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Working with Low Functioning Clients & Sexual Perpetrators

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1 Working with Low Functioning Clients & Sexual Perpetrators
Definition of Low Functioning Abuse & Brain Damage Behavioral Interventions

2 Preface Psychiatrist Psychologist Medical doctor
Trained in medicine, labs, NOT trained in psychometrics or behavior Following medical school, training in specializations (residency): Neurosurgery, Oncology, pediatrics Obstetrics & Gynecology, psychiatry Podiatry, Ophthalmology, cardiology Allergy, Dermatology, anaesthesiology In-field exposure (residency) to CBT Psychologist Ph.D. or Psy.D.: Cognitively (CBT) trained Trained in psych testing, behavior mod/mgt NOT trained in medicine Specialization in pre-/post-doc internship Child, Gerontology, Sports, Diversity, sex-abuse psychologists Forensic, Clinical, Counseling, School, Research psychologists Disabilities: LD/MR, low functioning, developmental disabilities Neuro-psychologist: neurological assessment, PET scan 1-class in psychopharmacology

3 Foreword 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 therapy EEG neuro-feedback, bio-feedback Eye Movement Desensitization and Reprocessing, EMDR American 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 yr University of Hawaii; Chaminade University; Heald College Behavioral Consultant to Hawaii School System 10 yr Autism/disabilities Specialist Applied Behavioral Analysis [Felix Waihee Consent Decree ] Lovass’ 1987 landmark Young Autism Study Wikipedia: Preferred treatment for individuals with disabilities 2 courses integrated into MFT program at U of G

4 Low 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

5 DSM-IV-TR: Mental Retardation
Essential Feature Significantly 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-4 Adaptive Functioning How effectively the individual copes with common life demands Determined by presenting symptoms versus low IQ Problems in adaptation can improve with repetition, but cognitive IQ tends to remain relatively stable.

6 Low Functioning: AC age 14 female CSC
Scale Score Percentile Range Verbal, VCI Extremely Low Perceptual, PRI Low Average Working Memory, WMI Borderline Processing Speed, PSI Low Average Full Scale IQ Extremely Low

7 DSM-IV-TR: 317 Mild Mental Retardation
IQ level to approximately 70 Educable, 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.

8 DSM-IV-TR: 318 Moderate Mental Retardation
IQ level to 50-55 Trainable; 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.

9 Moderate MR: DC age 14 male CSC
Scale Score Percentile Range Verbal <.1 Extremely Low Performance Borderline Working Memory <.1 Extremely Low Processing Speed Extremely Low Full Scale IQ <1 Extremely Low

10 How is Level of Functioning Determined?
IQ tests Wechsler Intelligence Scale for Children, fourth edition, WISC-IV Wechsler Adult Intelligence Scale, fourth edition, WAIS-IV Test of Nonverbal Intelligence, fourth edition, TONI-4 Myth of IQ tests True IQ No 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 IQ Heavy metal/toxin exposure, TBI, prenatal alcohol/drug use, birth trauma Physical/emotional traumas: violence, child/sex abuse, abandonment. Nutrition, digestion (McBride, 2010), exercise Early training: music, sign, (whole brain learning age 0-5) IQ is most flexible throughout childhood

11 Experiential/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 kinesthetic Aka 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: Visual Auditory Kinesthetic

12 “Myths” of ‘Low Functioning’
There are obvious indicators: False Speech-impaired: good articulation is deceptive Thought processes impaired: limited, not impaired Physically recognizable: attractiveness is deceptive Their feelings are like my feelings: hypersensitive False assumptions: If he talks then he understands me: limited comprehension He needs counseling: CBT is insufficient. Since he talks, he can say what’s bothering him: no He is choosing not to talk: not necessarily Conflicting emotions confuse/block concept formation Emotions impede verbalization Unable to conceptualize response

13 Abuse Affects the Brain and Functioning
R: Alcohol Abuse L: Head Trauma, Drug Abuse Arlene Gadia, CPS supervisor: 1200 referrals/yr child abuse; KUAM Lyndia Tenorio, CPS supervisor: 2000 referrals/yr child abuse; KUAM

14 Scans Show Brain Damage in Abused Teens
University of Pennsylvania School of Medicine, 2011 study on effects of childhood maltreatment on neuroimaging of gray matter volume in adolescents childhood 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 regulation Boys: deficits concentrated in regions related to impulse control. At risk for development of mood disorders addictive disorders other psychiatric disorders

15 Prefrontal cortex, striatum, amygdala, cerebellum: grey matter volume deficit

16 Effects 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 Neuroscience SW 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. Cognition Corticotrophin, 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 cycle Imbalance impairs functioning (pouring battery acid over brain) Sleep deprivation impairs brain repair; insomnia common Symptoms: shut-down/acting-out, suicidal ideation/gestures = distress Emotional pain drives compulsions. compulsions precipitates self-medication/addictions (alcohol-substance abuse, neg. compulsive behaviors).

17 Childhood maltreatment changes brain structure and function
Childhood maltreatment changes brain structure and function. Abuse/chronic trauma hx = Left Prefrontal Cortex Damage

18 Dr. JD Bremner: Incest Yale Psychiatric Institute. April 1999, Biological Psychiatry The 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, PTSD Mind 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.

19 Childhood Sexual Abuse Causes Physical Brain Damage: An Alarming New Study

20 Frontal Temporal BeforeAfter Tx

21 Frontal-Temporal Rotated

22 McLean 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.

23 Irritable Limbic System: more self-destructive behaviors & aggression

24 Corpus Collosum: deficit in size of 24-42% in neglect, 18-30% in sex abuse, affects dramatic mood & personality shifts.

25 Hyperactive Cerebellar Vermis: Impaired ability to maintain emotional balance Brain wired for fear, anxiety, stress

26 Daniel Amen, M.D.: Magnificent Mind at Any Age (2008) Treat Anxiety, Depression, Memory Problems, ADD, and Insomnia Cerebellum: 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 situations Motor control, posture, gait Executive function, connect to prefrontal cortex, speed of cognitive integration Problems in the cerebellum = easily confused. Slowed thinking Slowed speech Trouble learning routines Disorganization Sensitivity to noise, touch; light sensitivity Tendency to be accident prone Found low in activity in autism, ADD, learning disabilities Major coordination center in the brain Major strategies to optimize: coordination exercises as sports and music, dancing or table tennis Healthy diet, targeted behavioral exercises, mental exercises, supplements (multiple, fish oil, vit D, medications).

27 Drug AbuseHealthy Brain Grey matter volume reduced: prefrontal cortex, striatum, cerebellum, amygdala per child abuse

28 Grey 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)

30 Neurobiology Behavior-learning problems plague 3/4 of children in child welfare system. stress-regulating hormone production altered key 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.

31 Verbal 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 damaging multiple cases of victims who have all the symptoms of physical abuse but were never physically abused

32 What 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, limited Responses 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 anxiety Non-directive inquiry to assist thinking process.

33 Speech & Comprehension are different parts of the brain

34 Low 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 thinking Choice is insufficient Weak coping skills* Ineffective ability to deal with negative emotions Explosions: physical, verbal, emotional aggression Implosion: compulsions, self-harm, suicide Teach emotion vocabulary, verbalizing format Social blindness* Unaware of social convention Social initiative, reciprocal conversing, social inquiry are absent Teach looking into faces (visual cues), social questions

35 Label feelings, verbalize feelings Process emotions, de-intensify emotional pain

36 Low Functioning Characteristics
Weak ability to implement learning* Low information transfer from concept to ‘doing’. Signs contract but repeats offenses Repeats what you said then fails to follow through Need for kinesthetic versus conceptual learning Difficulty learning in group format Difficulty with sedentary learning, need to move, to do, experience. Weak to absent assertiveness skills Authoritarian parenting = aggress or submit Suppression is not respectfulness Misunderstood disabilities elicit abuse in uneducated families Low receptive auditory interpreted as Not Listening Low information implementation interpreted as disobedience Repeat offenses interpreted as defiance No response, blank stare, walking away, interpreted as disrespect Disciplinary stress affects 2ndary brain damage

37 L: Left temporal deficit-suicidal child R: Worried & Rigid

38 Undoing Neurobiological Effects of Trauma
Alexandra Cook, Ph.D. Trauma Center at Justice Resource Institute, MA Positive 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.

39 NY Times Magazine, April 2012: Evidence-based Interventions
Aerobic Exercise 1990s research: Exercise jump-starts neuro-genesis Mice/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 annually Exercise 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 flexibly Only thing that mattered in improving the brain: aerobic exercise. Aerobic exercise increased Brain-derived neurotropic factor, BDNF BDNF 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 60 Walkers had larger hippcampi after a year Walkers regained 2+ yr of hippocampal youth (65yr -->63yr) Stretchers lost volume to normal atrophy

40 Interventions Daniel Amen, MD, ‘Use Your Brain to Change Your Age,’ 2012 1-hr aerobic exercise daily; Effects wear off after 24 hr. Magnificent Mind at Any Age, 2008: ANT & ANT eaters 9 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 Intense Amygdala 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. Enactment Trauma 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.

41 Kinesthetic Intervention
Walk through learning experience, repetitively Enactment: pre-experience drama therapy. CSC-- Clarify rules, enact Touching 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 behavior Rehearse then re-enact drama while coaching appropriate behavior, words.

42 Heal the brain: Exercise, verbalize feelings, laughter, secure attachment, nurture, enactment, diet

43 What to Do Capitalize on strength: Kinesthetic
Engage in kinesthetic vocational training early Aerobic exercise Increases brain’s vascular networking, oxygen/nutrients to neurons Improves 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 harm Symptoms of a stressed brain: compulsions, suicidal ideation, aggression Neural plasticity during development maximizes exercise’s effect on brain Nonverbal therapies can reduce/eliminate PTSD, lifelong anger, historic angst Stress is cumulative, has delayed effects Autonomy in adulthood exacerbates seemingly innocuous compulsions into addictions. Pharmaceutically managed depression requires lifelong medication. Brain sustains impairments throughout lifespan without appropriate treatment. Low functioning Low Vocabulary: Keep it Simple (KIS) Low Information: Keep it practical Low Comprehension: ‘do’ desired behavior, kinesthetic: must “do” to learn.

44 Intervention Know the function the behavior serves.
Target the function not the behavior Behaviors are symptoms; function is the purpose it serves. Symptoms: Nail biting, binge eating, restlessness, OCD behaviors, compulsive masturbation, trichotillimania, skin/scab picking, cutting Function: anxiety/stress release, auto-stimulus Behaviors may look different but serve the same function: e.g. stress release Nail-biting, masturbating, skin picking, hair pulling Cigarette smoking, alcoholism, drug use, promiscuity Behavior may look the same but serve multiple functions: attention, escape, tangible Disruptive behavior for attention + escape To reduce the behavior, discontinue reinforcement Reinforce desired behavior intermittently Rehabilitative intervention takes longer, achieves more Reduces compulsions, self-harm, reduces suicidal ideation, suicide gestures/attempts Reduces acting out, aggression, assault Increases verbalization, assertiveness, and adaptive functioning

45 Insufficient Interventions
APA Ethic: Do no harm (Iatrogenic treatment) Corroborate Seek persons w/higher education, more experience, training Ask questions before implementing interventions Consult, consult consult. Authoritarian approach Neither authoritarian nor permissive is therapeutic. Assertive is therapeutic Attend to (nonverbal) feelings to prevent behaviors, feelings drive behavior Fastest way to achieve goals: ‘Motivate’ via client desired incentives. Cognitive therapy Repeat 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 removal Stacked consequences Choice

46 *Interventions NOT for Low Functioning Individuals*
Rewards & Punishment ‘Incentive only’ is preferred treatment approach Punishment, stacked consequences provoke anxiety, victim stance Punishment stops behavior, doesn’t teach appropriate behavior; Broad based education & experience Learning takes so long, focus on high risk behaviors. Prioritize reducing self-harm/other harm, heal the brain. Target: strengths to maximize competency; income earning Intergenerational government dependency status perpetuated. Avoid unnecessary stress: 2ndary damage suffered when stressed Flooding Prolonged 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.

47 Notes 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.

48 Track Progress, Why? Objective Comparison with Baseline Behaviors
Quarterly outcome data Retain focus on original primary goals until achieved Provides client a measure by which to chart progress Progress is measured in quarters and years Tracking Monitors Intervention effectiveness Ineffective: self-harm/other harm continues or escalates Needs adjustment: intervention is quasi successful Effective: target behavior reduces as intervention is mastered. Advance intervention Client succeeds 90%, is ready to advance intervention From 1 emotion program daily, increase to 3-5/daily on negative feelings From 1 collaborative problem solving daily to 2 daily on differences.

49 Performance Measures 2 Types of data Behavioral Frequency
ABC: Antecedent, Behavior, Consequence To seek purpose of behavior 1) seek attention, 2) escape, 3) tangibles, 4) auto-reinforce To know 1) setting event, 2) behavior, 3) reinforcer Monitors interventions, client behaviors, staff performance Are interventions implemented as intended? Do client behaviors reflect increased competency to intervention? Is staff behavior therapeutic to client? Data must be monitored for validity Preferably by ABA trained therapist Frequency Counts the number of times a behavior occurs. Counts the number of replacement/goal behaviors.

50 Behavior data collection

51 Frequency data collection

52 Setting up Goals Chart the frequency of behaviors Behaviors & goals
Baseline: per month. Quarterly: comparison Provides progress report, monitors intervention, staff Behaviors & goals Name behavior + frequency Ignores staff 3x daily Shuts down when he disagrees with staff 1x daily Name goal in objective measurable terms He states his feeling, the cause, and what he wants 3x daily. He participates in collaborative problem solving 1x daily.

53 Scott Miller, PhD Evidenced based: working with Difficult Clients
Listen to the Client They will tell you what they need They will tell you what works for them and what doesn’t They will tell you how you can motivate them Follow the Client’s motivation It is the strongest drive to facilitate goals Innate drive harnesses the client’s own energies Support the Client toward their motivation The client’s goals are paramount Client drive toward their goal is your goal.

54 Chronic trauma affects structural & functional changes in the brain

55 Resources Amen, Daniel MD
Child & Adult psychiatrist, medical director of Amen Clinics World’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 author Use 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 ADD Making a Good Brain Great Healing the Hardware of the Soul The Brain in Love Comprehensive Textbook of Psychiatry Co-author: Unchain Your Brain, Healing Anxiety & Depression, Preventing Alzheimer’s 49+ published research articles

56 Resources Bremner, 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 Publishing Cook, A. (2010). Sensory Motor Arousal Regulation Treatment (SMART): Bottom-up Interventions for Childhood Trauma Greene, R. (2001). The explosive child. New York, NY: Harper-Collins Publishers Johnson, 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. Understanding Children’s Sexual Behaviors. Helping children with Sexual Behavior Problems Treatment Exercises for Child Abuse Victims Sexuality Curriculum Space Invaders: game about boundaries

57 Resources Kahn, 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 2000 Miller, Scott, PhD. Coauthored: Feedback Informed Treatment Manuals (6) The Heart & Soul of Change: What Works in Therapy Psychotherapy with Impossible Cases Staying on Top & Keeping the Sand Out of Your Pants Teicher, 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.

58 American 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 certification the preferred treatment for individuals with disabilities

59 Eligibility to sit for the BCaBA certification examination: Board Certified Assistant Behavior Analysis A. 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 Requirements Coursework: 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 hours Definition & characteristics and Principles, processes & concepts - 40 hours Behavioral assessment and Selecting intervention outcomes & strategies - 25 hours Experimental evaluation of interventions, & Measurement of behavior and Displaying & interpreting behavioral data - 20 hours Behavioral change procedures and Systems support 40 hours Acceptable Coursework: College or university courses in behavior analysis, that are taken from an institution that meets the requirements specified in Section A.

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