merrill winston, ph.d., bcba-d professional crisis ... copy with copyright.pdf · mac paperback and...

Merrill Winston, Ph.D., BCBA-D

Professional Crisis Management Association

Copyright 2013 PCMA, Inc. 1

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Adventures

in Special

Education!

The movie!

Still “Winning”


Antecedent Manipulations: What are we talking about?

The role of antecedent manipulations in treatment

Antecedent manipulations AS treatment

Why are antecedent manipulations so prevalent?


Person-centered planning gone wild

Elimination of aversives as antecedent manipulations (or providing constant reinforcers)

How can we make better decisions regarding the elimination of aversives? What is reasonable? What is unreasonable?

How else can we deal with aversives?


These can be very broad and may include immediate antecedents, altering motivation, changing general aspects of the environment, and changing staff behavior

Immediate antecedents: “Triggers” Being told “no” being asked to wait, certain noises, certain places, certain people, certain hairstyles


Altering Motivating Operations: keeping deprivation low by supplying very high rates (sometimes unrealistic rates) of reinforcement

Changing general aspects of the environment: rearranging classrooms, changing the general noise level, this would include prostheticizing the environment


Changing staff behavior counts as antecedent manipulations as well: This might include approaching people differently, changing proximity, changing interaction styles, minimizing coercive interactions, changing the way staff members prompt individuals, etc.


Certainly, antecedent manipulations can comprise an important part of behavioral treatment, but there is a tendency to overemphasize these manipulations because:

THEY DO NOT REQUIRE THAT YOU TEACH THE PERSON ANYTHING!

People who are uncertain about WHICH BEHAVIORS to teach and HOW to teach them will often use antecedent manipulations as a crutch.


There is absolutely nothing wrong with using antecedent manipulations as PART of a well-rounded treatment program

It’s even quite reasonable to go a bit “heavy” on antecedent manipulations to gain quick control of a dangerous behavior problem until more skill-acquisition based measures can be put into place


Sure these can lead to stable behavior, but how difficult is it to maintain these manipulations no matter where the person goes?

How specialized does the person’s physical and social environment have to become to “support” them?


They can work immediately

They require very little analysis

They require no time spent teaching skills

Anyone can implement them

It makes it appear as though we are helping the person “get better.”

They reflect an understanding of the person’s likes and dislikes, which is generally a good thing to know about a person.


Person centered planning (PCP) does NOT mean that we blindly do whatever the person wants all the time and always eliminate or avoid what the person doesn’t want.

This is NOT how some people interpret PCP however…

Merrill: Why has Jeffery been sitting in the grass doing self-stim with a shiny DVD in the sun sitting in the grass for 3 hours at his “day-treatment program?”


Staff at day treatment program: Oh, that’s his choice…

He sure was well behaved….

Merrill: Why is James being driven around by staff in the van 4 hours per day?

Staff: That’s his choice…


You may notice that when a client “chooses” to sit naked in the front yard waving at the people passing by that this is no longer “their choice.”

There is nothing wrong with giving people some control over their lives. However, NONE of us has control over every aspect. We must be cautious about any strategy or choice that may decrease the response effort/responsibility of a provider agency/staff


Rolando exhibited severe aggression, SIB, and cigarette butt pica at the residential facility and he had injured many staff members and himself over many years

His frail, elderly mother said she had absolutely no problem managing him at home by herself…We visited her home…


He was transported home in a modified station wagon with a police barrier separating the back seat from the front seat…

There were barrel bolt slide locks on the outside of the passenger doors…

There was a wrought-iron ceiling to floor partition (bars) separating the kitchen from the rest of the home

Rolando ran around the house naked from the pool to his bedroom all day and would get Cuban pastries through the bars of the kitchen


Rolando was VERY happy and safe at home…

Was it wrong for mom to resort to these measures given her circumstances?

Did Rolando learn anything that might help him in different settings?

Is this person-centered treatment?

Is it “wrong” in any absolute sense?


Justine would eat anything she could find on the floor

She could not be left alone even for a moment because of the behavior

We crushed the motivation to engage in pica by giving her a fanny-pack filled with puffed rice

While wearing the fanny-pack….no pica!

Is this the optimal long-term solution?


The elimination of reinforcers that are more powerful than Superman, Batman, Spiderman and The Incredible Hulk put together


Zach loved TV, but he loved it a little too much

Anytime he saw one he would try to play videos

If you stopped him…..Crisis!

If he accessed it calmly, and it was time to stop….Crisis!

Solution: The teacher removed the TV from the classroom


Although some manipulations involve altering motivation to engage in problem behavior by upping the reinforcement available, or eliminating über reinforcers, many manipulations involve simply eliminating aversives

It is reasonable to eliminate some, but do we attempt to eliminate all?

How do we determine where to stop? What is reasonable? What is unreasonable?


A Quote on the matter….

“Trying to eliminate ALL aversives is a road you don’t want to travel. It’s poorly lit, filled with potholes and it gets narrower the further you travel.”

Merrill Winston---5 seconds ago…


Some people eliminate so many aversives that soon we are “walking on eggshells”

Then we are walking on cotton balls on top of eggshells on top of mouse-traps

If we are not careful we can end up creating a situation in which the individual’s world starts collapsing in on them and they may become more and more sensitive to smaller and smaller aversives…


It can be tough to determine where to draw the line, but I like to turn to…

“The Grid of Acceptability!”


Unacceptable Unreasonable Reasonable

Reasonable

1

Unreasonable

2

Unacceptable

3


Situation

Behavior

1: A reasonable reaction (behavior) to an unacceptable situation. (What is reasonable for the individual will depend in large part on their level of functioning and skill level)

An individual bites, but only when attacked by another individual

An individual begins to pound on furniture when other clients are screaming

Is it a situation that would cause you to possibly lose it?


2: An unreasonable reaction to an unreasonable situation (an unreasonable situation is “not very nice” but something that could possibly be tolerated)

Many problems fall into this category.

Joey is playing with the fire-truck,

Billy grabs it from him

Joey commandeers a police car and clocks Billy in the head with it! (may be borderline unreasonable/unacceptable depending on severity)


3: An unacceptable reaction to a reasonable situation

Ricky begins to engage in self-injurious eye-gouging (unacceptable behavior) whenever he hears another student coughing (reasonable situation)

Do we buy a case of Robitussin for the entire classroom as an antecedent manipulation?


Most of the time we are working with people who show unacceptable or unreasonable behavior in response to either unreasonable or reasonable situations

There are times, however, when WE say that the person has a “behavior problem” but when you look at some of the unacceptable situations that happen to people with disabilities, it’s hard to say that the client’s behavior is truly unreasonable/unacceptable


Is the event something that happens to most people?

Is the event likely to be encountered by the person on a regular or semi-regular basis?

Is the occurrence of the event difficult to control for or does it occur frequently but unpredictably?

Example: One individual becomes agitated when he hears the word “hello!”

Example: Mommy takes 20 extra minutes getting home because she can’t take any right turns!


Eliminating aversives, although one of the most popular ways of dealing with them, is just one of a number of strategies that can be used when faced with these problems…


Procrastinate

Eliminate

Terminate

Compensate

Acclimate

Tolerate


This is a good strategy for things that eventually need to happen, but you want to give the person the ability to delay it.

We all have things that we know we eventually HAVE to face. Still, when given the ability to put things off we value it.

You cannot evit the invevitable…but you can delay it….

You will have to set limits on how many times someone can delay or for how long, but given the choice of being able to delay or have to do something now, it’s a nice choice to have


Easily the most overused, but this is good for situations that are simply intolerable for anyone or for gaining quick control over a bad situation until a comprehensive treatment plan can be put into place

This is not so much “treatment” as it is “support”


This is when we teach the person how to stop the aversive in an appropriate manner (replacement behavior)

It is reasonable to allow people the means to stop things they don’t like under certain circumstances

Terminate may not always be possible but there are other strategies that can be used when it isn’t

Once the terminating behavior is “solid” one can start thinking about other strategies


Nothing makes a bad thing suck less like MO’ MONEY!

We will tend to “put up with” things we don’t like if there is another reinforcer concurrently available

Listening to music while running

Having the TV on while working

Posting to facebook on your iPhone while Merrill is droning on and on…


Sometimes just raising the general level of reinforcement can reduce the aversive nature of some events

For sibling rivalry types of problems you can make powerful reinforcers freely available ONLY when the siblings are together


This is essentially habituation This particular strategy, like compensate

does not require the person to learn new skills but it does require the aversive to be repeatedly presented

This must be done in a manner in which the aversive is presented purposely, carefully and systematically (brief reinforcer removal)

It’s best to have something that can be somewhat varied in duration or intensity (fire alarm recording)


This is easily the toughest of the bunch, but one of the most valuable

This is different from acclimate because with acclimate you simply get “used to it” and it doesn’t bother you very much anymore

Tolerating is where the event still bothers you very much but you “keep your $%*! together”


You might want to think of tolerating as a commodity that gets “used up” that is, you only have so much of it.

You’re on my last nerve

That was the straw that broke the camel’s back

It is something that you can get better at.

Many of the other “Ates” can work to together to make tolerating easier


We DO want to be careful, however, that we are not attempting to teach people to “tolerate the intolerable.” We wouldn’t do it, why should people with disabilities.


In addition to these strategies, there are a couple of general skills that can help with almost any kind of situation in which we must be exposed to aversives

Learning to stay relaxed when already calm

Learning to GET relaxed when already upset (much harder)


Steve Ward and Terry Grimes: Calm Counts

Wholechildconsulting.com


This is quite a bit harder, and like learning to stay relaxed it requires using a hierarchy of upsetting events and a strong repertoire of self-calming behaviors (breathing deep, covering one’s ears, engaging in soothing types of self-stim, progressive muscle relaxation, etc…)

I wouldn’t attempt this until the individual can tolerate the presentation of an aversive when already calm…


There’s nothing wrong with some antecedent manipulations as PART of treatment

Be wary of behavior plans that tend to weigh too heavily on antecedent manipulations

Simply eliminating unpleasant things, making desirable things continuously available, and preventing contact with potent reinforcers creates highly restrictive lives

Teaching people to effectively cope with strong reinforcers and strong aversives enables them to be more successful in more situations


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