Functional Outcomes

In context of any type of therapy, functional outcomes must be Measurable, Behavioral, Observable and Repeatable. For the purpose of our discussion I’ll define functional as: being able to complete a personally practical, purposeful task or behavior.

Just writing a good measurable behavioral objective is a difficult task for many therapists; however, good measurable behavioral objectives should never be your final goal. Outcomes should be functional, while it may take numerous steps to reach that goal, it should be the end you have in mind and even incrementally you should get there as soon as possible.

A very simple example of a functional outcome would be: "When Joey comes home from school he will make him self a peanut butter and jelly sandwich". This would be an example where Joey has basically mastered this skill and has a need for a snack on arrival home from school. Something better for an emerging skill would be: "When Joey arrives home from school, after removing his coat and back pack and within 10 minutes of entering the house, he will go to the kitchen and remove the bread from the bread basket, 4 out of 5 times for 5 consequtive weeks".

When you think about functional objectives, ask the question, what would a person, or a child in this family, typically do if there wasn’t a disability involved?

For example, a child who lives on a farm may typically have chores out on the farm. Perhaps for an older child this may mean something as simple as some kind of assistive accommodation. Some people might think, well this kid just doesn’t need to be going out around the animals, but today, there is a strong belief (and frankly for many, they have had this strong belief for a very long time) that kids and people in general need to be able to participate in life as fully as possible. This is really what functional outcomes are all about, not just on the farm but in the home and school and wherever a typical child might be found. For the same child on the farm at a younger age, perhaps the outcome would have the child in a little wagon, scooping food from a bucket into the feeder. This sort of outcome provides all kinds of therapeutic opportunities, communicating with mom or dad or an older sibling who are pulling the wagon, working on both fine and possibly gross motor therapeutic needs, building self-efficacy (see letter e.) and subsequently self-esteem and being a part of regular life.
Two things you need to remember about a functional objective. It will almost always be in the natural environment for the child, or adult, and it still must be measurable and behavioral.

For additional information on Natural Learning Environment Practices click here.

Functional Behavioral Assessments or What’s causing the short?

Many years ago, early in my marriage, my wife and I owned a Ford Escort. It was a good car for our very young family. After about a year, we started having electrical problems. We took it back to the shop over and over again. A number of different things were replaced but the problem kept recurring. One day, someone discovered that we kept a spare key in the ash tray. That key was causing the short. As soon as we stopped keeping the spare key in the ash tray, the problem stopped, no more shorts.
Sometimes behavior problems are really that simple, sometimes they are not; however, diagnostics, until you find the problem, are essential. The more experienced I become, the more I believe that good upfront and ongoing assessments, to include functional behavioral assessments are absolutely essential. It is better to spend the time and resources finding the problem and the right solution than to skip this step and spend thousands and tens of thousands of dollars address the wrong problem or using the wrong solution (which of course, is usually not a solution at all).  (A Functional Behavioral Assessment is also called a Functional Analysis of Behavior.)




Additional Resources:
Functional Behavior Assessment (FBA) and Behavior Intervention Plans (BIP)
Functional Behavioral Assessment Generator
Example of a Functional Analysis Assessment Report
FUNCTIONAL ANALYSIS OF PROBLEM BEHAVIOR: A REVIEW
Teaching Children with Autism: Functional Behavior Analysis
Free tools for Functional Behavioral Assessments, as well as other therapy tools.
Functional Behavioral Assessment
multimodal functional behavioral assessment
Functional Behavioral Assessment
An IEP Team's Introduction To Functional Behavioral Assessment And Behavior Intervention Plans (2nd edition)
Functional Behavioral Assessments: What, Why, When, Where, and Who?
Functional Behavioral Assessment

What are some of the often overlooked independent variables? (sometimes referred to as Setting Events)

Medications
Medical or physical problems
Sleep cycles
Eating routines and diet
Daily schedule
Staffing patterns
Density of people (too many people present)
Stimulation (is the environment overly stimulating, this can change over time where initially it is not overly stimulating but becomes so as the person reaches and goes beyond capacity).

What are intervening variables ie motivation, fatigue, hunger, intelligence, expectations?


Additional resources and links:
Dependent and independent variables
http://msxml.excite.com/excite/ws/results/Web/independent%20variables/1/417/TopNavigation/Relevance/iq=true/zoom=off/_iceUrlFlag=7?_IceUrl=true

Intervening variable
http://en.wikipedia.org/wiki/Intervening_variable

Variable
http://en.wikipedia.org/wiki/Variable

Supplemental Material:
Setting Events
Setting Events Checklist

Manipulating (and understanding) Variables: Getting an idea of what might and what might not work.

Sometimes you have to poke around a little, turn over a few rocks. You have to test some hypothesis. Sometimes this may be a part of the functional behavioral analysis; sometimes it may be part of the ongoing assessment you are (or at least should always be) conducting. Taking everything at face value is usually not good enough. Is a hug always reinforcing? Just with certain people? Are there times when it is more reinforcing than another? Is it possible to reach the point of satiation?
Sometimes this is called in-situational hypothesis testing. Sometimes simply: hypothesis testing by manipulating the independent variables.
I remember many years ago as a mental health counselor working with a family of children who had been severely and ritualistically sexually abused. One of the older children who had become very sexualized was also working one on one with a tall gorgeous blond therapist in her late 20’s. The therapist once commented to me that every time the boy would get out of control, have bursts or anger, or become non-compliant she would hold him tightly (he was about 10) and he would almost immediately calm down. Upon hearing this I immediately thought of many variables including some possibly unintended consequences and reinforcing that might be going on. The important point though is that I did not know for sure. This was an opportunity to test a lot of different variables before adhering to a specific plan of intervention for any extended period of time.
Testing variables can be quite tricky. If you manipulate more than one variable at a time, how do you know which variable is influencing any change that may occur? Is it possible that the change is caused by a compounding of the two variables?
In the case mentioned above, there are a number of ways we could test some of the variables. First, collect detailed data about when and where behaviors occur and with whom. If there is an increase in certain behaviors in the presence of the therapist, then there is a possibility that the holding by the therapist is reinforcing and actually having the effect of increasing the behavior. Note, while this is a possibility, we still don’t know for sure. What are some of the other variables that could influence this behavior at this time? Sometimes children will display aggressive behaviors in the presence of the therapist or another outside authority figure because it’s safe. They understand at some level that while they may have a consequence, they are not going to get knocked around…at least at that time. It becomes a safe place to blow up. Sometimes victims of domestic violence display violent behavior against their perpetrator when the police show up. This can take place because they have so much emotion and anger built up that when the police show up, they realize there is safety and they explode. They may then get hauled away and charged, but in the immediate situation that too may be the lesser of two evils. The bottom line here is that you still don’t know the cause of the behavior.
Even after you develop a good working hypothesis; it is always a “working hypothesis.” This is why you continually take data and periodically adjust your plan as needed. So what else can we do to further assess the behavior (manipulate the variables)? Here are a few possibilities:
1. Teach the child that it’s ok to ask for a hug and that he can get one when he appropriately requests one. (Stop using holding as a consequence.)
2. Change to a male therapist.
3. Keep the same therapist but use a different consequence.
4. Teach and help the child to implement more appropriate ways to release frustrations and/or get his needs and appropriate wants met.

These are just a few possibilities.

Before you write a plan, it is critical to review existing data, gather data and try out your hypotheses to the extent possible. Once the plan is written, take the time to manipulate one variable at a time and find out what happens if???? Allow an appropriate amount of time to find out if a manipulated variable is actually helping or making the situation worse.

Additional resources:

Functional Assessment and Program Development for Problem Behavior: A Practical Handbook O'Neill, Horner et al &
Functional Behavioral Assessment, Diagnosis, and Treatment: A Complete System for Education and Mental Health Settings Cipani & Schock

Click here for additonal information on writing measurable behavioral objectives

When teaching calming or de-escalation skills.

When teaching calming activities and de-escalation skills, it is important to include a program to teach those skills when the child/individual is already relatively calm. Some activities to focus on are aerobic activities (within the safety range that the child/individual's physician will approve), such as walking, and big bubble blowing activities (I say big bubbles because big bubbles require slow deep breathing), deep breathing, and sometimes just taking a safe break away from things/people. When these things are taught as a part of the overall program it makes it easier to access these skills in an emerging crisis situation if needed.


Click here for additional information on writing measurable behavioral objectives

Getting what they want

One of the simplest but often overlooked concepts is helping an individual in therapy get what they want. Therapists have actually taught kids how to request a hug and then given them a “high five” or a “thumbs up” or another reinforcement other than a hug. Sometimes therapists try to teach a frustrated client who wants/needs something, how to identify their feelings or deescalate without actually dealing with what they want/need.
Your priorities should be, (after safety, because safety is always first):
1. Help clients identify what they want.
2. Help clients request what they want in a socially appropriate manner.
Once this is done, there are three options.
1. They get what they want. No need for further reinforcement.
2. They get what they want at a more appropriate time/place. In this case it may be helpful to teach de-escalation/coping techniques and/or feeling identification (may need some reinforcement). The appropriate time and place must be made clear as well as what they need to do (if anything further needs to be done) in order to get what they want. When the person finally gets what they want, there is no further need for reinforcement.
3. They do not and can not get what they want. In this case, there are two things to consider and do. Teach coping techniques (may need reinforcement) and discover underlying needs/wants and teach alternative ways to get underlying needs/wants met (no need for further reinforcement when they get their underlying needs/wants met).


Click here for more information on writing measurable behavioral objectives

When you have to decrease a behavior for safety reasons.

I believe and overwhelming research confirms that it is better to focus on increasing a behavior than decreasing one; but sometimes, there are behaviors that can not be totally ignored and must be addressed for safety reasons. (Please see What is an Asset? http://communitycollaboration.blogspot.com/2007/11/what-is-asset.html for additional information on assets vs deficits.) Sometimes you may want to do this, not because it is a particular focus, but because you want to gather valid and reliable data regarding the behavior.
Remember:
Conduct a functional assessment (see functional assessment under Writing a Plan for Problem Behaviors http://bestoutcomes.blogspot.com/2008/05/writing-plan-for-problem-behaviors.html ) to determine, as much as possible, and continually adjusting with additional information, what the functional purpose is of the problem behavior. Sometimes, a problem behavior becomes the most efficient way for a person to get their needs met.

Write a program/plan to provide an alternative and more appropriate way to achieve the same and underlying appropriate outcomes. If you look deep enough, there will be a basic and underlying reason for the behavior that can be fulfilled through another behavior.
Spend as much time as possible working on increasing positive behaviors. Ideally you should spend at least three times as much of the program time on increasing behaviors as on decreasing behaviors.

Click here for more information on writing measurable behavioral objectives

Additional Resources for Measurable Behavioral Objective writing

Benjamin Bloom's Taxonomy of Behavioral Objectives
Applying Bloom's Taxonomy
Learning Domains or Bloom's Taxonomy
Rubric: Guidelines for Evaluating Behavioral Objectives

Click here for more information on writing measurable behavioral objectives

CLASSIFICATION OF INTERVENTIONS FOR YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDER *

Excerpts from:
AUTISM SPECTRUM DISORDER WORKGROUP
CLASSIFICATION OF INTERVENTIONS FOR YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDER *
January 2007
Provided by Dr. Richard Solomon (P.L.A.Y. Project)

Early Intensive Behavioral Intervention (EIBI)
Comprehensive behavioral programming that aims to improve socially important behavior by using interventions that are based upon principles of learning theory (i.e., Applied Behavior Analysis) and that have been evaluated in experiments using reliable and objective measurement. EIBI methods are intended to increase behaviors (e.g. on-task behaviors, social interactions) teach new skills (e.g., life skills, communication skills, or social skills), maintain existing behaviors, generalize or transfer behavior across situations or responses, and to restrict or narrow conditions under which interfering behaviors occur and reduce interfering behaviors. (e.g., self injury or stereotypy). Individual curricula and teaching approaches may vary but commonly used approaches include the UCLA model (Discrete Trial Training, Applied Behavior Analysis) and Applied Verbal Behavior (VB).

http://www.behavior.org/autism/index.cfm?page=http%3A//
http://www.cofeat.org/data/201/documents/ParentsPacket2005January.pdf

Learning experiences: An Alternative Program for Preschoolers and Parents (LEAP)
LEAP was originally established as a federal demonstration program in 1982 at the University of Colorado School of Education. LEAP includes a Preschool component and a behavioral skill-training program for parents. The Preschool curriculum provides opportunities for learning related to social, emotional, language, adaptive behavior, cognitive, and physical development. The preschool setting includes typically developing children and peers with autism. This program has been shown to be effective for students with and without disabilities. The research suggests that this program produces improvements in social and language skills.

Pivotal Response Training (PRT)
PRT is a behavioral treatment intervention based on the principles of applied behavior analysis (ABA). Researchers have identified two pivotal behaviors that affect a wide range of behaviors in children with autism: motivation and responsivity to multiple cues. These behaviors are central to a wide area of functioning, so positive changes in these behaviors should have widespread effects on other behaviors. Thus PRT is able to increase the generalization of new skills while increasing the motivation of children to perform. PRT works to increase attempts and interspersing maintenance tasks. PRT has been used to target language skills, play skills and social behaviors in children with autism.
http://psy.ucsd.edu/autism/prttraining.html
http://www.dbpeds.org/articles/index.cfm

Positive Behavior Supports (PBS)
Positive behavior support (PBS) is the application of behavior analysis in the assessment and reengineering of environments so people with challenging behaviors: Experience reductions in their problem behaviors; learn how to replace inappropriate behaviors with acceptable appropriate behaviors; and increase social, personal, and professional qualities in their lives.

PBS emphasizes the development and implementation of individually tailored support plans that focus on proactive and educative approaches.

The PBS process involves engineering the environment to prevent problems from occurring; teaching individually acceptable alternative behaviors to replace problem behaviors; and consistently providing for positive consequences that encourage appropriate behavior outcomes over time.

Pyramid Approach: includes using Picture Exchange Communication System (PECS)
One of the methods used under an ABA approach, PECS uses pictures and other symbols to develop a functional communication system. PECS teaches students to exchange a picture of a desired item for the actual items (e.g., requisting). The application of ABA methods to teach PECS is an appropriate intervention for children with ASD who have limited or no communication skills. To increase the utility of this intervention, an important area for future research is to investigate PECS procedures for promoting initiation of communication and acquisition of complex, flexible language.

http://www.pecs.com/

Hanen Program/More Than Words
Integrates more traditional behavioral approaches with developmental, social-pragmatic approaches into a single program.
Does not replace the need for an intensive intervention program, rather it provides parents with practical tools for facilitating social and communication skills in their young child with ASD; parent training is considered an effective practice for early intervention.
Parents are extensively involved in their child’s intervention program, which can be more appropriate and effective, and less expensive than direct speech/language therapy for very young children.

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH)
The foundation of this structured teaching intervention is the modification of the environment to assist the child in the learning process. The focus of this intervention is on organizing the child’s physical environment to facilitate overall task success, capitalizing on visual strengths typically displayed by students with ASD and minimizing reliance on auditory processing/verbal expression. Visual schedules are used to describe sequence of activities, work systems are used to teach students to work independently and task organization provides information regarding how to perform task.

http://www.teacch.com/

Denver Model
Denver Model is a developmentally oriented approach for preschool age children. Focus of intervention is on intensive teaching and developing social-communicative skills. Provided in home setting, inclusive preschool programs & in one-to-one direct instruction. The skills to be targeted are determined by the family in collaboration with the intervention team.

Developmental, Individual difference, Relationship based (DIR) Including Floortime, Play Project & Responsive Teaching
Social Pragmatic Interventions (SPI). Focus on reciprocal, contingent interactions. Play-based, child led and structured by developmental level of child.
Well-structured parent training approaches. Manual includes extensive training materials.

P.L.A.Y. Project
http://www.playproject.org/

ECO/Communication Partners
Emphasizes importance of parent education and involvement – parent child interactions are viewed as the primary opportunity for teaching young children to talk.
Aims to prevent speech and language delays by treating infants and preverbal children to ensure healthy development of socialization and communication.
Focuses on social-pragmatic language skills rather than simply building the size of the child’s vocabulary.
Targets children who are considered to be at high risk for speech and language problems.

http://jamesdmacdonald.org/Articles/MacDonaldStart.html

Gentle Teaching
Gentle Teaching is a philosophical approach that addresses how caregivers interact with individuals with disabilities. This approach can be used with persons of all ages and with various disabilities. The focus of Gentle Teaching is to create a bond between the person with a disability and their caregiver as a means to promote positive changes. This method is opposed to the use of punishment and physical restraint.

http://www.gentleteaching.nl/

Music Therapy
Refers to the application of music with the intent to enhance functioning. It consists of using music therapeutically to address behavioral, social, psychological, communicative, physical, sensory-motor, and/or cognitive functioning. The music therapist involves clients in sensing, listening, moving, playing instruments, and creative activities in a systematic, prescribed manner to influence change in targeted responses or behaviors and help clients meet individual goals and objectives. Musical activities may also be highly preferred for an individual with autism (e.g., listening to music, dancing, playing an instrument). Access to such activities may be used as a reward; this is different from music therapy, in which the musical activities themselves are viewed as therapeutic.

http://www.musictherapy.org/
http://www.autism.org/music.html

Prompt
Seeks to understand sensory-motor systems and how these systems function in typical and delayed/disordered child development.
PROMPT therapists do not use oral-motor exercises, speech drills, or traditional speech development hierarchy.
PROMPT therapists do utilize tactile-kinesthetic information to improve motor control, and facilitate the development of functional cognitive, social, and communication skills.
PROMPT provides treatment individualized to each person’s specific needs.

http://www.promptinstitute.com/

Relationship Development Intervention
Relationship Development Intervention is an ongoing program of clinical development and research begun in 1996. The primary goal of RDI is to remediate the recognized core deficits of ASD. RDI provides individuals with ASD the cognitive, emotional, communicative and social tools that are geared towards remediation rather than compensation. Recognized deficits of individuals with ASD include emotional referencing, social co-regulation, experienced based communication, autobiographical or episodic memory, executive functioning and dynamic thinking. RDI is a family centered treatment program that prepares parents to act as ‘participant guides’, creating daily opportunities to remediate the developmental deficits of ASD. The provider undergoes an eighteen month internship in the program in order to become certified.

http://www.rdiconnect.com/

Sensory Integration (SI) Therapy
SI refers to how an individual’s nervous system, including the five senses of pain, vision, taste, smell and hearing, receives and organizes input from the body and the environment. SI therapy was developed based on the belief that some individuals with disabilities experience dysfunction in their nervous systems capacity to organize sensory input and, as a result, their responses to sensory input are non-adaptive. SI therapy seeks to restructure the way the nervous system responds to input so the child can better make sense of the world around them and, consequently, increase their adaptive responses. SI therapy programs are highly individualized. However, generally the therapy is focused on correcting deficits in the proprioceptive (muscles and joints), vestibular (gravity) or tactile (touch) sensory systems. Activities used to address these deficits include the use of weighted vests or blankets, swings, jumping on trampolines and deep brushing.

http://www.autism.org/temple/visual.html

Social Communication Emotional Regulation Transactional Supports (SCERTS)
Early identification and intervention that targets children who are developmentally from 8 months to 10 years of age. Multidisciplinary team collaboration, ongoing staff training, professional development, and administrative support. Adherence to all components of the SCERTS model with a sequential, logical procession from assessment to educational programming and less complex to more complex goals. Child-and family-centered approach with emphasis on family involvement and support. Transactional Supports should be implemented in a variety of settings (home, school, and community) to address Social Communication and Emotional Regulation objectives and promote generalization of learning within natural contexts. Promotes learning opportunities in inclusive settings. Promotes learning opportunities in inclusive setting. Supports low child to adult ration (2:1 for many or most children with ASD).

http://www.scerts.com/

Facilitated Communication
Facilitated Communication (FC) is an augmentative communication method that uses a facilitator as a physical support to aide the child in communication through pointing, writing or typing. The facilitator helps the child to isolate the index finger and to stabilize the hand, wrist, forearm or arm during typing. The facilitator also helps the child maintain focus on the process by encouraging the child to remain on task and redirecting the child back to task.

Parsimony

One of the four assumptions of science is that it is parsimonious. Therapeutic plans should also be parsimonious.
The purpose of the information found throughout this site is to help you keep not only the measurable behavioral objective but the entire plan as simple, clear, concise and parsimonious as possible.
In other words and as much as possible, Keep it Simple!

Shaping Compliance

Therapist often turn in plans that focus on getting a person to be compliant. I must confess that this idea is also not mine but makes perfect sense. Instead of working so hard to get someone to do something that s/he does not want to do, try getting them to do something that they do want to do. After a while, start throwing in something here and there that they may not be as motivated to do, always going back to including things that they do want to do. Over time you can include requests that are increasingly objectionable or difficult, continuing to include reinforcement. Before long they may be much more compliant in all appropriate areas.


Remember:
Almost no one is compliant 100% of the time, (and we worry a little about those who are). [For example, if you are working with a kid with special needs in a classroom and it is almost the end of the day or perhaps even the end of the school year and the rest of the class is off task, why in the world would you be trying to make the kid with special needs stay on task?]
&
If you are trying to get a kid to do something, make sure that it is within his or her capabilities. [Sometimes we even see plans trying to get a kid to do something that a typical kid of the same age would be unlikely to do, especially on their own and without help.]
&
Make sure you ask a child/kid to do easy and or preferred activities at least some of the time and on a regular basis. Even as adults, most of us don’t want to do something hard or unpleasant all the time. It’s good to learn and to stretch but not all the time. [You don’t ever want to be seen by the child as that person who only wants me to do things that are either extremely difficult or unpleasant all the time.]

Click here to continue with this information: Parsimony

The DEAD MAN (or WOMAN) test

Recently I attended a training/meeting where the DEAD Man test was mentioned. It’s the same concept as I have written about previously under the heading, “nature abhors a vacuum.” The concept here, though the same as previously discussed, is presented in a very different way and may strike a chord of understanding for some.
This is the idea. If your objective is to begin or increase a behavior that a “dead man or woman” could do, then you probably have a poor or even dead objective.
For example: Any time that your objective is that someone NOT do something, then that is something a dead man could do and is almost always a very poor objective.
There are some exceptions to this rule. There may be a time that you need someone to sit quietly for a brief period. Well a dead man could do that but it still may be appropriate.

Click here to continue with this information: Shaping Compliance

Writing a Plan for Problem Behaviors

When writing an ABA (Applied Behavioral Analysis) or similar plan, the following worksheet may be helpful. (This is specific for children; however, it would be similar for adults.)
Plan Writing Work Sheet
Complete all that apply. In most cases all will apply.

What is the problem behavior? ________________________

What is the function of the problem behavior? What benefit is the child getting from this? Remember that the same problem behavior may derive different benefit in different settings. ____________________

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­
Measurable Behavioral Objective:

1. Whose behavior is being modified? (name of child) _____________________________________________

2. What behavior do you want to increase or initiate? ______________________________________________


3. What is the cue that will tell the child that it is time to do the behavior? _____________________________


4. How will you know that the objective has been met? _____________________________________________


How will you show (data) that this has been met? _________________________________________________


What is the current baseline for the desired behavior? (Don’t know, is unacceptable. Trials should be run

during the comprehensive, functional assessment or previous therapy) _____________________________________________


What is the reinforcement for the child if the child completes the desired behavior as prescribed? _________________________________

What will be the reaction of the therapist (or parent) if the child does not do the desired behavior within the

prescribed time? ____________________________

What additionally will be done to prevent the problem behavior? _____________________________________


What will be done to minimize aversives in this interaction? _________________________________________


What will be the next steps in this objective? _____________________________________________________


How will this skill (behavior) be generalized? ____________________________________________________

Could any therapist or the parent pick up the plan, carry it out and collect data as required without any additional background or discussion? Yes ____ No ____


Additional resources for a Functional Behavioral Analysis:
http://cecp.air.org/fba/default.asp
http://www.teach-nology.com/currenttrends/functional_behavior/
http://cie.asu.edu/fall98/miller_tansy_hughes/index.html
http://www.cde.state.co.us/cdesped/fbaguidelines.asp
http://specialchildren.about.com/od/fba/g/FBA.htm
Functional Behavioral assessment FAQ

To continue with this information click here: The DEAD MAN (or WOMAN) test

Writing Measurable Behavioral Objectives for P.L.A.Y.

“The P.L.A.Y. (Play and Language for Autistic Youngsters) Project is a community based/regional autism training and early intervention program dedicated to empowering parents and professionals to implement intensive, developmental interventions for young children with autism in the most effective and efficient way”.
“Created by Richard Solomon MD and based on the DIR® (Developmental, Individualized, Relationship-based) theory of Stanley Greenspan MD”
(Additional information about P.L.A.Y. can be found at: http://www.playproject.org/ )
I am very impressed with P.L.A.Y. and want therapists to understand that it is completely compatible with the components of a good plan as prescribed in this blog. I also want therapists to understand that writing good goals and measurable behavioral objectives is compatible with and supportive of P.L.A.Y.
Ok, now for a measurable behavioral objective:
When therapist (or mom) initiates a preferred activity with Sally and in Sally’s (child) comfort zone, Sally will sign or gesture to the therapist for the activity to be repeated within 5 seconds of completing the first activity at least one time 50% of the time that a preferred activity is initiated over a one month period.
Operational definition of gesture: This can include Sally; taking the hand of the therapist and moving it towards the activity, sally signing “more” or “again,” or moving the activity towards the therapist.
Data clarification: When Sally gestures that she wants the activity repeated just one time, within 5 seconds) after the activity has been initiated, that counts as having been accomplished. The objective is met when she can do this 50% of the time over a one month period.
Response: When Sally indicates, as mentioned above, that she would like the activity to be repeated, the therapist will sign “more” or “again” and say the word and repeat the activity.
Additional note about the objective: It may be counter productive to repeat the same activity over a long period of time (more than 15 minutes). After completing a good assessment of Sally you will have a better idea about preferred activities and when they are most preferred. Start with preferred activities at a time that she is most likely to want to repeat them.
This is only one way that this objective might be written. Notice that it includes:
When; when the therapist initiates a preferred activity with Sally
Who; Sally
What; sign or gesture to the therapist to repeat the activity
How (will we know that it has been achieved); by gesturing to the therapist at least one time after the initiation 50% of the time.

Measurable Behavioral Objectives are the Foundation of a Good Plan

Measurable Behavioral Objectives are the foundation of a good plan. They do not come first. Assessment/Evaluation or a study come before, goals come before but Measurable Behavioral Objectives are the foundation. Colleges and Universities do a disservice to Social Workers and Therapists if they do not teach this skill. Government, organizations, agencies and even businesses do a disservice to customers, taxpayers, participants and the organization itself if they do not demand Measurable Behavioral Objectives.
When written well, additional instructions are much easier to write in a clear and concise fashion. When written well, data collection is easier to conceptualize and clearly define. When written well, the rest of the plan can be parsimonious. When written poorly, in order to be understood and consistent, more verbiage is required and at times even ongoing and continuous explanations and clarifications are required.
This is a tough skill for some people to acquire. It takes time and effort; however this time and effort pale in comparison to the waist of time and money when there is not a clear and mutual understanding of what you and others are doing and how it will be measured.

Click here to continue with this information: Writing a Plan for Problem Behaviors

Additional resources for the theraputic setting, the home, the classroom, or the boardroom.

Here are a few additional resources to help you in writing Measurable Behavioral Objectives in a variety of settings. From the therapeutic setting, to the classroom, to the board room.

The Dreaded Behavioral Objective
http://www1.appstate.edu/~mamlinnl/behavior.htm

How to Write Learning Objectives that Meet Demanding Behavioral Criteria
http://www.adprima.com/objectives.htm

Topic 4 : Developing Goals and Objectives Instructor’s Notes
http://www.roundworldmedia.com/cvc/module4/notes4.html

Rubric: Guidelines for Evaluating Behavioral Objectives
http://pixel.fhda.edu/id/Goals/goals_rubric.html

Clinical Resources: Writing Behavioral Objectives
http://home.hvc.rr.com/wmbrooks/Clinical%20Resources.htm

ABC's of Behavioral Objectives--Putting Them to Work for Evaluation http://www.joe.org/joe/2005october/tt3.shtml

Information About Behavioral Objectives and How to Write Them
http://med.fsu.edu/education/FacultyDevelopment/objectives.asp

Writing Behavioral Objectives for the Clinical Presentation Curriculum
http://www.oucom.ohiou.edu/fd/objectivesforcpc.htm

Click here to continue with this information: Measurable Behavioral Objectives are the Foundation of a Good Plan

Crisis Plans

Crisis Plans

The best crisis plan is the one that you prepare for but never implement. It incorporates all the things already talked about. It focuses on behaviors that you want to increase, rather than the ones that you want to eliminate. Sometimes though, people go into crisis and sometimes they take you with them. When this happens there are a few things to prepare for and keep in mind.
1. Someone else may be better at helping with the de-escalation than you. A team approach is often, though not always, helpful.
2. When someone is going into crisis there is usually a physiological change. In order to help them reduce their own stress levels, they may need another physiological change. Aerobic exercise (to include a fairly brisk walk) may be a helpful component to the plan. (Sometimes a quiet/relaxing break with low stimulation is all that is needed or can be a great follow-up to something more aerobic.)
3. Choices (when possible, I like three) can be very helpful to relieve the stress, de-escalate the crisis and help people to return to a more thoughtful place.
4. After the crisis, when all seems calm, can be a dangerous place particularly if the crisis erupted fully. The calm after the crisis can sometimes turn into depression.

Additional notes:
I have found music to be very helpful when applied correctly and the pace is gradually used to help people to relax. (It’s sort of like driving at 70 mph then turning into a town where the speed limit is 25. Kind of drives you crazy for a while. It can be the same with music. You usually can not relax someone who is super hyper with super relaxed music. You have to start some place in between then move to more and more relaxed music.
For children and some adults blowing REALLY big bubbles can be very helpful. It changes the breathing patterns without the other person knowing what’s going on. Slow, deep breathing is helpful for relaxation. Adding good music can be helpful.
If this is a significant concern for you and in your situation, I recommend four resources:
One is the MANDT system http://www.mandtsystem.com/
Another is an excellent book by Joan Borysenko, Minding the Body Mending the Mind. (Don’t do the neck exercise, research after the book’s publication has questioned the efficacy of this particular exercise)
The third is Crucial Conversations by VitalSmarts http://www.vitalsmarts.com/
Each may have some applications across situations and some that may be more applicable to some situation than others.
The last little resource that I recommend is baroque music (for REALLY relaxed) and my very favorite is Timeless Motion by Daniel Kobialka. He also has some additonal music that may be more appropriate for other situations. http://www.danielkobialka.com/

Click here to continue with this information: Additional resources for the theraputic setting, the home, the classroom, or the boardroom.

Continuous Evaluation and Adjustment

Continuous evaluation; of a plan, the implementation of the plan, data collection and progress or lack of progress are essential. In depth periodic evaluation is also essential.
Very simply...
You need to ask yourself "What worked?", "What didn't work?" ( or what could have made it better?) and Why? All three questions are essential for best outcomes even when everything seems to be working well or fairly well. It is a disciplined thought process that helps bring about better outcomes for clients/participants and helps to improve you as a therapist/interventionist. This process requires good "Critical Thinking" http://en.wikipedia.org/wiki/Critical_thinking
You need to ask these questions for all aspects of the intervention but especially about:
The environment;
The antecedents and reinforcers;
The plan;
Plan implementation; and
Data collection. Of course you must always take into consideration what is going on internally as well and how that is impacting everything else. IE. illness, reactions to medications, hormones, etc.
When you have gone through this process, adjust for better outcomes.

To continue with this information click here: Crisis Plans

Transition Plans

Think of a transition plan as a “to do” list.
It still must be measurable, but does not usually need the same strict formula (there are exceptions which shall be explained below).
The plan may need to be adjusted as you move forward. That’s ok, all plans need to be flexible.
The first part of the transition plan consists of specific tasks that need to be done, when they will be done, and who will do them.
For a child moving into an adult system there are usually specific eligibility issues that need to be taken care of. Some times guardianship and living arrangements need to be made.
If there are partners working with the same child and the partner is taking care of some of the specifics, reference the partner’s plan and attach it. For example if you are a Developmental Disability Agency and there is a Service Coordinator from another agency who is taking care of specific tasks, reference the Service Coordination plan and attach.
The next part of the transition plan consists of specific activities that will help the individual acclimate and become comfortable in any new setting.
The last part of the plan (and it doesn’t have to be in this order) should address any specific skills/behaviors that will need to be increased in order to help the individual be successful in the new environment. This part should follow the strict criteria for a measurable behavioral objective. This could also be contained in another part of the overall plan and just referenced in the transition plan and attached; however, where ever this part is located, it needs to address the specific skills/behaviors that will help the individual in the new situation.

Click here to continue with this information: Continuous Evaluation and Adjustment