Behavioural Intervention Service – Hobb’s House “ It’s a place like no other” - client, age 12 Orientation and Service Overview 2007: Winner of the CYWHS.

Behavioural Intervention Service – Hobb’s House

“It’s a place like no other” - client, age 12

Orientation and Service Overview

2007: Winner of the CYWHS Exceptional Teamwork and Collaboration Award

Presentation Overview

• This presentation covers…

– A brief description of the Behavioural Intervention Service (BIS)

– BIS referral criteria– Common presenting features of BIS clients– The Positive Behaviour Support Framework– From referral onwards– BIS Day program– BIS Consultancy

A snapshot of BIS• BIS is a state-wide, interagency partnership

between Child and Adolescent Mental Health Service (CAMHS), Department and Education and Children’s Services (DECS) & Families SA (FSA)

• BIS provides an intensive day program & consultancy service for young people with significant mental health issues & long standing, pervasive and persistent behavioural problems

• BIS is staffed by a multidisciplinary team of CAMHS clinicians & DECS teaching staff– Psychologist, Mental Health Nurse, Speech

Pathologist, Social Worker, Occupational Therapist, Psychiatrist, Teachers, SSO

Referral Criteria• Aged 5-18 years old• Mental health issues

– E.g. features of depression, anxiety, low self-esteem etc

• Previous intervention provided by more than one agency or two or more programs with at least one agency which were ineffective– E.g. DECS programs, community CAMHS

interventions, private clinical therapy etc• Persistent, pervasive (more than 1 setting) &

long standing behavioural problems

Features of BIS Clients• Generally aged between 9-13 years old• More than 80% of BIS clients are males• 60% have Families SA involvement (including

living in foster care or community residential units)

• Common life experiences often include…– Exposure to domestic violence– Abuse and/or neglect– Family breakdown– Rejection & abandonment– Experiences of grief & loss– Substance abuse within the family– Other traumas (see Attachment, Trauma and Brain

Development Presentation)

Features of BIS clients• Other common compounding issues include…

– Developmental disorders/delays– Intellectual and/or physical disabilities– Speech & language deficits– Learning difficulties and learning gaps– Systems issues– Sensory and motor issues– Limited experiences of success– Poor social skills – Poor play skills– Poor sleep hygiene

Features of BIS clients• Common emotional characteristics of BIS

clients…– Insecure/disorganised attachment profile

(See Attachment Presentation for more information)

– Display high levels of anger & aggression– Negative self-concept & low self-esteem– Have low tolerance for frustration – Few experiences of success & many

experiences of failure – Display high levels of fear – Emotionally ‘shut down’

Features of BIS Clients• Common challenging behaviours exhibited by

BIS clients include…– Aggression & violence (towards other people or property)– Obsessional or ritualistic behaviours– Abusive/controlling interactions– Sexualised behaviours– Avoidance behaviours– Risk taking behaviours

So how do we work with such challenging young

people?

• Positive Behaviour Support (PBS) provides the theoretical underpinning of the educational & therapeutic program at BIS.

• PBS is a non-punitive approach to behavioural change that encompasses a broad range of systemic and individualised strategies for achieving social and learning outcomes while reducing challenging behaviours

• PBS differs from traditional “reactive” methods of behaviour management often used in schools.

• BIS clients are those young people who are least responsive to these reactive behaviour management practices

Positive Behaviour Support

PBS – Functions of challenging behaviours

• PBS assumes that all behaviour serves a specific function for that person, no matter how maladaptive or ineffective it appears to others

• Common functions of a young person’s challenging behaviour– Avoid/escape a non-preferred person/activity– Obtain a preferred object/activity– Initiate or maintain a social contact– Express distress, emotion or sensory need

• Hypotheses and competing pathways plans are developed to describe the function of a challenging behaviour and then are tested or observed

• Hypothesis template– When __(insert setting event)__ young person will

__(insert challenging behaviour)__ in order to __(insert intended outcome/function)__.

PBS – Competing Pathways

Setting Events:

Being in the classroom

Triggers:

Being asked to do maths

Challenging Behaviour:

Yelling, Swearing & Threatening

Maintaining Consequence:

Getting sent out of room. And not having to do maths

Acceptable Alterative:

Walk out of classroom

Desired Behaviour:

Attempt maths tasks Ask teacher for help

Maintaining Consequence:

Experience of success Positive relationship with teacher

Example Hypothesis: When asked to do a maths task Mike yells, swears and threatens to harm the teacher in order to get sent out of the classroom (thereby avoiding the maths task)

In the short term an acceptable alternative is reinforced as it is ‘less

worse’ than the challenging behaviour

It is hoped young people will develop new skills with new

reinforcers to replace challenging behaviour

Positive Behaviour Support• PBS incorporates 2 key goals of intervention

1. Strategies with the specific purpose of diffusing the immediate situation, maximise safety & normalising the environment (reactive strategies – use 10% of the time)

2. Strategies intended to decrease the likelihood of future incidents & thereby facilitate long term behavioural change (proactive strategies – use 90% of the time)

The best behaviour management occurs when the challenging behaviour is not happening.

The best personal support occurs when the

challenging behaviour is present.

PBS – Proactive Strategies• Proactive Strategies target modifications to the

environment or build skills in the young person

• Environmental (changing the world to suit the young person)– Modify physical characteristics of environment– Modify planned timetable and activities– Modify communication strategies/style used

• With the young person (changing the young person to suit the world)– Develop functionally equivalent skills

(acceptable alternatives to challenging behaviours) & desired behaviours

– Coping & tolerance skills (build resilience)– Build skills such as language, academic, sports,

social and play skills

PBS – Reactive Strategies• Reactive strategies have a focus on

maintaining/restoring the safety of the young person & those around them

• For each young person an incident management plan is developed that identifies potential triggers, warning signs, communication strategies, de-escalation strategies & an exit plan

• Some examples of reactive strategies include…– Removing other young people/staff from the area– Removing dangerous objects– Providing an easily accessible escape route & a safe place to

cool off

• This is not a time for teaching/learning new skills that happens as a result of the proactive strategies when the challenging behaviour is not occurring

• Following an incident relationships are repaired & the young person can then be re-engaged with the program

PBS Plan TemplatewwwPOSITIVE BEHAVIOUR SUPPORT PLAN

Understanding Young Person Helping World to Suit Young Person Helping Young Person to Suit World Strengths Environment Multi-Disciplinary Goals Protective factors

Highlight particular interests or strengths of the YP

People with whom the YP has strong, positive relationships.

Strategies to manipulate physical and social environment in order to: - reduce triggers for challenging behaviours - enhance supportive relationships. Taking into consideration:

Informal & formal Assessment Existing environment(s) with

their unavoidable constraints Be realistic and specific. Set up an environment to foster and repair relationships

This includes goals to address skill deficits and build on existing strengths. Opportunity for adults to co- ordinate and prioritise their goals These goals developed by the collaborative team and aim to increase young person’s opportunities to develop skills

Emotional regulation Leisure Social Academic

Challenging Behaviours Communication Focussed Behavioural Goal May wish to list in order of priority Collaborative decision making re which behaviours are the current focus of intervention Refer to hypothesis development

Strategies to assist people to adapt their communication to suit the level and emotional state of the YP. Devised using information from a variety of sources including:

Speech and language assessment

Psychology assessment Observations

Function of Behaviour Timetable Tips Please note that a hypothesis describes the suggested triggers, form and function of a challenging behaviour. List hypotheses that are currently being tested by team

Contains strategies to help organise YP’s day according to what we know about his strengths and needs. Eg. YP has been observed to have

difficulty attending to structured task before access. Psychologist suggests…

YP has positive relationship with Home Group teacher – schedule in routine contact

Positive Reinforcement is essential in helping YP shaping target behaviours into more socially acceptable and functionally equivalent behaviours. Reinforcement is given when desired behaviours are performed, not when challenging behaviours occur. Refer to hypotheses and competing pathways to establish appropriate replacement behaviours and reinforcement schedules.

How does a young person get to BIS & what happens

when they get here?

Pathway to BIS1. 1. A young person’s referral is coordinated by

Interagency Student Behaviour Managers (DECS)

2. The appropriateness of the referral is considered by the BIS Intake Panel made up of CAMHS, DECS and FSA managers

3. If appropriate the young person is placed on the waiting list (approximately 12 months) & a series of recommendations and supports are put in place to assist the young person during this period

e.g. funding for increased SSO support at school

Pathway through BIS1. Client is allocated a clinical and an educational key

worker from the BIS team2. Information is compiled from a variety of sources

(family, other services, CAMHS file) and any necessary assessments are conducted (e.g. Functional Behavioural Assessment, psychology)

3. Hypothesis Development – Develop hypotheses around the functions of challenging behaviours

4. PBS Planning – develop goals for the young person: skill building, reinforcement strategies

5. Multi-disciplinary Team Intervention Planning – plan interventions to address goals

6. Decide whether client would be best served by attending the day program or by consultancy service

7. Ongoing liaison with other systems supporting the young person

The Day Program• The day program (9:30am-3pm) has both an

educational & clinical focus.• Young people spend a majority of the day in a

classroom environment with scheduled clinical sessions throughout the week

• The day is highly structured with most activities lasting only 15-30 minutes

• Young people participate in a number of group activities such as gardening, bike riding, social skills & art therapy

• The number and length of days attended by each young person is determined in partnership with the family & the enrolled school and depends on the young person’s needs and goals.

Educational Program at BIS• Each young person’s education at BIS is

modified to their individual academic level• A key educational goal at BIS is to support

young people to re-engage with the curriculum

• To increase young people’s capacity to transition to a school setting & succeed in a classroom environment

• To further develop literacy & numeracy skills• To develop social & emotional competency in

a classroom setting

Example TimetableTime Activity Comment Student’s rating

9:30 Organisation and morning chat

9:45

Language theme – Aboriginal studies

10:00

Reading and Art

10:15 Computer work

10:30 Spelling – THRASS work

10:45 Sharing success!

11:00 Recess

11:30 Relaxation

11:45 Maths

12:15 Time with clinician

12:45 Sharing success

1:00 LUNCH

1:30 Relaxation

1:45 Communication Folder

2:00 Time with clinician

3:00 HOME

Goals of Clinical Intervention• Develop trusting relationships with adults• Develop safe personal boundaries• Change cognitive behavioral processes• Conflict resolution and negotiation skills• Provide experience of success and mastery• Appropriate self awareness and expression• Family work & systems education/support• Development a positive sense of self• Specific skills development e.g.

– Speech and language– Emotional Regulation– Play

• Social skills & peer relationship development

Consultancy Service• A consultancy service is offered to young

people and families who… – Live too far away to access the day program

(BIS is a state-wide service) – Who are connected and engaging in their

enrolled school, but require additional support

• It includes assessment & the development of a comprehensive PBS plan

• BIS staff engage, educate and train the young person’s key supports to put in place agreed interventions

• The role is flexible depending on the needs of the young person & those who support them