How to Baffle and then Appreciate a Psychiatrist:

A Look at Complex Needs and Setting Event Strategiesfor Individuals with Intellectual Disabilities

Presenters:

Dr. John C.C. Chan, M.Sc., M.D., FRCPC

John Kosmopoulos, B.A., BST, MA(c)

March 25th, 2011Kingston, ON

Objectives

§ Applied Behavior Analysis & Behaviour Consultation

o Setting Events: Definitions & Typeso Traditional & Expanded Models of Behaviour Analysiso Biopsychosocial & Setting Events Assessment Modelso Assessment of Setting Eventso Setting Event Intervention Model

§ Psychiatry & How The Two Disciplines Shall Meet

o Interdisciplinary Support Flowcharto Complex Cases: Interactive Vignetteso Setting Events & Biopsychosocial Intervention Models

SETTING EVENTS

Applied Behavior Analysis & Behaviour Consultation

Setting Events• Setting events are often referred as “slow triggers” or “setting

the stage” for the likelihood of behaviour.

• Setting events are types of antecedents that can precede or occur at the same time as a problem behaviour.

• In specific terms, setting events may be defined as broad, complex and distant antecedent events or conditions that may occur days before or simultaneously with immediate antecedents across different settings and temporarily alter the effectiveness and value of reinforcers (Alberto and Troutman, 2006).

Setting Events

• Setting events strategies address the specific events that increase the likelihood that immediate antecedent events will evoke a problem behaviour

• Setting event strategies make the behaviour less likely.

Setting EventsExample: • few hours of sleep or is tired (presence of

setting events / slow trigger) • less likely to fulfill a request to do a task at

work (immediate antecedent / fast trigger) or any other setting

• Would normally be cooperative with the same request because they got a good night’s sleep (absence of setting events / slow trigger).

Traditional & Expanded Model of Behaviour Analysis

(Adapted From: Sprague & Horner, 1999)

Types of Setting Events

• Physiological

• Environmental

• Social

• Motivational

Physiological / Biomedical Setting Events

• Not enough exercise • Agitation due to

emotions,• Physiological conditions • Sleep disturbance • Illness • Pain • Allergies • Infections • Injury Mood • Mental illness

• Hunger/Thirst• Hypothyroidism • Menses • Medication changes• Mediation dosage and

administration problems

• Medication side effects • Difficulty sleeping • Constipation • Headache • Stomach problem • Lethargy

Environmental Setting Events

• Crowded conditions • Barren environment • Noise level • Heat/Cold • Time of day • Music • Physical lay out of

environment

• Group instruction • Independent seatwork • Curriculum • Being late for school • Staffing patterns • Moving to new

school/home • Transitions

Social Setting Events

• Major life changes • Fight with peers • Negative social

interactions • Family divorce/Discord• Certain individuals • Losing a game

• Changes in teacher or classmates

• Fight on the bus or playground

• Loss of a loved one• Expectations• Lack of rapport

Motivational Setting Events• To escape aversive situations• To obtain attention or tangible• To escape / remedy / decrease anxiety, medical

events, discomfort, pain, etc.• To relieve boredom• To increase or decrease stimulation• Deprivation of biological reinforcers (e.g., hunger,

thirst, etc.), environmental and social reinforcers (e.g., quiet environment, adequate support and resources)

• To make things easier (less effortful)

Examples Of The Traditional ABA Models

• Why did the task, that the person is able to do and would normally comply with, provoke problem behaviour?

Example of Expanded Model of Behaviour Analysis

• The setting event (slow trigger) “sets the stage” and “increase the likelihood and motivation” for problem behaviour when a demand is placed.

The Synergy Of Setting Events• Notice how each of these potential setting events may be available

at the same time for the challenging behaviour of hitting:

╬ Physiological Setting Event = cold / flu ╬ Environmental Setting Events = high noise level & density of

people╬ Social Setting Event = aversive demand situation(s)╬ Motivational Setting Event = to escape (by hitting) / deprivation

or satiation states / to be left alone / to enter a peaceful environment / to help her cold / flu symptoms

• Psychiatric symptoms (e.g., negative affect) may be a synergy or cumulative impact of setting events (Carr et al., 2003; Durand & Mapstone, 1998).

Biopsychosocial Model (BPS)• Biological

o Medical conditions, medication side effects, syndromes, developmental, etc.

• Psychologicalo Mental / emotional health, psychiatric, cognitive

abilities, coping with stressors

• Socialo Social and physical environments (interactions and

supports), stimulation, choices, motivation

Biopsychosocial & Setting Events Assessment Models

• Both are compatible and complimentary• Both are forms of comprehensive assessment

o BPS: used as an overall assessment of a clinical problem or problem behaviour for possible diagnosis and biological, behavioural, psychological remediation

o SE: used as an overall assessment specific to the likelihood,

context and function of problem behaviour

• Both are “holistic” (they consider the whole person)• Both are best practice and evidence-based• Psychiatrists and behaviour consultants use both models

but conceptualization is different based on each discipline

Setting Events: Assessment Methods

• Example assessment procedures & tools

o Interviewso Functional Assessment Interview (O’Neill et al., 1990)

o Scaleso Setting Events Checklist (Gardner et al., 1986) oProblem Behavior Questionnaire (Lewis et al., 1994)oContextual Assessment Inventory (McAtee et al., 2004)oAnalysis of Setting Events Questionnaire (Kosmopoulos, 2006)

Analysis of Setting Events Questionnaire (ASEQ) (Kosmopoulos, 2006)

o Comprehensive, multi-itemed (117) rating scale.o Single or Inter-observer administrations.o Likert-type scale (0-3) to determine the degree of

relationship or the level of association between the specific target behaviour and various setting events (currently or within the last month).

o 2-1 Scale (setting events & function of behaviour).o Reviewed and supported by psychologists.o Data analysis section and grapho Good overall psychometric propertieso Other scales limited in scope, diagnoses, settings and

psychometric properties (based on research)

ASEQ ASEQ – 4 SETTING EVENT CATEGORIES– 4 SETTING EVENT CATEGORIES

Traditional: medical illness, medication change, moods, allergies, constipation, diet, etc.

Unique: family history, syndromal features, brain injury or dementia, licit / illicit drug use

Traditional: time of day, physical environment, routines, seasons

Unique: stressful family environment, access to transportation, professional assistance, medical / dental appointments

Traditional: demands, lack of choices, critical incident, disappointments, proximity, level of attention, etc.

Unique: specific treatments provided, language barrier, limited coping abilities, inconsistent implementation of strategies

Traditional: to access attention, to escape or avoid an aversive situation, to relive boredom, to access tangibles, communicate wants and needs, etc.

Unique: as a category in SE assessment tools; to satisfy a biological need or deprivation state (e.g., hunger, thirst, sleep); response effort

ASEQ VARIABLES – TRADITIONAL & “UNIQUE” SEASEQ VARIABLES – TRADITIONAL & “UNIQUE” SE

ASEQ – Who can benefit?

• User-friendly and versatile in its breadth as it was designed to be utilized across:

ages (i.e., children, adolescents, adults) behaviours (e.g., tantrums, SIB, property destruction) diagnoses (e.g., autism, DD, dual diagnosis, syndromes,

mental health, etc.) settings (i.e., home, school, treatment centre, group

home, community, etc.)

• Comments section after each category of setting events

ASEQ-FS (Function Subscale)

• Specific items from each of the setting event categories are itemized according to functions similar to the QABF:

Attention Escape Tangible Sensory I (Physical) Sensory II (Alone / Non-Social)

• On The ASEQ Scale, there are red tags to correspond to items found in the ASEQ-FS data analysis table.

ASEQ – SAMPLE PAGE

On The ASEQ Scale, there are red tags to correspond to items found in the ASEQ-FS data analysis table.

SETTING EVENT INTERVENTION MODEL

• Behaviour support plans that include the setting events treatment model for individuals that present with complex needs compliment interdisciplinary investigations and multimodal treatments.

• The setting events strategy models emphasize a reduction of specific behavioural challenges and behavioural health problems and an enhancement of adaptive alternative and coping behaviours.

• Several setting event intervention models have demonstrated effectiveness and success in their use.

Setting Event Intervention Model (Adapted: Gardener et al., 1986, Carr & Owen-DeSchryver, 2006)

1. Eliminate or minimize the setting events2. Neutralize setting events 3. Redesign the physical environment4. Increase positive interactions and positive

reinforcers5. Teach coping and communication skills

Setting Events Intervention Model

1. Eliminate or Minimize the Setting Event– Modify or minimize the likely occurrence of the setting event for

problem behaviour

• Medical and behavioural advice for illness, pain, sleep problems, overwhelming anxiety, etc.

• Decrease crowding, change fluorescent lights to prevent seizures, decrease noise level, consider visuals within a class, etc.

• Decrease or eliminate demands when tired, reinforce cooperation and communication around setting events, etc.

• Use of communication for seeking medical and emotional support• Provide greater 1:1 attention if required, etc.

– Early intervention for warning signs of behavioural agitation or possible health symptoms

Setting Events Intervention Model

2. Neutralize the Setting Event– Intervene after the setting event occurs but

before the antecedent for problem behaviour

oDecrease demands and aversive events

o Increase preferred activities and routines

oDirectly change the individual's response to the setting event (e.g., instead of fighting, prompt use of negotiation or relaxation)

Setting Events Intervention Model

• 3. Redesign the Physical Environment• Is the physical environment stressful or unpleasant to the

individual?

o Change the physical layout of the environmento Create opportunities to respond in socially appropriate wayso Availability of social interactionso Availability of stimulating activitieso Consider lighting, noise levels, density of people, proximity to

otherso Minimize distractionso Increase visual systemso Adaptations for mobility, navigation, easy entrance and exito safety

Setting Events Intervention Model4. Increase Positive Interactions & Positive

Reinforcers

– Does the person have access to a sufficient variety of preferred stimulating activities?

– Does the person have the skills and opportunities to engage in preferred stimulating activities?

– Does the person have sufficient access and choice of foods?– Does the person have sufficient access to items and activities that are

reinforcing to that person?– Is the activity boring or monotonous to the person?– Are the expectations unclear due to a lack of routine?– Are the established routines inappropriate for that person (i.e. doing

homework before bedtime when they are too tired to think; setting a chore to be done during their weekly TV program; or having a schedule that does not include chosen activities)?

– Is the person’s daily schedule so flexible that the environment seems unpredictable?

– Are there recent changes in caregivers, teachers, staff or peers?

Setting Events Intervention Model

4. Increase Positive Interactions & Positive Reinforcers (continued)

o Increase motivation for appropriate responseso Decrease effort for appropriate responseso Increase preferred activitieso Encourage choiceso Etc.

Setting Events Intervention Model

5. Teach Coping & Communication Skills

o Teach tolerance for waiting, lack of attention, etc.o Teach specific coping skills (e.g., what to do if it’s

noisy, crowded, the bus is late or takes a different route, etc.).

o Teach communication skills re: illness, mood states, discomfort, etc.

o Reinforce all functional communication around the need for support.

CASE VIGNETTES TO BAFFLE & APPRECIATE

PSYCHIATRIC SUPPORT & APPLIED BEHAVIOR ANALYSIS: A COMPLIMENTARY PERSPECTIVE FOR INDIVIDUALS WITH COMPLEX NEEDS

Objectives

• Interdisciplinary Flowchart• Clinical case vignettes• Evidence & observation-informed treatment

rationale • Discussion

Interdisciplinary Support: Flowchart

Vignette 1

• 16 yo female• Non-verbal• No History of Violence• One wk history of sleep, frustration

tolerance, obsession• On Prozac for anxiety• Family members worry about his sleep

Changes

• Few days graduate from school with months of transition

• Pt uncle passed away a week ago

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Physical Observation

• Rocking Back and forth• Slightly febrile and increase pulses• Physical examination grossly normal• OTITIS MEDIA on the Left Ear• Rx - Amoxicillin

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Discussion

• Environmental Changes (Consider setting event and other behavioural strategies)

• Biological Organic Medical difficulties• Sleep issue• Non-verbal is an issue• Physical exam by medics is very important• Cold? Allergies? Constipation? Dental

Caries? Etc…

Vignette 2

• 13 yo male• Short phrase and single words• Some ADL but not all• IQ = 65• Just started a new school

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Vignette 2

• Decrease speech except for a few words• Sleep disruption at night & nap during the day• Enuresis & Smearing feces after BM (new)• Irritable, isolated and oppositional (worsen)• Agitation while waiting at the ER

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Medical Exam

• ‘Normal’• ER MD referral to Beh. Neurologist or C&A

psychiatrist.

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Significant Behavioural Regression

• Physical abuse• Sexual abuse

• Emotional abuse

Significant Behavioural Regression

Sleep problem + language regression + ADL regression

New onset of seizure? Bimodal onset: < 5yo & onset of puberty

Vignette 3

• 14 yo male• Autism and Sever MR• agitation and aggression• Recent move to new group home• Difficulties in adjustment

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Clinical Rationale

• WHY NOW?• Victimized in new environment?• Significant difference in routine?• Puberty Mood disorder ‘equivalents’• New seizure disorder?• Medical Biological Organic?

Vignette 3

• Behavioural specialist working with group home staff to address increase pacing, anger outburst and minor physical aggression

• He struck a staff member• Certified for involuntary Psychiatric

assessment in 72 hours at Schedule 1 facility

Vignette 3

Recently adjusted medication…

• Paroxetine (Paxil) 20 mg po qam (NEW)• Divalproex Sodium (Epival) 250 mg po bid• Quetiapine (Seroquel) 50 mg po bid

Medication

• New agents added or removed chronologically related to behaviour?

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Vignette 4

• 21 year old mild/borderline DD young female • Recent ER visit for slashing wrist• Three prior overdoses on medication• Recent breakup with boyfriend – feeling hopeless• She hoped to “just get his attention”• Impulsive• Brief & intense relationships• Abusive relationships• Criminal record for mischief• missed social cues

MedicalOrganic

Biological

PsychiatricPsychological

SocialEnvironmentalMotivational

BPS & SE?

Clinical picture

• Lack of awareness• Blame other people for their problems• Cannot cope adequately with stress• Tend to responds in ways that are

stereotypical (not tailored to the situation)• Their inflexibility – vicious cycles of

consequences

Personality disorder

• A set of inflexible, maladaptive character traits• Functional impairment• May cause significant subjective distress to the

person • Affect 2 or more of these areas

– cognition – emotion– interpersonal relationship– impulse control

Healthy Personality

• Enable a person to adapt to stressful situations

Personality Disorder

• They tend to have trouble with relationship, employment or the law

Because personality traits are so ingrained, it is difficult to help people with personality disorders to develop

healthier coping styles

Not all annoying personality traits are symptoms of a personality disorder!

Borderline Personality Disorder (BPD)

• Unstable self-image• Unstable emotion• Chronic feeling of emptiness & fear of abandonment• Intense & inappropriate anger• Recurrent thoughts of self-harm• Impulsive• Unstable & intense relationships• Idealize or devalue other person

Approach to clients

• Inherent difficulty with relationship • Chronic problem• Coexisting mental disorder• Often idealize and devalue staff

Approach to clients

• Crystal clear professional boundary• Clear, consistent interaction style• Avoid manipulation – help clients to adjust

their expectation (reality check)• Validate the clients’ subjective reality of crises• Encourage clients’ problem-solving skills

Treatment

• No Pill can Cure Borderline Personality Disorder!

• Dialectic Behavioral Therapy• Cognitive Behavioral Therapy• Intervention for substance abuse• Family or Group therapy• Treat coexisting mental disorder

Pearls of Wisdom for Staff

• Always remember the bio-psycho-social and setting event models

• NEVER underestimate the environmental, social, psychological and motivational factors

• Medical ailments can contribute to challenging behaviours in DD population

Pearls of Wisdom for Staff

• Medication can help but can BACKFIRE!!!• DD population is exquisitely sensitive to

psychotropic medication • Limited evidence for psychotropic usages

THANK YOU!!!

• For further information on the ASEQ or for future presentations, please contact:

John Kosmopoulos johnkos@rogers.com