-
If professionals and parents can accept thechallenge of taking
on new roles and ex-pectations by working creatively and
coop-eratively with each other and by establish-ing an atmosphere
of mutual trust andrespect, children with diverse needs and
ca-pabilities can benefit enormously. (Wood,1996, p. 173)
Over the past decade, the field ofpositive behavior support
hasgrown rapidly as a set of prac-tices that focus on the
function(s) ofproblem behaviors in order to developand teach
functional alternatives (Hor-ner, 2000). Based solidly on both a
valuesbase about the rights of people with dis-abilities and the
principles of applied be-havior analysis, positive behavior
supportinterventions (a) consider the contextswithin which the
behavior occurs; (b) ad-dress the functionality of the behavior;and
(c) result in outcomes that are ac-ceptable to the individual, the
family, andthe supportive community (Koegel, Koe-gel, & Dunlap,
1996).
When problem behavior occurs in thefamily home,
parent–professional collab-
oration is needed in order to designinterventions that fit the
context for in-tervention. Moving toward a truly col-laborative
approach with regard to inter-vention planning should reduce
theoccurrence of “systems that fail,”whereby “a fix [that is]
effective in theshort term [may have] unforeseen longterm
consequences which . . . requireeven more use of the same fix”
(Senge,1990, p. 388). Often, traditional behav-ioral interventions
fail due to a lack of“buy in” from the family, or becausethere is
“poor fit” between the problembehavior and the behavioral
interven-tion. When either of these consequencesoccurs, more time
and effort are requiredby the behavior support interventionistand
the family to arrive at an effective so-lution.
A small number of studies havedemonstrated the efficacy of
parent–professional collaborative partnershipsrelated to the design
and implementationof positive behavior support interven-tions in
the context of natural family rou-tines. For example, Lucyshyn,
Albin, and
FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIESVOLUME 17,
NUMBER 4, WINTER 2002
PAGES 216–228
Parent–Professional Collaborationfor Positive Behavior Support
in the Home
Joanne Kay Marshall and Pat Mirenda
Over the past few years, a number of studies have demonstrated
the efficacy ofcombining positive behavior support and
family-centered intervention in home set-tings. Family-centered
positive behavior support is often conducted within the contextof
natural routines that occur regularly in home or community
settings. The purpose ofthis article is to describe many of the
unique challenges and benefits related to assess-ment, intervention
design, and implementation that are inherent in
parent–professionalcollaboration for positive behavior support.
This is accomplished through an exampleof a partnership that
resulted in the provision of a variety of visual supports to a
youngchild with autism who exhibited severe problem behaviors
during daily routines.
Nixon (1997) described a 26-month in-tervention conducted by the
parents ofan adolescent girl with multiple disabili-ties in the
context of dinner time, homeleisure, restaurant, and grocery
storeroutines. Vaughn, Dunlap, Fox, Clarke,and Bucy (1997) provided
support to aboy with Cornelia DeLange syndrome,severe intellectual
disabilities, and chronicmedical problems. In this case, a
positivebehavior support intervention was im-plemented during
family-centered com-munity routines that included shoppingin a
grocery store, eating at a fast-foodrestaurant, and banking at a
drive-throughwindow. Vaughn, Clarke, and Dunlap(1997) worked with
the family of a boywith multiple disabilities and agenesis ofthe
corpus callosum to decrease problembehaviors during fast-food
restaurant andhome toileting routines. Finally, Clarke,Dunlap, and
Vaughn (1999) describedan intervention with a boy with
Aspergersyndrome who exhibited severe problembehaviors during his
morning “gettingready for school” routine. In each case,the
intervention resulted in a marked de-crease in the frequency and
intensity ofproblem behavior as well as an improvedquality of life
for both the child and hisor her family.
Typically, collaborative behavior sup-port planning requires
professionals andfamily members to participate togetherin five
successive phases that involve “re-ciprocal information sharing,
creative prob-lem solving, and shared decision mak-
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VOLUME 17, NUMBER 4, WINTER 2002
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ing” (Snell, 1997, p. 219). The fivephases include
1. building relationships between thefamily and the
professionals,
2. conducting a functional assessmentof the behaviors of
concern,
3. identifying natural routines as con-texts for
intervention,
4. developing behavior support plansrelated to each of the
routines, and
5. implementing and revising the sup-port plans as needed.
Such collaborative efforts have the po-tential of resulting in
substantial and en-during behavior change and improvedquality of
life for the children involvedand their families through the use
ofmulticomponent intervention packages(Carr & Carlson,
1993).
The purpose of this article is to de-scribe the process of
parent–professionalcollaboration for positive behavior sup-port and
illustrate it with an example ofWyatt, a preschooler with autism,
and hisfamily. In order to accomplish this, thearticle will operate
simultaneously ontwo levels: (a) the general level, with re-gard to
principles and practical strategiesthat apply to family-centered
positive be-havior support interventions, and (b) thespecific
level, with regard to how theseprinciples and strategies were
actualizedon behalf of Wyatt by his family and theconsultant who
provided them with sup-port. The article will address many of
theunique challenges that must be facedwhen implementing such
interventionsin homes, including those related to as-sessment,
intervention design, and im-plementation within the family
context.
Introducing Wyatt and His Family
At the time of intervention, Wyatt Mal-lard was a high-spirited
and active 4-year-old with an engaging smile who had beendiagnosed
with mild/high-functioningautism at the age of 3 years by a
multi-disciplinary hospital team in the Cana-dian province where he
lives (see Note).
He enjoyed playing with trains, using acomputer, watching
videos, riding his bi-cycle outside, and swimming at a
localcommunity pool. Although he was ver-bal, his language
comprehension and pro-duction were delayed for his chronolog-ical
age. Wyatt used both immediate anddelayed echolalia as well as
generativelanguage and problem behaviors to makehis wants and needs
known and to com-ment. His social skills were markedly im-paired;
he usually played by himself andhad difficulty interacting with
other chil-dren, joining them in play, knowing therules of play
activities, taking turns, andsharing materials.
Wyatt lived at home with his motherand father, Laura and Martin,
and withhis younger brother, Elliott. Laura was afull-time
homemaker at the start of theintervention, and Martin was
employedas a medical instrument repair technician.A respite worker
provided childcare inthe family’s home two mornings a weekand some
evenings. Wyatt attended aninclusive preschool program for
childrenwith autism and their typical peers everyweekday afternoon
for 3 hours.
The intervention was carried out col-laboratively by Wyatt’s
parents with thesupport of a consultant (the first author),who was
then the coordinator of his pre-school. Wyatt’s parents were highly
mo-tivated to address his problem behaviorusing a collaborative
approach becauseWyatt was eligible for behavioral supportservices
through his preschool for only 1 year due to his upcoming
transition tokindergarten, and his family had no ac-
cess to alternative behavior support ser-vices. They were aware
of the time com-mitment that would be required and theyagreed to
record and share their percep-tions of the experience. Table 1
summa-rizes the major phases and subphases ofthe assessment and
intervention process.
Phase 1: BuildingRelationships
The positive behavior support paradigmexemplifies a systems
model of support inwhich each participant affects the othersas
learning and change occur among all.A family-centered orientation
to positivebehavior support requires consultantsand family members
to work together byfirst establishing trust, openness, and
rec-iprocity (Dunst, Trivette, & Deal, 1988).This means that
the first step in any in-tervention involves developing a
rela-tionship between the consultant andfamily that enables the
former to bet-ter understand the family’s structure,strengths,
routines, capacities, and needs.In so doing, positive behavior
supportoffers an opportunity for both the con-sultant and the
family to engage in a mu-tual problem-solving process. This
pro-cess can lead to more relevant questions,more acceptable and
feasible interven-tions, and more meaningful outcomes inrelevant
contexts (Dunlap, Fox, Vaughn,Bucy, & Clarke, 1997; Graves,
1991;Turnbull & Reuf, 1996; Turnbull &Turnbull, 1993;
Vaughn, Dunlap, et al.,1997).
Table 1Summary of Assessment and Intervention Phases
Phase 1: Building Parent–Professional Relationships
Phase 2: Conducting a Functional Assessment of the Behaviors of
Concern• Identifying Behaviors of Concern• Conducting a Functional
Assessment• Collaborating to Develop a Hypothesis• Identifying
Family Routines for Intervention
Phase 3: Collaborating to Develop a Behavior Support Plan
Phase 4: Collaborating to Implement and Revise the Support Plan•
Regular, planned snacks• Visual schedules and choice symbols
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The Mallard Family
Initially, the consultant spent time get-ting to know Wyatt and
his family out-side of the preschool environment. Shevisited the
family home several times dur-ing the day when Wyatt, Elliott,
andLaura were present. She also accompa-nied the three of them to a
communitypool on several occasions and cared forElliott while Laura
and Wyatt were atWyatt’s swimming lesson. A visit to thefamily home
in the evening allowed herto establish rapport with Martin and
ob-serve the family’s evening routines. Dur-ing this visit, Laura,
Martin, and the con-sultant also discussed the process
ofcollaboration and what it meant to eachof them. They concurred
that collabora-tion meant working together on a com-mon goal and
agreed to attempt to worktogether in a partnership of equals.
Phase 2: Conducting aFunctional Assessment ofthe Behaviors of
Concern
This phase of assessment is quite complexand can be divided into
four main sub-steps: (a) identifying the behaviors ofconcern, (b)
conducting a functional as-sessment, (c) collaborating to develop
hy-potheses, and (d) identifying family rou-tines as contexts for
intervention. Each ofthese will be described in the sectionsthat
follow and illustrated with examplesfrom the Mallard family.
Identifying Behaviors of Concern
Donnellan and Mirenda (1984) recom-mended that parents have
access to allnecessary information that affects theirchild, be
directly involved in the inter-vention process, and participate in
criti-cal decisions. One such decision involvesthe focus of an
intervention, particularlywhen there are multiple behaviors
ofconcern. Often, decisions in this area aremade by a consultant
“expert,” who de-termines which behaviors are most im-portant and
how to address them. How-ever, as Snell (1997) noted, the
efficacyof behavior support interventions largelydepends on the
degree to which the pro-
cedures used fit the ecological and famil-ial contexts in which
they are imple-mented. Dunlap et al. (1997) remarkedthat “such
congruence cannot be ac-complished without access to the
dis-tinctive preferences, beliefs, habits, andworld views of the
participants” (p. 222).
The Mallard Family. During the sec-ond evening visit with the
consultant,Laura and Martin reported that, in gen-eral, Wyatt was
well behaved in the com-munity and when he was in the companyof
people other than themselves. Becauseof this, the family was able
to enjoy a va-riety of community outings together, in-cluding
Wyatt’s weekly swimming les-sons with his mother, a sports class
withhis father, and family outings to fast-foodrestaurants and
shopping malls. In con-trast, they recited an extensive list ofhome
behaviors that were of concern.These included having problems
withtoileting, refusing to share toys with El-liott or include him
in activities, refusingto take turns or share (e.g., in a game
set-ting), demonstrating aggression towardhis brother and peers,
picky eating,screaming, saying “no” when asked toparticipate in
daily routines, hitting, kick-ing, and refusing to go to bed at
night,among others.
Because the list was quite extensive,Laura and Martin were asked
to priori-tize their concerns. After considerablediscussion, they
agreed that Wyatt’s in-sistence on “following his own agenda”was
their top priority because if hisagenda was violated he engaged in
a va-riety of noncompliant and aggressive be-haviors that were
disruptive to the entirefamily. During an initial interview withthe
consultant, Laura and Martin to-gether described Wyatt as “having
somelittle game plan in his head about how itshould work and if it
doesn’t work thatway, he loses it and it takes forever tocalm him
down.” However, they admit-ted to being unaware of the “rules” in
his“game plan” and offered that “Some-times we don’t know what
we’re bat-tling. Usually, we scramble and try toback up our steps
and think about whatwas the last thing that happened. Some-times
that’s not possible or practical.”They voiced the hope that by
addressing
this problem first, Wyatt’s increasedcompliance might decrease
some of theirother concerns, such as those related toturn-taking
and sharing.
Conducting a FunctionalAssessment
The purpose of a functional assessment isto understand a
person’s strengths, pref-erences, and communication strategies
inaddition to the events and circumstancesthat influence his or her
problem behav-ior (Koegel et al., 1996). Many usefultools have been
devised over the years toaccomplish this (e.g., Carr, Levin,
Mc-Connachie, Carlson, Kemp, & Smith,1994). One of the most
commonly usedfunctional assessment approaches in-volves two primary
assessment tools, thefunctional analysis interview (FAI) andthe
functional analysis observation (FAO),and a process for analyzing
and summa-rizing them (O’Neill et al., 1997). TheFAI provides
information about 10 as-pects related to the problem behavior(s)of
concern, including descriptions of (a) the behaviors themselves;
(b) the eco-logical (i.e., setting) events that predictor set up
the behaviors; (c) the specificimmediate antecedent events that
predictwhen the behaviors are likely and notlikely to occur; and
(d) the consequencesand functions of the behaviors. The FAIcan
easily be conducted in the homethrough an interview of one or more
in-dividuals who know the person well (e.g.,parents) by someone who
is familiar withits use (e.g., teacher, behavior
supportconsultant).
The FAO is useful for validating andclarifying hypotheses
regarding the func-tion(s) of problem behavior that are gen-erated
on the basis of the FAI. Accord-ing to O’Neill et al. (1997), the
FAOdocuments (a) the number of occur-rences of problem behaviors
and howthey are interrelated; (b) the situationsand times of day in
which problem be-haviors are most and least likely to occur;(c) the
events that predict the occurrenceof problem behaviors; (d)
observers’ per-ceptions of the functions of the problembehaviors;
and (e) the consequences thatfollow the behaviors.
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The Mallard Family. All but twomeetings related to functional
assessmentand intervention planning occurred inthe family home over
the 2-month inter-vention period. The consultant and theMallards
completed the FAI over threesuch meetings that totaled
approximately21⁄2 hours. Both parents were providedwith copies of
the form in advance, sothey would be aware of the questions tobe
asked and could follow along duringthe interview itself. This
approach wasused in all situations in which writtenquestions were
asked. They were alsoprovided with a packet of written infor-mation
related to the assessment andplanning process and were encouraged
torefer to the packet throughout the inter-vention period.
Following completion of the FAI,baseline data were obtained over
a 2-dayperiod at home using the FAO. Lauraand Martin were taught by
the consul-tant to use this form to record informa-tion regarding
the topography and fre-quency of Wyatt’s problem behaviorsthat were
related to following his ownagenda. Subsequently, this
informationwas used to confirm the initial hypothe-ses they
developed about the functions ofWyatt’s problem behaviors.
When reflecting on the functional as-sessment phase 2 months
later, Lauracommented, “The FAI was [really] help-ful. In fact, I
just went through it again.[It] was thorough . . . and all aspects
ofWyatt’s routine were covered.” Lauraalso commented that, despite
the time ittook for her to record data on the FAO,it was a helpful
tool and provided her andMartin with insights about Wyatt and
hisbehavior. For example, she offered ananecdote about an incident
that occurredon the day that Wyatt returned topreschool after
spring break:
Had I not had to chart this day, I wouldhave said that Wyatt was
just being bel-ligerent. But . . . then I thought, now waita
minute. It was his first day back afterspring break and he hadn’t
had a bowelmovement and that does make himgrumpy. All of a sudden
he wasn’t a bel-ligerent kid. He was a kid with issues. Andso it
wasn’t that he was trying to be bad.It’s that his behavior was
reflecting things
going on in his head that day, so thathelped me see him in a
whole new light.
Collaborating to Develop a Hypothesis
Descriptions of the collaborative process(Bruner, 1991;
Hargrove, 1998) empha-size that collaboration requires
partici-pants to come together around a com-mon goal and to
cooperate in ways thatconsider the perspectives of each ofthem. In
the case of positive behaviorsupport, one of the first such
cooperativeventures is the development of hypothe-ses about the
function(s) of the target be-havior, based on the information
ob-tained during assessment. This can beboth challenging and
frustrating, be-cause it requires the collaborators to de-termine
how the “puzzle pieces” gath-ered during assessment “fit
together.”
O’Neill et al. (1997) provided a prac-tical approach to assist
with hypothesisdevelopment and designing related be-havior support
plans following functionalassessment. They suggested that the
re-sults of the FAI and FAO be integratedinto “summary statements”
that describethe setting events, antecedents, problembehaviors, and
function(s) of the behav-iors. A summary statement typically
takesthe following form: “When [antecedent]occurs, [person]
[behaviors] in order to[consequence/function]. This is morelikely
to occur if [setting event].” One ormore summary statements may
resultfrom the assessment process, dependingon the specific
behaviors, their functions,and the contexts in which they
occur.O’Neill et al. suggested that the sum-mary statements also be
written in theform of “behavior diagrams” that pro-vide the basic
assessment information ina form that can be readily used for
inter-vention planning.
The Mallard Family. Together,Laura, Martin, and the consultant
re-viewed the FAI and the FAO to form hy-potheses about the
function of Wyatt’sproblem behaviors. Several things be-came clear
during this review. First, it ap-peared that there was a higher
frequencyof problem behavior in the morning be-
fore Wyatt left for preschool than in theafternoon after he
returned home. Sec-ond, the number of morning incidentsappeared to
escalate as the time ap-proached for Wyatt to leave for pre-school,
especially during dressing, eating,and toileting or diaper-changing
rou-tines. Laura noted that the morning wasvery rushed and that the
schedule wasoften unpredictable and inconsistent. Shealso reported
that as the morning pro-gressed, she tended to become increas-ingly
anxious about completing his per-sonal care and breakfast routines
in atimely manner. She observed that themore she tried to hurry
Wyatt, the lesscooperative he became and the more heinsisted on
doing only specific, highly de-sirable activities of his own
choosing.Predictably, Laura’s stress level escalatedas Wyatt’s
problem behaviors increased,creating an “upward cycle” of
maternaltension and increasingly disruptive be-havior from
Wyatt.
Based on the information gatheredfrom the FAI and FAO and using
theO’Neill et al. (1997) procedure, the con-sultant and the family
drafted severalsummary statements that Laura and Mar-tin agreed
represented their experienceswith Wyatt and his problem
behaviors.After Laura and Martin made revisionsand additions, the
resulting summarystatement read as follows: “When he isengaged in a
preferred activity and is pre-sented with a demand related to an
un-preferred activity, Wyatt either makes noresponse or is
noncompliant, hits, kicks,and screams in order to escape from
thedemand. This is more likely to occur if heis hungry, rushed, or
tired.” The sum-mary statement was also written as a be-havior
diagram, depicted in the top sec-tion of the form in Figure 1.
Identifying Family Routines for Intervention
Routines such as getting dressed forschool or work in the
morning, eatingmeals at home and/or in a restaurant,going shopping,
bathing, toileting, andengaging in various leisure activities
areinherent in the structure of virtually allfamily ecologies. One
of the core com-ponents of contemporary family-centered
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220
FIGURE 1. Hypothesis diagram and intervention plan developed in
collaboration with Wyatt’s parents regardingproblem behaviors at
home. Note. From Functional Assessment and Program Development for
Problem Behavior: APractical Handbook, 2nd Edition by
O’Neill/Horner/Albin/Sprague/Storey/Newton. © 1997. Reprinted with
permissionof Wadsworth, a division of Thomson Learning:
www.thomsonrights.com
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VOLUME 17, NUMBER 4, WINTER 2002
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positive behavior support is the notionthat family routines
constitute a primaryunit of analysis (Lucyshyn, Blumberg,
&Kayser, 2000). Thus, behavior supportinterventions should be
designed to helpfamilies support children in the midst ofdaily
routines, so that they experiencethese interventions as practical
tools foraccomplishing the necessities of liferather than as add-on
programs that addto their existing burdens and may actu-ally
interfere with their ability to functionas a family.
The Mallard Family. In identifyingthe primary behaviors of
concern, Lauraand Martin implicitly identified problem-atic
routines for Wyatt as well. For ex-ample, they noted that Wyatt
“does notget his agenda the majority of the timebut it also depends
on the severity of thesituation—[we] don’t sweat the smallstuff ! .
. . Eating, toileting, and sleep-ing—Wyatt controls.” In
discussionswith the consultant, Laura and Martinwere encouraged to
identify more explic-itly a few key routines for intervention.They
selected the aforementioned meal-time and toileting routines, as
well ashand washing, tooth brushing, and dress-ing in the morning
as the primary areasof concern. They decided that Wyatt’sbedtime
routine, although problematic,was not a top priority at that time
andcould be addressed later on, if necessary.
Phase 3: Collaborating toDevelop a Behavior
Support Plan
Horner (1997) noted that positive be-havior support requires
fundamentalchanges with regard to how support isdesigned and
implemented vis a vis tra-ditional approaches to behavior
manage-ment. These changes fall into three areas.First, a change
occurs with regard to thedesired outcomes of the intervention
be-cause mere reduction of problem behav-ior is no longer the only
goal. Rather, thegoal is to produce a substantive, durablebehavior
change for the child and mean-
ingful lifestyle enhancements for thechild and family. Second, a
change occurswith regard to the comprehensive natureof the
intervention because more thanone intervention procedure will
almostalways be required. Finally, a change oc-curs in the contexts
for intervention be-cause it is applied in the real environ-ments
in which people live, learn, play,and work instead of in highly
structuredand controlled settings.
An effective positive behavior supportplan requires more than
conceptualchanges with regard to the desired out-come, the nature
of the intervention, andthe intervention contexts. The plan
itselfmay involve changes related to variablessuch as physical
setting, medications,schedule, teaching strategies,
interactionstyle, and/or consequences for behavior.In addition, the
process by which theplan is designed and implemented “in-volves
change in the behavior of the fam-ily, teachers, staff, or managers
in varioussettings” (O’Neill et al., 1997, p. 65).Given the scope
of the changes that maybe required, the active involvement offamily
members in the design and imple-mentation of behavioral
interventions“may be the most important variable thatdetermines
whether the intervention willbe effective and implemented with
fi-delity and durability” (Vaughn et al.,1997, p. 186). As Dawson
and Osterling(1997) noted,
Because parents spend so much time withtheir children, it is
recognized that they canoften achieve greater understanding oftheir
child’s needs and provide unique in-sight into creating a treatment
plan. Byincluding parents in the treatment of chil-dren, greater
maintenance and generaliza-tion of skills also can be achieved. . .
.[I]ncluding parents in the treatment ofyoung children with autism
can [also] in-crease parents’ feelings of relatedness withtheir
child and increase their sense ofcompetence as parents, thereby
decreasingemotional stress and facilitating well-being.(p. 320)
Of course, a positive behavior supportplan must be directly
based on the resultsof the functional assessment process.
Specifically, interventions related to theidentified setting
events and antecedentsare included in order to make the prob-lem
behaviors irrelevant. Interventionsthat involve teaching and
promoting de-sired and alternative behaviors are de-signed to make
the problem behaviorsrelatively inefficient. Finally,
interven-tions related to the consequences orfunctions are required
to make the prob-lem behaviors ineffective. O’Neill et al.(1997)
suggested that the behavior dia-gram that was generated from the
assess-ment be used to brainstorm multiple in-tervention strategies
related to each ofthese components. From this list of
sys-tematically derived intervention possibil-ities, the family
members responsible forimplementing the support plan can thenmake
decisions about which strategiesconstitute the best fit with the
family’svalue and belief system, time and re-source constraints,
and priorities.
The Mallard Family
Once the assessment process was com-pleted, it was not difficult
for the collab-orators to develop an extensive list of
in-tervention possibilities related to Wyatt’sproblem behaviors.
This was accom-plished during a brainstorming session inwhich all
three used the behavior dia-gram depicted on the top of Figure 1
togenerate potential strategies in each ofthe four main areas. From
the extensivelist of potential strategies, Laura andMartin selected
several to implement atthe outset (see the bottom section of Figure
1).
With regard to setting events, thefunctional assessment
suggested thathunger was a major setting event forWyatt’s
noncompliant and aggressive be-havior. His parents were concerned
thathis food intake was nutritionally inade-quate and observed that
“a lot of behav-ior comes out when he’s hungry.” Laurafelt that she
would be more able to en-sure that Wyatt ate a balanced diet if
sheroutinely prepared morning and eveningsnacks for both children.
She and Martindecided that, due to time constraints andthe fact
that hunger was the primary set-
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FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES
222
ting event, they would not include inter-ventions related to the
other two settingevents as part of the initial plan.
With regard to antecedents, the Mal-lards decided to use (a)
visual schedulesto enhance the predictability of the rou-tines
Wyatt frequently resisted and (b) symbols for food and drink
choices to provide Wyatt with opportunities formaking choices
related to mealtimes.Laura explained, “[We] chose the
[visualschedules because] we realized that hewas a visual learner,
so it was a logical wayto go.” Within-task visual schedules(Mirenda
& Erickson, 2000) were de-vised to assist Wyatt in completing
theidentified routines more successfully,thereby reducing the
likelihood that hewould engage in problem behaviors toescape from
them. The visual choice-making symbols were provided to assistWyatt
in choosing the foods he wished toeat for snacks and for some
meals, withthe hope that this would reduce his food“pickiness” and
the problem behaviorsthat appeared to be related to it.
Martinprovided this rationale:
If you start rhyming a whole bunch of[food choices] off, he has
absolutely no in-terest; but if you start showing him the
pic-tures, just point to all of them, he [might]see it and say,
‘Oh, that.’ Because by thetime you get to the third thing just
verbally,he forgot what the first thing was. At leastthat’s what I
think. I think [they’ll] workwell.
Teaching strategies for modeling andprompting the use of the
visual schedulesand choice symbols were also included inthe plan
because it was unlikely thatWyatt would understand how to usethese
supports without adequate instruc-tion from Laura and Martin.
Finally, theMallards agreed that, when he completedroutines
successfully or asked for food ordrink items using either the
symbols orhis speech, they would provide enthusi-astic praise and
extra attention in addi-tion to the item requested. They alsoagreed
that if problem behavior occurredthey would attempt to (a) redirect
himback to the unpreferred routine ratherthan allowing him to
escape from it and(b) avoid providing him with preferredactivities
as much as possible at that time.
Phase 4: Collaborating toImplement and Revise the
Support Plan
One of the major difficulties in imple-menting behavioral
interventions is re-lated to maintenance and sustainabilitybecause
the effort and time commitmentrequired to carry out such
interventionsover time may be beyond the ability ofmany families.
As Schwartz (1997) noted,“Anyone who has conducted a
functionalanalysis of problem behaviors recognizesthe difficulty of
matching effective inter-ventions to specific behaviors and
con-texts. The difficulty increases when theemphasis is on do-able
and sustainableinterventions” (p. 213). However, sev-eral recent
studies (e.g., Fox, Vaughn,Dunlap, & Bucy, 1997; Lucyshyn et
al.,1997; Vaughn, Dunlap, et al., 1997)have provided evidence that
a parent–professional collaborative process maysubstantially
increase the willingness of afamily to continue the intervention
afterthe initial stages have passed. Part of thiscollaboration
involves handing over tothe family as many of the tools and
strate-gies used during intervention as they areable to manage and
providing them withinstruction and ongoing support regard-ing
implementation.
The Mallard Family
The consultant provided Wyatt’s familywith access to a software
program, Board-maker™ (Mayer-Johnson Co., 1994),which they used to
create the necessaryvisual supports. The software producespicture
communication symbols (PCS;Johnson, 1994) that can be used to
de-sign and print visual schedules, scripts,and choice-making
displays. One ofWyatt’s preschool teachers providedLaura with
instruction about how to cus-tomize the PCSs in Boardmaker™
tocreate visual supports specific to Wyatt’sneeds. As Laura was
already computerliterate, she quickly learned to use thesoftware
and, together with the consul-tant, developed a number of visual
sched-ules. In addition, midway through theintervention period,
Laura and the con-sultant attended a local workshop con-
ducted by a nationally known expert inthe use of visual supports
for childrenwith autism. Laura had many ideas aboutthe types of
supports that Wyatt neededand throughout the intervention
periodmade modifications to them.
After the visual supports were created,the consultant provided
brief written in-structions to Laura and Martin abouthow to use the
visual supports on an on-going basis during daily routines.
Usingdemonstration and role playing, shemodeled how to direct
Wyatt’s attentionto the display, point to each of the sym-bols in
sequence, provide verbal direc-tions that were brief and relevant,
andprovide praise or corrective feedback asappropriate. Following
the initial train-ing, the consultant stepped back and of-fered the
family ongoing support only asneeded. This support included
valuingwhat each parent had to say, respectingtheir actions, not
taking sides, givingthem time to communicate with eachother rather
than intervening immedi-ately when problems occurred,
modelingproblem-solving skills, and providing re-sources and advice
when asked to do so.Thus, implementation of the behaviorsupport
plan took shape primarily underLaura and Martin’s direction.
Morning and Evening Snacks. De-spite the Mallards’ initial
enthusiasmabout providing regular morning andevening snacks to
Wyatt and his brother,this component of the intervention wasnot
implemented consistently. Accordingto Laura, morning snacks were
providedmore often than those in the evening:
I ask [Wyatt] if he wants breakfast and if hesays, “No,” then at
9:30, I bring out asnack for him and Elliott to eat so that atleast
he has had something in his stomach.[That way], if by 11:00 I can’t
get him toeat, he’s not going to school on an emptystomach. [But] .
. . before bed, it’s just sohairy we tend to forget about it. If
every-body is very calm, then we will [rememberthe snack]—but he
will often ask us forsomething if he’s hungry when he’s goingto
bed.
The Mallards’ inability to implementthis component of the
support plan con-sistently can probably be related to the
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concept of “goodness of fit” that hasbeen described by several
authors (e.g.,Albin, Lucyshyn, Horner, & Flannery,1996; Bailey
et al., 1990). Behavior sup-port plans that exemplify goodness of
fitinclude at least the following characteris-tics: (a) Key players
are comfortable withthe plans and strategies; (b) plans
areconsistent with the strongly held valuesand living patterns of
the persons in-volved; and (c) plans tap into existing re-sources
so that the required time, effort,and dollars are not prohibitive
(Snell,1997). In this case, although the supportplan appeared to be
consistent withCharacteristics (a) and (b), Laura’s previ-ous
comment suggests that the time andeffort required for
implementation wasperhaps not available as regularly as
theyinitially planned. Thus, implementationfailure can be accounted
for in this caseby a lack of goodness of fit rather than by,for
example, lack of motivation or will-ingness on the part of the
family to fol-low the plan they helped to design.
Visual Schedules and Choice Sym-bols. In contrast to the
strategy formorning and evening snacks, Laura andMartin were able
to implement consis-tently the use of a variety of visual
sched-ules to assist Wyatt through daily routines.Periodic counts
of Wyatt’s “following hisown agenda” behaviors by Laura andMartin
suggested that this interventioncomponent was effective in reducing
thefrequency of his behavioral episodes fromapproximately 20 per
day prior to inter-vention to 4 or fewer per day 4 and 6 weeks
later. In addition, the Mallardsreported a marked increase in the
fre-quency of Wyatt’s attempts to do thingsfor himself during daily
routines. Towardthe end of the intervention period, Lauracommented,
“[We] didn’t have a prob-lem implementing the visual sched-ule. . .
. The only problem was where toor what to start with. [We] didn’t
wantto bombard him with stuff so it was justchoosing which ones
would be most ef-fective at the time.” Examples of Wyatt’suse of
visual schedules and choice-making displays are provided for each
ofthe target routines in the sections thatfollow.
Toileting. According to Laura, Wyattimmediately recognized and
liked the vi-sual schedule that was posted in the bath-room to
depict the steps involved in toi-leting. From the outset, the
symbolsappeared to exert considerable controlover his behavior. For
example, the initialtoileting schedule contained a PCS sym-bol of a
person sitting on the toilet, andLaura noted that, “Because I
suggestedsitting rather than standing to pee, he didso.” After
Laura revised the schedule sothat it had two PCS symbols, one of
aperson standing to urinate and anotherof a person sitting to
defecate, Wyatt “re-verted to his preference for peeing—standing.”
Wyatt’s revised toileting sched-ule is depicted in Figure 2.
Laura reported that, over the inter-vention period for which
documentationwas available (i.e., 6 weeks), Wyatt pro-gressed from
wearing diapers 100% ofthe time to urinating in the toilet
inde-pendently most of the time at home andin untrained settings
such as his pre-school. Laura offered the following anec-dotes:
The other day they [Wyatt and Elliott]were wrestling. He ran
down [the hall] andI thought he was still playing, [but] he raninto
the bathroom, [urinated in the toilet],ran back, and continued
playing.
One day I was sitting down here and I hearthis ominous noise and
I think, “Oh my!”So I go tearing upstairs and Elliott’s stand-ing
in the bedroom smiling, and I look atWyatt ‘cause I know the
toilet’s flushedand Wyatt’s standing there looking nor-mal, and I
thought, “What’s going on?”Wyatt goes, “Mommy, I go pee pee.”
He’dwalked in there of his own accord, dideverything, flushed it,
walked back in themiddle of one of his favorite movies . .
.completely independently—and he’s donethat a few times now!
Hand washing. Wyatt watched Lauramake a pictorial schedule
depicting thesteps of his hand-washing routine andplace “hot” and
“cold” symbols on thetaps of the bathroom sink (see Figure 3).Wyatt
immediately “read” the hot waterand cold water symbols to Laura,
and webegan to follow the schedule as it was de-picted. He began to
rinse his hands thor-
oughly only after Laura revised theschedule to include a “rinse
hands” step.In addition, he was no longer afraid toturn on the taps
by himself after the hotand cold water taps were clearly
labeled.Martin reported a concomitant decreasein Wyatt’s problem
behaviors during thisroutine as well:
I found the ones in the wash room [mosthelpful]—“after you go
pee, you wash yourhands,” which really helps because hewould fight
you on that. Now you point tothe picture and he will do it that
way, sothat’s helped.
Teeth brushing. Like the hand-washing schedule, Wyatt’s
teeth-brushingschedule depicted all of the essential stepsin this
routine. Laura noted, “I’ve gothim brushing his teeth before he
goes toschool, which has never happened be-fore. And he doesn’t
fight that at all.”
Dressing. Shortly after a schedule de-picting the steps in his
morning dressingroutine was put up in Wyatt’s room,Laura suffered a
back injury and was un-able to get out of bed. Laura was soproud to
find that “Wyatt got himselfcompletely dressed without help by
fol-lowing the pictures, [except to say] ‘Iwant help’ for one
sock.” Over time, sherevised the dressing schedule to includea
“What’s the weather like, and what doI wear outside?” section, to
teach Wyattto make these decisions. For example,Laura would ask
questions such as,“What’s the weather like outside?” and“Which coat
do you want to wear?” andWyatt used symbols (e.g., “rainy,”
“bluecoat,” “yellow boots”) to respond andselect the appropriate
outerwear. Laurareported that this system helped decreasehis
problem behaviors prior to leavingthe house for preschool.
Mealtime. A simple visual schedulefor the mealtime routine also
was intro-duced to remind Wyatt of the expecta-tion that he sit at
the table and eat hisfood. Although use of these supports didnot
appear to affect Wyatt’s mealtime be-havior significantly, he would
occasion-ally look at them and comment “Eat” or“Sit on chair.”
Martin explained, “We’venever really fought him on that. . . .We’ve
never really forced the issue of eat-
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FOCUS ON AUTISM AND OTHER DEVELOPMENTAL DISABILITIES
224
ing. You can’t force-feed a 4-year-old kidno matter how hard you
try.” From thisand similar comments, it appears that themealtime
routine may not have been ashigh a priority for the family as the
otherroutines.
In addition to the mealtime schedule,Laura used Boardmaker™ to
create anumber of food and drink choice-makingsymbols for Wyatt. He
watched as Lauraselected and printed out these symbolsand even
requested symbols for a num-
ber of foods when he saw them on the computer screen. For
example, atWyatt’s request, Laura included the “icecream” symbol as
one of his food op-tions, even though ice cream was notsomething he
typically chose to eat. Thewisdom of involving Wyatt in the
symbolselection process was evident when Lauraput the food choice
PCSs on the fridgeand he immediately asked for a ham-burger, one of
his selections. He hadnever asked for a hamburger at home be-
fore but happily ate it after Laura quicklyprepared it.
Wyatt’s use of the symbols to makefood choices generalized
almost immedi-ately to both Martin and his respiteprovider, with
the result that the range offoods he would eat expanded
consider-ably. Laura recounted how Wyatt usedthe food choice array
in a new way:
Today he came in here, he wanted a hotdog while I was cooking
the potatoes [but]
FIGURE 2. Wyatt’s revised toileting schedule.
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I hadn’t started the hot dog yet. He gotreally mad and he came
and he grabbed it[the hot dog PCS] off the fridge, pointedto the
hot dog and said, “I want a hotdog.” That’s the first time I knew
he wasso aware of it. He grabbed it and pointeddirectly to it and
he was like, “See, this iswhat I want.” So, I said, “Whoa, I’ll
makethe hot dog right now.” It thrilled me be-cause he usually just
scans it [the choicearray] like a menu and picks what he wants.
This was the first time he really used it toget his point
across.
Conclusions
Previous descriptions of family-centeredpositive behavior
support have empha-sized the importance of professionals’“relating
to families as colleagues, recog-
nizing family expertise, and conductingassessment and
intervention activitieswith families in their homes and
commu-nities” (Lucyshyn et al., 2000, pp. 113–114). The need for
participants to cometogether around a common goal and tocooperate
in ways that consider the per-spectives of each is also critical to
thisendeavor. All of these elements wereevident throughout the
assessment and
FIGURE 3. Wyatt’s revised hand-washing schedule.
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intervention period described for theMallard family, as each
participant cameto recognize and appreciate the perspec-tives of
the others. As they shared in-formation and perspectives, all
threeparticipants arrived at a new, shared un-derstanding of Wyatt
and his needs. Thesuccessful nature of the collaborative pro-cess
was reflected in a comment Lauramade toward the end of the
consultant’sformal involvement with the family:“You [the
consultant] may have moreeducational expertise in this [than wedo],
but you didn’t make us feel sec-ondary.”
Successful collaboration, however, isnot sufficient in order for
family-centered positive behavior support inter-ventions to be
effective. In addition toreducing or eliminating behavior
identi-fied as socially problematic, such inter-ventions should
also result in an im-proved quality of life for the focusindividual
and his or her family. In thisregard, Albin et al. (1996) suggested
thatpositive behavior support plans that “in-clude only
child-focused strategies, butfail to address needs of the family as
awhole, [are] not likely not to be a goodcontextual fit” (p. 93).
They also notedthat, ideally, behavior support plans withgood
contextual fit “will strengthen thefamily as a unit” (p. 91). These
state-ments underline the importance of con-sidering factors such
as family relation-ships, communication styles, and
culturalbackgrounds in both the design and im-plementation of
positive behavior sup-port plans.
The collaboration between the Mal-lards and their consultant
exemplified theneed for considering multiple aspects ofthe family
ecology, especially with regardto Laura and Martin’s divergent
com-munication and parenting styles. Martinoffered this
insight:
What with discussing this whole situation,I find out a lot more
about what’s goingon during the day. Where Laura might takea lot of
things for granted that she may nottell me . . . when we’re sitting
here [at themeetings with the consultant], things willcome out and
I go, “Really?” It does helpin terms of our communication
aboutreally what’s going on with Wyatt and fill-
ing each other in. We usually talk aboutthings afterwards: “Oh,
he does really dothat?” It does give me a different outlookon
Wyatt.
Laura and Martin also came to under-stand more about why Wyatt
reacted tothem differently at different times. Mar-tin noted, “I
guess in most cases Laura isat home with the kids all day so she
hasmore contact. Weekends are usually [a]completely different story
than the setstructure during the week. It’s usually alittle more
open.” Laura added, “We’velearned that too. And I don’t know thatwe
noticed that before. What you [Mar-tin] deal with and what I deal
with arenot the same . . . necessarily.” Out of thisunderstanding
came a new appreciationfor the positive aspects of their
divergentparenting styles. Laura in particular madean effort not to
interfere with interac-tions between Martin and Wyatt. Towardthe
end of the intervention period, shemade the following comment:
When I hear Martin dealing with Wyattand . . . realizing our
different attitudes toparenting, I’ve really tried to . . . pull
backand not get in their faces about doing it myway. . . . His way
is different and so I’vetried to accept that his way is different
andnot wrong—just different. So I really triedto back off, and
that’s a result of this [sup-port plan] as well.
Laura and Martin were able to usetheir increased communication
and un-derstanding to solve problems that aroseduring the initial
intervention period.For example, during one of the regularmeetings,
they discussed an incident thathad occurred earlier that day with
Wyatt,which Laura referred to as a “meltdown.”Together, they
reviewed and analyzedthe incident in detail and developed aplan to
prevent its recurrence and to re-spond to it, if necessary.
In addition to improved parent-to-parent communication, Dunlap
and Fox(1996) noted that another importantquality-of-life indicator
that should resultfrom an effective behavior support pro-gram is
improved social relationships,both within and outside of the
family.Decreased family stress and increased
positive interactions among family mem-bers are often seen as
positive side effects,once effective behavior supports have
re-sulted in reduced problem behavior. Thiswas certainly the case
for Wyatt and hisfamily, as described by Laura:
Our family certainly benefited [from thisintervention]. Life is
a little easier andquieter, and our confidence in
handlingsituations and foreseeing situations has grown. . . . Wyatt
probably benefited themost without even realizing it because itmade
his life easier or at least less stressful,which is a good thing
for him. And perhapsfor Elliott, because they’re getting
alongbetter and when Wyatt’s uptight, Elliottgets nervous—so
Elliott’s [as] happy as hecan be, some days.
With regard to the interaction be-tween the two brothers, Laura
reported,“Wyatt and Elliott played puzzles for 20minutes
[yesterday], and that certainlywasn’t on his agenda for the day.”
Mar-tin agreed, “They’re playing togethermuch better than they
were.” Both par-ents reported that they frequently hearWyatt call
to his brother, “Come on, El-liott, come and play.” Wyatt’s
interest incrafts and drawing activities at home alsoincreased
substantially once the interven-tion was in place, and he began to
spendtime engaged with his family in these ac-tivities. For
example, during one of theconsultant’s visits, his parents
proudlydisplayed a Mr. Potato Head picture onwhich Wyatt had cut
out, glued, andprinted his name over a 40-minute pe-riod. Laura and
Martin also observedWyatt reaching out more to other chil-dren over
the course of the intervention.One day, he played at home with the
6-year-old sister of a classmate and askedher to come in to play
again on an-other day. When she responded that she couldn’t, Wyatt
tried to coax her tochange her mind, saying, “Come on,Nina, come on
in.” He was happy whenshe agreed to come 2 days later, and gaveher
a hug as she left. His parents werethrilled and commented that it
was “niceto see him inviting others in.”
Perhaps the most important test of theeffectiveness of any
family-centered col-laboration is the extent to which its ef-
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fects endure over time. Positive behav-ioral interventions that
truly exemplifythe concept of goodness of fit (Albin et al., 1996)
should continue to be im-plemented even after formal
consultantsupports are discontinued because theyhave become
seamlessly integrated intothe family’s lifestyle and interaction
pat-terns. This appeared to be the case forWyatt and his family,
who continued touse visual supports at home for the re-mainder of
his time at preschool, whichextended for 5 months after
terminationof the initial intervention. One year later,the
consultant contacted Laura and Mar-tin to follow up on Wyatt’s
progress dur-ing his kindergarten year in school. Theyreported that
his noncompliant behaviorat home was greatly diminished, and
theyeven described him as “eager to please.”Laura noted that she
also had initiatedthe use of visual supports in several newareas.
For example, symbols for variousclothing items were posted on the
draw-ers of his dresser to aid him in dressingmore readily and
independently. He alsoused a job chart at home with symbolsfor
tasks such as setting the table, mak-ing his bed, and putting his
laundry away,as well as a visual schedule at school de-picting his
activities and choices. Lauraalso reported that Wyatt’s language
andplay skills had improved dramatically, ashad his drawing skills
and his relationshipwith his brother.
Finally, it is important to note that thebenefits of
family-centered positive be-havior support are not achievable
with-out the expenditure of considerable timeand effort on the part
of both the con-sultant and the family. It should be clearfrom the
example of the Mallard familythat the consultant and the family are
re-quired to enter into a reciprocal contractof commitment to both
the collaborativeprocess and the implementation of thebehavior
support plan that results fromthat collaboration. This may appear,
onthe surface, to be a much less efficientmodel for behavior
support than the tra-ditional expert model in which a behav-ior
consultant seeks information from thefamily in order to design a
support planto address a child’s problem behavior butthen makes all
of the necessary decisions
about what to do and how to do it andmay implement the plan as
well. How-ever, the likelihood of achieving durable,meaningful
changes that are integratedinto the ecology of the family are
muchless likely without “buy in” from the fam-ily during all
phases, including assess-ment, intervention planning, and
imple-mentation. Thus, it can be argued thatthe expenditure of the
additional timeand effort required for family-centeredbehavior
support has the potential ofbeing more “cost effective” in the
longrun. This certainly appeared to be so forthe Mallards who, when
asked to evalu-ate the success of the collaborative in-tervention,
assigned it a score of 4 on a 5-point scale (1 = not at all
successful and5 = very successful). When asked if it wasworth the
effort, Laura emphatically re-sponded,
Oh, my, and 10 times more. For us it’sbeen immeasurable—the
schedules havehelped immensely when time is an issue,such as before
school. . . . It helps Wyattbecause there’s a consistency for him.
Ithink . . . the biggest thing was that Mar-tin and I actually sat
at a table and discussedit [Wyatt’s behavior] together. We
didn’tused to talk about it; we just dealt with it.There was so
much time spent dealing withit that we never actually had time [to
talk]. . . . It’s just been an incredible expe-rience for us as far
as learning goes.
ABOUT THE AUTHORS
Joanne Kay Marshall, MA-LT, is the clinicalcoordinator of the
early intensive behavioral in-tervention program for children with
autism atthe Delta Association for Child Development.She was the
coordinator of LEAP Preschool inDelta, BC, at the time this case
study was con-ducted. Pat Mirenda, PhD, is an associate pro-fessor
of special education at the University ofBritish Columbia and
conducts research inaugmentative communication and positive
be-havioral supports. Address: Pat Mirenda, Fac-ulty of
Education,University of British Colum-bia, 2125 Main Mall,
Vancouver, BC V6T 1Z4,Canada, e-mail: [email protected]
AUTHORS’ NOTES
1. This paper is based on a thesis completed inpartial
fulfillment of an MA degree in
Leadership and Training (MA-LT) by thefirst author at Royal
Roads University inVictoria, BC.
2. The authors are grateful to the “Mallard”family for their
participation in the collab-orative process and for allowing us to
sharetheir story with others.
NOTE
All family names are pseudonyms.
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