8/17/16 Building capacity to implement posiBve behavior ... · Building capacity to implement...

8/17/16

NevadaPBISTechnicalAssistanceCenterNVCenterforExcellenceinDisabiliBesUniversityofNevada,Reno

BuildingcapacitytoimplementposiBvebehaviorsupportwithlong-

termsustainabilityDonaldA.Jackson,Ph.D.ElaineC.Brown,Ph.D.

LARGE-SCALEIMPLEMENTATIONOFSCIENCE-BASED,INDIVIDUALIZEDPOSITIVEBEHAVIORALHEALTHSUPPORTS

Thefirst20yearsarethehardest

Outline

•  PosiBvebehavioralhealthsupports•  Research:whatweknowanddon’tknow•  PBSinNevada•  StatusofimplementaBon

Context–circa1966•  Vietnamwar(1955-1975)•  JFKassassinaBon(1963)•  LBJ&TheGreatSocietyprograms,“waronpoverty”

•  CivilRightsAct&theEconomicOpportunityAct(1964)

•  HeadStart•  VISTA•  1968:King&KennedyassassinaBons;democraBcconvenBoninChicago

KalamazooPsychiatricHospitalaka

WesternMichiganAsylumMichiganAsylumfortheInsane

KalamazooRegionalPsychiatricHospital(KRPH)

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“InthetenyearsthatbehaviormodificaBonhasexistedasanidenBfiablediscipline,workersintheareahaveproducedawidevarietyoftechniqueswhicharequiteeffecBvetomodifythebehaviorsofabnormalpopulaBons.TheireffecBvenessindevelopingtechniquestoproducBvelymodifythebehaviorsofprofessionalandadministraBvepersonsisnotasapparent.Perhapstherewillbeanimprovementinthisproblemduringthenexttenyears.Akerall,thefirsttwentyyearsarethehardest.”

-B.L.Hopkins,1970 14

MontroseWolf

ToddRisley

DonaldM.Baer

AppliedBehaviorAnalysis1960s

•  “BelerapplicaBons,itishoped,willleadtoabelerstateofsociety.”

•  Appliedresearch“isnotdeterminedbytheresearchproceduresusedbutbytheinterestwhichsocietyshowsintheproblemsbeingstudied.”

-Baer,Wolf&Risley,1968

“…ThemostimportantsourceofourcurrentdisappointmentisthefactthatourtechnologyhasbeensuccessfulinchangingthebehaviorsofthespecialpopulaBonsbutgovernmentserviceagentshavenotwidelyboughtorusedourtechnology.”

(COMMENTSONTHEFUTUREOFAPPLIEDBEHAVIORANALYSIS,B.L.HOPKINS,JABA,1987)

Earlylarge-scaleprograms

•  AchievementPlace– MontWolf,DeanFixsen,etal.

•  BehaviorAnalysisFollowThrough–  DonBushell,Jr.

BUT…

Ittook28yearstounderstandtheneedforthesite-basedexperBsemodel(fixsen,2016)

Thenatureofsystems“AllorganizaBons[andsystems]aredesigned,intenBonallyor

unwiqngly,toachievepreciselytheresultstheyget.”-R.SpencerDarling

“Thetyrannyofthestatusquo.”

-FritzOser•  Healthcare•  Prisons•  GreatSocietysocialiniBaBves•  NAEPdata–mediocremean•  Behavioralhealthcare–ACEStudy

8/17/16

CitedbyFixsen,2016 hlp://www.cdc.gov/violenceprevenBon/acestudy/ace_graphics.html

THEMISSIONANDVISIONOFPOSITIVEBEHAVIORSUPPORT/ABA

Areweontarget?

PosiBvebehavioralheathsupportsHistorical/FoundaBonalPerspecBve

•  BehaviormodificaBon/conBngencymanagement•  Appliedbehavioranalysis1970s-80s•  Disability/civilrightsmovementsmid/late80s•  PBSbeginnings:severedisabiliBes–“nonaversivebehaviormanagement”mid80s

•  PBSapproachwellestablished1990s•  Circa2000:ExpansiontomulB-Beredsystemsofsupport/prevenBonmodel

Science,Values&Visionv PosiBvebehaviorsupport(PBS)isagreatandworthyideapredicatedonthenoBonthatcreaBngalifeofqualityandpurpose,embeddedinandmadepossiblebyasupporBveenvironment,shouldbethefocusofoureffortsasprofessionals.”

v Carr,E.G.,(2007)TheexpandingvisionofPosiBveBehaviorSupport:ResearchperspecBvesonhappiness,helpfulness,hopefulness.JournalofPosi/veBehaviorInterven/ons,9,3-14,p.3.

8/17/16

StandardsofPracBce

•  ReducBonofproblembehaviorisanimportant,butnotthesole,outcomeofsuccessfulintervenBon:effec<vePBSresultsinimprovementsinqualityoflife,acquisi<onofvaluedskills,andaccesstovaluedac<vi<es.

hlp://apbs.org/files/apbs_standards_of_pracBce_2013_format.pdf

DefiniBonofPosiBveBehaviorSupport

•  Includesresearch-basedassessment,intervenBon,anddata-baseddecisionmaking

•  Buildingsocial&othercompetencies,creaBngsupporBvecontexts,&prevenBngproblembehaviors

•  Strategiesrespectul&drawnfrombehavioral&othersciences

•  AmulB-Beredframeworkatindividualorlargersystemslevel

Kincaidetal.,2016

TheprocessesofPBSThreeBersofimplementaBon

•  Individual:–  Individualized(intensive)behaviorsupportplan

•  Group/targeted:– Buildingcompetenceinspecificareas(e.g.,social)

•  System/universal:– Program-wideorschool-wide,providedforall

All/ersareneededforop/mumimplementa/on

ConBnuumofservices

IntensiveSupport

TargetedFollow-Up

UniversalTraining

QualityofLife

LinkalleffortstoQualityofLifeAgoodqualityoflifeexistswhenpeoplewithdisabiliBes:

•  Receivethesupport,encouragement,opportunityandresourcestoexploreanddefinehowtheywanttolivetheirlives;

•  Chooseandreceivetheservicesandsupportsthatwillhelpthemlivemeaningfullives;

•  Directtheservicesandsupportstheyreceive;•  Leadaliferichwithfriendships;•  Havetheirrights,dignityandprivacyprotected;•  Areallowedtotakerisksintheirchoices;and•  Areassuredofhealthandsafety.•  AdaptedfromAAIDDathlp://www.aamr.org/content_143.cfm

EXTENDINGTHEREACHOFPBSPBSandRelatedFieldsofStudy–HowRelevantandImportant?

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MissionandVision

•  “PosiBveBehaviorSupportisasetofprocessesthatcombineinforma<onfromsocial,behavioral,andbiomedicalscienceandappliesthisinformaBonattheindividualand/orsystemsleveltoreducebehavioralchallengesandimprovequalityoflife.”

–  apbs.org/about-apbs

“…seekcollaboraBvepossibiliBeswithourcolleaguesinmanydifferent

sciencessothatwecantranscendoursuperficialdifferencesandfocuson

deepercommonaliBes.”-Carr,2007,p.12)

"Thehistoryofscienceisrichintheexampleofthefruitulnessofbringingtwo

setsoftechniques,twosetsofideas,developedinseparatecontexts,forthepursuitofnewtruth,intotouchwithone

another.”--J.RobertOppenheimer

PBSandNeuroscience

•  BuildsynergybetweenABAandbiomedicalintervenBontoadvanceassessment&treatment,andpromotebroadchangesinqualityoflife(Carr&Herbert,2008)

•  Nowabletoassembleaclearpictureoftheneurologicalunderpinningsoffear&anxiety(Pilman,etal.,2015)

Fortunately,studiesinneuroplasBcityandgeneexpressionsuggesttheremaybeapotenBalforreversal

SotheneedforposiBvebehaviorsupportsand

nurturingenvironments,especiallyearlyinlife,isnot

justamalerofhappiness,butamalerofphysicalhealthandlongtermwell-being

ResearchonIndividualPBS

8/17/16

IndividualPBS•  LargebodyofresearchoncomponentsofPBS•  FuncBonalassessmentcanleadtosuccessfulintervenBons

•  Assessmentofseqngevents,contextualfit,etc.canbebeneficial

•  Person-centered-planning•  FuncBonalequivalenceandfuncBonalcommunicaBontraining

•  BuildingfuncBonalskills•  ManipulaBonofantecedentevents•  MulB-componentPBSintervenBons

Dunlap&Carr,2007;Dunlap,Jackson&Greenwald,inpress NevadaPBISTechnicalAssistanceCenterNVCenterforExcellenceinDisabiliBesUniversityofNevada,Reno

Preschool

Children

Adolescents

Adults

Au<sm/DD

BxDisorder

ProblemBx

AdultJus<ce

JuvJus<ce

1999-2003TOTAL2010-2014TOTAL

JPBIResearch–PopulaBonsPercentofArBcles

PosiBveBehaviorSupportandAppliedBehaviorAnalysis

•  ScaleupeffecBveinnovaBons&intervenBons

•  Improvehumanservicesystems

-Fixsen,2016

LargerscalePBS

•  Structuresforcapacitybuilding•  MTSS/School-widePBS•  ModelsofPBSImplementaBon

– PTR– PTR-YC

Researchonlarge-scalePBS

School

Correc<onal

Preschool

Residen<al

College

1999-2003TOTAL2010-2014TOTAL

JPBIResearch–SeqngsPercentofarBcles–early&mostrecentyears

8/17/16

Whatweneedtoknowmoreabout:Gapsinresearch&appliedstrategies

•  PopulaBons&venuessBlllimited•  Maintenance•  Wellbeingofcaregivers/familyfuncBoning•  Lifestylechange•  QualityoflifeconBnuestobeachallenge•  Scalingup–fewevaluaBonsoflarge-scalePBSimplementaBon

•  OrganizaBonalsystemsvariables

Dunlap&Carr,2007;Dunlap,Jackson&Greenwald,inpressNevadaPBISTechnicalAssistanceCenterNVCenterforExcellenceinDisabiliBesUniversityofNevada,Reno

IMPLEMENTATIONWhatwe’relearning

Scalingup

ImplementaBon

•  Evidenced-basedinnovaBons•  Evidence-basedimplementaBonofevidence-basedprograms

•  ScalingposiBveoutcomesinhumanservicesystems

•  Arewedeliveringtheservicesweintendedtodeliver?WithFIDELITY?

•  ThesystemdeterminesouroutcomesFixsen,2016

DegreesofImplementaBon

•  PaperimplementaBon•  ProcessimplementaBon•  PerformanceimplementaBon

Fixsenetal.,2005

“ImplementaBonoccursinthecontextofcommunity.”

“Thecommunitybothdefinestheproblemtobesolvedandteststheadequacyoftheanswer.”

-Felner,1997

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SchoolsusingPBISAugust,2015 21,278

00 01 02 03 04 05 06 07 08 09 10' 11' 12' 13' 14' 15' 16' 17' 18'

Horner,Sugai&colleagues

StructuresforBuildingCapacitytoImplementPBS

•  ImplemenBngwithfidelity•  Comprehensivestatewidetraining•  Raiseyoursites…•  TheNevadaexperience

BuildingPBSImplementaBonCapacityNevada’s20-yearexperience

>Geographically&poliBcallydiverse>7thlargeststate;80%rural>35thmostpopulous;88%liveinurbanareas>Highgrowthrate>Lowfundingforschools&disabilityservices,butalsonolargesystemofinsBtuBonalcare

TotalPopulaBon:2.7million

8/17/16

ThelargercontextinNevada

•  1980s-90s:Fullcommunityinclusion(Inclusiveclassrooms;grouphome“placements”)

•  Early1990s:Firstsupportedlivingarrangements(SLA)withindividualizedplan&budget

•  Somecapacity-buildingefforts&useofPBS•  ConBnueduseofaversiveintervenBons•  1999:LegislaturepassesAB280–aversivesstrictlylimited,traininginPBSrequired

•  ImpactoftheOlmsteaddecision(1999)•  AccreditaBonCouncil–seqng,teachingandevaluaBngstandards

GrowthofPBSinNevada•  1999:PBS-Nevadafounded•  NVacceptedintoResearch&RehabilitaBonTrainingCenter(RRTC)

•  Totalof26statesparBcipated•  RRTC–naBonalexpertspreparedstatewidePBStrainingteam&assistedinimplemenBnglocalcapacityinPBS–  Familymembers,schoolandIDDagencystafftrainedasateam

– Upto60hrstolearnPBS,createandimplementsupportplan

ExpertsupportforNevada

•  RobHorner*•  RickAlbin•  AnnTodd•  RachelFreeman•  HeatherGeorge•  GlenDunlap**•  KentMcIntosh•  JackieAnderson

Strategies&achievements•  ManypresentaBons/meeBngs,legislaBvehearings,stateadvisorycommileereportstobuildbuy-in&support

•  EndorsedbyNVCommissiononMH&DS•  IncludedaskeystrategyinGovernor’s10-yrplanforIDD(2002Olmsteadplan)

•  Statutoryauthorityforfunding(2002-present)•  Supportedbystakeholdersanddecisionmakers•  Numeroussourcesoffinancial/in-kindsupport

OtherPBS-NevadaprojectsandacBviBes

•  AssisBnginwriBngpolicy•  TrainingoflocallybasedstaffasPBStrainers•  School-widetraining•  OpenedregionalPBS-NevadaofficeswithBCBAs•  Developed3-Beredapproachtoservices(basedonintensityofneeds)

•  ParBcipaBon/collaboraBonwithnaBonalnetworkofresearchers&pracBBoners

•  Projectsinschools(SWPBS,Schoolmentalhealth),auBsm,juvenilejusBce,aging,courtmandatedparenttraining

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Nevada’sVision(1999)

v PeoplewithdisabiliBesparBcipatefullyintheircommuniBes

v Peoplechoosepersonalgoalsandservicesv Peopleliveintypicalfamilyorothernaturalsupportseqngs

v ServicesaredesignedusingbestpracBcesbasedonresearch

v Peoplearesafe,respectedandexercisefullrights

VisionforPBS/Behavioralhealthsupports(1999-present)

v Increasechoices,independence,andqualityoflifeofconsumersthroughtheapplicaBonofposiBvebehavioralsupports(PBS)acrossseqngs

v DevelopanetworkofindividualsthroughouttheStatethatcanprovideleadership,training,andconsulBngonPBSandrelatedtopics

v Buildthecapacityofindividualsprovidingdirectcare,treatment,oreducaBonforindividualswithdisabiliBestoprovidePBS

v Createadurablestateandregionalnetworktosupporttrainer/consultantsindeliveringPBSservices

CurrrentstatusofPBSinNevada•  RenamedtheNevadaPosi/veBehavioralInterven/onsandSupports(PBIS)TechnicalAssistanceCenter

•  100%grantfunded–stateandfederalfunds•  OperaBngbudgetofover$1million/year.•  Arrayoftrainingandtechnicalassistanceservicesinavarietyofseqngs,acrossmanystateagencies,andwithdiverseclientele.–  PBS-NVFamilyServices,PBS-NVAgingServices,juvenilejusBceandtheSchoolClimateTransformaBonProject.

•  Currentlyemploysatotalof12BoardCerBfiedBehaviorAnalysts(BCBAs)acrossthestate

•  EveryacBvity/projectofthecenterisfocusedonbuildingPBScapacity.

Figure1.3PBSServiceRegions–NortheastwithcoordinaBoninElko,NorthwestwithcoordinaBoninReno,andSouthernwithcoordinaBoninLasVegas.

$401,197

$568,451

$477,337

$361,690 $361,690 $361,690

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

FY08 FY09 FY10 FY11 FY12 FY13*

PBS-NVPeopleServed,TrainingsandBudgetDataFY08-FY13

Budget FI Trainings

LocalizedLeadership

RegionalizedLeadership

$401,197

$568,451

$477,337

$361,690 $361,690 $361,690

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

Budget FI Trainings

LocalizedLeadership

$401,197

$568,451

$477,337

$361,690 $361,690 $361,690

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

Budget FI Trainings

LocalizedLeadership

$401,197

$568,451

$477,337

$361,690 $361,690 $361,690

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

Budget FI Trainings

LocalizedLeadership

$401,197

$568,451

$477,337

$361,690 $361,690 $361,690

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

Budget FI Trainings

LocalizedLeadership

Figure2.Numberoffocusindividuals(FI)supported,numberoftrainingsheld,andoverallbudgetperyear,beforeandakerregionalizaBon.*FY13isaprojecBonbasedondatacollectedthroughquarter2.

8/17/16

Washoe

Humboldt

Pershing

Lander

Douglas

SchoolClimateTransformaBon

Project93schools,7schooldistricts

Tier1PracBces

•  Focusesonthe“smallestfuncBonalunits”requiredforgeneraBngoutcomes– Contextuallyandculturallyrelevant

•  E.g.definingandteachingexpectaBons

•  Matrix– EstablishessBmuluscontrol&discriminaBonbyteachingsocialskillsinthenaturalcontextandprovidingbehaviorexamples

Tier2/3PracBcesTier2:•  Designedforstudentsthatwouldbenefitfrom:– Moresalientandfrequentantecedentprompts

– AddiBonalstructure–  Increasedrateofreinforcement

–  Enhancedsupportinteachingappropriateskills

IntensityofServicesIncreaseasbehaviorsincreasein

frequency,intensityand/orco

mplexity

Horner&Sugai,2015

8/17/16

TwoTypesofEvaluaBon

1.   Evalua<ngImplementa<on–  ArewefollowingtheAcBonPlan?–  ArewemeeBngtheneedsofourstaff?

2.   Evalua<ngSW-PBSanditseffects–  Arewegeqngtheoutcomeswewant?–  ArewemeeBngtheneedsofourstudents?–  Arethereproblemareastoaddress?

76 NevadaPBISTechnicalAssistanceCenterNVCenterforExcellenceinDisabiliBesUniversityofNevada,Reno

SixKeyFeaturestoAchieveLarge-scaleApplicaBonofEvidence-basedPracBces

1.Focusoncomprehensiveoutcomesdefinedbythevaluesofthesocialsystem

2.Expandtheunitofanalysis3.Measureprocessaswellasoutcome4.MakeABAprinciplesmoreaccessible5.Focusonsustainedeffects6.Defineproceduresforscaling-upeffecBvepracBces.

Horner&Sugai

School-widePBIS

2.Expandtheunitofanalysis– Wholeschool

• Classroom– Groupsof�at-risk�students

» Individualstudentsneedingintensivesupport

Students=unitofimpactSchools=unitofintervenBon

Districts=unitofimplementaBon

School-widePBIS

4.MakeEvidence-basedPracBcesAccessible–  UsethelanguageoftheimplementaBoncontext–  Combinetechnologiesneededtoachievevaluedoutcomes.

•  ABA+Person-centeredplanning+OrganizaBonalSystems+Bio-Medical

–  Collaboratewithotherdisciplines•  MentalHealth,JuvenileJusBce,SchoolPsychology,Sociology

–  StudyimplementaBonaswellasapplicaBon•  FuncBon-basedintervenBon•  Contextualfit Bergstrom

Benazzi

Ingram

McIntosh

McKenna

Nevadapbis.org

ThepromiseofPBSArewemeeBngit?

•  “WeneedtodevelopamuchbroaderandricherdatabasesothatthepromiseofPBSasanapproachtoallhumanbehaviorchallengescanbemorefullymet.

•  Toaccomplishthisgoal,weneedtolink[our]behavioranalyBcandspecialedmethods…withconceptsstrategies,andproceduresderivedfromotherrelevantsciencesanddisciplines.” (Carr,2007,p.8)

8/17/16

Takehomepoints

•  PeopleweserveneedanddeserveaposiBvehomeandcommunityclimate(predictable,posiBve,safe,consistent

•  Climatechangehappensatasystemslevel•  MulB-BeredbehaviorframeworksallowformaximizaBonofresourcesinimpact

•  PBShappensacrossthecountryandeachstatehasavailableresourcesandsupport

20YearsLater…(SeguetoElaine’ssecBon)

•  Whatwelearned…•  Didwesustaincapacity-buildingstructures?•  Whatsurvivedfor20years...•  Whatdidnotsurvive...•  OrganizaBonalsystemsvariables

•  BarriersandopportuniBes...(Elaine)

Theproblem

ThankYou!

Namaste

DonJackson,Ph.D.donj@unr.edu

8/17/16 Building capacity to implement posiBve behavior ... · Building capacity to implement...

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