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1 Implementation of PBIS in a Children’s Residential Mental Health Treatment Program Lisa Davis, LMFT, Clinical Director Eleanor Castillo, Ph.D., Director,

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Presentation on theme: "1 Implementation of PBIS in a Children’s Residential Mental Health Treatment Program Lisa Davis, LMFT, Clinical Director Eleanor Castillo, Ph.D., Director,"— Presentation transcript:

1 1 Implementation of PBIS in a Children’s Residential Mental Health Treatment Program Lisa Davis, LMFT, Clinical Director Eleanor Castillo, Ph.D., Director, Outcomes & Quality Assurance 3 rd International Conference on Positive Behavioral Supports Reno, NV March 2006

2 2Overview I. Description a. EMQ and Residential Services a. EMQ and Residential Services b. Population Served b. Population Served II. Context for redesign a. Overview of change process and a. Overview of change process and changes implemented changes implemented b. Detail of PBIS implementation b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors a. Facilitative factors b. Challenges b. Challenges V. Next steps V. Next steps

3 3 EMQ Mission and Vision  To work with children and their families to transform their lives, build emotional, social and familial well-being and to transform the systems that serve them. to transform their lives, build emotional, social and familial well-being and to transform the systems that serve them.  EMQ will lead the nation in service excellence, innovation and social policy improvement for children and families.

4 4 EMQ Children & Family Services  Services in 18 California counties  Wraparound  Residential Treatment  Therapeutic Behavioral Services  School Based Mental Health Services  Mobile Crisis Intervention  Outpatient Treatment  Chemical/Alcohol Dependency Education & Prevention  In Home Family Treatment  Sexual Abuse Treatment  Foster Care-Professional Parent, ITFC  Family Partnership Institute

5 5 Core Philosophy Consistent with the Child and Adolescent Service System Program Principles (CASSP) Consistent with the Child and Adolescent Service System Program Principles (CASSP) Strengths BasedStrengths Based Family CenteredFamily Centered Community BasedCommunity Based Culturally CompetentCulturally Competent IndividualizedIndividualized Natural SupportsNatural Supports Team Based/CollaborativeTeam Based/Collaborative PersistencePersistence Outcome BasedOutcome Based

6 6 Agency-wide # of Youth (FY2004-2005) Crisis778 Wraparound503 FFA471 Outpatient227 Sexual Abuse Treatment 150 System of Care 150 Addiction Prevention Service 129 School Based 102 Residential85 Matrix46 Total2,641

7 7 EMQ Referral Sources (FY2004-2005) EMQ Referral Sources (FY2004-2005) DFCS101937% Education40915% Self/Family32912% EMQ32112% JPD1796% County MH 1746% Medical Facility 943% Other2139% N = 2738

8 8 Residential Referral Sources (FY2004-2005) DFCS5059% EMQ1315% JPD34% County MH 78% Medical Facility 911% Other34%

9 9 Logic Model Program draws from the following theories: Positive Behavioral Intervention and Supports, Bronfrenbrenner, Love & Logic Parent Training Program, Family Finding Model of Catholic Community Resources, and systems theory Program draws from the following theories: Positive Behavioral Intervention and Supports, Bronfrenbrenner, Love & Logic Parent Training Program, Family Finding Model of Catholic Community Resources, and systems theory

10 10 Residential Service Goals  Establish permanency for youth in a safe, loving and supportive family.  Provide 24-7 structure, supervision and therapeutic intervention.  Stabilize acute behaviors and improve daily functioning.

11 11 Residential Services Description  4 RCL (Rate Classification Level) 14 cottages Two units for children ages 6-12 years Two units for children ages 6-12 years Two units for youth ages 12-18 years Two units for youth ages 12-18 years 3 are co-ed and 1 is all male 3 are co-ed and 1 is all male Each unit has capacity to serve up to 10 children Each unit has capacity to serve up to 10 children

12 12 Staff Resources  Clinical Director  Clinical Program Manager  Clinician/Case Manager  Residential Cottage Supervisor  Milieu Activity Therapist  Psychiatrist  Educational Resources  Recreational Therapist  Registered Nurse

13 13 Array of Services  Comprehensive assessment of all life domains  Family Therapy  Individual Therapy  Intensive case management and linkage to community activities  Nursing services  Psychiatric Assessment and Treatment  Psychoeducational and psychotherapeutic groups  Academic support  Family Finding  Family Partner Services  Medical/Dental Assessment and Linkage  Recreational, Music and Art Therapy  Therapeutic milieu based on PBIS principles

14 14 Cottage Structure  Schedule of activities  Points system  Level system  Incentive and behavior management system  Team meetings  Day treatment  Mental health model

15 15 Overview I. Description a. EMQ and Residential Services a. EMQ and Residential Services b. Population Served b. Population Served II. Context for redesign a. Overview of change process and a. Overview of change process and changes implemented changes implemented b. Detail of PBIS implementation b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors a. Facilitative factors b. Challenges b. Challenges V. Next steps V. Next steps

16 16 Residential Targeted Population  Children with Severe Emotional Disturbances  Youth who are experiencing: Maladaptive response to trauma Maladaptive response to trauma Severe impairment in capacity to function in their daily activities Severe impairment in capacity to function in their daily activities Psychotic features or dangerousness to self or others Psychotic features or dangerousness to self or others  Need repetitive, consistent interventions that structure their environments and teach adaptive behaviors  Many with co-morbid disorders (primarily mood disorders and behavioral disorders)  Need 24/7 supervision, support, and observation under clinical direction of a therapist and psychiatrist, to maintain safety

17 17 Youth Characteristics ResidentialGenderMale59% Female41% LanguageEnglish95% Spanish3% Other3% Ethnicity African American 13% Asian/Pacific Islander 8% Caucasian30% Latin American 46% Native American 1% Other3%

18 18 Youth Characteristics (cont.) Residential Age at Program Entry 6 to 12 Years Old 46% 13 to 18 Years Old 54% % of Out- of-Home Placements Less than 3 16% 3 or More 79% Not Applicable 5% CAFAS at Program Entry Marked (100 to 130) 31% Severe 140 and Higher) 69%

19 19 Youth Characteristics (cont.) Residential History of Abuse PhysicalNo36% Yes64% SexualNo60% Yes40% Drug/AlcoholNo23% Yes77%

20 20 Overview I. Description a. EMQ and Residential Services a. EMQ and Residential Services b. Population served b. Population served II. Context for redesign a. Overview of change process and a. Overview of change process and changes implemented changes implemented b. Detail of PBIS implementation b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors a. Facilitative factors b. Challenges b. Challenges V. Next steps V. Next steps

21 21 Context for Change  Concern sited nationally regarding poor outcomes for residential services  Concern regarding the negative effects of congregate care for certain youth  High cost of services, particularly in context of diminishing resources  Effectiveness of community based services, which highlights the question of the need for residential services  Focus on the right for permanency and the result foster care has had on severing family connections  The need to re-conceptualize residential in thinking about services as a 24/7 clinical intervention versus an emphasis on a living environment

22 22 Why Re-design Residential Services?  To implement evidence based services including PBIS, Trauma Focused CBT, and Parent Management Training  To utilize residential services as an intervention, not as a placement  To achieve improved outcomes  Increase youth and family connections  Develop sustainable community supports  Ensure permanency for youth in a loving, supportive family  To ensure consistent implementation of a strength based, needs driven, family centered, individualized and culturally relevant philosophy in all aspects of care  To partner with families and ensure family involvement in all aspects of care  Maintain families connection with their community and increase natural supports

23 23 SAMHSA’S Residential Best Practice Principles  Strengths imbedded in ALL aspects of care  Focus on resiliency and developmental needs  Families are full partners  Focus on permanency planning  Truly individualized and culturally competent  Focus on the need to be successful in community  Full integration of residential services into the community and continuum of services  Comprehensive developmentally appropriate assessments (psychosocial, trauma, physiological, cognitive, language, safety, etc.)  Use of specific evidence-based interventions  Respectful, strength-based relationships and interactions are a cornerstone

24 24 The Role of Residential Services  In partnership with the family and youth, meet unmet needs with the goal of returning youth to the home and community as soon as possible.  Short-term stabilization when all other resources have been unable to maintain safety.  To provide short-term intensive services to sustain family stability and maintain permanency. The level of intensity of service supports accelerated healing and change.  Multidisciplinary assessment to understand the youth and family’s needs.  Frequent psychiatric intervention and observation to stabilize functioning and meet needs so that community resources can be effectively utilized.

25 25 Change Process  Work team approach with inclusive decision making  Established a leadership team  Well developed communication plan  Use of change methodology-Implementation Management Associates (IMA) Business Case for Action Business Case for Action Charter Charter  Use of quality improvement techniques  3 phase change process: Gathering data/information Gathering data/information Implementation Implementation Evaluation Evaluation

26 26 Redesign Work Teams

27 27 Redesign Work Teams

28 28 Phases of Change Process Phase 1 - Data Gathering  Focus groups with families and children  Staff questionnaires  Customer questionnaires  Reviewed 7 years of internal data  Literature review of Evidence-Based Practices  Benchmarking other residential programs  Attendance at “Best Practices” conferences

29 29 Phases of Change Process Phase 2 – Implementation  Implemented PBIS  Family Finding  Family Inclusion Practices and Procedures  Community Based Practices  Switch to Mental Health Model vs. Day TX.  Developed Transitional Services

30 30 Why PBIS?  Evidence in schools that approach creates pro social positive environments  Alignment with agency philosophy  Goodness of fit: congruent with behavioral approach already utilized  Focus on increasing quality of life, achieving broad goals and supporting portable skills  Use of a proactive and educative approach to support elimination of “control based” interventions including restraints  Eber, Sugai, Smith, & Scott (2002); Scott & Eber (2003 a & b)

31 31 PBIS Implementation Strategies  PBIS Overview Training for all staff  Consultant Role: Observed each cottage to understand current operations, staff skills and knowledge and population Observed each cottage to understand current operations, staff skills and knowledge and population Provided 3 8-hour trainings for all 60 staff Provided 3 8-hour trainings for all 60 staff on development of Functional Behavioral Assessment and Behavior Support Plans on development of Functional Behavioral Assessment and Behavior Support Plans Between trainings staff practiced skills and brought plans back to each training Between trainings staff practiced skills and brought plans back to each training

32 32 PBIS Implementation Strategies Training Model BoosterTraining Exposure Consultation Staff – FBA, BSP CPMsDirectors

33 33 PBIS Implementation Strategies  PBIS implementation work team created to discuss operational issues (director, managers, program sups, clinicians, MATs and consultant) Meet two times a month Meet two times a month  Developed “Support team” Consultant/Trainer provides bi-monthly consultation Consultant/Trainer provides bi-monthly consultation Membership includes 4 line staff and 2 therapists Membership includes 4 line staff and 2 therapists  Consultant attended team meetings to discuss plans and provided booster trainings

34 34 PBIS Implementation Strategies  Management Infrastructure Develop behavior and cottage management system Develop behavior and cottage management system Reviewed past point and level system, develop new systems based on values matrix Reviewed past point and level system, develop new systems based on values matrix Establish core values/expectations and settings Establish core values/expectations and settings Develop universal rules Develop universal rules Provide consultation and problem solve barriers Provide consultation and problem solve barriers Development of internal training capacity to sustain PBIS Development of internal training capacity to sustain PBIS Develop and adapt all program policies and procedures to reflect PBIS implementation Develop and adapt all program policies and procedures to reflect PBIS implementation

35 35 PBIS Implementation  Currently entering daily point sheets into SPSS database to analyze trends  Goal is to revise point and level system using newly developed behavioral goals and expectations and have point and level system support the positive values and expectations  Ultimate goal is to have staff enter daily point totals into the agencies electronic record system for each child at the end of each shift This will enable real time analyses of data trends within each cottage This will enable real time analyses of data trends within each cottage

36 36 PBIS Implementation  Core values/expectations chosen Respect, Safety, Responsibility and Cooperation. Respect, Safety, Responsibility and Cooperation.  Process of choosing settings Examples are meal times, community time, family visits, hygiene, chores etc. Examples are meal times, community time, family visits, hygiene, chores etc.  Translation from school based to residential based different Settings activity based vs. physical environment Settings activity based vs. physical environment Accommodate 24-7 vs. school hours Accommodate 24-7 vs. school hours Focus on daily living skills, participation in treatment program etc. Focus on daily living skills, participation in treatment program etc.

37 37Overview I. Description a. EMQ and Residential Services a. EMQ and Residential Services b. Population served b. Population served II. Context for redesign a. Overview of change process and a. Overview of change process and changes implemented changes implemented b. Detail of PBIS implementation b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors a. Facilitative factors b. Challenges b. Challenges V. Next steps V. Next steps

38 38 Living Situation at Exit

39 39 Reason for Discharge

40 40 Average Number of Runaways Per Month

41 41 Average Number of Restraints Per Month

42 42 Average Number of Assaultive Behaviors Per Month

43 43 Case Presentation 1: “Roger”  Male, 13 years old  Caucasian  Referred from The Dept of Social Services as a result of failed foster home placement and lower group home level  Primary Diagnosis- ADHD Co-morbid diagnoses- ODD, Tourette’s Co-morbid diagnoses- ODD, Tourette’s

44 44 Case Presentation 1: “Roger”  Broad goals: Making and keeping friends  Strengths: Friendly, cares about others  Challenges: Low cognitive ability, no strong familial relationships  Target behaviors: hitting, kicking, throwing playground equipment Baseline frequency- 6-10 times a day during activities Baseline frequency- 6-10 times a day during activities  Types of data collected Interviews with the Milieu Activities Therapist Interviews with the Milieu Activities Therapist Observations conducted by several staff Observations conducted by several staff Record reviews Record reviews

45 45 Case Presentation 1: “Roger”  Antecedents: When in a physical activity involving peers, specifically when there is down time or during a transition and he has easy access to sports equipment  Consequences: Usually staff attention for misbehavior and peer agitation  Hypothesized function: Self-stimulation or adult attention

46 46 Case Presentation 1: “Roger”  Proactive strategies Keep tactile object in pocket to use during transition times Keep tactile object in pocket to use during transition times Engage in energy release prior to transitions Engage in energy release prior to transitions  Educative strategies Describe what happens when he throws an object without others awareness Describe what happens when he throws an object without others awareness Teach how to use equipment appropriately Teach how to use equipment appropriately  Functional/consequence-based strategies Earn sticker as a reward for positive behaviors; Earn sticker as a reward for positive behaviors; Get more staff attention at bedtime if he uses equipment safely Get more staff attention at bedtime if he uses equipment safely

47 47 Case Presentation 1: “Roger”  Outcomes of Plan: Behavior has reduced to 1-2 times daily during activities Behavior has reduced to 1-2 times daily during activities Increased more self esteem and enjoys physical activities more often Increased more self esteem and enjoys physical activities more often Improved peer interactions during physical activity Improved peer interactions during physical activity  Other positive effects Made one friend Made one friend Seeks positive attention from staff more frequently Seeks positive attention from staff more frequently

48 48 Case Presentation 2: “Charles”  Male, 9 years old  Latino American  Referred from the Dept of Social Services  Primary Diagnosis: ODD Co-Morbid Diagnoses: Depressive D/O NOS, Anxiety D/O NOS, Cognitive Disorder NOS, ADHD Co-Morbid Diagnoses: Depressive D/O NOS, Anxiety D/O NOS, Cognitive Disorder NOS, ADHD

49 49 Case Presentation 2: “Charles”  Broad goals: Decrease aggressive behaviors and make friends.  Strengths: Intelligent, cute, good sense of humor, strong sense of loyalty.  Challenges: Disrespectful of others feelings, rude and defiant.  Target behaviors: Telling others what to do Baseline frequency- 15-20 times a day Baseline frequency- 15-20 times a day  Types of data collected Interviews with the Milieu Activities Therapist, therapist, Foster Parent and Social Worker. Interviews with the Milieu Activities Therapist, therapist, Foster Parent and Social Worker. Observations conducted by several staff using ABC scatter plots. Observations conducted by several staff using ABC scatter plots. Record reviews Record reviews

50 50 Case Presentation 2: “Charles”  Antecedents: Interacting with peers and when others are getting negative attention.  Consequences: Looses points, staff engage with him/set limits and give time outs.  Hypothesized function: Attention seeking

51 51 Case Presentation 2: “Charles”  Proactive strategies Attention cards Attention cards Staff check ins particularly during transitions Staff check ins particularly during transitions  Educative strategies Taught him positive ways to get staff and peer attention Taught him positive ways to get staff and peer attention Role played how to talk with others, how disengage, what tone of voice to use and the difference between telling and asking. Role played how to talk with others, how disengage, what tone of voice to use and the difference between telling and asking.  Functional/consequence-based strategies Received stickers every time he walked away or didn’t do target behavior Received stickers every time he walked away or didn’t do target behavior Received a certificate with stickers Received a certificate with stickers Earned one on one time with staff Earned one on one time with staff

52 52 Case Presentation 2: “Charles”  Baseline frequency for target behavior 15-20 times a day.  After implementation target behavior reduced to 2-3 times a day.  Other positive effects Improved school behaviors and earned student of the month Improved school behaviors and earned student of the month Made a friend Made a friend Number of restraints reduced from 1-3 times per week to 1 time a month. Number of restraints reduced from 1-3 times per week to 1 time a month.

53 53 Case Presentation 3: “Jason”  Male, 11 years old  Latino American  Referred from the Dept of Mental Health  Primary Diagnosis: Dysthymic Disorder Co-Morbid Disorders: ODD, Asperger, Rett Co-Morbid Disorders: ODD, Asperger, Rett

54 54 Case Presentation 3: “Jason”  Broad goals: Decrease social anxiety and improve social skills and interactions  Strengths: Smart, quick to learn, good verbal skills  Challenges: Can be egocentric, rude to others  Target behaviors: Manipulating, arguing with staff, not following staff directions Baseline frequency- 2-3 times every 15 minutes Baseline frequency- 2-3 times every 15 minutes  Types of data collected Interviews with parents and youth Interviews with parents and youth Observations conducted by several staff Observations conducted by several staff Record reviews Record reviews

55 55 Case Presentation 3: “Jason”  Antecedents: Attention is on other youth, when Jason is in unfamiliar situations  Consequences: After interrupting or arguing Jason received attention from staff (usually in the form of reprimands and redirections)  Hypothesized function: Attention from staff

56 56 Case Presentation 3: “Jason”  Proactive strategies Predicted for Jason that he would use nice words Predicted for Jason that he would use nice words Reminded him of the incentives Reminded him of the incentives  Educative strategies Taught positive ways to get attention Taught positive ways to get attention Taught him to ask for what he wants directly Taught him to ask for what he wants directly Taught skills to be appreciative Taught skills to be appreciative  Functional/consequence-based strategies Praise when he is engaging in positive behavior Praise when he is engaging in positive behavior Gets one puzzle piece per 15 minutes if not engaging in target behaviors (arguing, not following directions) and for demonstrating replacement skills. After 32 pieces, he gets Jamba juice Gets one puzzle piece per 15 minutes if not engaging in target behaviors (arguing, not following directions) and for demonstrating replacement skills. After 32 pieces, he gets Jamba juice

57 57 Case Presentation 3: “Jason”  Time 2 frequency: Target behavior reduced to 2-3 times per day  Other positive effects Family visits: More successful family visits, less rude, increased safety Family visits: More successful family visits, less rude, increased safety School: Increased participation School: Increased participation Made a friend in the unit Made a friend in the unit

58 58 Overview I. Description a. EMQ and Residential Services a. EMQ and Residential Services b. Population served b. Population served II. Context for redesign a. Overview of change process and a. Overview of change process and changes implemented changes implemented b. Detail of PBIS implementation b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors a. Facilitative factors b. Challenges b. Challenges V. Next steps V. Next steps

59 59  Agency and PBIS philosophy alignment  Outcome and evaluations department  Data management practices  Use of change methodology and quality improvement techniques  Trainer/consultant thoroughly learned operations, built relationship with staff  On going support from consultant  Sponsorship and resources from management Facilitative Factors

60 60 Facilitative Factors  Structuring discussions of BSP in team meetings  Development of a “Support Team” and an Operations work team  Key staffs’ skill sets and enthusiasm  Resource binders and books  Clearly delegating tasks to specific people with timelines  Being open to concerns and seeing resistance as helping to inform the change process

61 61 Facilitative Factors  Building PBIS job expectations into staff evaluations  Acknowledging staff and celebrating successes  Developing Program Procedures to support implementation  Using electronic record to gather and report data

62 62 Challenges  Implementing significant change while caring for children 24-7  Deciding what practices to discontinue to make room for new practices  Development of a sustainability plan  Considering multi-systemic needs and regulations, particularly in terms of documentation  Maintaining focus and prioritizing PBIS implementation with multiple other demands

63 63 Challenges  Learning curve on how to utilize data to inform practice  Establishing consistency and accountability across three shifts, 20 staff and registry  Overcoming agency culture “flavor of the day”

64 64 Overview I. Description a. EMQ and Residential Services a. EMQ and Residential Services b. Population served b. Population served II. Context for redesign a. Overview of change process and a. Overview of change process and changes implemented changes implemented b. Detail of PBIS implementation b. Detail of PBIS implementation III. Review data and case examples IV. Lessons learned a. Facilitative factors a. Facilitative factors b. Challenges b. Challenges V. Next steps V. Next steps

65 65 NEXT STEPS  Continue to evaluate outcomes  Continue evaluation of universal interventions and individual FBAs/BSP  Develop a system to incorporate documentation of BSP into current documentation  Continue development of sustainability plan  Start implementation in other EMQ programs

66 66 REFERENCES  Scott, T.M. & Eber, L. (2003). Functional Assessment and Wraparound as Systemic School Processes: Primary, Secondary, and Tertiary Systems Examples. Journal of Positive Behavior Interventions, Vol 5 (3), pp 131-143.  Eber, L., Sugai, G., Smith, AC.R., & Scott, T.M.  (2002). Wraparound and Positive Behavioral Interventions and Supports in the Schools. Journal of Emotional and Behavioral Disorders, Vol 10 (3), pp 171-180.

67 67 CONTACT INFORMATION Lisa Davis, LMFT, Clinical Director Email: ldavis@emq.org ldavis@emq.org Eleanor Castillo, Ph.D., Outcomes & Quality Assurance Director Email: ecastillo@emq.org ecastillo@emq.org


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