Saturday, August 3, 2013

Behaviour Support Plans or Person Centered Planning

The first step in creating a Behaviour Support Plan (BSP) should be to do a Functional Behaviour Assessment (FBA).  The purpose of an FBA is to figure out why a student is displaying a specific behaviour.  The idea is that if we know the purpose of the behaviour we can plan and implement interventions to help the student display "more acceptable behaviours". 

I belong to a group on Facebook called the Autism Discussion Page.  The page is packed full of information on what we can do as parents and teachers to ensure that children with autism feel safe, accepted and competent.  Recently, there was a post about Autism and PTSD that read as follows...
It has amazed me how long it has taken for the field to accept sensory processing dysfunctioning in autism spectrum disorder. For years, the field of psychology practically ignored the sensory issues. Applied Behavior Analysis ignored it while forcing children to obey and stay in situations that were overwhelming for them. If the children “acted out”, we made them “stick it out...”;so their acting out behavior was not reinforced by escaping the unwanted situation. Over twenty years ago when I first started incorporating sensory processing strategies into my “behavior plans”, the psychologists all looked down on it because you could not observe it and measure it. Agencies would try and stop me from using the strategies because they were not “evidenced based.” Sensory processing problems were not “real.” They were in the business of “changing behavior”. Treating autism was nothing more than “changing their behavior.” The child’s internal experiences were not recognized, considered, nor valued. The ends (changing behavior) justified the means (extinction, punishment, forcing compliance).” Sensory processing issues were not “real.” Even though adults on the spectrum were writing extensively about these traumatizing experiences, the psychologists still claimed they were not real. 
Sensory dysfunction in autism is being recognized now. Finally after many years of people on the spectrum speaking out and demanding to be listened to, this experience is being taken serious. However, another topic not mentioned much in autism spectrum disorder is Post Traumatic Stress Disorder. Since most PTSD is caused by extreme sexual or physical abuse, and war time emotional trauma, it is not often suspected in ASD. However, I see evidence of it, and many of the self reports of adults on the spectrum relate experiences that seem very similar to post traumatic stress. Post traumatic stress occurs when there is severe insult to the nervous system. It results in changes in both brain chemistry and suspected structural changes in the brain. The person exhibits generalized anxiety, depression and isolation. panic attacks for no apparent reason, and sometime rages.   
My guess is PTSD can come from one of more emotional traumas, or long term distress from severe sensory processing dysfunction. Many of the nonverbal people on the spectrum, who also experience severe sensory defensiveness, are often experiencing intense physical and emotional trauma from the overwhelming sensory insult to their nervous system. Since the child never knows when the “sensory bombardment” is going to occur, it often attacks without warning, leaving the child helpless in defending against it. The constant “fight or flight”, panic reaction has long term effects on the nervous system; leaving the individuals battling stress and anxiety for many years. Each time the nervous system experiences intense sensory bombardment, the “stimulus characteristics” of the event becomes associated with the severe “panic response.” At other times in the future, when these common stimuli occur again it can produce an immediate “panic reaction” that was originally associated with the traumatic event. For these individuals, immediate panic occurs, for “no apparent reason. Neither the person, or those around him, may understand why the “panic reaction” occurs. This response can occur when a given sound, color, or smell occurs that was originally associated with the traumatic event. Our sensory memories are very intense. When your sensory experiences are very intense and inconsistent, like those experienced for people with sensory processing disorders, such overwhelming emotion can be associated with, and set off easily, by simple sensory memories.

So, when working with severely impaired individuals on the spectrum, tread very lightly. Be very respectful of their comfort zones. Be very careful of how you touch them, talk to them, and press them. Their nervous systems are very vulnerable and easily traumatized. Their reactions can be very guarded, and intense. They can be very emotionally reactive, and need you to be very calm, gentle, and compassionate. Always be looking for “defensive reactions” and immediately pull back when you see it. Never press the child into situations they are scared off. Guide them, but let them pace their actions. Let them feel “in control” so they can immediately end any situation of “panic.” Learn what touch, words, actions, and stimulation helps them feel safe and secure. Always listen and understand first, before intervening and redirecting their actions. Always assume that underlying their defensive reactions is intense emotional upheaval. Be respectful and compassionate, allow them to pull back, escape and rebound. Teach them coping skills for dealing with these intense experiences, but most importantly teach them to feel safe in your presence, and to trust following our lead.
Generally, an FBA involves data collection using an A-B-C chart.  We track the antecedent (A), the behaviour that occurred (B) and the consequence (C) or what happened after the behaviour.  By looking at the data, particularly the consequence, we can come to understand what the student "gets out of the behaviour" - the function of the behaviour.  For example, if the student consistently throws things and the response is that he/she needs to pick up what he/she threw before moving on to the next task, the function of the behaviour might be to get the opportunity to move or to avoid doing the work. What we believe about the function of the behaviour then gets moved in to our BSP.  If we believe it is about movement, we might create opportunities for movement throughout the day or look at things like alternate seating that allows the student to move while doing work.  If we believe it is about avoiding work we would look at whether the work is too hard and make a plan around scaffolding the work with either extra supports or modifications/adaptations.  In the end, we will have fixed the throwing problem in this one context and we can move on to the "next most pressing behaviour". 

What appears to be missing in the process is actually communicating with the student about what is going on.  But does this model actually work?  We need to consider what else we extinguish when we focus on extinguishing behaviours.  Pulling from the quote above, how do we ensure that the student's internal experiences are recognized, considered, and valued?  We can not and should not be aiming to change a person's internal state.  How do we ensure that we are not sending the message that a person's internal state is "wrong" and must be extinguished?  How do we ensure that we are building the skill of self-understanding and communication that will turn in to personal empowerment and the ability to self-advocate? 

According to the MyMarilee blog "person-centered planning is a set of approaches to help increase the independence and self-determination of individuals who have historically been disempowered."  She goes on to explain how this contrasts with traditional planning methods:
I often contrast the term person-centered with system or service-centered. Person-centered means we listen, respond to, and create a life plan based on an individual’s hopes, dreams, and goals. In contrast is creating a life plan based on what’s available through a system or service delivery model.
The goal of person centered planning is to increase a person's quality of life - both now and in the future.  Quality of life indicators are many and may include such things as choice, opportunities, participation, inclusion, safety, self-determination, relationships, fun, variety, access to belongings, access to learning, developing abilities, being treated with dignity and respect, being listened to, feelings of control over own life, knowing there are possibilities...etc.  Increasing quality of life sits at the center of person centered planning.  It may be argued that increasing a person's quality of life could be a by product of a BSP but I think it is worth stepping back and thinking about the underlying ableist message in that statement.  Does conformity to what someone from outside decides as "appropriate behaviour" really increase a person's quality of life in the long run? Has any understanding of self and how we influence the world been established through that process? Are we, in essence, starting from the point of not giving a student their voice? 

Part of the BSP should be related to proactive strategies like creating structure to space and routines, using visual schedules, having communication supports available,  implementing a consistent sensory diets, using social stories, scripting or behaviour mapping to facilitate understanding of the social world, working with a student to come up with strategies for emotion regulation...etc. Part of the BSP is also a plan for how we should be interacting with a student to assist with managing stressor and to ensure that we are de-escalating potential crisis situations.  Finally, the BSP has a "crisis management" that seems to get interpreted as the meat of the BSP all too often.  This is the piece that many see as the "consequence" that sits in the middle of traditional beliefs about behaviour.  Which brings one back to the question... does this model actually work?  Maybe instead of increasing the intensity of the "consequence", we should be increasing opportunities for the student to explore what they are feeling and why they are feeling it and then coming up with a way to increase supports and strategies tied to what we have discovered.  Maybe instead of tracking forms we need safe spaces to build self-understanding, communication skills and trust. 

Do we really believe that we can make others do good by making them feel bad? 

In the post Deconstructing Daniel: Autism and Respectful Relationships - Why it Matters, William Stillman speaks of a different way to approach finding the function of behaviours when working with people with Autism.  Rather than looking at specific situations and trying to come up with what is happening in that one situation, he thinks more broadly about quality of life indicators. 

The question then becomes what can we do to increase quality of life indicators?  It forces us to think more broadly.  If a child is pushing other children on the playground, rather than thinking about what is happening in that one situation where the pushing is happening, we think about quality of life indicators associated with recess.  It is a time rich with opportunities to build relationships and engage in personally satisfying activities.  Given the resources that are already there, what can we do to increase quality of life indicators during recess rather than how we stop them from hitting. 

It requires thinking about the A-B-C chart differently.  It requires thinking about the situation and all the people in that situation rather than the student and the targeted "behaviour".  The consequence actually becomes the behaviour by thinking about it this way. 
  • Antecedent - Describe the actual situation as it stands now. In this case it is recess. What does it currently look like?  What activities are going on? Of those activities, which ones are appealing to the student or which ones might provide a ramp to something that is appealing to the student? Who is present? Of those people, who might have a common interest or an established bond?  Who is participating in activities that are appealing to the student? Who might be looking for something new to do or someone new to hang out with? 
  • Behaviour - Look at what is currently happening.  How is the person feeling (ask them)? How does it make the person act?  How is the activity structured (or not structured)? How is growth, learning, interaction, choice...etc. currently supported?
  • C - What happens as a result of the situation as it stands now? How does the person act? How does the person feel?  

From here, rather than thinking about a "replacement behaviour" we think about how to create the circumstance that will allow the student to develop the skills needed to increase their quality of life. Maybe at first we need to find a small group of students who have a common interest and structure activities and facilitate interactions for them. Maybe we need to create a more effective and efficient means of communication. Maybe we need to write some social stories related to something specific the student wants to learn how to do during recess.  Either way, we are taking a proactive approach that has potential to transfer beyond just a single incident.  We are focusing on building relationships and communication skills as well as developing personal interests rather than finding a single alternative to hitting in a specific situation. 

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