parent professional collaboration for positive behavior support in … · 2018. 10. 5. · 1....

If professionals and parents can accept thechallenge of taking on new roles and ex-pectations by working creatively and coop-eratively with each other and by establish-ing an atmosphere of mutual trust andrespect, children with diverse needs and ca-pabilities can benefit enormously. (Wood,1996, p. 173)

Over the past decade, the field ofpositive behavior support hasgrown rapidly as a set of prac-tices that focus on the function(s) ofproblem behaviors in order to developand teach functional alternatives (Hor-ner, 2000). Based solidly on both a valuesbase about the rights of people with dis-abilities and the principles of applied be-havior analysis, positive behavior supportinterventions (a) consider the contextswithin which the behavior occurs; (b) ad-dress the functionality of the behavior;and (c) result in outcomes that are ac-ceptable to the individual, the family, andthe supportive community (Koegel, Koe-gel, & Dunlap, 1996).

When problem behavior occurs in thefamily home, parent–professional collab-

oration is needed in order to designinterventions that fit the context for in-tervention. Moving toward a truly col-laborative approach with regard to inter-vention planning should reduce theoccurrence of “systems that fail,”whereby “a fix [that is] effective in theshort term [may have] unforeseen longterm consequences which . . . requireeven more use of the same fix” (Senge,1990, p. 388). Often, traditional behav-ioral interventions fail due to a lack of“buy in” from the family, or becausethere is “poor fit” between the problembehavior and the behavioral interven-tion. When either of these consequencesoccurs, more time and effort are requiredby the behavior support interventionistand the family to arrive at an effective so-lution.

A small number of studies havedemonstrated the efficacy of parent–professional collaborative partnershipsrelated to the design and implementationof positive behavior support interven-tions in the context of natural family rou-tines. For example, Lucyshyn, Albin, and

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Parent–Professional Collaborationfor Positive Behavior Support in the Home

Joanne Kay Marshall and Pat Mirenda

Over the past few years, a number of studies have demonstrated the efficacy ofcombining positive behavior support and family-centered intervention in home set-tings. Family-centered positive behavior support is often conducted within the contextof natural routines that occur regularly in home or community settings. The purpose ofthis article is to describe many of the unique challenges and benefits related to assess-ment, intervention design, and implementation that are inherent in parent–professionalcollaboration for positive behavior support. This is accomplished through an exampleof a partnership that resulted in the provision of a variety of visual supports to a youngchild with autism who exhibited severe problem behaviors during daily routines.

Nixon (1997) described a 26-month in-tervention conducted by the parents ofan adolescent girl with multiple disabili-ties in the context of dinner time, homeleisure, restaurant, and grocery storeroutines. Vaughn, Dunlap, Fox, Clarke,and Bucy (1997) provided support to aboy with Cornelia DeLange syndrome,severe intellectual disabilities, and chronicmedical problems. In this case, a positivebehavior support intervention was im-plemented during family-centered com-munity routines that included shoppingin a grocery store, eating at a fast-foodrestaurant, and banking at a drive-throughwindow. Vaughn, Clarke, and Dunlap(1997) worked with the family of a boywith multiple disabilities and agenesis ofthe corpus callosum to decrease problembehaviors during fast-food restaurant andhome toileting routines. Finally, Clarke,Dunlap, and Vaughn (1999) describedan intervention with a boy with Aspergersyndrome who exhibited severe problembehaviors during his morning “gettingready for school” routine. In each case,the intervention resulted in a marked de-crease in the frequency and intensity ofproblem behavior as well as an improvedquality of life for both the child and hisor her family.

Typically, collaborative behavior sup-port planning requires professionals andfamily members to participate togetherin five successive phases that involve “re-ciprocal information sharing, creative prob-lem solving, and shared decision mak-

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ing” (Snell, 1997, p. 219). The fivephases include

1. building relationships between thefamily and the professionals,

2. conducting a functional assessmentof the behaviors of concern,

3. identifying natural routines as con-texts for intervention,

4. developing behavior support plansrelated to each of the routines, and

5. implementing and revising the sup-port plans as needed.

Such collaborative efforts have the po-tential of resulting in substantial and en-during behavior change and improvedquality of life for the children involvedand their families through the use ofmulticomponent intervention packages(Carr & Carlson, 1993).

The purpose of this article is to de-scribe the process of parent–professionalcollaboration for positive behavior sup-port and illustrate it with an example ofWyatt, a preschooler with autism, and hisfamily. In order to accomplish this, thearticle will operate simultaneously ontwo levels: (a) the general level, with re-gard to principles and practical strategiesthat apply to family-centered positive be-havior support interventions, and (b) thespecific level, with regard to how theseprinciples and strategies were actualizedon behalf of Wyatt by his family and theconsultant who provided them with sup-port. The article will address many of theunique challenges that must be facedwhen implementing such interventionsin homes, including those related to as-sessment, intervention design, and im-plementation within the family context.

Introducing Wyatt and His Family

At the time of intervention, Wyatt Mal-lard was a high-spirited and active 4-year-old with an engaging smile who had beendiagnosed with mild/high-functioningautism at the age of 3 years by a multi-disciplinary hospital team in the Cana-dian province where he lives (see Note).

He enjoyed playing with trains, using acomputer, watching videos, riding his bi-cycle outside, and swimming at a localcommunity pool. Although he was ver-bal, his language comprehension and pro-duction were delayed for his chronolog-ical age. Wyatt used both immediate anddelayed echolalia as well as generativelanguage and problem behaviors to makehis wants and needs known and to com-ment. His social skills were markedly im-paired; he usually played by himself andhad difficulty interacting with other chil-dren, joining them in play, knowing therules of play activities, taking turns, andsharing materials.

Wyatt lived at home with his motherand father, Laura and Martin, and withhis younger brother, Elliott. Laura was afull-time homemaker at the start of theintervention, and Martin was employedas a medical instrument repair technician.A respite worker provided childcare inthe family’s home two mornings a weekand some evenings. Wyatt attended aninclusive preschool program for childrenwith autism and their typical peers everyweekday afternoon for 3 hours.

The intervention was carried out col-laboratively by Wyatt’s parents with thesupport of a consultant (the first author),who was then the coordinator of his pre-school. Wyatt’s parents were highly mo-tivated to address his problem behaviorusing a collaborative approach becauseWyatt was eligible for behavioral supportservices through his preschool for only 1 year due to his upcoming transition tokindergarten, and his family had no ac-

cess to alternative behavior support ser-vices. They were aware of the time com-mitment that would be required and theyagreed to record and share their percep-tions of the experience. Table 1 summa-rizes the major phases and subphases ofthe assessment and intervention process.

Phase 1: BuildingRelationships

The positive behavior support paradigmexemplifies a systems model of support inwhich each participant affects the othersas learning and change occur among all.A family-centered orientation to positivebehavior support requires consultantsand family members to work together byfirst establishing trust, openness, and rec-iprocity (Dunst, Trivette, & Deal, 1988).This means that the first step in any in-tervention involves developing a rela-tionship between the consultant andfamily that enables the former to bet-ter understand the family’s structure,strengths, routines, capacities, and needs.In so doing, positive behavior supportoffers an opportunity for both the con-sultant and the family to engage in a mu-tual problem-solving process. This pro-cess can lead to more relevant questions,more acceptable and feasible interven-tions, and more meaningful outcomes inrelevant contexts (Dunlap, Fox, Vaughn,Bucy, & Clarke, 1997; Graves, 1991;Turnbull & Reuf, 1996; Turnbull &Turnbull, 1993; Vaughn, Dunlap, et al.,1997).

Table 1Summary of Assessment and Intervention Phases

Phase 1: Building Parent–Professional Relationships

Phase 2: Conducting a Functional Assessment of the Behaviors of Concern• Identifying Behaviors of Concern• Conducting a Functional Assessment• Collaborating to Develop a Hypothesis• Identifying Family Routines for Intervention

Phase 3: Collaborating to Develop a Behavior Support Plan

Phase 4: Collaborating to Implement and Revise the Support Plan• Regular, planned snacks• Visual schedules and choice symbols

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The Mallard Family

Initially, the consultant spent time get-ting to know Wyatt and his family out-side of the preschool environment. Shevisited the family home several times dur-ing the day when Wyatt, Elliott, andLaura were present. She also accompa-nied the three of them to a communitypool on several occasions and cared forElliott while Laura and Wyatt were atWyatt’s swimming lesson. A visit to thefamily home in the evening allowed herto establish rapport with Martin and ob-serve the family’s evening routines. Dur-ing this visit, Laura, Martin, and the con-sultant also discussed the process ofcollaboration and what it meant to eachof them. They concurred that collabora-tion meant working together on a com-mon goal and agreed to attempt to worktogether in a partnership of equals.

Phase 2: Conducting aFunctional Assessment ofthe Behaviors of Concern

This phase of assessment is quite complexand can be divided into four main sub-steps: (a) identifying the behaviors ofconcern, (b) conducting a functional as-sessment, (c) collaborating to develop hy-potheses, and (d) identifying family rou-tines as contexts for intervention. Each ofthese will be described in the sectionsthat follow and illustrated with examplesfrom the Mallard family.

Identifying Behaviors of Concern

Donnellan and Mirenda (1984) recom-mended that parents have access to allnecessary information that affects theirchild, be directly involved in the inter-vention process, and participate in criti-cal decisions. One such decision involvesthe focus of an intervention, particularlywhen there are multiple behaviors ofconcern. Often, decisions in this area aremade by a consultant “expert,” who de-termines which behaviors are most im-portant and how to address them. How-ever, as Snell (1997) noted, the efficacyof behavior support interventions largelydepends on the degree to which the pro-

cedures used fit the ecological and famil-ial contexts in which they are imple-mented. Dunlap et al. (1997) remarkedthat “such congruence cannot be ac-complished without access to the dis-tinctive preferences, beliefs, habits, andworld views of the participants” (p. 222).

The Mallard Family. During the sec-ond evening visit with the consultant,Laura and Martin reported that, in gen-eral, Wyatt was well behaved in the com-munity and when he was in the companyof people other than themselves. Becauseof this, the family was able to enjoy a va-riety of community outings together, in-cluding Wyatt’s weekly swimming les-sons with his mother, a sports class withhis father, and family outings to fast-foodrestaurants and shopping malls. In con-trast, they recited an extensive list ofhome behaviors that were of concern.These included having problems withtoileting, refusing to share toys with El-liott or include him in activities, refusingto take turns or share (e.g., in a game set-ting), demonstrating aggression towardhis brother and peers, picky eating,screaming, saying “no” when asked toparticipate in daily routines, hitting, kick-ing, and refusing to go to bed at night,among others.

Because the list was quite extensive,Laura and Martin were asked to priori-tize their concerns. After considerablediscussion, they agreed that Wyatt’s in-sistence on “following his own agenda”was their top priority because if hisagenda was violated he engaged in a va-riety of noncompliant and aggressive be-haviors that were disruptive to the entirefamily. During an initial interview withthe consultant, Laura and Martin to-gether described Wyatt as “having somelittle game plan in his head about how itshould work and if it doesn’t work thatway, he loses it and it takes forever tocalm him down.” However, they admit-ted to being unaware of the “rules” in his“game plan” and offered that “Some-times we don’t know what we’re bat-tling. Usually, we scramble and try toback up our steps and think about whatwas the last thing that happened. Some-times that’s not possible or practical.”They voiced the hope that by addressing

this problem first, Wyatt’s increasedcompliance might decrease some of theirother concerns, such as those related toturn-taking and sharing.

Conducting a FunctionalAssessment

The purpose of a functional assessment isto understand a person’s strengths, pref-erences, and communication strategies inaddition to the events and circumstancesthat influence his or her problem behav-ior (Koegel et al., 1996). Many usefultools have been devised over the years toaccomplish this (e.g., Carr, Levin, Mc-Connachie, Carlson, Kemp, & Smith,1994). One of the most commonly usedfunctional assessment approaches in-volves two primary assessment tools, thefunctional analysis interview (FAI) andthe functional analysis observation (FAO),and a process for analyzing and summa-rizing them (O’Neill et al., 1997). TheFAI provides information about 10 as-pects related to the problem behavior(s)of concern, including descriptions of (a) the behaviors themselves; (b) the eco-logical (i.e., setting) events that predictor set up the behaviors; (c) the specificimmediate antecedent events that predictwhen the behaviors are likely and notlikely to occur; and (d) the consequencesand functions of the behaviors. The FAIcan easily be conducted in the homethrough an interview of one or more in-dividuals who know the person well (e.g.,parents) by someone who is familiar withits use (e.g., teacher, behavior supportconsultant).

The FAO is useful for validating andclarifying hypotheses regarding the func-tion(s) of problem behavior that are gen-erated on the basis of the FAI. Accord-ing to O’Neill et al. (1997), the FAOdocuments (a) the number of occur-rences of problem behaviors and howthey are interrelated; (b) the situationsand times of day in which problem be-haviors are most and least likely to occur;(c) the events that predict the occurrenceof problem behaviors; (d) observers’ per-ceptions of the functions of the problembehaviors; and (e) the consequences thatfollow the behaviors.

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The Mallard Family. All but twomeetings related to functional assessmentand intervention planning occurred inthe family home over the 2-month inter-vention period. The consultant and theMallards completed the FAI over threesuch meetings that totaled approximately21⁄2 hours. Both parents were providedwith copies of the form in advance, sothey would be aware of the questions tobe asked and could follow along duringthe interview itself. This approach wasused in all situations in which writtenquestions were asked. They were alsoprovided with a packet of written infor-mation related to the assessment andplanning process and were encouraged torefer to the packet throughout the inter-vention period.

Following completion of the FAI,baseline data were obtained over a 2-dayperiod at home using the FAO. Lauraand Martin were taught by the consul-tant to use this form to record informa-tion regarding the topography and fre-quency of Wyatt’s problem behaviorsthat were related to following his ownagenda. Subsequently, this informationwas used to confirm the initial hypothe-ses they developed about the functions ofWyatt’s problem behaviors.

When reflecting on the functional as-sessment phase 2 months later, Lauracommented, “The FAI was [really] help-ful. In fact, I just went through it again.[It] was thorough . . . and all aspects ofWyatt’s routine were covered.” Lauraalso commented that, despite the time ittook for her to record data on the FAO,it was a helpful tool and provided her andMartin with insights about Wyatt and hisbehavior. For example, she offered ananecdote about an incident that occurredon the day that Wyatt returned topreschool after spring break:

Had I not had to chart this day, I wouldhave said that Wyatt was just being bel-ligerent. But . . . then I thought, now waita minute. It was his first day back afterspring break and he hadn’t had a bowelmovement and that does make himgrumpy. All of a sudden he wasn’t a bel-ligerent kid. He was a kid with issues. Andso it wasn’t that he was trying to be bad.It’s that his behavior was reflecting things

going on in his head that day, so thathelped me see him in a whole new light.

Collaborating to Develop a Hypothesis

Descriptions of the collaborative process(Bruner, 1991; Hargrove, 1998) empha-size that collaboration requires partici-pants to come together around a com-mon goal and to cooperate in ways thatconsider the perspectives of each ofthem. In the case of positive behaviorsupport, one of the first such cooperativeventures is the development of hypothe-ses about the function(s) of the target be-havior, based on the information ob-tained during assessment. This can beboth challenging and frustrating, be-cause it requires the collaborators to de-termine how the “puzzle pieces” gath-ered during assessment “fit together.”

O’Neill et al. (1997) provided a prac-tical approach to assist with hypothesisdevelopment and designing related be-havior support plans following functionalassessment. They suggested that the re-sults of the FAI and FAO be integratedinto “summary statements” that describethe setting events, antecedents, problembehaviors, and function(s) of the behav-iors. A summary statement typically takesthe following form: “When [antecedent]occurs, [person] [behaviors] in order to[consequence/function]. This is morelikely to occur if [setting event].” One ormore summary statements may resultfrom the assessment process, dependingon the specific behaviors, their functions,and the contexts in which they occur.O’Neill et al. suggested that the sum-mary statements also be written in theform of “behavior diagrams” that pro-vide the basic assessment information ina form that can be readily used for inter-vention planning.

The Mallard Family. Together,Laura, Martin, and the consultant re-viewed the FAI and the FAO to form hy-potheses about the function of Wyatt’sproblem behaviors. Several things be-came clear during this review. First, it ap-peared that there was a higher frequencyof problem behavior in the morning be-

fore Wyatt left for preschool than in theafternoon after he returned home. Sec-ond, the number of morning incidentsappeared to escalate as the time ap-proached for Wyatt to leave for pre-school, especially during dressing, eating,and toileting or diaper-changing rou-tines. Laura noted that the morning wasvery rushed and that the schedule wasoften unpredictable and inconsistent. Shealso reported that as the morning pro-gressed, she tended to become increas-ingly anxious about completing his per-sonal care and breakfast routines in atimely manner. She observed that themore she tried to hurry Wyatt, the lesscooperative he became and the more heinsisted on doing only specific, highly de-sirable activities of his own choosing.Predictably, Laura’s stress level escalatedas Wyatt’s problem behaviors increased,creating an “upward cycle” of maternaltension and increasingly disruptive be-havior from Wyatt.

Based on the information gatheredfrom the FAI and FAO and using theO’Neill et al. (1997) procedure, the con-sultant and the family drafted severalsummary statements that Laura and Mar-tin agreed represented their experienceswith Wyatt and his problem behaviors.After Laura and Martin made revisionsand additions, the resulting summarystatement read as follows: “When he isengaged in a preferred activity and is pre-sented with a demand related to an un-preferred activity, Wyatt either makes noresponse or is noncompliant, hits, kicks,and screams in order to escape from thedemand. This is more likely to occur if heis hungry, rushed, or tired.” The sum-mary statement was also written as a be-havior diagram, depicted in the top sec-tion of the form in Figure 1.

Identifying Family Routines for Intervention

Routines such as getting dressed forschool or work in the morning, eatingmeals at home and/or in a restaurant,going shopping, bathing, toileting, andengaging in various leisure activities areinherent in the structure of virtually allfamily ecologies. One of the core com-ponents of contemporary family-centered

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FIGURE 1. Hypothesis diagram and intervention plan developed in collaboration with Wyatt’s parents regardingproblem behaviors at home. Note. From Functional Assessment and Program Development for Problem Behavior: APractical Handbook, 2nd Edition by O’Neill/Horner/Albin/Sprague/Storey/Newton. © 1997. Reprinted with permissionof Wadsworth, a division of Thomson Learning: www.thomsonrights.com

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positive behavior support is the notionthat family routines constitute a primaryunit of analysis (Lucyshyn, Blumberg, &Kayser, 2000). Thus, behavior supportinterventions should be designed to helpfamilies support children in the midst ofdaily routines, so that they experiencethese interventions as practical tools foraccomplishing the necessities of liferather than as add-on programs that addto their existing burdens and may actu-ally interfere with their ability to functionas a family.

The Mallard Family. In identifyingthe primary behaviors of concern, Lauraand Martin implicitly identified problem-atic routines for Wyatt as well. For ex-ample, they noted that Wyatt “does notget his agenda the majority of the timebut it also depends on the severity of thesituation—[we] don’t sweat the smallstuff ! . . . Eating, toileting, and sleep-ing—Wyatt controls.” In discussionswith the consultant, Laura and Martinwere encouraged to identify more explic-itly a few key routines for intervention.They selected the aforementioned meal-time and toileting routines, as well ashand washing, tooth brushing, and dress-ing in the morning as the primary areasof concern. They decided that Wyatt’sbedtime routine, although problematic,was not a top priority at that time andcould be addressed later on, if necessary.

Phase 3: Collaborating toDevelop a Behavior

Support Plan

Horner (1997) noted that positive be-havior support requires fundamentalchanges with regard to how support isdesigned and implemented vis a vis tra-ditional approaches to behavior manage-ment. These changes fall into three areas.First, a change occurs with regard to thedesired outcomes of the intervention be-cause mere reduction of problem behav-ior is no longer the only goal. Rather, thegoal is to produce a substantive, durablebehavior change for the child and mean-

ingful lifestyle enhancements for thechild and family. Second, a change occurswith regard to the comprehensive natureof the intervention because more thanone intervention procedure will almostalways be required. Finally, a change oc-curs in the contexts for intervention be-cause it is applied in the real environ-ments in which people live, learn, play,and work instead of in highly structuredand controlled settings.

An effective positive behavior supportplan requires more than conceptualchanges with regard to the desired out-come, the nature of the intervention, andthe intervention contexts. The plan itselfmay involve changes related to variablessuch as physical setting, medications,schedule, teaching strategies, interactionstyle, and/or consequences for behavior.In addition, the process by which theplan is designed and implemented “in-volves change in the behavior of the fam-ily, teachers, staff, or managers in varioussettings” (O’Neill et al., 1997, p. 65).Given the scope of the changes that maybe required, the active involvement offamily members in the design and imple-mentation of behavioral interventions“may be the most important variable thatdetermines whether the intervention willbe effective and implemented with fi-delity and durability” (Vaughn et al.,1997, p. 186). As Dawson and Osterling(1997) noted,

Because parents spend so much time withtheir children, it is recognized that they canoften achieve greater understanding oftheir child’s needs and provide unique in-sight into creating a treatment plan. Byincluding parents in the treatment of chil-dren, greater maintenance and generaliza-tion of skills also can be achieved. . . .[I]ncluding parents in the treatment ofyoung children with autism can [also] in-crease parents’ feelings of relatedness withtheir child and increase their sense ofcompetence as parents, thereby decreasingemotional stress and facilitating well-being.(p. 320)

Of course, a positive behavior supportplan must be directly based on the resultsof the functional assessment process.

Specifically, interventions related to theidentified setting events and antecedentsare included in order to make the prob-lem behaviors irrelevant. Interventionsthat involve teaching and promoting de-sired and alternative behaviors are de-signed to make the problem behaviorsrelatively inefficient. Finally, interven-tions related to the consequences orfunctions are required to make the prob-lem behaviors ineffective. O’Neill et al.(1997) suggested that the behavior dia-gram that was generated from the assess-ment be used to brainstorm multiple in-tervention strategies related to each ofthese components. From this list of sys-tematically derived intervention possibil-ities, the family members responsible forimplementing the support plan can thenmake decisions about which strategiesconstitute the best fit with the family’svalue and belief system, time and re-source constraints, and priorities.

The Mallard Family

Once the assessment process was com-pleted, it was not difficult for the collab-orators to develop an extensive list of in-tervention possibilities related to Wyatt’sproblem behaviors. This was accom-plished during a brainstorming session inwhich all three used the behavior dia-gram depicted on the top of Figure 1 togenerate potential strategies in each ofthe four main areas. From the extensivelist of potential strategies, Laura andMartin selected several to implement atthe outset (see the bottom section of Figure 1).

With regard to setting events, thefunctional assessment suggested thathunger was a major setting event forWyatt’s noncompliant and aggressive be-havior. His parents were concerned thathis food intake was nutritionally inade-quate and observed that “a lot of behav-ior comes out when he’s hungry.” Laurafelt that she would be more able to en-sure that Wyatt ate a balanced diet if sheroutinely prepared morning and eveningsnacks for both children. She and Martindecided that, due to time constraints andthe fact that hunger was the primary set-

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ting event, they would not include inter-ventions related to the other two settingevents as part of the initial plan.

With regard to antecedents, the Mal-lards decided to use (a) visual schedulesto enhance the predictability of the rou-tines Wyatt frequently resisted and (b) symbols for food and drink choices to provide Wyatt with opportunities formaking choices related to mealtimes.Laura explained, “[We] chose the [visualschedules because] we realized that hewas a visual learner, so it was a logical wayto go.” Within-task visual schedules(Mirenda & Erickson, 2000) were de-vised to assist Wyatt in completing theidentified routines more successfully,thereby reducing the likelihood that hewould engage in problem behaviors toescape from them. The visual choice-making symbols were provided to assistWyatt in choosing the foods he wished toeat for snacks and for some meals, withthe hope that this would reduce his food“pickiness” and the problem behaviorsthat appeared to be related to it. Martinprovided this rationale:

If you start rhyming a whole bunch of[food choices] off, he has absolutely no in-terest; but if you start showing him the pic-tures, just point to all of them, he [might]see it and say, ‘Oh, that.’ Because by thetime you get to the third thing just verbally,he forgot what the first thing was. At leastthat’s what I think. I think [they’ll] workwell.

Teaching strategies for modeling andprompting the use of the visual schedulesand choice symbols were also included inthe plan because it was unlikely thatWyatt would understand how to usethese supports without adequate instruc-tion from Laura and Martin. Finally, theMallards agreed that, when he completedroutines successfully or asked for food ordrink items using either the symbols orhis speech, they would provide enthusi-astic praise and extra attention in addi-tion to the item requested. They alsoagreed that if problem behavior occurredthey would attempt to (a) redirect himback to the unpreferred routine ratherthan allowing him to escape from it and(b) avoid providing him with preferredactivities as much as possible at that time.

Phase 4: Collaborating toImplement and Revise the

Support Plan

One of the major difficulties in imple-menting behavioral interventions is re-lated to maintenance and sustainabilitybecause the effort and time commitmentrequired to carry out such interventionsover time may be beyond the ability ofmany families. As Schwartz (1997) noted,“Anyone who has conducted a functionalanalysis of problem behaviors recognizesthe difficulty of matching effective inter-ventions to specific behaviors and con-texts. The difficulty increases when theemphasis is on do-able and sustainableinterventions” (p. 213). However, sev-eral recent studies (e.g., Fox, Vaughn,Dunlap, & Bucy, 1997; Lucyshyn et al.,1997; Vaughn, Dunlap, et al., 1997)have provided evidence that a parent–professional collaborative process maysubstantially increase the willingness of afamily to continue the intervention afterthe initial stages have passed. Part of thiscollaboration involves handing over tothe family as many of the tools and strate-gies used during intervention as they areable to manage and providing them withinstruction and ongoing support regard-ing implementation.

The Mallard Family

The consultant provided Wyatt’s familywith access to a software program, Board-maker™ (Mayer-Johnson Co., 1994),which they used to create the necessaryvisual supports. The software producespicture communication symbols (PCS;Johnson, 1994) that can be used to de-sign and print visual schedules, scripts,and choice-making displays. One ofWyatt’s preschool teachers providedLaura with instruction about how to cus-tomize the PCSs in Boardmaker™ tocreate visual supports specific to Wyatt’sneeds. As Laura was already computerliterate, she quickly learned to use thesoftware and, together with the consul-tant, developed a number of visual sched-ules. In addition, midway through theintervention period, Laura and the con-sultant attended a local workshop con-

ducted by a nationally known expert inthe use of visual supports for childrenwith autism. Laura had many ideas aboutthe types of supports that Wyatt neededand throughout the intervention periodmade modifications to them.

After the visual supports were created,the consultant provided brief written in-structions to Laura and Martin abouthow to use the visual supports on an on-going basis during daily routines. Usingdemonstration and role playing, shemodeled how to direct Wyatt’s attentionto the display, point to each of the sym-bols in sequence, provide verbal direc-tions that were brief and relevant, andprovide praise or corrective feedback asappropriate. Following the initial train-ing, the consultant stepped back and of-fered the family ongoing support only asneeded. This support included valuingwhat each parent had to say, respectingtheir actions, not taking sides, givingthem time to communicate with eachother rather than intervening immedi-ately when problems occurred, modelingproblem-solving skills, and providing re-sources and advice when asked to do so.Thus, implementation of the behaviorsupport plan took shape primarily underLaura and Martin’s direction.

Morning and Evening Snacks. De-spite the Mallards’ initial enthusiasmabout providing regular morning andevening snacks to Wyatt and his brother,this component of the intervention wasnot implemented consistently. Accordingto Laura, morning snacks were providedmore often than those in the evening:

I ask [Wyatt] if he wants breakfast and if hesays, “No,” then at 9:30, I bring out asnack for him and Elliott to eat so that atleast he has had something in his stomach.[That way], if by 11:00 I can’t get him toeat, he’s not going to school on an emptystomach. [But] . . . before bed, it’s just sohairy we tend to forget about it. If every-body is very calm, then we will [rememberthe snack]—but he will often ask us forsomething if he’s hungry when he’s goingto bed.

The Mallards’ inability to implementthis component of the support plan con-sistently can probably be related to the

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concept of “goodness of fit” that hasbeen described by several authors (e.g.,Albin, Lucyshyn, Horner, & Flannery,1996; Bailey et al., 1990). Behavior sup-port plans that exemplify goodness of fitinclude at least the following characteris-tics: (a) Key players are comfortable withthe plans and strategies; (b) plans areconsistent with the strongly held valuesand living patterns of the persons in-volved; and (c) plans tap into existing re-sources so that the required time, effort,and dollars are not prohibitive (Snell,1997). In this case, although the supportplan appeared to be consistent withCharacteristics (a) and (b), Laura’s previ-ous comment suggests that the time andeffort required for implementation wasperhaps not available as regularly as theyinitially planned. Thus, implementationfailure can be accounted for in this caseby a lack of goodness of fit rather than by,for example, lack of motivation or will-ingness on the part of the family to fol-low the plan they helped to design.

Visual Schedules and Choice Sym-bols. In contrast to the strategy formorning and evening snacks, Laura andMartin were able to implement consis-tently the use of a variety of visual sched-ules to assist Wyatt through daily routines.Periodic counts of Wyatt’s “following hisown agenda” behaviors by Laura andMartin suggested that this interventioncomponent was effective in reducing thefrequency of his behavioral episodes fromapproximately 20 per day prior to inter-vention to 4 or fewer per day 4 and 6 weeks later. In addition, the Mallardsreported a marked increase in the fre-quency of Wyatt’s attempts to do thingsfor himself during daily routines. Towardthe end of the intervention period, Lauracommented, “[We] didn’t have a prob-lem implementing the visual sched-ule. . . . The only problem was where toor what to start with. [We] didn’t wantto bombard him with stuff so it was justchoosing which ones would be most ef-fective at the time.” Examples of Wyatt’suse of visual schedules and choice-making displays are provided for each ofthe target routines in the sections thatfollow.

Toileting. According to Laura, Wyattimmediately recognized and liked the vi-sual schedule that was posted in the bath-room to depict the steps involved in toi-leting. From the outset, the symbolsappeared to exert considerable controlover his behavior. For example, the initialtoileting schedule contained a PCS sym-bol of a person sitting on the toilet, andLaura noted that, “Because I suggestedsitting rather than standing to pee, he didso.” After Laura revised the schedule sothat it had two PCS symbols, one of aperson standing to urinate and anotherof a person sitting to defecate, Wyatt “re-verted to his preference for peeing—standing.” Wyatt’s revised toileting sched-ule is depicted in Figure 2.

Laura reported that, over the inter-vention period for which documentationwas available (i.e., 6 weeks), Wyatt pro-gressed from wearing diapers 100% ofthe time to urinating in the toilet inde-pendently most of the time at home andin untrained settings such as his pre-school. Laura offered the following anec-dotes:

The other day they [Wyatt and Elliott]were wrestling. He ran down [the hall] andI thought he was still playing, [but] he raninto the bathroom, [urinated in the toilet],ran back, and continued playing.

One day I was sitting down here and I hearthis ominous noise and I think, “Oh my!”So I go tearing upstairs and Elliott’s stand-ing in the bedroom smiling, and I look atWyatt ‘cause I know the toilet’s flushedand Wyatt’s standing there looking nor-mal, and I thought, “What’s going on?”Wyatt goes, “Mommy, I go pee pee.” He’dwalked in there of his own accord, dideverything, flushed it, walked back in themiddle of one of his favorite movies . . .completely independently—and he’s donethat a few times now!

Hand washing. Wyatt watched Lauramake a pictorial schedule depicting thesteps of his hand-washing routine andplace “hot” and “cold” symbols on thetaps of the bathroom sink (see Figure 3).Wyatt immediately “read” the hot waterand cold water symbols to Laura, and webegan to follow the schedule as it was de-picted. He began to rinse his hands thor-

oughly only after Laura revised theschedule to include a “rinse hands” step.In addition, he was no longer afraid toturn on the taps by himself after the hotand cold water taps were clearly labeled.Martin reported a concomitant decreasein Wyatt’s problem behaviors during thisroutine as well:

I found the ones in the wash room [mosthelpful]—“after you go pee, you wash yourhands,” which really helps because hewould fight you on that. Now you point tothe picture and he will do it that way, sothat’s helped.

Teeth brushing. Like the hand-washing schedule, Wyatt’s teeth-brushingschedule depicted all of the essential stepsin this routine. Laura noted, “I’ve gothim brushing his teeth before he goes toschool, which has never happened be-fore. And he doesn’t fight that at all.”

Dressing. Shortly after a schedule de-picting the steps in his morning dressingroutine was put up in Wyatt’s room,Laura suffered a back injury and was un-able to get out of bed. Laura was soproud to find that “Wyatt got himselfcompletely dressed without help by fol-lowing the pictures, [except to say] ‘Iwant help’ for one sock.” Over time, sherevised the dressing schedule to includea “What’s the weather like, and what doI wear outside?” section, to teach Wyattto make these decisions. For example,Laura would ask questions such as,“What’s the weather like outside?” and“Which coat do you want to wear?” andWyatt used symbols (e.g., “rainy,” “bluecoat,” “yellow boots”) to respond andselect the appropriate outerwear. Laurareported that this system helped decreasehis problem behaviors prior to leavingthe house for preschool.

Mealtime. A simple visual schedulefor the mealtime routine also was intro-duced to remind Wyatt of the expecta-tion that he sit at the table and eat hisfood. Although use of these supports didnot appear to affect Wyatt’s mealtime be-havior significantly, he would occasion-ally look at them and comment “Eat” or“Sit on chair.” Martin explained, “We’venever really fought him on that. . . .We’ve never really forced the issue of eat-

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ing. You can’t force-feed a 4-year-old kidno matter how hard you try.” From thisand similar comments, it appears that themealtime routine may not have been ashigh a priority for the family as the otherroutines.

In addition to the mealtime schedule,Laura used Boardmaker™ to create anumber of food and drink choice-makingsymbols for Wyatt. He watched as Lauraselected and printed out these symbolsand even requested symbols for a num-

ber of foods when he saw them on the computer screen. For example, atWyatt’s request, Laura included the “icecream” symbol as one of his food op-tions, even though ice cream was notsomething he typically chose to eat. Thewisdom of involving Wyatt in the symbolselection process was evident when Lauraput the food choice PCSs on the fridgeand he immediately asked for a ham-burger, one of his selections. He hadnever asked for a hamburger at home be-

fore but happily ate it after Laura quicklyprepared it.

Wyatt’s use of the symbols to makefood choices generalized almost immedi-ately to both Martin and his respiteprovider, with the result that the range offoods he would eat expanded consider-ably. Laura recounted how Wyatt usedthe food choice array in a new way:

Today he came in here, he wanted a hotdog while I was cooking the potatoes [but]

FIGURE 2. Wyatt’s revised toileting schedule.

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I hadn’t started the hot dog yet. He gotreally mad and he came and he grabbed it[the hot dog PCS] off the fridge, pointedto the hot dog and said, “I want a hotdog.” That’s the first time I knew he wasso aware of it. He grabbed it and pointeddirectly to it and he was like, “See, this iswhat I want.” So, I said, “Whoa, I’ll makethe hot dog right now.” It thrilled me be-cause he usually just scans it [the choicearray] like a menu and picks what he wants.

This was the first time he really used it toget his point across.

Conclusions

Previous descriptions of family-centeredpositive behavior support have empha-sized the importance of professionals’“relating to families as colleagues, recog-

nizing family expertise, and conductingassessment and intervention activitieswith families in their homes and commu-nities” (Lucyshyn et al., 2000, pp. 113–114). The need for participants to cometogether around a common goal and tocooperate in ways that consider the per-spectives of each is also critical to thisendeavor. All of these elements wereevident throughout the assessment and

FIGURE 3. Wyatt’s revised hand-washing schedule.

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intervention period described for theMallard family, as each participant cameto recognize and appreciate the perspec-tives of the others. As they shared in-formation and perspectives, all threeparticipants arrived at a new, shared un-derstanding of Wyatt and his needs. Thesuccessful nature of the collaborative pro-cess was reflected in a comment Lauramade toward the end of the consultant’sformal involvement with the family:“You [the consultant] may have moreeducational expertise in this [than wedo], but you didn’t make us feel sec-ondary.”

Successful collaboration, however, isnot sufficient in order for family-centered positive behavior support inter-ventions to be effective. In addition toreducing or eliminating behavior identi-fied as socially problematic, such inter-ventions should also result in an im-proved quality of life for the focusindividual and his or her family. In thisregard, Albin et al. (1996) suggested thatpositive behavior support plans that “in-clude only child-focused strategies, butfail to address needs of the family as awhole, [are] not likely not to be a goodcontextual fit” (p. 93). They also notedthat, ideally, behavior support plans withgood contextual fit “will strengthen thefamily as a unit” (p. 91). These state-ments underline the importance of con-sidering factors such as family relation-ships, communication styles, and culturalbackgrounds in both the design and im-plementation of positive behavior sup-port plans.

The collaboration between the Mal-lards and their consultant exemplified theneed for considering multiple aspects ofthe family ecology, especially with regardto Laura and Martin’s divergent com-munication and parenting styles. Martinoffered this insight:

What with discussing this whole situation,I find out a lot more about what’s goingon during the day. Where Laura might takea lot of things for granted that she may nottell me . . . when we’re sitting here [at themeetings with the consultant], things willcome out and I go, “Really?” It does helpin terms of our communication aboutreally what’s going on with Wyatt and fill-

ing each other in. We usually talk aboutthings afterwards: “Oh, he does really dothat?” It does give me a different outlookon Wyatt.

Laura and Martin also came to under-stand more about why Wyatt reacted tothem differently at different times. Mar-tin noted, “I guess in most cases Laura isat home with the kids all day so she hasmore contact. Weekends are usually [a]completely different story than the setstructure during the week. It’s usually alittle more open.” Laura added, “We’velearned that too. And I don’t know thatwe noticed that before. What you [Mar-tin] deal with and what I deal with arenot the same . . . necessarily.” Out of thisunderstanding came a new appreciationfor the positive aspects of their divergentparenting styles. Laura in particular madean effort not to interfere with interac-tions between Martin and Wyatt. Towardthe end of the intervention period, shemade the following comment:

When I hear Martin dealing with Wyattand . . . realizing our different attitudes toparenting, I’ve really tried to . . . pull backand not get in their faces about doing it myway. . . . His way is different and so I’vetried to accept that his way is different andnot wrong—just different. So I really triedto back off, and that’s a result of this [sup-port plan] as well.

Laura and Martin were able to usetheir increased communication and un-derstanding to solve problems that aroseduring the initial intervention period.For example, during one of the regularmeetings, they discussed an incident thathad occurred earlier that day with Wyatt,which Laura referred to as a “meltdown.”Together, they reviewed and analyzedthe incident in detail and developed aplan to prevent its recurrence and to re-spond to it, if necessary.

In addition to improved parent-to-parent communication, Dunlap and Fox(1996) noted that another importantquality-of-life indicator that should resultfrom an effective behavior support pro-gram is improved social relationships,both within and outside of the family.Decreased family stress and increased

positive interactions among family mem-bers are often seen as positive side effects,once effective behavior supports have re-sulted in reduced problem behavior. Thiswas certainly the case for Wyatt and hisfamily, as described by Laura:

Our family certainly benefited [from thisintervention]. Life is a little easier andquieter, and our confidence in handlingsituations and foreseeing situations has grown. . . . Wyatt probably benefited themost without even realizing it because itmade his life easier or at least less stressful,which is a good thing for him. And perhapsfor Elliott, because they’re getting alongbetter and when Wyatt’s uptight, Elliottgets nervous—so Elliott’s [as] happy as hecan be, some days.

With regard to the interaction be-tween the two brothers, Laura reported,“Wyatt and Elliott played puzzles for 20minutes [yesterday], and that certainlywasn’t on his agenda for the day.” Mar-tin agreed, “They’re playing togethermuch better than they were.” Both par-ents reported that they frequently hearWyatt call to his brother, “Come on, El-liott, come and play.” Wyatt’s interest incrafts and drawing activities at home alsoincreased substantially once the interven-tion was in place, and he began to spendtime engaged with his family in these ac-tivities. For example, during one of theconsultant’s visits, his parents proudlydisplayed a Mr. Potato Head picture onwhich Wyatt had cut out, glued, andprinted his name over a 40-minute pe-riod. Laura and Martin also observedWyatt reaching out more to other chil-dren over the course of the intervention.One day, he played at home with the 6-year-old sister of a classmate and askedher to come in to play again on an-other day. When she responded that she couldn’t, Wyatt tried to coax her tochange her mind, saying, “Come on,Nina, come on in.” He was happy whenshe agreed to come 2 days later, and gaveher a hug as she left. His parents werethrilled and commented that it was “niceto see him inviting others in.”

Perhaps the most important test of theeffectiveness of any family-centered col-laboration is the extent to which its ef-

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fects endure over time. Positive behav-ioral interventions that truly exemplifythe concept of goodness of fit (Albin et al., 1996) should continue to be im-plemented even after formal consultantsupports are discontinued because theyhave become seamlessly integrated intothe family’s lifestyle and interaction pat-terns. This appeared to be the case forWyatt and his family, who continued touse visual supports at home for the re-mainder of his time at preschool, whichextended for 5 months after terminationof the initial intervention. One year later,the consultant contacted Laura and Mar-tin to follow up on Wyatt’s progress dur-ing his kindergarten year in school. Theyreported that his noncompliant behaviorat home was greatly diminished, and theyeven described him as “eager to please.”Laura noted that she also had initiatedthe use of visual supports in several newareas. For example, symbols for variousclothing items were posted on the draw-ers of his dresser to aid him in dressingmore readily and independently. He alsoused a job chart at home with symbolsfor tasks such as setting the table, mak-ing his bed, and putting his laundry away,as well as a visual schedule at school de-picting his activities and choices. Lauraalso reported that Wyatt’s language andplay skills had improved dramatically, ashad his drawing skills and his relationshipwith his brother.

Finally, it is important to note that thebenefits of family-centered positive be-havior support are not achievable with-out the expenditure of considerable timeand effort on the part of both the con-sultant and the family. It should be clearfrom the example of the Mallard familythat the consultant and the family are re-quired to enter into a reciprocal contractof commitment to both the collaborativeprocess and the implementation of thebehavior support plan that results fromthat collaboration. This may appear, onthe surface, to be a much less efficientmodel for behavior support than the tra-ditional expert model in which a behav-ior consultant seeks information from thefamily in order to design a support planto address a child’s problem behavior butthen makes all of the necessary decisions

about what to do and how to do it andmay implement the plan as well. How-ever, the likelihood of achieving durable,meaningful changes that are integratedinto the ecology of the family are muchless likely without “buy in” from the fam-ily during all phases, including assess-ment, intervention planning, and imple-mentation. Thus, it can be argued thatthe expenditure of the additional timeand effort required for family-centeredbehavior support has the potential ofbeing more “cost effective” in the longrun. This certainly appeared to be so forthe Mallards who, when asked to evalu-ate the success of the collaborative in-tervention, assigned it a score of 4 on a 5-point scale (1 = not at all successful and5 = very successful). When asked if it wasworth the effort, Laura emphatically re-sponded,

Oh, my, and 10 times more. For us it’sbeen immeasurable—the schedules havehelped immensely when time is an issue,such as before school. . . . It helps Wyattbecause there’s a consistency for him. Ithink . . . the biggest thing was that Mar-tin and I actually sat at a table and discussedit [Wyatt’s behavior] together. We didn’tused to talk about it; we just dealt with it.There was so much time spent dealing withit that we never actually had time [to talk]. . . . It’s just been an incredible expe-rience for us as far as learning goes.

ABOUT THE AUTHORS

Joanne Kay Marshall, MA-LT, is the clinicalcoordinator of the early intensive behavioral in-tervention program for children with autism atthe Delta Association for Child Development.She was the coordinator of LEAP Preschool inDelta, BC, at the time this case study was con-ducted. Pat Mirenda, PhD, is an associate pro-fessor of special education at the University ofBritish Columbia and conducts research inaugmentative communication and positive be-havioral supports. Address: Pat Mirenda, Fac-ulty of Education,University of British Colum-bia, 2125 Main Mall, Vancouver, BC V6T 1Z4,Canada, e-mail: [email protected]

AUTHORS’ NOTES

1. This paper is based on a thesis completed inpartial fulfillment of an MA degree in

Leadership and Training (MA-LT) by thefirst author at Royal Roads University inVictoria, BC.

2. The authors are grateful to the “Mallard”family for their participation in the collab-orative process and for allowing us to sharetheir story with others.

NOTE

All family names are pseudonyms.

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