National Association of Residential Providers for Adults with Autism

NARPAA ECLASS Autism Education for Direct Care Staff

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MODULE TEN PROACTIVE REACTIVE MODEL

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MODULE TEN
As a result of completion of this module, the participant will be able to: Identify with the Phases of Behavior. Identify the role of the Support Person during any of the Phases of Behavior. Explain the concept of Episodic Severity. Recall the core concepts of proactive models of support. Recall the core concepts of Reactive models of support. Explain what is included in positive behavior support.

PROACTIVE VS REACTIVE APPROACHES

When dealing with behavior that challenges us, we may spend a lot of time and energy developing plans that focus on what we will do when the behavior occurs. While this is still an important concept, in this module we will try and focus on reducing the need or likelihood of behavior occurring in the first place, thus rendering the need for reactive strategies less necessary. Let us first define the differences between Proactive and Reactive Responses.

PROACTIVE VS REACTIVE APPROACHES

By definition Reactive Responses occur when a behavior has already happened. We think you will agree that this somewhat defeats the goal of reducing the occurrence of undesired behavior. And yet, this is exactly how we have traditionally worked with people who challenge us.

PROACTIVE VS REACTIVE APPROACHES

In contrast, Proactive Responses aim to reduce the need and likelihood of behavior occurring in the first place. We think you will agree that this is more desirable than having to work reactively. However, it is important to remember that no matter how effective we are in reducing the likelihood of that behavior, there will still be occasions when undesired behavior will occur despite our best efforts. It is during these times when well planned Reactive Strategies can play an important role.

PROACTIVE INTERVENTIONS
Proactive Interventions are designed to render challenging behavior less necessary for the individual by addressing the needs that may be driving the behavior in the first place. We work proactively by considering three main concepts: Ecological Mismatches Positive Programming Focused Support. .

ECOLOGICAL MISMATCHES
Behavior occurs in context. Undesirable behavior often occurs due to mismatches that exist between the needs of the individual and their environment. When we try to understand behavior from the persons point of view, we often find there are aspects of his or her environment that are mismatched with the person. These might include things that are in the environment that shouldnt be, or things that should be there but arent. By making planned changes to his or her environment we can often influence the occurrence of behavior.

ECOLOGICAL MISMATCHES
Keeping this concept in mind, consider the following three environmental aspects that may be contributing to behavior and ask yourself the questions that follow.

PHYSICAL ENVIRONMENT
Is there anything within the physical environment that should or shouldnt be there?

PHYSICAL ENVIRONMENT
Example 1: If the person tends to target windows: Are there a lot of windows in the environment? Are the windows covered with sheer curtains to deemphasize them? Is there furniture placed in front of the windows to make access more difficult (e.g. couch, table etc.)?

PHYSICAL ENVIRONMENT
Example 2:

If the person enjoys the sound and touch of running water: Is there an indoor water feature available that the person can access? Is there access to a Jacuzzi?

ECOLOGICAL MISMATCHES: INTERPERSONAL ENVIRONMENT

Interpersonal Environment: Is the person matched well with others in his or her environment? This includes staff and other clients or residents.

ECOLOGICAL MISMATCHES: INTERPERSONAL ENVIRONMENT

Example 1: If a person has an aversion to loud noises: Do any other clients or residents have screaming behaviors? Do any other clients or residents have behaviors that might include banging doors or making other loud noises?

ECOLOGICAL MISMATCHES: INTERPERSONAL ENVIRONMENT

Example 2: If the person becomes anxious in busy or crowded environments: How many people are usually in the environment? What is the quality of the interactions between the person and others?

ECOLOGICAL MISMATCHES: PROGRAMMATIC ENVIRONMENT

Programmatic Environment: Does the support plan include things the person does or doesnt enjoy?

ECOLOGICAL MISMATCHES: PROGRAMMATIC ENVIRONMENT

Example 1: If the person enjoys water: Have trips to a swimming pool been included in the plan?

Can they access a Jacuzzi?

ECOLOGICAL MISMATCHES: PROGRAMMATIC ENVIRONMENT

Example 2: If the person becomes anxious and aggressive in crowded environments:

Do we take them to loud crowded shopping malls?

POSITIVE PROGRAMMING
The term Positive Programming refers to the ongoing skill acquisition and development to which a person should be continuously exposed. The purpose is to increase his or her repertoire of positive behaviors and means of getting his or her needs met so there is less need to engage in the more challenging behavior.

POSITIVE PROGRAMMING
We address positive programming by considering three domains. These are: General Skills Development

Behavioral Alternatives

POSITIVE PROGRAMMING
General Skills Development: General skills development may reduce problem behavior in several ways. In general, people with disabilities are not afforded the same opportunities for inclusion and exposure to opportunities to learn the general skills others may have. As such, we must provide both the opportunity and the instruction for general skills to be developed. By doing this, it is hoped that people will become less excluded from their communities and become more independent

POSITIVE PROGRAMMING
General Skills Development: Increasing the degree of control individuals have over their own lives increases both opportunity and less reliance on others. By virtue of this, the likelihood of conflict and misunderstanding may also be reduced, thus resulting in fewer incidences of unwanted behavior. Remember, no one intervention will resolve all issues, but collectively will help to decrease unwanted behavior and the likelihood of challenges.

GENERAL SKILLS DEVELOPMENT

General skills that should be developed may include a range of things. It would be helpful to assess the persons ability and skill level in such domains as:

GENERAL SKILLS DEVELOPMENT

Domestic Skills including:
Cooking Laundry Cleaning

GENERAL SKILLS DEVELOPMENT

Personal/Hygiene Skills including:
Washing Grooming Teeth Feet

GENERAL SKILLS DEVELOPMENT

Leisure Skills including:
Hobbies/Interests Exercise/Activities Clubs Likes/Dislikes

GENERAL SKILLS DEVELOPMENT

Community Skills including:
Using Public Transport Seeking Assistance Shopping Money handling What to do in Conflict/Risk Situations

GENERAL SKILLS DEVELOPMENT

These examples are representative and used as a guide. The identification of specific skills to be developed is best done following a comprehensive assessment process.

BEHAVIORAL ALTERNATIVES
People continue to use established patterns of behavior for a number of reasons, not the least of which is that it has worked in the past. Like most of us, when we find something that is successful we tend to stick with it. Another reason people continue to engage in particular behaviors is a lack of alternatives. That is to say, they dont know what else to do.

BEHAVIORAL ALTERNATIVES
By working with individuals to learn what else they can do to get their need met, rather than engaging in less appropriate behavior, we can assist them in identifying more appropriate alternatives. Lets look at some examples.

BEHAVIORAL ALTERNATIVES
Example 1: Over the years, while living in a group home, Alan has learned that when he is thirsty and wants a drink all he has to do is scream, say the word drink and lash out at another person (e.g. attempts to hit another person with a closed fist). After trying several interventions to combat this behavior without success, the staff decided to change the rules of the house and teach Alan how to get a drink for himself while ensuring there was always a range of easily accessible drink options available to him.

BEHAVIORAL ALTERNATIVES
Example 2: Mary lives in a residential home for adults with Autism. If anyone sits too close to her while she is eating her dinner, she will pick up her plate and throw it at the person. Mary then becomes loud and targets the person for ruining her food.

BEHAVIORAL ALTERNATIVES
The staff works together with the residents in the home to identify what too close means for people (without singling out Mary). They decide to teach Mary and the other residents to hold up a red card when they feel others are too close to them and ask them to please give them space. Over time, the problem diminishes and becomes less of an issue for staff and the residents.

BEHAVIORAL ALTERNATIVES
In these examples we can see that by teaching alternative behaviors to these individuals, they have less need to engage in the problem behavior. An important point to remember, however, is that behaviors are conditioned over extended periods of time, sometimes years, and behavior change can take time. We must always make sure we measure whether change is occurring and make adjustments accordingly. We also need to rememberbe patientchange takes time!

TEACHING COPING, TOLERANCE AND RELAXATION Increasing general skills and competencies will assist the
person to gain greater independence and control over their life. Teaching behavioral alternatives can provide the person with choices that help render challenging behavior less necessary. However, some situations and environments are difficult, or cannot be changed. In such situations, the individual has to learn to cope and tolerate these situations and environments until alternatives can be found. This is the case for all of us, and is an important skill to develop.

COMPETENCY BASED TRAINING

The following excerpt by La Vigna and Willis (Competency Based Training, 1992) provides an excellent discussion of coping, tolerance, and relaxation strategies.

COMPETENCY BASED TRAINING

Three strategies exemplify this positive programming approach to teaching tolerance for the unavoidable stressors and naturally occurring aversive events in one's life.

The first involves teaching a generalized relaxation response. Cautela and Groden (1978) have developed a particularly useful guide for teaching people with developmental disabilities how to relax when they are feeling stressed or upset. At the Groden Center, relaxation training is a standard part of the curriculum and is taught as a self-control strategy. It is not unusual to see a student guiding himself through a relaxation exercise in order to calm down when he or she is becoming tense or agitated. This self-control, stress management behavior replaces the previous repertoire of tantrums, aggression, or other undesired responding.

COMPETENCY BASED TRAINING

Another strategy for teaching tolerance is to desensitize a person to those stimulus conditions that have been associated with the problem behavior (Wolpe, 1973). For example, in one case an adult who had a severely handicapping condition would often exhibit tantrum aggression whenever in close proximity to loud noises such as another person's screaming, vacuum cleaners, floor polishers, automatic dishwashers, and so forth. The initial target was to desensitize her to screaming.

COMPETENCY BASED TRAINING

A cassette tape recording was made of one of her housemate's screaming tantrums (a problem that was also being addressed). During the initial sessions, she was first guided to a state of calm and relaxation. Once this state had been achieved, the tape recorder was turned on, but at extremely low volume. To further assure that she remained calm, she was given some of her favorite food to eat. Over subsequent sessions, the volume of the tape was very gradually turned up until she could tolerate it at full volume and still stay calm and relaxed.

COMPETENCY BASED TRAINING

At this point, a similar strategy was followed to desensitize her to the vacuum cleaner. For example, in the initial session, once she was calm and relaxed the vacuum cleaner was turned on in the next room with the intervening door closed. Over subsequent sessions, the door was very gradually opened and the vacuum cleaner was moved closer and closer until she could tolerate it when it was right next to her and still stay calm and relaxed. At this point, the effects of treatment spontaneously generalized and noise no longer elicited problem behavior.

COMPETENCY BASED TRAINING

Desensitization can be programmed for criticism, crowds, or any other stimuli functionally related to the problem behavior. Another example of this variation of positive programming involves delay in reinforcement, which often is discriminative for problem behavior. How can we teach a person to be tolerant of waiting for something?

COMPETENCY BASED TRAINING

In a case study, just that was taught to a young adult who previously was aggressive at least some of the time when he had to wait. Teaching him to tolerate delays contributed significantly to the treatment of this aggressive behavior.

COMPETENCY BASED TRAINING

FOCUSED SUPPORT
Changing peoples environment to help render challenging behavior less necessary, and teaching skills and competencies so that they can gain the independence and self reliance they deserve, may indeed resolve many behavioral issues. However, it is fair to say that sometimes we also may need to implement well designed, consistently delivered behavioral interventions as a part of our support planning.

FOCUSED SUPPORT
Along with behavioral interventions, a good focused support program might also include the use of medications when appropriate or indeed the use of other therapies and interventions. As necessary as they are, addressing ecological mismatches and arranging for positive programming take time. By implementing well designed, focused support plans, we can gain more rapid control over a behavior while other strategies take hold.

REACTIVE STRATEGIES
As mentioned earlier, no matter how effective we are with our proactive plans and interventions, challenging behavior remains a possibility. It is during these times that we must have a host of previously identified strategies we can call on with one goal in mind, to not make the situation worse!

REACTIVE STRATEGIES
The more effective our proactive interventions are, the less often we will need to rely on reactive strategies. There are risks in responding reactively. First, there is a risk that we can become punitive and aversive. That is to say, we may engage in behaviors ourselves that in fact escalate the situation or make it worse. Punishment-elicited aggression, a well researched event, can occur when we respond reactively, leading to aggression or worse.

REACTIVE STRATEGIES
A second risk of responding reactively is that we may actually reinforce the very behavior we are trying to eliminate. If the behavior achieves what it was designed to achieve, then it is more likely to occur in the future. For example, Mary knows that by screaming and becoming aggressive every time she is asked to remove the dinner dishes from the table it results in her removal from the immediate environment. Being removed results in Mary avoiding having to complete the task. In this example, the screaming behavior has been successful. That is to say, the undesirable behavior we want to eliminate is being reinforced.

REACTIVE STRATEGIES
Be Prepared
The solution to situations such as those previously described is to be as prepared as possible. The objective is to identify, ahead of time, a range of responses we know will neither reinforce the behavior nor risk making it worse.

REACTIVE STRATEGIES
Lets use an example of Fred at the movies to demonstrate what we mean. Of course, the proactive goal is to work with Fred so he is more able to cope and to tolerate such environments. To do this, we might use a slow progressive process of introducing Fred in to increasingly more crowded and noisier environments in controlled fashion. We might also teach Fred to use breathing and relaxation techniques in such situations to help him cope. This, as well as working with him ahead of the outing describing what he is going to experience and practice his coping and relaxation skills thus reducing the likelihood that a problem will occur. However, there will still be times when Fred will struggle no matter how successful he is.

REACTIVE STRATEGIES
To plan for these situations, we might adopt such reactive strategies as identifying Freds desired activities or objects so we can introduce these to focus him or redirect him to a quieter, less crowded place. The point is we should identify these things ahead of time so we have planned and are prepared rather than reactive.

EPISODIC SEVERITY
Episodic Severity is defined as the measure of intensity or gravity of a behavioral incident (La Vigna &Willis, 2005). Until recently, most research in Applied Behavior Analysis has measured changes in behavior over time. The reality is, however, that this may not be the best measure of behavior change. The problem is behavior change as a function of time may not actually represent an improvement.

EPISODIC SEVERITY
On the face of it, George has vastly improved his behavior. However, if we look at the episodic severity of his behavior, we get a very different picture.

EPISODIC SEVERITY
On the face of it, George has vastly improved his behavior. However, if we look at the episodic severity of his behavior, we get a very different picture.

EPISODIC SEVERITY
Scenario 2: George has managed to reduce the number of incidents each week by almost 70%. However, when he has an occurrence of behavior, it now lasts 15 minutes or more. Also, he has physically attacked staff and other clients causing injury. He has also broken several windows costing over $500 to repair.

EPISODIC SEVERITY
Scenario 2: As we can see from this example, George now exhibits challenging behavior for an excess of 30 minutes a week representing a 30% increase in the total time spent. He has also injured staff and clients as well as caused several hundred dollars worth of damage. If we had just measured Georges behavior in terms of number of times it occurred, we would have a very different impression of his progress.

EPISODIC SEVERITY
Scenario 2: In this example it might have been better to use a measure of Episodic Severity as an alternative. Examples of what we might have measured in this case may be: Average time of the incident Average cost of replacement or repairs Number or severity of injuries to George or others

EPISODIC SEVERITY
Scenario 2: Fewer, more severe behaviors should not be our goal. If we focus more on the severity of each episode and aim for reductions in that severity, then this may represent greater progress than we have traditionally thought. In short, our aim is to reduce episodic severity of behavior in any given situation.

PHASES OF BEHAVIOR
It is important to understand the way in which behavior occurs. By understanding this, we will see that there are in fact several opportunities to intervene prior to a full blown episode of behavior.