R.D. Dickson, M.A. and Suzanne LeSure, Ph.D., Medina County Board of Developmental Disabilities
The article describes the components of a behaviorally-based day program for adults with intellectual disabilities and mental illness and/or severe challenging behaviors. Group data collected on replacement behaviors and use of aversive strategies indicated positive outcomes. Next steps for further program development are discussed.
Report on an Intensive Needs Day Program for Adults
One of the most challenging populations to serve is individuals with intellectual disabilities and severe behavioral problems (Jacobson & Mulick, 2002). The Medina (Ohio) County Board of Developmental Disabilities (MCBDD) responded to these challenges by opening an Intensive Needs Unit (INU). As part of the adult services day programming, three adjoining classrooms were allocated for the unit which served 19 individuals through 2008. Enrollment was envisioned as temporary, with the goal of using behavioral techniques to reduce challenging behaviors and increase appropriate behaviors, thus enabling individuals to transition to less restrictive settings.
Individuals enrolled in INU typically have dangerous physical acting out, self injurious behavior, or high frequency disruptive behaviors (e.g., screaming, teasing, and noncompliance). These are individuals who have failed in previous placements (public schools, enclaves, sheltered workshops, adult classrooms) due to ongoing behavioral challenges.
The INU program was developed and refined over the first 18 months of operation. This article will review the components of programming used in INU and provide a summary of the data collected since the inception of INU.
Demographics of Enrollees
Seventeen of the individuals served are male, and two are female. The majority of these individuals are dually diagnosed. Only two individuals (11%) do not have a mental health diagnosis along with their intellectual disability, and one of these two has phenylketonuria. Another two individuals (11%) have a genetic disorder (Down Syndrome, Cornelia de Lange). Ten of 19 have an Autism Spectrum Disorder (53%). Of the individuals with a DSM-IV diagnosis, only four, or 24%, carry only one DSM diagnosis; 76% have more than one DSM-IV diagnosis. The diagnoses are listed in Table A along with ages of the
clients and respective levels of intellectual disability. The majority of individuals are taking psychotropic medications (16 or 84%); only 3 individuals, or 16%, are not prescribed medications for diagnosed mental health disorders or behavior support. Most individuals (63%) live in a professionally supported residence (Intermediate Care Facility, group home, waiver home), with 37% living with their parents/family. Ages range from 18 to 68.
Critical components of the INU program are a positive education approach, increased reward levels, consistent environmental structure, and individualized skill development activities (Griffiths & Gardner, 2002). A strong data collection system allows for constant monitoring of progress with feedback loops to alter behavioral interventions as needed. In addition, there is strong agency support for increased staff training and favorable staff to client ratios.
The most important component of INU's programming is a standardization of positive behavioral expectations. The agency has a Code of Conduct (Table B), and this set of positive behavioral expectations is the focus of programming in INU. It is included in each person's behavior support plan. Individuals earn choices of rewards if they follow the Code of Conduct, and staff collect interval data indicating whether the person demonstrates each Code behavior all of the time, more than half the time but not all the time, or less than half the time or not at all, for each ½ hour period the individual is in the program. This is a five day per week program with total program hours amounting to five to six hours per day depending on the individual's transportation and arrival time. The Code of Conduct is reviewed with the individual at the beginning of the day and throughout the day as needed. Staff consistency is increased by standardizing responses to lapses in Code behaviors. Three standardized responses to minor violations of the Code of Conduct ensure consistency of responding and a teaching/corrective approach. Unsafe behaviors are managed with blocking or response interruption and manual restraint if needed. Accuracy and consistency of data collection is improved by the interval data collection system tracking Code behaviors.
A reward system is an integral part of the program. Code behaviors are: (a) specifically and intermittently reinforced throughout the day; (b) differentially reinforced using a twice per day fixed interval schedule; and (c) differentially reinforced with a larger reward (e.g., a special item or outing) for long term (weekly) compliance with the Code of Conduct. The program schedule follows the Premack principle of following high demand activities with periods of free time and choice of activity. Additionally, the environment is enriched with noncontingent rewards of pleasurable activities through the day. In spite of the highly managed environment, six of the nineteen individuals have additional rewards included in their behavior plans due to their inability to earn the half-day rewards for Code of Conduct behaviors because of high frequency inappropriate behaviors.
Skill Development Activities
The curriculum includes specific instruction in relaxation breathing, muscle relaxation, problem-solving, and coping statements. Board games focusing on social skills and managing anger are used as small group activities. There is an ongoing sign language class as well as classes focusing on activities of daily living. Regular community outings provide opportunities for practice of skills learned in INU to other settings. A variety of work is offered to individuals in INU from laundry tasks, document shredding, re-stocking vending machines, to packaging and assembly jobs. In addition to these types of activities, most individuals have a specific skill development/habilitation program designed to increase a skill thought to assist with reducing behavioral challenges such as learning to wait for what is desired, working with staff to de-escalate oneself, engaging in work, using words before doing, or task attending.
Structure is increased with individualized daily schedules, either typed or in picture format. This enhances the ability of both reading and non-reading individuals in the program to conceptualize the order, timing, and transitions of their day. Staff has a master schedule to ensure that each individual's schedule is accurately and consistently displayed. The physical environment is arranged for maximum safety. Items are stored behind cabinet doors, and large items (TV, radio, and computer) are secured so that they cannot be thrown. Work and relaxation areas are defined visually (rug and easy chairs vs. tables or desks). Several individuals who are bothered by close proximity of others have cubicles created by partial walls. The three rooms used by the program are connected to allow staff to move quickly and provide support if necessary.
Staff to Client Ratios
INU has three classrooms. Staff-to-individual ratios are 1:3 in the first classroom, 2:3 to 4:5 in the second classroom, and 2:5 in the third classroom. One individual with particularly intense needs was served in 2008 in an auxiliary room across the hall beginning with 4:1 staffing, then 2:1 staffing, with 1:1 to start in 2009.
Staff of INU are non-degreed paraprofessionals ranging in age from 23 to 48 with an average age of 34 years. A high level of training is required for this unit and training is ongoing. The work day has been altered to allow earlier staff arrival so training can be completed in the morning when staff are mentally fresh. Also, behavioral episodes in the afternoons sometimes interfere with planned training. One morning segment per week is devoted to review behavior programs. A second morning provides practice of physical techniques or role-play of Code of Conduct violations and INU responses. Other training is provided on specific topics (e.g., positive behavioral supports, using attribution theory to provide effective feedback to individuals) or relates to specific behavior programs for the individuals involved. Over 30 hours of training have been developed for INU staff that offer continuing education units; presented in Table C.
Each individual's response to INU interventions is discussed at a Case Review meeting held monthly. Case Reviews involve all INU staff, the unit supervisor, the clinician, and any other team member who would like to attend. At these meetings, new interventions may be agreed upon since INU utilizes a basic template behavior plan that encompasses all positive and aversive strategies (except chemical restraint) allowable to county boards of MRDD by the state of Ohio. Each template plan also includes individualized supports and responsive strategies, if needed, and is approved by the guardian and a behavior plan review committee. Team members are notified if a different intervention is to be used with the individual based on a Case Review meeting. Typically, program decisions are data-driven. In addition to these monthly Case Reviews, the individual and their team also meet every 90 days to discuss any issues or needed changes to the individual's behavior plan or overall service plan.
Results: Outcome Measures
Code of Conduct Performance
Staff of INU were initially surprised to discover that the most behaviorally challenged individuals selected for this program actually followed the Code of Conduct on average over 90% of the time. Table D shows the gains in the percentage of clean intervals (total compliance with the Code of Conduct) over the two years of INU programming. Note that four individuals were discharged from INU due to progress and the INU template plan was not used with them, so no Code of Conduct data is available for these enrollees. The greatest gains were evident in the first year of the program.
Objectives with Progress
Figure 1 and Figure 2 show the percentage of objectives with progress, stability, and regression. Objectives include those from formal skill development (habilitation) programs as well as the objective for following the Code of Conduct. Determination of the status of an objective, whether data is showing progress, stability, or regression, is based on linear regression trend lines. The data clearly indicate increasing numbers of objectives with progress over time.
Use of Aversive Interventions
Figure 3 and Figure 4 indicate the declining frequency of the use of contingent restraints (manual restraint, mechanical restraint such as a spit mask) and time out, respectively. The trends over time show decreases in these aversive interventions in spite of adding new individuals to the program during the two years of INU programming and adding time out as a strategy for various individuals when the team agreed it would be more effective than emergency manual restraint.
Successful Transitioning from INU to Less Restrictive Settings
Five individuals have been successfully transitioned to other Board settings such as the workshop floor or an adult vocational classroom. Another four individuals are going to be transitioned out of INU in January of 2009.
The average yearly cost per consumer was $28,102 excluding the one individual who needed 4:1 staffing and $31,908 per year with that individual included. These figures
are from staff salaries and benefits. Other costs, such as program materials and rewards, were approximately $1500-$2000 in 2008. These costs are comparable to other programs that serve youth with intense needs in our area.
Implementation of clear expectations, increased rewards, and environmental structure by well-trained, consistent staff results in increased appropriate behaviors and decreased need for aversive interventions with individuals possessing a variety of dual diagnoses (intellectual and developmental disabilities with mental illness) and/or Autism Spectrum Disorders. The gain in appropriate behaviors (Code of Conduct skills) is evident without taking into account the functional purpose or motivational analysis of the individuals' behaviors. In fact, the authors thought initially that programming based solely on the Code of Conduct and the standard outlined responses would be implemented for about six months, then programming would be individualized according to functional analyses. After two years of INU programming, only one individual requires different responses in order to demonstrate progress. For this individual, the staff instruction (attention) provided at the time of the violation of the Code of Conduct behavior was reinforcing, so a planned ignoring approach with redirection back to the scheduled task is utilized with this individual, coupled with (noncontingent) hourly, scheduled reminders of the expectations of the Code of Conduct.
Next steps could include expanding INU to include a residential component for a seamless support system and even greater consistency of programming for the individual with dual diagnosis. Within the INU program in 2009, there will be an increased emphasis on social skills development and principles of self-determination. Due to the high level of
dual diagnosis, it may be possible to qualify the program as a partial hospitalization program. Working with the local mental health board, it may be possible to implement a half-day program for individuals with mental illness and mild intellectual disability that could include therapy groups, education about mental illness, and mapping of strategies for health and other goals of the individual. Finally, with or without partial hospitalization status, the INU program would benefit from the services of a psychiatrist experienced with individuals with intellectual disabilities. Individuals with untreated mental health problems and those undergoing medication changes with adverse effects often show regression on their objectives in the INU program in spite of the extensive supports.
From a staffing perspective, a next step could include offering a new job title for staff working in INU, with an associated pay increase, to recognize the increased training inherent in the INU program and increased exposure of staff to physically acting out individuals. The agency also could offer key trainings to staff outside of the INU program to promote the positive components of INU to prevent the need for more restrictive placements in the future for dually diagnosed individuals and to assist transitioning individuals out of INU to less restrictive environments.
Jacobson, J., & Mulick, J. (2002). Dual diagnosis residential and day services. In J. Jacobson, J. Mulick, & S. Holburn (Eds.) (pp. vi-xiv) Contemporary dual diagnosis: MH/MR. Kingston, NY: NADD Press.
Griffiths & Gardener (2002). Residential and Day programs for persons with dual diagnosis: A summary. In J. Jacobson, J. Mulick, & S. Holburn (Eds.) (pp.123-139), Contemporary dual diagnosis: MH/MR. Kingston, NY: NADD Press.
The authors thank the Medina County Board of Developmental Disabilities for its ongoing support of the Intensive Needs program for adults and its dedication to serving individuals with intellectual disabilities and mental illness/severe behavior disorders.
For additional information, contact Robin Dickson at email@example.com.
Gender Age Level of ID* DSM-IV diagnoses & select medical diagnoses
1Male43 Severe IDSchizoaffective Ds, Generalized Anxiety, Down Syndrome
2Male56Severe IDImpulse Control Disorder NOS, History of Psychosis
3Male44Severity UnspecifiedAutistic Disorder, Mood Disorder NOS, Anxiety Disorder NOS
4Male55Moderate IDAutistic Disorder, Generalized Anxiety Disorder
5Male18Mild IDAttention-Deficit/Hyperactivity Disorder
6Male68Profound IDObsessive Compulsive Disorder, Seizure Disorder
7Male24Mild IDAutistic Disorder, Impulse Control Disorder NOS, Obsessive-Compulsive Disorder
8Male52Severe IDSchizophrenia, Bipolar Disorder, Anxiety Disorder NOS
9Male22Severe IDStereotypic Movement Disorder with SIB, Tourette's Disorder, Pervasive Developmental Disorder NOS, Mood Disorder NOS, Impulsive Control Disorder NOS, Cornelia de Lange Syndrome
10Male29Mild IDPervasive Developmental Disorder NOS, Impulse Control Disorder NOS, Stereotypic Movement Disorder
11Male30Severity UnspecifiedBipolar Disorder
12Male42Profound IDPsychotic Disorder NOS
14Female19Mild IDAutistic Disorder, Selective Mutism
15Male25Mild IDAutistic Disorder, Attention-Deficit/Hyperactivity Disorder, Tourette's Disorder, Seizure Disorder
16Male37Severe IDAutistic Disorder, Schizoaffective Disorder, Intermittent Explosive Disorder
17Male22Severe IDPervasive Developmental Disorder, Mood Disorder NOS
18Male36Severe IDBipolar Disorder, Obsessive-Compulsive Disorder
19Male33Severe IDAutistic Disorder, Fetal Alcohol Syndrome, Ancephaly, Seizure Disorder
*ID = Intellectual Disability
Mild/Moderate Intellectual Disability = 6/19 or 32%
Severe/Profound/Severity Unspecified Intellectual Disability = 13/19 or 68%
Code of Conduct with Planned Responses
Behavioral expectation: Staff response for violations:
I will Use Polite WordsReview of Code of Conduct ruleRehearsal Redirection to activity per schedule, or if free time, staff selected activity
I will Keep My Hands/Feet to My Own BodyReview of Code of Conduct ruleRehearsal Redirection to activity per schedule, or if free time, staff selected activity
I will Leave Things Where They BelongReview of Code of Conduct ruleTen second prompting sequence (repeat verbal, gestural/pointing, warning of impending physical assist, then physical assistance) to return/restore object(s)/environment Redirection to activity per schedule, or if free time, staff selected activity
I will Follow RequestsReview of Code of Conduct ruleTen second prompting sequence (repeat verbal, gestural/pointing, warning of impending physical assist, then physical assistance) to return/restore object(s)/environment Redirection to activity per schedule, or if free time, staff selected activity
I will Be Safe With My BodyPlanned ignoring of the behavior for 2 minutesVerbal prompts to take care of own body every 2 minutes thereafterMonitor for injury or potential for injury, and use, as needed for dangerous behaviors: non-confrontational blocking, interpositioning of soft objects to block self injury, or manual restraint
Training Topics for INU Staff
Training Duration CEU's
Mission, Vision, Values and Goals of Intensive Needs Services to Individuals with MRDD and Behavioral Challenges1 hour1
MCBMRDD Policy and Procedures on Behavior Support1 hour1
ABC's and Functions of Behaviors1 hour1
Techniques and Methods of Behavior Management2 hours2
Agency Code of Conduct and Intensive Needs Response to Violations1 hour1
Nonviolent Crisis Intervention Training--Basic8 hours8
Nonviolent Crisis Intervention Training-Refresher (required annually)33
Review of Terms, Procedures and Mastery of Skills Test: Intensive Needs Services1 hour1
Terms and Strategies of Intensive Needs Unit Template Behavior Plans1 hour1
Intensive Needs Unit Skill Development1 hour1
Effective Communication Strategies1 hour1
Environmental and Verbal De-escalation Strategies1.25 hours1
Applied Physical Training of Crisis Prevention Institute3.5 hours3
Positive Behavior Supports and Crisis Intervention1-2 hours1
Problem Solving the Physical Techniques1 hour1
Therapeutic Behavior Interventions1 hour1
Team Building 1011 hour1
Stress Management1 hour1
CEU = continuing education unit
By Individual, Changes in Intervals with Code of Conduct Behaviors by Year
Baseline200720082008 Difference from baselineDifference from previous year
1100.0%Not enrolled99.9%--.1Not enrolled
1393.0%Not enrolledEnrolled 1 monthEnrolled 1 monthNot enrolled
Figure 1. Objectives with Progress & Stability Over Time
Figure 2. Objectives with Regression Over Time
Figure 3. Contingent Restraint Data
Figure 4. Time Out Data