Rage to Reason
Behavioral Intervention and Treatment for Explosive Behaviors in Children with Emotional Disorders Amy Buie, MEd, BCBA, LBA
[email protected]
Regulation
The ability to experience and maintain stress within one’s window of tolerance. Generally referred to as being calm, focused or relaxed. This term is utilized by literally every scientific discipline
Dysregulation
The experience of stress outside of one’s window of tolerance. Generally referred to as being stressed out, or in a state of distress. It is believed that affect dysregulation is a fundamental mechanism involved in all psychiatric disorders (Taylor, et. Al 1997)
Dysregulation
Dysregulation
Hyper-­‐arousal
Hypo-­‐arousal
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Unable to focus or sit still
Will not adhere to rules
Aggressive
Resistant to directives
Argumentative
Anxious before tests
Impulsive
Risk-­‐Taking Behavior
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Defiant
Withdrawn from peers
Tardy
Absent
Disassociates-­‐shuts down
Avoids tasks
Numbs out— “I don’t care”
Forgetful
Communication of Needs
• Communicating that he is in a state of stress
• Voicing his needs
• Unequipped to self regulate
• Unable to calm his own nervous system
Planned Ignoring
An extinction procedure for behavior maintained by positive reinforcement of attention.
No longer give attention to the behavior so that it is no longer reinforced and therefore extinguishes the behavior
What about using planned ignoring when a child is dysregulated?
When problem behavior occurs:
1. Determine the function of the behavior
2. Determine the reinforcement 3. Determine consequences
Immediately following a problem behavior we typically ask ourselves, “What should I do about this behavior?”
This leads to consequences
New questions
FIRST: “What can I do at this very moment to improve my relationship with this student?”
SECOND: “What do I want them to do instead?”
Heather Forbes
Beyond Consequences
Creating a Trauma Sensitive Classroom!
Create a sense of belonging
• Historically, humans lived in multi-­‐
generational and multi-­‐cultural settings
• We are biologically designed to be in a community
• We all need to belong and fell like we are important
• “You are one of us” verses “You are not one of us”
Create a sense of belonging
• Take time to talk and acknowledge each student. When the student walks into the classroom, convey the message, “Welcome. This class would not be the same without you here today!”
• Recognize that student’s moods and help to regulate instead of ignoring or criticizing the moods
• Listen to the student (you don’t have to agree)
• Smile at the student and stay in a warm place in your heart, no matter their attitude or disposition
• Take an interest in what’s important to each student
• Ask the students for help with things and share their ideas with others.
Perhaps it’s not attention seeking behavior but rather a cry that they NEED your attention.
They can’t do it without you.
Pro-­‐Active Strategies
1. Regulation
2. Academic Modifications
3. Prompting Most to Least
4. Empathy and problem solving
Regulation
Self Regulation is the ability to:
• Detect how you are feeling
• Match emotions to events
• Change level of behavior and emotion to match environment and cultural expectations
Brenda Smith Myles
Regulation
The Incredible 5 Point Scale
by Kari Dunn Buron and Mitzi Curtis
During a meltdown (level 5), children lose up to 30 IQ points in their ability to understand directions, process language and learn from consequences.
Ross Greene
Regulation
It’s important to know that you can not operate under the belief that he or she knows what or how to do something just because he or she has done it in the past.
“I know he knows it. He’s done it before”
Every opportunity to respond and their success is based on the level of dysregulation!
The Zones of Regulation
Leah Kuypers
Three ways to teach regulation
1. Sensory and Movement
2. Relaxation
3. Cognitive Behavior Strategies
Stress Management Station-­‐-­‐Sensory
Tension release activities
Stress/mad basket
Exercise
Running an errand
Working in ways that do not involve sitting in a chair
Stress Management Station-­‐-­‐
Relaxation
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Lazy 8 breathing
The six sides of breathing
Visualization
Music with head phones
Time in
Stress Management Station-­‐-­‐CBT
• Big Problem vs. Little problem
• Flex brain vs Rock brain
• Positive affirmations
– I am smart
– I am successful
– I am beautiful
– I am fun
– I am happy
Cognitive/Academic Strategies
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The Stopping Point Strategy
Visual Prediction
Warm up activities
Modified work (someone else to write, shortened assignments, etc.)
Checklists
Self monitoring
Voice Control Monitor
Organizational binder system
Have back up items
“Think Three” 1. Does he understand?
2. Is the reinforcement clear?
3. Have you incorporated choice?
One: Does he understand?
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Visual Prediction
Curriculum Adaptations
Most to Least Prompting
Behavior Momentum
Two: Is the Reinforcement Clear?
• Consequence Maps
• “As soon as…”
• “I am working for…”
www.behaviormappingmaker.com
Three: Have you incorporated choice?
• Do you want to do this one or this one? (Two different math papers or math and reading)
• Do you want to do it with the crayons or markers?
• Do you want to do it sitting here or there?
• Do you want me to do the first one or do you want to do the first one?
Research on Rage to Reason
• Dr. Wayne W. Fisher, Monroe Myer Institute
• Research shows that FCT is effective and preferred but is it practical?
• Using FCT and EXT with a signal
Beginning “Rage to Reason”
1. Stress Management Station
2. Functional Behavior Assessment
3. Reinforcement
Functional Behavior Assessment
Determine behaviors that are maintained by escape and avoid, specifically to following academic demands
R2R’s FBA Guide can get you started.
It does not constitute a full Functional Behavior Assessment
Functional Behavior Assessment Guide
• Does the behavior occur in response to requests to do academic work?
• Does the behavior occur in response to demands to follow directions (classroom routines)?
• Are there types of academic work that increase the likelihood of behavior like writing or reading out loud?
• Do these behaviors occur frequently during classroom instruction and less likely during free time or recess?
Student Directed Functional Behavior Assessment “We are meeting today to find ways to change school so you like it more. This interview will take about 30 minutes. I can help you best if you answer honestly. You will not be asked anything that might get you in trouble.”
R2R Phase 1: “Assessment and Reinforcement”
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Determine Reinforcement
Reduce all anxiety (no demands)
No work—play and build relationships
Create an A and a B list
Practice transitions
Reinforcement
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Preference assessment
Observation
Reinforcement Inventory
Ask the student
Create an A list of highly preferred activities and a B list of preferred activities
No academic demands
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Play
Build relationships
Reduce anxiety/dysregulation
Determine reinforcement
Practice Transitions
Practicing Transitions
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Set a timer of 20 minutes
Ask student to get to a stopping point
Student stops activity
Student can pick another activity. It can be the same one he just finished or a new one
If he does not end the activity
• After getting to a stopping point, physically assist student to stop activity
• Maintain safety
• When calm, the student can pick another activity however, the activity that they refused to terminate will NOT be an option until the next transition
Example
• Billy is on the computer for 20 minutes
• The timer goes off and Billy gets to a stopping point
• Billy turns off the computer
• Billy chooses the same activity or a new activity
Example
Billy is on the computer for 20 minutes
The timer goes off and Billy gets to a stopping point
Billy refuses to turns off the computer
The teacher turns off the computer for Billy
The teacher keeps Billy safe
Once Billy is calm he can choose a new activity. The computer is NOT a choice because he did not stop when asked (after the stopping point) the last time
• Billy chooses new activity
• After the new activity is over and Billy transitions, the computer is available again as a choice
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R2R Phase 2: “Functional Communication Training”
• Prepare a schedule such as math at 9:00 and social studies at 10:00, or use the current schedule
• Tell the child, “Let’s check your schedule”
• Use the green “ask and get” card and the FCT map
• Allow the student to say, “No thanks”
• Student chooses an activity from the A or B list
Phase 3 “Differential Reinforcement”
Introduce the A list and the B list
• Present a Green
• Choosing “no thanks” get the B list and doing the work gets the A list
R2R Phase 4: “Extinction”
• Continue to have student, “Check the Schedule”
• Introduce the red “Must and No” card along the with red Extinction map
• Tell the child that a red means he has to do it
Phase 4: “Extinction”
• Use most to least prompting
• Start with a very simple task like one addition problem
• Wait him out until he does the task
• Use an “As soon as” statement “As soon as you do your math, you can have freetime.”
• Ignore any behaviors (verbally) but block and redirect as needed
• As soon as he finishes the task, let him pick an A list activity
What if I wait him out and he does not comply? How long do I wait and what do I do?
If the child is young (third grade or below) or you believe you can successfully use physical guidance:
• After 15-­‐20 minutes say, “It’s time for math. This is a red. As soon as you do your math you can have free time. I’m setting a timer for 1 minute. When the timer goes off I will help you.”
• Set a timer and walk away
• After the time goes off say, “Ok a red means you have to do it so I am going to help you. 3-­‐2-­‐1” (Count with 2 seconds between each number) • Use physical assistance to complete the task
• Do an A list activity
Physical Guidance
This should absolutely take no more than 3 weeks. If you are still using physical guidance after this time, or you need to use it for longer than one minute, stop immediately and use the “Wait Out Procedure” If the Child is older (third grade and above) or can not tolerate physical assistance, or after 3 weeks of using the physical guidance procedure without success:
Use the “Wait Out” Procedure:
• Incorporate “Think Three” (Give a choice)
• Give direction and wait until he complies even if that means for a significant amount of time after school.
• Give water, snacks if needed and take a break for lunch
• Make arrangements to follow through for as long as it takes!
• If he tries to leave, block with the least amount of physical assistance.
• If he sleeps, have his stay at his desk if possible.
• Use the “As soon as” statement
• When he is finished, do an A list activity or let him go home and do an A list activity first thing when he walks in the door.
“Increasing Work”
• Increase the work on a red and give two choices (Think Three)
• May want to start a token system
• Use most the least prompting
• Do not increase the difficulty, just the amount (1 addition problem to 3 addition problems)
• Do an A list activity
Case Study -­‐ Sam
BASELINE
• Samuel is a 10 year old boy • Medical diagnosis of Autism Spectrum Disorder, Intellectual Impairment, Attention Deficit Hyperactive Disorder, and Oppositional Defiant Disorder • History of aggression, property destruction, refusal, and inappropriate language • In November hospitalization • Learning Momentum was contracted starting in January • 3.25 hours of school each day, in isolation, 1 teacher and 1 para
• 16.3 behaviors per day (one behavior every 11 minutes)
Phase 1
• No Demands • Build relationships • 2 behaviors occurred across 4 days(both inappropriate language) • Average .5 per day • Practicing transitions Challening Behaviors in Student throughout Rage to Reason Program 70
Baseline No Intervention
Phase 1
No Phase 2
FCT
Phase 3
Extinction
Phase 4 Increasing Work
Daily Total of Challenging Behaviors
60
50
40
30
20
10
0
16.3 per day
.5 per day
20.6 per day
5.8 per
day
1.3 per day
Phase 2
• Functional Communication Training • Present work as a choice and student can say….
• Average of 20.6 behaviors per day Challening Behaviors in Student throughout Rage to Reason Program 70
Baseline No Intervention
Phase 1
No Phase 2
FCT
Phase 3
Extinction
Phase 4 Increasing Work
Daily Total of Challenging Behaviors
60
50
40
30
20
10
0
16.3 per day
.5 per day
20.6 per day
5.8 per
day
1.3 per day
Phase 3 • Extinction • Add the “Red” tasks which are “have tos”
• Average of 5.8 behaviors per day Challening Behaviors in Student throughout Rage to Reason Program 70
Baseline No Intervention
Phase 1
No Phase 2
FCT
Phase 3
Extinction
Phase 4 Increasing Work
Daily Total of Challenging Behaviors
60
50
40
30
20
10
0
16.3 per day
.5 per day
20.6 per day
5.8 per
day
1.3 per day
Phase 4 • Increasing work • Add more Red tasks
• Average 1.3 behaviors per day Challening Behaviors in Student throughout Rage to Reason Program 70
Baseline No Intervention
Phase 1
No Phase 2
FCT
Phase 3
Extinction
Phase 4 Increasing Work
Daily Total of Challenging Behaviors
60
50
40
30
20
10
0
16.3 per day
.5 per day
20.6 per day
5.8 per
day
1.3 per day
Case Study -­‐ Bobby
BASELINE
• 10 year old boy
• Medical diagnoses of Bi-­‐Polar, Attention Deficient and Hyperactivity Disorder, and Obsessive Compulsive Disorder • Behaviors reported; threatening, aggression, property destruction, inappropriate language, cursing, and making unreasonable demands • Student was on homebound and previously hospitalized
Percentage of Day Spent Engaged in Behavior
100%
90%
Phase
1
Phase 2
FCT
Phase 3
Extinction
Phase 4
Increasing Work
80%
70%
60%
50%
Avg. 16%
Avg. 4%
Avg. 2%
40%
30%
20%
0%
1/5/2015*
1/7
1/9
1/13
1/16
1/26
2/3
2/9
2/11
2/19
2/23
2/25
2/27
3/3
3/5
3/9
3/11
3/13
3/17
3/19
3/23
3/25
3/27
3/31
4/2
4/8
4/10
4/14
4/16
4/20
4/22
4/24
4/28
4/30
5/4
5/6
5/8
5/12
5/14
5/18
5/20
5/22
5/27
10%
Phase 3 • Extinction • Add the “Red” tasks which are “have tos”
• Average 4% of day spent engaged in challenging behaviors • Introduced “Coping Skills”
Coping Skills
Coping Skills Percentage of Day Spent Engaged in Behavior
100%
90%
Phase
1
Phase 2
FCT
Phase 3
Extinction
Phase 4
Increasing Work
80%
70%
60%
50%
Avg. 16%
Avg. 4%
Avg. 2%
40%
30%
20%
0%
1/5/2015*
1/7
1/9
1/13
1/16
1/26
2/3
2/9
2/11
2/19
2/23
2/25
2/27
3/3
3/5
3/9
3/11
3/13
3/17
3/19
3/23
3/25
3/27
3/31
4/2
4/8
4/10
4/14
4/16
4/20
4/22
4/24
4/28
4/30
5/4
5/6
5/8
5/12
5/14
5/18
5/20
5/22
5/27
10%
Rage to Reason
www.learningmomentum.com
www.behaviormappingmaker.com
[email protected]
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