Defining PBS and promoting evidence based practice 8-9 May, Glasgow

Transcription

1 The BILD Positive Behaviour Support International Research and Practice Conference 2014 Defining PBS and promoting evidence based practice 8-9 May, Glasgow

2 Fiona Davis BILD PBS Conference 2014 Defining PBS and promoting evidence based practice

3 The importance of developing quality Positive Behaviour Support Plans Ms Fiona Davis, A/Principal Clinician, Forensic Disability Department of Communities, Child Safety and Disability Services Centre of Excellence for Innovation and Behavior Support Queensland, Australia

4 Challenging behaviour Challenging behaviour is an issue of significance for people with intellectual disability: prevalence; impact (client / family / carer s) technology available that can remediate; efficacy of Positive Behaviour Support.

5 To summarise PBS is an efficient and effective way to increase: quality of life; access to inherent human rights; and decrease harm.

6 We understand the problem so how do we fix it....?

7 However Good quality Positive Behaviour Support is critical to ensure the aims, goals and objectives of positive behaviour support and person-centeredness are achieved.

8 What is positive behaviour support? Positive Behaviour Support is the framework in which supports can be designed and delivered for an individual, which: embraces their human rights; uses two specific technologies (ABA and PCP) to ensure that interventions are specific to the individual and their specific needs, to: increase the individual's quality of life; and reduce challenging behaviours.

9 The Behaviour Support Plan Quality Evaluation scoring guide Version Two (Browning-Wright, et.al. 2006) contextualised to a Queensland context adult examples, template references, reviewed and approved by a BCBA and removal of references to punishment.

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11 What we have learnt PBS is rocket science Using the tool validly takes sustained effort Professionals embedded in PBS do better than others Unlearning is hard Using the tool dramatically increases technical acuity in PBS

12 The BSPQEII and PBS

13 Important The BSPQEII does not interrogate the veracity of the functional hypothesis identified in the plan. The BSPQEII cannot measure the value base of the plan. The BSPQEII identifies whether specific clinical and implementation elements are in the plan or not.

14 6 key concepts in behaviour support planning 1. Behaviour serves a purpose for the individual; 2. Behaviour is related to the context/environment in which it occurs; 3. Two strands to address environmental and skills teaching;

15 4. New behaviours must be reinforced to maintain; 5. Reactive strategies; and 6. Communication between all stakeholders is frequent enough to ensure good implementation.

16 Applied uses of the BSPQEII Peer and clinical integrity reviews - (highly recommended); Plan development; Troubleshooting; Implementation monitoring; Consultancy

17 BSPQEII Consists of 12 Domains: 9 clinical specifically about the individual s behaviour; and 3 Implementation key issues in implementation of the plan.

18 BSPQEII Template has 4 columns for each domain: Component to Evaluate Scoring Scoring criteria Example Key Concept

19 Components to Evaluate Scoring Scoring Examples Key Concepts D. ENVIRONMENTAL STRUCTURE (FOR PROBLEM PREVENTION AND PROMOTION OF REPLACEMENT BEHAVIOUR) IS LOGICALLY RELATED TO WHAT SUPPORTS (PROMPTS) THE PROBLEM BEHAVIOUR Specified environmental and/or interaction changes to remove need to exhibit the problem behaviour The environmental change(s) to be made to remove the person s need to use this behaviour is logically related to predictors: What supports (prompts) the person using the problem behaviour? Note: Sometimes there is a logically related, consistent relationship between the identified predictors and the specified predictors that need to be altered which was analysed in C above. But the team fails to logically relate that analysis to the interventions and changes. Therefore, in analysing the strength and weakness of a plan, both are considered separately, i.e., C and D. 2 = One or more environmental changes, i.e., changes in time, or space, or materials, or positive interactions are specified and are logically related, i.e., consistent with, what was identified as supporting problem behaviour. 1 = One or more environmental variable changes (time, or space, or materials, or positive interactions) are described BUT they are not logically related to what was identified as supporting the problem behaviour. 0 = No change in any of the following four environmental variables is described. No changes in time, or space, or materials, or positive interactions are described. Reactive strategies or interventions unrelated to the predictors are described. 2 = Bill will be provided one on one time with a support worker when requested to do chores when there is a substitute support worker on shift, for any chores that take longer than 10 minutes, is logically related to Bill needs support under these conditions. 1 = Bill will be given one on one support when requested to work (this is not logically related to what was identified as supporting the problem behaviour i.e. lack of support doing chores). 0 = Bill is given two prompted attempts then support staff is to call the team leader. One strand of positive behavioural support entails altering the environment to reduce or eliminate the person s need to use problem behaviour. Successful support of positive behaviour typically entails a variety of environmental changes in how time is structured, space is organized, materials are selected and positive interactions are Increased. Understanding the person s learning profile, personality, and disability (if any) will be helpful in determining typical environmental supports to consider to eliminate or reduce problem behaviour. When there is a logical relationship between environmental changes to be made and the predictor summary of what is supporting problem behaviour the likelihood of addressing the correct variables are increased. The team can now move on to the strand: specifying how to teach FERB(s). 19

20 Components to Evaluate Scoring Scoring Examples Key Concepts F. REPLACEMENT BEHAVIOUR(S) SERVE THE SAME FUNCTION AS THE PROBLEM BEHAVIOUR(S) Functionally Equivalent Replacement Behaviour (FERB) must be identified that will be taught and reinforced to allow the person s need (function) to be met in an acceptable manner. 2 = All specified FERB(s) serve the same function as the problem behaviour AND no functional contaminators are present (e.g., control, power, vengeance, revenge). FERB(s) must serve the same function as the problem behaviour(s). There is no score of 1 on this component. 0 = No FERB is identified, OR the function was not accurately identified on in terms of 1) to get something or, 2) to reject something (escape, protest, or avoid) and therefore cannot be evaluated. OR the function was not in behavioural terms (i.e., operationalised) so no FERB can be identified to match a nonbehavioural function OR a functional contaminator is present (see above). 2 = Bill will verbally request to work alongside a peer when he wishes to protest the supervisor s requirement that he work independently. (FERB for a protest of working alone) serves the same function as Bill is avoiding independent task/chore completion and protests termination of self-selected activity with profanity because he states he prefers working with a partner on requested activity For this component, score 2 or 0. There is no score of 1. 0 = Bill will do what staff requests. (The function was avoiding work; this is not a replacement behaviour allowing the avoiding of work in an accepted form) OR The function of the behaviour is low self-concept cannot be compared to any replacement behaviour OR He will get revenge in an appropriate way. The FERB is a positive alternative that allows the person to obtain the function that the problem behaviour provided, i.e., he/she either gets something or rejects something (protest/avoid) in a manner that is acceptable in the environment. The FERB should maximize the benefits (e.g., more positive feedback from staff and peers) and minimize the costs to the person and others in the environment (e.g., lost task/chore time, punishment from staff and peers). Note: The person may eventually not need to use a FERB when other changes are achieved. For example, she will no longer need to escape because we have made significant changes in the environment that removes her need to escape. Or, she has improved her general skill acquisition and no longer seeks to escape. The FERB must serve the same function as the problem behaviour and at least as easily performed as the problem behaviour. A function must have been operationalized, e.g., put in behaviourally observable terms, and must have avoided contaminators (revenge, power, control, vengeance) if an adequate FERB for conditional use is to be identified, taught and reinforced as an alternative to the problem behaviour. 20

21 Domain A: Domain B: BSPQEII Clinical Domains Problem Behaviour measurable and observable terms; Predictors of Behaviour within categories (physical setting, social setting, activities, scheduling factors, degree of independence; degree of participation, social interaction, degree of choice and health

22 Domain C: Domain D: Analysis of what supports the behaviour logically related to predictors identified for change; Environmental structure is logically related to what supports the behaviour

23 Domain E: Domain F: Domain G: Function of Behaviour; Replacement Behaviour serves the same function as the challenging behaviour; Teaching strategies identify how to teach and/or prompt the Functionally Equivalent Replacement Behaviour;

24 Domain H: Domain I: Reinforcers; Reactive strategies clearly communicated and understood by all implementers;

25 Domain J: BSPQEII Implementation Domains Progress monitoring 1 Goals and Objectives; Domain K: Progress monitoring 2 Team Coordination; Domain L: Progress monitoring 3 Communication;

26 BSPQEII Tool gives further information on goal writing (6 and 9 format); writing of communication strategies; a summary page of the domains (an easy to use format); description of functional contaminators and scoring sheets.

27 Remember The BSPQEII does not interrogate the validity of the hypotheses developed within a plan The BSPQEII assesses whether elements identified have been written into the plan or not.

28 The Outcomes for Participants of training in Positive Behaviour Support An evaluation of the Functional Assessment and Positive Behaviour Intervention training program Simon Wardale, Fiona Davis, Maria Vassos and Michael Carroll

29 Where are we going? Functional Assessment and Positive Behaviour Intervention Introductory level Positive Behaviour Support course An evaluation of outcomes for training participants 2012 calendar year

30 Functional Assessment and Positive Behaviour Intervention Conducting a functional behaviour assessment Developing data informed hypotheses Developing multi element support plans

31 How was the course evaluated? Kirkpatrick's (1959) Four Levels of Evaluation 1. Satisfaction 2. Learning and attitudes 3. Behaviour 4. Outcome

32 Who were the training participants? 1. Sex: M F 2. Age: 3. What is your current job? 4. How long have you been working with people with intellectual disabilities? 5. What level of training had you received on challenging behaviour* prior to this course? (select 1 only) No formal training on challenging behaviour Limited training (one or two short courses only) A fair amount of training (several courses) Detailed training (many courses, or coverage on a professional course) Extensive training (specialism in the management of challenging behaviours or a similar level of training)

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34 Level 1 - Satisfaction Significance to the Centre; Ongoing professional development of the sector Staff performance Workplace Evaluation Questionnaire (Milne & Noone, 1996); Prior use in evaluating training in disability services (Taylor, Keddie, & Lee, 2003)

35 Workplace Evaluation Questionnaire For the items rated on a scale ranging from strongly disagree to strongly agree Item N M SD Frequency (percentage) 1. Did the training improve your understanding of why behaviour occurs? 2. Did the training help you develop work-related skills? 3. This training has made me more confident in my work? Strongly disagree (1) Disagree (2) Unsure/ Neutral (3) Agree (4) Strongly agree (5) (0.0) 16 (8.8) 10 (5.5) 72 (39.8) 83 (45.9) (0.0) 1 (0.6) 10 (5.5) 80 (44.2) 90 (49.7) (0.0) 3 (1.7) 22 (12.2) 98 (54.1) 58 (32.0) 4. I expect to make use of this training at work? (0.0) 1 (0.6) 13 (7.2) 72 (39.8) 95 (52.5) 7. Did the training cover the topics you wanted? (0.6) 3 (1.7) 12 (6.6) 85 (47.0) 80 (44.2) 8. To what extent has the training met its aims? (0.0) 0 (0.0) 11 (6.1) 86 (47.5) 84 (46.4) 9. I would recommend this training course to a colleague (0.0) 0 (0.0) 14 (8.6) 60 (36.8) 89 (54.6) For the items rated on a scale ranging from poor to strong Item N M SD Frequency (percentage) 5. How competent was the trainer in presenting the content of this course? 6. In an overall, general sense, how satisfied are you with the training? Poor (1) Satisfactory (2) Unsure/ Neutral (3) Average (4) Strong (5) (0.0) 1 (0.6) 6 (3.4) 32 (17.9) 140 (78.2) (0.0) 4 (2.2) 7 (3.9) 60 (33.3) 109 (60.6)

36 Level 2 - Knowledge Knowledge Acquisition Test (O Neil et al) 1. the objectives of positive behaviour support; 2. behaviour chains; 3. functions of behaviour; 4. data collection methods; 5. topography and measurement; 6. the Competing Behaviour Model

37 Level 2 - Knowledge

38 Level 2 - Attitudes Challenging Behaviour Attribution Scale (Hastings, 1997) 33-item scale with statements relating to five causal models of challenging behaviour; learned behaviour; medical/biological factors; emotional factors; aspects of the physical environment; self-stimulation Pre existing attributions

39 Level 2 - Attributions Wilcoxon Signed Ranks Test Results Comparing CHABA Subscale Scores Pre- and Post- FAPBI Training Subscale Pre FAPBI Training Post FAPBI Training Wilcoxon Test M (SD) Mdn M (SD) Mdn Z p Biological 0.57 (0.59) (0.60) Physical Environment 0.49 (0.62) (0.65) <.001 Learned Behaviour 0.91 (0.54) (0.57) <.001 Learned Behaviour (Positive) Learned Behaviour (Negative) 1.03 (0.62) (0.61) < (0.63) (0.64) <.001 Stimulation 0.46 (0.63) (0.65) <.001 Emotional 0.99 (0.54) (0.58)

40 Level 3 - Behaviour An obvious gap Behaviour Support Plan Quality Evaluation guide, version two (BSPQEII; Browning-Wright, Mayer, & Saren, 2006) 12 domains 0-2 scoring Rigid scoring criteria <12 = weak plan; = underdeveloped ; = good ; = superior plan

41 Level 3 - Behaviour The Quality of Positive Behaviour Support Plans: (SD = 3.64) underdeveloped plan using the quality criteria from the BSPQEII. Limited comparative data significantly higher than the mean total plan score (M = 10.90, SD = 3.20) reported by Webber et al. (2011),

42 Level 3 - Behaviour Does work role impact upon plan score? A significant difference in BSPQEII scores across the five work categories was found; Allied health professionals (Mdn=15.00, M=14.92, SD3.21) score higher on the BSPQEII compared to direct support workers (Mdn=12.00, M=12.12, SD3.97) and managers (Mdn=13.00, M=12.95, SD3.60), and other professionals (Mdn = 18.00, M = 17.80, SD = 2.35) score higher than direct support workers, managers and service coordinators/team leaders (Mdn=14.00, M=13.90, SD2.91).

43 What we learnt 1. Participants were highly satisfied with this course; 2. All groups of professionals benefit from the course; 3. Allied health professionals benefit most; 4. Plan scores are significantly better than available comparisons; 5. The course requires increased focus on skills teaching; 6. Future evaluations must focus on implementation and outcome; and 7. Evidenced outcomes should be an explicit consideration when purchasing training

44 A Clinical Audit and Practice Review of Positive Behaviour Support Plans in Queensland Fiona Davis, Simon Wardale, Maria Vassos and Karen Nankervis,

45 Why conduct this project? Carter Report (2006); To establish a snapshot of current plan content Consider content against established objective measures; Conduct one of the first investigations into staff perceptions of Positive Behaviour Support

46 Methodology Phase 1: Objective measures of plan content The Behaviour Support Plan Quality Evaluation scoring guide version II (BSPQEII) (Browning White, et.al, 2007) Based on 400 effective plans Previous use in Australia (Webber & McVilly, et.al, 2011) Modifications for Queensland context Readability Included assessments of readability 46

47 Research team competency Research team leadership Leadership provided by manager / practitioners (Practice Leadership staff) Rigorous confirmation of agreement between team leaders (IRR) Confirmation of score accuracy Researcher consultation 47

48 Inter-rater reliability Training of scorers; Level of IRR expected and obtained; Scorers demographics; IRR process; Comparisons with McVilly, et.al. (2012) include approach used; Scorer consistency not by chance; Good levels of IRR can be obtained standard and between raters; Clinically sound scoring ensures clinical integrity operational plans; Domains C & D most difficult to score; Language of tool is challenging.

49 Readability: Flesch readability statistics Standardised extracts Score Readability level Easily understood by an average 11-year old student Easily understood by 13- to 15-year old students Best understood by university graduates Organisation* Logical clinical analysis* Easily understood by non-clinical staff/families* *Scale developed by the Centre of Excellence 49

50 Ethical approval UQ Recruitment Sector wide advertising Expressions of interest from 10 Queensland non-government organisations (NGOs) Government gatekeeper approval January - July 2013 Cairns to Gold Coast Multiple plan contexts 50

51 Findings - general 139 Positive Behaviour Support Plans Mix of authorship Organisations Private consultants Government teams Mainly plans for authority to approve restrictive practice 51

52 Domain Rating Percentage No problem behaviour(s) in observable and measurable terms (0) 6 A Problem behaviour Some problem behaviour(s) are not observable and measurable (1) 27 All problem behaviour(s) are observable and measureable (2) 67 No predictors of problem behaviour (0) 21 B Predictors/ triggers of problem behaviour One or more predictors provided but no detail (1) 33 One or more predictors provided with detail (2) 46 C Analysis of what supports the problem behaviour is logically related to predictors None of the predictors are logically related to the behaviour (0) 35 Less than half are logically related to the behaviour (1) 40 Half or more are logically related to the behaviour (2) 25 D Environmental change is logically related to what supports the problem behaviour E Predictors related to the problem behaviour No environmental changes described (0) 23 One or more changes mentioned but not logically related (1) 38 One or more changes mentioned and logically related (2) 39 No functions specified, and contaminators present (0) 78 All identified functions but not logically related, and no contaminators present (1) All identified functions specify WHY and logically related (2)

53 Domain Rating Percentage F Function related to the replacement behaviour No functionally equivalent replacement behaviour identified (0) 99 All specified Replacement Behaviours serve same function as problem behaviour and no functional contaminator (2) 1 G Teaching strategies specify the teaching of the FERB No strategies described (0) 88 Some strategies described with at least one element of detail, and no contaminators (1) 11 Teaching strategies with more than one detail described (2) 1 Contaminators is present or incomplete detail (0) 98 H - Reinforcers Reinforcer for Replacement Behaviours incomplete (1) 1 Reinforcer for Replacement Behaviours is complete (2) 1 A strategy for managing at least one problem safely absent, or a contaminator present (0) 70 I Reactive strategies A strategy for managing at least one problem safely must be present and no identified contaminator (1) A strategy for managing at least one problem safely must be present and no contaminators (2)

54 Domain Rating Percentage No complete goal (0) 99 J Goals and objectives One incomplete goal & Replacement Behaviours identified (1) 1 One or more Replacement Behaviours goal (2) - No responsibilities or team members identified (0) 42 K Team coordination in implementation Not all implementers or not all responsibilities identified (1) 43 All implementers and responsibilities identified (2) 15 L Communication of progress with plan implementation Absence of data exchange (0) 99 One data exchange for any one specified goal (no complete exchange) (1) Replacement Behaviours data with all components present will be exchanged (2) 1-54

55 Findings The aggregate mean score was 6.53 with a standard deviation of

56 Findings - Readability Additional Aspects of Positive Behaviour Support Plan Not suitable % Satisfactory % Excellent % Flow organisation Logical clinical analyses Strategies clearly defined Appropriate to the audience

57 Readability Readability level Score Easily understood by an average 11-year old student Easily understood by 13- to 15 year old students Best understood by university graduates Flesch readability scores Mean Readability function Readability strategies Flesch readability scores (U.S. school grade) Mean Read function Kincaid Read strategies Kincaid

58 Methodology Phase 2: Direct support workers views of Positive Behaviour Support Plans Survey developed by the Centre of Excellence Combination Likert scales and free text Teaching skills, implementation, goals, progress monitoring, accessibility, target audience Surveys matched to specific plans (n=131) 58

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60 Disability Support Worker questionnaire (%) Not at all Somewhat When implementing the Positive Behaviour Support Plan, I understand what new skills I need to teach the client Quite a lot Completely The Positive Behaviour Support Plan that I am working with has identified how I need to monitor changes to the client s behaviour The Positive Behaviour Support Plan identifies who I am required to report this information to I understand what aspects of the client s Positive Behaviour Support Plan I am required to gather information on The plan is written in language that is understandable The Positive Behaviour Support Plan influences what I do on a day-to-day basis with the client The client has achieved the goals identified in their current Positive Behaviour Support Plan

61 Implications for Policy and Practice Are these plans good quality plans? Discourse between what the sectors understanding is of PBS as opposed to legislative compliance; What needs to happen for practice : Clinical staff; Operational staff; Management of organisations; and Approvers of restrictive practices (QCAT/VCAT, etc.); Use of exemplar plans to guide practice change that meet legislative requirements; 61

62 Conclusion Developing Positive Behaviour Support Plans takes sustained effort and understanding of behaviour concepts and principles, as they relate to, specific individual behaviour, by clinical and operational staffing groups; It is critical that legislative Approvers understand what PBS is and is not; Clinical staff need to change their practice use of peer reviews, auditing of plans etc.; Implementation with operational teams is the most difficult aspect of ensuring that the plan is worked as intended that means sustained and continued monitoring and evaluation of responsibilities; supervision of staff teams; supervision of operational supervisor s and managers;

63 Development of a lay / easy to read checklist has been developed, needs to be rigorously tested within operational contexts due to commence in July 2014; Development of a holistic auditing tool that encompasses all aspects of PBS (technical ABA / PCP) and ideological (principles of normalisation / human rights) preliminary work has been commenced; Continued and sustained focus needs to remain on PBS as the technology which can remediate the impact of challenging behaviour; Provision of training for legislative approvers QCAT, Adult Guardian, Allied Persons, family s/carers; Exploration of what PBS looks like within an NDIS (free market/ fee for service) context.

64 Then, and only then, could we possibly consider that the planning with and support of people with intellectual disabilities and their families, could be seen to be effectively improving the quality of life of the individual s we serve.

65 Thank you Any Questions?