Presentation on theme: "Working with Low Functioning Clients & Sexual Perpetrators"— Presentation transcript:
1Working with Low Functioning Clients & Sexual Perpetrators Definition of Low FunctioningAbuse & Brain DamageBehavioral Interventions
2Preface Psychiatrist Psychologist Medical doctor Trained in medicine, labs, NOT trained in psychometrics or behaviorFollowing medical school, training in specializations (residency):Neurosurgery, Oncology, pediatricsObstetrics & Gynecology, psychiatryPodiatry, Ophthalmology, cardiologyAllergy, Dermatology, anaesthesiologyIn-field exposure (residency) to CBTPsychologistPh.D. or Psy.D.: Cognitively (CBT) trainedTrained in psych testing, behavior mod/mgt NOT trained in medicineSpecialization in pre-/post-doc internshipChild, Gerontology, Sports, Diversity, sex-abuse psychologistsForensic, Clinical, Counseling, School, Research psychologistsDisabilities: LD/MR, low functioning, developmental disabilitiesNeuro-psychologist: neurological assessment, PET scan1-class in psychopharmacology
3Foreword Associate Professor 5 yr Nonverbal Therapeutic interventions to work with lower functioning individuals:Neuro-Linguistic Programming (mid 1980s)Educational-Kinesiology (70 yr)Sand-play, Cognitive-behavioral play therapyEEG neuro-feedback, bio-feedbackEye Movement Desensitization and Reprocessing, EMDRAmerican Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines. * EMDR was determined to be an effective treatment of trauma. Department of Veterans Affairs and Department of Defense (2004, 2010). VA Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC. * EMDR was placed in the "A" category as “strongly recommended” for the treatment of trauma.Associate Professor 5 yrUniversity of Hawaii; Chaminade University; Heald CollegeBehavioral Consultant to Hawaii School System 10 yrAutism/disabilities SpecialistApplied Behavioral Analysis [Felix Waihee Consent Decree ]Lovass’ 1987 landmark Young Autism StudyWikipedia: Preferred treatment for individuals with disabilities2 courses integrated into MFT program at U of G
4Low Functioning: RC, age 16, CSC Scale Score Percentile Range Verbal, VCI 67 1 Extremely Low Performance , PRI 67 1 Extremely Low Working Memory, WMI Average Processing Speed, PSI 80 9 Low Average Full Scale IQ 70 2 Borderline
5DSM-IV-TR: Mental Retardation Essential FeatureSignificantly sub-average general intellectual functioning: IQ of about 70 or below (range 55-75)Exhibits significant deficits in adaptive behavior: social blindness.Not diagnosed MR w/o significant adaptive behavior deficits.General Intellectual Functioning: Intelligence Quotient (IQ)“1” or more standardized assessments, individually administered intelligence tests: WISC-IV, Kaufman, Stanford-Binet, TONI-4Adaptive FunctioningHow effectively the individual copes with common life demandsDetermined by presenting symptoms versus low IQProblems in adaptation can improve with repetition, but cognitive IQ tends to remain relatively stable.
6Low Functioning: AC age 14 female CSC Scale Score Percentile RangeVerbal, VCI Extremely LowPerceptual, PRI Low AverageWorking Memory, WMI BorderlineProcessing Speed, PSI Low AverageFull Scale IQ Extremely Low
7DSM-IV-TR: 317 Mild Mental Retardation IQ level to approximately 70Educable, 85% of population.Typically develop social/communication skills during preschool, have minimum sensory-motor impairment.Not distinguishable from children w/o MR until later age.Adolescents: Can acquire academic skills up to 6th grade level.Adults: Usually achieve social/vocational skills adequate for minimum self-support; may need supervision.Can usually live successfully in community, independently or in supervised settings.
8DSM-IV-TR: 318 Moderate Mental Retardation IQ level to 50-55Trainable; 10% of population.Acquire communication skills during early childhood.Can attend to personal care.Can benefit from social/occupational skills training.Unlikely to progress beyond 2nd grade level academics.Adolescents: difficulties recognizing social conventions interfere with peer relations. Can profit from vocational training.Adults: Can perform unskilled/semi-skilled work, supervised, in sheltered workshops/workforce.Adapt well to life in community, usually in supervised settings.
9Moderate MR: DC age 14 male CSC Scale Score Percentile RangeVerbal <.1 Extremely LowPerformance BorderlineWorking Memory <.1 Extremely LowProcessing Speed Extremely LowFull Scale IQ <1 Extremely Low
10How is Level of Functioning Determined? IQ testsWechsler Intelligence Scale for Children, fourth edition, WISC-IVWechsler Adult Intelligence Scale, fourth edition, WAIS-IVTest of Nonverbal Intelligence, fourth edition, TONI-4Myth of IQ testsTrue IQNo true IQ from birth to death: Genetics can be enhanced or impeded.*IQ is a measure in one point in time.IQ is less stable in childhood & adolescence than in adults.Factors affecting IQHeavy metal/toxin exposure, TBI, prenatal alcohol/drug use, birth traumaPhysical/emotional traumas: violence, child/sex abuse, abandonment.Nutrition, digestion (McBride, 2010), exerciseEarly training: music, sign, (whole brain learning age 0-5)IQ is most flexible throughout childhood
11Experiential/Kinesthetic/Tactile Learners Learning style: Learning takes place by actually carrying out a physical activity, versus listening (lecture) or watching a demonstration. Classroom = visual-auditory NOT kinestheticAka tactile learner, doers, physically oriented.Realizations occur through doing versus thinking.It helps them to move while learning, movt increases understanding.They do well with lab experiments, sports, art, acting, dancing.They remember things by recalling what their body was doing.Short and long-term memory is strengthened by body movement.They NEED to move, may seem restless, impatient, or bored.Various types of learning styles:VisualAuditoryKinesthetic
12“Myths” of ‘Low Functioning’ There are obvious indicators: FalseSpeech-impaired: good articulation is deceptiveThought processes impaired: limited, not impairedPhysically recognizable: attractiveness is deceptiveTheir feelings are like my feelings: hypersensitiveFalse assumptions:If he talks then he understands me: limited comprehensionHe needs counseling: CBT is insufficient.Since he talks, he can say what’s bothering him: noHe is choosing not to talk: not necessarilyConflicting emotions confuse/block concept formationEmotions impede verbalizationUnable to conceptualize response
13Abuse Affects the Brain and Functioning R: Alcohol AbuseL: Head Trauma, Drug AbuseArlene Gadia, CPS supervisor: 1200 referrals/yr child abuse; KUAMLyndia Tenorio, CPS supervisor: 2000 referrals/yr child abuse; KUAM
14Scans Show Brain Damage in Abused Teens University of Pennsylvania School of Medicine, 2011study on effects of childhood maltreatment on neuroimaging of gray matter volume in adolescentschildhood maltreatment affects subsequent psychopathology.Adolescents reporting a history of abuse (even nonphysical) had deficits in gray-matter brain volume in the prefrontal cortex, striatum, amygdala, cerebellum.Grey matter is made up of neuronal cell bodies. The grey matter includes regions of the brain involved in muscle control, sensory perception: seeing, hearing, memory, emotions, speech.Girls: atrophy in regions associated w/emotional regulationBoys: deficits concentrated in regions related to impulse control.At risk for development ofmood disordersaddictive disordersother psychiatric disorders
16Effects of Left Prefrontal Damage SW Anderson, A Bechara, H Damasio (2002). Impairment of social/moral behavior related to early damage to prefrontal cortex. Foundations in Social NeuroscienceSW Anderson, D Tranel, H Damasio (1996). Failure to respond autonomically to anticipated future outcomes following damage to prefrontal cortex. Cerebral Cortex.A Bechara, AR Damasio, H Damasio (1994) . Insensitivity to Future Consequences following damage to L prefrontal cortex. CognitionCorticotrophin, epinephrine, norepinephrine release unmediated = negative emotion overdrive.Right Temporal sexual passion is unmediated by impaired L prefrontal cortex.Impaired brain status is exacerbated by stress (flooding) = chemical cascade.Vicious cycleImbalance impairs functioning (pouring battery acid over brain)Sleep deprivation impairs brain repair; insomnia commonSymptoms: shut-down/acting-out, suicidal ideation/gestures = distressEmotional pain drives compulsions. compulsions precipitates self-medication/addictions (alcohol-substance abuse, neg. compulsive behaviors).
17Childhood maltreatment changes brain structure and function Childhood maltreatment changes brain structure and function. Abuse/chronic trauma hx = Left Prefrontal Cortex Damage
18Dr. JD Bremner: IncestYale Psychiatric Institute. April 1999, Biological PsychiatryThe problem is not that incest survivors want to stay miserable—Research: childhood sexual trauma causes actual shrinkage, damage to the hippocampus of the brain. Hippocampal loss of neurons related to stress.Hippocampus: associated with learning, memory. PTSD from Vietnam war and childhood abuse have neuropsychological deficits in hippocampal functioning.Symptoms associated with shrinkage of the hippocampus resemble Post Traumatic Stress Disorder, PTSDMind plays tricks on survivors: flashbacks, feeling uneasy and "on edge,” on guard constantly, nightmares, problems associated with memory.Gaps in memory occur, a few minutes to a few days; abuse memories suddenly "pop up” in a survivor's life.The hippocampus affects the prefrontal cortex, stress responses.Incest survivors have a far more serious response to stress than those who have not experienced severe childhood abuse.All survivors need to watch and monitor their stress carefully; brain damage is a side effect of sexual abuse.
19Childhood Sexual Abuse Causes Physical Brain Damage: An Alarming New Study
22McLean Researchers Document Brain Damage linked to Child Abuse & Neglect Harvard Medical School Affiliate. December 2000, Cerebrum. Early damage to developing brain causes anxiety & depression in adulthood.4 types of permanent abnormalities caused by abuse/neglect:Limbic irritability: emotion; EEG abnormalities are associated with more self-destructive behavior and aggression.Arrested L hemisphere development: language, perception/expression of negative affect; contributes to depression, memory impairment.Corpus Collosum deficiency: % size reduction = neglect, 18-30% size reduction = sex abuse; effects dramatic mood/personality shifts.Increased Cerebellar Vermis activity: emotion, limbic activity, trauma impairs ability to maintain emotional balance. Brain is wired to experience fear, anxiety, stress.
23Irritable Limbic System: more self-destructive behaviors & aggression
24Corpus Collosum: deficit in size of 24-42% in neglect, 18-30% in sex abuse, affects dramatic mood & personality shifts.
25Hyperactive Cerebellar Vermis: Impaired ability to maintain emotional balance Brain wired for fear, anxiety, stress
26Daniel Amen, M.D.: Magnificent Mind at Any Age (2008) Treat Anxiety, Depression, Memory Problems, ADD, and InsomniaCerebellum: 10 % of brain volume, 50% of brain’s neurons.Functions:Involved with processing speed, how quickly you can make cognitive/emotional adjustments in stressful/new situationsMotor control, posture, gaitExecutive function, connect to prefrontal cortex, speed of cognitive integrationProblems in the cerebellum = easily confused.Slowed thinkingSlowed speechTrouble learning routinesDisorganizationSensitivity to noise, touch; light sensitivityTendency to be accident proneFound low in activity in autism, ADD, learning disabilitiesMajor coordination center in the brainMajor strategies to optimize: coordination exercises as sports and music, dancing or table tennisHealthy diet, targeted behavioral exercises, mental exercises, supplements (multiple, fish oil, vit D, medications).
28Grey Matter Deficits: Limbic, L hemisphere, corpus collosum, cerebellar vermis, prefrontal cortex, striatum, cerebellum
29“Magnificent Mind at Any Age” Daniel Amen, M.D., 2008 People who experience extreme, uncontrollable early life stress (physical/sexual abuse) are more vulnerable to anxiety, depression, effects of stress later in life. To become resilient, strengthen the brain’s ability to resist stress.The sense of control is one of the most important factors in managing stress.Blame = signals feeling out of control, victim-stance.Poor control of prefrontal cortex function has been associated with depression and impulsivity.Long-term exposure to stress hormones has been found to kill cells in the hippocampus. Smaller hippocampal volumes are found in people with depression and chronic stress disorders.Early abuse/stress can cause long standing changes in brain circuits associated with resilience and learning.When children w/o abuse are exposed to more manageable forms of stress, these stresses aid in building resilience; stress inoculation develops immunity. i.e. Family moves, parental illness, loss of friendship, learning to deal with teasing. (Kibbutz study)
30NeurobiologyBehavior-learning problems plague 3/4 of children in child welfare system.stress-regulating hormone production alteredkey neuro-transmitters altered: epinephrine, dopamine and serotonin, chemical messengers in the brain affecting mood and behavior.1993 Dr. Martin Teicher linked abuse to brain wave abnormalities. The Journal of Neuropsychiatry and Clinical Neurosciences.Greater the severity of the abuse, the greater the impact on brain function.''Sex abuse by a family member is worse than abuse by a priest or a baby-sitter.'’Several studies document, abuse damages key brain structures: the cortex, and the hippocampus.1998 study showed left cortex of the abused group underdeveloped.Abuse typically lowers serotonin levels, leading to depression and impulsive aggression.
31Verbal Abuse Linked to Permanent Brain Damage Martin Teicher, Harvard Medical School associate professor of psychiatry at McLean Hospital. Biological Psychiatry, February 1, 2009 (neuroimaging).damage to neural pathways cause medical and physical problems when the children grow to adulthood such as depression, language processing issues and anxiety.verbal abuse of children may be just as damaging as other forms of abuse such as physical or sexual abuse.Witnessing the abuse of others is also very damagingmultiple cases of victims who have all the symptoms of physical abuse but were never physically abused
32What Characterizes Low Functioning ? Characteristics of ‘Low Functioning’Don’t know what they’re feeling, difficulty identifying their feeling, difficulty verbalizing their feeling(s), act on feelings, overwhelmed by feelings.Low vocabulary/comprehension (Receptive auditory)*Interpretation of experiences may be simplistic, limitedResponses may be brief, off-subject, vague, distorted.Common responses: No response, stare, walk-away, ‘I don’t know,’ child-like responses.Counseling/explanations may be limited in effectiveness.Need to do, multi-sensory to learn.Low vocabulary/low communication (Expressive auditory)*Communication is simple, limited; inability to describe events/feelings.Unable to express compounded feelings, At risk for cumulative anxietyNon-directive inquiry to assist thinking process.
33Speech & Comprehension are different parts of the brain
34Low Functioning Characteristics Weak to absent problem solving ability*Low vocabulary (limited expression) + low information + low comprehension (distorted cognition) = weak problem solving.Teach collaborative problem solving, use inquiry to elicit thinkingChoice is insufficientWeak coping skills*Ineffective ability to deal with negative emotionsExplosions: physical, verbal, emotional aggressionImplosion: compulsions, self-harm, suicideTeach emotion vocabulary, verbalizing formatSocial blindness*Unaware of social conventionSocial initiative, reciprocal conversing, social inquiry are absentTeach looking into faces (visual cues), social questions
35Label feelings, verbalize feelings Process emotions, de-intensify emotional pain
36Low Functioning Characteristics Weak ability to implement learning*Low information transfer from concept to ‘doing’.Signs contract but repeats offensesRepeats what you said then fails to follow throughNeed for kinesthetic versus conceptual learningDifficulty learning in group formatDifficulty with sedentary learning, need to move, to do, experience.Weak to absent assertiveness skillsAuthoritarian parenting = aggress or submitSuppression is not respectfulnessMisunderstood disabilities elicit abuse in uneducated familiesLow receptive auditory interpreted as Not ListeningLow information implementation interpreted as disobedienceRepeat offenses interpreted as defianceNo response, blank stare, walking away, interpreted as disrespectDisciplinary stress affects 2ndary brain damage
37L: Left temporal deficit-suicidal child R: Worried & Rigid
38Undoing Neurobiological Effects of Trauma Alexandra Cook, Ph.D. Trauma Center at Justice Resource Institute, MAPositive experiences that contradict a traumatized child's negative expectations are critical to helping the brain to readjust.Just saying to a child that you are sorry the event happened changes brain chemistry.Temper tantrums = amygdala can’t stop firing.Constructive ways to discharge overwhelming emotions (running, emotionally expressive activities)Estimated 1 million children abused/yr; less than 10% receive appropriate interventions.The more time that elapses between the abuse and appropriate treatment, the more entrenched the neurological abnormalities.Address sensorimotor dysregulation at the body level w/a new array of movement strategies to the standard mental health therapy repertoire to support children to become more organized, interpersonally available, and accessible for mental health treatments.
39NY Times Magazine, April 2012: Evidence-based Interventions Aerobic Exercise1990s research: Exercise jump-starts neuro-genesisMice/rats that ran a few weeks had twice as many new neurons in hippocampi as sedentary animals. *All animal studies involve running/aerobic activities.By age 20: approx 1% human hippocampus lost annuallyExercise slows, reverses brains’ physical decay, as w/muscles.2007 study: Comparison of environmental stimulus, learning tasks, aerobic exercise.1) Environmental stimulus (toys/tastes), 2) new learning, 3) exercise compared.1) No matter how stimulating, enriching environment did not improve brain.2) New learning generated task specific neurons that re-fire to task only.3) Exercise doubled new neurons in hippocampi compared to sedentary animals.Exercise made neurons nimble, could multitask and re-fire cognitively flexiblyOnly thing that mattered in improving the brain: aerobic exercise.Aerobic exercise increased Brain-derived neurotropic factor, BDNFBDNF sparks neuro-genesis, strengthens cells, axons, neural connections.After work-out = higher BDNF in blood stream.2011 Study: 1-year walking or stretching program w/age group over 60Walkers had larger hippcampi after a yearWalkers regained 2+ yr of hippocampal youth (65yr -->63yr)Stretchers lost volume to normal atrophy
40InterventionsDaniel Amen, MD, ‘Use Your Brain to Change Your Age,’ 20121-hr aerobic exercise daily; Effects wear off after 24 hr.Magnificent Mind at Any Age, 2008: ANT & ANT eaters9 types Anxiety & Negative Thoughts: 1) Overgeneralization, 2) Negative focus,3) Negative predictions, 4) Mind reading, 5) Believing negative feelings, 6) Guilt words, 7) Negative labeling, 8) Personalization, 9) Blame.Challenge your thoughts: talk back to ANTs. You don’t have to believe your thoughts.When stuck, distract yourself by jumping up and down, dancing, singing, etc. Repetitive thoughts worsen control, but lose control over time when blocked.Journal of Child Psychology & Psychiatry, January 2000, vol 41,Secure attachment buffers the effects of the stress response.Medical News Today, June 2007, Mathew Lieberman, UCLA psychologist (neuroimaging)Verbalizing Feelings Makes Sadness, Anger And Pain Less IntenseAmygdala is less active when an individual labeled a feeling (anger) (brain imaging)Right ventrolateral prefrontal cortex is more active: thinking in words about emotional experiences inhibits behavior and processes emotions.EnactmentTrauma therapy: Enactment is a form of therapy that facilitates trauma repair. Until expressed, the energy remains in the form of symptoms of depression and anxiety.Journal of Marital & Family Therapy, July 2004: Enacting relationships in Marriage & Family Therapy is a medium for mediating relationships.Handbook of Family Therapy, April 2012, Al Gurman, Ph.D. Enactments bring maladaptive interactional sequences into the therapy session and thus available for directed change.
41Kinesthetic Intervention Walk through learning experience, repetitivelyEnactment: pre-experience drama therapy.CSC-- Clarify rules, enactTouching others is off limits.Telling strangers you want to be close to them is off limits.Asking girls to ‘do it’ with you is off limits.Social questions are okay. Let’s practice social questions.Role-play, rehearse, then coach Emotion Program: I feel…because…I want….Empowers client to verbalize fears, upsets, resentments.Go from 2ndary to primary feelings.Experientially learn assertive verbalization with support.Win-win collaborative problem solving with client (Greene, 2001).Client participates in win-win resolution.Assertiveness is elicited and supported.Clients wants/needs are valued. Providing choice is not cps.Re-enactment: Post-conflict ‘acting’ desired behaviorRehearse then re-enact drama while coaching appropriate behavior, words.
43What to Do Capitalize on strength: Kinesthetic Engage in kinesthetic vocational training earlyAerobic exerciseIncreases brain’s vascular networking, oxygen/nutrients to neuronsImproves short-/long-term memory, brain repair/function w/sleep.Increases endorphin levels, elevating mood.Relieves stress in high anxiety individuals.And laughter drops defenses.Target Priority: Repair the brain; Reduce self/other harmSymptoms of a stressed brain: compulsions, suicidal ideation, aggressionNeural plasticity during development maximizes exercise’s effect on brainNonverbal therapies can reduce/eliminate PTSD, lifelong anger, historic angstStress is cumulative, has delayed effectsAutonomy in adulthood exacerbates seemingly innocuous compulsions into addictions.Pharmaceutically managed depression requires lifelong medication.Brain sustains impairments throughout lifespan without appropriate treatment.Low functioningLow Vocabulary: Keep it Simple (KIS)Low Information: Keep it practicalLow Comprehension: ‘do’ desired behavior, kinesthetic: must “do” to learn.
44Intervention Know the function the behavior serves. Target the function not the behaviorBehaviors are symptoms; function is the purpose it serves.Symptoms: Nail biting, binge eating, restlessness, OCD behaviors, compulsive masturbation, trichotillimania, skin/scab picking, cuttingFunction: anxiety/stress release, auto-stimulusBehaviors may look different but serve the same function: e.g. stress releaseNail-biting, masturbating, skin picking, hair pullingCigarette smoking, alcoholism, drug use, promiscuityBehavior may look the same but serve multiple functions: attention, escape, tangibleDisruptive behavior for attention + escapeTo reduce the behavior, discontinue reinforcementReinforce desired behavior intermittentlyRehabilitative intervention takes longer, achieves moreReduces compulsions, self-harm, reduces suicidal ideation, suicide gestures/attemptsReduces acting out, aggression, assaultIncreases verbalization, assertiveness, and adaptive functioning
45Insufficient Interventions APA Ethic: Do no harm (Iatrogenic treatment)CorroborateSeek persons w/higher education, more experience, trainingAsk questions before implementing interventionsConsult, consult consult.Authoritarian approachNeither authoritarian nor permissive is therapeutic. Assertive is therapeuticAttend to (nonverbal) feelings to prevent behaviors, feelings drive behaviorFastest way to achieve goals: ‘Motivate’ via client desired incentives.Cognitive therapyRepeat back to me, so I know you understand. They don’t.Explaining ‘why,’ providing logic, providing rational, providing consequences.Posting instructions, providing written instruction, contracting.Expecting follow through of responsibilities: provide checklist.Coercion:Privilege removal, item removalStacked consequencesChoice
46*Interventions NOT for Low Functioning Individuals* Rewards & Punishment‘Incentive only’ is preferred treatment approachPunishment, stacked consequences provoke anxiety, victim stancePunishment stops behavior, doesn’t teach appropriate behavior;Broad based education & experienceLearning takes so long, focus on high risk behaviors.Prioritize reducing self-harm/other harm, heal the brain.Target: strengths to maximize competency; income earningIntergenerational government dependency status perpetuated.Avoid unnecessary stress: 2ndary damage suffered when stressedFloodingProlonged exposure to desensitize individual to stressful stimuli exacerbates damage in an impaired brain.Any Stress: impaired brain is fragile, more vulnerable to stress, anxiety, depression in adulthood.
47Notes All behaviors serve a purpose. All behavior is communication. Animals that exercise aerobically generate double the new neurons compared to sedentary animals. These neurons refire to any need in the brain. Exercise is the only thing that mattered in improving the brain.Research has established, both desirable and undesirable behaviors are learned, through interactions with the social and physical environment.The function of a behavior can be thought of as the purpose a behavior serves for a person.All behaviors serve a purpose.All behavior is communication.Applied Behavior Analysis-based interventions are best known for treating people with developmental disabilities.
48Track Progress, Why? Objective Comparison with Baseline Behaviors Quarterly outcome dataRetain focus on original primary goals until achievedProvides client a measure by which to chart progressProgress is measured in quarters and yearsTracking MonitorsIntervention effectivenessIneffective: self-harm/other harm continues or escalatesNeeds adjustment: intervention is quasi successfulEffective: target behavior reduces as intervention is mastered.Advance interventionClient succeeds 90%, is ready to advance interventionFrom 1 emotion program daily, increase to 3-5/daily on negative feelingsFrom 1 collaborative problem solving daily to 2 daily on differences.
49Performance Measures 2 Types of data Behavioral Frequency ABC: Antecedent, Behavior, ConsequenceTo seek purpose of behavior1) seek attention, 2) escape, 3) tangibles, 4) auto-reinforceTo know 1) setting event, 2) behavior, 3) reinforcerMonitors interventions, client behaviors, staff performanceAre interventions implemented as intended?Do client behaviors reflect increased competency to intervention?Is staff behavior therapeutic to client?Data must be monitored for validityPreferably by ABA trained therapistFrequencyCounts the number of times a behavior occurs.Counts the number of replacement/goal behaviors.
52Setting up Goals Chart the frequency of behaviors Behaviors & goals Baseline: per month.Quarterly: comparisonProvides progress report, monitors intervention, staffBehaviors & goalsName behavior + frequencyIgnores staff 3x dailyShuts down when he disagrees with staff 1x dailyName goal in objective measurable termsHe states his feeling, the cause, and what he wants 3x daily.He participates in collaborative problem solving 1x daily.
53Scott Miller, PhD Evidenced based: working with Difficult Clients Listen to the ClientThey will tell you what they needThey will tell you what works for them and what doesn’tThey will tell you how you can motivate themFollow the Client’s motivationIt is the strongest drive to facilitate goalsInnate drive harnesses the client’s own energiesSupport the Client toward their motivationThe client’s goals are paramountClient drive toward their goal is your goal.
54Chronic trauma affects structural & functional changes in the brain
55Resources Amen, Daniel MD www.amenclinics.net/brain-science Child & Adult psychiatrist, medical director of Amen ClinicsWorld’s largest database of functional brain scans:70,000 Single Photon Emission Computerized Tomography (SPECT)30+ books translated into 24 languages.1 of the world’s experts brain imaging use in psychiatry.4x New York Times bestselling authorUse Your Brain to Change Your Age (2012)Change your Brain, change your Body*Change your Brain, Change Your Life*Magnificent Mind at Any Age (2008)*The Amen Solution*Healing ADDMaking a Good Brain GreatHealing the Hardware of the SoulThe Brain in LoveComprehensive Textbook of PsychiatryCo-author: Unchain Your Brain, Healing Anxiety & Depression, Preventing Alzheimer’s49+ published research articles
56ResourcesBremner, J.D. (April 1999). Does stress damage the brain? Biological psychiatry, Vol 47, 7, p (Yale Psychiatric Institute)Campbell-McBride MD, N. (2010). Gut and psychology syndrome. Cambridge, MA: Medinform PublishingCook, A. (2010). Sensory Motor Arousal Regulation Treatment (SMART): Bottom-up Interventions for Childhood TraumaGreene, R. (2001). The explosive child. New York, NY: Harper-Collins PublishersJohnson, Toni Cavanagh. (2011). Chairperson on California Professional Society on Abuse of Children task force. Developed guidelines for monitored visits. Sex abuse psychologist of 31 years, 5 books, 2 booklets, 3 therapeutic games. tcavjohn.comUnderstanding Children’s Sexual Behaviors.Helping children with Sexual Behavior ProblemsTreatment Exercises for Child Abuse VictimsSexuality CurriculumSpace Invaders: game about boundaries
57ResourcesKahn, T. (1999). Roadmaps to recovery. Brandon, VT: SaferSocietyPress* Bibliography of workbooks with interventions for sex offenders and victims of sex offenses written in 3rd grade language.McLean Hospital, a Harvard Medical School Affiliate (December 2000). McLean researchers document brain damage linked to child abuse, neglect. Cerebrum, Fall 2000Miller, Scott, PhD. Coauthored:Feedback Informed Treatment Manuals (6)The Heart & Soul of Change: What Works in TherapyPsychotherapy with Impossible CasesStaying on Top & Keeping the Sand Out of Your PantsTeicher, Martin (1993). Abuse linked to brain wave abnormalities. The Journal of Neuropsychiatry and Clinical Neuroscience. Harvard psychiatry associate professor, Biopsychiatry Research program director at McLean Hospital.
58American Psychological Association: Evidence-Based Robert Rosenthal and Lenore Jacobson (1966). Published results of a powerful study later known as the Pygmalion Effect. According to Tauber (1998), the Pygmalion Effect asserts that "one's expectations about a person can eventually lead that person to behave and achieve in ways that confirm those expectations.”Blind, double-blind studies are gold standard in psychology research Evidence-Based Guidelines for Diagnosis of Learning Disabilities: Response to Proposed DSM-5 Criteria for Learning Disabilities[PDF] Psychology has embraced evidence-based practice as a basis for serving children and adults. The purpose of evidence-based practice has been to make available to clinicians the best evidence to guide their assessment practices and treatment recommendations.79 accredited Applied Behavioral Analysis programs for certificationthe preferred treatment for individuals with disabilities
59Eligibility to sit for the BCaBA certification examination: Board Certified Assistant Behavior AnalysisA. Degree Requirement:Possession of a minimum of a bachelor's degree that was conferred in behavior analysis or other natural science, education, human services, engineering, medicine or a field related to behavior analysis and approved by the BACB.B. Coursework and Experience RequirementsCoursework: The applicant must complete 135 classroom hours of instruction (see Definition of Terms below) in the following content areas and for the number of hours specified:Ethical considerations – 10 hoursDefinition & characteristics and Principles, processes & concepts - 40 hoursBehavioral assessment and Selecting intervention outcomes & strategies - 25 hoursExperimental evaluation of interventions, & Measurement of behavior and Displaying & interpreting behavioral data - 20 hoursBehavioral change procedures and Systems support 40 hoursAcceptable Coursework: College or university courses in behavior analysis, that are taken from an institution that meets the requirements specified in Section A.