Making Behavior Interventions Happen - California · Making Behavior Interventions Happen Real...

MakingBehaviorInterventionsHappenRealstrategiesforsupportingimplementation

AustinH.Johnson,PhD,BCBAAssistantProfessor,GraduateSchoolofEducationUniversityofCalifornia,Riverside

Aboutme

BA:UniversityofArizona

MA:UniversityofConnecticut

PhD:UniversityofConnecticut

BCBA&LicensedPsychologist

UCRiverside AssistantProfessor SchoolPsychologyprogram

Research Observationally‐basedbehaviorassessment Researchtopracticegapinschoolsettings Effectivepracticesinbehaviorintervention

PENT Forum 2019 www.pent.ca.gov

Section 2: Strategies HO

Conflictofintereststatement

Dr.JohnsoniscurrentlyrevisingaGuilfordtextonschool‐basedbehaviorassessment,uponwhichhewillreceiveroyalties.

Whatisimplementation?

Weassumethatifwetellsomeonetodosomething,they’lldoit.Whywouldn’tthey?Becausebehaviorchangeisreallyreallyhard.

Butifpeopledon’tchange,theninterventionsdon’thappen,andpatients/clients/studentscannotbenefitfrominterventionsthattheydonotreceive.



Whatisimplementation?

HowmanypeoplemadeaNewYear’sresolutionthispastyear?

Howmanypeoplekeptit?

Thisisnotan“education”problem.

(Fleming,Nguyen,Afful,Carroll,&Woods,2018)



Thisisnotan“education”problem.

Spreadofmostinfectionsinhospitalscanbestoppedwithonesimplepractice

Onaverage,healthcareworkerscleantheirhandslessthan50%ofthetimestheyshouldHospital‐basedinfectionswerealeadingcauseofdeathin2011,cost$40billion/year

(Gawande,2004;Rosenberg,2011;CDC,2018)

Thisisahumanproblem.

We’veknownitfornearlytwocenturies!1847:we’respreadingpuerperalfever,sowashyourhandsbeforedeliveringababy!

ByDay10,mostimplementersarenotdeliveringtheinterventionasintendedWhetherit’sacademicorbehavioral,individualorgroup,atschoolorinhomeorinthecommunity

Interventionnotdeliveredas

intended

Studentdoesnot“respond”tointervention

Moreintensive,morerestrictiveinterventionsorplacements

(Dufrene etal.,2012;Gilbertson,Willt,Singletary,VanDerHeyden,2007;Sundman‐Wheat,Bradley‐Klug,&Ogg,2012,Fallon,Collier‐Meek,Sanetti,Feinberg,&Kratochwill,2016;Jeffrey,McCurdy,

Ewing,&Polis,2009;Mouzakitus,Codding,Tryon,2015;Sanetti,Collier‐Meek,Long,Byron,

&Kratochwill,2015)



So,whatdowedo?

2001:PeterPronovostCritical‐carespecialistatJohnsHopkinsFocusedonfixingoneproblem:infectionswheninsertingcatheterlinesFive‐stepchecklist

1. Washhandswithsoap2. Cleanpatient’sskinwithchlorhexidineantiseptic3. Putsteriledrapesoverentirepatient4. Wearsterilemask,hat,gown,andgloves5. Putsteriledressingovercathetersiteafterwards

(Gawande,2007)

So,whatdowedo?

Pronovost persuadesadministratorstoauthorizenursestostopdoctorsiftheysawanystepsskippedNeededtomakethisexplicit:“manynursesaren’tsurewhetherthisistheirplace,orwhetheragivenstepisworthaconfrontation.”

Lineinfectionrate:2001:11%2002:0%

Prevented43infections,8deaths,saved$2m

(Gawande,2007;Pronovost etal.,2006)



So,whatdowedo?

Howdoyoumakebehaviorchangehappen?HelppeoplerememberwhattodoOperationalizeitintodiscretestepsPutpreventionandresponsestrategiesintoplacetomakesurethatitcanandwillhappen

(Gawande,2007)

There’snoone‐size‐fits‐allapproach

Buttheseare principleswecanuseregardlessofthe IntensityofthebehaviorStakesofdecisions

Ourjobistodecidehowsimple orhowelaboratethesesystemsshouldbeforthecasethatwe’reworkingwith



Ourplanfortoday

1. Designingausablebehaviorsupportplan

2. Buildingtreatmentfidelityassessmentintoyourbehaviorsupportplan

3. Workingwithimplementersbeforeitbreaksdown

4. Supportingimplementersafteritdoesbreakdown

1.DesigningausablebehaviorsupportplanAKA:“peopleusePinterestbecauseit’sprettyandit’sthere”



Peoplewillproblem‐solveontheirown

“IfoundthiscoolthingonPinterest…”

Somakeourplaneasytoreadanduse

WecannotexpectimplementerstoreadfullparagraphsorpagethroughBIPsEspeciallywhenrespondingtobehavior!

Practice#1– WritequickguidetoBIPusingO’Neilletal.’s(2015)format

Practice#2– CreateaquickguideBasedonsameprinciplesasPronovost’s checklistsMakethestepseasytoseeandunderstand



Practice#1– MaketheBIPreadable

Antecedent

Presentedwithmulti‐stepmathproblem

Behavior

Cries(tearsonface,loudyelling)

Consequence

Escapetask

SettingEvent

Fightonbus

Prevent

Strategy1Strategy2…

Replace


Respond


Prevent




Practice#2– Makethestepsvisible

CreateaQuickGuide(“cheatsheet”)!

TwosectionsAntecedentstrategies[whatshouldIbethinkingaboutallthetime?]Consequencestrategies[howIrespondwhenIseepositiveornegativebehavior?whatiftheyescalate?]

(Mostly)Antecedentstrategies



Consequencestrategiesandcrisisplan

Whatabouttoughkids?

Integratethecrisisplanintothequickguide

Considerintegratingdatacollectionaswell!

Lesspaperwork=moretimesupportingthekid



2.BuildingtreatmentfidelityassessmentintobehaviorsupportAKA:“yeah,it’saboutcollectingevenmoredata,butIpromiseit’sworthit!”



Seriously,whydothis?

(Burns & Gibbons, 2008)

1. Problem Identification

2. Problem Analysis

3. Plan Development4. Plan Implementation

5. Plan Evaluation

ReviseModify

IntensifyWith Expanding Support

Seriously,whydothis?

(Burns & Gibbons, 2008)

1. Problem Identification

2. Problem Analysis

3. Plan Development4. Plan Implementation

5. Plan Evaluation

ReviseModify

IntensifyWith Expanding Support



Studentoutcom

es

ImprovingContinuecurrentpractice(orconsiderfading)

Worsening Changeintervention

(Collier‐Meek,Fallon,Sanetti,&Maggin,2013)

“Awesome!"

Studentoutcom

es


Worsening Changeintervention


“Well,wetried,andit’snotworking.It’stimetostarttalkingabout

[insertmorerestrictiveenvironmenthere].”

Butwereweactuallydoingwhatwesaidwewoulddo?Asoftenaswesaidwe’ddoit?Withsufficientquality?



Implementation

Atorabovecriterion Belowcriterion

Studentoutcom

es


Determineunknownissue

Worsening ChangeinterventionProvideperformance

feedback


Consultationorevaluation?

“Let’stakedataonthestudent!”=

“Let’stakedataontheteacher/para/aide!”=

Butwait!It’sjustconsultationskills

It’sthedifferencebetween “Here’stheplan,seeyouintwoweeks.” “Iwanttomakesurethisplanworksforyou.So,here’sachecklistyoucanusetotrackwhatpartsyou’reabletodo,andwhatpartsaren’tworkingforyouandyourclassroom.Let’smeetbackuptomorrowandseewhatpartsworkedandwhatpartsdidn’t.”



Whatshouldwemeasure?

TreatmentintegrityAdherence:whetherstepsweredeliveredQuality:howwell eachstepwasdeliveredExposure:howmuchoforhowlong thetreatmentwasprovided (andProgramDifferentiation…)

Complexityshouldbedrivenbycaseintensity!Adherenceisstillthemaingameintown

Quality

Exposure

Adherence

(Schulte,Easton,&Parker,2009)

• Interventionfidelity1. Adherence:whether stepwasdelivered2. Quality:howwell thestepwasdelivered3. Exposure:howlong thestepwasdeliveredfor

https://cbitsprogram.org/forms

☐ Adherence☐ Quality☐ Exposure



n/a (great day!)

2/8/18



3.WorkingwithimplementersbeforeitbreaksdownAKA:“anounceofpreventionisworthapoundofaspirin”

Weneedtoberealistic

Interventionsareadapted inpractice

Interventionsthathavecontextualfitaremorelikelytobeimplemented

Adaptedinterventionscanstillwork!

So,planfortheinevitableandimportant!

“We can thus say now with confidence that some measure ofadaptation is inevitable and that for curriculum developersto oppose it categorically, even for the best of conceptual orempirical reasons,would appear to be futile.”

(Durlak &DuPre,2008)



Implementationplanning

Planhasbeendrafted(theBIPexists)

Ideally,planwasdraftedwithabundantstakeholderinputwithaneyetowardsimplementation

Butwhatifit’sforasecondarystudent?Lotsofteachersandeducatorswhowedidn’ttalkto

So,nowweneedtofigureoutWhatmodificationsneedtobemadetotheplanWhatresourceswe’llneed,andifwecangetthemWhatbarrierstoimplementationexistHowwe’lladdressthosebarriers

ActionandCopingPlanning

1. Whatmodificationsneedtobemadetotheplan2. Whatresourceswe’llneed,andifwecangetthem

1. Whatbarrierstoimplementationexist2. Howwe’lladdressthosebarriers

BasedonresultsfromPRIMEProject

MultiplestudiestosupporteffectivenessofthisframeworkWithparentsandteachers Foracademicandbehavioralinterventions

(Fallon,Collier‐Meek,Sanetti,Feinberg,&Kratochwill,2016;Sanetti &Collier‐Meek,2015;Sanetti,Collier‐Meek,Long,Byron,&Kratochwill,2015;Sanetti,Collier‐Meek,Long,Kim,&Kratochwill,2014;Sanetti,Williamson,Long,&Kratochwill,2017)

ACTIONPLAN

COPINGPLAN



Howdoyoudothis?

Withameeting!(…hooray…)SitdownwiththestakeholdersActionPlanTaskanalyzeinterventionintodiscretesteps IdentifyresourcesneededforeachstepCopingplanDiscussforeseeablebarrierstoimplementationDiscussstrategiestosupportimplementation

Monitoroutcomes,modify,check‐in,discuss,andreviseonanongoingbasis

4.Supportingimplementersafteritdoesbreakdown



Welp,it’snothappening

Implementation


Studentoutcom

es




feedback


Welp,it’snothappening

Implementation


Studentoutcom

es




feedback




Performancefeedback

Somanystudiesexaminingitseffectontreatmentintegrityandstudentoutcomes

MeetsWhatWorksClearinghousestandardsforanevidence‐basedpractice!

Whenitcomestoevidence‐basedimplementationsupportstrategies,performancefeedbackisthemostwell‐researched

(Fallon,Collier‐Meek,Maggin,Sanetti,&Johnson,2015)

Whatisit?

“Informationthatisprovidedtoanindividualorgroupaboutthequantityorqualityoftheirbehaviorthatprovidesinformationabouthowwelltheyaredoing” “capturing,summarizing,andpresentingdatatoteachersregardingtheirplanimplementation”

(Noell &Gansle,2014)



Performancefeedback

ShowingdatatoapersonandreviewingitwiththemcanbeeffectiveonitsownCanembedwithothertrainingmethods

LogisticsBriefmeetings(5to15min)Ongoing (daily,weekly,as‐needed)Needgraphs ofdata

(Noell &Gansle,2014;Fallonetal.,2016)

Doingit

1. Ask implementerabout Interventionfidelity Studentoutcomes

2. Reviewfidelity datawithgraphs

3. Reviewoutcome dataandgoalprogress

4. Reviewandpractice stepsasnecessary

5. Followup!



OfthosestudiesthatfoundPFtobeeffective…

Typeoffeedback 97%providedverbalfeedback 69%providedgraphicTIfeedback 69%reviewedstudentdata 62%includedproblem‐solvingtosupportimplementation Less‐oftenusedweregoal‐setting(17%),reinforcementproceduresforadult(17.5%)

Frequencyoffeedback Variedgreatly(28%daily,21%weekly,7%onlywhenTIfellbelowacriterion)

Whenfeedbackwasprovidedrelativetointervention Sameday(21%),oneortwodaysafter(24%)

Studentcharacteristics 73%werewithkidsreceivingspedservices,27%withgened only

Superiortoothermethods

Resultsofrandomizedtrial

Consultationfollow‐upsBriefweeklyinterviewWeeklyinterviewwithcommitmenttoimplementPerformancefeedbackMeteverydayuntilat100%integrity,theneveryotherday,thenweekly

(Noell etal.,2005)



That’ssomuch

Yes,butrealistically:“Theliteraturesuggeststhatconsultingwithteachers,designing aninterventiontheyseemacceptable,providingmaterialsnecessaryfortheintervention,discussing theimportanceofinterventionimplementation,andtrainingteacherstoimplementtheinterventionarefrequentlyinsufficienttosupportlong‐term[implementation]”

(Noell &Gansle,2014)

Howtodoit?

Canoccurinthecontextof:One‐on‐oneconsultationPros:EasierforyoutoinfluencehowthisgoesCons:Dependingontherelationship,mightbedifficulttodoPFeffectively

EmbeddedintoaProblem‐SolvingTeamPros:Lessduplicationofresources,mayameliorateconcernsaboutevaluativerolesCons:Mayexacerbatetensionsindatacollection(havetoreportoutonmydatatoallthesepeople…)

(Duhon,Mesmer,Gregerson,&Witt,2009)



Wrappingup

Supportingimplementation

1. Designthematerialstobeused,nottobefiled “Writeitlikeyouwantsomeonetoreadit”

2. Takeimplementationdata,butmakesurethedataworkforyouandthecase “WhatquestionamItryingtoanswer?”

3. Berealisticandplanforadaptations

4. Ifandwhenitfails,usethosedatayou’retakingtoimplementPF:asimple,evidence‐basedpracticeforsupportingimplementation



Wrappingup

Doesn’tseemlikemuch?Prettystraight‐forwardstuff?

Iagree!That’swhyit’sgreat!

Thisstuffisnotcomplex.

Butit’sevidence‐based!

Andittakestimeandeffort.

Wrappingup

“Thesestepsareno‐brainers;theyhavebeenknownandtaughtforyears.Soitseemedsillytomakeachecklistjustforthem.Still,Pronovost askedthenursesinhisI.C.U.toobservethedoctorsforamonthastheyputlinesintopatients,andrecordhowoftentheycompletedeachstep.Inmorethanathirdofpatients,theyskippedatleastone.” (Gawande,2007)

Interventionnotdeliveredas

intended

Studentdoesnot“respond”tointervention

Moreintensive,morerestrictiveinterventionsorplacements



Nextsteps

Researchersneedtogivepractitionersthetoolstheyneed toimplementthepracticesthattheystudy

Thankyou!

Wanttopartnerondevelopingusable,evidence‐basedbehaviorinterventionmaterials?Otherideas?Contactme!

Email:[email protected]

Phone:951‐827‐5958

Twitter:@johnsonaustinh

Web:www.ahjohnson.com



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