Targeted Case Management

SECTION 1

As human beings we all behave. Behavior may be displayed through different modalities, including physical and verbal. Whether verbal or physical, behavior may be a form of communication. All behaviors have a function as to why they are preformed. It is our responsibility as professionals to try to understand what the person is communicating, and what the function their behavior is, rather than to simply try to manage the behavior.

TELL ME AND I'LL FORGET. SHOW ME AND I MAY NOT REMEMBER.
INVOLVE ME, AND I WILL UNDERSTAND.

(Native American Proverb)

A. Introduction to Positive Behavior Support (PBS)
PBS is a set of research-based strategies used to increase quality of life and decrease problem behavior by teaching new skills and by making changes in the person's environment.

PBS combines: Valued outcomes; Behavioral and biomedical science; Validated procedures; Systems change to enhance quality of life and reduce problem behaviors.

PBS is based on behavioral and biomedical science.

Research in applied behavior analysis has demonstrated the importance of analyzing the interaction between behavior and the environment. From this perspective, behavior is considered to be purposeful and to be under the control of the environmental factors that can be changed.

PBS assessment and intervention strategies are based on applied behavior analysis research, and emphasize the importance of implementing intervention strategies that are effective in natural everyday settings.

PBS assessment and intervention strategies are also based on biomedical science. In the past, behavioral and psychiatric interventions have often been managed separately with very little collaboration between behavior consultants and medical personnel. Information related to an individual's psychiatric state and the knowledge of other biological factors could assist professionals in understanding the interaction between the physiological and environmental factors that influence behavior.

PBS strategies are considered effective when interventions result in increases in an individual's success and personal satisfaction, and there is an enhancement of positive social interactions across home, work, academic, recreational and community settings.

Example: Ellen is a 14 year-old with severe disabilities who lives at home with two other siblings. Although Ellen likes to go out to eat, six months ago she began pinching other people on their arms and legs, sometimes causing bruises and redness. Ellen's mother and father were concerned because Ellen's problem behavior angered several restaurant owners who asked that she not return to their establishments. Ellen's behavior support team decided to intervene by avoiding all sit down restaurants and encouraging Ellen to go through the drive through to pick up dinner instead.

What is the problem with this intervention?

The behavioral intervention used by Ellen's team focused only on reducing the occurrence of problem behavior by avoiding public places. Although this intervention may be effective in reducing aggression, Ellen will never learn the skills she needs to socialize in her community successfully. Problem behaviors occur for a reason and often individuals engage in problem behavior to communicate what they want or need.

The goal of PBS is to improve quality of life, not only for the focus individual, but also for all of the persons within their social network. PBS is now used in many different situations and contexts and with different types of problem behavior including aggression, property destruction, and self-injury. All individuals, with or without disabilities, can benefit from the PBS process, in all environments.

B. Critical features of PBS
"The best time to intervene with problem behaviors is when they are not occurring" (Carr et al., 1994, p. 15). This quote refers to the importance of preventing problem behavior by acting before a problem has a chance to arise.

1. Prevention:
Although it is usually easier to be reactive than proactive, in the long run, being proactive may have a much higher pay-off. As professionals we are trained to be proactive in all areas of support, and services for the consumer. In the area of behavior support, prevention strategies can be much less stressful and require lower levels of emotional energy when compared to the time spent coping with crises. Despite this, at times, you may encounter that family or support staff are resistant to invest the time and energy in prevention. In these cases, it will be important to understand that placing an emphasis on prevention will set the stage for fewer crises in the future. For example, by teaching social skills and designing predictable and positive environments, one may decrease the need for more reactive strategies.

2. Normalization and Inclusion: Normalization is the philosophical principle that focuses on the respect and dignity of all people, regardless of their level of ability, circumstances, or nature of their challenging behavior. All support team members must encourage the same respect and dignity we cherish for our families and ourselves. Team members should support the individual so that he/she will have the opportunity and ability to exercise his/her right to live and participate in his/her natural community, as well as encourage and support further integration and inclusion. With the implementation of positive behavior support the individual will have opportunities for improved family relationships, new or improved social relationships, integrated employment, classroom inclusion, preferred community activities and much more.

3. Person-Centered Values: The starting point and foundation for all successful support for an individual is through Person-Centered Values. Through the process of the Person Centered Support /Wraparound Planning, the focus person and their complete support team will identify the focus person's interests, strengths, preferences, communication methods, levels of ability, skills, limitations, and the supports needed to achieve the person's preferred lifestyle. The Person-Centered approach emphasizes the individual's strengths and focuses on meeting the individual's needs across life domains. It is based on the hypothesis that if an individual's needs are met, problem behavior will naturally decrease.

4. Life Span Perspective: Providing support is a never-ending process. As the focus individual changes or his/her environment changes, new skills and supports may be needed to successfully adapt to the transitions. The support team must be proactive in supporting the individual through normal life transitions as well as unexpected situations that require the focus individual to adapt.

5. Team-Based Approaches: As a member of the support team, you have knowledge of the focus individual's preferences and the supports needed to assure his/her preferred lifestyle. Most behavior occurs within a social network or system and changing a social network requires a team-based approach. Making modifications to environmental settings and teaching new skills naturally place the responsibility for behavior change upon those individuals within the social network that support the focus person. However, if additional support is needed, successful positive behavior support plans can be created in collaboration with an outside facilitator. The focus individual and each member of his/her support team are very valuable. All must be treated with respect. Each member must be an active participant at each stage of the behavior support planning, and everyone's input should be valued.

6. Multicomponent Interventions: Behavioral interventions that are successful in one situation or setting may not be successful in another. The focus individual must have the ability to transfer his/her skills across multiple settings. Components of the positive behavior support plan must address teaching the focus individual to generalize his/her skills across multiple environments. Multicomponent intervention plans may also involve changing organizational systems by enhancing staff development, reorganizing resources, and changing management strategies, in an effort at enhancing the focus person's life.

C. Identifying the need for PBS
As a case manager, you may have concerns regarding behaviors exhibited by the individual or how caregivers and/or support team members interact with the individual during your visits. You may also receive a request from a caregiver or a team member for additional behavior support or for a formal plan. The fist step may be to conduct a records review. The focus individual should already have a Person Centered Support Plan; review this plan, making sure there are no barriers to needed supports or services to meet his/her preferred lifestyle. If the target individual is a student, the Individual Education Program (IEP) should also be reviewed. If the student is displaying unwanted behaviors in the school environment, the school should include a behavior plan as part of the IEP. Remember that, as a case manager, it is your responsibility to be the student's educational advocate, making sure his/her needs are being met in the academic environment. The second step may be to conduct direct and indirect observations to gather more information about your concerns.

Included throughout this guide are many great resources on what positive behavior supports are and how they will benefit the focus individual in all domains. After reviewing the different resources and tools you will be able to understand and explain positive behavior supports to the focus individual and all members in his/her circle of support. With this information and understanding of the focus individual's needs, the caregivers, team members and supporting agencies can, as a team, develop a positive behavior support plan that the entire team commit to.

D. Glossary of Terms:
Overall Glossary of Terms
http://kipbs.org/new_kipbs/fsi/overallGlossary.html

E. Resources and Tools:
more information about system change
http://rrtcpbs.fmhi.usf.edu/rrtcpbsweb/Products/systemschange.pdf

School-wide PBS
http://www.pbskansas.org/schoolwide/index.html

KIPBS Home Page
http://kipbs.org/new_kipbs/index.html

APBS Home Page
http://www.apbs.org/index.html