BEHAVIOURAL ASSESSMENT REPORT

Name of Client: Date of Birth (DOB): Date of Report: INFORMATION SOURCES The following program is based on:

John Doe September 8, 1994 February 4, 2012

Parent/Classroom staff/Group home staff interviews Review of file documentation Client interview/observation Questions About Behavioral Function in Mental Illness (QABF-MI) completed by Ms. Doe; January 12, 2012 Durand Motivation Assessment Scale completed by Ms. Doe; January 10, 2012 Functional Assessment Interview (FAI) completed by School Behavioural Team (LB, CZ, NB); January 2012; and, EF, XXX Home Supervisor, January 20, 2012

REASON FOR REFERRAL A thorough assessment of John was conducted to provide sufficient information regarding his behavioural needs and abilities. Enclosed is a summary of John based on past reports, staff documentation, staff/client interviews and direct observations. BACKGROUND INFORMATION John Doe is a seventeen year old male with a diagnosis of autism and significant impairments are in the areas of communication and social interaction. John lives at home with his parents, Ken and Barbie, and his younger sister Minnie, age 14. He has an older brother who attends university and does not live at home. John currently attends ABC secondary school and receives respite services from XXX Childrens Homes XXX Home facility. Most recently, Mr. and Ms. Doe have been accessing the services of XXX Home on an increased basis as a means of respite during Johns behavioural crisis. John has a longstanding history of behavioural difficulties, including problems especially with selfinjurious behaviour that range from moderate to severe intensity. Episodes of self-injurious behaviour can last for several minutes at a time and the frequency of these episodes vary dramatically and unpredictably from day to day. Mediator reports indicate that these behaviours are complex and most likely to be multi-functional in nature. Mediators involved in his care could not identify clear antecedents. Further to this, John appears to have an obsessive-compulsive-like quality to his behavioural presentation insofar as he is largely routine-dependent, and will engage in repetitive, ritualistic behaviour regularly throughout the day. He becomes quite anxious when events of the day do not unfold as he expects. This typically leads to outburst behaviours.

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Behavioural Assessment Report

HEALTH AND MEDICATION According to a Status Report, completed by Ms. Barbie Doe (mother), and dated January 4, 2012, John is under the care of the following medical practitioners:

Dr. MT (family physician) Dr. TC (developmental pediatrician) Dr. RN (child psychiatrist)

John has been on a number of different medications in the past; however he is reported to be very sensitive to pharmaceutical intervention, and has responded atypically to medications in the past. As such, success was therefore limited in this regard. Trials have been attempted with the following medications: Dexedrine DMG Ritalin Resperidol Zoloft Abilify Prozac

In April 2011, John was on a moderately low dose of Zoloft, however his self-injurious behaviours tended to escalate in frequency at this time, prompting the discontinuation of the Zoloft and the introduction of a trial of Abilify, an antidepressant. According to parental reports, when Johns selfinjurious behaviours increased over the course of the 2011 calendar year, the dosages of Abilify were increased, though this did not have the desired effect, and he was put on a trial of Prozac just prior to the end of the 2011 academic year. Again, this was unsuccessful. At that time, John was prescribed Clonazapam 1mg (3 times per day), and this remains his most recent prescription, though it is unclear to what extent this medication is being regularly administered at this time. It is likely that Mr. and Ms. Doe are using Clonazepam on an as needed basis, i.e. PRN, in response to severe episodes of behaviour. John also takes 20 mg of Gravol at bed time to aid with sleep. It should be noted that on Friday, January 20, John had a seizure that lasted almost five minutes in duration while at school. This is an uncommon occurrence, and he was immediately brought to the hospital for medical attention, though no clear medical explanation was forthcoming. BEHAVIOUR John primarily has difficulties with severe self-injury. The operational definition has been provided below: Self-Injury: John will hit his face and head area with an open hand or closed fist with moderate to severe intensity when upset, anxious or agitated. In late November 2011, a specialized behavioural school team was temporarily assigned to support John within the classroom setting. Formal behavioural programming was eventually put in place for John in the school setting, with good success, though his behaviours continue to persist and/or reemerge across all environments. Despite this, the specialized school behavioural team was

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Behavioural Assessment Report

reassigned in January 2012, and is no longer available to support John within the classroom setting in a direct-care capacity. No formal behavioural data was available across any of the environments, including home, school, and group home settings, respectively. Moreover, despite numerous direct observations across the different settings, John was not observed to engage in self-injurious behaviours. The following A-B-C chart provides some examples only, as derived from anecdotal information, of Johns problematic behaviours, as documented by his mother. These are not intended to be comprehensive:
Date
Sat. Jan. 14, 2012 Mon. Jan 16, 2012

Setting
Movie theatre In bathroom, sitting on toilet

Antecedent
Sat down in theatre to prepare to watch movie Alone (invisible antecedent)

Behaviour
Began slapping the side of his head continuously Began slapping both sides of his head and face. Hitting continued.

Consequence
Was escorted out of theatre by support staff Ignored (initially)

Thurs. Jan. 19, 2012 Sat. Jan. 21, 2012

Bedroom Home at dinner table

Lying in bed, alone. JD wanted to put a large amount of chili peppers on his spaghetti. Parents prevented him from doing so.

Began hitting side of face (moderate intensity). Began hitting self.

Parents intervened and physically blocked the behaviours. Ignored. Behaviour stopped after approx. 12 minutes. Parents removed meal, and used corrective positive practice (made him sit down at table and try again). Meal continued, uninterrupted.

Ate meal without incident.

Sat. Jan. 21, 2012

Home in hot tub

Engaged in nighttime routine hot tub

Began slapping self.

Parents directed him out of bathtub and sent him to bath (next activity in routine). Parents directed him back to hot tub to try again (positive practice) x3.

Resumed slapping self x3. Mon. Jan 30, 2012 Wed. Feb. 1, 2012 In vehicle En route to skiing; traffic moving slowly. Stopped at lights. Sent to bathroom after having urine accident. Began slapping himself. Began slapping himself. JD continued to slap himself intermittently for several hours. Slapping continued at high intensity,

Blocked and redirected. Second staff called in to support. Attempts to ignore and/or block were unsuccessful. Clonazepam administered. Parents placed winter mitts on him and duct taped them. Slapping stopped.

In bathroom at home

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Behavioural Assessment Report

intermittently.

While the examples provided above do not give a comprehensive account of the frequency, range, and complexity of his behaviours, they provide insight into the severity and nature, and context of his selfinjurious behaviours. According to all mediators involved in his care, Johns problematic behaviours tend to be of moderate to severe intensity, and are brought on by a number of contributing factors, including his need to control environmental outcomes; in response to anxiety-provoking events (anxiety attenuation) typically associated with a change in routine; and, sensory-related needs. He sometimes engages in self-injury as a means of communicating displeasure with outcomes, and ultimately to escape demands. It is unclear at this point to what extent his behavioural presentation is influenced by biomedical factors, i.e., physical pain or discomfort, seizure-related activity, etc. which remain beyond his complete control. It is important that these variables should be investigated further and addressed as soon as possible, as necessary. Duration of behavioural episodes varies, ranging up to several minutes per episode, with the frequency of self-injurious episodes occurring several times per day during high crisis periods. Frequency of outburst behaviours varies dramatically however. The following chart summarizes his Johns behavioural presentation, based on mediator estimates only:
Behaviour SIB Frequency Up to 100(+) per day Intensity Severe Duration Several minutes per episode Discrimination Changes in routine; ritualized patterns same time of day or week; unpredictable at times

All behaviour is communicative. Functional behaviours serve to meet an individuals needs in some way. The purpose of a behavioural assessment is to determine which biomedical, environmental and functional variables are influencing behavioural presentation. In this case in particular, it is important to establish whether Johns behaviours are functional, i.e., within his control and purposeful; and to determine why he engages in the behaviours. If this can be established, then John could be taught functionally equivalent, appropriate replacement behaviours instead. These are meant to build his skills and meet his needs via more appropriate means. A review of available information gathered via a Functional Assessment Interview, completed by his school behavioural team, suggests that John is most likely to engage in self-injurious behaviours when presented with novel communication needs (since this serves to confuse him, and he may not have learned how to convey his thoughts) and other frustrating situations, such as being denied a request or access to a preferred item/activity. He is least likely to engage in outburst behaviours during familiar tasks or when he is able to communicate his wants and needs effectively. A review of a second Functional Assessment Interview, completed by EF, supervisor at XXX Home, suggests that John is more likely to engage in self-injury while in the bathroom or while preparing to shower. He also becomes agitated when required to wait for an activity or task. He is less likely to engage in these behaviours when engaged in a preferred activity, such as tobogganing or watching a

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Behavioural Assessment Report

movie; when wearing his winter mitts; or when eating. Results from the Questions About Behavioral Function in Mental Illness (QABF-MI) questionnaire, completed by Ms. Doe, suggest that the biggest (functional) factor contributing to his self-injurious behaviour is the need to attain attention, followed closely by the need to escape demands or nonpreferred activities, and finally, physical/sensory-related factors. It should be noted, however, that Johns scores across all possible behavioural functions (attention, escape, non-social, physical, tangible) were only mildly discrepant. This further suggests that Johns behaviours are likely multifunctional in nature. Scores on the Durand Motivation Assessment Scale (MAS) produced similar results. The information gathered herein suggests that there are a number of factors that serve to maintain the occurrence of Johns self-injurious behaviours. Since a percentage of his outburst behaviours are functional in nature, i.e., deliberate and purposeful, it is reasonable to assume that these behaviours have been inadvertently reinforced in the past. John has learned to escape demands or exert control and manipulate outcomes by engaging in behaviours that are difficult to ignore or manage effectively. It is likely that well-intended mediators have reacted to his self-injurious episodes by attempting to placate him when he has shown signs of escalation or aggression as a means of preventing his self-injury. However, in so doing, they have inadvertently reinforced the inappropriate behaviours at least on an intermittent basis - sometimes they have worked for him, and sometimes not. Johns episodes of self-injury are particularly problematic because they occur infrequently, often unpredictably, and can be severe in nature. It is important that a consistent approach is implemented that incorporates elements of prevention, behaviour management, and behavioural skill teaching in order to give him the best chance of success. Future behavioural programming should include: accepting choices, teaching relaxation strategies, frustration tolerance, visual schedule/high structure, high levels of program consistency, and opportunities for meaningful social, vocational and leisure activities. Identified reinforcers for John include: edibles such as fast food, cookies, pop tarts, salsa, hot peppers, and ice cream etc. Other possible reinforcers include: watching movies, listening to music, spending time on the computer, playing with beads, and active participation in physical activities such as: swimming, hot tub, skiing, walks, etc. In order to effectively address Johns behavioural presentation, it is important to build skills, and use preventative strategies in conjunction with the application of consistent and appropriate antecedent and consequence-based strategies in a structured, consistent and predictable environment. Ideally, this would be accomplished with the introduction of a comprehensive behavioural protocol, and a consistent application of behavioural strategies across all mediators supporting John. The implementation of a comprehensive and constructive approach will provide John with the best opportunity to achieve longterm behavioural success. Future behavioural programming should focus on teaching and reinforcing John to: accept choices, follow rules/adult direction, engage in functional communication and engage in effective relaxation strategies, meet sensory needs in a socially appropriate manner, as needed, while extinguishing his self-injurious behaviours. Ideally, this would be accomplished with the introduction of a comprehensive behavioural protocol, utilizing specific teaching methods best suited for his learning style: visual cues, highly structured, highly programmed environments, and repetition. John must be subject to clear rules and boundaries of behaviour, rigid and consistent application of behavioural principles, and behavioural incentives for engaging in desired replacement behaviours. RECOMMENDATIONS After extensive review of the information regarding John, several recommendations can be made:

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Behavioural Assessment Report

1. John would benefit from the introduction of a comprehensive behavioural management protocol aimed at teaching effective replacement behaviours, skill building, and preventative practice. 2. John and his parents would also benefit from continued access to behavioural consultation services and ongoing monitoring to help teach, reinforce and maintain appropriate coping strategies and socially appropriate replacement behaviours that serve the same function of his problematic behaviours within the home setting. A management program is necessary that reinforces high levels of structure, increased compliance levels, and promotes a reduction in self-injurious behaviours. 3. To promote a successful home program, it is necessary that increased trained staff resources are made available to the parents within the home setting to facilitate effective program implementation and increased family respite. 4. It is highly recommended that Johns parents, and all others supporting John in a direct-care capacity, access appropriate training in a provincially approved crisis intervention program, including physical intervention techniques, and behaviour management principles, and must be familiar with the behavioural protocol in place for John before working with him in this capacity. All future staff working with John must be acutely aware of his triggers, behavioural patterns, signs of escalation, and behaviour management approach. 5. Given the complexity and range of Johns behaviour, it is necessary to pursue a full medical review to investigate and rule out any biomedical factors that may be contributing to his presentation. This should include examining all possible pain and/or sensory components that may precede outburst behaviour, while also considering medical and pharmaceutical options that may benefit John, especially considering his medical history. 6. Finally, it is recommended that increased access to emergency respite services be made available to the family to help reduce stress levels and caregiver burnout. Ideally, respite services should offer qualified behaviorally trained staff, overnight services, high structure and predictability. 7. Behavioural data should continue to be taken on Johns targeted behaviours, and regular review of his progress is necessary. This practice will serve to inform future intervention practices.

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Pat Veleno, B.Sc. (Specialist) Behaviour Consultant

Dr. BL, Ph. D., C. Psych. Clinical Psychologist