Behavioral Interventions, Vol. 10, No. 2, 101-110 (1995)

CASE STUDY EXAMINING THE RELATIONSHIP BETWEEN

AND DIRECTIVE BEHAVIOR OF STAFF PERSONS IN A RESIDENTIAL SETTING

SELF-INITIATIONS OF AN INDIVIDUAL WITH DISABILITIES

Smita Shukla, AlanV. Surratt, Robert H. Horner and Richard W. Albin University of Oregon, Eugene, Oregon, USA

This case study examines the relationship between self-initiations of an adult woman with severe disabilities and the directive behavior of staff persons in a community residential setting. Hypotheses generated from functional assessment procedures indicated that (a) Susan’s low self- initiations were very likely related to high directive behavior of staff persons, and @) infrequent problem behaviors during the morning routine were maintained by escape from repeated staff demands. An intervention was implemented to enable Susan to increase self-initiation in choice and sequence of activities and simultaneously decrease staff directives. Results and discussion focus on the need for a contextual approach for addressing problematic situations and an affirmation of the effectiveness of the positive behavioral support technology for increasing adaptive behaviors in individuals with severe disabilities.

Research suggests that individuals with severe disabilities can be taught to exercise self-control (Gardner & Cole, 1989; Koegel & Koegel, 1990; Lovett & Haring, 1989; MacDuff, Krantz, & McClannahan, 1993; Morrow & Presswood, 1984; Shapiro, 1981). The opportunity to direct one’s own behavior is likely to promote personal independence (Lovett & Haring, 1989), job performance and maintenance (Lagomarcino & Rusch, 1989; Mank & Horner, 1987; Moore, Agran & Foder-Davis, 1989), on-task behaviors and academic skills (Holman & Baer, 1979; Lloyd, Bateman, Landrum, & Hallahan, 1989; Sainato, Strain, Lefebvre, & Rapp, 1990), and reduce problem behaviors (Koegel & Koegel, 1990; Morrow & Presswood, 1984; Reese, Sherman, & Sheldon, 1984).

Preparation of this manuscript was supported by the US. Department of Education Grant #H133B20004. However, the opinions expressed herein do not necessarily reflect the position or policy of the US. Department of Education and no official endorsement by the department should be inferred. The authors would like to thank Dr. Robert ONeill for his comments on the drafts of the paper. Reprints may be obtained from Smita Shukla at the College of Education, University of Hawaii, Honolulu, HI 96822.

CCC l072-0847/95/020101-10 0 1 9 9 5 by John Wdey & Sons, Ltd.

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However, it is not clear whether greater personal independence in individuals with disabilities serves to change the directive behavior of support persons. It is logical to assume that as one self-initiates tasks and activities, the need for external control might be reduced (Whitman, 1987). The present paper addresses the need to examine the relationship between self-initiations of an individual and directive behavior of staff persons.

METHOD

Problem situation

Susan, an adult woman in a community residential setting, was experiencing difficulties in performing the morning grooming and household chores like laundry and dishes. She would scream loudly when prompted to complete her routines, and would on occasion hit staff members, throw objects, pull her hair and hit her own head. Susan’s staff requested technical assistance in managing problem behaviors during the morning routine. This paper provides a description of the technical assistance (TA) process designed to facilitate successful implementation of the morning routine for Susan and her staff.

Setting and participants

This project was conducted in a house located in a regular residential area that was the home of three individuals (one female, two males) who had been diagnosed as having severe development disabilities and a history of very challenging behaviors. The three individuals had each lived in a state institution for over 15 years before moving into their community home about 2 years before the study was conducted.

Resident

Susan was 35 years old and diagnosed as having Cornelia DeLange Syndrome and severe mental retardation. She was ambulatory, participated in various community-based activities, and worked in a supported employment setting. Susan used gestures, some manual signs, and problem behaviors to communicate. Problem behaviors included screaming, crying, throwing herself on the ground, throwing objects, and hitting staff.

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Three direct care staff persons participated in the study. All three staff persons were female, their ages were 23, 40, and 42 years, and their work experience at the agency was 1 year, 2 months, and 2 years, respectively. All staff participants had some prior experience in human services, though not necessarily in rehabilitation settings.

Measurement phases

Assessment

Functional assessment procedures recommended by O’Neill, Homer, Albin, Storey, 8z Sprague (1990) were used to assess the problem situation and build hypotheses regarding the variables maintaining Susan’s problem behaviors. Initial interviews were conducted with three staff persons and the program manager. The information obtained from the interviews was used to set up the direct observation protocol. Direct observations were conducted for 1-2 h per day for 5 days to observe resident and staff behaviors during the morning routine and to identify the variables that contributed to the problem situation.

Assessment interpretation

The assessment interviews and observations suggested that Susan’s morning routine included a constant series of verbal prompts by staff. The staff woke her up and prompted her to get out of bed, make her bed, get her shower basket, take a shower, and get dressed. It appeared that Susan’s problem behaviors, although infrequent, functioned to provide escape from high rates of task- related staff demands. Other variables which were seen to contribute to problem behaviors during instruction included rapid repetition of demands, little or delayed staff praise for following through with demands, no choices in the sequence of activities to be performed during the morning routine, and the absence of clear signals in the environment indicating which activities to be performed during the day or what staff would be present.

Hypothesis

Based on the functional assessment information, it appeared that staff presented task demands continuously allowing no opportunity for Susan to

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respond to a request before another was delivered. It was also hypothesized that infrequent problem behaviors were maintained by escape from staff demands.

Measurement procedures

Data were collected for one staff behavior (demands) and one resident behavior (self-initiations). A “demand” was defined as any verbal or gestural prompt delivered by staff requesting a behavioral response from Susan. Independent demands were scored separately only if at least 5 s elapsed between subsequent demands. A “self-initiation” was defined as any morning routine behavior that Susan initiated without staff prompt (e.g., getting the shower basket, picking up her laundry, going to the dining table).

Data were collected by the first author during the morning routine which lasted approximately 2.5 h. Direct observation of resident and staff behaviors involved use of video tapes during the baseline condition and in vivo observations during the self-directed picture-schedule and follow-up phases. Data were recorded as the rate per min of staff and resident behaviors across 10 min observation sessions. Anecdotal information on relevant setting events was also obtained through staff and program manager interviews, and through a running record of incidental (nontargeted) observations made during the morning routine (e.g., type of tasks that Susan initiated without prompts, prompts/requests made by staff for types of activities, staff tone of voice). No formal interobserver agreement measures were collected during the course of the case study.

Intervention procedures

Baseline observations

Videotaped observations of Susan and her staff were done during the morning routine. Staff typically woke Susan up and prompted her to complete her grooming, household chores, and breakfast. Behavior data were collected for five consecutive days.

A Self-directed picture schedule training

Based on the functional assessment procedures, it was determined that the critical features of a support plan would focus on increasing Susan’s self- initiations and decreasing staffs repeated delivery of demands. Specific

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contextual elements that needed to be addressed included: (a) allowing Susan to make a choice in the sequence of activities to be performed during the morning routine, for example, breakfast before a shower; (b) reducing task demands, especially during specific setting event conditions like poor sleep, PMS discomfort, visit to a doctor, and absence of a preferred staff person; and (c) increasing predictability for Susan in activity and staff schedules.

The support process included the following procedures. First, two picture schedules were developed. One displayed photographs of all the different activities that Susan performed during the day including the morning routine. The other schedule consisted of photographs of all staff persons who worked with Susan each day of the week.

Second, staff were coached to help Susan use the picture schedule to indicate a choice in the sequence of the activities in the morning routine. For example, instead of telling Susan to take a shower as soon as she woke up, the trainer showed her a picture of two or three different activities and asked her to point out whichever activity she preferred to do first. When Susan indicated her choice, she was not prompted to initiate the activity but praised for making a choice. Staff waited for Susan to initiate the selected activity. Staff were then encouraged to use the same procedure with other activities during the routine. Staff also were trained in using the (staff) picture schedule to inform Susan about who would be working with her on the next shift. For example, before leaving for the day, the staff on a shift would show Susan the photographs of the two staff persons who came on the next shift and tell her who specifically would be working with her.

Coaching staff to train Susan in using the two picture schedules involved modeling the instructional procedure with Susan on how to use the picture schedule, observing staff persons doing instruction and providing immediate feedback, providing written (posted) guidelines to prompt staff about the effective use of the picture schedule, and encouraging staff to self-evaluate instructional behavior and consequent outcomes. The entire procedure was aimed at increasing resident initiative in selecting and starting an activity and reducing staff demands. The training occurred over a total period of approximately 10 weeks. Presentations and discussions were also held with other staff persons who worked with Susan but were not participants in this study. Training content included the use of the two picture schedules and the outcomes for Susan and the staff.

Self-directed picture schedule phase observations Resident and staff behaviors were recorded after the 10 week training

program was completed. This phase lasted for approximately 6 weeks (Sessions

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Data

Figure 1. Rate of staff demands during baseline, self-directed picture schedule, and follow-up phases.

6-12). Data were collected using the same measurement procedures described earlier.

Follow-up data were collected 2 weeks after the last session in the self- directed picture schedule phase. Data included observations of resident and staff behaviors and anecdotal information on events described in the measurement section.

RESULTS AND DISCUSSION

During baseline, the rate of staff demands occurred at a steadily increasing trend (see Figure 1) with a substantial increase in the last session of the phase (mean rate of 1.1 per min). Anecdotal reports emphasized that staff often repeated demands within a 5 s interval. Susan's activity initiations during baseline were low (mean rate of 0.062 per min), but showed an increasing trend

Examining relationship

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Dates

Figure 2. Rate of self-initiations during baseline, self-directed picture schedule, and follow-up phases.

at the end of the phase (see Figure 2). Anecdotal reports indicated that during this phase, Susan’s initiations were limited to getting food items from the fridge, using the bathroom, requesting tobacco, and going back to bed.

During the self-directed picture schedule phase, staff demands decreased substantially from baseline levels (mean rate of 0.21 per min) and remained at a low and stable rate of occurrence. Anecdotal records suggested that the delivery of repeated demands reduced too. During this phase, Susan’s initiations showed an initial increasing trend. A sharp drop in self-initiations occurring during Session #lo (February 5) may have been associated with physical discomfort from a urinary infection, a subsequent visit to a gynecologist, and changes in Susan’s daily routine including more rest periods. No staff demands were noted on this day either. Susan’s self-initiations once again increased after Session #lo. Anecdotal reports suggest that during this phase, Susan’s initiations included a broader range of activities such as getting the shower basket, putting clothes in the laundry room, making her bed, selecting music tapes of her choice, turning on the music, and asking for help with a difficult task. She also preferred to follow a different sequence of activities during the morning routine than her staff had arranged.

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At the 2 week follow-up measures, staff demands maintained at a low and stable rate of occurrence (mean rate of 0.25 per min). Anecdotal observations indicated that staff used prompts to remind Susan to refer to the picture schedule between activities when she appeared undecided. During this phase, Susan’s initiations also maintained at a higher rate of occurrence (mean rate of 0.175 per min). Although the mean rate is lower than what was observed during the self-directed picture schedule phase (mean rate of 0.125 per min), the trend appears to be more stable during this phase.

Anecdotal reports from the program manager indicated that the reduced rate of demands by the three staff persons generalized to other activities and routines throughout the day, such as evening and bedtime routines. Their reduced demands also generalized to other residents. The staff was reported to use more gentle tones and asked more questions of the residents instead of telling them what to do. The observation protocol used in this study was incorporated by the program manager. That is, either she observed staff behaviors or had the staff self-monitor their own rate of demands. A tribute to the effectiveness of the picture schedule is that it was included as a part of Susan’s Individual Service Plan (ISP) and was used regularly by all morning staff.

The present case study is an illustration of contextual programming designed to produce simultaneous change in both staff and resident behaviors. This approach is congruent with the values of positive behavioral support technology which emphasizes that problematic contexts need to be addressed by altering or removing the problematic antecedent conditions, or by teaching adaptive behaviors to deal with problematic conditions, or both. Functional assessment procedures were utilized to identify a problematic context and then design a support plan to produce contextual changes proactively to prevent problem behaviors from occurring during the morning routine. Although there is no empirical demonstration of a functional relationship between programing and behavioral change, there is evidence to illustrate that in order to design a competent environment, one needs to assess the behaviors of all individuals in a specific context rather than assessing the behaviors of just one individual.

This TA project illustrated that staff and resident behaviors changed during the self-directed picture schedule phase in both rate and quality (i.e., decrease in delivery of repeated demands by staff, increase in the type of activities Susan initiated). It is likely that staff prompts were reduced because Susan initiated the activity of her choice more frequently. Staff demands were not eliminated entirely. Susan still needed to be prompted to refer the picture schedule between activities to determine the next activity.

This case report is limited in its scope because it is an illustration of a technical assistance effort rather than an experimental study, and hence fails to

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demonstrate either experimental control or interobserver reliability in data collection procedures. However, the message this case study provides is that in an applied field where we continue to learn about the complexity of producing behavior change, knowledge can come from both experimental and clinical demonstrations. The present case study is an example of the latter, and provides direction for future research with more rigorous experimental controls. Two implications of this study are:

(1) The functional assessment procedures (O’Neill et aE., 1990) were useful for understanding that the context (organization of the morning routine) was problematic rather than the person (resident). In other words, it is unlikely that contextual programing using positive approaches could have been implemented without understanding the contextual nature of problem behaviors.

(2) The training procedure, which targeted specific instructional behaviors of staff persons, was found to be effective in producing behavior change because it was delivered in vivo, including demonstrating appropriate procedures and providing performance feedback. This may well be an area for further research.

REFERENCES

Gardner, W. I., & Code, C. L. (1989). Self-management approaches. In E. Cipani (Ed.), The treatment of severe behavior disorders; Behavior analysis approaches. Washington, DC: American Association on Mental Retardation.

Holman, J., & Baer, D. (1979). Facilitating generalization of on-task behavior through self- monitoring of academic tasks. Journal of Autism and Developmental Disorders, 9, 4 2 9 4 6 .

Koegel, R. L., & Koegel, L. K. (1990). Extended reductions in stereotypic behavior of students with Autism through a self-management treatment package. Journal of Applied Behavior Analysis, 23(1), 119-127.

Lagomarcino, T., & Rusch, F. (1989). Utilizing self-management procedures to teach independent performance. Education and Training in Mental Retardation, 24,297-305.

Lloyd, J. W., Bateman, D. F., Landrum, T. J., & Hallahan, D. P. (1989). Self-recording of attention versus productivity. Journal of Applied Behavior Analysis, 22(3), 3 15-323.

Lovett, D., & Haring, K. A. (1989). The effects of self-management training on the daily living of adults with mental retardation. Education and Training in Mental Retardation, 24, 306-323.

MacDuff, G. S., Krantz, P. J., & McClannahan, L. E. (1993). Teaching children with autism to use photographic activity schedules: Maintenance and generalization of complex response chains. Journal of Applied Behavior Analysis, 26( I), 89-97.

Mank, D. M., & Homer, R. H. (1987). Self-recruited feedback A cost-effective procedure for maintaining behavior. Research in Developmental Dbabilities, 8( l), 9 1-1 12.

Moore, S., Agran, M. & Foder-Davis, J. (1989). Using self-management strategies to increase the production rates of workers with severe handicaps. Education and Training in Mental Retardation, 24, 324-332.

Morrow, L. W., & Presswood, S. (1984). The effects of a self-control technique on eliminating three stereotypic behaviors in a multiply-handicapped institutionalized adolescent. Behavioral Disorders, 9, 247-253.

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O’Neill, R. E., Homer, R. H., Albin, R. W., Storey, K., & Sprague, J. R. (1990). Functional analysis: A practical assessment guide. Pacific Grove, C A Brooks/Cole.

Reese, R. M., Sherman, J. A., & Sheldon, J. (1984). Reducing agitated-disruptive behavior of mentally retarded residents of community group homes: The role of self-recording and peer- prompted self-recording. Analysh and Intervention in Developmental Disabilities, 4, 91-107.

Sainato, D., Strain, P., Lefebvre, D., & Rapp, N. (1990). Effects of self-evaluation on the independent work skills of preschool children with disabilities. Exceptional Children, 56, 540- 549.

Shapiro, E. (1981). Self-control procedures with the mentally retarded. In M. Hersen, R. Eisler, & P. Miller (Eds.), Progress in Behavior Modjkation pol. 12, p. 265-297). New York Academic Press.

Williams, T. (1 987). Self-instruction, individual differences, and mental retardation. American Journal on Mental Deficiency, 92, 213-223.