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Tuesday, March 24, 2015

Behavioral Specialist Through Family Support Services

In yesterday's post, I gave a very general overview of how the Medicaid Waiver Program works. There are many, many more details, but I doubt you want me to get into the nitty-gritty, eh? (No, I'm not Canadian...I just like to pretend to be every now and then!) Anyway, I found out today that we are looking to mail out our application in the middle of April sometime. So there is an end in sight! :)

Today I want to discuss something called Family Support Services.Family Support   Services are another avenue through which a family who has a child with disabilities can receive outside support. To receive Family Support Services (FSS), you do not need to have Medicaid or a Medicaid Waiver. I am still learning a lot about FSS, so by no means am I an expert on it. Basically what it is, though, is a program through which you can apply to different agencies for different things like emergency respite and some different material items that might be beneficial to your family to have in your home.  Now, you can get the material items through the Medicaid Waiver, as well, but if you don't qualify for Medicaid or a Medicaid Waiver, this is one more opportunity to seek out assistance. 

There are also programs funded by FSS that agencies run to help families such as ours with things like challenging behavior. I found out about the Behavior Support Program offered through our Medicaid Service Coordination agency.  With all of the challenging behaviors that I see at home, I knew this would be beneficial to us. Again, this is another waitlisted type of service. I was put on the waitlist forthe Behavior Support Program back in June, and we just finally started working with the behavioral specialist last week.

Typically, I guess the Behavioral Support Program works differently than we are receiving it at this time, however the professional who runs the program is pregnant and since her maternity leave would interrupt the flow of the normal program, they are offering me a different option that is a shorter length of time. With this option, I am being taught how to target specific behaviors and figure out the meaning behind them. For my education and therapy friends, you may know it as an Applied Behavior Analysis.

What it is, is a very scientific way of approaching the challenging behaviors we see from Miracle Man. Last week, the behavioral specialist and I met for three hours and she talked with me about Miracle Man's needs and explained to me how the program works. We also chose three specific behaviors to target during our seven-week session.

One of the behaviors I chose to focus on was Miracle Man's meltdowns. They can be very disruptive to the flow of the household. At times, they can continue for an entire evening (so 2 to 3 hours of non-stop screaming..sound like fun? Yeah, me neither.)  Another behavior that I chose to focus on is his destruction of property. He likes to cut, rip, tear, and destroy all sorts of things. He also likes to draw on anything...except paper. Lastly, I chose to address his issue of "improper elimination". Basically...he removes his diapers after they have been peed or pooped in. Sometimes he likes to play with his poop...those of you who are close to me may recall my favorite line "poopy is not play dough".  Recently, he has also decided to do a little something that I would like to call "squat and dump". He removed his diaper and went poop right in the middle of his bedroom floor...several times!! So, there is obviously a lot to work on in this area, as well. Now, when he does any of these targeted behaviors, they are not attention-seeking behaviors. They are meeting some other need within him, and that, folks, is what we are trying to figure out (and the purpose of doing this Applied Behavior Analysis).

Last week's "homework" for me after our first meeting with the behavior specialist was to track as many of these specific behaviors as I could. I had to fill out a chart where I briefly described what happened before the incident, what happened during the incident, and what happened after the incident. I also had to fill out a form called a Motivation Assessment Scale. This Scale essentially tries to break down the three target behaviors into what it is that he is getting out of doing them. For example, is it a sensory-based behavior, is he looking to "escape", is he seeking attention, or is there some tangible reason for it? We found that one of the behaviors is more tangible. And that was the meltdowns. He has a very difficult time transitioning between activities. In particular, transitioning between being asleep and being awake. So that would be considered a "tangible" reason behind the meltdown behavior.

This week, we met yesterday and discussed the results of last week's notetaking, as well as the plan for this coming week. I am actually quite excited to try this week's "homework"! We will be doing a Preference Assessment. This means that we will be looking at preferred items or activities, and preferred foods that Miracle Man seems to enjoy the most. I was surprised to learn what it actually meant to do this. I had assumed that meant that we would figure out what his favorite thing was and then use that every time to encourage better behavior. As I explain below, however, that is not quite how it works.

I will explain to you what we will be doing with the Preferred Foods Assessment before I explain the Preferred Items Assessment, because we all love and can understand food...am I right? So, a Preferred Foods Assessment, as you may have guessed, is geared towards figuring out what food, "reward", if you will, Miracle Man would be most motivated by, as well as which of his favorite treats are least motivating. I chose six different foods: mini marshmallows, M&Ms, Skittles, Reese's Pieces, Pringles, and Combos. The foods have to be something that he will like a lot, but they cannot be something that he eats routinely. I have to be able to withhold the food and only give it to him when he has cooperated fully. Now, Miracle Man's favorite food happens to be hummus. With pretzels.  But, if I withheld that until he cooperated fully, he would never eat! So the choices needed to be highly preferred, small, easy, and manageable "treats", rather than real foods that he already eats during meal times.

Later today, the behavioral specialist is actually coming to do the assessment with us because she is curious and interested in seeing how it goes. Also, she has not yet met Miracle Man, so this is a perfect opportunity for her to do so. What we will do is to sit down across from Miracle Man with all six food items on the side. I will pick up one mini marshmallow and one M&M and present them to him at the same time. I will tell him he can choose one. Whichever one he chooses first is the preferred treat. I will mark down on paper which treat he chose. Then I will take one M&M and one Reese's Pieces and present them to him to choose again. Having six different foods, we have to do this trial with all possible combinations in a systematic way. So next, I might take an M&M and a skittle and present both of them to him. Throughout this process, I will be keeping track of what treat he prefers each time in order to find out what he prefers the most. And then I will create a hierarchical list of the treats according to Miracle Man's preferences so that I can use them appropriately to reinforce good behavior. I cannot wait to see what treats he is most motivated by! It will be fun!

Now, the interesting part of this that the behavior specialist explained to me is that when I am trying to get him to cooperate with me throughout the week, I will offer him his least favorite treat as a reinforcement first. The goal behind this theory is to get him to cooperate fully--without needing his absolute favorite reward    every.single.time     he is asked to do something.

Now, the Tangible Item Preference Assessment is set up so that I choose six different things or activities that he likes to do--that are not things he uses all the time. It has to be something that I can remove (just like the treats), and only give to him as a reinforcer. So, his toy electronic smart phone that we use to get him to go on the bus in the morning (every morning) is not the best choice.

I chose stickers because he always goes into my craft drawers to take my stickers out...and put them all over our furniture. But perhaps, if he is earning stickers in a more controlled way, it will be highly motivating to him (and also safer for our furniture)??? That's my plan, anyway!  I also chose bubbles, because I thought it would be kind of fun to reward him with a quick bubble game or activity after behaving accordingly. Miracle Man loves music, so the next item I chose was allowing him to listen to his favorite song on my iPod. And for the fourth item, I chose to sing a song of his choice together. Typically, Miracle Man will stand in the middle of our kitchen and sing songs over and over...and over again. Sometimes, I sing with him, sometimes I don't. Sometimes he wants me to sing with them, other times he doesn't. But, if I offer it as a reward, maybe he would like to sing with me? We shall see! The fifth item I chose was for him to be able to choose a TV show that he could watch as a reward. And the sixth item was to be tickled. He loooooooves to be tickled, and I mean loooooooves it!  He often asks to be tickled! He is so adorable when he giggles!!

After we figure out his preferences for these items, we will then be able to start talking about plans for approaching his challenging behaviors...and tying in his preferred reinforcers. I am not sure yet exactly how that will look, but the behavioral specialist did explain that because Miracle Man understands "first, then" already, we will be using a lot of "first, then" approaches. For example, first he has to pick up his toys, then he can choose a TV show. Or, first he must eat his dinner, then he can have an M&M. 

Regardless of what preferences Miracle Man ends up having, this is going to be an exciting afternoon here!  It's like my own positive reinforcer!

Wishing you many positive reinforcers today,
Marathon Momma

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