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© 2015 Godbolt Behavior Consulting, LLC

T h e E f f i c a c y o f B e h a v i o r S u p p o r t P l a n s : A n

E v a l u a t i o n o f B e h a v i o r S u p p o r t P l a n s

E m p h a s i z i n g Te a m C o l l a b o r a t i o n , S o c i a l

V a l i d i t y , a n d T r e a t m e n t I n t e g r i t y .

110/30/2015


Question for today:

•What are the components for

implementing a behaver Support plan

based on function of behavior?

210/30/2015


Content for Today’s Discussion:• Evidence – The Efficacy of Behavior Support Plans: An

Evaluation of Professional Team Collaboration, Social Validity, and Treatment Integrity for Adults Diagnosed with Mental Retardation

• Research questions-1. To what degree does a BSP consisting of professional team collaboration and the development of socially valid treatments have on the reduction in the frequency of challenging behaviors?

• 2. What are the effects of professional team collaboration and socially valid treatments on the measures treatment integrity?

310/30/2015


Content for Today’s Discussion:• Community based Behavior Analysts

• Social Validity-the extent to which the objectives and

outcomes of interventions are meaningful for the lives of the

individuals for which they are intended

• Treatment Integrity-the level to which a treatment is

implemented as intended by the clinician

410/30/2015


Content for Today’s Discussion• FBA - Functional Behavioral Assessment a series of procedures by which the clinician

can investigate the factors that evoke and maintain a behavior. These maintaining variables are discovered through the manipulation of environmental variables, including both the antecedents and consequences of a behavior

• BSP - Behavior Support Plan-written plans that identify systematic steps of implementing developed interventions based on relevant data and measurable objectives

• Team Collaboration-a relationship in which all members of the treatment team agree to defer to each other’s judgments and expertise, as appropriate for the purpose of securing benefits for the client, the family and professionals

510/30/2015


Introduction• During the 1960s due to federal mandates the delivery of

mental health services for persons diagnosed developmentally or intellectually disabled moved towards the policy of deinstitutionalization.

• Under the policies of deinstitutionalization the federal government severely limited who could be involuntarily committed, placed limits on the duration of a hospital stay for patients with mental illnesses, and closed many large psychiatric hospitals

610/30/2015


Deinstitutionalization• The two main goals of deinstitutionalization were to close the

larger state psychiatric hospitals, and to create a network of community mental health centers and mental health providers who could treat clients.

• Deinstitutionalization resulted in many people diagnosed with varying mental illnesses being served by mental health professionals in the community.

• A recent advent in the delivery of these services has been the role of the community based behavior analyst.

710/30/2015


Community Based Behavior Analyst• The primary role of the community based behavior analyst has

been to develop treatments for clients, train the client’s staff or family on the appropriate implementation of the treatment and monitors the implementation of the developed interventions.

• The behavior analyst approaches this endeavor by developing interventions through studying an individual’s socially relevant behaviors within naturally occurring contexts.

• The focus for the behavior analyst is on overt behaviors that are measurable and observable, the influence of environmental variables on the occurrence or nonoccurrence of target behaviors and precisely measuring the client’s behavioral responses.

810/30/2015


Community Based Behavior Analyst• A frequent criticism of this approach to developing behavioral

interventions is that it does not consider the input of all the key players that work with the client. I find that particularly the direct care staff’s input is often not considered

• The above described approach to developing behavior interventions is one where the behavior analyst is doing something to the client, and for the team rather than something for the client with the team.

• Various researchers have argued that treatments that are viewed to be acceptable by the direct care staff and/or the client’s families are more likely to be implemented than treatments that are not viewed as acceptable.

910/30/2015


Community Based Behavior Analyst• Treatments that are deemed not to be working by staff or

family are generally treatments that were never completely understood or accepted by the staff and/or family.

• Treatments that do not consider the expertise or input of the people who are responsible for implementing them are treatments that lack social validity.

• Social validity is a construct that is one of the foundations of applied behavior analysis and refers to the extent to which the objectives and outcomes of interventions are meaningful for the lives of the individuals for which they are intended.

1010/30/2015


Social Validity• The issue of social validity is of incredible importance to all

behavior analyst because social validity is a necessary aspect of any applied behavior analytic endeavor.

• For the community based behavior analyst, often the analyst is not the person responsible for implementing the developed interventions. Thus, the connection between reducing a client’s target behaviors and social validity are quite clear.

• The main emphasis of treatment for the behavior analyst when working with adults diagnosed with mental retardation is generally focused on improving their quality of life and reducing the frequency, rate, and intensity of their identified target behaviors.

1110/30/2015


Social Validity• In the current decade for adult client’s specifically quality of

life is becoming the measuring stick by which to determine the effectiveness of the developed interventions.

• This is the focus of the behavior analyst because quality of life for a client is enhanced when a person’s repertoire of skills has utility and meaning in his or her life.

• The most effective approach to ensuring that a BSP is concerned with a client’s quality of life is to ensure that the BSP is socially valid to the client and the treatment team as a whole.

1210/30/2015


Social Validity• A BSP is much more likely to be implemented and effective if

the professionals or people who interact most with the client are provided with an opportunity to voice their opinion throughout the development of the BSP.

• Arguably the opinion of the client and the treatment team is much more important than any one professional involved with the team.

• Social validity of a BSP is synonymous with its level of implementation by the client’s direct care staff.

1310/30/2015


Social Validity• Social validity in a BSP is looking at the level of agreement

between the team members on the definition of target behaviors as well as the acceptability of defined interventions.

• Social Validity is simply the acceptability of a program or a procedure to the consumer.

• The lack of social validity in some BSPs stem from the behavior analyst making conclusions about appropriate interventions without getting agreement from the treatment team.

1410/30/2015


Social Validity• A study that was conducted that support this finding was conducted by

Fox and Emerson (2001). This study that was interested in investigating what different treatment team members viewed as socially valid outcomes for a client diagnosed Intellectually Delayed and exhibiting challenging behaviors.

• What was discovered during this study was that the clinicians and professional members of the treatment team identified different things more important than the family and the direct service providers.

• The development of BSPs should be a collaborative effort that that includes the voice of the people that spend the most time with the client and have the most vested in change occurring.

1510/30/2015


Social Validity• For clients diagnosed as intellectually or developmentally delayed the

generalization of developed skills or the ability to transfer learned skills to untrained environments are paramount to treatment success.

• It’s been found that the likelihood of a client being able to generalize learned skills increases dramatically when the client and his direct care staff are bought into the importance of the developed skills.

• The assumption of social validity is that interventions endorsed by significant people in the client’s life are more likely to produce generalization. When the treatment team rates certain behaviors or interventions as more effective it is more likely that these are the interventions that will be implemented when the Behavior Analyst is no longer present.

1610/30/2015


Treatment Integrity• Treatment integrity refers to the level to which a treatment is

implemented as intended by the clinician. • The success of a developed BSP is determined by the ability to

demonstrate a functional relationship between the developed intervention and a client’s target behavior. A functional relationship can not be demonstrated if the treatment is not implemented as developed by the treatment team.

• Many researchers have investigated treatment integrity and its relationship to social validity.

1710/30/2015


Treatment Integrity• The concern is that many mental health professionals including

behavior analyst are not regularly assessing treatment integrity. • Gresham, Gansel, & Noel (1993) conducted a meta-analysis

looking at some of the factors that prohibit the relationship between treatment integrity and social validity. This study was looking to see how often the behavior analyst in the study appropriately defined the developed interventions and monitored the implementation of the treatment.

• The researchers found that of all the studies reviewed only 6% made mention of treatment integrity.

1810/30/2015


Treatment Integrity• One of the reasons that the researchers gave for the lack of

treatment integrity in research is that researchers are not defining the treatment in terms that the direct care provider can understand.

• It is important that behavior analyst train the client’s staff and the client’s family in such a way that the treatment is understood and adaptable to the clients particular circumstances, rather than feeling inadequate if they cannot or do not wish to apply it exclusively and intensively when this may be neither appropriate nor practical for them.

1910/30/2015


Treatment Integrity• Wheeler, Baggett, Fox, & Blevins (2006) reviewed published

behavioral intervention studies with children with autism conducted between the years 1993 and 2004 to determine the extent to which investigators had empirically evaluated treatment integrity. Of the 60 studies reviewed only 11 assessed and reported treatment integrity data.

• A failure to adequately assess treatment integrity may result in inaccurate assumptions about the presence of functional relationships.

• It is these discussed functional relationships that the Behavior analyst must measure to determine the accuracy of the treatment.

2010/30/2015


Treatment Integrity• Functional behavior assessments have been shown to be the

most effective method for linking assessment to intervention. • Functional behavior assessments provide a procedure by which

the clinician can investigate the factors that evoke and maintain a behavior. Functional behavior assessments allow us to develop socially valid treatments and outline the steps to maintaining treatment integrity.

2110/30/2015


Functional Behavior Assessments (FBA)• Conducting a functional assessment will allow the researcher to

understand the function of the clients’ behavior, as well as the environmental variables that may be reinforcing the target behavior.

• A functional behavior assessment using descriptive methods includes using structured interviews of key personnel, direct observation in the participant’s natural environment, and administering a rating scale of behavior such as the Motivation Assessment Scale.

• A functional analysis of behavior utilizing experimental methods includes the direct manipulation of antecedent variables to assess the function of the behavior. The major strength of a functional analysis of behavior is that it allows for a systematic manipulation of environmental variables

2210/30/2015


Functional Behavior Assessments (FBA)• When conducting a functional behavior assessment a

researcher is able to develop interventions designed specifically to address the client’s needs. Functional behavior assessments allow the clinician to pinpoint the causes of the behavior and to design a treatment that is specifically tailored to treat the problem behavior.

• One of the limitations in the available research conducted on functional behavior assessments and functional analysis of behavior is that it does not address the role and the importance of the treatment team members throughout this process.

2310/30/2015


Functional Behavior Assessments (FBA)• Functional behavior assessments and functional analyses of

behavior are both procedures by which the clinician can investigate the factors that evoke and maintain a behavior. These maintaining variables are discovered through the manipulation of environmental variables, including both the antecedents and consequences of a behavior.

• Without the input of the client’s direct service providers it would appear that a developed functional behavior assessment or functional analysis of behavior has missed out on some very crucial information.

2410/30/2015


Functional Behavior Assessments (FBA)• With a descriptive assessment, there is no manipulation of

environmental variables. With this assessment the clinician conducts formal observations of the client in their natural setting and conducts structured interviews with the client’s key players to gather information about the antecedents and consequences of the behavior.

• During a descriptive assessment the clinician may use various rating scales to determine the function of a client’s behavior.

2510/30/2015


Functional Behavior Assessments (FBA)• Often the concern becomes who are the key players and how is

there voice represented in the development of the BSP. • FBA’s are based on three basic assumptions. These assumptions

are: 1. Behavior is purposeful and serves a function. 2. Behaviors are caused by interactions of environmental factors and factors inherent to the client. 3. Identification of these factors can lead to effective interventions

• FBAs are not interventions. FBAs is a process that is used to help identify the most appropriate and effective intervention. The interventions are then developed into a behavior support plan (BSP).

2610/30/2015


Behavior Support Plans (BSP)• Behavior support plans are written plans that identify

systematic steps of implementing developed interventions based on relevant data and measurable objectives.

• Behavior support plans generally start with the behavior analyst conducting a functional assessment. Direct service providers being included in this process can produce an assessment context that better establishes the conditions for problem behavior than a behavior analyst who is relatively unknown to the client.

2710/30/2015


Behavior Support Plans (BSP)• The development of an appropriate behavior support plan relies on, as

well as other things, the gathering of information concerning a child's preferences, history of previous interventions, strengths, communication skills, medical concerns, and daily routines.

• The better the gathered information, the more likely the behavior analyst and the collaborative team will have a comprehensive understanding of the child resulting in an effective behavior support plan.

• Undoubtedly the staff that has spent the most time with the client has the ability to provide the most extensive overview of the client, what has worked in the past and what has not worked. The client generally will spend more time with the direct service providers than all other members of the collaborative team.

2810/30/2015


Behavior Support Plans (BSP)• The direct service provider also has the most vested in the client

improving their target behaviors because they work most with the client and are usually the target of the client’s maladaptive behaviors.

• Behavior support plans neutralize setting events and remove antecedents that prompt problem behavior. Behavior support plans make the students problem behavior less efficient by selecting replacement behaviors that require less effort to access than reinforcers that maintain the behavior.

• A well developed behavior support plan makes the students problem behavior less relevant by decreasing access to the consequences that maintain the behavior and increasing access to consequences that maintain acceptable replacement behaviors.

2910/30/2015


Behavior Support Plans (BSP)• Horner (1994) identified features of a good behavior support

plan. Horner reported that an effective behavior support plan consists of eight distinct features: 1. The first feature in developing a good behavior support plan is to operationally define the problem behavior.

• It is during this step that a very specific and clear definition of the problem behavior is developed. This definition should be one that the collaboration team can agree on. Good treatment begins with an appropriate diagnosis or definition of the problem.

3010/30/2015


Behavior Support Plans (BSP)• The second step is to define the hypothesis that guides the

development of all features of the behavior support plan. • It should be evident from reading the hypotheses why the

behavior support plan has been developed. Furthermore, it is imperative that the behavior support plan is derived directly from the developed hypotheses.

• Step three: Identify and teach replacement behaviors. The clinician must ensure that the replacement behavior will meet the same need for the client that the previous problem behavior has been meeting. The clinician also wants to be aware of the client’s ability level so that the replacement behavior selected is not above the client’s ability.

3110/30/2015


Behavior Support Plans (BSP)• Step four: describe the specific behaviors expected of staff

and the context in which those behaviors should occur. • This places responsibility on the staff to know what their role is

in changing the client’s problem behavior. Often clinicians forget that change should be a collaborative effort involving all of the client’s treatment team members.

• Step five states: employ strategies that are the least intrusive procedures likely to produce a functional effect.

3210/30/2015


Behavior Support Plans (BSP)• Step five speaks to the use of positive behavior supports and person

centered planning when developing interventions aimed at changing a client’s behavior. Person centered planning strategies places emphasis on ensuring that all people, regardless of disability are afforded opportunities to be present and to participate in community life.

• Step six of a behavior support plan is to focus on the overall improvement of the client’s lifestyle in addition to the reduction of problem behavior

• Another characteristic of person centered planning is that when developing interventions the team members are developing strategies to ensure that clients are assisted in enjoying opportunities to fulfill respected roles within society and in living with dignity

3310/30/2015


Behavior Support Plans (BSP)• Step seven states: ensure that developed interventions are

consistent with local values, efficient, and minimally intrusive for the student, staff, and family.

• The social validity of interventions is a very important point of concern. If the developed interventions are not within the cultural framework of the student, staff, or family it is not very likely to be carried out appropriately.

3410/30/2015


Behavior Support Plans (BSP)• The final feature of an effective behavior support plan speaks to

treatment integrity. This step states: It is imperative that the developed plan includes procedures for accurate implementation, monitoring progress, and adjustment of the plan as needed

• It is important to monitor the progress of the client in order to determine if the developed plan is effective. It is after monitoring the implementation of the intervention and it success or lack there of, that the clinician is able to determine if the intervention was effective. If the intervention was not meeting the identified objectives it is at this time that the behavior support plan is adjusted.

3510/30/2015


Behavior Support Plans (BSP)• While Horner’s method to BSP development considers social

validity and treatment integrity it does not focus enough on the collaboration of the team members involved.

• There is an inherent problem associated with the process of a behavior analyst developing a behavior support plan without using a collaborative approach.

• If the behavior analyst develops a behavior support plan independently and then gives it to the direct service provider to implement, the issue of treatment integrity immediately arises.

3610/30/2015


Team Collaboration• The concerns for treatment integrity arises from the question will the

direct service provider implement the developed interventions with the level of integrity that is necessary for behavioral change if they don’t feel included in its development.

• A treatment process that does not depend on total collaboration amongst the team members causes the process to depend on a specialist clarifying the problem and developing interventions.

• This is a collaborative process that completely relies on the “experts” and could lead the other team members to feel as if they have been cut out of the process. Collaboration done appropriately should get away from the assumptions of a hierarchal, bureaucratic, and centralized problem solving process in which the specialist occupy the highest position and the direct service provider the lowest.

3710/30/2015


Team Collaboration• True collaboration allows the direct service provider to assist with the

development of interventions. It is important that all members of the consultative team approach the problem from a collaborative standpoint.

• Some direct service providers have reported that they are unable to specifically describe the interventions that were recommended by the behavior analyst. It has been suggested that the problem sometimes stems from the inability of the behavior analyst to describe the interventions in language that can be understood by the direct service providers. This breakdown in communication between the behavior analyst and the direct care provider is synonymous with the inability of the direct service provider to implement the established interventions.

• A recurring problem for collaborative teams has been treatment integrity.

3810/30/2015


Team Collaboration• One important feature for team collaboration is to identify is

the described maladaptive behavior a problem for all the team members involved.

• This assists with operationally defining the problem behavior so that all team members are on the same page in reference to what the behavior looks like and all team members feel heard.

3910/30/2015


Research• This researcher investigated the efficacy of BSPs developed using

professional collaboration to ensure the development of socially valid treatments.

• This study was also interested in the effect that BSPs developed in this manner have on the direct service provider in terms of treatments integrity.

• This main goal of this study was to investigate if this hypothesized relationship between professional collaboration, social validity, and treatment integrity of BSPs impacts the quality of the BSP and manifests into a decrease in the frequency of target behaviors in adults diagnosed with Mental Retardation to the extent that the interventions match the function of the target behavior.

4010/30/2015


Research Questions• 1. To what degree does a BSP consisting of professional team

collaboration and the development of socially valid treatments have on the reduction in the frequency of challenging behaviors?

• 2. What are the effects of professional team collaboration and socially valid treatments on treatment integrity?

4110/30/2015


Significance of Study• Behavior support plans are the most important tool for the

behavior analyst in regards to communicating treatment to direct service providers.

• Thus, it is important for the field of applied behavior analysis to research the most effective way to implement behavior support plans.

4210/30/2015


Significance of Study• There is a void in the literature investigating the relationship

between professional collaboration, social validity and the treatment integrity of BSPs.

• There is also a void in practice amongst community based behavior analyst, and the mental health profession in general, in regards to the relationship of professional collaboration, social validity and treatment integrity.

4310/30/2015


Limitations•1. Subjects cannot be randomly, or otherwise, assigned to treatment. •2. The independent variable cannot be manipulated.

•3. Causes are often multiple and complex rather than single and simple.

•4. This study may not generalize to other settings due to the small sample

size.

•5. Direct service providers only record the occurrence of target behaviors

rather than the occurrence of replacement behaviors

4410/30/2015


Research Design• A multiple baseline across behaviors design was utilized to evaluate

the efficacy of behavior support plans consisting of professional collaboration aimed at the development of socially valid treatments when attempting to reduce the rate and frequency of target behaviors in adults diagnosed with Mental Retardation.

• A multiple baseline design allows for the researcher to demonstrate a functional relationship between the variables without the withdrawal of an effective treatment

• This systematic order inherent in a multiple baseline design provides a better picture of the functional relationship of the variables. This demonstrated relationship allows this researcher to suggest that the change was due to the intervention.

4510/30/2015


Methodology:Setting and Participants

• The participants for this study were three adults identified by the Tennessee Department of Mental Retardation Services as requiring behavioral support services provided by a community based behavior analyst.

• The participants all lived independently in their homes which was staffed with 24 hour staffing by direct service providers.

• The participants had a primary diagnosis of Intellectually Disabled and were prescribed various psychotropic medications for their secondary diagnoses.

4610/30/2015


Methodology:Setting and Participants

• Each of the participants exhibited target behaviors that historically have had a negative effect on their daily quality of life. The treatment team identified the main behaviors that were the target of this study during the functional behavior assessment.

4710/30/2015


Data Analysis• Trained observers recorded any occurrences of the participants

target behavior that occur for each hour of their shift. The trained observers recorded all occurrences of target behavior to assist with presenting a visual representation of the established functional relationship between the variables.

• The gathered data was graphically represented to visually demonstrate if the developed behavior support plans were effective in reducing the occurrence of target behaviors in the participants.

4810/30/2015


Procedure• This study consisted of implementing a collaborative approach

to developing a behavior support plan aimed at reducing the frequency of a client’s target behaviors.

• All the key players involved with the client were identified prior to starting the FBA process.

• The first step was the structured interview. At this step all team members identify the target behaviors of concern, identify how the behaviors have typically been responded to, how effective was that approach and operationally define the identified behaviors.

4910/30/2015


Procedure• The next step was direct observations conducted in the home

and the community with the direct service provider that works with the client. Observations occurred weekly and lasted for 1-3 hours.

• During the observations the researcher and the direct service provider agreed on what constituted an behavioral occurrence and established inter-observer agreement.

• Once inter-observer agreement was established the researchers then determined the function of the behavior by using the Functional Analysis Screening Tool (FAST)

5010/30/2015


Procedure

5110/30/2015


Procedure• Staff were trained on the use of A-B-C Data sheets and on the

use of a scatter plot to record the occurrences of the client’s target behaviors.

• The scatterplot assisted with establishing multiple baselines for the occurrences of the target behaviors for each of the participants.

• ABC data sheets allowed the direct service provider and this researcher to clearly identifying the surrounding variables possibly contributing to the occurrence of the target behaviors.

5210/30/2015


Procedure• Concurrently, as the direct service provider established a

baseline for each participants target behavior, the researcher synthesized all received information and developed a behavior support plan targeting the identified behaviors.

• The researcher ensured that professional collaboration was utilized by adhering to the Positive Behavior Support six step planning process as identified in Behavior Management: Principles and Practices of Positive Behavior Supports (Wheeler & Richey, 2005).

5310/30/2015


Positive Behavior Support Six Step Planning Process

• Rationale/Mission- The guiding purpose, philosophy, and beliefs of the plan are made clear in writing and reflect a shared vision of team members.

• Goals- The broad goals/intents of the behavior support plan are specified. • Objectives- Short-term, measurable objectives for the behavior support

plans, connected to the identified goals are specified. • Strategies- Decisions are made about methods, interventions, and materials.

The interventions that the team approves are designed to meet the identified goals and objectives. The strategies chosen are always affected by the presence of constraints and resources. The team must assess the constraints and resources associated with meeting the identified goals and objectives.

• Implementation- The behavior support plan is carried out. • Evaluation- Using a variety of methods and instruments the team evaluates

the behavior support plan formatively and summatively.

5410/30/2015


Procedure• After the treatment team reviewed the plan, the researcher

administered the Treatment Acceptability Rating Form-Revised (Reimer & Wacker, 1988) specifically to the participants direct service provider as a means to measure social validity.

• It is most important that the direct service provider is in agreement with the developed plan because they will ultimately be responsible for day-to-day implementation. The Treatment Acceptability Rating Form-Revised (TARF-R) allowed the direct service provider to indicate how they felt about the developed behavior support plan.

5510/30/2015


Treatment Acceptability Rating Form-Revised (TARF-R)• Developed by: Reimers & Wacker, 1988 Treatment Acceptability

Rating Form-Revised (TARF-R) "

• 20 item questionnaire "

• Likert scale

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© 2015 Godbolt Behavior Consulting, LLC 57

Treatment Acceptability Rating Form-Revised (TARF-R)

Please complete the items listed below. The items should be completed by placing a check mark on the line under the question that best indicates how you feel about the developed treatment recommendations. 1. How clear is your understanding of this treatment? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very Clear clear 2. How acceptable do you find the treatment to be regarding your concerns about the client? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very acceptable acceptable 3. How willing are you to carry out this treatment? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very willing willing 4. Given the client’s behavioral problems, how reasonable do you find the treatment to be? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very reasonable reasonable 5. To what extent do you think there might be disadvantages in following this treatment? _______ ______ _____ ______ ______ ______ _______ None are Neutral Many are likely likely

6. How likely is the treatment to make permanent improvements in the client’s behavior? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very likely likely 7. How much time will be needed each day for you to carry out this treatment? _______ ______ _____ ______ ______ ______ _______ Little time Neutral Much time will Will be needed be needed 8. How confident are you that the treatment will be effective? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very confident confident 9. How included were you in the process of developing this treatment? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very included included 10. Compared with other client’s with behavioral difficulties, how serious is this client’s problems? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very serious serious 11. How disruptive will it be to the staff (in general) to carry out this treatment? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very disruptive disruptive

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12. How effective is this treatment likely to be for this client? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very effective effective 13. How much do you like the procedures used in this proposed treatment? _______ ______ _____ ______ ______ ______ _______ Do not like Neutral Like them very them at all much 14. How willing will other staff members be to help carry out this treatment? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very willing willing 15. To what extent are undesirable side-effects likely to result from this treatment? _______ ______ _____ ______ ______ ______ _______ No side Neutral Many side effects Effects are likely are likely 16. How much discomfort is the client likely to experience during the course of this treatment? _______ ______ _____ ______ ______ ______ _______ No discomfort Neutral Very much at all discomfort

17. How severe is this client’s behavioral difficulties? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very severe severe 18. How willing would you be to change your daily routine to carry out this treatment? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very willing willing 19. How well will carrying out this treatment fit into staff’s routine? _______ ______ _____ ______ ______ ______ _______ Not at all Neutral Very well well 20. To what degree are the client’s behavioral problems a concern to you? _______ ______ _____ ______ ______ ______ _______ No concern Neutral Great concern at all Modified from Reimers & Wacker, 1988 Treatment Acceptability Rating Form-Revised (TARF-R)

10/30/2015


Procedure• This researcher used the reliability/implementation checklist as a

means to ascertain the level of treatment integrity maintained by the direct support provider.

• The researcher collected the participant’s scatterplot and ABC data before and after the implementation of the behavior support plan. This researcher also collected all of the participant’s daily notes that were completed by the participants direct service provider during the research time.

• The scatter plots, ABC data sheets, direct observations, reliability/implementation checklist and daily progress notes were then used as a means to assess the treatment integrity of the developed behavior support plan.

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Procedure Score1. Staff trained to implement behavior support plan. Yes No 0 1

2. Staff scored at least 80% on the BSP post-training competency test.

Yes No 0 1

3. Verbally states target behavior(s). Yes No 0 14. Can locate “What I Do to Carry Out This Plan” section of the BSP.

Yes No 0 1

5. Compare data sheets, daily notes, staff’s verbal reports

Documentation all matched? Yes No 0 1If No, comment

Intervention Implementation circle one

Brief Description Staff’s response Score

Completed and following a daily schedule.

+ used appropriately - used inappropriately NA

1 0

NA

Used three step prompting procedure.


1 0

NA

Used developed bathroom routine.


1 0

NA

Recognized appropriate communication attempts.


1 0

NA

Prompted every two hours to use the bathroom.


1 0

NA 10/30/2015


Implemented four step procedure during repetitive questioning


1 0

NA

Provide Roger positive feedback for being patient without exhibiting any target behaviors


1 0

NA

Refer Roger to the schedule when he repetitively asked the same questions concerning his daily activities.


1 0

NA

Minimized attention during target behaviors


1 0

NA

Redirected him to quiet area


1 0

NA

Used response block + used appropriately - used inappropriately NA

1 0

NA

Documented target behaviors


1 0

NA

Score _______ / ________ = _______ % # correct # possible

Feedback given to staff: Y or N Staff Being Observed:

Staff initials: Date:

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Procedure• A multiple baseline across behaviors design was utilized to

evaluate the efficacy of behavior support plans consisting of professional collaboration aimed at the development of socially valid treatments when attempting to reduce the rate and frequency of target behaviors.

6210/30/2015


Results• BSPs consisting of professional team collaboration while

adhering to the development of socially valid treatments contributed to a reduction in the frequency of challenging behaviors in these three participants, as the developed interventions match the function of these participant’s behavior.

• This study found that by utilizing the Treatment Acceptability Rating Form-Revised this allowed each treatment team member voice to be heard and allowed each member to rate how included they were in the development of the BSP, thus giving the team more accountability for the treatment.

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Results• The results of this study showed that while professional collaboration

and socially valid goals are very important, treatment integrity has the largest effect on the success of developed interventions. Even when a treatment team rates that a plan was collaborative and acceptable, without treatment integrity a participant will still exhibit behaviors at high rates.

• This study also found that Professional collaboration and socially valid treatments has the most effect on treatment integrity when BSP importance was communicated to the direct staff providers by their employing agency. All treatment team members must be respected and their role must be identified for the collaborative process to work. Competing agency demands occasionally make it challenging for the direct service provider to implement the interventions as developed.

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© 2015 Godbolt Behavior Consulting, LLC 6510/30/2015


Participant One• The treatment team for Participant One identified the target

behaviors as Self Injurious Behavior (SIB) in the form of slapping herself during times of frustration and anxiety and Pica in the form of eating inedible objects such as hair and cigarette butts.

• Strategies for addressing participant one’s behavior was identified during the FBA process based upon the function the behavior served for the participant as identified by direct observations, structured interviews, and The Functional Analysis Screening Tool (FAST).

• The FAST was administered to the direct service providers that spends the most time with the participant.

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Participant One• The results of the FAST indicated that socially inappropriate

behaviors for participant one are likely maintained the participant’s need for attention and to a lesser degree, by escape. Staff and this researcher hypothesized that attention maintains her SIB and the main function of this participant’s Pica is escape.

• Once the researcher identified the function of this participant’s behavior this researcher and the treatment team developed interventions that provided the client with the same reinforcement that their present target behaviors offered them.

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Participant One• During Baseline participant one’s monthly mean level of

frequency for SIB was 51 and a monthly mean level of frequency for Pica was 47.

• During treatment Participant One reported a mean level of SIB at 14 and a mean level of Pica across observations at 12. During follow-up Participant one reported a mean level of frequency across observations for SIB at 5.25 and for Pica at 3.5.

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Participant Two• The treatment team for Participant Two identified the target behaviors

as physical aggression, verbal aggression, and property destruction. • Participant Two experienced frequent staffing difficulties throughout

the study which made it difficult for this participant’s staff to maintain treatment integrity. Thus, treatment integrity was a constant issue with this participant’s staff making it challenging to demonstrate a strong functional relationship.

• The two main threats to treatment integrity observed with Participant Two’s staff was lack of BSP implementation and lack of documentation of the participants target behaviors. This researcher continuously addressed treatment integrity with this treatment team but continued to find this to be an issue throughout the study.

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Participant Two• The strategies for addressing Participant Two’s behavior was

identified during the FBA process based upon the function the behavior served for the participant as identified by direct observations, structured interviews, and The Functional Analysis Screening Tool (FAST).

• The results of the FAST indicate that socially inappropriate behaviors are likely maintained by the need to escape and by attention and control. Staff and this BA hypothesize that control more than attention maintains his inappropriate behavior.

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Participant Two• During baseline the mean level of functioning across

observations were 2.75 for physical aggression, 3.75 for verbal aggression, and 1.25 for property destruction.

• During treatment Participant Two’s mean level of functioning across observations were 1.5 for physical aggression, 8.0 for verbal aggression and 4.0 for property destruction. During follow-up Participant Two exhibited a mean level across observations at 1.75 for physical aggression, 2.5 for verbal aggression and a mean level of functioning across observations for property destruction at 2.0.

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Participant Two• It is important to mention that during follow-up Participant

Two was hospitalized as a result of a behavioral outburst that was largely as a result of the lack of treatment integrity exhibited by the participant’s staff.

• It was also found during follow up that Participant Two exhibited his target behaviors more frequently on the shifts of the staff that were either new or less favored by the participant.

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Participant Three• The treatment team for Participant Three identified the target behaviors

as Physical aggression, tantruming, noncompliance, and incontinence. • Strategies for addressing participant three’s behavior was identified

during the FBA process based upon the function the behavior served for the participant as identified by direct observations, structured interviews, and The Functional Analysis Screening Tool (FAST).

• The results of the FAST indicate that aggressive behaviors were likely maintained by the need for attention and sensory stimulation. The results of the FAST indicate that the participant’s incontinence is likely maintained by escape. The results of the FAST indicate that the tantruming behavior is likely maintained by attention and sensory stimulation. The FAST results indicate that the noncompliance is likely maintained by attention.

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Participant Three• During baseline the mean level of functioning across observations were

33.4 occurrences of physical aggression, 12.8 occurrences of tantruming, 13.4 occurrences of noncompliance and 20.8 occurrences of incontinence.

• During treatment participant three’s mean level of functioning across observations were 10.0 occurrences of physical aggression, 14.0 occurrences of tantruming, 4.0 occurrences of noncompliance and 10.0 occurrences of incontinence.

• During follow-up participant three’s mean level of functioning across observations were 8.25 occurrences of physical aggression, 9.0 occurrences of tantruming, 6.25 occurrences of noncompliance, and 3.5 occurrences of incontinence.

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Recommendations• Agencies must insist that direct service providers record data

and implement treatments as developed. The competing demands of following agency protocol and agency politics often make it challenging for the direct service provider to implement the interventions as developed. Agencies should ensure that all staff is trained prior to being placed in the home of a participant. Treatment integrity must appear important to the agency to make it important to the direct service provider. Thus, further research should investigate ways to make this process more important to the provider agencies.

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Recommendations• Behavior analyst should ensure that when developing BSPs professional

collaboration, socially valid goals and treatment integrity are adhered to. This research supports earlier research into each of these individual variables that identifies each of these variables as important. This research adds credence to the belief that of all of these variables the most important is treatment integrity. Further investigation should be given to this issue.

• Finally, rather than focusing on the occurrence of target behaviors, future research should investigate the occurrence of replacement behaviors as well. Researchers should be equally concerned with how often the participant is exhibiting the replacement behavior rather than just the identified target behavior. This researcher found it challenging to get staff bought into tracking replacement behaviors.

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