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Trauma-Informed Behaviour Intervention (Part 2) - Text Transcript

- I just wanna say hello and welcome back to our presenter, Saundra Bishop.

I know many of you joined us two weeks ago for part one of this series and Saundra is the founder and CEO and clinical director of Basics, ABA Therapy.

If you joined us a couple of weeks ago, you'll know that she's a certified clinical trauma professional, that she comes at this work as a professional and as a parent as well and she's extremely passionate about trauma-informed behavior management and models that focus on self advocacy rather than compliance.

So, we're thrilled to have Sandra back with us and I'm happy to turn the presentation back over to her.

- Awesome, all right.

I am super excited to be here and so I'll hop into things.

So, we already got my bio and so super quick, I'm gonna go through very quickly, the business stuff from last time for people who weren't here and so this is for not just BCBAs, but for anybody, any type of clinician, teacher, things like that.

And so, again, it's anybody who's working with kids who have comorbid diagnosis of PTSD and foster care preservation programs.

And also it's gonna apply to all of our kids who've exposure to COVID, because that's gonna be a trauma event.

Today, we're gonna go through replacement behaviors.

So, that's gonna be the target of today's presentation.

So, we're gonna talk about replacement behaviors, that target function, right?

So that's what we all know how to do, but we're gonna talk about it again.

Then we're gonna talk about replacement behaviors that are gonna target setting events, which is what we talked about last time.

I'm gonna review it again and then we're gonna talk about out target replacement behaviors that target the trauma event, setting events that TESE, which was what the whole presentation was last time.

We'll do a mini reminder, but you should go back and watch the training last time to get the really in depth thing.

And then we'll go over that alternative behavior, right?

Which is where we want them to like eat the broccoli, instead of tantrum it over cookies, we're gonna spend like, just like a hot second on that though, 'cause that is the least important thing that we're gonna teach A quick things of business, right?

We're working on the assumption trauma's real.

I'm gonna use casual language.

I think we talked about it last time.

For those of you that are teachers, psychologists, you're gonna be used to language that's saying things about like anxious, safe, re- traumatized, things like that.

For those of you who are involved in like behavior analysis, things like that, you're not gonna be used to that kind of language.

I'm gonna say things like "Is this intervention kind?

"Are you being mean?" And I'm doing that on purpose, because I really want you to think about the human aspects of the interventions that we're doing.

And you'll see why that's important as we go through.

I'm also gonna be using identity first language.

It's generally preferred in the autistic community, to identify people by their autism, verus saying, person with autism.

However, the community isn't a monolith.

So sometimes I'll revert back and forth between them.

If you are talking to an autistic person, you should always ask them what they prefer.

And then as we go through this and we talk about trauma, you must work within your competency and please always work with, a psychology-based professional, before implementing any procedures.

And so, you know, those of you were here before, kind of know why I got into this.

And I think it's just really important to understand that as a clinician.

The reasons why we can go from changing our way that we practice.

When I first started in the field, I was very much a drill and kill, behavior therapist.

You sit at the table, you touch your nose, you don't touch your nose.

You're gonna touch your nose, until you know, I'm gonna wait for you, no matter how much you cry to touch your nose.

Because if you don't, I'm gonna teach you that you need, you're gonna, and to not follow directions and I'm the boss and it's the only way you're gonna learn.

But then I became a foster parent and learned trauma-informed models and all of a sudden I learned that, you can't do things like that, because it's re-traumatizing the kid, right?

And in those situations, right, if the kid won't touch their nose and then they throw a shoe at you, then you really don't let them getting out of touching their nose, right?

But in a trauma informed model, right and of course it's more complex than this, right?

But, from the foundational basic piece, if the kid throws their shoe at you, you're supposed to hug them right?

And love on them.

And in the ABA model, right?

That model, that's not very nice.

It works, most of the time.

Right?

And then the trauma informed model, it works most of the time with the kids with trauma, but a lot there are also times when neither of them works, or there comes a point where there has to be some way that you need to bridge them, because we can't have parents who are parenting kids with trauma.

We can't have teachers who have kids with trauma, just dealing with shoes, getting thrown at them.

'Cause it's not sustainable.

Right?

A therapist can deal with it for two hours in a session, but a family, or a classroom can't.

And so there has to be a way to bridge that.

And so that's what this model is.

And so it's really cool.

And so right now, last time we talked about preventing the behaviors and now we're gonna talk about what we can do to teach kids new behaviors and just sort of a note too, around cultural awareness.

We talk a lot in this presentation, the way it's built is around cultural awareness.

You may have heard it as cultural competency, cultural humility and a lot of it is around like thinking about, we talk a lot about white versus black, and I know that that's, an issue across, both of our countries.

But when I came in here last time, I actually did not have any information about the indigenous issues within Canada.

And, I feel like I left out that that was a key cultural issue that I was missing when I was talking about issues there.

So, I would like to apologize for, not being culturally aware in that area.

And so I've done some research on that and so I hope to be a little bit more culturally aware, as we discuss those issues.

I know there were several responses in the chats dealing with that, and I did not know what y'all were referring to.

And so, I hope to be able to bring a little bit more awareness to that.

So, that's just a little side note there.

And so just a reminder, we're gonna be talking about trauma.

So if you need to take a break, please do so.

I love participation.

If you're not engaging in materials, just sign off now, because you're not gonna learn anything.

This is super interactive.

You can ask questions in the comments, what we found last time and with groups this big, if you're asking comments now, because people are like, "This is great.", "I love this.", "You're so awesome".

'Cause I'm so awesome and people like to tell me that and I love to hear it, because my love language is praise, and I love positive reinforcement.

I lose questions sometimes in the chat.

So, if I don't answer your question, either, ask it again.

'Cause whatever, I don't care if I hear repeat questions, or be sure you ask it to me at the end, but questions are getting lost, because of the rapid fire comments in there.

And then we're gonna work through an example at the end.

Send me emails, send also the emails the last two weeks.

And I haven't gotten back to you.

I saw them.

I care about you.

I'm gonna respond, but feel free to email me.

I wanna make connections clinically, professionally.

So feel free to email me.

Okay, good.

Any questions?

Okay, groovy.

Okay, so super duper, duper quick recap of what we talked about.

If you weren't here last time, this is not gonna be enough for you to learn it super fast.

But, for those of you who were here, just a quick reminder.

So, what we talked about was, the main thing was about looking at setting events, right?

And so a setting event makes a behavior, more or less likely to make an antecedent cause of behavior, right?

And so when we're looking at antecedents the antecedent.

Maybe we've got a little chart here.

It's not over here.

I'm just gonna say it out loud.

The antecedent happens before the behavior, then you have a consequence right?

And that's our chain.

So the setting event makes it more likely that the antecedent is gonna cause the behavior.

Right?

So we've talked about this.

So, we know that if I skip lunch, if I see McDonald's, I am more likely to order the Big Mac.

Right?

So my setting event is that I skip lunch.

My antecedent is I see McDonald's.

My behavior is that I order my Big Mac, right?

So we all know that, setting events are super, super important, right?

And so my trauma, setting of my trauma event here, setting event here, might be that I had early food deprivation.

Right?

I wasn't fed enough as a kid and so that setting event, that trauma event, setting event, is gonna make it even more powerful, if I'm denied access to that food.

Right?

So, when we're doing our interventions, right?

We talked about, the first thing we're gonna do, is make sure I don't see a McDonald's sign.

Right?

Cause if I never see a McDonald's sign, I'm never gonna order McDonald's.

Well, if I actually see the McDonald's sign, the next thing we're gonna do, is make sure I don't skip my meal.

Right?

So if I don't skip my meal, I'm gonna be less likely to order McDonald's when I see the McDonald's sign.

Right?

The other thing, is we wanna address the food deprivation, right?

And last time we talked about, well, I have anxiety around not having enough food, so we can put out anytime food.

I can have fruit and I can have vegetables and things like that all the time.

I can have a meal chart out.

So I know when I'm getting food.

Right, so those are the interventions that we have in place.

Right, we'll see visuals about those friends that we saw earlier as we go, right?

So, that's our background there and so examples of trauma, setting events that we can see, is witnessing domestic violence, being hit by a parent, being in a car crash.

School's being shut down by COVID.

Being told you're gonna die for two months if you go outside, right?

These are all examples of trauma events.

Now again, please be sure that you're consulting with a mental health provider, before you're targeting these things, if you are not a therapist.

Okay.

Is that a quick review?

You guys good?

You remember all this?

Okay.

So, when we create behavior plans, just in real life, right?

These are the things that usually go into behavior plans, right?

So we determine what the function is.

Why is the kid doing what they're doing?

Right?

So, why am I getting my Big Mac?

Right?

Every time I order my Big Mac, I get one, right?

So, if we look at it over time, well, my function is access to my Big Mac.

I say, "Gimme a Big Mac".

They gimme a Big Mac every single time.

So we determine the function of getting my big, ordering my Big Mac, is I get a Big Mac, right?

And so then in a behavior plan, we teach replacement behaviors.

Right?

We teach kids how to get what they want.

Right?

And so typically, right, this is for, behaviors and effective behaviors, right?

Tantruming, things like that.

Things that we don't wanna see.

Then we're teaching alternative behaviors, right?

So, this is the stuff that, we actually want, right?

So, if we say, we give the kid their homework and they don't wanna do it and they fall out on the ground and then the replacement behavior would be to say, "No, thank you" and the alternative behavior would be to do their homework.

Right?

Then we teach the antecedent and then we do the antecedent interventions through replaced behavior, right?

Which she just talked about.

Then we create reinforcements, right?

We give them their tokens, or their screen times for, using their alternative behaviors and for the replacement behaviors, a good behavior plan as a we're gonna like do it.

Right?

So if they say, "No, thank you" to homework, we don't make them do their homework.

If they say, "Can I have a cookie, please?" We give them their cookie.

And then some people are gonna use extinction, which is where the person cries and says, "I don't wanna do my homework".

And then they're gonna represent the homework, over and over again, until they do it and that's harmful.

It's not kind, it's unnecessary.

When we talk about all the things we can do instead.

And so one example, of why we shouldn't be using these extinction procedures, is that there are so many other amazing things that we can do.

And so a simple example of this would be, there's a classic example, I don't know if you all have heard about this, of the soda machine, right?

This is a classic example they use of extinction, right?

Another way you can do extinction is if a kid's trying to get your attention, you just ignore them, until they do whatever it's you want and they always say "Ignore the behavior, not the child" but it's still ignoring the child.

You can't do both.

But, they, if somebody wants to get a soda out of the soda machine, right?

You push the button and if you want them to stop pushing the button, that's the behavior.

So you make it so soda doesn't push, doesn't make soda come out when you push the button.

So, in extinction so for those of you who know, if you push the button and no soda comes out, what is the next thing that happens?

What does the person do?

Somebody tell me in the chat.

What's the next thing that happens?

Push a button.

It doesn't work.

You push again.

Right?

Push, push, push, push, push.

And so that's what happens in extinction, right?

I don't give you the cookie.

Then you say "Cookie cookie, cookie, cookie".

Right?

Boop boop boop boop.

And so then, that doesn't work.

Then what happens?

You're pushing, you're pushing, you're pushing it.

You kick it.

Right?

You push it, you shake it.

Right?

Your behavior escalates, right?

Everybody says, "Don't worry, mom.

"The behavior's gonna get worse before it gets better".

Right?

But then if the soda comes out then, then the next thing you're gonna do is, you just taught the kid, right?

To shake the soda machine when it comes out and that's bad, right?

If somebody starts escalating, you don't wanna give in at that point, because that's just, that's harmful for the kid.

But OMG, like at what point they escalate, right?

Some kids are gonna start like jumping off furniture and sometimes you have to give in 'cause it's dangerous.

And then, oh my gosh, what have you just done?

So let's say, so we got our friend he's shaking the soda machine, right?

So, eventually he gives up, right?

But he's so mad.

Right?

Paid for his soda.

He pushed this button and no sodas and he's so angry, right?

And so then with extinction, eventually they come back and try, they'll come back a couple of times, they'll do this a couple of times and the whole thing repeats.

And then at some point, they might try again and if the soda comes out, it's like, the process never happened.

Sorta sucks.

That's so fun for anybody who wants to do that?

Instead though, if I came up to this person and I was like, "Yo, listen, I don't want you to push that button.", "I don't want you, I would prefer you weren't drinking soda, instead I'd like you to drink some water.".

"So this is what I'm gonna do."

"I'm gonna give you a mini fridge and I'm gonna put it next to your desk."

"I'm gonna put soda in it."

"I'm gonna put water in it."

"And all I want you to do instead of button pushing."

"I'm gonna open the mini fridge."

"That's your new behaviors, opening the mini fridge, but it's gonna be right next to your desk."

"And so when you take it out, you can take a soda."

"You can take a water, just want you to open the mini fridge."

Right?

How likely is it, that the person is even going to go over, to the vending machine and push the button?

Not likely, right?

Because I've given them a replacement behavior that is easier and more are effective and getting them what they want.

And it's giving them access to the new thing, just in case they're gonna try it out without fighting them and then there's no like meanness and nonsense.

Now, if they decide that they're gonna like go and push the button over there.

Well, I can't like give them the soda because they're kicking the soda machine, but they have a perfectly fine alternative that I can continue to remind them of.

So, I'm not doing an extinction burst.

I'm saying, "Dude, go, just get your soda over there."

"What are you doing?"

"That's nonsense what you're doing over there."

And that's what we can do with our interventions.

So, let's see what that looks like.

So, what we just talked about though, is what the interventions usually look like.

with those interventions though is, they're missing key components of replacement behaviors and two of those key components of the replacement behaviors are teaching our clients to access those setting event interventions.

Our clients can't access the antecedent interventions, 'cause that's just like preventing them being exposed to things.

So like if the antecedent intervention is the like seeing cookies, like you can't like teach them to like not see cookies, but we can teach them to access, to avoid, what we have put in place, for the setting events.

So, we still wanna teach the replacement behavior, right?

So we still wanna teach them to get their needs met, right?

So that's super important.

We also wanna teach a setting event, addressing a replacement behavior, addressing the setting event.

So we wanna teach them how to access the setting event.

So, if the intervention, so if the setting event is that they didn't take, they're more likely to engage in the behavior if they didn't their medication, then we should teach them , how to make sure they take their medication.

Right?

Because we know that part of what we're gonna do, is help make sure that they're gonna take their medication.

Right?

But we also should teach how to do that, because we know that that's gonna help prevent their behaviors.

We also need to teach them how to access the tools we're giving them to address their TESE.

To address their trauma event setting events.

Right?

So, if we have given them the tools of having a rules card, that says, "You're safe in this house.

"Our family doesn't hit each other".

We've given them access to anytime food.

We also need to be teaching them to go look at that stuff, right?

We also need to be presenting it.

That needs to be part of the plan.

But there also needs to be a goal that, when I feel a anxious, I walk over and access this stuff.

'Cause that's how they're gonna access independence and that's how they're gonna be addressing these things.

And then we need to teach the alternative behavior, right?

And so then that's when we teach them to the water and that's gonna look different for each client.

But what happens is, is we create these programs.

I cannot tell you how many times I walk into a school and there's a behavior plan.

And it says, "There's one replacement behavior "and it's an alternative behavior".

And so it says, "Johnny throws his desk".

The function is access to attention.

What is the replacement behavior?

He will sit in his desk for five minutes and that is not a replacement behavior.

The replacement behavior is, he'll ask for attention in whatever way he decides.

Does that make sense?

Are we on the same page right now?

Any questions about where I'm at so far?

So, somebody from the last workshop had asked for a list of, setting event interventions.

And, I thought that that was awesome and like a bank and so I'm working on that.

I have a couple that are right here and so this is like, I think there's, yeah, there's a couple here, but I am working on that just so you guys know, 'cause whoever came up with the idea was really great and so I'm gonna put that together.

But here are a couple of ideas for things that you can use to kind of address this anxiety, right?

That kids may have dealing with their trauma histories.

Now, this one is useful because you can use these, even if you don't know what the trauma history is, right?

These are just general anxiety things and really they can use them with any, I get panic attacks.

I use the grounding response myself.

In fact, like kind of a funny story, is I got really overwhelmed a couple weeks ago and I had so much stuff to do and I had this panic attack, but I like couldn't stop working.

And so I was like crying and I was hyperventilating and my partner came in and he was like, "What are five things you see?

And I was like, "I see my door".

But I like was still typing in like the information into this like grant document that I had to fill out that was due in like an hour, because I couldn't like stop doing it.

And I'm like, "I see a door" and so, I still, it helped me like calm down and like resettle, but I like still didn't even like have the time to have like a nervous breakdown, but it's a strategy that like really works and you can use it on kids in different ways, depending on how, what their level of language is too.

So, kids who can talk a lot, you can say, "Tell me five things you see.

"Tell me four things you feel".

For some kids, you have to do one at a time.

Tell me one thing you see.

For some kids, it's gonna be point.

For other kids, we have one kid who it's just like, what am I touching?

Right?

Because they can't articulate.

Another thing is, what is like touch my fingers, right?

Robert, so grounding, isn't a distraction, so much as it's mindfulness.

So it's like bringing yourself back into your body.

So it's about like, and so in some ways, right, it distracts you from like whatever you're like working yourself up about.

But it's really about like, where is my body in space?

What can I see?

Where is the universe right now?

Kind of.

So you can kind of look at it in whatever way makes the most sense to you, but that's more what it's supposed to be.

Like, what can I feel?

What can I see?

Where am I in now?

Yeah, Megan says, "I like to think about anxiety being about things "that are past or future "and bring grounding brings you into the present".

Yep and but yeah, so I have another kid who's just like, "How many fingers do I have?" "Touch my finger".

And so there's a lot of different ways to do it, but it's just about like, what is happening?

So, Corey, my impression is that that is more adult led, but I'm not as familiar.

This isn't not more like compression based, or no?

You can answer.

Oh, body feelings.

It's about being aware of how your body's feeling.

Yeah, I think so Corey.

Yeah, so people are talking about just different ways of how to recognize this and yeah, so basically it's within the concept of mindfulness, which is, hippy dippy, whatever, but also there's some science around it and around how the concept of doing these things is able to be calming in the moment.

And so whether or not the why, is not really the matter within the concept of what we're doing, behavior analytically, it's that the kids do a thing and the behavioral response is that they calm down.

Right?

And so for those of you that are in different fields, in OT and therapy and teaching and things like that, then the whys, I think are much more important to you.

But as far as like behavior analytic, or when I'm trying to convince BCBAs to do these things, we don't get into those details.

So yeah, so anyway I love that strategy.

It's really my favorite strategy.

Other things are self talk.

Having kids say that like "I'm safe.

"I'm doing the deep pressure with the self hugs".

We do like to avoid, adult mediated pressure, right?

Especially when a kid's upset, because it can very quickly turn into a physical management situation, or it's difficult to gain consent when a kid is upset.

And so it's really important that we're not doing that, that these things are self mediated, deep breaths, counting to 10.

I have never ever been able to get a kid to do deep breaths.

I do these workshops and people are like, "oh, I can do it all the time".

I have done this for 20 years and never in my entire life have I actually gotten a kid to successfully take deep breaths when they're upset.

So, some of y'all are magic.

I'm really good at my job and that is like my unicorn.

So, y'all live your best life, getting kids to take deep breaths.

I can't do it.

And then also body relaxation.

I also really like this one.

And so, this is where you like tense your body and really set your toes up and down.

This one's really good for nightmares, for kids who are like nervous about going to sleep, because they tend to like tense up for bedtime and then have trouble relaxing and so that's a use one.

Do you ever give access to most loved items during calming and grounding?

I've given a client, a photo album of their family and she talked about the family and it helped calm and grounding.

Yeah, so Nicole this is something we'll talk out in the next workshop around consequence interventions.

So the thing about the consequence interventions is that, we are no longer treating function once a kid is in high crisis.

It's all about de-escalation and then we can go back to function afterwards.

And so whatever it is, that's gonna to calm a kid in crisis, we're gonna do to support them and then we can follow, do our follow through.

And so, ideally right in a perfect world, we're not gonna give kid their favorite thing.

Right?

Because we don't wanna reinforce them punching you in the face.

So there's gonna be a little bit of like, we have to decide whether, or not they're like actually an emotional crisis or not.

But yeah, so, we'll talk about that a little more and so just a quick reminder that this is a prevention strategy.

So this would be yo, we're gonna go see your mom.

I know you love your mom super, super lots, but, sometimes you can feel worried when you go.

So what strategies can we use, to help you feel less worried?

Right?

'Cause this is a setting event intervention, right?

This is to address the anxiety in advance.

Now, they can also do this later on, right?

When they're in crisis and as consequence of things like that.

But for now, we're really trying to focus on it, as in advance.

I'm starting to feel worried, because of things are gonna happen, right?

This is before I'm tantruming for cookies.

I know I might see a cookie at the grocery store.

I'm gonna do this as a setting event.

That make sense?

Never withhold these from a child.

We don't wanna withhold basic needs, food, water, bathroom, sleep and we always wanna make sure that they have access to their schedules, their rule cards, their charts, their contracts, their photos, so, that they can have as their replacement behaviors, their access to these tools.

Right?

So, if they are starting to, get upset and they're gonna use their replacement behavior, because they've started to get agitated, we need to not say, "Well, your body's not safe.

"You can't look at your schedule" because if that is their setting event, antecedent of their trauma event.

Their TESE, they need to have access to it.

We also don't wanna withhold reassurance, right?

They may be being irritating, right?

This is obviously the non-professional term, but that's how it can feel to us.

But we still need to be sure that we're giving them access to, those terms that we have decided are gonna be part of their setting event, interventions.

If we have said that, one of the things we're gonna do as a TESE, is remind them they're safe.

We have to be able to give them access to this.

One of the things that's on here is, reassuring touch.

Now, this one's a little bit dicey here, because if, what we don't wanna say is, "You're being mean I'm not gonna hug you", right?

However, touch is about consent.

So if your kid is just touching you so much that you can't stand it, you can tell them you to don't consent to be in touched anymore.

Modeling consent around touch is perfectly appropriate and you should be doing it and then you also shouldn't prevent a child from going to get help.

So no, go tell.

So, if a child feels like they have been being touched inappropriately, you should let them, you know, no, go tell.

So yeah.

This is an example of what grounding looks like.

I wanna make sure that the sound is great.

- [Woman] All right, baby.

What's one thing you feel?

(indistinct) Okay, what's one thing you see?

- A bear.

- [Woman] Okay.

What's one thing you hear?

- My sister whining.

- [Woman] What's one thing you smell?

(indistinct) - [Woman] What's one thing you taste?

(indistinct) - So, that's an example of that.

- [Woman] All right, all right baby.

What's one thing you- - Okay.

Any questions, so far?

Okay, are we on board?

Does this all make sense?

Okay.

Yeah, Dana, the not denying a safe adult is really important, though it gets complicated 'cause you know, you'll get that kid that's like, "Well I'm mad at you.

"So I'm gonna like, "go tell on you every time you tell me something no".

But the reality is is that particularly with kids with trauma, people who like are supposed to take care of them, have hurt them and so there is a component of letting them act that out of being able to even tattle on the safe adult and then it's just, you just hear them and then redirect them back and just make sure they can't triangulate.

Because again, they're not gonna get out of it.

They're just gonna be sent back, to the other person, as long as you actually like consider that the adult they're like telling on, could have done something.

So, and typically they just stop, because if they're doing it just for nonsense, they'll see the nonsense doesn't work.

But a lot of people panic at that one.

Okay.

So, Marcos.

So Marcos was our friend that we followed along in the last workshop and so Marcos you will remember was four years old and has two vocal words.

He can say peepee and cookie.

He's potty trained, ambulatory and has age appropriate motor skills and he's diagnosed with autism.

Whenever Marco sees a cookie, he jumps up and down and screams and his mother gives him a cookie.

The data showed that this is more likely to occur if he didn't eat breakfast.

We have learned that Marco's experienced early food deprivation.

And so if we look at the chart for what we filled out in the last training, we can see that we came up with some amazing interventions, right?

We know that our ABCs right?

Were that if, or what we saw here is that antecedent is if he sees a cookie.

So, our antecedent intervention's gonna be he hides a cookie, if we forgot to do that.

We also know he didn't eat breakfast, then we're gonna make sure we feed a breakfast, super easy.

We also know that he experienced food deprivation.

So our TESE antecedent intervention, is that we're gonna make sure he has a food schedule and that he has free access to vegetables.

So, we have this really great intervention that hopefully is going to prevent all of his behaviors from happening.

But sometimes it doesn't work, right?

Sometimes he's gonna see the cookies.

Sometimes his anxiety's gonna be bad.

Sometimes, somethings gonna happen that we don't know.

So, now we have to have our replacement behaviors.

So, he's still gonna jump up and down and scream.

So now we need to figure out what we're gonna teach him.

So, the obvious answer, right?

Is we're gonna teach him to ask for a cookie, because we know that what he wants is a cookie.

So, the replacement behavior addressing the setting event, right?

So let's look back over and what is his setting event?

It is that he didn't eat breakfast.

So, we're gonna feed him breakfast, but let's say we forgot.

Well, we wanna teach him to ask for breakfast.

Now, if we're gonna teach him a setting event, a TESE, replace of behavior, addressing the antecedent intervention, right?

How can he access these independently?

What we know is a food schedule.

So, we want him to look at the food schedule.

We know he has access to food, so we wanna teach him to eat that food.

Right?

And then, we can also teach him to take deep breaths when he's anxious.

Right?

So, you can always add a couple extra if you want to and then our alternative behavior, right?

This other thing that we need to have happen, is he needs to wait when he sees a cookie, right?

He can't jump up and down every time he sees a cookie, he can't always get a cookie when he sees a cookie.

But that is our least important skill right now.

Because if we target all this other stuff, right?

He might not even, he might naturally develop that skill, but we should have it in the goals, because it is important.

Right?

But it can wait a half second.

All right, does that make sense?

Any questions on that?

Where'd you all go?

Okay, so the explanations are here, so when you guys get the slides, it'll lay it all out for you.

Okay, Hawa.

So this is one y'all are gonna help me with here.

So Hawa, we also hung out with last time.

So Hawa is 10 years old and speaks in full sentences.

She has delays and emotional regulation and sensory integration and has a diagnosis of fetal alcohol syndrome.

When she's asked to clean her room, she runs from the room.

The majority of the time, the babysitter says "Fine, I'll do it, nevermind".

We observed that when she slept only three hours, this increased the likelihood of the behavior.

We've just learned that Hawa is in foster care and experienced parentification.

This means that before she came to foster care, she was responsible for caring for two younger siblings, feeding them, taking care of the house and getting them to school.

So when we saw her last time, our interventions were also awesome.

We realized that the antecedent was when she was asked to clean her room.

And we said that well we can just ask her not to clean her room.

But also we realized that in interventions we could put in place was just to give her a checklist.

We could prime her in advance, or we could just ask her to do less.

Right?

So those are all antecedent interventions, we could put in place to make the task easier for her and hopefully, cause it to be less stressful.

We also noticed that this setting event was that she was tired, right?

So our antecedent, our antecedent intervention and targeting the setting event, right?

Is that we made sure she went to bed on time and so a strategy for that, was we would turn off the iPad, 30 minutes before bed, right?

To sleep with iPads, to help with sleep hygiene.

Right?

That was just an idea that somebody had.

And we know that her trauma event, setting event, her TESE, was parentification, to take care of her brothers and sisters.

So, her TESE antecedent intervention, is that we could make family rules that identify grown up jobs and kid jobs, so that she knows what she's responsible for and then what the adults are responsible for, to help reduce that anxiety.

So we know that we have that plan in place.

Right?

And that's what the adults are responsible for.

But we wanna give her some replacement behaviors as well.

So, we know she runs from the room, because she doesn't wanna clean it.

So what would the replacement behavior be, that we would give her?

Yep.

She would say, "I don't wanna clean my room", Christine for the win.

You get a gold star, or ask if I can do it later?

Yep.

She could ask for help, right?

Whatever it is that she, would prefer the answer to be.

Probably it would be like, I don't wanna do it.

So, then what would a replacement behavior be, addressing the setting event?

And so we know that, she's only sleeping three hours.

We know that we are going to make sure she goes to bed on time.

So, what are we gonna teach her to access that setting event?

Intervention.

Look at her clock, read the clock, learn a bedtime routine.

Different ways to fall asleep.

Alarm on the iPad to turn it off.

Right?

So, you have a goal directly related to sleep because we know that that's an issue.

Right?

And whatever the mom probably says like, "She has trouble sleeping".

But, we now know that it's specifically related to this intervention so we can be mindful about it.

And so our trauma, our TESE, antecedent intervention What's our rules card?

What are we gonna teach her, to help her access that?

Yeah, we're gonna teach her go look at the rules.

Teach her, show her where it's located.

Right?

And so that's gonna be some goal that's gonna be like, with prompts, look at it when calm.

While pointing at it, say, "Where's your list?" When escalated, walks over to her rules cards, you know, whatever it is like it's gonna be teaching her to go look at it.

Right?

And then what is the alternative behavior?

Yeah, cleans her room.

Emily, yeah.

Cleans up one toy, right?

That could be like the small goal that you're gonna like build up too, but like ultimately right, it's be clean her room.

But yeah, if you were writing your program, it would be like cleans for five minutes, or cleans up one toy, I don't know, or cleans with assistance.

Yeah Christine, you would definitely need to reinforce her and so then that would be part of your consequence, intervention procedure.

All right.

Y'all are so smart also.

Also, it's so like cool, isn't it?

And it's just like, oh, now I can target these things.

And obviously kids are more complicated, right?

It's not gonna be like, I have this one thing and now they're all better.

Right?

But also, in some ways, like there are stuff that you can just observe and create a plan.

It is kind to set people up for success.

Okay, so again, here's the explanations of it, for when you guys look at the PowerPoints.

Okay, Brendan, our last friend that we looked at, so Brendan's six and developmentally on track.

He's diagnosed with generalized anxiety disorder.

When he's asked to wear a mask, he shouts, cries and throws up, his father lets him stay home.

It appears the issue is wearing that mask, not the location they're traveling to.

We've observed that this occurs more frequently when it is hot outside.

Brandon has experienced a worldwide pandemic and he lost access to his school, his friends and his nanny in one day, plus his grandmother died of COVID.

So, Brendan.

Emily, you asked about handover, hand autonomy.

So, I, don't know if I specifically talk about it.

Can you ping it at the end?

'Cause I have lots of opinions on it, but it's not directly related to what I'm talking about right now.

Okay, so for Brendan, his antecedent is he's told to wear a mask.

The antecedent intervention is not, don't like let him not wear a mask.

It is with some of the other kids, that just like don't let them do things.

And the reason for that is because mask wearing is a health and safety issue and so they can't let him out of the task.

And so, some of the really creative things people came up with right, is trying different of masks, figuring out what the issue with the mask is, right?

Is it the type of mask?

Is it the detergent?

Like what's the issue with the mask?

The other thing is about priming, right?

Giving lots of warnings about what's happening in the mask.

Things like that.

We also realized that when it's hot outside, he's more likely to have issues.

So, somebody suggested having a cold water bottle, right beforehand that he can like put on his face, bring a handheld fan, wearing cool clothing.

And we know that his trauma event, setting event, his TESE is his COVID 19.

He has no control over his life.

Masks are scary.

He's afraid of getting sick and his trauma event, setting event, antecedent intervention, people came up with were, that we could do social stories, about going out in public and how you can stay safe with your mask on and what the day's gonna look like.

Giving him controls in other ways of his life and then just learning about COVID what he needs to be scared of and what he doesn't.

So, based off of that information, instead of shouting and crying and throwing up, which you know, this example I feel like is really powerful, because you know, when I do the other ones, I don't know if I talked about this last time, but when I do the other ones, people are always like, very like, oh well, he's tantruming for the cookie and like very clinical and easy about it.

But when I come to this one, they're like, "But he's throwing up.

"Oh, it's sad.

"Oh it's COVID".

And the tantruming for the cookie is just as upsetting to the child, as the COVID is, but we can relate to the COVID better.

And, just because he's throwing up, isn't really worse than the kid hyperventilating on the floor.

And, so the, like that juxtaposition there, isn't as much of a juxtaposition, as a lot of people think when they hear these examples.

But, when we look at this, right?

People are like, "But he can't help, but throwing up".

But sometimes they can, right?

Some kids make themselves throw up.

But when we talk about replacement behaviors, we still wanna look at these as replacement behaviors, 'cause what what can happen instead, right?

And it doesn't mean like what can they do instead, of making themselves purposely throw up?

It's what can they do instead of getting all worked up?

Right?

How can we support them, so they don't feel so out of control?

So, what could we do as a replacement behavior, for Brendan, so he doesn't have to wear this mask, that's making him feel so horrible and awful for whatever reason?

Oh, does nobody know?

Okay, he could say he doesn't wanna go outside.

Then he doesn't have to wear the mask.

That's a little bit more, that's a little bit extra.

There's an extra step there that you've got in there.

So, what he wants is to not wear his mask.

So, he can just say he doesn't wear the mask.

Now, what that means is he can't go anywhere, right?

So that's the follow up, unfortunately.

He can't go anywhere.

But the replacement behavior is for him to say, "No I'm not wearing the mask".

So Laura gradual exposure to teach him, is your teaching plan.

Right?

So that's not a replacement behavior.

That's how you're gonna teach.

And so that's just like a separate thing.

Yeah, no, don't apologize.

That's why we go through this.

'Cause it's super, that's what these concepts are here, because that's also something that somebody puts in a behavior plan.

You know and Robert, Robert said social distance and actually, now that this was actually, this example was written early in the pandemic, right?

When you had to wear your mask, no matter what, because nobody knew anything.

And it was like mask and social distance outside and you're gonna get COVID no matter what, if anybody looks at you and so to your point at, he could, you know, have a replacement behavior, of, asking to stay outside and social distance.

Like that could be an option.

So Stephanie says a face shield.

So that would be an antecedent intervention.

Right?

So right now we're talking about his replacement behavior.

So that's to get his need met, which is to not wear his mask.

Right?

So Stephanie, you could say masks or the face shield, but that's not part of what we said, was an option.

Right?

So really the answer is to say, "No, I'm gonna wear my mask".

Right?

We also, because we've said there are options, for other masks is that we could have him ask for his other masks.

Right?

We can't make somebody put something on their face, right?

So he could either tantrum and yell and scream while we like, what are we gonna do?

Like force something on his face until he throws up and then have him wear a throw up mask?

No.

"Cause he's not going out anyway, if he's screaming on the ground, throwing up, or we can have him say, nope, peace out and then stay home anyway.

So we just wanna teach him to say "No, thank you".

and then we can shape up that behavior later, once we've avoided re-traumatizing him, with these big giant behaviors.

'Cause we're not being successful anyway, Does that sense?

So, in the meantime though, we can try to address the setting events and we can see, well maybe if we address these setting events, so Laura you asked if you're teaching my way?

So sort of, but not really.

So, she's asking about Henley's My Way curriculum.

We don't do that.

We never go into the, My Way.

We stay in the collaborative way throughout the teaching.

And we find that the kids adapt back and that once they are able to have their needs met, that they end up following the directions.

And so that's been our experience with it.

I like his model.

I don't have a problem with it.

It's just not what we do.

So, yeah.

But, if we hit these setting events, we might be able to catch it, so we don't have to have the mask refusal.

So if we know it's hot, then we know we're gonna like give him a pen and all of this stuff.

So what replacement behaviors can we teach him, to address the setting event intervention?

Yep.

Teach him to get his water bottle right before and drink it to cool down beforehand.

Teach him to bring his fan.

Yep.

Teach him what clothes are appropriate for the weather.

Yep.

Right?

So it's about making sure that he is able to dress appropriately and do these things.

Yep.

All of those things.

And then the last one, well, not the last one, is the next one is for the trauma event setting event or TESE intervention.

How are we gonna teach them to access those things?

What are we gonna teach him, in order to access those things?

Melissa, how would he seek them out?

Teach him his social stories, present opportunities to look at them.

Have the story in COVID information, essential place, Teach him to talk to a safe adult and present opportunities to practice.

Teach him what he can control and allow him to.

Yep and so Melissa, I think in that way too, would be to teach him to advocate for control.

So, Laura give him lots of practices.

Lots of choices is what you would do.

So that's how you would implement the TESE antecedent intervention and then, he would, be able to advocate to do that.

So Elizabeth, we didn't, we weren't able to do, like in this example, we did not do a, so, Elizabeth just messaged me.

I don't think she meant to do that.

It said, do we know exactly why he won't wear a mask?

And Elizabeth, in the initial examples, we don't, our guess is that, we tried a bunch of different materials is our antecedent intervention.

But no, in these examples, we're still trying to figure it out.

So this is our intervention, where we're trying to figure things out.

All right and our traditional alternative behavior.

Yep, wear the mask.

Awesome.

All right.

So, this again is the preview of what the whole chart will look like.

This is what we are gonna go through next time and so this here is the trauma, or the antecedent.

This here is the behaviors we went through and this section is gonna be the consequences process and that'll all be fun and exciting.

So now, we have the opportunity to go through our behaviors.

Elizabeth asked if we could use communication to tell us more about why he doesn't like to wear the mask.

Yeah, Elizabeth, a good intervention is gonna like really focus on that.

It's just for the purposes of this, we are keeping it a little bit more vague, but yeah, absolutely.

That would be the first thing we would wanna try to do, is figure out what the issue with the mask was, 100%.

Yeah, that would be like the number one priority.

It's figuring out what the problem with the mask was.

Okay, so what we're gonna do for the next 15 minutes we'll do 10 minutes and then we'll take a break, is we're going to go through just like we did last time, your own kids.

And you're gonna come up with the behavior component of your replacement behaviors component, of the kid that you're working with.

Well, and I'll just kind of give some feedback while we go through it.

I am going to just sit here quietly for two minutes while if you would like to throw out the antecedent information, just to make sure you're on the right track, or for you to just write it down real quick, to make sure that you remember, and then we'll start with the behaviors, but I'm not gonna spend the whole time reviewing antecedents again, 'cause we did that last time.

So, just take a hot second and again, if you wanna ask me a question in the chat, about your antecedent interventions, but what you need to be prepared for is, what your antecedents intervention are, so that we can come up with your behavior, your replacement behaviors.

So (indistinct) for antecedent interventions, all the setting event ones, the trauma, the TESE ones, the traditional ones and your behaviors and you can put them in the chat if you want to, or you can just keep them in your brain and then we'll go line by line for the four replacement behaviors.

So take two minutes for your antecedent stuff and then we'll get going.

And I'm just gonna stand here and stare at you.

And just remember setting event makes the antecedent more or less likely to cause the behavior.

- [Shelly] And Saundra, it's Shelly, I'm just gonna pop in and let folks know if they're looking for the BACB continuing education code.

I'm going to put that in the chat during these few minutes.

- All right, one more minute to figure this stuff out.

I highly recommend you utilizing me as a resource for this, if you're not sure you're on the right track.

'Cause I'm really smart.

Okay, so let's get to the behavior piece.

This piece, I really, encourage you to actually participate in the chat, this stuff while it seems super easy and clear, people get it confused and so it's really helpful to have me pop things out.

So, I encourage you right now to put in the chat, your behavior and your behavior, your replacement behavior and your alternative behavior and just put the at all in one line.

So Emily, if they're throwing their food, and you want them to ask for more food, do you think they're hungry, or that they don't want their food?

You think they're like throwing the food for attention or something?

Got it.

So asking for something else.

So, I lost the thing, but somebody said hitting and not hitting.

So it wouldn't be not hitting, it would be what you want them to do instead of hitting.

So if they're hitting, 'cause they like want a ball, then it would be asking for a ball.

What's dismantling Vanessa?

Slams, head on the floor.

Yep.

Taking apart the electrical outlets and stuff in the house?

See, that's a behavior I would redirect to something really valuable too if you can, as part of your programming.

Refusal to put on snow gear outside.

Emily's trying to figure out why he's throwing the food.

Yeah, so Emily, probably, so that's something where, and I know that this is the replacement behavior training, but that's one that probably, I would super hyper focus on the antecedent strategies and yeah.

And about like, yeah, exactly.

Little a time dishes, having him help cook, like having him help serve, those type of things.

You can still, this is presuming competence.

So yeah, so anyway, we can talk more afterwards though 'cause that one, this is one of those things that gets went brain going, asking to join aggression towards co-resident.

Asking to join.

Yeah, great.

Okay, so people have the idea of the replacement behaviors, alternative behaviors.

So, now think about what your setting event is.

Somebody recommended the book, Anxious Eaters, Anxious Meal Times.

I don't know anything about it, but that's the recommendation.

So people can take a look at it if they would like to.

So now take a look at your replacement behaviors, addressing your setting events.

So remember your setting events, make it more or less likely that your behavior antecedent will cause your behavior.

So they're tired, they're hungry, all of that.

So what are you going to teach them to access your intervention?

So talk to your staff member to gain access to what you want, is most likely a replacement behavior.

Teaching all done is probably a replacement behavior.

So like Vicky, so like an example, like I don't actually know the situation.

So, if so Vicky's kid refuses to wear snow gear and the replacement behavior would be asking for help, and the would be asking for help.

So, a setting event, intervention, a setting event could potentially be like, it's hot in the house.

Right?

So you don't wanna put on like snow gear, if the heater's on in the house.

And so, a setting event intervention could be, put on the coat out on the porch, or something like that.

Some people are sending the chat.

So you actually just did it too Donna.

Some people are sending the chats to just host and panelists.

I think that must be the default.

Oh, sorry Donna, I just called you out.

(laughing) Donna says she can't see the chats.

Yeah, so anyway, so those are examples.

So people aren't responding, is it 'cause y'all just checked out, or do people not understand this?

Okay, so right now, so I see questions about TESE.

So right now we're not even at the TESE yet, we're still at the regular setting event, but we can hop over to the TESE if that's helpful.

So with the TESE sometimes we know the kid's history, right?

We know that they're in foster care, because of neglect, or abuse.

We know some things.

Often we just kinda get an idea, right?

We know that they like hoard food, right?

So we can kind of guess that they have issues around food.

Right?

And so if there are issues around food, then we can put in interventions, in place for a setting event interventions that target an issue around food anxiety.

Right?

If we know that they act out, when people are, if they seem to act some kind of way, when people are yelling right?

Then we can put in interventions around, as if we kind of have an idea of a history of, somebody who's witnessed violence, right?

If we have an idea be because we know the parents that we think something, we have an idea of what's going on, because we generally have an idea of what's going on at home.

We put in the intervention based off of what we suspect.

Now, some kids like if you just have like no idea, right?

We can assume that most of our kids who don't talk, have had neglect, right?

Not because their parents neglected them, but because the definition of neglect for an infant is based off of them communicating their needs and their needs not being met.

And so for our kids who have communication disorders, they were definitely trying to communicate their needs and no one could understand them.

And so there's not like big studies on this, or anything like that.

But I think that we can infer that there is some significant trauma there around not being able to have had their needs met with communication.

And so we can put in things in place, around being understood and having needs met.

Right?

And then there's also something called universal trauma precautions, which is just, we assume that we err on the side of caution that maybe this kid had trauma.

Now, not all trauma informed interventions have to have a TESE.

We have trauma informed consequences, which we'll learn next time, which is also a way to be trauma informed.

And if you don't have a TESE that's fine.

As long as you're addressing the setting events.

And so that's the answer to that, but you still need to be having the replacement behavior.

Does that make sense?

Okay, so it's 4:30, so people, or 3:30 or whatever time it is, where you live.

And so people can hop out if they want to.

There's, I'm happy to stay for a couple more minutes if people have questions.

So Cassandra your question is he could have had like medical pain around rashes in the past.

And so you can look at it that way.

So his current setting event is a current rash, but his trauma event could be pain, really, really bad pain in the past.

Kelly or Shelly, do you need to like say something and like kick me out?

- No, no, not at all.

- Okay.

- I was just gonna let folks know if they do need to hop off, certainly go ahead.

But, but I will keep the meeting open for as long as you want to respond to questions.

So go for it.

- Perfect.

Before I respond to the handover hand, did people feel like they to answer the replacement behavior questions?

Did anybody have a question left on the replacement behavior for the setting events, or the TESE setting events?

Okay, if you do, you can ask it, but I'll just like keep talking, but y'all sign off if you need to.

As far as the handover hand, we are super, super focused on consent and not even consent, but ascent and dissent and so we do not touch students without permission.

We ask students before we touch them.

If a kid can't respond, then we will ask and then we'll say like, "You didn't respond so I'm going to touch you, "but let me know if you want me to stop".

And so we'll reach out and touch them.

If they move away at all, we stop immediately.

Typically, hand over hand is like we don't find is necessary.

Most of the time handover, hand prompting is for things like clapping your hands and touching your nose.

And most of the time handover hand prompting doesn't actually teach a skill.

Like if you're hand in hand prompting, it's somebody's wrist to like tie their shoes.

Like it's not like real, but in the times that it is necessary, we always make sure we have consent.

Emily for sign language again, we like ask permission, but if somebody's not able to tolerate, or consent to touch for the sign, they're not gonna learn the sign anyway, if they're fighting you.

And so that's the way that we look at it and that there's model prompts, there's other types of prompting.

And so that's how we address that.

I'm wondering about student who's visually impaired has been removed?

I lost the question.

Removed for family foster care.

I can't see the question.

(indistinct) - [Shelly] So wondering about a student who's visually impaired has been removed from family and is in foster care.

Her behavior is around independence.

When things get hard, they become anxious and it can escalate to problem behavior.

This person's thinking that the trauma is being visually impaired and not having the help when needed.

What are your thoughts around that assumption?

- That would be outside my competency.

I've actually never worked with as somebody in that population before.

So, I do not have any input in that.

I'm really sorry.

I just don't wanna give input on something that I don't.

Okay.

So, then the next one is about this.

Oh, here we go.

Oh, now I can see.

Okay.

What's this one?

Okay.

This is everything I utilize, especially coming out of training, but presently utilize low arousal, which presents strategy based on stress reduction, considering trauma.

Looks different in regard to behavior, replacement behavior and the way your pathway looks, such as head banging, present access to outside, or away.

I'm sorry, Robert, I don't understand.

Are you just telling me?

I don't understand the last part.

Present access to outside.

Do you mean you offer a break basically?

If the behavior happens?

- [Shelly] And I'm not seeing Robert in the meeting.

Oh, okay, he may have had to sign off.

- Yeah, if he means they offer a break, we do that too.

And we'll get to that next week.

More antecedent strategies for throwing food.

I would go with chair placement.

I would look at that.

I would look at a setting event, would be like noise level.

I would look at lights.

I would look at, for setting events, I would look at transitions right before.

But yeah, antecedent intervention I would look at if a place mat of where things go might be helpful.

Probably not, but maybe a plate with like, like a separated plate in case he doesn't like food touching.

I have no idea, like what it is about.

If there's something about what's on the plate, that's a problem.

Like how it like shows up on the plate.

I dunno, do other people have ideas and strategies for (indistinct).

But yeah.

Yeah those are all things that I would look at.

Okay, any other questions?

Changing food.

Also, if it's the order, if you think that it's 'cause he has to wait, then like feed him first, last or whatever order.

Yeah, Nancy, about the trauma thing, I don't tell parents that.

Also when working with, even parents who have had kids who have been in foster care, we don't call it trauma when we're writing their behavior plans.

Because even if their kids have been in foster care, it's still a lot of language to use for them.

We don't give families these charts.

We just keep them internal.

- All right.

I'm not seeing any more questions I don't think coming in, but we'll certainly wait a minute, or two just in case, but Saundra, I wanna just thank you again, for sharing your strategies and your expertise and experience with the group today.

I know everyone is messaging already and saying, they're looking forward to part three and putting all of the pieces together.

I do wanna mention, there is a slide on this screen.

Saundra has put all of this together into a workbook, that is available for purchase if anyone's interested in that resource.

So we'll make sure that the link is included in the recording as well.

Thanks so much to everyone.

Look forward to seeing everyone back here, same time, same place in two weeks.

So thank you so much.

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