Integrating approaches to maximize therapy outcomes NADD International Conference, Miami, FL 5/8/2014 V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 1 Integrating approaches to maximize therapy outcomes VERONIQUE PARENT, NATHAN LAMBRIGHT, AND MELANIE DUBARD THE MAY INSTITUTE, RANDOLPH, MASSACHUSETTS (USA) NADD INTERNATIONAL CONFERENCE, MIAMI, FLORIDA, 8 MAY 2014 Acknowledgements May Center School for Autism and Developmental Disabilities Students & their families Clinical and educational staff Psychology and counseling interns Disclaimer The authors have no conflict of interest to report Examples of clinical resources are provided in this presentation for information purposes only Presentation Outline Intro: CBT and Developmental Disabilities (DD)(5-10 min) Intervention (60 min) Baseline phase (20 min) Skill acquisition (20 min) Skill generalization (20 min) Conclusion (5 min) Questions? (5-10 min) Emotion regulation in individuals with DD Bio-psycho-social vulnerabilities High-risk population Comorbidity with mental health disorders Complex medical needs Behavior problems (e.g., aggression, self-injury, threats) and adaptive skills deficits Psychiatric hospitalizations Other: homelessness, trouble with law enforcement Condillac, 2007; Dozier et al., 2010; Lunsky & Balogh, 2010 Interventions and DD Behavior treatments Relaxation training Self-monitoring Function-based treatments (e.g., applied behavior analysis, positive behavior supports) Cognitive-behavior therapy (CBT) Anxiety and mood disorders Anger management and emotion regulation Social skills training Brown et l., 2013; Condillac, 2007; Dozier et al., 2010; Lang et al., 2010; Mullins & Christian, 2001; Paclawskyj, 2011
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Integrating approaches to maximize therapy outcomes
NADD International Conference, Miami, FL 5/8/2014
V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 1
Integrating approaches to maximize therapy outcomesVERONIQUE PARENT, NATHAN LAMBRIGHT, AND MELANIE DUBARDTHE MAY INSTITUTE, RANDOLPH, MASSACHUSETTS (USA)
NADD INTERNATIONAL CONFERENCE, MIAMI, FLORIDA,8 MAY 2014
Acknowledgements
May Center School for Autism and Developmental Disabilities Students & their families Clinical and educational staff Psychology and counseling interns
Disclaimer
The authors have no conflict of interest to report
Examples of clinical resources are provided in this presentation for information purposes only
Presentation Outline
Intro: CBT and Developmental Disabilities (DD)(5-10 min)
Cognitive-behavior therapy (CBT) Anxiety and mood disorders
Anger management and emotion regulation
Social skills training Brown et l., 2013; Condillac, 2007; Dozier et al., 2010; Lang et al., 2010; Mullins & Christian, 2001; Paclawskyj, 2011
Integrating approaches to maximize therapy outcomes
NADD International Conference, Miami, FL 5/8/2014
V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 2
Why combining treatment approaches?
Most therapy models = general population Individual variability and need to adapt treatment Difficulty with generalization High-risk clinical population
I – Baseline AssessmentINTERVENTION PHASE (1/3)
Initial steps
Screening Interviews with caregivers Classroom observations
Prerequisite skills Emotion recognition Understanding of social situations Cognitive and communication abilities
Baseline assessment Standardized measures
Behavioral and socio-emotional functioning Child Behavior Checklist (CBCL, Achenbach) Behavior Assessment System for Children, 2nd edition (BASC-II, Reynolds &
Classroom data collection (e.g., coping strategy use, engagement)
Behavior Support Plan (BSP) daily data collection (if available)
Qualitative reports from student, parents, and teachers
Assessment challenges
Difficult items Rewording, give examples, show Always supplement verbal instructions with visual supports Consider developing your own instruments
Self-report biases Use multiple informants, across settings Use multiple methods (e.g., observations + questionnaires) Get both student’s + caregivers’ perspective
Rewording items
How would you reword the following items? “I am more critical of myself than I used to be” “I have much greater difficulty in making decisions that I
used to be” “Numbness or tingling” “Wobbliness in legs” “I feel I do not have much to be proud of”
Developing assessment tools
What are we measuring? Good definition = clear, objective, and complete Test your definitions Clarify definitions, as needed
How are we measuring it? Dimensions of behavior measured: frequency, intensity, duration, etc. Density (how often?): minutes, hours, sessions, weeks, pre-post, etc. Procedures: event recording, time sampling, datasheets, instruments,
etc.
Definition of “Escalation Signs”:Non-examples
Any instances when student looks upset. Any instances when student becomes upset in order to get
what he wants. Every time student starts hitting others.
Questions Are the definitions clear? What is missing? Using frequency vs. episodes? How much time does it take to calm
down?
Definition of “Escalation Signs”:Example
Signs of escalation: Any episodes when student appears to be upset, as noted by the presence of the following physical or verbal behavioral signs: a. Physical: body tensing (e.g., such as clenched jaw or fists), hitting the
table or the wall with his fists, and moving his arms/fists as if punching something in front of him.
b. Verbal: raising his voice, telling people to stop “imitating” him or stop “looking” at him, and making verbal threats to others.
Episodes are separated by 5 minutes intervals. If student presents symptoms during that time interval, count as the same behavioral episode.
Integrating approaches to maximize therapy outcomes
NADD International Conference, Miami, FL 5/8/2014
V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 4
Definition of “Coping Skills”:Example
Coping strategy use: Any instances when student uses one of the following coping strategies: a. Take a deep breath: student takes deep breaths to relax. Student
tries to have a calm body while taking deep breaths, this includes calm legs, arms, and head. Student’s eyes can be opened or closed to his preference while taking deep breaths.
b. Help strategy: Student reaches out to staff when upset and asks for their help or tells them what’s wrong (e.g., “I’m upset” or “Can you help me?”).
Developing assessment tools (cont’d)
Data validity Inter-observer agreement (IOA) -> data collection
% of agreement between 2 observers/ raters (Total Agree/ Total Agree + Disagree) x 100Goal = IOA >80%
Treatment integrity -> implementation% steps in treatment plan completed accuratelyGoal = 100% steps correct
Example: Treatment integrity and IOA Data validity (cont’d)
Social validity (e.g., target behavior, instrument use)Qualitative: Pre/post interviews with caregivers + students Quantitative: improvement in daily functioning (e.g., ability
to participate in academic activities, independent level)
Ongoing monitoring of IOA + Treatment Integrity Provide corrective feedback and training, as needed
Data analysis: Line graphs
Data analysis:Bar graphs
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Data analysis:Within subject comparisons (clinical scores)
10
20
30
40
Pretest Posttest
Self-esteem (self-report)
Rosenberg Scale
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10
20
30
40
50
60
Pretest Posttest
Symptoms of anxiety (self-report)
BAI
0
10
20
30
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50
60
Pretest Posttest
Symptoms of depression (self-report)
BDI
II – Skill AcquisitionINTERVENTION PHASE (2/3)
Introductory sessions
Build rapport Familiarize individual with process Identify student’s interests and preferences Identify optimal participation times Identify significant others (e.g., favorite staff) Individual’s perception of his/her own strengths /
weaknesses
Teaching prerequisite skills: Emotion identification Present students with age-appropriate facial expressions
Receptive: ID: Ask: “Show me the child who looks happy/ sad/ mad?” Expressive ID: Ask: “How is he/she feeling?”
Electronic resources Teaching prerequisite skills: Reading social situations Present students with age-appropriate social situations pictures
Receptive: ID: Ask: “Show me the one which is okay/ not okay?” Expressive ID: Ask: “What is happening here?,” “is it okay or not okay?,”
“How is he/she feeling?”
Integrating approaches to maximize therapy outcomes
NADD International Conference, Miami, FL 5/8/2014
V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 6
Therapy model and goals
Feel
Do Think
Increase self-awareness of: Learn and develop:
Problem-solving skillsMaladaptive thoughts and actions
Feelings + precursor signs
Situation triggers
Coping skills
Relaxation skills
Identifying triggers and related emotions
Use matching exercisesAsk student to draw pictures of situations that
make him/her feel happy, sad, etc.
Play board games:Children resources
Board games:Adolescents and young adults resources
Create your own! Teaching precursors and warning signs
Use human body picture and ask: “where do you feel it in your body when you are ___?,” “what do you feel/do?”
Ask student to color, put “x,” point, etc. Use everyday examples Discuss situations that happened in the last week Ask student to draw a picture or create a story Prepare a hand-out with different pictures and ask
student to point
Integrating approaches to maximize therapy outcomes
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Electronic resources Connecting body signs to emotions:Worksheet
Teach self-monitoring
Rating scales Create a hierarchy (mild, moderate, and severe
upsets) Journaling Have student develop his/her own rating scale
Example of rating scale
Rating scale:Visual hand-out
Rating scale:Feeling thermometer
Integrating approaches to maximize therapy outcomes
NADD International Conference, Miami, FL 5/8/2014
V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 8
Self-monitoring results –Student with generalized anxiety
0
1
2
3
4
Anxiety about people leaving
0
1
2
3
4Anxiety about graduation
Identifying actions and thoughts
Use cartoons and thought bubblesUse dark cloud analogyUse story board to create A-B-C stories
Develop behavior protocol Triggers and precursors (e.g., math exercises, hands in fist)Define target behaviorsDefine coping skills to prompt when noticing triggers/precursors
Integrating approaches to maximize therapy outcomes
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III – Skill GeneralizationINTERVENTION PHASE (3/3)
Skills generalization
Programming for skills generalization and maintenance is a key component to any CBT treatment and any
behavioral intervention with children with ASD or developmental disabilities
Skills generalization
“The occurrence of relevant behavior under different non-training conditions
without the scheduling of the same events in those conditions”
Stokes & Baer, 1977
Environmental supports: Implement a behavior protocol
Include the following: Triggers and precursors (e.g., math exercises, hands in fist)Define target behaviorsDefine coping skills to prompt when noticing
triggers/precursors Prompting and differential reinforcement strategies Preventive antecedent strategiesDe-escalation strategies for crisis situations
Monitor effectiveness and follow-up
Data collection + analysis, IOA, treatment integrity Staff training + corrective feedback Identification of new triggers and precursors Need to add new coping strategies Need to update student’s clinical tools
In-session supports
Review events of the week Develop solutions for new challenges Prepare for upcoming transitions or stressors Practice, role-play, develop new tools Progressive fade out of individual sessions Replaced by classroom consultations with student and
teachers
Integrating approaches to maximize therapy outcomes
NADD International Conference, Miami, FL 5/8/2014
V. Parent, N. Lambright, & M. DuBard (May Institute, Randolph, MA) 11
Conclusion CBT + BT can be effective with students with DD Baseline, skill acquisition + skill generalization treatment