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Post-crisis Intervention for Individuals with Autism Spectrum Disorder and Related Communication Challenges

by Renée Fucilla
CPI Professional Staff Instructor

Managing problem behaviors is a common challenge for staff members who support individuals with Autism Spectrum Disorder (ASD). Studies suggest that a majority of individuals with developmental disabilities engage in some problem behaviors that warrant intervention, and that individuals with limited communication skills are particularly at risk for developing problem behaviors (Durand, 1993). Approximately fifty percent or more of people with Autism are nonverbal or have limited verbal skills (Repa & Walker, 1983). Because of frustration with communication, it is more common among persons lacking verbal abilities to display physical aggression, attention-seeking behaviors and self-injurious behavior (Talkington, 1971). Challenging behavior is often considered a form of nonverbal communication, and many behaviors observed in a person with limited verbal capacity must be interpreted as sincere attempts to communicate by a person who may have no other means of doing so (Repa & Walker, 1983).

However, problem behaviors can lead to crisis situations. Examples of such crisis situations may range all the way from the anxiety level (withdrawal, vocalizations, unresponsiveness, sleeping problems, lack of focus, or self-stimulating behaviors), to defensive behaviors (screaming, growling, aggressive demands, banging, noncompliance, avoidance, tantrums) all the way to physical aggression (hitting, kicking, biting, throwing, self-injurious behaviors, destructive behaviors) (Crisis Prevention Institute, 2004). According to a research synthesis examining 37 children with Autism, the most common behaviors targeted for intervention are tantrums (76%), aggression (59%), stereotypy [repetitive movements or speech] (14%), and self-injurious behaviors (11%) with some individuals displaying more than one type of problem behavior (Horner et al., 2002). Such behaviors can be major barriers to effective education and social development, and a serious obstacle to ongoing efforts to include children within school districts and communities. Such crises can also be frustrating for staff, parents, educators, and other caregivers.

Once problem behaviors have become an established part of an individual’s behavioral repertoire, the problem behaviors are not likely to decrease, and often worsen, without intervention. The CPI Postvention model is designed to enable effective post-crisis intervention and to prevent or reduce the frequency and severity of problematic behavior in the future (Crisis Prevention Institute, 2004). Without Postvention, it is likely that the same behaviors will occur over and over again, and it is important to break the cycle in order to work toward more positive behaviors.

Unfortunately, it is the same communication limitations at the root of problem behavior that make it very difficult for staff members to intervene after a crisis. Another factor that makes post-crisis intervention difficult is that individuals with Autism frequently lack the ability to generalize learning experiences from one crisis to future situations. This lack of generalization from one context to another is a common impairment of individuals with Autism (Hall, 1996).

This article is designed to help staff members overcome such barriers and help them utilize the Postvention model by incorporating aspects of Applied Behavior Analysis, Functional Behavior Assessment, Functional Communication Training, Structured Learning, and other strategies tailored to the needs of individuals with ASD. Effective and comprehensive behavioral interventions, especially those utilizing a functional approach, can result in an 80-90% reduction in problem behaviors compared to traditional approaches to behavior modification (Horner, 2002).

The “traditional approach” vs. a contemporary approach to managing problem behavior

Traditional approaches toward problematic behavior were reactive in structure, and focused on “fixing” behaviors through punishment. For example, if a child were to hit or push someone because she didn’t want to do something, a traditional approach might be to revoke privileges or spank her in order to stop the behavior. The problem with this approach is that although it may temporarily cause the behavior to cease (Nuzzolo-Gomez et al., 2002), the punishment fails to address the cause of behavior or to teach more appropriate means of communicating a need. Such reliance on negative consequences to gain control of the child bypasses the fundamental issue of, “Why is she hitting and how can we address those concerns?”(Durand, 1993).

The cornerstone of the more contemporary approach toward behavioral support is to do just that. The most recent best practices focus on Functional Behavior Assessment, Functional Communication Training, and Structured Teaching (TEACCH) so that problem behavior can be prevented and patterns of problem behavior can be altered. An important development in the contemporary approach is examining how staff members’ interventions influence the behavior of the individual, which is also a key purpose of the CPI Postvention model.

Because problem behaviors are maintained by their functional effect, Functional Assessment is the process of identifying the variables that reliably predict and maintain problem behaviors in order to develop effective interventions for future occurrences (Horner et al., 2002). A Functional Behavior Assessment is a process which seeks to identify the problem behavior an individual may exhibit, to determine the function or purpose of the behavior, and to develop interventions to teach acceptable alternatives to that behavior. Direct observation of the actual behavior in question, within the natural context under which it regularly occurs, is at the heart of the functional assessment process. That process generally includes:

• Identifying the behavior that needs to change;
• Collecting direct observation data on the behavior;
• Developing a hypothesis about the reason for the behavior;
• Developing an intervention to change the behavior;
• Evaluating the effectiveness of the intervention;
• Having patience to see how the behavior changes and being open to what the data indicate about this or new behaviors (Montgomery & Montgomery, 2004).

Essentially, “if we can identify what people are ‘saying’ with their behavior then we can teach them other, more constructive ways to communicate the same thing as an alternative to the challenging behavior” (Durand, 1993).

A key element in this process is Functional Communication Training (FCT). FCT utilizes behavioral interventions to teach alternative ways of communicating in order to eliminate or minimize challenging behaviors (Durand, 1993). This method assumes that if an individual can gain access to desired consequences more effectively with a new behavior, they will use the new behavior and reduce their use of the undesirable behavior. In other words, if staff can teach individuals more acceptable behaviors that serve the same function as the problem behavior, inappropriate behaviors will no longer be necessary (Durand, 1993). Examples of alternative functional communication systems include: Picture Exchange Communication System (PECS), sign language (ASL), augmentative communication systems (i.e., picture boards), spoken words, or written words. Research on FCT has shown that when individuals with Autism acquire new communication methods, there is a greater chance that the positive behaviors will generalize to other contexts and be maintained over time (Durand, 1993).

Increased attention on functional assessment has led to the development of a variety of other positive behavioral support interventions. “Over the past decade, the field of positive behavior support has grown rapidly as a set of practices that focus on the function of the problem behaviors in order to develop and teach functional alternatives” (Horner, 2002). It is based solidly on both a values base about the rights of people with disabilities and a functional approach that considers the contexts within which behavior occurs and attempts to identify outcomes that are acceptable to the individual, the family, and the supportive community (Horner, 2002). As opposed to the traditional approach, positive behavioral support interventions utilize an individual’s learning strengths and provide an opportunity to empower an individual toward developing abilities to independently function in daily life.

POSTVENTION: A DUAL CHANGE PROCESS

Functional assessment and Structured Teaching can be used to augment the CPI Postvention Model, and together they can provide an overall framework that guides staff members through the process of Postvention. Therapeutic Rapport as represented in the CPI COPING model^SM is a critical and necessary element of crisis intervention and a total part of the CPI intervention process (Crisis Prevention Institute, 2004). FCT, Structured Teaching, and the COPING model all rely on a dual-change process dependent on both the individual and the staff members. This means a) facilitating alternative ways that clients can respond and b) finding alternative ways that staff can respond. It requires that staff be willing to adapt to new procedures and intervention strategies in order to build positive environments. For this reason, the COPING model is utilized twice: a) once in relation to the client – to investigate the function of behavior and teach new behavior alternatives to the individual, b) and secondly, in relation to the staff - to help staff members adjust their intervention style and work as a team to improve the environment in order to reduce the frequency and severity of problematic behavior.

THE CPI COPING MODEL^SM: CLIENT

Staff emphasis in this part of the Postvention process should be on identifying the reason for the crisis (the function of the behavior) and assisting the client to find more productive behaviors to communicate their need. It is important to use an individualized approach with every client. Keep in mind that every individual is unique and what works with one individual may not be the same with other individuals.

Control
After crisis, a client’s energy will begin to subside as she reaches the Tension Reduction level (Crisis Prevention Institute, 2004). Signs of tension reduction may include crying, apologizing, being tired, or remorse. Even if the individual doesn’t realize that a crisis occurred, it is still necessary to continue the Postvention process. In this phase, staff members “assist the individual in regaining physical and emotional self-control in a nonjudgmental manner that allows staff to empathize with the client’s perspective” (Tibbets, 19XX). In order to assist the individual in regaining control, return them to a familiar routine in an individual quiet place to provide comfort and help the person regain their composure (Repa, 1983). The staff member should remain with the client to provide a model of calm and self-control (Tibbets, 19XX). However, staff should avoid reinforcing negative behaviors by removing consequences, and be careful not to reinforce negative behavior by providing too much attention, positive rewards, or eliminating the original request. Requests, limits, and consequences should be followed through with, and learning can be done within that context. In fact, it is essential to begin post-crisis intervention at this point so that the individual makes a connection between the behavior and the modification efforts.

Orient
To “orient” means that staff members seek to understand the function of the problem behavior so that they can identify alternative behaviors that match that function. If the individual is able or willing to communicate, assist them in exploring why the behavior occurred. You might ask the individual to use pictures or play “emotion games” to enable the individual to explain the function of the behavior or what need instigated the behavior. If communication is limited, staff members might provide visual choices in the form of written statements and prompt the individual to point. For example, the Rapid Prompting Method? encourages a teacher to write two statements (e.g., “I’m mad because I want my ball” and “I’m mad because I’m tired”) and prompt the individual to point to their choice (Mukhopadhyay, 2004).

According to the TEACCH program (Treatment and Education of Autistic and Related Communication Handicapped Children) the needs of individuals with Autism are unique, and behaviors may relate to one of six functional areas (social, communicative, sensory, routines, receptive, and cognitive) identified in Chart 1. Even if the individual is not able to communicate the function of the behavior, this inventory may be useful in helping staff do a functional assessment to understand how the individual may be using behavior to communicate an underlying need. If possible, involve family members and other caregivers in hypothesizing what may be the function communicated through the behavior.

Chart 1: Inventory of Behavior Functions (Mesibov, 2004)

FUNCTION--THE BEHAVIOR MAY BE COMMUNICATING A NEED FOR:	OUTWARD BEHAVIOR
Social needs: independence, quiet time, sanctuary, individual space, escape from social pressure, sense of ownership, sense of control, positive reinforcement, attention, amusement	Outward Behaviors related to social needs: Refusal to share, selfishness, resistance to social norms, lack of response to social cues, lack of social initiation, unusual comments, inappropriate violation of others’ space, physical aggression toward peers, hyperactivity, self-focused communication, attention-seeking behaviors, impatience, impulsive behaviors, inability to empathize, lack of interest in others, aggression, or rejection of people
Sensory needs: internal and external sensory stimulus; olfactory, auditory, tactile, visual senses; or hypersensitivity to sensory stimulus oral fixations, escape from sensory overload, sensitivity to proximity and touch, need for deep pressure, need for energy release, need for stimulation	Outward behaviors related to sensory needs: self-stimulating behaviors, pica, running, tantrums, biting, self-injurious behaviors, hair-playing, chewing, throwing/playing with food, playing with feces, vocalizations, eating non-edibles, strong food preferences, covering ears, banging head, slapping/pounding head, seeking restraint
Communication needs: visual communication, clear/simple communication, desire to communicate need to others	Outward behaviors related to communicative needs: Confusion, task avoidance, physical aggression, literal interpretation of directives, hesitancy to initiate communication, repetitive verbalizations, vocalizations, seems like doesn’t show emotion, absence of body language
Need for routines: need for sameness, predictability	Outward behavior related to need for routines: Resistance to change, fixations, patterned behavior, fixed interests, stubborn behavior, tantrums, non-compliance, confusion
Receptive needs: clear explanations, visual or augmentative communication	Outward behavior related to receptive needs: Difficulty answering questions, unresponsive to reprimands or consequences, confusion, seems withdrawn, echoing, repetitive vs. responsive, defiance, refusal to participate, avoidance, slow cognition, lack of feedback/response, seems lazy or unmotivated
Cognitive needs: Prompting, visual or augmentative communication, individualized attention, clarification of tasks, comforting activities	Outward behavior related to cognitive needs: Waits for prompts, overly dependent on others, doesn’t always see the connection between cause and effect (repeats same negative behavior despite consequences), doesn’t understand punishment, generalization or transfer issues (a skill learned in one setting may not transfer to another setting, people, or materials), reluctant to initiate communication, more focused on details than big-picture, unapparent organizational skills, fixations, preoccupation with minutiae

Patterns

In addition to identifying the function of behaviors, staff members should also keep track of any potential patterns that occur in relation to:

• Antecedents (environmental cues which trigger or set the stage for behavior)
• Behaviors (time, duration, frequency, etc)
• Consequences (what consequences were used? Did they reinforce or help extinguish the behavior?)
• settings or events

In order to help identify trends and patterns, Marshall (2002) suggests that staff members note their observations according to the following statement: “when __(antecedent)__ occurs, he/she will ___ (behavior) __ in order to __(function of behavior or consequence)__. This is most likely to occur if ___(setting/event)_ ”.

According to the TEACCH program, behaviors are often related to the setting, events, scheduling, or activities precipitating the behavior. For example, the behavior may have been triggered if:

• the individual was denied a request or activity
• the individual was hurried or rushed
• the individual experienced negative interactions with staff or peers
• there were unfamiliar people present
• there was a change in schedule or medication
• the individual was worried about an upcoming event
• the individual was ill or experiencing pain
• there was overstimulation or confusion about the environment or schedule
• the individual didn’t like the activity
• the length of the activity was too long or the demands were too high
• the transitions between activities were unclear (Love, 2004).

Investigate

Collaborate with all involved parties to develop hypotheses about the function of the target behavior. Based on observations about the function of behaviors and the apparent patterns, the staff (and if possible, the client), should try to identify alternative behaviors. Like a functional assessment, observe the behavior in context, and try to evaluate what the behavior intends to communicate. We are most likely to be successful when we choose alternative behaviors that match the function of the challenging behavior. In other words, the new behavior should evoke the same consequences as the targeted challenging behavior. There are two primary avenues that should be investigate: 1) ways to help the client communicate their needs (discussed in the next section), and 2) ways to alter the environment so that the clients’ needs can be more easily met, thereby reducing the need for acting out behavior (Structured Learning/TEACCH program). The behavior inventory discussed in Chart 1 can help to identify possible functions of the behavior and Chart 2 coordinates the function to some ways in which the environment can be better structured to meet the needs of individuals with Autism.

Chart 2: Functional Alternatives (Mesibov, 2004)

Function of Behavior	Examples of Functional alternatives
Social function	Using social stories. Providing sanctuary, tents, sleeping bags, private work areas, opportunities for breaks, organized activity schedules, a safe place to escape, personal space during social activities, and personalized work materials/toys. Providing opportunities for clients to give input during schedule-making, better ways to understand schedules, appealing to personal interests, practicing turn-taking and other social norms, positive reinforcement, individualized attention, short duration for activities, games/practice in understanding emotions and needs of others, gradual introduction of new people Resources: Social Stories http://www.thegraycenter.org/Social_Stories.htm , play therapy (Sigafoos & Littlewood, 1999), video modeling (LeBlanc, 2003), Joint-Attention training (Walen, 2003), Social games http://www.do2learn.com/
Sensory function	Providing sensory areas, hand toys, sensory games, sensory outlets, texture bags, weighted vests, rocking, swinging, dancing, chew rings, scented lotions, aromatherapy, music therapy, physical exercise, relaxation strategies, safe places to expend physical energy, headphones, sensory brushing (Wilbarger Protocol) Resources: Wilbarger Protocol (Wilbarger, 1991), Sensory Approaches (Champagne & Stromberg, 2004), http://www.do2learn.com/
Communicative function	Use of visual and experiential learning methods, simplified communication, augmentative communication, Picture Exchange Communication system (PECS), vocal-output assistive devices, sound boards, visual prompts, help expressing emotions and feelings through cards, games, pictures, validating strengths and interests, encouraging use of words, positive reinforcement Resources: PECS www.pyramidproducts.com, Behavior Chain Interruption Strategy (Goetz, Gee & sailor, 1985), Self-management procedures (Mancina, 2000), http://www.teacch.com/ http://www.autismsociety-nc.org/ , http://www.tasksgalore.com/
Need for Routine	Providing visual schedules, structured time and schedules, structured predictable learning/home environments, repetitive activities, clear project areas, gradual changes, role playing new routines, using fixations to motivate (i.e. computers, dinosaurs, titanic) , preparing individuals for changes and transitions Resources http://www.teacch.com/ , http://www.autismsociety-nc.org/ , PECS www.pyramidproducts.com, Categorization strategy training (Bock, 1999)
Receptive needs	Provide uncomplicated, do-able tasks, break tasks into small steps, allow processing time, don’t force responses, reinforce communication with pictures, patience, repetition, encourage active engagement, specific and positive reinforcement of behaviors, eliminate distractions, be precise and concise about instructions Resources: Dalrymple (1980) Helping People with Autism Manage their Behavior, www.teacch.com
Cognitive needs	Providing visual and experiential learning methods and visual structure, frequent activity changes, method to request breaks, use of timers to clarify duration of tasks, teach rules, limits, and boundaries in advance, give adequate information in advance, immediate results and rewards without delay, Task Analysis, chaining and fading techniques. Resources: (Martin & Pear, 2003) - Task Analysis, chaining and fading techniques Dalrymple (1980) Helping People with Autism Manage their Behavior, http://www.teacch.com/ PECS www.pyramidproducts.com,

Involve the individual as much as possible in planning behavioral alternatives. The staff member should provide motivation for the client to change or to give up the negative behavior. In doing so, the staff member has to help the client see options and understand the link between behavior and consequences, focusing on how positive behavior can result in more benefits and positive outcomes (Tibbets, 1987). This can be done through limit setting (Crisis Prevention Institute, 2004). For example, a facilitator might say, “I can see you need a break. When you need a break, should you give me a ‘break card’ (show break card), or hit me?” (write statement or show picture). Prompt the individual to hand you the break card and then immediately give a break (Mukhopadhyay, 2004). As utilized in the TEACCH program (“Minding the Gap”), visual reinforcement can be used to explain how behavior A results in consequence X, and Behavior B results in consequence Y. For instance, polaroid pictures of the client receiving the consequence (e.g., smiling and playing with a favorite toy) can help to individualize limits and assist clients in understanding the meaning of the limits (Love, 2004).

It is extremely important for staff members to consistently and immediately follow through with positive consequences if clients utilize the desired behavior to communicate a need. In fact, the new behavior should be MORE effective than the challenging behavior in accessing needs (i.e. requires less physical effort, regularity of reinforcement, less delay in gratification) (Marshall, 2002). Durand (1993) identified three factors that positively effect generalization and maintenance of new behaviors: 1) acceptability by individual and affected parties, 2) recognizability by the general public, and 3) contexts that are receptive and supportive. Research has shown that new behaviors acquired in this way have a better chance of being generalized to other contexts and with other people (Durand, 1993). Mere reduction of the behavior should not be the only goal, however; there should be an overall endeavor to teach new behavior that produces functional and durable lifestyle enhancements for the individual and those who interact with him (Marshall, 2002). As such, that has to be negotiated with both the client and the affected parties.

Negotiate

Once behavioral alternatives have been investigated, it is important to negotiate a new behavioral plan with both the client and the other affected parties. Such a behavioral plan should clearly explain (through limit setting and visual reinforcement): a) what the individual should do, b) when, c) for how long, and d) what will be the result or consequence of doing or failure to do so (Schopler et al., 1995). This is often achieved by creating picture schedules (Lord & Schopler, 1994). New behavioral plans can be reinforced through role-plays, by practicing the alternative behaviors, and through desensitization and rehearsal strategies (Dalrymple, 1980). For example, Dalrymple (1980) explains how staff members can devise new behavioral plans and role play behaviors for daily tasks such as: getting ready to go home on the bus, washing hands after using the bathroom, lining up to go outside, or going to the dentist.

Another strategy is to develop short phrases, or sentences that can be memorized by the client to remind them of appropriate responses. These cues can then be repeated by staff to the client in crisis situations with the eventual goal being for the client to be able to cue himself out of a crisis situation (Tibbets, 1987). Reinforcement puzzles are another positive behavioral support strategy (Love, 2004). The method uses a series of puzzle pieces that, when earned by the client for good behavior, result in completion of a picture puzzle indicating a reward. Reinforcement puzzles create an errorless learning method because pieces are never taken away; they are only earned when a client chooses appropriate behaviors or when the client refrains from a specific behavior for a specified amount of time.

Give

After completing this process with the client, give positive support to the new behaviors by providing reinforcement and consistently enforcing consequences. It is important to give time to new plans, because sometimes it takes a while before a client begins to make the connection between behaviors and consequences. As they do, begin to reduce prompts and increase expectations gradually to encourage independence. Be sure to give a feeling of control back to the client by ensuring that the client recognizes that it is his own responsibility to control his own behavior.

COPING MODEL^SM: STAFF

The most effective interventions are based on a dual-change process that recognizes the importance of staff adaptations as well as client adaptations. Therefore, it is essential for staff members to utilize the CPI COPING model^SM to improve their responses as well.

Control

Staff can get frustrated by challenging behavior, and they need time to regain emotional and physical control of themselves just as much as a client does. Seeing a client enact the same behaviors time and time again, and constantly developing new interventions can be a very draining process. Before beginning the Postvention process, staff should allow themselves time to calm down, breathe, remove themselves from the situation if necessary, and utilize other staff members and organizational support in order to regain their composure (Crisis Prevention Institute, 2004).

Orient

For staff members, this means understanding as much as possible about what is effective in meeting the individual needs of a person, and documenting and keeping thorough data.
It is important to learn through observation, informal and formal assessments about a person’s strengths and interests (Johns, 2004). This allows staff members to know what types of reinforcement are most effective and provide individualized support for learning and behavioral efforts. The inventory of behavioral functions and alternatives in Charts 1-2, can be utilized to teach behavior by appealing to the strengths of an individual. The TEACCH program has a strong emphasis on re-conceptualizing “deficits” as opportunities and strategies for providing individualized support for a person (Love, 2004). For instance, if someone has a preoccupation with dinosaurs, that interest can be used to stimulate participation in other activities (i.e. using dinosaurs as part of visual schedules, Social Stories, games, and learning activities).

Systems of data collection can help validate the effectiveness of such interventions and also ensure that the effects of staff interventions may be assessed (Horner et al., 2002). Documentation should include as much information as possible about the relationship between client behavior and staff responses. This may include: journals or logs indicating what types of interventions are used to address behaviors, perceptions about the effectiveness of the interventions, date and time of incidents when behavior becomes problematic, staff on duty, duration of behaviors, location, chronological explanation of events and staff responses, and observations about environmental factors such as weather, noise levels, lighting, people present, activities, and other antecedents. Accurate and complete documentation helps to identify possible staff behavior or intervention patterns that help to reduce or contribute to the acting out behavior.

Patterns

An incident review helps staff identify patterns or trends in staff responses that may be contributing to the undesirable behaviors of the client. Staff members should try to identify some areas where they can improve their own responses in order to support more positive behavioral choices. For instance, the TEACCH program (2004)encourages staff members to look for occasions where:

• Communication of instruction was unclear, unspecific, or inconsistent
• Task duration, expectations, and completion points were not clearly identified to the client
• Staff failed to provide assistance or respond to an individual’s requests
• Staff responded in a way that reinforced negative behavior
• Staff could have provided other alternatives to the client

Also, staff should try to identify patterns of: a) what has worked, and b) what has not worked in past interventions. Looking for patterns helps staff understand what reinforces or contributes to negative behavior. For example, it is useful to determine if a client is more responsive to changes in antecedents or changes in consequences. Individuals with Autism are often more responsive to changes in antecedents than manipulation of consequences. If a staff member’s use of consequences (positive or negative) doesn’t seem to impact behavioral choices, than staff should put more focus on altering the antecedents. For example, if a “time out” consequence doesn’t seem to reduce selfish behavior, it may be because the individual doesn’t care about social interaction. It may be more effective to alter the antecedents leading up to the selfish behavior, for instance, by individually labeling everyone’s toy box.

Investigate

Staff should investigate systematic methods that are conducive to learning and generalizing new behaviors, and focus on managing physical environments to support the direct teaching and shaping of appropriate behavior (Heflin & Alberto, 2001). The TEACCH program emphasizes the importance of “Structured Teaching” as a way of providing a foundation and structure for learning. Structured teaching strategies are taught to give people with Autism organizational strategies they can use at school, at home, and at work. The four components of Structured Teaching are: 1) Physical structure (eliminating distractions, providing visual organization, and enabling predictability), 2) Individualized schedules (to help connect behaviors to consequences, visualize process, and see order with minimal prompting/cueing to help develop independence), 3) Work Systems (to answer four key questions in advance: What work will I do? How long will I do it? How do I know when I’m finished? And what’s next?) and 4) Visual Structure within Tasks (visual reinforcements that help individuals organize tasks) (Schopler et al., 1995). The structured teaching strategies used in the TEACCH program enhance learning and provide predictability, which results in minimizing anxiety and minimizing behavioral problems. One of the resources utilized in investigating how to create a more structured teaching system is a list of “57 questions” that staff members can use to examine how the environment they create can impact a client’s behavior (Love, 2004). The questions encourage staff members to examine their efforts in each of the key areas. For example:

• Can the physical environment be changed or made clearer?
• Have we set up a clear structure and schedule?
• Do we have clear and predictable routines?
• Do we build on the individuals’ strengths and interests to develop activities?
• Do we offer social, leisure, solitary, and exercise opportunities?
• Do we offer an effective communication system? Do clients know how to use the system effectively?

Negotiate

Negotiating an effective communication system that connects clients, staff members, family members, and even members of the general public is one of the staff member’s most important tasks. Since a key element of Functional Communication Training is to replace challenging behaviors by teaching individuals how to communicate their needs, an easy and effective communication system is essential in this process. Communication methods that may be available to a client are: spoken communication, sign language, picture exchange communication system (PECS), augmentative communication systems (picture boards), and vocal output devices (Durand, 1993). PECS and vocal output devices have several advantages; they are personalized, easy to use, and most importantly, others may be more likely to respond to them. In a 1982 study (Durand, 1993), less than two-thirds of the initiation made by students with simple communication boards was responded to by adults. If individuals do not respond, the applicability of such tools in public settings is limited, and may cause greater communication frustration. PECS and vocal output devices, however, can produce requests that are recognizable by anyone (i.e., “Could you help me with this?”), which provides an effective means of communicating wants/needs and results in reduced rates of challenging behavior (Durand, 1993).

Based on the staff members’ answers to other areas of the “57 questions” list, staff will probably identify additional areas where they can help support positive communication, structured environments, and generally improve their interventions. As such, they will need to negotiate new plans for prevention and intervention. An emphasis on generalization of skills through application in real-life situations and collaboration with parents and professionals is essential. Often, whole systems need to be redesigned to support behavioral modifications. It is important to negotiate system-based collaboration in developing behavioral plans with: family members, teachers, psychologists, caregivers, therapists, administrators and other influential individuals. Across the board training may be necessary to ensure that behavioral expectations and limit setting are consistent. Parent Education initiatives can help to integrate new behaviors and responses into family routines and other specific contexts in which challenging behavior occurs (Moes & Frea, 2002). Research suggests that consideration of family context in the assessment and intervention planning process contributes to the stability and durability of reductions in challenging behavior achieved with functional assessment and FCT (Heflin & Alberto, 2001).

Give

Give time for new plans to take effect before re-evaluating them. Several interventions are almost always necessary because behavioral change is an ongoing process. Be sure to act as a team and give immediate consequences and positive reinforcement to help clients connect the new behaviors to the consequences. Reduce prompts and increase expectations gradually in order to encourage independence, and give control back to the client to develop a sense of ownership over their own behavioral choices. Promote comprehensive programs that focus on developing life skills for a variety of contexts and situations (Dalrymple, 1987).

The CPI Postvention Model^SM, in conjunction with many of the resources and suggestions discussed in this article, provides effective ways to turn the post-crisis experience into preventative opportunities. However, successful prevention, intervention and postvention require patience, creativity, a willingness to adjust staff strategies, and a commitment to an ongoing process of learning. When preventative and comprehensive programs are utilized, positive effects can be seen in a variety of areas. Organizations focused on employing such “best practices” report a 95% reduction in restraint, have reduced the use of seclusion by 86%, have seen a statistically significant reduction in rates of staff injury, have found success in helping individuals with ASD learn new skills, and have profoundly contributed to the quality of the lives of people with ASD and their supportive communities (Carlson, 2004). Although the use of alternative interventions is often more time consuming and more creatively challenging, your contributions to this process are essential in providing the best care, welfare, safety, and security for you and the individuals you care for.

For additional information and ideas to help you and your staff successfully implement the Postvention process with clients with Autism Spectrum Disorder we recommend the following resources:

TEACCH Program http://www.teacch.com/ (research, networking, and training)

Applied Behavioral Analysis http://www.iaba.com/

PECS www.pyramidproducts.com (PECS resources and training)

Social Stories http://www.thegraycenter.org/Social_Stories.htm

http://www.autismsociety-nc.org/ (information, services, conferences, online bookstore)

http://www.do2learn.com/ (games, resources, picture systems, learning tools)

http://www.tasksgalore.com/ (curriculum & assessment materials for teachers and psychologists)

Indiana Resource Center for Autism at the University of Indiana, Bloomington. Call (812) 855-6508 to order a list of publications.

Fouse, B. Creating a win-win IEP for students with autism: A “how to” manual. University of Texas at Tyler. ISBN: 1-885-477-28-7.

REFERENCES

Bock, M. (1999). Sorting laundry: Categorization strategy applied to an authentic learning activity by children with autism. Focus on Autism and Other Developmental Disabilities, 14(4), 220.

Carlson, S. (2004). Supporting individuals with autism spectrum disorder. Journal of Safe Management of Disruptive and Assaultive Behavior, 12(2), 3-5.

Champagne, T. & Stromberg, N. (2004). Sensory approaches: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing, 42(9), 35-44.

Crisis Prevention Institute (2004). Instructor manual for the Nonviolent Crisis Intervention^® training program. Brookfield, WI: Compassion Publishing.

Dalrymple, N. (1987). Helping people with autism manage their behavior. Bloomington, IN: Indiana Resource Center for Autism.

Durand, M. (1993). Using functional communication training as an intervention for the challenging behavior of students with severe disabilities. In L. Kupper (Ed.), (2nd Ed.) The national symposium on effective communication for children and youth with severe disabilities. McLean, VA.

Goetz, L., Gee, K., & Sailor, W. (1985). Using behavior chain interruption strategy to teach communication skills to students with severe disabilities. Journal of the Association for Persons with Severe Handicaps, 10, 21-30.

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This article is reprinted with permission from the Journal of Safe Management of Disruptive and Assaultive Behaviors, Volume XII, Issue II, published by the Crisis Prevention Institute. © Crisis Prevention Institute, all rights reserved.