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| Supporting Adults with Extreme Behavior Challenges in Community Settings: Practical and Conceptual Issues |
| Saturday, May 23, 2009 |
| 1:00 PM–2:20 PM |
| North 131 A |
| Area: CSE/CBM; Domain: Service Delivery |
| Chair: Jeffrey C. Brittain (Pathways Community Mental Health) |
| CE Instructor: Jennifer Symon, Ph.D. |
| Abstract: Providing applied behavior analysis support to persons with extreme behavior challenges in typical community settings is perhaps the most complicated and difficult task facing many clinicians and agencies, particularly in the public sector. Extreme behaviors (e.g., behaviors resulting in injuries to staff/consumers) often exceed the capacity of staff, programs, and settings which effectively meet the needs of nearly all others served by an agency. The process of developing solutions is influenced by multiple and often sharply conflicting forces, including state/agency administrative regulations, behavior analyst practice standards, individual and parent/guardian decision making, practical limitations within some communities, and various resource limitations. Solutions developed by a large public mental health agency are reviewed, highlighting changes in agency policy/focus as well as attempts to develop specific new support systems. Several common approaches to community treatment are examined in detail, with particular attention to concerns that emerge in practice, but are not typically acknowledged in policy and treatment negotiations. Suggestions for reconciling conflicting needs, priorities, and decisions are discussed. |
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| When Difficulty Approaches Impossibility: Coping with Extreme Behavior Challenges in Typical Community Settings |
| DENISE CLARK (Pathways Community Mental Health) |
| Abstract: Persons engaging in extreme aggression, self-injury, and other behaviors posing safety risks strain treatment support systems capacities. Viewed from an applied behavior analysis perspective and addressed under ideal conditions, these behaviors can be difficult to treat. Immediate pressure builds around maintaining staff and consumer safety, a complicated clinical process that often requires providing increased staff training, additional clinical supports, and attempts to limit the use of emergency response options that have significant risks or detrimental effects (e.g., public safety, psychiatric hospitalization). Additional considerations present in the public mental health system and other typical contexts can create seemingly intractable situations. Administrative rules defining limitations and requirements on behavioral treatment can become seriously disconnected from clinical reality. High-level philosophical shifts, while laudable, may likewise over-reach current resources and may be contraindicated in extreme situations. Staffing, funding, community resources, and professional resources place practical limits on available support options. Guardian and individual decision making may further complicate this picture. Without careful guidance and thought, clinic decision making in these contexts can loose comprehensive focus and become seriously off course. |
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| Preparing Group Home Staff to Succeed with Individuals Who Display Extremely Challenging Behaviors |
| JEFFREY C. BRITTAIN (Pathways Community Mental Health) |
| Abstract: State level policy changes limiting the use of physical management procedures, along with a mandate to document Positive Behavioral Supports (PBS), brought to light the need for changes in direct care worker training (DCW). DCWs and home managers need advanced training in PBS if they are to succeed in treating individuals with extremely challenging behaviors. An established PBS curriculum was selected and additional specialized topics such as: improving teamwork, developing reinforcing relationships, handling negativity and clarifying the process of developing behavior programs are woven in to the training. Effectiveness of behavior program implementation, decreasing the need for physical crisis management procedures, staff injury and turnover are overall goals of PBS training. This customized DCW training is a key component of preparation for work in a specialized group home designed to treat individuals with extreme behavioral challenges. The scope and importance of this training presented numerous logistical challenges regarding roll out, data collection, evaluation of skills and standardization of delivery. Presentation of effectiveness data suggest strengths and areas in need of further development in the training. |
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| Re-Engineering and Improving Community Treatment Options for Persons with Challenging Behaviors |
| Ralph L. Olson (Pathways Community Mental Health), Jeffrey C. Brittain (Pathways Community Mental Health), DENISE CLARK (Pathways Community Mental Health) |
| Abstract: Public mental health agencies commonly provide behavioral and other supports in a variety of community settings to persons with behavioral challenges. De-institutionalization, person-centered planning, and self-determination concepts have driven demand for individualized housing, smaller group homes, and other customized living arrangements. Behavioral supports delivered in these settings often produce highly variable results based on several key factors. These include the behavioral and other clinical support needs of the individual, general community characteristics, staffing arrangements, the array of supports that can be realistically orchestrated, and financial/administrative constraints. A four-county public mental health agency’s history supporting persons in individualized and group home settings is reviewed in detail, highlighting problems and successes. Based on these experiences, new and better implementations of individualized and group home placements have been conceptualized. The process of creating new options is explored, with particular attention to features contributing to success. |
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| Beyond Politics and Rhetoric: Moving Toward a Pragmatic Appraisal and Approach to Community Support Options |
| RALPH L. OLSON (Pathways Community Mental Health), Jeffrey C. Brittain (Pathways Community Mental Health), Denise Clark (Pathways Community Mental Health) |
| Abstract: As suggested at the outset of this symposium, many factors must be considered in designing and providing community-based behavioral supports for persons with extreme behavior challenges. Unfortunately, this endeavor is often hampered by a critical lack of information about, or outright rejection of, basic behavior analysis principles and practice standards. Instead, the process of developing specific support options becomes dominated by administrative and ideological emphases, often which seem inherently in conflict. Several unintended consequences impacting persons served and those supporting them commonly emerge, including breakdowns in skill development efforts, safety concerns, staffing difficulties, and an inability to provide effective ongoing monitoring. In some cases, support options identified as universally desirable and appropriate become a focus or mandate, at the expense of carefully analyzing their implementation and potentially serious drawbacks when considered case-by-case. Suggestions for bringing more order and clarity to this entire process are presented, emphasizing the need for education regarding behavior analysis practice and a more careful and expansive examination of support options. |
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