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Evaluation of a standardized protocol for parent training in positive behavior support using a multiple baseline design
h [electronic resource] /
by Robin Lane.
[Tampa, Fla] :
b University of South Florida,
Title from PDF of title page.
Document formatted into pages; contains 73 pages.
Thesis (M.A.)--University of South Florida, 2008.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
ABSTRACT: Challenging behaviors such as hitting, kicking, screaming, destruction of property and other socially-inappropriate behaviors are common among children with significant disabilities. Behavior Parent Training (BPT), which is based on basic principles of Applied Behavior Analysis (ABA), has been shown to be effective in reducing these problem behaviors. Traditional approaches to BPT have typically emphasized consequence-based interventions, however, advances in the field of ABA (e.g., FBA, antecedent-based interventions) and PBS have led to more strategies that are more effective in complex community environments. Evidence of such practices is emerging but has not been adequately documented. The current study evaluated the use of a standardized PBS protocol in decreasing problem behaviors of four children with developmental disabilities. The success of the parent education protocol was evaluated using a multiple baseline across participants design. Results of this study showed that after participating in parent education using a standardized protocol, participants' children displayed decreases in problematic behavior as well as increases in adaptive behavior, for all but one of the participants.
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Advisor: Meme Hieneman, Ph.D.
Behavior support plan
Children with developmental disabilities
Function based interventions
x Applied Behavior Analysis
t USF Electronic Theses and Dissertations.
Evaluation of a Standardized Protocol for Parent Tr aining in Positive Behavior Support Using a Multiple Basel ine Design by Robin Lane A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Child and Family Studies College of Behavioral and Community Sciences University of South Florida Major Professor: Meme Hieneman, Ph.D. Mark Durand, Ph.D. Shelley Clarke, M.A. Date of Approval: November 17, 2008 Key words: Intervention strategies, Behavior suppor t plan, Children with developmental disabilities, Parental implementation, Function bas ed interventions Copyright 2008, Robin Lane
Dedication For everyone who stood by me through this whole or deal, without all of your support and sometimes nagging I never would have go tten to where I am today. Thank you for everything.
Acknowledgements I would like to thank all of the faculty and staff who have helped guide and support me through this endeavor. Without each and every one of you I could not have accomplished this lofty goal. I want to especially thank Dr. Meme Hieneman, without whom I most certainly would not have kept it togeth er long enough to finish this work. Your encouragement and support have meant the world to me and I couldnÂ’t have imagined doing it without you.
i Table of Contents List of Tables iii List of Figures iv Abstract v Introduction 1 Literature Review 5 Method 11 Selection Criteria & Participants 11 Bobby (K aren) 13 Lilly (Sandy) 13 Cam (Michelle) 14 Amanda (Susan) 14 Dependent Measures 14 Behavioral Definitions for Videotaped Child Behavio r 15 Standardized Measures 16 Experimental Design 1 7 Measurement and Reliability 18 Procedures 21 Procedural Fidelity of Intervention Sessions 28 Data Analysis 28 General Procedure 29 Downward Trends 29 Upward Trends 29 Results 30 Child Behavior 30 Scales of Independent Behavior Revised 35 Discussion 40 References 47
ii Appendices 53 Appendix A: Questionnaire on Resource and Stress ( QRS) 54 Appendix B: Informed Consent Agreement 57 Appendix C: Example of Specific Child Behaviors 60 Appendix D: Sample Videotaping Protocol 61 Appendix E: Sample Data Collection Sheet 63 Appendix F: Behavior Plan for Bobby (Karen) 64 Appendix G: Behavior Plan for Lilly (Sandy) 66 Appendix H: Behavior Plan for Cam (Michelle) 68 Appendix I: Behavior Plan for Amanda (Susan) 70 Appendix J: Sample Procedural Fidelity Checklist 72
iii List of Tables Table 1 Participants Scores for Inclusion Criteria 13 Table 2 Categories for GMI Scores 17 Table 3 Description of the Objectives of Individual Sessions 23 Table 4 Skills/Procedures Taught during Sessions f or Individual Participants 26 Table 5 ParticipantsÂ’ Child Average Percentage of Problematic and Adaptive Behaviors for Baseline and Follow-Up 30 Table 6 SIB-R Results for Baseline and Follow-Up 35
iv List of Figures Figure 1. SIB-R Results for Karen/Bobby at Baseline and Follow-Up 34 Figure 2. SIB-R Results for Sandy/Lilly at Baseline and Follow-Up 35 Figure 3. SIB-R Results for Michelle/Cam at Baselin e and Follow-Up 37 Figure 4. SIB-R Results for Susan/Amanda at Baselin e and Follow-Up 38 Figure 5. ParticipantsÂ’ Child Data for Baseline and Follow-Up 39
v Evaluation of a Standardized Protocol for Parent Tr aining in Positive Behavior Support Using a Multiple Basel ine Design Robin Lane ABSTRACT Challenging behaviors such as hitting, kicking, scr eaming, destruction of property and other socially-inappropriate behaviors are comm on among children with significant disabilities. Behavior Parent Training (BPT), which is based on basic principles of Applied Behavior Analysis (ABA), has been shown to be effective in reducing these problem behaviors. Traditional approaches to BPT ha ve typically emphasized consequence-based interventions, however, advances in the field of ABA (e.g., FBA, antecedent-based interventions) and PBS have led to more strategies that are more effective in complex community environments. Evide nce of such practices is emerging but has not been adequately documented. The current study evaluated the use of a standardized PBS protocol in decreasing problem beh aviors of four children with developmental disabilities. The success of the pare nt education protocol was evaluated using a multiple baseline across participants desig n. Results of this study showed that after participating in parent education using a sta ndardized protocol, participantsÂ’ children displayed decreases in problematic behavio r as well as increases in adaptive behavior, for all but one of the participants.
1 Introduction Challenging behaviors such as hitting, kicking, scr eaming, destruction of property and other socially-inappropriate behaviors are comm on among children with significant disabilities. There is some research to suggest tha t these problem behaviors can be up to four times more likely to occur in this population than among typically developing children (Lowe et al., 2007). These problem behavio rs along with parental concern on how to manage these behaviors can cause significant stress for the parents (Moes, 1995). In addition, problem behaviors can have an effect o n the entire family by limiting family routines, access to the community, and socializatio n (Cole & Meyer, 1989; Fox, Vaughn, Dunlap, & Bucy, 1997; Vaughn, Dunlap, Fox, Clarke, & Bucy, 1997). Behavioral Parent Training (BPT) is one approach u sed to address problem behavior. BPT has been demonstrated to be effective in helping families reduce problem behavior of their children with disabilities. BPT i s based on basic principles of Applied Behavior Analysis (ABA; Baer, Wolf, & Risley, 1968) and involves teaching parents intervention strategies to better manage their chil drenÂ’s behavior. BPT has been evaluated using primarily group designs and has been shown to be effective in reducing problem behaviors such as non-compliance, temper tantrums, defiance, and aggressiveness (Serketich & Dumas, 1996). In the past, BPT has focused primarily on consequen ce-based strategies (Eyeberg & Boggs, 1989), however, advances in the field of A BA have led to strategies that
2 maximize the effectiveness of behavior change proce dures in BPT. Advances include the use of functional assessments to determine the purp ose problem behaviors serve (Day, Horner, & OÂ’Neill 1994; Durand & Crimmins, 1988; Iwata, Dorsey, Slifer, Bauman, & Richman, 1994), function based intervention strateg ies, and antecedent based strategies that address the contexts in which problem behavior s occur (Dunlap, Kern-Dunlap, Clarke, & Robbins, 1991). These evolutions in ABA h ave in-turn led to more positive, proactive, and individualized behavior intervention s (Conroy, Dunlap, Clarke, Alter, 2005). Positive Behavior Support (PBS) is an effort to int egrate the principles and features of ABA into complex community environments by contextualizing the process to fit the particular family who needs assistance a nd including key stakeholders in all aspects of the intervention process (Carr et al., 2 002). More specifically, individualized interventions seek to decrease problem behavior thr ough the use of multi-component interventions. These multi-component interventions include prevention strategies, positive consequences, and teaching replacement beh aviors to take the place of the problem behaviors which can be readily implemented by direct support providers in natural contexts. PBS not only embraces the ABA pri nciples of functional assessments and the use of antecedent and consequence-based int ervention strategies to improve childrenÂ’s behavior, but also focuses on the import ance of making greater lifestyle changes in general (Risley, 1996). PBS has been shown to be effective in improving be havior in children with disabilities with a wide range of needs and charact eristics (Buschbacher, Fox, & Clarke,
3 2004; Vaughn et al., 1997; Vaughn, Wilson, & Dunlap 2002). While robust, PBS research has focused primarily on in-school interve ntions with the teacher or researcher as the intervention agent (Conroy et al., 2005). Th rough the years PBS has been most commonly evaluated and shown to be effective using single-case designs, primarily multiple baseline across behaviors or settings (Luc yshyn et al., 2007; Vaughn et al., 1997). A probable explanation for the extensive use of single subject designs in PBS is that the idiosyncratic, comprehensive nature of the approach lends itself most readily to single subject investigations. PBS is seen as an i mplementation approach using not just one procedure but multiple, individually-selected p rocedures that can be implemented as a package in less controlled settings. Single subje ct research, while important with regard to internal validity, makes it hard to evaluate int erventions across children, especially since there is a lack of a standardized PBS protoco l. To further demonstrate the effectiveness of PBS it is necessary to evaluate a standardized PBS protocol that can be used across participants employing the parent as th e intervention agent. The purpose of this research project was to take a standardized PBS protocol (Durand & Hieneman, 2008a; Durand & Hieneman, 2008B ) that combined the principles of ABA (i.e., functional assessments, antecedent ba sed strategies) and the components specific to PBS (i.e., contextual fit, stakeholder emphasis) and evaluate it with pessimistic families. The goal was to demonstrate the effective ness of BPT in PBS with the parents operating as the intervention agents. This research project intended to use four participants from a larger study being run out of t he University of South Florida directed by Drs. Mark Durand and Meme Hieneman. Participants were compared in a multiple
4 baseline across participants design to determine if the use of a standardized protocol to parent education was effective on an individual lev el. The hypotheses for this study were: 1) participation in parent education would lead to a decrease in the problematic behavior of the participantÂ’s child and 2) participation in parent education would also lead to an increase in the adaptive behavior of the participan tÂ’s child. Changes in a standardized measure (i.e., SIB-R) were also expected.
5 Literature Review Behavioral Parent Training (BPT) is based on the pr inciples of applied behavior analysis (ABA; Baer et al., 1968) and is used to he lp families develop the skills to manage their childrenÂ’s behavior. BPT grew out of a need to expand intervention programs to provide services to more families and c hildren, especially those with disabilities (Symon, 2005). One way of expanding se rvices is to empower parents to implement strategies themselves. BPT does just that by teaching parents ways in which they can implement intervention strategies in order to address their childÂ’s problem behavior. In general, BPT has been shown to be effe ctive in reducing problem behavior in children, with children whose parents participat ed in BPT having better outcomes than 80% of those whose parents did not participate in B PT (Serketich & Dumas, 1996). More specifically, research in BPT has shown that includ ing parents in the implementation of intervention strategies is a relatively inexpensive way to expand intervention services and provide these services to more families (Koegel, Bi mbela, & Schreibman, 1996; McClannahan, Krantz, & McGee, 1982). In the past BPT has focused heavily on the use of consequence based strategies, employing differential reinforcement and time-out a s their main behavior change techniques. Both of these methods are illustrated i n manuals that have been used to modify Â“antisocialÂ” behavior in children (Eyeberg & Boggs, 1989). While BPT has been shown to be effective in the literature using group designs to evaluate its procedures
6 (Feldman & Werner, 2002; MacKenzie, Fite, & Bates, 2004) there have been advances in the field of ABA which have led to more proactive, positive, and individualized intervention strategies. Advances in ABA include the use of functional ass essments (OÂ’Neill et al., 1997) to identify interventions that address the function of the problem behavior (Day, et al., 1994; Durand & Crimmins 1988; Iwata et al., 1994; P eterson, Derby, Berg, & Horner, 2002; Scott & Eber, 2003) and antecedent based stra tegies that address the contexts in which problem behaviors occur (Dunlap et al., 1991; Kern & Clemens, 2007). Functional assessments are used to identify the consequences m aintaining problem behavior (Day et al., 1994; McNeill, Watson, Henington, & Meeks, 200 2; Newcomer & Lewis, 2004) and the environmental variables surrounding the behavio r (Duda, Dunlap, Fox, Lentini, & Clarke, 2004). Once an assessment has been conducte d interventions are developed based on the assessment and the function the problem beha vior serves. Preventive strategies involve the modification of a ntecedents and setting events. These strategies are based on the idea that modific ations made to the environment around the child can lead to decreases in problem behavior s. Antecedent manipulations such as curricular modifications (Dunlap et al., 1991), inc orporation of choice or preference (Blair, Umbreit, & Bos, 1999), and introducing Â“neu tralizingÂ” routines (Horner, Day, & Day, 1997) have all been shown to be effective in r educing problem behavior. Positive Behavior Support (PBS) is an effort to i ntegrate the advancements in the field of ABA into a comprehensive system effective in complex community settings (Carr et al., 2002; Dunlap, et al., 2000; Horner et al., 1990). PBS seeks to use features
7 and concepts that have been shown to be effective i n the field of ABA, such as functional behavior assessments and antecedent based strategie s. More specifically, individualized interventions seek to decrease problem behaviors th rough multi-component interventions such as prevention, positive consequences, and teac hing replacement behaviors. In combination with the advancements in the field of A BA, PBS seeks to not only decrease problem behaviors but there is also a strong focus on improvements in quality of life (e.g., independence, enhanced relationships). The elements of PBS intervention plans fall into th ree categories: prevention strategies, replacement behaviors, and consequence management. Prevention strategies involve making adjustments to the environment aroun d the behavior to make the behavior less likely to occur (Cihak, Alberto, Frederick, 20 07; Conroy et al., 2005; Cote, Thompson, & McKerchar, 2005; Kern & Clemens 2007). Replacement behaviors involve teaching a new skill which will replace the problem behavior. Consequence management refers to the removal of reinforcing stimuli that h ave previously followed challenging behavior and instead presenting that reinforcing st imuli for appropriate behavior (Duda et al., 2004) Through the use of functional behavior assessments (OÂ’Neill et al., 1997) as the foundation for treatment, functionbased intervent ions such as functional communication training (FCT) (Durand, 1990; Durand 1999), and the use of antecedent strategies (Buschbacher et al., 2004; Dunlap, et al., 1991; Ho rner et al., 1997), PBS is quickly becoming a popular approach to teaching parents how to effectively deal with the problem behaviors of their children with disabiliti es. In addition to these behavior
8 analytic components PBS also incorporates an emphas is on the stakeholder (i.e., the parents) participation and the contextual fit of in terventions (Albin, Lucyshyn, Horner, & Flannery, 1996; Hieneman & Dunlap, 2000; Hieneman & Dunlap, 2001; Ruef & Turnbull, 2001; Soodak, et al., 2002). Positive behavior support is considered a collabora tive process. Parents, family members, and other important people in the childÂ’s life are included in all aspects of the PBS process. Once a team is established they are th e ones who choose target behaviors as well as help to design the plan and implement the i ntervention strategies (Hieneman & Dunlap, 2000; Hieneman & Dunlap, 2001). During the PBS process parents are taught to conduct functional behavior assessments (FBA) and d esign and implement strategies themselves. This teaching process is typically guid ed by a professional however, by including the family in every step of the process P BS almost ensures that strategies will be implemented because they will address what is im portant to the family and also take into consideration the family values and how the pl an will fit into their everyday lives (Albin et al., 1996; Lucyshyn, Dunlap, & Albin, 200 2). Research in PBS has shown it to be effective in dec reasing problem behaviors (Buschbacher et al., 2004; Vaughn et al., 1997; Vau ghn et al., 2002). For instance, Koegel, Stiebel, and Koegel (1998) conducted a stud y in which they sought to decrease aggression in children with autism toward a sibling They did so by providing instruction to the parents on ways to rearrange the environment to make problem behaviors less likely and teach replacement behaviors that would m ake aggression less functional. The parents were to develop and implement strategies in their home with only minor
9 prompting when required. Results of the study showe d that changing contextual stimuli associated with problem behavior and using function al communication training to replace aggression was an effective way to reduce aggressio n in children with autism. Moes and Frea (2000) conducted a study which illust rates the effectiveness of contextualized interventions in which the parents a re involved in all aspects of the planning. In this study, all assessment and interve ntion sessions took place in the participantÂ’s home and took place during routines t he parents identified as problematic. Intervention strategies during the contextualized t reatment planning condition were develop based on family preferences and input. Duri ng the prescriptive treatment planning condition a treatment package was provided to the parents without their input. Both conditions produced strategies based on the re sults of the functional assessment. However, substantial reductions in problematic beha vior and increased compliance during family routines were observed only during th e contextualized treatment planning condition. Results from this study illustrate the i mportance of stakeholder involvement and contextual fit of the intervention strategies. Most research has used single case designs which ha s created a strong foundation by showing the procedures used are effective and pr oduce a change in a single childÂ’s behavior, however, this cannot be said to generaliz e to other children (Barry & Singer, 2001; Lucyshyn, et al., 2007; Vaughn, et al., 1997) Studies which use a multiple baseline design are generally multiple baseline across behav iors or settings but not across multiple children. (Vaughn et al.,1997).
10 The Association for Positive Behavior Support (APB S) has defined PBS as: Â“a set of research-based strategies used to increase quali ty of life and decrease problem behavior by teaching new skills and making changes in a person's environment. Positive behavior support combines: valued outcomes, behavio ral and biomedical science, validated procedures, and systems change to enhance quality of life and reduce problem behavior.Â” However, APBS does not define what the v alidated procedures are and has yet to develop a standard protocol for individuals to f ollow. The ideas behind PBS have been articulated in the literature but how to translate that into practice has not been well documented. In studies involving PBS there is no st andard protocol or procedure that is followed making it hard, if not impossible to repli cate, across people. In order to add to the PBS literature it is important to determine if parent education using a standardized protocol is effective in reducing problematic behav ior in multiple children.
11 Method This research study was designed to add to the PBS literature through the evaluation of the effectiveness of parent education using a standardized PBS protocol (Durand & Hieneman, 2008a; Durand & Hieneman, 2008b ) through the use of a multiple baseline design across four participants who have c hildren between the ages of 3 and 5 with a developmental disability and severe problem behaviors. After participation in the intervention sessions each participantÂ’s child was expected to have 1) decreased levels of problematic behavior and 2) increased levels of ada ptive behavior as measured by scoring videotaped probes using a partial interval system. Changes in standardized measures (e.g., SIB-R) were also expected. Selection Criteria & Participants Participants in this study were 4 mothers of childr en between the ages of 3-5 with diagnosed developmental disabilities (e.g., Autism, PDD-NOS, Williams syndrome) who had no previous training in PBS. Participants were also required to score high on pessimism as indicated by the Questionnaire of Reso urces and Stress (QRS) (See Appendix A) because this study was part of a larger research program targeting parents who are pessimistic and therefore less likely to co mplete training and implement interventions. This was measured using the pessimis m subscale of the QRS, with participating parents scoring 6 or higher. In addit ion to the pessimism criteria a parent
12 was eligible for the study if their child exhibited significant problem behavior as indicated by the following criteria: the Child Behavior Checklist (CBCL) (Achenbach & Re scorla, 2000), with a minimum inclusion percentile score for probl em behavior being the 90th percentile or above; the Scales of Independent Behavior Revised (SIB-R) (Bruininks, Woodcock, Weatherman, & Hill, 1996), with a minimum score of -31 or below or Â“seriousÂ” on the general maladaptive index (GMI); and evidence of problematic behavior in an average of 2 0% or more of the intervals during one to four 30-minute videotaped s essions of a problematic routine. Based on these criteria four participants were chos en. Participants were recruited via schools, parent support groups, therapy centers and pediatricians. Prior to administering assessments, videotaping, or initiati ng intervention the researchers obtained written informed consent (See Appendix B). Of note, the larger study of which this was a part has been IRB approved with the University of S outh Florida Research Compliance Office. Table 1 lists the four selected participants and t heir scores in order to meet inclusion criteria.
13 Table 1. Participants Scores for Inclusion Criteria Child Behavior Checklist (CBCL) Scales of Independent Behavior (SIBR) Average % of Intervals with Problematic Behavior Questionnaire on Resources and Stress (QRS) Bobby >97 th percentile -43 (Very Serious) 71% 8 Lilly 90 th percentile -40 (Serious) 27% 7 Cam >97 th percentile -33 (Serious) 46% 7 Amanda >97 th percentile -55 (Very Serious) 45% 9 Bobby (Karen) Karen was a mother with 3 children. She contacted the study to get assistance with her 4 year old son, Bobby. Bobby was diagnosed with autism. His problem behaviors as reported by his mother included non-co mpliance (i.e., falling to the floor, not following directions, hiding in his closet) and aggression (i.e., hitting with an open hand) were of concern to his mother. On the baselin e measures Bobby met criteria with scoring greater than the 97th percentile on the CBCL, -43 (very serious) on the GMI index of the SIB-R; and 76% of intervals with problematic behavior during baseline routine videotaping. Due to the level of problematic behavi or displayed during the first video probe no other video probes were conducted. Lilly (Sandy) Sandy was a part-time substitute teacher with 3 ch ildren. Her daughter, Lilly, was 4 years old and had been diagnosed with WilliamÂ’s S yndrome. LillyÂ’s behaviors of concern were aggression (i.e., hitting with an open or closed hand, kicking her legs), destruction (i.e., slamming doors, kicking her bike helmet), and opposition (i.e., saying
14 Â“noÂ”, folding arms, walking away). Lilly scored in the 90th percentile on the CBCL; -40 (serious) on the GMI index of the SIB-R; and over t he course of 3 video probes had an average of 27% of intervals in which problematic be havior occurred. Cam (Michelle) Michelle was a stay at home mother with 2 children Cam was 3 years old and had been diagnosed with autism. His behaviors of concer n were tantrums (i.e., screaming, dropping to the floor), biting, and screaming when not having a tantrum. Cam scored greater than the 97th percentile on the CBCL; -33 (serious) on the GMI i ndex of the SIBR; and over the course of 3 video probes had an ave rage of 46% of intervals in which problematic behavior occurred. Amanda (Susan) Susan worked part-time as a piano instructor and ha d only one child. Amanda was 5 years old and had been diagnosed with WilliamÂ’s Syndrome and PDD-NOS. AmandaÂ’s behaviors of concern were throwing things at others and aggressive behaviors (i.e., pinching, hitting, kicking other people). Am anda scored greater than the 97th percentile on the CBCL; -55 (very serious) on the G MI index of the SIB-R; and over the course of 4 video probes had an average of 45% of i ntervals in which problematic behavior occurred. Dependent Measures Dependent measures included: child problematic and adaptive behaviors as measured by a partial interval scoring system of vi deo probes, as well as scores on the
15 standardized measure of the SIB-R. The dependent me asures are described in the following section. Behavioral definitions for videotaped child behavi or. Child behavior was grouped into problematic and ada ptive behavior categories for data analysis purposes. Problematic child behavior included: 1) aggression Â– striking or attempting to strike or injure another person with any part of their body or an object (e.g., hitting, kic king, biting, pushing, throwing objects at a person) 2) vocalization Â– crying or screaming involving hi gh-pitched sounds which exceed normal conversational volume 3) destruction Â– slamming, striking, or throwing w ith risk of damage to those items (i.e., versus tossing a ball during play) 4) opposition Â– refusing to follow a direct reques t by saying or shaking head Â“no,Â” turning or pulling away from the adult, activ ely resisting physical guidance (e.g., dropping to the ground, running away, strugg ling to retain an item), or engaging in behavior again immediately after being told no 5) self-stimulation Â– repetitive movements or mani pulation of items that serves no functional use (i.e. flapping, rocking, manipula ting fingers, flipping items) 6) other Â– behaviors of concern specific to child.
16 Adaptive child behavior included: 1) engagement Â– participating in a physical activit y through the manipulation of items or objects independently to complete a functi onal task (even if accompanied by problem behavior) 2) interaction Â– initiating or responding to anoth er person verbally (words, sounds) or non-verbally (gestures, movement, contac t). The tapes were viewed prior to scoring in order to make notes of specific examples of each childÂ’s behavior. If necessary, sp ecific examples of each childÂ’s behavior were added to the above definitions. For a n example of specific child behaviors see Appendix C. Standardized measures. The SIB-R is Â“a comprehensive measure of adaptive and problem behaviors. It is primarily designed to measure functional independen ce and adaptive functioning in school, home, employment, and community.Â” The SIB-R was given during baseline and follow-up to compare participantÂ’s perceptions of p roblematic behavior with actual levels as indicated by the videotaped probes. Questions on the SIB-R fell into 8 categories: hurtful to self, hurtful to others, destructive to property, disruptive behavior, unusual or repetitive habits, socially offensive behavior, wit hdrawal or inattentive behavior, and uncooperative behavior. Parents were asked about th e frequency and severity of behaviors in each category. The general maladaptive index (GMI) is an aggregate measure of all problem behaviors and was scored to determine if there was a decrease in the severity of problematic behavior following inte rvention. The maladaptive index
17 scores range from approximately +5 to -70, with an average of 0 and a standard deviation of 10 (among clinical samples). See Table 2 for the level of seriousness and index values associated with those levels. Table 2. Categories for GMI Scores Level of Seriousness Index Value N Normal +10 to -10 MgS Â– Marginally Serious -11 to -20 MdS Â– Moderately Serious -21 to -30 S Serious -31 to -40 VS Â– Very Serious -41 and below Experimental Design A non-concurrent multiple baseline design across p articipants was used to evaluate whether parent participation in parent edu cation sessions had an effect on child behavior, both problematic and adaptive. The reason for using a non-concurrent baseline was because families started the assessment process at different times. Baseline video probes were discontinued once stability in disrupti ve behavior (i.e., not a decreasing trend) was achieved or videotaping was terminated d ue to the severity of problem behavior. Due to the severity of problem behavior, it was unethical to carry out further baseline and postpone treatment if the behavior was considered to be harmful or destructive as indicated by the parent. Interventio n sessions were begun as soon as possible. Participants were administered the SIB-R and began with a baseline stage during which 1, 2, 3, or 4 video probes were conducted in order to capture initial levels of problematic and adaptive behavior of the participan tÂ’s child. Following baseline,
18 participants attended eight parent training session s (independent variable). After intervention, participants were involved in a follo w-up phase in which the SIB-R was repeated and three video probes were conducted for comparison to pre-intervention percentages of problematic and adaptive behavior. T heir data were graphed for visual analysis using procedures in the data analysis sect ion. Measurement and Reliability For the purpose of this study participants identifi ed a routine in which problematic behavior of their child was likely to occur. The ro utine was videotaped during baseline and repeated during follow-up. Videotaping was comp leted for the purpose of obtaining a baseline estimate with which to compare following i ntervention and to compare with other (e.g., standardized) measures. Baseline sessi ons were terminated early if problem behavior was considered dangerous or destructive. A project staff member, a student in the psychology department who had been trained in t he procedures, worked with the family prior to videotaping to identify a routine t hat was particularly troublesome. They scripted out the details of the routine, including the time of day, people to be present, materials and activities, and parental presentation of demands and reactions. An example of the videotaping procedure form is included in Ap pendix D. Participants were reminded of the routine prior to research staff arrival. Bef ore videotaping began the staff member placed themselves in an unobtrusive area of the roo m and refrained from interacting with the family. BobbyÂ’s videotaped routine was getting dressed for school. LillyÂ’s videotaped routine was coming in from outside to brush her tee th and wash her hands. CamÂ’s routine
19 was play time where either Michelle or CamÂ’s sister would try and get him to play. AmandaÂ’s routine was tutoring where AmandaÂ’s tutor would come into the home and try to direct Amanda to engage in activities. ParticipantsÂ’ baseline and follow-up videos were us ed to determine if there was any change in child behavior (i.e., decrease in pro blematic behavior, increase in adaptive behavior). Thirty minute videotaped probes of child behavior were scored using a tensecond partial interval system that provides a perc entage of intervals in which problematic and adaptive child behaviors occur. The intervals were signaled by audiotape, with 10Â” observation periods followed by 5Â” recording periods. The trained observers watched the videotape during each ten-sec ond interval, noting whether or not the target behaviors occurred at all during the int erval using the data sheet created as part of the study (see Appendix E). If the child engaged in one or more of the problematic behaviors during a particular interval that interva l was scored as problematic. If the child engaged in either of the adaptive behaviors during the interval the interval was scored as adaptive. In both instances the duration of the beh avior(s) had no bearing on how the interval was scored. Both problematic and adaptive behaviors could have been scored in the same interval. The data yielded a percentage of intervals in which problematic and adaptive behaviors occurred. Interobserver agreement (IOA) was calculated on ap proximately 1/3 of the videotapes, scoring to ensure accuracy. When conduc ting IOA, both observers scored the tape at the same time, shielding their answers from one another. IOA was calculated by dividing the number of intervals with agreements by the total number of intervals (i.e.,
20 agreements + disagreements) and multiplying by 100% in order to calculate total agreement. The mean total agreement for all depende nt measures was 89% (range=80%100%). The mean agreement for problematic behavior was 90% (range=81%-100%) and adaptive behavior was 89% (range=80%-97%). Reliabil ity was achieved at a level of 98.5% (range=97%-100%) for Bobby, 89.5% (range=81%100%) for Lilly, 84.75% (range=80%-91%) for Cam, and 88.75 (range=85%-92%) for Amanda. As a self-report measure conducted with only parent s, the SIB-R will not have an IOA measure completed by project staff. However, th e SIB-R has documented test-retest reliability characteristics in the comprehensive ma nual. The two tests were completed by the same respondent within a 4 week period. The tes t-retest correlation was .97. The SIB-R will be used to make comparisons between chan ges in problematic behavior according to direct observation (i.e., videotaped p robes) and participantÂ’s perception of the changes in problematic behavior following inter vention. Following participation in the eight parent trainin g sessions participants were given post-assessment measures at no more than 2 we eks after completion of treatment. Measures given to the participants during post-asse ssment included the SIB-R and videotaping of the previously identified problemati c routines for baseline was videotaped during all three follow-up probes. Pre and post-vid eos were compared to determine if there was a decrease in problematic behavior and in crease in adaptive behavior among participantÂ’s children following treatment.
21 Procedures The intervention was parent education using a stand ardized protocol teaching PBS principles and practices. The parent training was d elivered in eight 90 minute sessions with a parent educator who had a MasterÂ’s degree or higher with training in ABA and clinical psychology. The purpose of the program was to teach the parents principles of PBS and have them engage in all aspects of the asse ssment, design, and intervention process. The sessions followed the protocols precis ely so that each parent created a comprehensive behavior support plan which was indiv idual to them and contextualized to their life and environment. The sessions began with a functional and ecological assessment that identified broad lifestyle goals for the child and the family, clearly defined behaviors of concern, baseline estimates of problematic behavior, and the collection and analysis of data to identify environmental events contributing to the b ehavior. Participants were taught to use indirect methods such as the Motivation Assessm ent Scale (Durand & Crimmins, 1986) and functional assessment interviews. They al so employed direct observation measures (e.g., scatter plot, frequency/duration me asures, ABC observations). The probable purposes (i.e., functions) and antecedent conditions associated with problem behaviors were determined using these tools. Based on data obtained, hypothesis statements which include a description of the behav ior, antecedent variables surrounding the behavior, and the consequences maintaining the behavior were developed to guide intervention design.
22 The intervention included strategies focused on 1) preventing problem behaviors (e.g., modifications to the physical and social env ironment), 2) managing consequences to maximize reinforcement for positive behavior rat her than problem behavior, and 3) developing skills to replace problem behavior (e.g. through the use of functional communication training) and function more effective ly in targeted contexts. Strategies were consolidated into a specific written plan, wit h action steps, deemed acceptable to the parent(s). The behavior plan (see Appendices F, G, H, and I) specified strategies developed for each individual child as well as a pl an for monitoring the outcomes of their intervention efforts and making changes to the plan if necessary. Participants share the behavior plan with the rest of their team to encour age consistent implementation. Although the same format was used for each particip ant the content of the behavior plan was individualized for each family. To see a more d etailed description of individual session content refer to Table 3.
23 Table 3. Description of the Objectives of Individua l Sessions Session Module Objectives 1 Introduction & Goal Setting 1. Understand PBS, including its key concepts and p rocess as illustrated in scenarios. 2. Determine who needs to be involved in the PBS pr ocess for their child and how to engage them. 3. Identify broad goals related to lifestyle change for their children and families. 4. Define their childrenÂ’s behaviors of concern obj ectively (in terms of what they say or do) 5. Establish a system for tracking (i.e., frequency duration) their childrenÂ’s behavior to establish a baseline. 2 Gathering Information 1. Understand the purpose and goals of understandin g behavior through functional (behavioral) assessment 2. Examine their current assumptions about what is influencing their childÂ’s behavior. 3. Learn how to gather information through watching their children talking to other people recording simple data (i.e., ABC charts) 3 Analysis & Plan Design 1. Be able to identify the events surrounding their childÂ’s behavior, including circumstances in which their childÂ’s behavior is mo st likely and least likely (antecedents and setting events) the results, outcomes, our functions of the behavio r 2. Summarize these patterns into a brief sentence o r paragraph (i.e., a hypothesis) to be used as a foundation for intervention planning. 3. Using the hypothesis, identify possible strategi es for preventing problems managing consequences replacing behavior 4 Preventing Problems 1. Understand the impact that circumstances precedi ng behavior (i.e., antecedents, setting events) may have on behavior. 2. Identify and prepare to implement strategies for preventing their childÂ’s problem behavior. 5 Managing Consequences 1. Understand the impact that consequences may have on behavior. 2. Identify and prepare to implement strategies for encouraging their childÂ’s positive behavior and responding to problem behavior. 6 Replacing Behavior 1. Understand the purpose and criteria for selectin g skills to replace problem behavior. 2. Identify specific skills that meet the functions of their childÂ’s problem behavior and allow them to deal better with circumstances. 3. Create step-by-step plans for teaching replaceme nt skills. 7 Putting the Plan in Place 1. Develop a written plan that includes all of the components (preventing problems, managing consequences, and replacing behavior). 2. Ensure that the strategies they select fit their child, family and circumstances and focus on lifestyle change. 3. Create an action plan for implementing the behav ior plan. 8 Monitoring Results & Wrap-Up 1. Develop a plan for monitoring the results of the behavior plan including both changes in behavior and lifestyle outcomes. 2. Understand the longitudinal, problem-solving nat ure of positive behavior support and discuss how adjustments may need to be made to the plan over time.
24 The sessions were presented in order and included a ll the content listed in the session summaries. At the beginning of each session the parent educators reviewed the previous session, asking participants if they had a ny questions regarding the content from the previous week. They then went over the weekly progress report used to track changes in behavior, interventions were implemented, and ad ditional homework the participant was to complete. If the participant had not complet ed all of the homework, the therapist assisted them in doing so and/or reassigned it for the following week. Throughout the review, parent educators provided feedback and guid ed the participants to modify assessment or intervention procedures as needed. Pa rent educators then outlined the goals of the session and presented the content, intersper sing examples from the protocol and/or their own experience. Timelines for each section we re identified on the protocol. Following each main section, the parent educators p rovided additional examples (as needed) and helped participants to apply the concep ts and procedures to their own children, families, and circumstances. Parent educ ators encouraged the participants to write down the ideas they generated (on homework fo rms) and documented the relevant information shared by the participants on the thera pist notes. At the end of each session, parent educators go ove r the homework instructions and forms, making sure participants were prepared t o complete the homework. Homework consisted of activities designed to help t he participant implement concepts and procedures relating to the content addressed in the session. Parent educators took the participant through specific steps to clarify assig nments (i.e., data collection and analysis, implementation). Participants were asked to apply t he concept they learned during
25 sessions at home (i.e., data collection, implement prevention, replacement behavior, and consequence management strategies) as well as conti nue to collect data and complete progress reports and report back the next week. Examples of individual participantÂ’s operationally defined behaviors, hypothesis statement, and strategies developed during sessions are presented in Table 4. See Appendices F, G, H, and I for completed behavior pl ans for all participants.
26 Table 4. Skills/Procedures Taught during Sessions f or Individual Participants Participant Problematic Behaviors Data Collection Hypothesis Statements Examples of I ntervention Strategies Bobby Tantrum Hurting himself Stripping Picking fuzz Frequency graph; ABC observation; MAS When Bobby is left to entertain himself for exten ded periods of time he will remove his clothes or pick at fuzz for comfort/amusement. In the afternoon when Bobby is hungry and tired, he grunts, screams, and hurts himself while his mother offers him various snacks. This occurs until his needs are met (e.g., dinner). When Bobby is prevented from going outside, he dr ops to the floor, kicks, and sometimes urinates which ensures he can go outside. When Bobby is guided to get in the car, he cries and resists, which delays the transition and having to leave home. Thi s escalates when he is rushed. Prevention: anticipate needs for food and rest (e.g., provide a full meal in the afternoon and a snack at dinner time) Teaching: request food when provided with picture choices Management: give him the items he requests from his choice menu quickly when possible and praise him for waiting patiently and accepting other options Lilly Not following directions Hurting self Throwing things Frequency count; scatter plot; behavior logs; MAS; interviews When Lilly is given an instruction to transition/ change/end an activity she will not follow directions and sometim es escalates into her throwing things, as a result Lilly gets to dela y or avoid the instruction and she will sometimes get attention fr om Mom in he form of physical guidance to change activities or c omplete the demand. When Lilly sees a preferred item or activity and is told she canÂ’t have it she will not following directions which som etimes escalates into her throwing things, as a result she will some times gain access to the item/activity or Mom will distract her with another preferred item or activity. Prevention: provide verbal cues, explaining what is coming next and preparing her for next steps of activity or expectation Teaching: use social stories to learn steps of new routines (e.g., getting ready for pool, going out to eat) Management: reduce the amount of attention she receives (e.g., eye contact, donÂ’t be in close proximity if possible and follow through with the demand if problem behavior occurs Cam Tantrum Head banging Behavior logs (ABCS); duration of tantrums; MAS When Cam sees or becomes aware of the availabilit y of an object (e.g., ball, cookie, video) he will scream, cry, fa ll to the floor, and kick his feet, as a result he sometimes gains acces s to the desired object. When Cam is instructed to end a preferred activit y he will cry, scream, fall to the floor, and kick his feet, as a result he will delay ending the activity or he will sometimes avoid endi ng the activity all together. When Cam is instructed to engage in a non-preferr ed self care skill (e.g., go to the potty) he will tantrum and will so metimes avoid having to engage in the self care skill. Prevention: provide specific verbal instruction of what he is suppose to do and the steps he is expected to complete when giving him a direction to engage in a non-preferred self care skill Teaching: say Â“noÂ” or Â“waitÂ” to a non-preferred self care skill -Management: allow him to delay non-preferred activities if he asks appropriately
27 Amanda Not following directions Snatching and grabbing items Property destruction Frequency count; Duration of morning and evening routines, Teacher Reports, MAS When Amanda is given an instruction or demand she does not follow directions, as a result she will delay or av oid the demand or transition. If Amanda is not engaged in an activity and her p arents are not interacting with her she will snatch or grab items and as a result she will get attention from her parents in the form of reprimands. When Amanda sees a preferred item and canÂ’t have it she will snatch and grab items and will sometimes gain acces s to the item. When Amanda is asked to transition from a preferr ed activity she will consume, destroy, break, or throw objects and as a result will delay the transition and receive attention from par ents in the form of reprimands or assurances. Prevention: provide a timer to let her know how long she has access to preferred item/activity, use as a countdown for when she will obtain time with parent (use during waiting times) Teaching: request attention in an appropriate way (i.e., using verbal or gestural cues) to indicate she wants to play or wants a hug Management: allow her to have one on one attention when she requests it and reduce Â“chatsÂ” she receives for problem behavior
28 Procedural Fidelity of Intervention Sessions All intervention sessions were videotaped and the f idelity of the sessions were scored. Procedural fidelity was scored to determine the extent to which the parent educators adhered to the training protocol during t he sessions. A yes/no checklist based on the objectives of each session (for an example s ee Appendix J) was scored while watching the videotaped session, making notes as ne eded to clarify the rating or to draw attention to particular strengths of the session or concerns that may need to be addressed. Fidelity was scored by dividing the number of items covered by the total number of items on the checklist. Mean level of therapist fidelity was 99% (Range = 93% to 100%) for KarenÂ’s intervention sessions, 100% for S andyÂ’s intervention sessions, 100% for MichelleÂ’s intervention sessions, and 100% for SusanÂ’s intervention sessions (only 3 of SusanÂ’s sessions were scored for fidelity due to tape malfunction). Inter-rater reliability was conducted on a minimum 3 out of 8 sessions. Inter-rater reliability was be scored by comparing the secondar y raterÂ’s checklist item by item with the primary raterÂ’s checklist. Reliability was be c alculated by dividing the number of items agreed upon by both raters by the total numbe r of items. Mean level of reliability across all sessions was 99% (Range=98%-100%) for Ka renÂ’s sessions reliability was 98% (Range=93%-100%), for SandyÂ’s sessions 100%, fo r MichelleÂ’s sessions was 100%, and for SusanÂ’s sessions 100%. Data Analysis The percentage of intervals with problematic and a daptive behavior were analyzed graphically and the visual analysis of the graphs was used to interpret data. The
29 structured criteria presented were adapted from the work of Hagopian and colleagues (1997). The data were analyzed to ensure there were no decreasing trends in baseline behavior and no increasing trends in data following treatment. General procedure. An upper criterion line (CL) and a lower CL for ad aptive and problematic behaviors were drawn approximately 1 SD above and b elow the mean of the baseline condition. Criterion for differentiation between ba seline and follow-up was based on the number of data points for each condition that fall beyond the CLs. Differentiation was said to occur if at least two data points fall belo w the lower CL for problematic behavior and above the upper CL for adaptive behavior. If t he lower CL is zero, each zero point will be counted as below the lower CL. Downward trends A downward trend was suggested by a 2 or more data point being below the mean level. Upward trends. An upward trend was suggested by 2 or more data poi nts being above the previous data point. The SIB-R was used to determine if there was a chan ge in the severity of the problematic behavior. A substantial change in sever ity was said to occur if there was a change of at least one category (e.g., 10 points) t owards a less severe category.
30 Results Child Behavior The participantsÂ’ childrenÂ’s behavior data at base line and follow-up are presented in Table 5. The data are presented as the average p ercentage of intervals in which problematic and adaptive behaviors occurred. Table 5. Average Percentage of Problematic and Adap tive Behaviors for Baseline and Follow-Up Problematic Adaptive Participant Baseline Follow-Up Baseline Follow-Up Bobby 76 5 10 45 Lilly 23 10 54 57 Cam 46 16 41 28 Amanda 45 18 43 73 Average (Group) 48 12 37 51 For Bobby problematic behavior decreased from basel ine to follow-up and adaptive behavior increased from baseline to follow -up. During baseline problematic behavior was 76% (only one video probe due to the s everity of problematic behavior) during baseline while adaptive behavior was 10%. Du ring follow-up problematic behavior was scored during 1%, 8%, and 6% (M=5%) of the intervals during 3 video probes and adaptive behavior was scored during 51%, 38%, and 46% (M=45%) of the intervals during the 3 video probes. Although crite ria outlined in the data analysis section cannot said to be met since there is only one data point in baseline there was an average
31 of 93.42% decrease in problematic behavior and an a verage of 350% increase in adaptive behavior from baseline to follow-up. For Lilly problematic behavior decreased from base line to follow-up while adaptive behavior remained stable throughout. Durin g 3 baseline probes problematic behavior was scored as occurring during 21%, 19%, a nd 28% (M=23%) of the intervals and adaptive behavior was scored as occurring on 46 %, 59%, and 56% (M=54%) of the intervals. At follow-up problematic behavior was sc ored as occurring during 0%, 20%, and 11% (M=10%) of the intervals and adaptive behav ior was scored as occurring during 63%, 52%, and 57% (M=57%) of the intervals. There w as an average of 56% decrease in problematic behavior and an average of 5.6% increas e in adaptive behavior from baseline to follow-up. For problematic behavior the standard deviation was 4.75 making the lower criterion line (CL) 18.25. For adaptive behavior th e standard deviation was 6.82 making the upper CL 60.82. According to the criteria descr ibed in the data analysis section problematic behavior shows differentiation between baseline and follow-up with 2 data points falling below the lower CL. However, adaptiv e behavior does not meet criteria to show differentiation. For Cam problematic behavior decreased while adapt ive behavior also decreased and was highly variable from baseline to follow-up. During 3 baseline probes problematic behavior occurred during 51%, 48%, and 40% (M=46%) of the intervals and adaptive behavior occurred during 48%, 36%, and 39% (M=41%) of the intervals. At follow-up problematic behavior occurred during 16%, 17%, and 14% (M=16%) of the intervals and adaptive behavior occurred during 25% 52%, and 6% (M=28%). There was
32 an average of 65% decrease in problematic behavior and an average of 31% decrease in adaptive behavior from baseline to follow-up. For p roblematic behavior the standard deviation was 5.7 making the lower CL 40.3 meaning problematic behavior meets criteria for showing differentiation between conditions with all 3 data points falling below the lower CL. For adaptive behavior the standard deviat ion was 6.24 making the upper CL 47.24 meaning adaptive behavior does not meet crite ria for showing differentiation. For Amanda both problematic and adaptive behaviors were highly variable during baseline. At follow-up problematic behavior decreas ed and became stable while adaptive behavior increased and became less variable. During 4 baseline probes problematic behavior occurred during 49%, 58%, 19%, and 52% (M= 45%) of the intervals and adaptive behavior occurred during 58%, 16%, 71%, an d 26% (M=43%) of the intervals. At follow-up problematic behavior occurred during 2 2%, 13%, and 20% (M=18%) of the intervals and adaptive behavior occurred during 79% 92%, and 77% (M=73%) of the intervals. There was an average decrease of 60% in problematic behavior and an average increase of 69.77% in adaptive behavior from baseli ne to follow-up. For problematic behavior the standard deviation was 17.4 making the lower CL 27.6. For adaptive behavior the standard deviation was 26 making the u pper CL 69. According to the criteria described in the data analysis section both problem atic and adaptive behaviors can be said to show differentiation between baseline and f ollow-up with all 3 problematic data points falling below the lower CL and 2 adaptive da ta points falling above the upper CL. Figure 1 shows results for all participantsÂ’. Overa ll, participantsÂ’ children displayed a greater percentage of problematic behav iors during baseline compared to
33 follow-up and 3 of the 4 participantsÂ’ children dis played a lesser percentage of adaptive behaviors during baseline as compared to follow-up. For problematic behaviors, the average percentage of intervals in which behavior o ccurred for all participantsÂ’ children was 47.5% at baseline and 12.25% at follow-up. For adaptive behaviors, the average percentage of intervals in which behavior occurred was 37% at baseline and 50.75% at follow-up. This led to an average decrease of 68.6% in problematic behavior and an average increase of 97.6% in adaptive behaviors fro m baseline to follow-up for all participants. Based on the criteria outlined in the data analysis section 1participant met criteria for differentiation between baseline and f ollow-up with both problematic and adaptive behaviors having at least 2 data points fo llowing below the lower CL and above the upper CL, respectively. Two families met criter ia for differentiation with only problematic behavior have the required 2 data point s following below the lower CL and 1 family could not be said to meet or not meet criter ia for differentiation due to having only 1 video probe during baseline.
34 Figure 1 Child data for baseline and follow-up. Gra phs indicate the percentage of intervals in which p roblematic and adaptive behaviors occur. 0% 20% 40% 60% 80% 1 2 3 4 Percentage of Intervals Baseline Follow Up Adaptive Problematic Bobby 0% 10% 20% 30% 40% 50% 60% 70% 1 2 3 4 5 6 Percentage of IntervalsBaseline Follow Up Adaptive Problematic Lilly 0% 10% 20% 30% 40% 50% 60% 1 2 3 4 5 6 Percentage of Intervals Adaptive Problematic Cam Baseline Follow-up 0% 20% 40% 60% 80% 100% 1234567Percentage of IntervalsVideo Probes Adaptive Problematic Amanda Baseline Follow Up
35 Scales of Independent Behavior Revised (SIB-R) SIB-R results for baseline and follow-up are shown in Table 6. Table 6. SIB-R Results for Baseline and Follow-Up Baseline Follow-Up Participant GMI Score Category GMI Score Category Bobby -43 Very Serious -25 Moderately Serious Lilly -40 Serious -17 Marginally Serious Cam -33 Serious -17 Marginally Serious Amanda -55 Very Serious -46 Very Serious Average (group) -42.75 Very Serious -26.25 Moderate ly Serious Figure 2 shows SIB-R results for Bobby as reported by Karen. During baseline Karen scored BobbyÂ’s behavior as very serious with a score of -43 on the GMI. At follow-up Karen scored BobbyÂ’s behavior as moderate ly serious with a score of -25. This improvement met criteria to be considered a differe ntiation between baseline and followup with problem behavior by improving by 18 points and 2 categories. These scores also correspond with the improvement of problematic beha vior shown in the data from the video probes.
36 Figure 2 SIB-R results for Bobby as reported by Kar en at baseline and follow-up. Figure 3 shows SIB-R results for Lilly as reported by Sandy. During baseline Sandy scored LillyÂ’s behavior as serious with a sco re of -40. At follow-up Sandy scored LillyÂ’s behavior as marginally serious with a score of -17. As with the previous participant this improvement meets criteria to be s aid to show differentiation between baseline and follow-up with problem behavior improv ing by 23 points and 2 categories. SandyÂ’s perception of LillyÂ’s problem behavior corr esponds with the decrease in problematic behavior shown in the data from the vid eo probes. nrn rn nrn nrn n
37 Figure 3 SIB-R results for Lilly as reported by San dy at baseline and follow-up. Figure 4 shows SIB-R results for Cam as reported by Michelle. During baseline Michelle scored CamÂ’s behavior as serious with a sc ore of -33. At follow-up she scored CamÂ’s behavior as marginally serious with a score o f -17. This improvement of 16 points and 2 categories meets criteria to be said to show differentiation between baseline and follow-up. Improvement in problematic behavior as i ndicated by the video probes corresponds with MichelleÂ’s perception of improveme nt in problematic behavior. nrn rn nrn nrn n
38 Figure 4 SIB-R results for Cam as reported by Miche lle at baseline and follow-up. Figure 5 shows SIB-R results for Amanda as reported by Susan. During baseline Susan scored AmandaÂ’s behavior as very serious with a score of -55. At follow-up Susan scored her behavior as very serious with a score of -46. With only a 9 point change and no change in the level of seriousness this particip ant failed to meet criteria to say there was a differentiation between baseline and follow-u p in change in the SIB-R score. However, video probes of child behavior do not corr espond with the perception of the participant with child behavior showing differentia tion between baseline and follow-up on the video probes. n nrn rn nrn nrn n
39 Figure 5 SIB-R results for Amanda as reported by Su san at baseline and follow-up. Overall, there was a general trend of participantÂ’s scoring their childÂ’s problematic behavior as making improvements from ba seline to follow-up. ParticipantsÂ’ SIB-R scores average -42.75 (very serious) during b aseline and an average score of 26.25 (moderately serious) at follow-up. Three part icipants met the criteria of a decrease of at least 10 points and at least one change in th e level of seriousness, all three scored their childÂ’s behavior as improving by 2 categories Also, these same participantsÂ’ SIB-R scores correspond with the changes in problematic b ehavior as evidenced by the data from the video probes. However, one participant fai led to meet criteria to say there was a substantial change in SIB-R score from baseline to follow-up by not move up a category in the level of seriousness. Of note, this particip antÂ’s score did not correspond with the changes in problematic behavior as indicated by the video probes, a 60% decrease in problematic behavior from baseline to follow-up. nr nrn rn nrn nrn n
40 Discussion The results of this study showed that after partic ipating in parent education using a standardized protocol, participantsÂ’ children dis played decreases in problematic behavior and increases in adaptive behavior in gene ral. All four participantsÂ’ children displayed decreases in problematic behavior that me t criteria for differentiation between baseline and follow-up following parental participa tion. For three of the participants, child adaptive behavior increased, however, not eno ugh to show differentiation between baseline and follow-up and for one participant chil d adaptive behavior actually decreased. The standardized measure of the SIB-R generally sh owed parental perception of a decrease in problematic behavior of their child tha t was consistent with the decreases in problematic behavior as evidenced by the video prob es. These changes in SIB-R scores support and extend the results of the videotaped pr obes because the SIB-R has the parent evaluate behavior in general and rather than perfor mance within a routine. One participant failed to make a substantial change in perception of child problematic behavior according to the SIB-R. Interestingly, thi s particular participantÂ’s score on the SIB-R was not consistent with the decrease in probl ematic behavior which was seen on the video probes. One explanation for this is this participant had the single lowest SIB-R score of all participants, -55 (very serious). Give n the severity of the problematic behavior at baseline it could have taken longer for the participant to see changes in problematic behavior. Also, even if the participant had scored the SIB-R is increasing by
41 10 points, the change still would not have met crit eria of a change in category of the level of seriousness (i.e., the index value for the very serious category is -41 and below). Verbal report from participants, given during sess ions 7 and 8 of intervention, provide a qualitative description of the impact par ticipation in this parent training study had on not only their childÂ’s behavior but greater lifestyle improvements as well. All participants reported progress towards achieving th eir broader goals they outlined during the first session of the intervention. They also re ported being able to go more places and do more things as an entire family (i.e., going out to eat, visiting family, participating in more activities, date nights for the parents) as a result of improvements in their childÂ’s behavior and their ability to prepare for and handl e new settings and routines. One participant in general reported several change s from baseline to follow-up that have improved her life and her childrenÂ’s live s greatly. Sandy reported some of her broad goals she identified had already been achieve d by the end of intervention. Her goals of more snuggle time with Lilly, the entire f amily being able to go to special events together, and providing new opportunities for Lilly (i.e., enrolling her in a dance class) had already been achieved. Also, she reported that LillyÂ’s sisters wanted to spend more time with Lilly and they were able to play together for longer periods of time. Sandy also reported that while she did not think that Lilly wa s ready to attend her older sisterÂ’s softball games, she did report that she felt confid ent that she could go home and use the process she had learned during intervention and ach ieve this goal and had plans to do so at the end of intervention.
42 The reasons adaptive behavior did not change to the extent of problematic behavior cannot be said for sure but there are many possible explanations. One possible reason is the targeted routines were associated wit h problem behavior and not necessarily skills deficits. Both engagement and interaction we re defined in such a way that if the routine specified by the parent required the child to sit quietly or the parent was not in the room with the child, he/she would have had little o pportunity to be scored as engaging in adaptive behavior. Another possibility that seems t o be most probable is adaptive behaviors may take longer to see improvements in be cause adaptive behaviors generally require skill development. Replacement skills and h ow to teach them arenÂ’t discussed until session 6 in the intervention sessions giving the parents only 3 to 4 weeks to work on skill development with their child. The developm ent of these skills could take longer and that could be why there is not a substantial ch ange in adaptive behavior from baseline to follow-up. In relation to other studies, results of this stud y support the literature which shows antecedent strategies (Duda et al., 2004; Dunlap et al., 1991; Kern & Clemens, 2007), the use of functional assessments to determine the func tion of behavior (Day et al., 1994; McNeill et al, 2002; Newcomer & Lewis, 2004; OÂ’Neil l et al., 1997), and function based interventions ( Day et al., 1994; Durand & Crimmins 1988; Iwata et al., 1994; Peterson et al., 2002; Scott & Eber, 2003) to be effective i n changing child behavior by integrating these concepts into the standardized protocol. Resu lts also support the concept of using parents as intervention agents and employing key st akeholders through the process (Hieneman & Dunlap, 2000; Hieneman & Dunlap, 2001, Symon, 2005) by providing
43 participants with knowledge of PBS and allowing the parents to apply and implement the skills/concepts at home on their own with distal su pport. In addition to supporting the current and past literature this study adds to the literature by using a multiple baseline design across participants and showing parent educa tion to produce consistent results across multiple people instead of across behaviors or settings in a single case. Also, this study looked at the use of a standardized protocol to parent education and was able to consistently teach the process with fidelity across participants. Each participant received the same skills and processes for producing behavio r change in their child and follow-up showed that each participantÂ’ children had consiste nt decreases in problematic behavior. In general, the use of a standardized protocol in parent education was a successful way of teaching parents and can be a factor in prod ucing behavior change in the participantsÂ’ children. The use of a multiple basel ine design across participants showed an individualized protocol to parent education was able to produce consistent outcomes across 4 participants. Consistent outcomes were ach ieved across all participants, all of whom had varying backgrounds (i.e., single-parent/t wo parents, educational background, financial resources, problem behaviors). For exampl e, Michelle and Cam were both from Puerto Rico and while Michelle was married, her hus band lived out of the country and she was caring for two children while trying to fin d a job. Cam was non-verbal and engaged in little interactive behavior with his mot her. Karen and Bobby on the other hand were Caucasian and both were born in the United Sta tes. Karen was also married but her husband was in the home and able to provide some su pport when he wasnÂ’t at work. She was also dealing with problem behavior from her dau ghter who also had been diagnosed
44 with autism. Since participants were so diverse and yet consistent outcomes were achieved for all the results can be said to have go od generalization across those who completed the intervention sessions. Despite the positive outcomes it is important to co nsider some of the limitations of the study. The first limitation is for the parti cipant Karen/Bobby only one video probe was obtained during baseline. With only one video p robe it canÂ’t be said whether or not the extent of the behavior was representative of ty pical levels of problematic behavior. However, according to participant self report this level of problem behavior was typical and due to the severity of the problem behavior it was unethical to carry out further video probes simply for the purposes of a baseline measur e. The second limitation is the variable baseline data for two of the participants. Baseline should have been carried out until problematic behavior was stable. However, for the purposes of this study it was determined that there was enough evidence of proble matic behavior to move to intervention. Future research could support and build on the out comes of this study by including a measure of parental implementation. By adding a measure of parental implementation it would be possible to determine if participant behavior changed during follow-up. Future research could look at parental i mplementation specifically and compare the skills and strategies that are develope d during intervention strategies with the skills and strategies that are used during vide o probes during baseline and follow-up. This is a necessary direction research should take in order to say with greater certainty that it is the intervention that was actually creat ing changes in problem behavior and not
45 another variable, for instance simply spending time with a professional outside of the home. Another component future research would want to tak e into consideration is maintenance of the outcomes. The larger study of wh ich this is a part of is currently using 1and 2-year follow-ups to assess maintenance. How ever, the current study gave followup measures no later than 2 weeks following partici pation in intervention because 1and 2-year follow-up data was not yet available and the refore has no data on the maintenance of the effects. The outcomes could be strengthened by showing effects to maintain over a longer period of time. Also, if follow-up were exte nded we would be able to better evaluate changes in adaptive behavior over time as skill development increased. An area of future research that would be interesting would be to look at more than baseline and follow-up measures. One option is to conduct video probes before, during, and after intervention sessions. This would provide data on h ow child behavior is changing after each session as well as making it possible to colle ct data on parental behavior and if they are implementing the specific skills and strategies learned during each session. In conclusion, this study showed that a standardize d parent training protocol could be used successfully to teach parents the skills th ey need in order to track behavior, create hypotheses and intervention strategies, and impleme nt these strategies at home in order to change their childÂ’s behavior. The use of a multipl e baseline design across participants provides strong results since consistent outcomes w ere achieved across all participants. These results are further strengthened by having th ose participants who completed intervention being so diverse. Participants were fr om varying cultures and backgrounds
46 and had differences in marital status, employment, number of children, economic status. Also participants were also dealing with varying be haviors and functions from their children. Further research needs to look at parenta l implementation and long-term effects on behavior so we can truly say the use of a standa rdized protocol can be successful.
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50 Kern, L., & Clemens, N. (2007). Antecedent strategi es to promote appropriate classroom behavior. Psychology in School 44, 65-75. Koegel, R. L., Bimbela, A., & Schreibman, L. (1996) Collateral effects of parent training on family interactions. Journal of Autism and Developmental Disorders 26, 347359. Koegel, L. K., Stiebel, D., & Koegel, R. L. (1998). Reducing aggression in children with autism toward infant or toddler siblings. The Journal of the Association for Persons with Severe Handicaps 23, 111-118. Lowe, K., Allen, D., Jones, E., Brophy, S., Moore, K., & James, W. (2007). Challenging behaviours: Prevalence and topographies. Journal of Intellectual Disability Research 51(8), 625-636. Lucyshyn, J., Albin, R., Horner, R., Mann, J. C., M ann, J. A., & Wadsworth, G. (2007). Family implementation of positive behavior support for child with autism: Longitudinal, single-case, experimental, and descri ptive replication and extension. Journal of Positive Behavior Interventions 9, 131-150. Lucyshyn, J., Dunlap, G., & Albin, R.W. (2002). Families and positive behavior support: Addressing problem behavior in family contexts Baltimore, MD: Paul H. Brookes. MacKenzie, E. P., Fite, P. J., & Bates, J. E. (2004 ). Predicting outcome in behavioral parent training: Expected and unexpected results. Child & Family Behavior Therapy 26, 37-53. McClannahan, L. E., Krantz, P. J., & McGee, G. G. ( 1982). Parents as therapists for autistic children: A model for effective parent tr aining. Analysis & Intervention in Developmental Disabilities 2, 223-252. McNeill, S., Watson, S.T., Henington, C., & Meeks, C. (2002). The effects of training parents in functional behavior assessment and prob lem identification, problem analysis, and intervention design. Behavior Modification 26, 499-515. Moes, P. (1995). Parent education and parenting str ess. In R. L. Koegel & L. K. Koegel, Teaching children with autism: Strategies for initi ating positive interactions and improving learning opportunities (pp. 79-93). Baltimore, MD: Paul H Brookes Publishing. Moes, D., & Frea, W. D. (2000). Using family contex t to inform intervention planning for the treatment of a child with autism. Journal of Positive Behavior Interventions 2, 40-46.
51 Newcomer, L., & Lewis, T. (2004). Functional behavi or assessment: An investigation of assessment reliability and effectiveness of functi on-based interventions. Journal of Emotional and Behavioral Disorders 12, 168-181. OÂ’Neill, R., Horner, R., Albin, R., Sprague, J., St orey, K., & Newton, J. (1997). Functional assessment and program development for p roblem behavior Brooks/Cole Publishing Company. Peterson, S.M., Derby, K.M., Berg, W.K., & Horner, R.H. (2002). Collaboration with families in the functional behavior assessment of and intervention for severe behavior problems. Education and Treatment of Children 25, 5-25. Risley, T. (1996). Get a life! Positive behavioral intervention for challenging behavior through life arrangement and life coaching. In L. K. Koegel, R. L. Koegel, & G. Dunlap, Positive behavioral support: Including people with difficult behavior in the community (pp. 425-437). Baltimore, MD: Paul H Brookes Publi shing. Ruef, M. B., & Turnbull, A. P. (2001). Stakeholder opinions on accessible informational products helpful in building positive, practical s olutions to behavioral challenges of individuals with mental retardation and/or auti sm. Education & Training in Mental Retardation & Developmental Disabilities 36, 441-456. Scott, T., & Eber, L. (2003). Functional assessment and wraparound as systematic school processes: Primary, secondary, and tertiary system s examples. Journal of Positive Behavior Interventions 5, 131-143. Serketich, W., & Dumas, J. (1996). The effectivenes s of behavioral parent training to modify antisocial behavior in children: A meta-ana lysis. Behavior Therapy 27, 171-186. Singer, H. S., Goldberg-Hamblin, S. E., Peckham-Har din, K. D., Barry, L., & Santarelli, G. E. (2002). Toward a synthesis of family support practices and positive behavior support. In J. Lucyshyn, G. Dunlap, & R. W. Albin, Families and positive behavior support: Addressing problem beha vior in family contexts (pp. 155-183). Baltimore, MD: Paul H. Brookes. Soodak, L. C., Erwin, E. J., Winston, P., Brotherso n, M. J., Turnbull, A. P., Hanson, M. J., et al. (2002). Implementing inclusive early ch ildhood education: A call for professional empowerment. Topics in Early Childhood Special Education 22, 91-102. Symon, J. (2005). Expanding interventions for child ren with autism: Parents as trainers. Journal of Positive Behavior Interventions 7, 159-173.
52 Vaughn, B., Dunlap, G., Fox, L., Clarke, S., & Bucy M. (1997). Parent-professional partnership in behavioral support: A case study of community-based intervention. The Journal of the Association for Persons with Sev ere Handicaps 22, 186-197. Vaughn, B., Wilson, D., & Dunlap, G. (2002). Family -centered interventions to resolve problem behaviors in a fast-food restaurant. Journal of Positive Behavior Interventions 4, 38-45.
54 Appendix A: Questionnaire on Resources and Stress ( QRS) This questionnaire deals with your feelings about a child in your family. Imagine that your childÂ’s name is filled in on each blank on the questionnaire. Please give your honest feelings and opinions. Answer all of the questions even if they do not seem to apply to your family. If it is difficult to decide true (T) or false (F), answer in terms of what you or your family feel or do most of the time. 1. __________ doesnÂ’t communicate with others of hi s/her age group. T F 2. Other members of the family have to do without things because of __________. T F 3. Our family agrees on important matters. T F 4. I worry about what will happen to __________ whe n I can no longer take care of him or her. T F 5. The constant demands for care of __________ limi t the growth and development of someone else in our family. T F 6. __________ will be limited in the kind of work h e/she can do to make a living. T F 7. I have accepted the fact that __________ might h ave to live out his or her life in some special setting (e.g., residential program, group home). T F 8. __________ can feed himself/herself. T F 9. I have given up things I have really wanted to d o in order to care for __________. T F 10. __________ is able to fit into the family socia l structure. T F 11. Sometimes I avoid taking __________ out in publ ic. T F 12. In the future, our familyÂ’s social life will su ffer because of increased responsibilities and financial stress. T F 13. It bothers me that __________ will always be th is way. T F 14. I feel tense whenever I take __________ out in public. T F
55 Appendix A: (Continued) 15. I can go visit with friends whenever I want. T F 16. Taking __________ on a vacation spoils the plea sure for the whole family. T F 17. __________ recognizes his/her own name. T F 18. The family does as many things together now as we ever did. T F 19. __________ is aware of where he/she lives.. T F 20. I get upset with the way my life is going. T F 21. Sometimes I feel very embarrassed because of __ ________. T F 22. __________ doesnÂ’t do as much as he/she should be able to do. T F 23. It is difficult to communicate with __________ because he/she has difficulty understanding what is being said to him/ her. T F 24. There are many places where we can enjoy oursel ves as a family when __________ comes along. T F 25. __________ is overprotected. T F 26. __________ is able to take part in games or spo rts. T F 27. __________ has too much time on his/her hands. T F 28. I am disappointed that __________ does not lead a normal life. T F 29. Time drags for __________, especially free time T F 30. __________ canÂ’t pay attention very long. T F 31. It is easy for me to relax. T F 32. I worry about what will be done with __________ when he/she gets older. T F 33. I get almost too tired to enjoy myself. T F 34. One of the things I appreciate about __________ is his/her confidence. T F
56 Appendix A: (Continued) 35. There is a lot of anger and resentment in our f amily. T F 36 __________ is able to go to the bathroom alone. T F 37. __________ cannot remember what he/she is doing from one moment to the next. T F 38. __________ can ride a tricycle. T F 39. It is easy to communicate with __________. T F 40 The constant demands to care for __________ limi t my growth and development. T F 41. __________ accepts himself/herself as a person. T F 42. I feel sad when I think of __________. T F 43. I often worry about what will happen to ______ ____ when I no longer can take care of him/her. T F 44. People canÂ’t understand what __________ tries t o say. T F 45 Caring for __________ puts a strain on me. T F 46. Members of our family get to do the same kinds of things other families do. T F 47. __________ will always be a problem to us. T F 48. __________ is able to express his/her feelings to others. T F 49. __________ is still in a diaper. T F 50. I rarely feel blue. T F 51. I am worried much of the time. T F 52. __________ can dress himself/herself without he lp. T F
57 Appendix B: Informed Consent Agreement Positive Family Intervention Consent Agreement The purpose of the Positive Family Intervention stu dy is to compare different approaches to parent education for families of chil dren with disabilities and challenging behavior. The study is being conducted as a collab orative effort involving the College of Arts and Sciences at the University of South Florid a, St. Petersburg and Center for Autism and Related Disabilities in Tampa, Florida/A lbany, New York. Participants in this study will be randomly assigned to one of two groups, however each group will receive a treatment proven to be very effective This study will require you to attend 8 sessions wi th trained therapists, and will focus on helping you deal with your childrenÂ’s beha vior problems. Each of the sessions will last a maximum of 1 hours and will be arrang ed to accommodate your schedule and that of the therapist conducting the training. With your permission, these sessions will be videotaped so that the integrity of the int ervention can be verified by the research staff at USF St. Petersburg. In addition to attending training sessions, you wil l be asked to complete certain assessments that will allow the researchers to eval uate the impact of the training on your childrenÂ’s behavior and how you are addressing them These assessments will include questionnaires on parenting and your childÂ’s behavi or and observations, and videotaping of your child at home. They will be conducted prio r to initiating the training sessions and following their completion. There are no known risks associated with participat ing in this study, and the possible benefits include improvements in your pare nting skills and childÂ’s behavior at home and school. Your privacy and the research rec ords will be kept confidential to the extent of the law. In accordance with USF policy, authorized research personnel, employees of the Department of Health and Human Ser vices, the USF Institutional Review Board and its staff, and other individuals, acting on behalf of USF may inspect the records from this research project. The confid entiality of your records will be maintained unless: 1) you express intent to harm yo urself or others or 2) you report that you have abused a child. If you have any questions about this research study contact Dr. Meme Hieneman or Dr. Mark Durand at USF St. Petersburg (727-553-4814). If you have questions about your rights as a person who is taking part in a research study, you may contact the Division of Research Compliance at the University of South Flor ida at 813-974-5638.
58 Appendix B: (Continued) If you wish to be considered for participation in t he Positive Family Intervention study, please read and sign the following statement: I understand that my participation in this study is voluntary and that I may change my mind at any time and withdraw my consent. My ag reement or lack of agreement to participate will in no way affect my ability to see k future services from the Center for Autism and Related Disabilities or USF. I understa nd that only the Center for Autism and Related Disabilities staff and research site at USF St. Petersburg will have access to any records kept during the study and that my name and my childÂ’s name will not be used in record keeping or dissemination. I understand t hat I can contact the Center for Autism and Related Disabilities for referrals to alternati ve services. I understand that participation in this study will require weekly attendance at individual meetings with Center therapists for 8 we eks. I agree to complete the required assessments prior to and following the training ses sions and understand that I may refuse to answer any or all of the questions. I provide c onsent for my child to be observed and data recorded on his or her behavior at previously scheduled times. I also provide my permission for my 8 sessions with the therapists to be videotaped. Signed _____________________________________ Date __________________ Signature of Subject Signed _____________________________________ Date __________________ Signature of Investigator
59 Appendix B: (Continued) Confirmation of Videotaping I agree to be videotaped as part of the research study on Positiv e Family Intervention. I understand that the researcher(s) in this study w ill videotape 1) my childÂ’s behavior in our home during difficult routines and 2) my sessio ns with the therapist. The reason for videotaping my child is to document the frequency a nd severity of his or her behaviors of concern and to provide a starting point for compari son during follow-up. The reasons for videotaping the sessions are to ensure that the the rapist adheres to the study protocol and observe our interactions (e.g., to evaluate my resp onsiveness to the sessions). Care will be taken to avoid videotaping other children and fa mily members not participating in the study. If such individuals are inadvertently taped either those tapes will not be used or consents will be obtained from those individuals pr ior to using the tapes. I have been informed that the videotape may be shown to other p rofessionals at research meetings. Signature of Subject Date Signature of Investigator Date
60 Appendix C: Example of Specific Child Behaviors DATE: 8/28/08 TIME: 5:30 pm PARTICIPANT: Tommy PRE POST SETTING: Dinner time DATA COLLECTOR: CHILD BEHAVIOR DEFINITION DESCRIPTION FROM VIDEO Aggression Striking or attempting to strike or injure another person with any part of their body or an object (e.g., hitting kicking, biting, pushing, throwing object at a person). Hitting and kicking directed at mom or dad Vocalization Crying or screaming involving high-pitched sounds which exceed normal conversational volume. Destruction Slamming, striking, or throwing with risk of damage to those items (i.e., versus tossing a ball during play). Throws plate of food and other dishes at the walls or on the floor Opposition Refusing to follow a direct request by saying or shaking head Â“no,Â” turning or pulling away from the adult, actively resisting physical guidance (e.g., dropping to the ground, running away, struggling to retain an item), or engaging in behavior again immediately after being told no. Falling to the ground, going limp with entire body, and saying Â“noÂ” repeatedly Self-Stimulation Repetitive movements or manipulation of items that serves no functional use (i.e. flapping, rocking, manipulating fingers, flipping items or opening and shutting door repetitively). Other Behaviors of concern specific to child. Engagement Participating in a physical activity through the manipulation of items or objects independently to complete a functional task (even if accompanied by problem behavior). Eating food from his plate with his fork or spoon. Interaction Initiating or responding to another person verbally (words, sounds) or non-verbally (gestures, movement, contact);
61 Appendix D: Sample Videotaping Protocol Videotaping Protocol Name of Child: Tanner ____ Name of Parent(s):_John and Sarah ___ Phone Number(s): __727-777-7777 _____________________________________ Address: _____771 South Street, Clearwater, FL 7777 7 __________________________ ___________________________________________________ _____________________ (Staple map/directions to this form, if available) Description of Routine: __transition from playing w ith play-doh to dinner ___________ Time of Day: _5:30pm ____ Location: ___living room to dinner table _______________ Sequence of Activities/Steps: 1) Tanner will have been playing with play-doh for 10 minutes before the project staff arrives 2) Five minutes after the project staff arrive Mom wil l ask Tanner to stop playing and come to dinner. 3) Once Tanner is seated at the table Mom will put her plate in front of her consisting of two favorable foods (i.e., meat, frui t) and one unfavorable food (i.e., vegetables). 4) Mom will sit next to Tanner and ask her to eat her entire meal (including her vegetables) 5) If Tanner gets up to leave the table Mom will get u p and bring her back to the table where she will continue to ask Tanner to eat her vegetables 6) The routine ends after 30 minutes, if Tanner become s too aggressive (starts to hurt her little sister), or Tanner eats her dinner inclu ding vegetables. Expectations for Child Behavior: 1) Tanner is expected to stop playing with play-doh wh en mom asks and come to the table for dinner. 2) She is expected to sit at the table with her butt i n the chair. 3) When mom puts her plate in front of her she is expe cted to eat the foods mom has put on her plate. 4) Tanner is expected to sit in her chair until she is finished eating her meal. Expectations for Parent Behavior: 1) Mom will ask Tanner to come to dinner a maximum of 3 times, if Tanner doesnÂ’t come to the table she will be walked over hand over hand by mom.
62 Appendix D: (Continued) 2) Once at the table mom will sit in the seat next to Tanner and try and prevent her from leaving the table when asked to eat her vegetables. 3) Mom will not let Tanner go back to playing or leave the table until she has eaten a specified amount (i.e., half of the amount on her p late) of vegetables Other Notes (e.g., camera set up): __The living roo m is right next to the dining room; the camera can be set up in the far corner of the dinin g room in order to see both rooms ____ ___________________________________________________ _____________________ \Video 1: __7/7/08 ________ Video 2: __7/9/08 _______ Video 3: __7/10/08 __________ (date, initial) Reminders: Call ahead prior to going to the family home to ensure the parent and childÂ’s availability and readiness for videotaping. Review the routine you will be videotaping on the phone. If the parent cancels, ask them for pos sible dates to reschedule. Have parent suggest where you should position yourself during v ideotaping and minimize interaction with the child and parent during the taping. After the videotaping, email Viviana to let her know that the taping has been completed (or if it was cancelled) and how it went. Return the camera and tape to the office within 48 hours.
63 Appendix E: Sample Data Collection Sheet DATE: ______________ TIME: _________ PARTICIPAN___ ________ PRE POST 1 2 SETTING/ACTIVITY: _________________________________ DATA COLLECTOR: ____________________ 1. AGG VOC DES OPP ENG INT SS 2. AGG VOC DES OPP ENG INT SS 3. AGG VOC DES OPP ENG INT SS 4. AGG VOC DES OPP ENG INT SS 5. AGG VOC DES OPP ENG INT SS 6. AGG VOC DES OPP ENG INT SS 7. AGG VOC DES OPP ENG INT SS 8. AGG VOC DES OPP ENG INT SS 9. AGG VOC DES OPP ENG INT SS 10 AGG VOC DES OPP ENG INT SS 11. AGG VOC DES OPP ENG INT SS 12. AGG VOC DES OPP ENG INT SS 13. AGG VOC DES OPP ENG INT SS 14. AGG VOC DES OPP ENG INT SS 15. AGG VOC DES OPP ENG INT SS 16. AGG VOC DES OPP ENG INT SS 17. AGG VOC DES OPP ENG INT SS 18. AGG VOC DES OPP ENG INT SS 19. AGG VOC DES OPP ENG INT SS 20. AGG VOC DES OPP ENG INT SS 21. AGG VOC DES OPP ENG INT SS 22. AGG VOC DES OPP ENG INT SS 23. AGG VOC DES OPP ENG INT SS 24. AGG VOC DES OPP ENG INT SS 25. AGG VOC DES OPP ENG INT SS 26. AGG VOC DES OPP ENG INT SS 27. AGG VOC DES OPP ENG INT SS 28. AGG VOC DES OPP ENG INT SS 29. AGG VOC DES OPP ENG INT SS 30. AGG VOC DES OPP ENG INT SS NOTES: ___________________________________________ ________________________________ ___________________________________________________ ________________________________ ___________________________________________________ ________________________________
64 Appendix F: Behavior Plan for Bobby (Karen) Behavior Support Plan ChildÂ’s Name: Bobby Team Members: Mom, Dad, Cecelia (little sister), G randma, Grandpa Larry, OT, PT, Speech, Teacher Goals Description of behavior: Tantrum crying, kicking, red face, guttural throat nois es, kicking others, scratching others, dropping to the floor; 3-30 minutes in length; 1-2 x daily Hurting himself Â– smacking hand over mouth, banging head Stripping Â– removing all clothing and walking aroun d naked Fuzz picking Â– removing all lint/fuzz from cloth it ems with his fingers Broad Goals: 1) Bobby will enjoy parties and outings in the communi ty (e.g., restaurants). 2) Bobby will go to Sunday school on his own. 3) Bobby will join his family for dinner. 4) Bobby will communicate appropriately. 5) Bobby will interact nicely with peers. 6) Bobby will follow daily routines. Summary Statements When this occurs .. my child does ... to get or avoid ... 1) When Bobby is left to entertain himself for exte nded periods of time he will remove his clothes or pick at fuzz for comfort/amusement. 2) In the afternoon when Bobby is hungry and tired, he grunts, screams, and hurts himself while his mother offers him various snacks. This occurs unti l his needs are met (e.g., dinner). 3) When Bobby is prevented from going outside, he d rops to the floor, kicks, and sometimes urinates Â– which ensures he can go outside. 4) When Bobby is guided to get in the car, he cries and resists, which delays the transition and having to leave home. This escalates when rushed.
65 Appendix F: (Continued) Strategies Prevention : provide an earlier dinner time simplify the menu respond to requests in a timely fashion update tech talk provide two or three choices of activities he can engage in during free time remove as many sources of fuzz as possible create a daily schedule of activities and warn him prior to transitions, explaining what is expected engage him in appropriate activities such as playing with toys/puzzles provide him with limited choices between clothing items when getting dressed and snack options anticipate needs for food and rest (i.e., provide a full meal in the afternoon and a snack at dinner time) allow him to take toys and snacks with him in the car Teaching : ask for appropriate activities in which he can take his clothes off (i.e., take a bath) engage himself in activities independently remove clothing only in his bedroom or bathroom remain at the dinner table and eat during meals request food when provided with picture choices play with hand held toys and puzzles use Tech Talk to communicate basic needs say or gesture Â“noÂ” and request delays use the potty and dress himself Management : When positive behavior occurs: allow him to take his clothes off if he requests an activity in which this is appropriate praise him for keeping clothes on at the appropriate time and place give him the items he requests from his choice menu quickly when possible an praise him for waiting patiently and accepting other options When problem behavior occurs: prompt him to go to his room or bathroom if he begins to remove his clothes redirect him to a more appropriate activity if he engages in fuzz picking with minimal attention or reaction guide him to complete tasks and transitions do not allow him to go outside following tantrums or urination away from the toilet remove him to a safe place if he engages in tantrum behavior that could be harmful to himself or others Action Plan What will be done? By Whom? By When? Provide Bobby with many options Mom & Dad Start t oday Update Tech Talk list Mom before start of school Create picture schedules Mom end of weekend Prepare snacks in advance Mom New puppet game Mom end of the week New toys/activities Â“SantaÂ” Extra help hired Mom as soon as one accepts How often will the plan be monitored? _X daily __ weekly __ monthly_ other How will implementation and outcomes be evaluated? Behavior logs including antecedents, behavior, and consequences
66 Appendix G: Behavior Plan for Lilly (Sandy) Behavior Support Plane ChildÂ’s Name: Lilly Team Members: Mom, Dad, sisters, Grandmother, staf f at new school Goals Description of behavior: Not following directions Â– not completing a request or instruction (to do something, stop or change activity), leaving area without permission, falling to the ground, not moving, folding arms and saying Â“noÂ” Hurting self Â– hitting head or part of face with a closed fist, hitting head on an object Throwing things Â– picking up items in her immediate area and throwing them either at a person or a wall Broad Goals: 1) Lilly will be out of pull-ups 2) Lilly will become more independent (i.e., gettin g dressed in the morning) 3) Lilly will improve and have consistent safety sk ills 4) Lilly and the family will be able to go out to s pecial events together 5) Lilly will make smooth transition to new class 6) Lilly will be provided new opportunities for cho ices with mom and sisters 7) Lilly will get more snuggle and hang out time wi th mom Summary Statements When this occurs ... my child does ... to get or avoid ... 1) When Lilly is given an instruction to transition /change/end an activity she will not follow directions escalates into her throwing things as a result Lilly gets to delay or avoid the instruction and she will sometimes get attention from Mom in th e form of physical guidance to change activities or complete the demand. 2) When Lilly sees a preferred item or activity and is told she canÂ’t have it she will not follow directions which sometimes escalates into her throw ing things as a result she will sometimes gain access to the item or activity or Mom will distract her with another preferred item or activity.
67 Appendix G: (Continued) Strategies Prevention : provide verbal cues, explaining what is coming next and preparing her for next steps of activity or expectation remind her how long an activity will last or when it will be over provide choice of activities or order in which to complete required demands/routines shorten length required for an activity if the routine is new to her hide preferred items/activities so she doesnÂ’t see them if she canÂ’t have them incorporate a fun activity (i.e., play Â“mommy monsterÂ” game) when getting ready to transition from a preferred activity to an non-preferred activity provide a lot of one-to-one unconditional play time with mom provide first/then statements to help with predictability and help her with transitions Teaching : use social stories to learn steps of new routines (i.e., getting ready for pool, going out to a restaurant) participate in transition activities (i.e., putting away beach ball and/or other pool toys) take turns with her sisters when playing with preferred toys request items/alternatives when she is told she canÂ’t have a preferred item/activity request a delay in a transition or end of activity Management: When positive behavior occurs: provide specific praise when she is behaving appropriately telling her exactly what she is doing that you like provide physical affection (hugs and kisses) when behaving appropriately verbally acknowledge a change or transition is hard (i.e., Â“you must be sad that we canÂ’t swim todayÂ”). Follow-up with hugs for accepting without problem behavior allow her to delay a transition when she asks appropriately When problem behavior occurs: verbally redirect her to what she should be doing follow through with demand, donÂ’t withdraw the demand if she continues to have problem behavior instruct and redirect her by using a normal, calm tone of voice. By raising voice, attention is inadvertently given to her reduce the amount of attention she receives (i.e., eye contact, donÂ’t be in close proximity if possible) if problem behavior appears when asked to complete demand, task, or transition Action Plan What will be done? By Whom? By When? Create social stories for routines Lilly a nd her sisters over the next weeke nd, as new routines come up How often will the plan be monitored? _X daily __ weekly __ monthly __ other How will implementation and outcomes be evaluated? Talk with teacher, family meetings, if problem beha vior reemerges begin keeping behavior logs
68 Appendix H: Behavior Plan for Cam (Michelle) Behavior Support Plan ChildÂ’s Name: Cam Team Members: Mom, dad, sister, grandma, grandpa, t eacher, speech therapist Goals Description of behavior Tantrum screaming, crying, falling to the floor, kicking feet; lasting 5-10 minutes Head banging Â– lying on bed and throwing his head i nto a pillow near a wall Broad Goals: 1) Cam will increase communication and interaction skills 2) Cam will be able to go out in public places (gro cery store, mall) 3) Cam will be quiet at times and control his sound s (no babbling, squeaks, high pitched scream) 4) Cam will be able to recognize dangerous situatio ns 5) Cam will increase daily living skills (tooth bru shing, bathing, dressing) Summary Statements When this occurs ... my child does ... to get or avoid ... 1) When Cam sees or becomes aware of availability o f an object (i.e., ball, cookie, video) he will scream, cry, fall to the floor, and kick his feet a s a result he sometimes gains access to the desired object. 2) When Cam is instructed to end a preferred activi ty he will cry, scream, fall to the floor, and kick his feet as a result he will delay ending the activ ity or he will sometimes avoid ending the activity all together. 3) When Cam is instructed to engage in a non-prefer red self care skill (i.e., go to the potty) he will tantrum and will sometimes avoid having to engage in the self care skill.
69 Appendix H: (Continued) Strategies Prevention : allow him to play longer, or remove demands when tired or sick give him a verbal countdown when ending a preferred activity (i.e., Â“Five minutes until we leave the parkÂ”) and let him know what he can get after he ends the activity without problem behavior provide specific verbal instruction of what he is suppose to do and the steps he is expected to complete when giving him a direction to engage in a non-preferred self care skill allow him help by walking and carrying his own toys when ending a preferred activity provide choice of food item or other fun activity when he cannot have access to a desired item/activity keep off limits toys out of sight and let him know what he can have Teaching: use pictures or PECS to communicate his needs and preferences express choice of items, activities, materials through the use of pictures walk quietly to the next activity when ending a preferred activity say Â“noÂ” or Â“waitÂ” to a non-preferred self care skill (i.e., potty) Management : When positive behavior occurs: allow him to earn preferred items after he engages in a non-preferred self care skill without problem behavior allow him to delay non-preferred activities if he asks appropriately give him alternative choices if he cannot have access to a request item/activity show physical affection only when he is displaying positive behavior provide specific praise by describing what he is doing appropriately When problem behavior occurs: withhold items/activities when he engages in problem behavior -withdraw extra attention use normal tone of voice (limit reaction to problem behavior) follow through with the demand or transition, donÂ’t let him delay or avoid Action Plan What will be done? By Whom? B y When? Daily schedule school staff, mom 2 weeks Visual pictures school staff, mom 2 weeks Fun passes for Sea World to use for a reward mom next week How often will the plan be monitored? daily _X weekly __ monthly __ other How will implementation and outcomes be evaluated? Daily talks with teachers (before and after school) journal of problem behaviors paying close attenti on to antecedents and setting events, family meetings to go over journal on the weekends
70 Appendix I: Behavior Plan for Amanda (Susan) Behavior Support Plan ChildÂ’s Name: Amanda Team Members: Mom. Dad, Grandma (maternal), Granny (paternal), Teachers, Babysitter Goals Description of behavior Not following directions Â– not responding, either v erbally or gesturally, to a demand or instruction, physically resistant (i.e., pulling away, dropping to the floor), not completing steps of daily routin es, may be followed by property destruction Snatching and grabbing items taking items with ha nds or using another object to retrieve an item from table, dresser, or wall Property destruction Â– consuming, destroying, break ing, or throwing objects taken without permission Broad Goals: 1) Amanda will increase her ability to be successfu l in completing routine steps appropriately and following directions. 2) Amanda will be able to complete routines without constant supervision (i.e., potty, morning and bedtime routines) 3) Amanda will increase her independence and have h er be safe without implementing extra safety precautions. 4) Amanda and the family will spend quality time to gether without concern for addressing challenging behavior. 5) Amanda will be able to participate in age approp riate activities. 6) The family will be able to have a Â“typicalÂ” livi ng room, home environment. Summary Statements When this occurs ... my child does ... to get or avoid ... 1) When Amanda is given an instruction or demand sh e not follow directions and as a result she will delay or avoid the demand or transition. 2) If Amanda is not engaged in an activity and her parents are not interacting with her she will snatc h or grab items and as a result she will get attentio n from her parents in the form of reprimands. 3) When Amanda sees a preferred item and canÂ’t have it she will snatch and grab items and will sometimes gain access to the item. 4) When Amanda is asked to transition from a prefer red activity to a non-preferred activity she will consume, destroy, break, or throw objects and as a result will delay the transition and receive attention from parents in the form of reprimands or assurances.
71 Appendix I: (Continued) Strategies Prevent Behavior : allow her participate and help in daily routines (example: putting silverware on table) stay in close proximity when she is engaging in a task that may be difficult for her provide predictability of expectations, visual cues when activities occur during the day, a way to char her appropriate behavior provide a timer to let her know how long she has access to preferred item or activity, use as a countdown for when she will obtain time with parent (use during waiting times) -give her warnings if parent will be leaving area, or will be busy with another activity provide preferred item if she has to wait without adult attention include Â“mommy timeÂ” routine in daily schedule, after she gets home from school Mom will incorporate 5 minutes of 1 to 1time. add breaks within activities that are non-preferred or difficult establish structured routine for going to bed, broken down into predictable steps Replacement Behaviors: taking turns when playing with other people request attention in an appropriate way (i.e., using verbal or gestural cues) to indicate she wants to play or wants a hug request a delay from a non-preferred activity or task wait for activity, attention or item after she requests it Manage Consequences : When positive behavior occurs: provide specific praise for appropriate behavior so she knows exactly what behaviors you like honor requests from her when possible give her a delay from a non-preferred activity if she requests it appropriately allow her to have one on one attention when she requests it provide physical affection when she is engaging in appropriate behaviors use stickers to reinforce appropriate behavior allow her to pick a toy from the treasure box after appropriate behaviors When problem behavior occurs: ignore problem behavior when possible so as not to reinforce redirect her with calm/neutral voice donÂ’t engage in verbal debates with her once she is already told Â“noÂ” reduce Â“chatsÂ” she receives for problem behavior donÂ’t provide physical affection when she is displaying problem behavior Action Plan What will be done? By Whom? By When? How often will the plan be monitored? daily _X weekly __ monthly __ other How will implementation and outcomes be evaluated?
72 Appendix J: Sample Procedural Fidelity Checklist Session 2: Gathering Information Therapist: _____________ Code: _________ Partic ipant(s): _____________________ Criterion Notes Yes No I. A. Reviewed and provided feedback on homework (i .e., definition of behavior, broad goals, initial data collection) and collected weekly progress report Yes No II. A. Provided a rationale for gathering informati on (i.e., determining what predictably occurs before and after behavior) Yes No II. B. Explained the purpose and content of the MAS Yes No Had participant(s) complete the MAS and provided fe edback on results Yes No III. Explained ways of gathering information about a childÂ’s behaviors of concern and provided examples Yes No A. Watching (observing behavior) Yes No B. Talking (interviewing other people) Yes No C. Recording (collecting data via tools such as the scatterplot and behavior log) Yes No D. Practiced recording information using a behavior log (using videotaped example) Yes No Helped participant(s) identify strategies for gathe ring information through watching (when, where), talking (to whom), and recording (how) Yes No IV. Provided instructions and reviewed forms for c ompleting homework (i.e., work with family and others to comp lete plan for gathering information, talk to others, watch and re cord behavior at least once per day) Session Date: _____________________________ Total Time: _______:________ (rounded to minute) RaterÂ’s Initials: ________ primary secondary
73 Appendix J: (Continued) Session 3: Analysis and Plan Design Therapist: _____________ Code: _________ Partic ipant(s): _____________________ Criterion Notes Yes No I. A. Reviewed and provided feedback on homework (i .e., information gathered, MAS, current hypotheses) and collected weekly progress report Yes No II. A. Explained the purpose of analyzing informati on to figure out the patterns affecting behavior (i.e., 4 Ws, outcom es/reactions, broader issues) and provided examples Yes No II. B. Practiced analyzing patterns using videotape d examples and/or interviews and observations (identified at least on e antecedent/one consequence) Yes No III. Explained and provided examples of hypothesis statements Yes No Guided participant to review the information they h ave collected and develop at least one hypothesis state ment Yes No IV. Described how summary statements provide the f oundation for intervention and shared examples; introduced 3 cate gories of intervention: preventing problems, replacing behavi ors, and managing consequences Yes No Practiced identifying intervention strategies to pr event problems, teach skills, and manage consequences bas ed on an example of a summary statement Yes No Helped participant brainstorm ideas for interventio n for their child based on one of the hypotheses they generated (at least one to prevent problems, teach skills, and manage conseque nces) Yes No V. Provided instructions and reviewed forms for co mpleting homework (i.e., work with family and others to deve lop summary statements and continue gathering data) Session Date: _____________________________ Total Time: _______:________ (rounded to minute) RaterÂ’s Initials: ________ primary secondary