TRE-ADDTreatment, Research and Education for Autism and Developmental Disorders

An Interdisciplinary Treatment Program for Youth with ASD, ID, and Severe Behaviour Challenges: Key Components, Processes and Partnerships for Success

Gerry Bernicky, Program DirectorVikram Dua, Clinical DirectorNovember 8, 2018

Learning Objectives

• Review an effective service model for severe behaviour disorders in ASD and ID

• Consider the roles of key interdisciplinary members (e.g., ABA, psychiatry, and education)

• Appreciate the need for inter-sector and cross-agency collaboration in supporting complex children and youth

Outline

1. Surrey Place and CTCC/Section 23 programs2. TRE-ADD Assessment and Treatment Services3. TRE-ADD Clinical Pathways4. Challenges and Innovations5. Inter-sector Collaboration and Future Directions

Surrey Place

• Leading developmental disability service-provider in Toronto

• $65m annual budget (MCCSS, MOH, other)

• 7,000+ clients yearly• 450+ multidisciplinary staff

Care and/or Treatment, Custody and Correctional Programs (CTCC)

• Also referred to as “Section 23” programs• Ministry of Education is primary host, in collaboration with

other ministries (for TRE-ADD it is MCCSS)• Students demitted from community school and admitted to

CTCC due to primary need for care and treatment.• All CTCC supported by school board based teachers and

educational assistants (School Boards also frequently provide the physical space).

• Assessment/Treatment services supported by funding from different ministries (MCCSS in the case of TRE-ADD)

TRE-ADD CTCC Partners

TRE-ADD Clients

Day treatment program to targeted for school aged children/youth with: • ASD and Intellectual Disability and• severe complex challenging behaviours

• Most are not attending, modified hours, and/or at risk of being excluded.

• All clients have complex needs

TRE-ADD Clinical Programs

•3 Service Streams :• Intake and Community Support Services (with

Surrey Place and other agency partners)• School-Based Day Treatment (with School Board

partner)• Specialized Respite (with Community Living

Toronto partner)

TRE-ADD School-Based Day Treatment

• 6 classrooms based at partner public-schools (3 Boards)

• 4 elementary and 2 secondary classrooms• 4 students per classroom• 4.5 days/week• Length of admission from 6 months to 2 years

TRE-ADD and Partner Public Schools

G

TRE-ADD Partner: St. Theresa’s Shrine School

Surrey Place Interdisciplinary Team

• Clinical Director: Senior clinical oversight of interdisciplinary/assessment• 3 Clinical Supervisors: BCBA oversight of ABA assessment/treatment• Child and Adolescent Psychiatrist: Psychiatric/Developmental

assessment/treatment• 6 Supervising Therapists: Manager of classroom operations• Nurse, Social Worker, and Family Support Coach: Health, psychosocial and

resource needs, community links.• 24 Instructor Therapists/Behaviour Support Workers: Frontline directly

delivering ABA protocols with clients• Consultants: Dedicated psychologist, SLP, OT, and pediatrician.

TREATMENT TEAM

Education Partners

• 3 School Board Leads: Principals/VPs who assist with planning and MOU

• 6 Classroom Teachers: Oversee and deliver learning curriculum and treatment generalization.

• 6 Educational Assistants: Support teacher in educational goals.

Respite Partner – Community Living Toronto (CLT)

•Respite Coordinator: Service administrator•Behavioural Analyst: Assessment, treatment needs in respite home

•Respite Providers: Direct care staff

Pre Tre-add Tre-add Post Tre-add

• Student experiencing difficulty achieving success in an academic setting

• Primary need is behaviour challenges, lacking requisite skills, other

• Classroom model (teacher + supports; curriculum; classroom expectations)

Pre Tre-add Tre-add Post Tre-add

• Student returns to an academic setting likely similar to pre-admission.

• Some change to behaviour challenges, has additional requisite skills

• Classroom model (teacher + supports; curriculum, classroom expectations)

Pre Tre-add During Tre-add Post Tre-add

• Complete academic and clinical assessment.

• Develop a clinical treatment program to support primary need for the student and an individualized academic plan.

• Continuously monitor and adapt until student is experiencing some success **

• Shift from treatment to academic programming as student succeeds.

• Shift from 1:1 to dyad or small group.

TRE-ADD Program Phases

1.Intake and Eligibility screening2.Assessment (pre-admission and entry)3.Interdisciplinary School-Based Treatment and

Generalization.4.Transition and Discharge to less-intensive

placement.

Registration

Eligibility

TRE-ADD PathwaysIntake

School Based Treatment

Up to 3 months in

next School

ICSS Family Supports Services

Parent Education Wellness Services

Pre SB In SB

Parent Respite (if deemed necessary)

D/C from SB

TRE-ADD Pathways

Manny @ Referral10 years old; ASD, ID

Behaviour: head hitting since 1 yr, head-banging by 3; in KG aggression, property destruction, eloping, and skin-gouging; ++ increase since 7

Learning and Skills: non-verbal, limited AAC; not toilet-trained; no pre-academicsPsychiatric: multiple medications attempted (SGA, alpha-agonists,

stimulants; current Rx aripiprazole and lisdexamfetamine with uncertain benefit

Health: morbid obesity (112 kg), metabolic syndrome,; started on metformin (GI) ; chronic eczema with skin picking – multiple open wounds; anaphylactic peanut allergy

Participation; partial attendance in segregated classroom with 2:1 support; negligible community exposure

Family Function; brother with Trisomy 21; parent physical injuries, family in crisisSupports and resources; attended 3 years of IBI then supported by outpatient/school ASD

services; child protection

1. Intake and Eligibility screening

Step 2

By 12

week

s or 1

6 wee

ks w.

Med

Eligib

ility

STEP 1

6 week

s

Initial Referral (Family, School, SP)

Info Gathering(Phone & F-F)

Review the intake process, interview/observation, complete forms, collateral info sources and consents

Recommend options, warm handoff

Family / Community Update

Screen

YES – Letter # 1

IDT Initial Review(Decision # 1)

Recommendations, warm handoffCS Observation IDT Review

(Decision #2)

1. YES - eligibleLetter # 6Wait List

School Based Service – Admission Criteria:1. ASD diagnosis from referral source; and 2. Intellectual disability and deficits in adaptive functioning (based on historical documentation and consistent with current presentation); and3. Challenging behaviour (aggression/SIB/property destruction/disruptive behaviour) resulting in restrictive participation/exclusion/ expulsion from school setting; and4. Age

Exclusions1. Co-morbid health issues (medical/psychiatric) are the primary contributor to CB2. More appropriate or less intensive treatment options have not been fully utilized e.g., less restrictive, appropriate alternatives such as ASD classroom, ASD or SLP consultation and implementation of recommended strategies

Steps 1. CS observation is the first step following IDT review of FSC Screen 2. Recommendations following CS observation: a) appears INELIGIBLEb) appears ELIGIBLEc) unclear at this time - requires further interdisciplinary discussion

Waitlist Services:including:-psychiatric treatment-CS consultation-Family Support-Social Work

YES /UNSURE

YESNO

Letter # 5

2. NO - Not eligibleLetter # 5

YES Wait list / Pre-Admission Path

Additional interdisciplinary assessment adn/or community consultation required

3. Unsure/more info needed

Manny’s Intake (< 3 months)Family Support Coach (FSC) Intake:• Parent/child meeting, observation, intake info and consents signed• Obtain background reports, confirm diagnoses; send school package with 1 week data log to

complete.FSC presents case to Interdisciplinary Team Meeting (IDT):• Diagnoses confirmed, data logs support severity, less intensive resources have been exhausted. Clinical Supervisor (CS) classroom behavioural observation:• Confirms profile amenable to TRE-ADD treatmentCS presents to IDT:• Manny deemed eligible and placed on waitlist (estimated 6-12 months)Waitlist Services:• May access TRE-ADD respite; SW begins family work to prevent breakdown; psychiatry takes over

medication management to reduce risks prior to admission

2. Assessment (minus 3 mos to plus 1 mos)

OAFSC

Community Support /Referral / School Liaison (Admin)

CS – Beh Treatment Lead ST- Classroom Lead SW – Family Intervention Nursing Psychiatry – Med Treatment Lead School Board

With

in 12

– 4 w

eeks

prio

r to s

tart

-Classroom Observation(s)-Prep first day-BL data system

Family Assessment1-2 interviews

• QRS• F COPES• PSI

Document Findings & Tr Recommendations

Medical/Psychiatric Assessment

1-2 interviews

Additional Paediatric Assessments / Medical Clearance as required

Document Findings & Tr. Recommendations

TBD

Pre-Admission Assessment:

Confirm admission with Home School &

Family

Resources/Referrals

-ISP / PPE-Transition Plan **ISP sent for ministry approval for <12 (PM)

Confirm / Initiate Pre-Admission Process

? Book medical appointments

1. Book ID Formulation Meeting w. School Board2. Book Family ID meeting(Tuesdays/1 Wed @ mos)

Future:-IEP development

-Educational Review at previous setting

(engage board leads in development of this area)

Set FA dateDesign and write

Manny’s Assessment (1)Clinical Supervisor and Supervising Therapist:

• complete FBA and 3 extended observations at community school = Safety Plan; • upon admission ABA assessments/Functional Analysis completed =

Behavioural Support Plan.Psychiatrist:

• completes mental health and developmental assessment to establish admission diagnoses; other that some tic-like features, to evidence of comorbidity such as ADHD and SGA’s used for reduction of irritability; goals established to conduct trial off stimulant, and then attempt to optimize SGA dosage.

Nurse:• in coordination with community professionals establish treatment goals of

weight reduction/diet management, skin care (and stopping metformin).

Manny’s Assessment (2)Social Worker:

• Meet with parents and identify marital and individual challenges warranting attention, develops plan to work with parents; begin discussions regarding long term placement needs.

Family Support Coach:• Work with other community providers to coordinate services.

Teacher:• Completes baseline educational assessments

Interdisciplinary team meets within 30 days of admission to create/provide written Formulation and Treatment Goals and projected length of admission to family and partners.

V

3. School-Based Treatment & Generalization

CS – Behaviour Treatment LeadNote: See ABA Service Sequence for

detail

IT – Implementation of Behaviour Tr.

PsychometricAssessments

PSYCHIATRY/NURSINGMedical treatment

SOCIAL W -Family Intervention

FSC - Community Support/Referral/

School Liaison

SLP/OTHER – Specialized Assessment and Treatment

ST-Classroom LeadNote: See ABA Service Sequence for

detailSchool Board Teacher

Wee

ks 4

+ to D

ischa

rgeW

EEKS

1 -

2W

EEKS

3 +

Data review of target behaviour & refine, preference assess., describe initial FA method(s)

Conduct initial FA within 3 weeks

Initiate assessments

Tools: IQ, Acad. Adat.Beh., Lang, skills, ASD

Report

Regular follow up with family re resource needs,

referrals

Script FA Consent if not done previously

Ongoing assessment and treatment evaluations

Daily/Weekly:• Behavioural assessment, treatment evaluation, treatment

and/or treatment generalization sessions (at least 80% of day)• Monitoring data/ progress• Skill Acquisition Programs (SAPs) - 3-5 skill acquisition

targets and written program (Week 4)• Ongoing staff training re assess, tr protocols, SAP• Consults with interprofessional team as needed, IDT• Team Meetings

Weekly CS-ST Supervision

Supervision Note

Document decisions

Treatment Reviews: School Based Conferences/reformulation – 4x yr per client

Transition D/C Pathway

Interventions as per treatment plan

Staff training of FA

Update tr goalsDocument on Portal

TRE-ADD report card (Jan/June)

? Discharge

Assessment of academic skills

IEP

Family meeting as needed with CS/ST

Intervention

Communication and ReportingInterdisciplinary Treatment Team meets:

• Initial formulation• Every 6 weeks at School-Based Conference• Within 48 hrs if serious occurrence

Family and Community Involvement:• Support from SW as needed• Sibling support groups by FSC• Integrated psychiatric/nursing care• Biannual Treatment Progress Review with school-based team

Reporting and Documentation:• Initial Interdisciplinary Formulation report and Treatment Plan• Treatment Progress Review• Transition/Discharge Report

Treatment EvaluationFrom assessment findings treatment approach is developed, implemented, and evaluated for effectiveness in a very controlled process•Treatment sessions throughout school day• Implemented by IT/BSW•Careful data-collection and analysis

Treatment GeneralizationFrom treatment evaluation an effective approach is determined • Clinical team support academic staff to incorporate

treatment into ongoing and increasing academic activities scheduled

• This treatment then in a measured process, is primarily implemented by teacher/EA, in expanding learning activities and environments.

Manny in Treatment (1)ABA: • CS developed treatment plan delivered by IT/BSW) under direction of ST. • Initial target behaviours are skin-gouging and aggression.Education: • Teacher takes increasing learning time with client to generalize treatment

strategies across the day.Psychiatric:• Discontinue stimulant and metformin, add guanfacine, reduce dose of SGA. Health:• RN supported meal and activity plan, first implemented in classroom then

generalized to home; access effective eczema treatment.

Manny in Treatment (2)Respite:• Behavioural treatment address to aversive response to toileting assessed across

settings; treatment developed and delivered at respite with parent involvement• Successfully after 3 broken toiletsConsultants: • Psychology; IQ reported in severe-profound range; SLP; AAC consultationSW• Parents make gains in marital therapy; father identified to have PTSD related to

son’s behaviour and seeks out individual treatment; parents reach conclusion that residential placement is needed.

FSC • Initiate residential application; and begin coordination of transition to community

services.

4. Transition and DischargeTRE-ADD discharge

decision & target date

TRE-ADD Notifies respective School Board

Leads **Pre-IPRC/SEPRC process within each Board

• IPRC Package (TRE-ADD Teacher)• Special needs consultant assigned (TDSB)• Identification & meeting with potential

receiving school (case conference/transition planning meeting) (PDSB, TDSB, TCDSB, YRDSB, as possible)

IPRC/SEPRC Placement Decision

TRE-ADD Transition Planning Case Conference: Family, TRE-ADD staff, teacher, & receiving school teacher

IEP Transition PlanTRE-ADD Transition Plan

Pre-visits, training (as appropriate), TRE-ADD documentation sharing with receiving school

• 1st day of school, TRE-ADD provides in classroom support for 1 week.

• Follow up consultation - up to 3 mos.

Discharge from TRE-ADD

Feb 2, 2018

Parent Decision

Sign off

NOAlternative

Type of classroom identified

Receiving school observation of TRE-

ADD Classroom/Student

YES

SchoolPlacement Identified

** See TRE-ADD Discharge Path Addendum for Board timelines

Discharge (Final 3-4 months)Treatment Time Academic Time

Manny’s Transition WorkTeacher: “IPRC” about 3-4 months prior to discharge to identify next school placement; informs goals for future IEP.CS and ST: Coordinate with receiving school for them to observe in TRE-ADD and initial training in treatment program. ST and IT/BSW: 1 week of direct training to receiving school staff.FSC and SW: Smooth handoff to community agencies. MD and RN: Ensure prompt medical follow-up Team: Disseminate discharge interdisciplinary treatment plan. Available for consultation up to 3 months post discharge

Manny @ DischargeBehaviour: No skin-gouging, other SIB at low intensity; aggression

uncommon and severity much lower; no eloping.Learning and Skills: Utilizing PECS, toilet-trained; more self-care, able to tolerate

20 min of desk-work without behaviourPsychiatric: Psychopharmacology treatment optimized with improved

risk profile; no additional medication trials suggestedHealth: 86kg on discharge (26 kg weight loss); working diet plan at

school and home; skin intact.Participation; Discharge to a less intensive CTCC classroom with

anticipated return to public school in 12 months; family now regularly has community outings

Family Function; Marital relationship more stable and risk of family breakdown averted

Supports and resources; Transition to outpatient behavioral and medical supports, long-term residential placement identified and pending.

Inter-Sector RelationshipsWith School BoardsWins:• Teachers as part of the interdisciplinary team• Board staff hiring, service planning• Investments by boards

Not quite wins YET:• Space for program (e.g., rooms, size of rooms)• Classroom needs/repairs• Discharge back to school system

G

Inter-Sector RelationshipsOther Government initiatives:• Special Needs Strategy; Coordinated Service Planning• Ontario Autism Program• Moving on Mental Health

Community Agencies • Other CTCC programs, residential homes• Community case managers; CAS• Planning tables

G

TRE-ADD Service Pressures

• Multiple high needs students in each classroom• Ministry of Ed wanting increased enrolments • Staffing resources• Staff injuries• Staff burnout• Service disruptions with staffing vacancies• Slow gains made by complex clients

External Expert Review (2016)External Program Review by Kennedy Krieger Institute, John Hopkins Hospital, Baltimore

• Internationally recognized experts • Lengthy experience delivering similar services to more complex

clients• KKI team

• Reviewed extensive documentation• 3 day on-site observation

• Classrooms and treatment• Interviews with staff, teachers, parents, ministry staff

• Provided written report with specific recommendations

KKI ReportExternal Review (2016) Kennedy Krieger Institute, Johns Hopkins University:

V

KKI Review Recommendations:

1. Realign positions to more clearly delignate clinical vs admin2. Enhance clinical focus, create Clinical Director position3. Reduce admin from key clinical position = clinical time4. Enhance CS consultation supports Expert Level “Virtual”

Behavioural Consultation with KKI5. Move from multi-disciplinary to full interdisciplinary model6. Program re-fresh (service pathways, documentation)

TREADD: Organizational Diagram

Clinical Director

ConsultantsPsychologyPediatrics

SLPOT

Clinical Supervisors

NursingSocial Work

FSCProgram Director

Program Manager

Supervising Therapists ITs /

BSWs

AdministrativeSupports

CLINICAL OPERATIONS

Challenge: Staff Injuries

• Injuries will occur• Level 2, first aid in classroom, no lost time• Level 3, seek medical input, lost time• Management and staff concerns, union, WSIB, Ministry of

Labour• Target methods to reduce these

Innovations:

Workplace injuries in the classroom

Cause and Effect Diagram (Fishbone)Contributors to staff injuries in TRE-ADD Classrooms

(Project Team & Staff)

March 14, 2017

Rapid Incident Review

•Tested “Rapid Incident Review” (RIR) process for staff injury incident review meetings for timely adjustment of treatment protocols, training, other

•Very enthusiastic internal project team of front line staff, managers, HR reps.

• Implemented and continue to evaluate RIR.

Injury reduction data

CL 0.3915

UCL

0.8340

LCL 0.00000.000

0.200

0.400

0.600

0.800

1.000

1.200

14_09 14_10 14_11 14_12 15_01 15_02 15_03 15_04 15_05 15_06 15_09 15_10 15_11 15_12 16_01 16_02 16_03 16_04 16_05 16_06 16_09 16_10 16_11 16_12 17_01 17_02 17_03 17_04 17_05 17_06 17_09 17_10 17_11 17_12 18_01 18_02 18_03

Tota

l L2

and

L3 in

jurie

s pe

r stu

dent

per

mon

th

Months

Total Injuries Sept 2014 through March 2018

2014/15 school yr 2015/16 school yr PPE Policy RIR

Challenge: Generalizing Gains to Community Settings• Not funded/resourced for home-based services• Transition back to school:

• Slow process to identify next placement (IPRC)• Boards have preferred transitions points that do not align

with clinical status• Limited time to support transitions out (exchange of

strategies, modeling in new classroom)

Innovation: CLT Parent Training Pilot• Collaborative pilot between TRE-ADD and CLT staff, October,

2018. • TRE-ADD provides CS, ST and IT support• CLT provides respite space and behavioural staff twice weekly

• The goal is to increase parent involvement in understanding the treatment early on, and developing their skills to implement at home.

• Aim to develop an integrated parent treatment arm for TRE-ADD.

Challenge: Optimizing Complex Psychopharmacology

Prescribing At Admission

N (%)

One-year follow-up

N (%)

Group 1

(Gr 1)

N= 19

Group 2

(Gr 2)

N= 16

p-value Group 1

(Gr 1)

N= 19

Group 2

(Gr 2)

N= 16

p- value

Polypharmacy 7 (36.8) 4 (25.0) 0.452 9 (47.4) 6 (37.5) 0.557

SGA 10 (52.6) 8 (50.0) 0.877 13 (68.4) 8 (50.0) 0.268

SSRIs 1 (5.3) 2 (12.5) 0.582 2 (10.5) 6 (37.5) 0.105

Alpha 2 blocks 3 (15.8) 1 (6.3) 0.608 6 (31.6) 1 (6.3) 0.096

ADHD medication treatment

6 (31.6) 2 (12.5) 0.244 8 (42.1) 2 (12.5) 0.071

The team-based psychiatric care for youth with ASD and severe maladaptive behaviors reduces non-specific use of SGA’s and polypharmacy and increases utilization of SSRI’s

ABA Treatment Research• Applying Stimulus Fading and Escape Extinction to Reduce Aggressive

Behaviours of an Adult Diagnosed with ASD in a Classroom Setting• The Predictive Validity of Open-ended Interviews to Inform Functional

Analysis Design• Reducing Aggression and Disruptive Behaviour in a School-Based Setting• Using a Comprehensive Treatment Package to Reduce Aggression in a

School-Based Treatment Setting• The Use of Response Interruption and DRA to Teach Functional

Communication and Decrease Self Injurious Behaviour in the Classroom

G

Program Evaluation

• Support from Surrey Place Research and Evaluation Unit• Service process measures in place• Developing database of pre-post measures• Parent feedback at multi-points during service, end of

service and follow-up, teacher feedback at d/c and follow-up• Staff feedback (what is working, systems, process)• Developing database on ABA outcomes across clients

The Future• Addressing staffing challenges• Extension of interdisciplinary processes• Coordination/collaboration with growing number

of service providers across regions (OAP, CSP)• Development of less-intensive treatment program

(“step-up or step-down”)