be reintroduced periodically to verify continuing relevance/identify new factors)

42 Brief Functional Assessment Based on BBQUIP Dan Crimmins

43 1. What behaviours are creating a problem Hurts other Hurts self Cries/ Screams/ Shouts If yes, how? Scratches/ Pinches/ Bites/ Slaps/ Pulls hair/ Punches/ Kicks If yes, how? Scratches/ Pinches/ Bites/ Slaps/ Pulls hair/ Punches/ Kicks/ Hits head Swears Takes things Breaks things Throws things Food refusal Absconds Withdraws Other

44 22. Is the behaviour more likely to occur in any particular situations (tick more than one if applicable)? Morning/ Afternoon/ Evening Su M T W T F S Breakfast/ Lunch/ Dinner Transitions Staff Handover Alone/ Small Group/ Large Group Toilet/ Bathroom/ Personal Care Kitchen/ Lounge/ Dining Room Bedroom Home/ Day Service/ Community Training/ Free time Activity time Other

45 23. What appears to trigger the behaviour Asked to do something Being in a group Told no Transitions Difficulty with task Alone/ No attention Change to routine Waiting Activity ending Sees something they cannot have Other

46 24. What is the first sign that the behaviour is about to occur? Change in facial expression Change in body language Change in tone/ volume of speech Change in content of speech Change in motor actions Withdrawal Proximity Other

47 Brief Functional Assessment: Based on the BBQUiP (Dan Crimmins) Behaviour Support Plan Summary Hypothesis Client engages in identified behaviour (2) which is problematic as it impact (3). In the past early attempt (4) was tried, unfortunately this had limited success as intervention barriers (5) (6). The behaviour occurs frequency (18) and lasts duration (20). This usually takes place times & places (22) and when triggers (23). The first sign that the behaviour is about to occur are precursors (24) and using secondary prevention strategy (12) may prevent the situation from escalating.

48 The function of the behaviour appears to be function (28) (29) and motivation (30) would appear to make this train of events more likely to occur. Our concern is that our typical responses may be reinforcing the behaviour.

49 Behaviour Support Plan Prevention: Prevention strategy 1 (31) & prevention strategy 2 (31) have been identified as ways to make this problem behaviour less likely to occur. In addition, the simple strategy of making things the person likes more readily available accessible and removing disliked situations often leads to decrease in challenging behaviour. In this case increasing access to preferred items (9) and removing disliked items (10/11) might help, providing it is safe & practical to do so. Secondary prevention: Response (12) (25) is the best way to prevent the first signs the behaviour is about to occur escalating into more serious incidents. Replacement: Replacement behaviours (33) has been identified as a skill that if the person learned would result in reduced need to engage in the difficult behaviour. In the recent past they learned to new skill (16) by teaching method (17) which may give an indication as to the optimal way in which the person learns.

50 Communication: When attempting to meet their basic needs the person often comes up against the following issues basic needs (13) and will express themselves by expressive ability (14). The introduction of communication strategy (15) may well be of benefit both generally and specifically in helping to reduce the need for challenging behaviour. The condition of medical condition (7) would need to be addressed in order to eliminate it as a contributing to the presentation of challenging behaviour. In addition, the recent life event (8) might also need to be revisited in order to deal with any outstanding issues. In order to bring about a safe resolution to any incidents reactive strategy (34) needs to be incorporated into the person s behaviour support plan. Commitment: names of those who helped develop this plan developed this plan on date. They will review it on review date

51 Formulation & Summary Statements Triangulating Data Triangulation Grid Behaviour Setting Events Specific Antecedents Maintaining Functions Be mindful of the fact that not all measures tap the Self same Injury sorts of data; the Menstrual (repeated MAS does hitting not measure discomfort right setting temple events, with for example, clenched and the CAI right does not look hand) at maintaining variables. Some cells will therefore have a not applicable entry. Lack of sleep Demands Cancelled activities Confrontational inter-personal style Escape From non preferred activity Access to preferred activity FAI CAI N/A N/A MAS N/A N/A N/A ABCs