1. Implementing a Tier 3 System In AN Alternative ASD Program
Bob Putnam, Ph.D., BCBA-D
Shannon Barry, Ph.D., NCSP

2. Problem Behaviors
Children with autism are at significant risk to develop problem behaviors
Without intervention, problem behaviors are more likely to worsen than improve
The impact of problem behaviors on educational, social, and community opportunities is dramatic and detrimental (Horner, Carr, Phillip, Strain, Todd, & Reed, 1999)
© 2006 National Autism Center
Reproduce Only with Author’s Written Permission

3. Positive Behavior Support
Mind and Body in Autism
Positive Behavior Support
Carr et al. (2000) reported that in over 2/3 of published studies, interventions using positive behavior support resulted in reducing behavior problems by 80% or more.
Interventions were more likely to be effective if they were guided by functional behavior assessment.
Carr et al 2000? 3

4. Intensive (Tier 3) Supports
FEW
High risk
Individualized strategies, interventions, and practices
Intensive teaching, acknowledgement, and correction procedures
Frequent monitoring and data analysis, and treatment integrity
BABAT 2015

5. Tier 3 System
Purpose: To provide a venue for teams to systematically analyze behavioral data, make decisions based on those data, and monitor individuals’ progress
Objective: To find the simplest solution that will make the biggest change in the behavior problem

6. Criteria for Placement in Tier 3
The individual has required 2 or more physical holds within a 24-hour period or over a 30 day period to insure their safety or that of others or
The individual has engaged in behaviors that are dangerous to themselves or others on a regular basis, not necessarily requiring physical holds.
The individual has had long standing behavior problems which has not been responsive to current interventions
The most frequently recorded behavior problems are aggression, self-injury, elopement, and property destruction.

7. Tier 3 Criteria: Behavioral Outcomes
Tier 1 Tier 2 Tier 3

8. Systems Team vs. Individual Team
Brief data review of all students in Tier 3
Has administrative participation
Behavioral expertise
Other expertise e.g.; nursing, speech
Reviews on a ongoing basis systems treatment integrity
Individual team
Focused on one student
Review of data of one student’s performance
Behavioral expertise
Team includes staff working with the student
Family and/or significant others involved

9. Tiered Initiated Problem Solving (TIPS)
Emphasis on team members’ ongoing use of data to inform decision making about each of the problem solving process
Using data to identify and define significant problems
Establish baseline and goal rates/levels of the problem
Select solutions likely to be effective, given the hypothesized function of the problem behavior
monitor and achieve implementation integrity of solution
monitor problem behavior and adjust solution actions as necessary to achieve the objectively-defined resolution goal

10. Tier 3 Team System Meetings
Each person is discussed during the meeting for no more than 2 or 3 minutes.
Graphs of the daily frequency of no more than 3 of their most challenging behaviors over the past 60 days are reviewed.
Determine current trends by using trend line and/or mean frequency per day of behavior
Decreasing trend/Behavior improving (+)
About the same/No change in behavior (0)
Increasing trend/Behavior not improving (-)
Decisions are made as to what should be done to address the problem behaviors that are not improving
Develop an action plan

11. Administrator/resource & operational expertise Behavioral expertise
Tier 3 Systems Team
Administrator/resource & operational expertise
Behavioral expertise
Clinical staff
Program staff

12. Tier 3 Practices: BSP Prevention Strategies Consequence Strategies
Antecedent interventions
Teaching procedures
Environmental design
Communication style
Consequence Strategies
Positive acknowledgement & reinforcement procedures

13. Tier 3 Data-based Decision Making
What do we have in place for our most intensive population? And are the systems and practices implemented with fidelity?
Is what we have in place effective for those with high risk behavior?
Are there trends or patterns across those individuals’ behavior?
Guiding questions of Tier 3. These systems and tools have been created to help answer these questions.
Overall, are individuals’ behavior improving, staying the same, or getting worse? Have they acquired skills?
Are interventions implemented with fidelity?

14. Systems Implementation and Monitoring: Tier 3
Tiered Fidelity Inventory
What do we have in place for our most intensive population? And are the systems and practices implemented with fidelity?
Are interventions, systems, and practices implemented with fidelity?
Emphasis on measuring systems integrity – not just individual treatment integrity
Tool (history, components, assign scores collaboratively based on established criteria)
ABAI 2015

15. TFI Tier 3 Data

16. Are interventions implemented with fidelity?
Tier 3 System
Overall, are individuals’ behavior improving, staying the same, or getting worse? Have they acquired skills?
Are interventions implemented with fidelity?
Purpose: To provide a venue for teams to systematically analyze behavioral data, make decisions based on those data, and monitor individuals’ progress
Goal: To prevent problem behaviors by using data based decision making.
Objective: To find the simplest solution that will make the biggest change in the behavior problem

17. Decreasing Trend (+)

18. Flat/No Change-(0)

19. Increasing Trend (-)

20. Data Based Decision Making
Modification: Some change needs to be made
FBA
Preference assessment
Medical
Treatment integrity
Monitor: Continue to observe for change
(e.g., Have a meeting to discuss alternative behavior reduction strategies, treatment Integrity issue-retrain staff), referral to Peer Review, preference assessment, FBA (clinical team makes these decisions)
generally following a recent behavior strategy change or medication change
Medical-if modifications have been made and treatment integrity is high then present to psychiatrist for possible medication solutions, look at constipation, dental problems, etc.
BABAT 2015

21. Tier 3 Outcomes: Cohort 1
21 individuals
7 females, 14 males
Diagnoses of ASD and other developmental disabilities
Some have mental health and psychiatric diagnoses
All attend and/or live in May Institute day and residential programs

22. Data Unavailable

26. All are diagnosed with ASD
Tier 3 Outcomes: Cohort 2
20 individuals
4 females, 16 males
All are diagnosed with ASD
14 have additional diagnoses including Down’s Syndrome, PTSD, TBI, and Schizoaffective Disorder
All attend and/or live in May Institute day and residential programs

27. Goal: 80%

30. Eliminated
Reduced by 90%

31. 69% decrease
Change dates
BABAT 2015

32. Building Tier 3 Systems Build representative teams
Leadership & oversight
Accountability
Resources & support
Create or streamline data collection systems
Data based decision making
Monitoring effectiveness of systems and practices
Utilize evidence based practices
Systematize current practices
Determine each individual’s level of support
Universal, targeted, intensive
Identify risk

33. Save the Date!
12th Annual New England PBIS Conference November 9th & 10th Norwood, MA

34. Please Provide Feedback
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35. bputnam@mayinstitute.org sbarry@mayinstitute.org