The purpose of this Story from the Field is to illustrate a real experience with Positive Behavior Support through a case study example.

Introduction

The following case study describes how comprehensive, positive behavior support was provided to Aaron and his family through the Individualized Support Project (Dunlap & Fox, 1996, 1999; Fox, Dunlap, & Philbrick, 1997). The Individualized Support Project (ISP) was a federally funded model demonstration program that used positive behavior support as the framework for providing comprehensive, family-centered early intervention to young children with autism and their families in natural environments. A complete description of the intervention approach and data on the effects of the behavior support efforts for Aaron and other participating children are available in Dunlap and Fox (1999).

A fundamental and unique element of the ISP model was the development and implementation of a behavior support plan in partnership with the family that was applicable to all problematic environments and routines. A key component of the model was the provision of family support. This component proved to be vital in assisting families in developing the skills necessary to understand their child's problem behavior and implement effective intervention strategies. Project staff worked with the family to ensure that everyone who supported the child with problem behavior was able to implement the behavior support plan effectively.

Aaron was 32 months old and diagnosed as having pervasive developmental disorder and moderate delays including significant deficiencies in social and communication skills. Aaron vocalized frequently, but did not verbally communicate with language.

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Background

He attended private community childcare two mornings a week and received speech and occupational therapy from private service providers. Aaron's caregivers reported intense tantrums throughout the day. His preschool teacher was very concerned about his problem behavior, difficulties with transition, and inability to interact with peers. The preschool staff was concerned about meeting Aaron's needs and wished to reevaluate his enrollment in their program.

When ISP project staff met Aaron and his family, his parents reported that they were experiencing increased frustration and anxiety propelled by Aaron's problem behavior. Aaron's parents were aware that they had responded to his problem behavior by dramatically altering their family activities and expectations of him. Daily routines such as mealtimes, dressing, and bedtime were difficult because of Aaron's noncompliance. His parents reported that he would not sit at a table to eat. Aaron refused to remain clothed and insisted on sleeping in his parent's bed at night. Aaron had very limited play skills and spent most of his time watching videos.

A person-centered planning meeting was held in Aaron's home to bring together his family, friends, and early intervention providers. The adults who attended Aaron's person-centered planning meeting expressed their concerns about his problem behavior and how they limited his inclusion into the community. In addition, they expressed their commitment to supporting Aaron and his family. The person-centered planning meeting resulted in a vision for Aaron that included the following: developing effective communication skills; spending time away from home with relatives and friends; increased play skills, friendships; independence in self-care; attending regular kindergarten; and less fear of the future by his family.

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Assessment and Intervention

A functional assessment of Aaron's problem behavior revealed that Aaron used tantrums to escape demand situations. When a developmentally and age appropriate demand was presented (e.g., play with this toy, come to the table), Aaron responded by crying, screaming, dropping to the floor, and banging his head. If the demand situation persisted, Aaron would seek adult comfort by clinging to the adult to escape the demand situation, or inhibit the adult from making additional demands. Aaron would become calm after removal of the demand. He also used tantrums to escape transitions. For example, when Aaron was prompted to leave an activity or setting, he responded by crying, screaming, and dropping to the floor. In response to the tantrum, Aaron was often comforted and the transition delayed.

Following the functional assessment, a comprehensive behavior support plan was developed for Aaron with his family. This plan was written in plain language and was designed to be used across all environments and activities. For Aaron, increased predictability was crucial. The assessment process revealed that Aaron could not understand what activity was coming next. A photo activity schedule was implemented to inform Aaron of the activities of the day and choices that he could make. Caregivers (i.e., parents, child care teachers, therapists) were instructed on ways to prepare Aaron for transitions using the picture schedule and safety signals (i.e. warnings that transitions were about to occur). In addition to having a predictable schedule, a uniform set of expectations and limits were set for Aaron by his daily care providers. Caregivers were taught strategies to facilitate Aaron's communication and social development within play sequences. Adaptive communication behaviors, that matched the communicative function of his problem behavior, were identified and included in skill instruction. Aaron was taught to use word approximations and natural gestures to signal “ no ”, ” help ”, ” up ” and “ want." There was also a focus on increasing Aaron's action schemes and play level through the use of naturalistic instruction (Fox & Hanline, 1993; Kaiser, Yoder, & Keetz, 1992). The entire team felt that ongoing communication was essential for consistency. Therefore, a notebook was developed to accompany Aaron to different settings (e.g., speech, preschool, occupational therapy). In addition, the interventionist coached all care providers in the strategies outlined in the behavior support plan and how to understand and intervene with problem behavior from a communication-based perspective.

Although Aaron was in a class with typically developing children, there were low levels of social interaction between him and the other children. Outside of school, Aaron would occasionally see his classmates, either at a birthday party or at the park. These visits were also accompanied by relatively low levels of social interaction between Aaron and his peers.

Intervention was focused on increasing Aaron's play and communication skills, with an emphasis on developing these skills within meaningful social contexts. Naturalistic teaching strategies were used to teach Aaron how to play with his peers. As other children made play initiations to Aaron, his responses were interpreted for the children without disabilities. In addition, Aaron's teacher and family were taught how to adapt activities so Aaron could participate.

During non-school days, Aaron and his mother began participating in a playgroup with some children from his classroom. This participation increased Aaron's mother's sense of connection and support, and gave Aaron and his peers the opportunity to strengthen their friendships.

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Outcomes and Plans for Future Support

Intervention support by the ISP project was provided to Aaron's family and caregivers that amounted to over 12 hours a week for six months. Intervention support occurred in all of the contexts where Aaron had difficulties and included time for family support. The initial days of behavior plan implementation were particularly difficult for the family. The family needed the support of the ISP interventionist as they began to learn new skills in preparing and responding to Aaron and increased their expectations of his participation in routines. After six months of focused intervention, Aaron's recurrent and intense problem behavior had completely diminished and there were notable gains in his communication development. He used sophisticated gestures and word approximations to indicate, "no" "want" "more" "yes" and "help" and became proficient at selecting choices of activities and objects. Aaron also began showing pride in his achievements by smiling and vocalizing, and then gazing at the adult for recognition. His play schemes increased from single actions to three and four action schemes within a play sequence. At school, Aaron joined the other children to play with them in a variety of play centers.

At home, Aaron began to follow age appropriate routines and expectations. Aaron's parents reported that they felt confident in understanding and resolving Aaron's problem behavior from a communication-based perspective. They learned new ways to support Aaron in play and routines and, as a result of their efforts, Aaron's engagement in social interactions and reciprocal play dramatically increased. Aaron's parents were able to develop consistent and predictable home routines and implement strategies from his behavior support plan that resulted in his sitting at the table for meals, sleeping in his own bed at night, remaining clothed, and participating in self care activities.

The ISP project was able available for technical assistance following the focused intervention effort. An exciting outcome of the intensive effort in providing family-centered intervention was that Aaron's parents were able to facilitate continued efforts in behavior support as he made the transition to public school.

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Summary and Lessons Learned

A major component of Aaron's comprehensive behavior support plan was to provide family support. Person-centered planning meetings that gathered family, friends, and care-givers helped set the tone that A we are all in this together. ” Aaron's parents felt very supported by the attendance of 15 people who cared about Aaron and wanted to be involved in the behavior support process.

The ISP project offered an opportunity to work side-by-side with the family in the development and implementation of the behavior support plan. This proved to be absolutely essential to family success. Aaron's family had been shaped by Aaron to not insist on transitions, to decrease demands, and to change their routines in accommodation to his problem behavior. It was critical that project staff were available to demonstrate for the family how to implement the behavior support plan and encourage the family to “ hold their ground ” when Aaron reacted to elements of the plan with an extinction burst. In addition, the project interventionist was able to assist with plan implementation across environments by offering coaching and modeling to all of his caregivers. The involvement of the project interventionist in all of Aaron's environments ensured procedural fidelity and Aaron's rapid response to the behavior support process.

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References

• Dunlap, G., & Fox, L. (1996). Early intervention and serious problem behaviors: A comprehensive approach. In L.K. Koegel, R.L. Koegel, & G. Dunlap (Eds.), Positive behavioral support: Including people with difficult behavior in the community (pp. 31-50). Baltimore: Paul H. Brookes Publishing.

• Dunlap, G. & Fox, L. (1999). A demonstration of behavioral support for young children with autism. Journal of Positive Behavior Interventions, 1, 77-87.

• Fox, L., Dunlap, G., & Philbrick, L. A. (1997). Providing individualized supports to young children with autism and their families. Journal of Early Intervention, 21, 1-14.

• Fox, L. & Hanline, M. F. (1993). A preliminary evaluation of learning within developmentally appropriate early childhood settings. Topics in Early Childhood Special Education, 13, 308-327.

• Kaiser, A. P., Yoder, P. J., & Keetz, A. (1992). Evaluating milieu teaching. In S. F. Warren & J. Reichle (Eds.), Causes and effects in communication and language intervention volume 1 (pp. 9-48). Baltimore: Paul H. Brookes

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Aaron's Behavior Support Plan

The problem

1. Aaron is likely to have tantrums (intense and sustained screaming, dropping to the floor, crying, and head banging) to escape demand activities (self care activity, playing with someone). If the demand situation persists, Aaron is likely to seek the comfort of an adult by clinging to the adult to get out of the demand activity or keep the adult from persisting. When this happens the adult takes the demand away and offers Aaron comfort.
2. Aaron is likely to have tantrums (intense and sustained screaming, dropping to the floor, crying, and head banging) to escape transitions. In response to the tantrum, Aaron is provided with comfort and the transition is delayed or dropped.

Long term support

1. Aaron will be provided with a more predictable activity schedule. A photo activity schedule will be used to inform Aaron of the activities of the day and the choices he can make.
2. Aaron ’ s care-givers will be taught strategies for supporting Aaron ’ s social and communication development within routine activities and play sequences. Aaron ’ s play partners will be taught how to use pacing and wait time to encourage Aaron ’ s engagement in social play.
3. Care-givers will be taught strategies they may use to assist Aaron in actively participating in the routines of the day.
4. Care-givers will establish a uniform set of expectations that will exist across environments.

Skills to teach throughout the day

1. Aaron will be taught to use a picture activity schedule to understand transitions and the schedule of the day.
2. Aaron will be taught to make choices using concrete objects and pictures.
3. Aaron will be taught to use a natural gesture (head shake) or say “ no ” to express a protest.
4. Aaron will be taught to take turns (i.e., simple turn-taking) within activities with an adult or peer.

To prevent the behaviors

1. Aaron will be prepared for transitions that are going to be difficult by the use of a safety signal and visual from the picture schedule by care-givers. Care-givers will tell him “ Aaron, pretty soon we will ____ ” and then the transition will follow within five minutes.
2. Aaron will be prepared for the actions of care-givers by stating the action before initiating. For example, stating “ Aaron, I ’ m going to help you put the toy away ” before assisting him in putting the toy on the shelf.
3. Care-givers will linguistically map for Aaron what is happening using simple language. For example, “ Mommy is leaving ” , “ Good Bye Mom ” and “ Time to Play ” .
4. If Aaron expresses a request that cannot be met, the care-giver will state “ Aaron wants___. I ’ m sorry, not a choice. You can have ___ or _____ ” while offering two possible choices.
5. When Aaron expresses no (verbally or through gesture), respect his "no" when possible. If he pulls you to a toy or cabinet, make an effort to let him communicate his request.
6. Care-givers will provide concrete choices of activities and objects throughout the day.
7. Care-givers will use simple language when interacting with Aaron or making requests. For example, “ Aaron, sit, chair ” , “ Sit in chair ” .
8. Care-givers will wait at least 4 seconds after making a request to allow Aaron wait-time to respond.
9. Care-givers will provide Aaron with frequent and specific praise for engagement and accomplishments (e.g., “ Aaron is sitting at the table! It ’ s nice to each lunch with you. ” )

When the behaviors happen

1. If Aaron has a tantrum, put a language label on what he is expressing before you do anything else. For example, “ Aaron is mad. No play ” . Then if you can ’ t change the situation, explain “ You can do it, take a turn. ” Assist Aaron with responding to the demand. Do not attend to the tantrum if it continues (after insisting that Aaron comply with one more action). Do not pick him up, walk away if necessary.
2. If Aaron has a tantrum because he does not want a toy or object that is offered, say to him A you are telling me no. ” Pause and then say “ Say no ” (while modeling a head shake). Pause for a response, but after 4 seconds remove the toy or object even if no attempt was made by Aaron to communicate conventionally.
3. If Aaron has a tantrum because he wants to escape a demand with a toy, say to him "You don ’ t want to ” , pause and say “ Let ’ s do it one more time ” (or if dressing “just put on one more sock ” ), do the action and then say “ Finished ___ ” and remove the toy.
4. If Aaron has a tantrum to escape a transition, state the action and where you are going paired with visual (if available) and then state "I'll help you" and physically assist if necessary. Do not attend to the tantrum by consoling, carrying him, or delaying the transition.

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