PSY 4600 U7: Gerontology andStaff Management

ScheduleLecture: Thursday and TuesdayExam: Thursday, 4/09Instructional assistance: Wednesday, 4/08

(these are two rapidly growing areas, and while the topics don’t seem to be related, they are. Studies have been donein long term care facilities – nursing homes and facilities for those with dementia; but right now most staff mgtis being done in group homes/residential homes for developmentally disabled adults, schools/programs for autistic children)

Behavioral Gerontology

Linda LeBlanc, Ph.D.

Allison Jay, Ph.D.

Alyce Dickinson, Ph.D.

Based on:LeBlanc, L. A., Raetz, P. B., & Feliciano, L. (2011)

Gerontology

• Behavioral gerontology is a growing field

• There are not many Ph.D. level behavioral gerontologists in the world

• Obviously, as the upcoming slides will point out we need more!

Gerontology: Expanded Services•More living options for seniors

– In-home with assistance (daily living tasks)– Retirement communities with many different options

and continuous care – Assisted living communities that specialize in

dementia (these are not nursing homes)

•WMU’s Center for Disability Services– Care management

• Assessment and recommended options for care needs

– Senior day programs– Supported living in-home, personal care– Respite care for caregivers

(Also, governmental agencies provide assessment, care mgt & transportation

Gerontology: Expanded Services• Hospital-based medical in-home care• Commercial in-home service agencies • WMU’s Center for Gerontology at WMU

– Minor in gerontology

• Behavioral Gerontology SIG affiliated with ABAI: Great resource!– bgsig.wordpress.com

• Provides publications in the area, 1975-2014• Provides recent presentations and posters• Provides a list of universities and professors providing

training in this area• Provides employment and postdoc opportunities!

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SO1: Aging of America

• The proportion of the population over age 65 in the U.S. increased from 4% to 13% in the 20th Century

• It is predicted to be 20% of the population by 2030

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SO2: Aging of America, Contributing Factors

• Medical advances increased life expectancy about 30 years between 1900 & 2000

• 1900: 47 years• 1950: 67 years• 2000: 76 years

• Aging of Baby Boomers• Born during the post-World War II baby boom• Years between 1946 and about 1953

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SO3: Effects of Aging

Living longer means a substantial portion of elders live with chronic illness and disability– Higher total cost of care– Greater care needs– Potentially lower quality

of life

(more doctor’s visits, more medication, more MRIs,, more protthestics - hearing aids, walkers, etc.)

Behavioral Gerontology

• Application of behavioral principles to aging issues– Clinical/Rehabilitation Issues– OBM/Staff Training Issues

• Different approach to aging from typical medical model of inevitable biological decline

9(Just because you lost it, doesn’t mean you can’t get it back; provide behavioral/environmental supports; teachpeople how to self-prompt)

SO4: Behavioral Gerontology• From a behavioral perspective, when a

person ages (examples of each follow)– Fewer discriminative stimuli control

behavior – Different motivating operations are likely – Contingencies of reinforcement tend to

support the wrong behaviors

10(Go back and look at examples of each)

SO4: SDs become less effective• Get lost when driving to someplace you go to frequently (i.e.,

the grocery store) and don’t know how to get home• Faces may no longer evoke correct names - even of loved

ones• Trouble with ordinary conversations; words don’t evoke typical

responses, particularly with a quick change of topics• Can’t write a check anymore, and certainly cannot master

web banking (how do you pay bills?)• TV/DVD/TIVO remotes: two or more remotes, each one is

different (stimulus control combined with punishment), can’t figure out how to do things

• Changing technology – phones used to be easy; using menus and navi keys are 2nd nature to you – not to seniors; too many buttons, too many options!

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Stimulus Control & Punishment

12(buttons are all in different places, symbols v. words, not one but two navi pads, jitterbugs)

Great Call Jitterbug phoneGreat for seniors!

SO4: Different MOs• Deprivation of social contacts makes elders

susceptible to telephone solicitors and scams by strangers (someone comes to the door - they let them in)

• Foot pain, hip replacement, arthritic pain make a decrease in pain reinforcing and evoke behaviors that lead to decreased pain – inactivity, watching TV, etc. win out over activities such as gardening, walking in the woods, needlepoint (also pain punishes those behaviors if engaged in)

• Sleep deprivation is often present so evokes more irritable behaviors (when cut off when driving, or a relative is late for a visit, or a grandchild begins to cry/scream)

13Fact that not only quantity but quality of sleep changes with age

SO4: Reinforcement for dependent behaviors and punishment for active behavior• When do you go see Grandma? When she is not

feeling well. (reinforcement for complaining and behaviors related to not feeling well)

• Punishment for verbal behavior when can’t “find the right word” or “follow the conversation”

• “Does it hurt to do that? Why don’t you rest and let me do it?” (reinforcement for dependent behaviors)

• “Let me go to the grocery store for you”

14(same issue as with Fordyce, chronic pain)

Behavioral Gerontology

• Use of behavioral procedures to solve problems related to SDs, MOs, and wrong reinforcement/punishment contingencies– No different than the approach we take in other

areas of specialization

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Enjoy Old Age, 1983

16(click, animation)

SO5: Why behavioral gerontology is needed

• Behavior problems, not health declines or medical problems are – Major cause of caregiver stress– The most common cause of

institutionalization• I “can’t take it anymore” on the part of the

caregiver– aggression, arguing, losing things, wandering,

incontinence

• 65% of individuals in nursing homes have significant behavior problems

• Can lead to high staff turnover 17

NFE: Obstacles to widespread behavioral services

• Practitioners are reluctant to serve elders – no training– Because of that it is hard to locate behavioral

services

• Older people and caregivers perceive stigma for accessing mental health services– Older adult: means “I’m crazy”– Caregiver: “a good son/daughter/wife/husband”

could handle it without help

18(Cont. on next slide)

Obstacles, cont.• Medical Model Myths

– Psychotropic medications are the only thing that will work - most common intervention

– Once a skill is lost it cannot be regained

• Cost and effort constraints– Simple and/or cheap will always be selected

Which is simpler and less effortful?

Medication or behavioral interventions? Elders are taking an average of 5 different meds

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SO6: NFE: Anxiety and Depression

• Anxiety and depression are not common in seniors, contrary to popular belief

• Anxiety: – Only about 6% of healthy elders have clinical anxiety– Higher rates in elders with medical conditions

• Depression– Only occurs in 2 - 10% of older adults– 2x more in women (as in younger population)– 40-50% of people in nursing/retirement homes

• Which comes first, the chicken or the egg?

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Behaviorally . . why depression/anxiety?– Loss of reinforcers due to changes in the environment

• Including deaths of siblings, friends, and perhaps life mate

– Loss of reinforcers due to physical deterioration of receptors

• can’t hear or see as well• aren’t as strong• have trouble opening containers

– Increased dependence but don’t want to be a burden• can’t drive anymore (can’t go shopping when you want to)

– But remember, healthy seniors are not depressed or anxious

• Economically stable (hopefully)• Tend to become more “forgiving” and “kinder”• Not as concerned about what other people think

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Behavioral Gerontology Services

• Typical Nursing Home– No active engagement, even in leisure

activities– No social interaction or conversations – Memory problems– High rates of problem behavior

Behavioral gerontologists have tackled each of these problems successfully

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SO7: Aggression• 85% of seniors with dementia physically aggress their

care providers– This is one of the most common behavioral problems that

leads to placement in long-term care facilities, physical constraints, and/or medication

• 75% of the aggressive behaviors have been shown to be escape behaviors from antecedent task demands (MOs) related to daily living activities– Dressing, taking the senior to the bathroom,

showering/bathing, brushing teeth, shaving, etc. (moderate to severe)

– Antecedent MOs include verbal prompts, physical prompts, task demands: it’s time to get up, you need a bath/shower, put on your out-door clothes, why don’t you take a walk, you shouldn’t be drinking that glass of wine (mild to moderate)

• NAG, NAG, NAG all day long! 23

SO7: Aggression

• Common behavioral interventions:– Care provider moves away and stops the demands

• Often done to prevent the senior from “being too upset”• Care provider doesn’t want to be hurt

– Time out (a punishment procedure)

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What’s wrong with these interventions??

(answer, next slide)

SO7: Aggression

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What’s wrong with these interventions??

MO: R Sr-Task demands, prompts Aggression No task demands

(This is why functional assessment, determining the cause of the behavior is so important before designingan intervention )

In words:These interventions terminate the task demands,which negatively reinforces the aggression

SO7: NFE, What to do instead?

• Noncontingent escape– Determine interresponse time of aggression

• Seconds before onset, seconds in-between– Provide escape (terminate the activity or prompt)

before aggression occurs • Form of differential reinforcement

Example:Elder in a nursing home aggressed against care givers during toileting. Found it was escape-maintained. It started ~30 s after toileting began, and thereafter every 25 s. Care givers prompted toileting, but stopped after 20 s, paused for 10 s, then began prompts again. Repeated this until end of toileting. Aggression decreased to near 0 levels.

(extinction next)26

SO7: NFE What to do instead?• Extinction is also possible if the senior will not

hurt himself/herself or the care giver– There is, of course, concern about an extinction burst

• Seems “cruel” but– Literature suggests that alternatives have been

punishment or high doses of medication• Physical restraints• Strong verbal reprimands

Food for thought: Think of respondent conditioning, what happens if strong verbal reprimands and other stimuli that elicit unpleasant emotional responses are consistently paired with the care provider?

27(How would you extinguish? Are these kinder? Drugs do decrease aggression, but are systemic and decrease the entire activity level of the elder. Do you want a doped up Grandpa?)

SO8: Bourgeois (1993), Memory Wallets

• Effects of memory aids (wallet) on conversations of individuals with dementia

• People with dementia appear incoherent in conversation because they (mainly intraverbals)– Substitute vague words for specifics

– Don’t follow the content or topic

– Cannot spontaneously generate topics

• Interventions like memory wallets do result in better conversations

28(really like this, simple intervention; if you ask them what they did that morning, they may start complainingabout the food at dinner or staff , or talk about an event that was a very long time ago)

My Nieces:Caroline, Courtney, Jessica

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My favorite color is blue.

My cat is Mr. Snuffles and he is a Siamese.

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I live at 427 Bloomfield Ave

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Bourgeois (1993) Memory Wallets

• Participants: 6 individuals at adult day care centers

• Two individuals talk to each other• Memory wallet for one of the two was used

– Interviewed family members to develop list of facts and topics

– Took corresponding pictures to include in wallet

• 5 minute conversations 3 times per week• Measured

– Statements related to the memory aid– On-topic statements

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SO8: Bourgeois (1993) Memory Wallets• Research design

– Reversal: BAB

• Results (exception one P, most demented)– Quite a few statements directly related to the aids– More on-topic statements about the aids, but also

about other areas (generalized to other topics)– More on-topic statements by the partner - it wasn’t

their aid!

• Social Validity– 13 Speech Staff listened to tapes and rated quality– Aided conversations rated higher on staying on topic,

being less ambiguous, and in general, just being more comfortable to listen to, 33

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No Aid Memory Aid

SO9 Intro (NFE): The Intersection of Gerontology and OBM/Staff Mgt

• It’s important for behavior analysts to develop and experimentally evaluate interventions to deal with problem behaviors

• However, if we want to alter/improve the behaviors of consumers permanently, we need care givers and staff to implement those interventions

• This is where OBM/Staff Mgt comes in

35(OBM in business and industry, but typically staff mgt in human services)

Gerontology and OBM/Staff Mgt

• Direct care staff in nursing homes– Are CNAs (Certified Nursing Assistants)– Often receive low pay and work long hours– Have many potentially unpleasant aspects to their

job– Are often kind people who sincerely want to help– Often have no idea that their actions are directly

contributing to an environment that • Suppresses independence and activity• Reinforces problem behavior

36(note medical model, nursing, rather than hiring direct care staff with behavioral background – different than in group homes andresidential facilities for DD and autistic children supervisors have a psychology/behavioral background)

Gerontology and Staff Mgt

• Staff training and performance monitoring are a critical part of providing good care in nursing home settings

• Staff will often acquire knowledge of procedures in in-service then fail to use the procedures when they interact with clients– No system in place to make it worthwhile or

feasible to maintain new procedures

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SO9: Engelman, Altus & Mathews (1999),Increasing Leisure Activities

• Designed to increase engagement in leisure activities• Engagement in leisure activities is believed to:

– Increase the quality of life of individuals by bringing them into contact with reinforcers they enjoy

– Decrease inappropriate behaviors• Often, however, elders with dementia don’t initiate

activities without assistance• While staff are encouraged to facilitate this, they are not

trained to help them choose or maintain leisure activities• Furthermore, staff have a lot to do and may have many

competing job responsibilities

38(Basically, just make them happier; True of other at-risk populations as well, DD)

SO9: Engelman, Altus & Mathews (1999)

• 5 residents in a nursing home with dementia • Intervention:

– CNAs were trained to• Check-in with each of their assigned residents every 15 min• If engaged, praise activity• If not engaged, offer activity choices and assist if necessary

– CNAs were observed and given written performance feedback

• Measured appropriate engagement, inappropriate engagement, no engagement of residents

• Research Design = MB across morning/afternoon

39(really cool design)

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• Results – All participants experienced increased

appropriate engagement • over 80% of intervals in morning• over 70% of intervals in afternoon

– MB design clearly shows the increase was due to the check-in procedure

– Greater diversity of activities • 7 in baseline, over 20 in intervention

Engelman, Altus & Mathews (1999)

(Piano player; sometimes the problem is they just can’t get started by themselves) 43

SO10: Engelman et al. (2003), Increasing independence

• Well meaning staff may increase resident dependence by doing everything for them

• System of “Least to Most” Prompts ensures opportunity to perform independently– Verbal (least help/prompt, fosters most independence)– Gestural (next level of help/prompt, independence)– Physical (most help/prompt, fosters least independence)

• Intervention– Interactive 30 min training on System of Least to Most

Prompts (model, rehearse, feedback)– Feedback: Daily monitoring of consumer performance

by CNA44

• Participants: 2 CNAs; 3 elders with dementia• Measured

– CNA use of Least to Most Prompts– Time it took to dress elders

• Research Design = MB across elders• Results

– Prompts increased for all CNAs across elders– No increase in time it took to dress elder (6.7 vs. 6.5

min)• Why is the above result very important?

SO10: Engelman et al. (2003),Increasing Independence

45(during baseline, no prompts at all, they were dressing the elders)

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Conclusions: Behavioral Gerontology

• Increasing need for professionals with experience and expertise in aging

• Opportunity to create new models for service delivery that allow individuals to retain independence as long as possible

• Allows you to blend clinical and OBM interests

Interested in this area?

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Again see: bgsig.wordpress.com

Staff Management• Staff management, while similar to OBM interventions in business

and industry, offers some unique challenges• One is that few professionals in human services are trained in

staff management; rather they are trained to develop effective training and behavior management programs for their consumers

• There has been increasing recognition over the past 10 years that staff management skills are essential for professionals in human services

• Most individuals who obtain graduate degrees to work in human services, end up as supervisors or managers – they do not implement the programs with the consumers themselves, rather they supervise those that do

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SO11: Staff Management• Furthermore, many professionals manage several different units

or programs within human service agencies and some have started their own human service organizations, but again they have no or little training in staff management or organizational systems analysis

• Yet, it is quite clear that no matter how well designed a training or behavior management program is, unless it is implemented correctly by staff, the consumers will not benefit (answer to SO11)

• In business and industry, it’s a given that employees need to acquire new skills and supervisors/managers need to know how to supervise their employees but in most HSS, individuals are hired/promoted based solely on their clinical skills

– We know in business and industry there is little correlation between technical skills and supervisory/management skills: they are different skill sets!

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Staff Management

• Most business organizations hire experts in training, performance management, and organizational systems analysis, usually in the human resources dept.

• Human service agencies have not done that• Human service professionals, therefore, have little or

no training in staff training, performance management, and organizational systems analysis

• And yet, there aren’t experts in the organization to help them

50(At WMU, over the years, no idea how many of our graduates in human services have told me thatthey wished they had taken all of our OBM courses while in graduate school here)

Why haven’t students been trained in staff mgt or OBM?

• Failure to recognize the importance of staff mgt• Lack of availability of courses in staff mgt/OBM at the

undergraduate and graduate level– Very few graduate training programs in OBM

• OBM courses that are offered typically focus on business and industry and are marketed that way, thus students pursuing a career in human services don’t recognize the relevance of these courses– How many of you who are interested in human services (working

with autistic children, developmentally disabled, brain injured) have considered taking PSY 3440, Organizational Psychology?

51(WMU has historically been the exception; since 80s; our graduates in academic positions are primarily the ones who are infusing staff mgt into training of human service professionals, so this is changing)

What three OBM courses should human services personnel take?

• Performance management– PSY 3440, Organizational psychology, undergrad– PSY 6450, Psychology of Work

• Personnel Training*– PSY 6440, Training

• Organizational systems analysis– PSY 6510, Behavioral Systems Analysis

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(WMU has historically been the exception; since 80s; our graduates in academic positions are primarily the ones who are infusing staff mgt into training of human service professionals, so this is changing;Personnel selection might also be good, but not as necessary; business course in accounting/finance)

*Note the spelling: personal training means something very different

Challenges for the direct care staff• Pay is typically low• Sometimes staff get “kicked, bitten, and scratched”• They often have little or no professional training before

being hired– High school degrees

• Job responsibilities are often not well defined after hire– Often are excellent at daily care of consumers and scheduled

activities (meal preparation, outings, etc.)– Often not given much guidance about what to do when there is

“free time” for consumers

53(similar to the factors I talked about earlier with respect to DCS in gerontology; don’t blame the staff, butyou can’t blame mgt either!)

DCS need job training and support that managementis often not trained to give them.

SO23A: The Results of Lack of Supervisor Skills in Staff Mgt

Research has consistently shown:• Developmentally disabled individuals who live in

residential facilities or group homes spend ~65% of their time off-task– That is, not doing any meaningful activities or leisure activities

• Direct care staff who work in such facilities spend ~45% of their time off-task– That is, not doing any work-related activities

54(I just want to mention the data on this before moving on…this is SO23A, I haven’t made a mistake on the slide)

SOs 13-22: Reid et al. Article in Course Pack, Summary

• Supervisors in human service settings use the least effective training and management procedures– Verbal training methods (lectures and written material) rather than

performance-based training methods (modeling and practice)– Antecedent interventions (training alone, memos, instructions)

rather than feedback (the most common performance mgt procedure in the research; money, etc., is too expensive for human service agencies)

– Punishment instead of feedback

55(Reid et al. make all of the points I have made about the lack of training for supervisors in their article – it is a terrific article. SOs are straightforward and on your own.

SOs 13-22: Reid et al. Article in Course Pack, Summary, cont.

• Why do supervisors use the least effective staff training and management procedures?– Lack of training– Time and effort required by the effective procedures

56(two reasons, always the same)

Green, Reid, Perkins, & Gardner (1991):Increasing Staff On-task Performance

• Participants– 8 direct care staff– 14 consumers who were profoundly mentally retarded,

non-ambulatory, and had multiple physical disabilities• Setting: State residential facility• Goal: Increase staff on-task performance

– Interactions with consumers– Training with consumers

57Example of a multifaceted program to increase staff on-task performance)

SO24: Green et al. (1991):Increasing Staff On-task Performance

• First step: Determination of when DCS had free time to implement interactions and training– Did not want to schedule a time for interactions and

training that would interfere with basic care of consumers

• Observed the DCS throughout the day– Lowest level of basic care and highest levels of

nonwork: 10:30-11:00 AM and 2:00-2:30 PM• Scheduled interactions and training with consumers

during those times

58Example of a multifaceted program to increase staff on-task performance)

NFE: Green et al. (1991):Multifaceted Staff Mgt. Program

• Assigned each DCS to a specific consumer to increase accountability

• Individualized performance training for DCS based on their assigned consumers

• Daily observations and vocal feedback to DCS re their interactions/training with consumers

• Weekly written feedback summarizing daily feedback

59(6 basic components, cont. on next slide, NFE, but I wanted to give you an example)

NFE: Green et al. (1991):Multifaceted Staff Mgt. Program

• Self-recording: DCS initialed a chart posted in the living area when they completed assigned interactions/training

• Monthly reward drawing for DCS who completed at least 80% of their interaction/training sessions, 1 winner– Free lunch– 30 extra minutes for lunch– Leave 30 minutes early one shift– Reserved, private parking place– Written commendation letter placed in personnel file

60(choose a prize, similar to the ones listed, results next; illustrates how much effort and timeis required by supervisors for this type of program.)

SO25: Green et al. (1991):Results

• Nonwork– Baseline: ~30%-95% – Intervention: 2%-8%– Decrease: 28 and 87 percentage points (30&85 OK FE)

• Interactions/Training– Baseline: 7%-0%– Intervention: 86%-91%– Increase: 79 and 91 percentage points

61(first number, 10:30, second number, 2:00; % = percentage of observation intervals, last slide)

Instructional Assistance Hours

• Wednesday, 4/08

• 6:30 – 8:00 pm

• Jessica will be there!

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