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Adapting our Practice to New Needs (Part 2) - Text Transcript

- And I'll turn the floor over to Dr. Kolu to go into part two of this two part series.

- Thank you so much, Shelley.

And I'll look and make sure people are nodding and you can hear me.

Okay, wonderful, and welcome back to everybody here.

I'm really excited to bring this second piece to you all.

And one thing I'll be doing a little bit differently tonight is slowing down a bit and we'll have a few less slides and they're a little bit meaty, so we can spend a little bit of time with each one of those.

I also did this expressly because I wanted to make sure we integrate your questions really well.

It's completely possible, you asked me something wonderful last time and I have forgotten that I wanted to integrate it.

So if I'm looking past you, it's because I have a chat open and I would love for you to enter your questions just as they come up or really any time, and we'll get to them when they're relevant, and especially at the end, I'll scroll back up and make sure that we haven't missed anything important from all of you folks.

So I'll go ahead and scroll through so you can just spend a couple minutes with the abstract again, if you would like to see that.

And certainly, thank you so much to APSEA, the websites you see on the screen, in addition, or just, I think I went over last time.

I blog occasionally at cuspemergence.com.

And I also provide some continuing education over at cusp.university.

So if you wanted to type those in, I think you can always email me straight from there and get some resources too.

So today were kind of focusing on the second half of this.

I give you a lot of the meetup front, but today is going to be really rich in terms of the tools that I use professionally and personally, and almost all of these are going to be available to the educator teams that I work with.

Some of them are a little bit more internal and I'll use them to guide my own decision-making process as I'm working with a team, but I almost always share them, because it's really helpful to be able to communicate in sort of a job aid way.

And if you're not familiar with that, it means if I have something to try to communicate, I wanna be able to leave an educator with something one page long so that they can look back and reflect on it and just have that when I'm gone.

And I find that that really helps to have a visual posted in the classroom later about what we've been trying to emphasize.

So everything that I do, and I know that I shared this last time, is really collaborative.

Part of that is on purpose, because the more collaboration that I have and the more that I honor, all of the inputs from my whole team.

And I think I mentioned last time that sometimes it could be 25, even 40 professionals, really diverse teams at multiple levels.

So sometimes we're looking at multiple states even.

Looking at, are we going to take the students?

Should we send them to New Jersey where there's this program?

Are we gonna go down to Texas and work with those folks?

And then there's all of the elements of the educational team, all of the behavioral side, all of the mental health aspects and really everything in between when you're talking about trauma.

You could have all kinds of layers of families, multiple generations of people.

And so these can be really complex and I love the collaborative approach.

It's effective in a way that it's something I try to do myself, problem solving and then telling people what to do, that's never effective or as effective at all.

So again, refocusing a lot today on tools and I will use a couple of case studies sort of building on what we talked about last time to share with you a little bit more about how I use the tools.

And I'll just revisit the learning objectives for a moment.

Last time we talked, we discussed that there are some procedures that whether you're in education or in behavior analysis, or you're walking the line in between all of the professional disciplines, serving a student after trauma, we have this idea of best practices don't weigh.

But the problem is often that we have to individualize very specifically and in a bit of a more complex way after somebody has gone through trauma.

And when we individualize, sometimes the practices that really are best for other students become contraindicated not all the time, but for a temporary time period where we're working things out and learning more about the students.

And so that's one of the pieces that we spoke about last time.

Just an example that we started with was I believe are a lot of the professionals working around me would sometimes begin with pairing themselves with credible reinforcers.

That might not be as true in education, I realized, as it is in some of my circles where we're working out of district to serve an individual with autism, whose behavior is so severe that they cannot be served in the classroom.

And so we're serving them in a different setting and the behavior analyst might come in and automatically think, I'm going to build a rapport with the person, I'm going to pair myself with everything they love.

When we start doing things like preference assessments, seeing which things someone likes the best and then presenting that thing contingent on their behavior.

But everything that I just mentioned is sort of fraught with problems after trauma, in some cases, because we're presenting things and then taking them away, big no-no, we're making a big deal about some of the consequences for somebody's behavior right away, big no-no.

And we may be using specific praise to kind of get somebody to start to approach us.

Again, a lot of things that might be best practice for some of our students, but after trauma and autism it's certainly very different.

And so we did talk a lot about those contraindicated procedures last time.

We also talked a bit about some tools and I will be showing you several more today.

And I think everything that I have for you except for one tool has been either provided to you, or is embedded in this presentation and in the documents that you'll see.

So if you just printed out a PDF of this presentation, you would see a half sheet of the tool and be able to see what it's like and work with it.

Today, we'll also talk a little bit more about some of the interdisciplinary work that we do.

And I've included a little section specifically on how educators and their administrators in particular, have been supportive or not.

And so this will help us not only know what to expect from our administrators on our teams, but also what to guide them with if they ask, "How can I be a more effective supporter of you all?" Then there are some things we can ask for and some things that have made a significant difference to my work too.

So that last piece, the last objective, since this is one of the first that we didn't really cover last time, I thought it would just delve into it right away.

Some features of interdisciplinary cases in which behavior analytic procedures are supportive components of our support.

Well, when we're supportive, it's usually because all of this stuff is present.

So we've got system support, good administrative support.

Each person on the team is participating in this regular way, but by that, I do not mean in a reactive way.

And so there's a significant difference, isn't there?

Between being responsive and always being there and also amping up our response after a crisis and then sort of the opposite, being reactive, not being present most of the time and then jumping in after a crisis, and not doing that in a teaming way.

We also have to value the expertise and clinical oversight that we might receive on a team.

And it's a case in which we request and we share input regularly and if you're doing that in advance.

So if you program for that to happen in advance, where in a better place to be sharing risks in an ongoing way, and to document those concerns and then discuss preventively, what we're gonna do about those things.

If we're not doing it preventively, then it sort of seems like putting out fires approach, and these are the cases that sort of go on and on.

And we have the same problem in the spring that we thought we were dealing with in the fall.

And it's really because we're not being as proactive, for lack of a better word there, as we could be.

Additionally, the tools that I'm gonna share with you, we have to use those to facilitate collaboration and cohesion among our team members and along the path that maybe the trauma takes us or along the path that our student takes us as it unfolds and we learn more and more.

It's we're using that information that we're learning along the way.

And again, they don't usually tell us everything at the beginning, of course, who would?

And so I might screen for trauma but don't learn a lot until I really build a relationship with a student, and suddenly, I'm learning a lot more.

Well, whenever I learned that I keep feeding it into the documentation and adding all that great information about their background, pulling that into the forefront.

If it's necessary, we're putting that into the FBA or the behavior assessment, and letting that inform and guide our behavior plans and our support plans for all of the levels of educators and therapists we've got working together.

And so I just thought you might wanna start by seeing that these are some features of when I have a successful interdisciplinary case, this is usually part of what's going on.

I've got a case study for you.

And so I thought I would focus on one of our students who was, everybody thought that there had been something going on that was difficult for this person, but it was not documented.

And one of the things I learned about all the tools I developed a few years ago and have been using this far, is that educators and professionals want to know more and certainly we try to get everything we can.

There are lots of ways to document information people give us.

But what if they don't give us much to go on?

There's a lot of reasons for that, like a case might be ongoing.

There might be something at the court level that prohibits sharing of information.

Certainly there's protections legally for people who can't share all the information they have.

There's also a lot of cases that I work with and I'm sure you do too, where we suspect something that no one wants to be forthcoming with it and maybe abuse is ongoing.

Somebody going through challenges at home and all kinds of things.

And so I thought I would talk with you about a case where this is the case, we knew trauma probably was happening, but we didn't really know what was going on and that we can still do something about it, is my point.

And so here's our little guy, this is Marco.

He comes to school irregularly, of course, that's your first red flag.

His teachers aren't sure why, but there's no one really close to his family.

One of the teachers knows that there's a foster parent involved, but she's been told to not discuss his home life with too many people.

So there are sensitive issues going on, perhaps maybe one of the parents is involved in something and we are trying to protect the child here.

So we're not sharing information from that perspective.

Well, he's brought to school by different people every day.

He comes in acting very differently sometimes than he did the week before.

And people are describing his behavior as erratic, like his attendance.

So sometimes he just spaces out in class, sometimes he avoids other children.

But sometimes he doesn't avoid them, sometimes he really acts aggressively and sort of flies off the handle, attacking somebody who's just walking by.

So little Marco seems docile on some days, but then there's also those times, where is that, there's an out of proportion response is something in the environment.

So when it's loud or chaotic, people are starting to notice, the lunchroom is super difficult for him.

He doesn't handle substitutes well.

His holidays seem to be just really sad because he has meltdowns leading up to all the holidays.

So that's what we're looking at.

Now, the hopeful piece is what can we do?

Well, we can do all of this, we can still gather information.

What information we can gather?

I'm gonna chat with you a little bit about next and what tools can help?

What techniques could we use?

What supports and strengths can our interdisciplinary teams bring to this kind of case?

And if you can do it with this kind of case, by the way, you can do it with any cases, especially when there is great history documented for you.

It just becomes easier in terms of the more we know, the better we can handle it.

So some helpful information to gather.

Well, even if I don't know what situations the child has been through at home or out in the community, I can find out this part, I can learn number one, what do they avoid?

What do they find difficult?

Last time I showed you all a tool called the IPASS, and it was used to look at all the different sensory environments around somebody.

So what do they experience visually right before a challenging thing happens?

What's going on?

Are there some kind of strange smells wafting through?

Sometimes you won't notice these kinds of things until you're told to look at all five of the senses and be very, very vigilant.

I think that I shared Cassandra and I pass last time in PDF.

If I did not though, I can certainly make that available to Shelley so she can distribute it, because it was one of the tools that either this week or last time we had on the docket to share with you all.

We also looked at this other little PDF, an attention preference survey.

And this is something that I've used with teachers because educators often know so much about what's not working.

Often, it's my parent educators in a classroom or the therapist who comes in for an hour a week.

They have a great need to know this information.

Okay, Patsy, thank you so much, we will get that to you.

We need to know this information about if a child who's been through trauma is finding a certain kind of adult attention of verses.

So for instance, maybe Marco is really set off and starts using inappropriate behavior.

The second is that you say, "Great job sitting in your seat." And you're really confused because he was sitting in a seat, you praised it, and all of a sudden it just hit the fan and he starts bouncing off the walls instead.

Or maybe they're the kind of student who might just completely shut down after you try to call them out in class for something either good or not so good.

And so we do have this little PDF available that you can use.

I use it in a visual way with my learners themselves that they can tell me.

And sometimes I'll use the cards where there's just a smiley face or a frowny face.

And I'll say, "Show me how you feel when I, when Ms. Kolu does this." And I'll say, "I'm pretending I see you working hard on math. And I say, great job, Marco, from the front of the room, do you feel good or bad about that?" And people give us more and more information about what's working and what's not?

The best information is from the horse's mouth, as they say.

And so a kid can come up with his or her own way to tell me what they really want.

And sometimes they just want a signal.

They want me to put a discreet little mark on the board that no one knows what it means, or they want a little discreet thumbs up, or they want to note passed to them after class.

And at this point, I'm kind of sharing with you lots of examples from different levels of education.

When the kids are nonverbal and my students are older, we might do it in a different way than assessing it when they're five and six, but either way you want information from the students and you want information from the educational team around this person.

So we can use those tools to help us understand, what do they find avoidant?

What are they avoiding or find difficult?

And that's behavioral information.

It gives us some information about what they find diversive.

So the second piece there is what times of day, or week, or year, or month are difficult for this student.

Often, they will have gone through something that's cyclical.

And I see this no better than when there is a particular time of year that something happens.

Maybe thinking of one of my students, for whom dad moved out at a certain time of year, she went right into foster care because there was problems with her mother.

And then she had to run away from foster care to avoid something really significant that was happening to her in terms of the abuse there.

And so that was at a particular time of year, and every year around that time, there's something really challenging.

And if you didn't know that, think about how frustrating it would be to see that over and over every year, not know that it's coming and then to continue to wrestle with it.

And every substitute that comes in has to wrestle with it a new.

And so you're kind of getting an idea from what we look for, do what are the supports might look like on the other side.

The third piece here on this screen is we need to know lots of information about behavior.

And if there is lots of potentially trauma-related behavior.

I can document that on a screening tool, and I'll be sharing that with you and showing it to you in a few minutes.

Now, this fourth piece is fun.

Everybody likes to be forthcoming about what's not working.

If you can get this information from your team upfront, it's so helpful rather than waiting, trying to give them your own ideas and then saying, "Oh, but you knew this wouldn't work. Well, thanks for telling me." Well, often people didn't say anything, because they simply weren't honest and information about how basic techniques are not effective with this student is a huge red flag, a huge cue to me that something is a miss in terms of their background.

And so if they just don't respond typically to praise, if they just don't respond typically to prompting, if it promotes a huge emotional reaction in other words, maybe the foster parent comes in and says, "I have been a parent for 25 years, and this is my foster child. And nothing I do in terms of your behavioral parenting techniques, nothing works with this one." Okay, again, huge red flag that something's going on or has in the past.

Number five, getting down to the bottom here is information about the response itself.

And so if somebody is using a challenging behavior and the team is kind of talking about what to do about it?

Well, the behavior analysts on the team, if there is one, should be very, very vigilant for whether there might be signs that this is not just a typical operant response.

In other words, he's not just doing it for attention or doing it to escape something or the word for.

It doesn't have a purpose in other words, maybe there are signs of conditioned responses embedded here, or it looks like something that's just scheduled related, it just gets worse in a certain time of day, and it doesn't seem related to what's going on around him.

There's also clues we can gather about situations, without knowing the details.

And so for instance, if I know a student went through several foster placements or they were adopted and given back, that's really all I need to know in terms of I can document at point.

Okay, they were adopted and given back, that tells me a lot about the challenging history they were exposed to unfortunately.

So the second piece I asked you a minute ago is what do we need to know?

Well, we need to know what tools might help.

And the first two that I mentioned were things we spoke about last time and that I can share if we didn't already, once the IPASS, once the adult attention preference survey.

And so, again, the IPASS just stood for inventory of potential aversive stimuli and situations.

I think that's what the SSR.

And the preference survey about attention is the one that I just discussed.

So those are available.

This safety screening is a new one that I'll share with you in a few minutes today, I'll just share an excerpt, it's simply a one-page form.

The safety assessment on the other hand is an elaborated version of that.

And so that's more of a 200 item assessment that goes through a lot of different components and I'll show you it, but it's not something I provide because we do have it available on the website, but it only comes with the training that you buy with it because I found that it's just really important when you're talking about assessing for trauma, that you make sure you do a training specifically related to how to do that and how to interpret the results.

The buffers score on the other hand is something we will chat about today and I'll give you.

And then we'll look at a couple of templates, ways to do risk versus benefit analysis.

Ways to talk risk mitigation and document this among your team.

And then I've got a couple of graphics about how to make your FBA a little bit more TIBA related.

By that, I just mean trauma-informed behavior analytic, not just in FBA, but making sure we take these other things into consideration, same applies to your behavior intervention plan.

So we'll discuss this.

Yes, Cassandra it's available.

It is.

It's about four or five hours, it's on demand, so you take it at your own pace, then it comes to the book.

Okay, so this is the safety screening tool.

I'm going to show you first on the left, you can see that there are two columns.

We're just wanting to know on the left, what behaviors are being used?

And so this is a piece that you can gain for any student, you can observe them and see any of this that's going on, or you can look in their behavior plan from last year and document these were issues in the past, and yes, they're still going on now.

One thing that the safety assessment, as opposed to the screening does is it pulls out all of the ways that some of these behaviors are related to trauma.

And so I'm just gonna give you an example or two.

And first, I think I'll give you the caveat that nothing by itself is an indicator of anything.

So for example, if I acted out sexual roles with others, and I'm a four year old playing doctor at some point, that's pretty age typical, and it depends on what you do and what you've seen, and it's curiosity thing, it's related to typical childhood development.

What we look for is convergent evidence.

And so for example, there are several items here related to sexualize behaviors.

If a child is acting out a sexual role with their peer, and depicting sexual events in their drawing, and always planning in a sexually aggressive way with their Barbies and doing something sexual with the dog.

So we're looking at convergence in terms of professionals who are monitoring these kinds of behaviors.

There's others here that might be a red flag to me.

For instance, eating out of the garbage or eating hygiene products, that's something that I see after trauma.

You might also see that in the case of maybe PICA, you might see many of these in terms of at a developmental disorder.

So anyone being wouldn't be a red flag, and one of the pieces of what we do is making sure that anything we document isn't happening because of another diagnosis that's already on record.

So if somebody had PICA plus they're eating products out of the garbage, not necessarily trauma, if somebody has been through neglect and is hoarding food and eating out of the garbage and smearing feces, then there's a cluster of three or four things that might be related to trauma.

On the right side are things that I screen for.

And again, this first item is something you can know without knowing what situation somebody has been through.

It says everyday caregiving techniques seem to make challenges worse.

And so that's something that as a teacher or as a therapist, who's trying your bag of tricks, and it really seems to worsen behavior when we do something that's typical.

This is a red flag, but other ones here, a lot of these are ACEs, so things that people are exposed to that would be called adverse childhood experiences, especially things like there's documentation of abuse and neglect, or they were homeless as a child and exposed to drugs in utero, and they have a sexual abuse history.

So if we know that, of course, that's not suspected trauma at that point, we're screening for the fact that it did happen.

But again, going back to our example with Marco, that we're gonna focus on today, you don't have to know all of these things for you to understand that something is going on with this little boy that makes us need to use a more trauma-informed and supportive approach.

So that's one safety screening tool, I have shared that with Shelley, and she will get that to you all.

Why I wanted to share this?

It was a real intake that I did, just to kind of give you an idea of how it's very serious.

If somebody has been through one or two, often, they've been through a lot and you often won't know that.

All you see is perhaps the tip of the iceberg.

Well, we spoke a little bit last time about how in terms of the medical impacts of trauma, they are lifelong, they're also dose dependent.

And so somebody who got a massive dose, maybe they're completing my form and they have 15 out of 24 pieces.

They are severely affected by it.

And I certainly do need to do a more educated approach with them.

I don't always use a trauma-informed approach, I don't use the same approach for everybody.

But I certainly try to individualize, and it's something that you can do, in terms of how you're differentiating your procedures for all your students.

So I mentioned that safety assessment, I just wanted to share just a little excerpt of it to show what we're looking at.

We're looking at professional support.

So all the items and all the ways that a team needs to gel together, it goes over maybe 35 or 40 different kinds of professionals that might be involved in the case.

And sometimes it gives us information on who we need to call in if they're not already there.

It also looks at family variables, things that they went through as a family or things we could be doing to support the family.

Behaviors of concern, things in their learning and their development and their repertoire.

So for instance, a lot of times students will miss a lot of educational opportunities, won't they?

Because they're being taken out of school, maybe they're involved in an unstable caregiving situation.

Somebody's not getting them to school or they're moving county to county as they really try and struggle to find a permanent placement.

So their development might look different just because of what they were not exposed to, or things can get really derailed because of what they were exposed to.

We also look at section e, is interaction with caregivers.

So how are we supporting their current team?

And if they're in a placement, how are we supporting those folks and any exposure to possible adverse experiences?

So that's what we assess for.

And this is the last slide about that piece.

We just basically ask yes or no, is this item present?

And if it is associated with a risk, then we go and we do a different followup and look at needs that are conferred by the risks related to these items.

So there's something exciting.

I was really interested and I hope I spoke about her last time.

I was really interested in Nadine Burke Harris' work, and this is the pediatrician who has done a lot of the ACEs work with children, as opposed to the old, sort of the middle age cohort of men from Kaiser Permanente who were involved in that initial study about how ACEs impact us medically through our lifespan.

Well, Dr. Nadine Burke Harris has been working with children as a pediatrician and has written some compelling articles and books.

Well, one of the things that I love that she brings out is the buffers, the things that we can do to make sure that our clients are as resilient as they can be after trauma.

And it seems to be a dose dependent thing here as well, where if somebody has gone through trauma, but all of these things are in place, then they are going to handle what they go through in a more protected way.

They're going to be okay, they're going to deal with it all right.

Their medical history is gonna look different.

Their stress response is going to be better.

They're going to be better parents when they grow up.

There's a lot of measures being taken right now in the literature.

And so I just thought I would share these with you.

And my reasoning for doing this is I have several purposes.

First of all, it's really devastating to take a look at everything somebody went through.

When you look at a result from that 200 item questionnaire, and you start documenting these maybe hundreds of interactive risks that they're going through, and then you look at this buffer score and you think, and they're still in the thick of it.

They've got all these risks, they don't exercise, they can't sleep, they're not eating, they don't have any relationships and God knows they have no mental health support.

Well, you know what?

I could do something about some of these things, I may not be able to change their home life.

But as an educator and as a mental health therapist and as a behavior analyst who knows how to program, to bolster some of these as skills, just think people could learn and that could follow them, that's hopeful to me.

And so I really appreciate that, I'm gonna delve a little bit more into this.

The first one is proper exercise.

Are they getting a little bit healthy diets on there, but pause for a second, think about stress relieving techniques and, okay, so this goes with your caregiver buffers.

One of the things Dr. Bruce Perry mentions in probably Bessel van Der Kolk too, if you look at some of his work.

So Bruce Perry is a psychiatrist, I believe I mentioned last time, who's done a lot of work with supporting children after trauma and looking at who heals and who can't.

Well, stress-relieving techniques are important in the compliment.

So if you're a caregiver who has those stress relieving techniques, and you fly off the handle when you're under the slightest bit of stress, and you're not able to model and appropriate coping response, when your principal walks by and says something a little bit, maybe inflammatory that you didn't expect, and all of a sudden you're breaking down in your class, you can't handle a student who is going through something really terrible in the moment, at the moment you're going through that too.

And so thinking about how parents need all of these buffers as well, this gives us somewhere to grow in terms of what could we do about our cases.

We can help all of our staff make sure they are maintaining all of this stuff too.

We don't wanna leave them out in the cold.

And when we're able to teach a stress relieving response, this might look very simple.

It might be deep breathing or something like an act tool.

And often we're finding that in the research, this is where mindfulness intersects with our buffers to help folks who've been through trauma and protect them if they will go through something with difficult.

Here to help a whole lot with enough sleep.

Some of the people I work with can, so if I'm working with a residential team and they have access to monitoring equipment and supportive pools and all kinds of ways to help somebody calm down at night and work with them when they do wake up, there's more you can do there of course.

Mental health care though, there's a bunch of you.

And so just appreciating how critical your role is, I often see that the mental health care piece is not pulled in nearly often enough or early enough in the cases I'm working with.

And so it's part of why I put the professional support upfront in the assessment to teach anybody we're doing this with.

That if that is a no, if you're checking that box off, no, then you should add that right away, because somebody will need mental health care.

Now, it doesn't always mean that the student needs to go and process verbally, everything that's happening or that happened right away.

There is research to show that's not always supportive to do right away.

In fact, the 6th piece, having a relationship with a trusted adult is sometimes very, very important, and may trump, the mental health care piece for a time being.

And you'll see this in a lot of cases after abuse that the child will be doing pretty well, even if he's living with a previously abusive caregiver, when there is at least still a relationship with somebody they trust.

And unfortunately, they can trust the wrong people, of course.

But starting mental health care and ripping all of that support away, sometimes causes the child to do a little bit worse.

Now, I wanna talk about what does this mean?

A relationship with a trusted adult.

For a lot of the work we do, I'm gonna give you this little acronym here.

It should be SARA, so safe, appropriate, reliable, and available.

We often we've asked this question, does this student have a good relationship with somebody that they can trust?

Well, if the answer is one thing in terms of what the family says, but a no, a hard, no, when you observe the relationship, then I would still mark this as a no.

I would say it's reported, but not observed.

But so we still wanna foster this, maybe within the educational setting too.

We wanna carve out somebody who can be a person that the student is going to know, they can go to regularly.

Whether they feel like they're in trouble or not, whether things are going okay or not.

We wanna have somebody they can go to.

So safe, appropriate, reliable, available.

Safe means that we're going to need to teach that caregiver or that person that we're fostering the relationship with at school, we need to teach them how to make sure it has all the appearances of safety and honors all of them.

I wanna share that because some of the most well-meaning individuals will accidentally behave in a way that sort of helps groom the child for other individuals.

This is a terrible thing to happen.

And often, it's again done by the most well-meaning of people.

Hey, I think I've spoken to somebody people in Canada about CASA before.

If you don't know what that is in the US, do you all have CASA?

I'm looking at the chat to see.

It's court appointed special advocate, and it's somebody that's assigned by the court to every single foster case or a case that goes into a CPS system.

And so there will be an adult who was supposed to follow the students from the case opening, maybe to adulthood, if they need that and be this person.

However, sometimes that person doesn't realize that maybe by sharing certain details with the child or by calling themselves a friend, which is maybe the same thing that another adult who was not safe was calling themselves.

Just really by violating some of these basics of being trauma-informed and supportive after abuse, it is not safe because it's teaching the student maybe that boundaries don't matter and different things like that.

So sometimes your team will need to do a little education first, to educate a person who's going to be that safe person.

What we're going to be like?

What we're gonna do?

What we're gonna call ourselves?

What we're gonna say?

When we're gonna give gifts?

All of those things.

They could be at home or at school, it could be both.

And some of the things you're looking for, I mentioned evidence is important.

So the student relaxes around this person, they approach them as opposed to avoiding them.

If they are using the relationship for just when things are going okay, and they still avoid the person when things are not going okay.

I wouldn't say you're there yet.

And so again, this is something we actually build in to some of our behavior plans.

And I'll show you a little bit about that later, when we look at a little graphic of what would a TIBA behavior plan look like?

Okay, so one of the big things that we need to do, and number one, that's imperative in the ethics of many professions that are involved here, is that when we see something going on, we document that risk.

Well, a risk documented is worth nothing if you don't communicate about it, go on and mitigate it, get to a plan about it.

And so I've just shown you here something brief, these are available if you need them, but I think you can get everything you need just from looking at this screen, printing it out, maybe posting it and following that a little process, whatever it looks like for your team.

On the left, you have a risk versus benefit.

It's just a simple, it's sort of like a T-Chart, where you think about an option you have, say, should we stay or should we go?

Should we go to this educational facility or that one?

This classroom or that one?

Or should we use this behavioral procedure or that one?

Should we change medications or leave them where they are?

Should the student move, or should the student be in this household?

Thinking then you're gonna think through all the options.

And so sometimes it's not as binary as it seemed, it's should we stay or should we go?

Or should we stay with modifications or go under this condition and train these people?

And it becomes more elaborate as you talk about it with the team.

You typically describe what would be the short-term risks or long-term risks?

Of anything you can think of.

And so I'll have a long list for every potential target.

So let's say the student is using some really unsafe behaviors and reusing a risk documentation tool to try to get that on paper.

Well, he elopes, he runs away from supervision.

Okay, well, there's a big risk.

There's a risk he'll get injured.

There's a risk he'll hurt someone while he's out.

There's a risk that the school will be sued because they don't have a fence.

There's a risk he'll drown because the property is boarded by a little body of water.

So it could be hypothetical.

You could talk about this all day long, but you're gonna do this out loud with the team.

And you're thinking, what are the potential outcomes of all of these risks that we're gonna enumerate?

And who are the target of all of these risks?

And you had all of that stuff, what are the potential benefits of this?

And what is our summary gonna look like?

And so this is sort of a cover, covering your what move, for a school.

Sometimes they tell me, "Dr. Kolu, we don't actually want to enumerate all the risks, because we don't want anybody seeing on paper how bad this is." Well, you know what?

That's really bad.

It's much worse.

It's much worse than you think then if you can't even talk about them, because you're so afraid of the outcomes.

And so this is a tool that gets teams thinking out loud.

If you are trying to change a team's direction, because something is not working and you have a lot of naysayers there, well, what better tool to help them all be heard and to put that information somewhere and actually include it, then looking at it this way.

Because I can say, "Okay, you think it's a terrible idea? Brilliant, tell me exactly why, what do you think is the worst case scenario? What if we do this and it fails? Tell me about it and then I write it down." So this is sort of its own training to how to do a good risk assessment and analysis.

And after that, a mitigation plan to document and move on and select a great decision-making outcome in the end.

And so again, on the website, we have a big one coming up, it's like four hours or so to just teach people how to do this with trauma or not.

But basically, it's as simple as it looks here, you could make it involved.

Often, I'll use this as a prior written notice component of an individual education plan.

In the States, that's what we call it and I'm not sure if you have something, I mean, I know you have something commensurate, but I'm not sure what you call it.

After we do this, we turn to the right side and we make a mitigation plan based on everything we learned, what it weighs out to, we select an outcome and we think, okay, how can we prevent this?

And if can't, to the extent that we can, what are we gonna do about it?

What are the procedures we're gonna put into place to be protective?

And so I will share you just a really simple example of that.

So this is a little risk versus benefit analysis excerpt for our client Marco.

So here's the problem.

His foster family, unfortunately, had hold him they would keep him.

You may have heard this before.

They said, "We wanna be your forever home." And imagine the damage done when you say that and it can't be true.

Okay, so he's struggling at school.

Well, option number one was going to be, the team said, "Let's just keep him there as long as we can."

And then we'll finally find somebody, when we find somebody, it might be in six months, it might be in 12 months, and we'll just shift everything at that point.

We don't wanna stir the applecart, in other words, we don't wanna mess up anything.

Well, that's certainly an option.

And so we talked about this, and we thought, well, there's some potential short-term risks to him though, because if we do that, and then he experiences a major change and we didn't tell him about it, but obviously we knew, we're gonna damage his mental health.

And last time, this kind of thing happened.

He was at great risk of hospitalization.

He's gonna miss more education opportunities now.

He's gonna maybe be moved from all his friends, and there will be increased behavior problems.

And so we're kind of thinking out loud and documenting the risks.

At the same time, what might happen long-term?

Well, one of the members raised her hand and she said, what if he stops trusting us?

And I thought that's a great point, because that means that we have been lying to him this whole time and he's going to know.

And we're using reactive moves by the team due to predictable behavior concerns, those are the worst kinds really.

When you know something might happen and you can predict it, but you're not planning for it, even though it's going to happen.

Are there any short-term benefits to the client?

You always wanna ask that too.

The other side is that, yeah, they thought the reason we're doing this is we're avoiding challenges temporarily, we're lying to them every day.

We're saying, "Yes, yes, it's your permanent home.
This is your brother now.
This is your sister.
This is your mom.
This is your dad." And we're avoiding upsetting things.

So option two, we started looking at it from the other side and we said, "Well, what if we just faced this head on, we give him a meeting and we start behavior support right now."

So we're gonna start providing some education on what to say and what not to say, because clearly that was missed last time.

Why would a foster family start promising that they could take him forever when they wouldn't?

Or maybe they weren't told all about the unsafe behaviors he used.

And so when they started to happen, they all of a sudden realized, you know what?

He's a danger to our family too, we can't continue this, we're gonna give him back and we're not gonna go for adoption the way we told him we would.

Again, all predictable in a lot of these concerns will be.

Everybody needed to be trained in advance on when there's gonna be an increase in unsafe behavior.

What do you do about it?

Don't just wait.

What's a fake response to when he uses a challenging behavior, don't just wait until they experience it.

Foster families and adoptive families need a lot of support.

Okay, so you've seen that's just a brief excerpt from his risk versus benefit analysis.

Now, we ended up using something very similar to that option two, as you'll remember, he was really struggling in school though, that's where we were seeing the challenges.

And so I thought at this point, I would talk a little bit more about the ID team, the interdisciplinary team, and some strengths that they are bringing to these problem-solving scenarios.

Well, what are the best pieces I love about interdisciplinary collaboration?

Is that I often get great information about goals I should target, but that I would be missing because of my own lack of expertise, of course, in what somebody else can bring to the table.

I'll give you examples of those in a minute.

It also helps us to have support from a systems perspective, where everybody's team role is really working together to impact this one issue.

We're listening and valuing all perspectives, again, I'm gonna mention the naysayers of they're bringing a very important group of risks to consider in the risk versus benefit analysis.

If they didn't say them, and we didn't document them, they are often dismissed as things that, oh, well, these don't apply to us or we somehow spend a lot of energy on discounting their viewpoints and maybe arguing back.

No, behavior analysis is never harmful.

No, behavior support is never a bad thing right after trauma.

Well, of course it can be.

And to look straight at that problem and say, "It can be, here are the conditions under which it can be helpful. Here are the conditions under which it might harm the student." We have to do all of these things.

So we make a time to ask for the challenges, we show that we value them, we hear from everybody and we document the pieces of risk that we see and we act on them.

So I shared with you a couple of ways to do that earlier.

I wanted to kind of go over what some of our key therapists bring in terms of the goals that I mentioned earlier.

So often, especially after trauma, the occupational therapist is really helpful to alert me to sensory differences a student goes through after trauma or because of trauma they went through long in the past.

And now this is the difference for them in terms of their whole life, they're gonna be a little bit different in terms of their sensory system, so they can help me design supportive sensory environments.

Think about how helpful that is to do in advance.

When you know about trauma, often we're thinking only about behavior, and we're thinking we'll design that when the behavior shows us that it's a problem, but what if we knew this piece and we did it preventively, it can be so supportive for students, to not have to use the challenging behavior in the first place.

These OTs that I'm speaking about, they often helped me assess sensory needs and challenges.

A great example is somebody's pain threshold, which might be different.

It might be above or below the typical threshold for people in their age group and with their cluster of diagnoses.

Now, in terms of mental health here, and social workers, I'm often able to find they have a safe place to hold the trauma for the students.

And so sitting there in the middle of class or in my behavior session, isn't really the place where they're going to talk about the trauma.

And often when they do, the people in those environments, don't exactly know where to put it, but if we're collaborating well with the social workers and mental health clinicians, they do, and they can help us know how to redirect in the moment, whether it would be nice to discuss it right then if it comes up, or whether we should honor it and say, "Thank you for bringing it up, your session with Ms. Laurie is this afternoon, would you like to talk about it right now or would you like to wait until you meet with her?" And so all of this is advice that we get from the mental health component of the team.

They're also teaching us as team members, how to support a client in crisis without representing the trigger?

Now, this may seem a little different from a behavioral approach, where sometimes we are told you've got to present that trigger until extinction occurs, not so necessarily, maybe not ever helpful.

In fact, if you don't know what the triggers are, then how would you even know if you were presenting it or doing nothing about it when it did happen?

So all of these procedures are going to depend on things like knowing what they are, first of all, and documenting them.

But second, having a strategy, not just doing it willy nilly, not only taking a behavioral or operative approach.

Again, it's not anti behavioral to take a trauma-informed approach, it's more individualized.

Yes, and it is taking history into account is one of the trauma-related functions of behavior.

They can also, so I'm still talking about mental health and social workers.

They can help me differentiate whether it's difficulty in terms of mental health, might be a learning difference or something going on that's maybe an impact of the trauma.

And so it's really important to always honor expertise, as you know, and sometimes people, if they're not, they don't hold a particular piece of expertise, they might think this is all due to his xyz diagnosis, or we need to behave as though this is about his his ADHD, or this is just because of his oppositional defiance.

And here's some strategies we read about in the book for all kids with ODD.

However, a lot of those diagnosis are simply because of the different brains that children present with after going through trauma.

And so we should still be really careful to differentiate and to be individualized.

So I won't say a lot more about that role, but obviously these are all important, and I could do this for so many roles is the thing, we don't have time today to go over the many, many roles.

But there's just so much here that everybody brings that's unique.

The speech and language pathologists or my speech therapist, they often are helping me.

They teach us to design communication and speech and language goals that are related to self-efficacy needs that the student may have after trauma.

And so here, we're honoring their communication attempts.

We need to meet them where they are.

They can help me do that.

They can help me bring in all the technology I need, minimizing the effort it might take.

Have you ever done an assessment with speech and figured out that a child can do a, b, c and d, but first reason when there's triggers presence or when stress is involved, they're not.

And so making sure that we always meet a student where they are, and we honor that this may be because it was really difficult to use that kind of that part of speech or that function of verbal behavior when they were stressed out or because they were punished for doing it at home, or God knows what else.

There's a lot that I might need to do to give leeway to a student and really give them a spectrum of communication responses so that they don't have to use the hardest thing all the time.

And to know when to use that sort of depends on the collaboration between the behavior analyst, the mental health therapist, the speech path, the educator who's seeing how it's triggered by educational related stimuli.

Then all of that.

So the next thing we're gonna go over is about behavioral team members.

You or me, we can help a team understand why now, why this behavior, why is this happening right now?

Well, often we don't look enough.

We don't look farther than, okay, we are going to look at these functions of behavior that we know about, this hard and fast, four to six, depending on who you're reading.

However, I wanna share with you all of these things on the screen are things that a behavior analyst would find compatible with what we do know, for example.

Believe that student and their body, look at all the aspects.

So all the aspects of avoidance.

So for instance, not just operate, not just in the moment, they're getting something out of this interpretation, but also we can help you tell if maybe the reason they're using this behavior in the moment is it's painful, something is painful for them.

The environment is painful, they're using some response.

Or number two, this is something that was modeled for them.

So oh, gosh, I have lots and lots of stories about students who have gone through terrible things that their families modeled in their environment and their home life early on, things that you would never expect a child to have to see or do.

And sometimes these will show up in the worst kinds of ways, and will automatically want to go to punishment and isolation and restraint and all of these things without going, "But why are they using that behavior? Where did that come from?" One of my favorites is on the bottom left.

This thing was helpful for them.

This was a survival skill for them.

If that's true then, oh, my gosh, why would you wanna punish that or extinguish it?

Even if it seems like a very challenging behavior.

So professionals and behavior analysis, like Greg Hanley have gotten us to this point.

I think they've been very helpful.

And Dr. Hanley helps us look at, sometimes we just need to honor a precursor behavior and then build something else later.

But maybe for the moment, it's better to honor this piece of communication, than it would be to try to extinguish it punishment, use some kind of other differential reinforcement of something else, wait on an appropriate response.

Sometimes we shouldn't start there.

Another behavioural pieces, maybe this is a conditioned response for them.

And so the simple example, I have shared these examples for years because they are so inaccurate and they happen with all of my students with a certain history.

You're standing in the hallway, a certain person comes in with a resemblance of a person from their past and they just urinate right then.

Maybe they soil themselves or something.

Well, that's very simple behavior.

It's something my animals did in the laboratory too, when they're stressed out, or they're shocked, or they're reminded of the thing that was present when they were shocked.

So conditioned response.

There's nothing that I could do about it in that moment, except see it happened and know that it was not based on what I was doing.

It also might be that this skill is too difficult for them, or there wasn't enough payoff for them to use this skill I'm trying to teach because it was once punished by the environment, so they're not gonna use this fancy new behavior, they know how to do.

Or we're trying to teach an alternative skill in the classroom, not realizing that when they go home, that that's not reinforced anymore.

Or that their parents don't have the resources to reinforce it, or something is going on at home that might be counteracting what we're trying to do at school.

And so really behavior analysts can help with all of these things, if we're willing to look beyond just the functions in the moment.

If we're willing to look at historical impacts of trauma and behavior.

Now, I mentioned that we would talk about administrative team members and certainly, I'm kind of monitoring if anybody wants to ask a question, please feel free.

But special thoughts for you, if you're in administration or if you have access to those people, support the team.

Backup team members who need to ensure your ethics are being followed.

Protect the time and space for meetings.

Pay staff for having an extra meeting because this client has extra needs.

Follow guidelines that are set to protect the client.

And so, for example, if there's a program and you've asked for attention to not be provided after certain events or ensure attention is provided, maybe regularly, then the administration can help by trying to be a part of that.

So I ran a school for, I think I mentioned an out of district placement for autism at some point, and we had an administrator once who would come in, just in the middle of the day, interrupt the classroom.

You have a lot of attention to this student who he didn't know had just been using some really significant behaviors and we were trying to give him quiet time to calm down.

Or the kind of administrator who promised to be involved, but then was never available to do those one-on-ones that we knew were so important.

And so follow guidelines that we're trying to set, just be the model for the team.

Follow guidance or team leadership.

And so if a certain team member is providing some clinical input, and saying, for example, we've got a list on how to speak to a client in front of him, and we're gonna try to avoid these topics.

Don't be that administrator that brings up all their challenging behavior in the meeting for the first time after you haven't seen them for a month.

So all of these things look a little simple or obvious until you've had this go on, and then you realize maybe we should just be more specific and supportive with our administrative team members, just like we would want all of our team members to know the protocol, not just the ones who are in the clinical roles.

There are some other thoughts that I had more on following clinical guidance, honoring everybody's need to provide input, sometimes we're gonna have to make medical recommendations, even if they're not gonna be followed.

And as an administrator, you can protect that space by ensuring that it's okay for your team members to make the right medical recommendations.

I'm not saying that we are making medical recommendations, by the way, I'm saying we're making referrals to get medical input.

So for example, if I have a client that I desperately need to rule out a certain physical problem before it's ethical for me to treat that behaviorally, if you don't support me in that, and you say, "No, we don't wanna give that referral because then we'll be liable. Oh, gosh." That's not a supportive approach to this person whose role is trying to do this ethical thing to protect the client.

And so those are conversations that shouldn't be happening about a certain client for the first time in the meeting when mom's there and all of this, it should be a system support conversation between the people responsible for honoring all those ethics and the administration way in advance.

And so it's really, you may have to sit down with your administrators and educate them about your ethics and about some boundaries that you'll have to be following.

I don't mean to move on, I thought I would also mention these lasts pieces here are about connecting us.

So us meaning all the other team members to resources.

So if you're an administrator, but you don't have a budget for any more training, and yet the team desperately needs more training to treat this new behavior.

So think about what a situation that is.

What could you do instead?

Well, there's a lot of things we could think outside of the box with, maybe you could connect us to other resources or find a trainer who's willing to do something pro bono for your district once or twice, and then budget it for next year.

Work and grow with the community.

So here's where a lot of educators, we won't have all the resources in house, but if we connected with a good social worker who might be willing to foster a relationship with our school for the next couple of years, maybe eventually we'll have more to offer and we can connect parents to things that we don't have.

There are just a couple more visuals I thought I would share with you.

Some of you have seen this before.

There's one for the FBA and there's one for the behavior plan.

So this is the visual that shares some of my ideas, what I always try to put on a trauma-informed FBA template, a space for all these things.

So the first piece where the FBA would be, I need some behavioral descriptions of adverse conditioning experiences.

In other words, if somebody went through something hard and there's some trauma-related stimuli and triggers, I'm gonna try to put that in the FBA.

I don't want it to be this esoteric common knowledge.

The whole school sort of has, but nobody ever documents because what if he's transferred or what's gonna happened in 5th grade when Ms. Nino is not there anymore?

I also always wants supportive timing built into the plan.

And so this might be a preventive schedule for how somebody is going to approach my student.

I want supportive timing in the template so that everybody kind of has the onus is on them to figure out what supportive timing is gonna look like and how we're gonna preventively build that in before my trauma impacted student is gonna need it.

The next is, if there are functions of behavior that are related to trauma, I want them documented.

I don't just want the momentary functions of this behavior is probably for attention and escape.

I want to know in the FBA that he went through food-related neglect.

And so in the cafeteria, he elopes to other tables and takes food.

I want people to know that this is related to the past.

If there's anything medical or physiological, I need that documented.

And if there are past or present schedules, that are difficult for the person, I want that in there.

If everything happened on Christmas day, I want to know about it, so we don't just send him home to the wolves on December 20th, or if you have a different holiday that's significant for the child.

And triggering environmental events and how they typically respond.

And here, I might simply say, see examples from IPASS, it's stapled to this form.

I'm gonna go over with you and take a look for a moment and read Patsy's question.

So she's looking for advice on how to educate teacher team members that are using this approach.

Resilience focused approach is, oh, educate them that this is not letting kids do whatever they want.

And they're looking for dispensing consequences that are contraindicated.

So in terms of advice, sometimes what I start with is a conversation like I did with you all on why is something counter-indicated?

So I might start with taking maybe the top three things schools might do for all kids, such as around here, they might almost always wanna use consequences for behavior, challenging behavior, and they wanna use token systems where everybody is involved and sees everybody's points on the wall.

And so the first thing I might do for those teachers is educating them on, number one, how important they are to the students?

And as an important person to the student, if the student has been through trauma, the teacher has an important role in terms of being different.

We could be safe.

We could be a caregiver that the student is gonna learn to approach and see as somebody who is approachable.

And the reason that's important by the way, is you're gonna be delivering educational stimuli instructions.

We're gonna be teaching them things about math and reading and science.

And so we need that, don't we?

And so, first of all, getting that conversation going where the teachers now say, "Yes, I value that. I value being a good relationship for this student." And then saying, "Okay, now let's talk about what might happen if we violate a couple of things." If we all of a sudden make ourselves unsafe, by telling the child, through our behavior, that we don't care how they're feeling or doing, we just care about their being good right now.

We just care about what they're doing in the moment.

Don't we wanna be present for them, don't we want them to be able to come to us with a problem?

Or do we want them to be scared of us and hide when they're scared?

And then usually Patsy, the teachers will start to say, "Oh yeah, no, I don't want them to do that." And then after they start to agree with us on values, so I do value this relationship piece, and I do start to understand the why, then all of a sudden, I start to see, okay, well, I'm listening now.

The teacher say, "I'm listening. What am I doing that could hurt?" And that's when we bring up the counter indicated procedures.

And so I appreciate that Patsy, and I think we might get to that at the end again.

Let me see what Carla is sharing too.

Yes, that's that really about cyclical events before, yeah, document those in the future, that's amazing to start to do.

And you know what it shows me?

It tells me what to do for my caregivers and temporary people?

Like the person who's gonna be filling in for so-and-so on maternity leave needs to know that on Easter, it's gonna be really hard because that's when grandpa killed grandma.

They need to know that on Thanksgiving, it's gonna be horrible 'cause all the other kids are having parties and this kid has no family.

But it's not the teacher that needs that because she's on break, it's gonna be the substitute that week who needs kind of a primer.

So appendices, I include in my FDA's, I usually include some description of the social network of the client and their team.

If there are preventative things in place, like I have a letter to police for this student, because he's gonna need preventive visits to the police or to the principal, or medical staff describing important preventive interventions.

I might include that as a little appendix.

I might also include an example of a risk versus benefit analysis for what we've been working on at home, things like that.

And now we have the same thing for the behavior plan.

So features there we've got a safe person.

I recommended that you do that earlier.

Well, this is somebody who's gonna start and practice check-ins at a regular safe place.

We've got descriptions in the plan and we wanna help them foster the relationship.

That person is probably also gonna do some time in, and so instead of time out, we'll be doing this antecedent strategy.

So high-level attention back to Patsy's point.

It's not gonna be contingent with acting out, but it's gonna be regularly scheduled.

So those preventative check-ins are used in the behavior plan.

They're based on the data the behavior support team can gather.

And we're gonna include, we're gonna teach therapists and teachers who aren't privy to this, build safe relationships, and we're gonna include that in their life.

So how do you neutralize an adversive interaction?

How do you debrief after prompting session gone wrong?

We might also include some ideas in the plan about how to give adult attention in a way that doesn't set them off every time?

If medical factors were part of our FPA results, then we're gonna provide recommendations for how to communicate about that with the team, what it's gonna mean in terms of the child's behavior and the student's training that all the team members are gonna need to factor that piece in.

And we're gonna include to your point, Carla, presented procedures for important times of day, month, year, it's better.

And we're gonna practice this in advance, just like you practice a fire drill, just like that.

Finally, we like to add the buffering items to the plan.

If those aren't already present, we might build in some time during the day to work on mindfulness or breathing or responses to stress, practice it, model it with all the kids.

And we're gonna include activity schedules and procedures, so typical things for what you do in autism.

But we're gonna really try to target appropriate repertoire development based on what they're missing, because of what they went through or the times they didn't have.

And I will share little bit more about that real quick.

I can get you this as a visual too.

That there are lots of tools out there that will help you with this repertoire piece.

So I love TAPS, if you haven't heard of it.

Talk aloud problem solving.

This is work by Joanne Robbins, who's the principal of Morningside Academy, which is over in Seattle.

It's a fluency-based school that remediates kids years in a couple months, if they can't read, write, do math.

There's also work by AIM or by Mark Dixon on the AIM Curriculum, which is really nice for social-emotional skills.

There's the IISCA stuff by Greg Hanley.

If you're needing to target executive functioning skills in a behavioral way to really meet all those needs, there's "Flexible and Focused" programming.

And so I've put all this in your handout.

And again, the buffering items are always good to include and I mentioned those earlier.

So after you do that, we'll just quickly review that we saw that case study, we saw a bunch of tools, we looked at a little bit more about the interdisciplinary team, and all the tools should be free, at least in this version, except for that actual assessment.

The three books that I chat about usually are all here.

So if you wanted more information on this last one, this is a book that behavior analyst had been using since 2017 or so.

This version has chapter five, which is all about behavioral risk assessment.

There's also just some reading there that you can see as you download and the slides later.

Just some selected articles on all kinds of things that are related to this, behavioral training, studying emotion, seclusion and restraint, harmful experiences related to that, and certainly, a little bit of info on mindfulness.

So I'm gonna go ahead and go to this goodbye slide so that you all can come back and ask some questions before we wrap in a second here.

And at the same time, if there's any of those references or resources, we can get you those through Shelley.

Serving Children & Youth Who are Deaf, Hard of Hearing/Blind or Visually Impaired