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Overview of Tertiary Prevention |
Positive behavior support is an application of a behaviorally-based
systems approach to enhance the capacity of schools, families,
and communities to design effective environments that improve
the fit or link between research-validated practices and the
environments in which teaching and learning occurs. Attention
is focused on creating and sustaining primary (school-wide),
secondary (classroom), and tertiary (individual) systems of
support that improve lifestyle results (personal, health,
social, family, work, recreation) for all children and youth
by making problem behavior less effective, efficient, and
relevant, and desired behavior more functional.
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Examples of Tertiary Prevention |
Hannah
Riley
What
is Tertiary Prevention?
Tertiary Prevention was originally designed to focus on the
needs of individuals who exhibited patterns of problem behavior.
Research has demonstrated the effectiveness of PBS in addressing
the challenges of behaviors that are dangerous, highly disruptive,
and/or impede learning and result in social or educational
exclusion. PBS has been used to support the behavioral adaptation
of students (and other individuals) with a wide range of characteristics,
including developmental disabilities, autism, emotional and
behavioral disorders, and even students with no diagnostic
label.
Tertiary Prevention is most effective when there are positive
primary (school-wide) and secondary (classroom) systems in
place. In addition, the design and implementation of individualized
supports are best executed when they are conducted in a comprehensive
and collaborative manner. The process should include the individual
with behavioral challenges and people who know him/her best
all working together to promote positive change all working
as a behavioral support team (BST). Support should be tailored
to people's specific needs and circumstances. It should involve
a comprehensive approach to understanding and intervening
with the behavior, and should use multi-element interventions.
The goal of Tertiary Prevention is to diminish problem behavior
and, also, to increase the student's adaptive skills and opportunities
for an enhanced quality of life.
Tertiary Prevention involves a process of functional behavioral
assessment (FBA) and a support plan comprised of individualized,
assessment-based intervention strategies, including a wide
range of options such as: (1) guidance or instruction for
the student to use new skills as a replacement for problem
behaviors, (2) some rearrangement of the antecedent environment
so that problems can be prevented and desirable behaviors
can be encouraged, and (3) procedures for monitoring, evaluating,
and reassessing of the plan as necessary. In some cases, the
plan may also include emergency procedures to ensure safety
and rapid de-escalation of severe episodes (this is required
when the target behavior is dangerous to the student or others),
or major ecological changes, such as changes in school placements,
in cases where more substantive environmental changes are
needed.
What differentiates tertiary
(individual) intervention from other systems of positive behavior
support?
The main difference between tertiary and other levels of
positive behavior support is the focus of the interventions.
The defining features of Tertiary Prevention (i.e., identification
of goals, data collection and analysis, summary statements,
multi-element plans, and a monitoring system) address the
needs of individual children. It is support that is focused
on meeting individual needs; and the characteristics of individual
students and specific circumstances related to them (e.g.,
differences in the severity of behavior, complexity of environment)
dictate a flexible, focused, personalized approach. This means
that Tertiary Prevention allows teams to vary features of
the process (e.g., data collection tools used, breadth of
information gathered, specificity and number of hypotheses
generated, extent of the behavioral support plan, and degree
of monitoring) to provide the most individualized behavior
support possible.
When should a
program of Tertiary Prevention be implemented and who should
be involved?
Mandates provided by educational and human services agencies
define conditions in which individual systems should be used
to address concerns related to behavior. For example, IDEA
requires that a functional behavioral assessment (FBA) be
completed and a behavioral intervention plan (BIP) be implemented
when disciplinary sanctions result in extended periods (i.e.,
the first removal beyond 10 cumulative days and every change
in placement) in which a student is removed from an environment
or suspended (34 C.F.R. 300.520 (b) (c)). Individual systems
of support are warranted in other circumstances as well (e.g.,
when problem behavior is interfering with educational progress).
Who should be involved
in functional behavioral assessments and behavioral intervention
planning?
Tertiary Prevention is most effective when approached as
a collaborative (rather than expert-driven) process. Support
teams including the student’s family, educators, and/or other
direct service providers should be involved in assessment
and intervention. It is also helpful to include people who
have specific expertise in applied behavior analysis and intervention
design. In general, support teams should include people who
know the student best, have a vested interest in positive
outcomes, represent the range of environments in which the
student participates, and have access to resources needed
for support.
How can we address
the needs of individuals within group environments?
Individual systems and other levels of positive behavior
support are complementary in that well-structured group applications
(e.g., classroom management systems) provide a foundation
for effective individualized support. Often, the need for
individual systems is minimized by these broader systems;
however, some people require a greater degree of individualization
and support. It may be necessary to adapt features of group
applications (e.g., physical arrangement, routines, types
of rewards) to meet the needs of individuals within certain
settings
How
is Tertiary Prevention implemented?
Tertiary Prevention interventions are implemented through
a flexible, but systematic, process of functional behavioral
assessment and behavioral intervention planning. The following
outline illustrates the general steps of the process.
I. Identify goals of intervention.
Based on the available information, the team identifies the
specific concerns and goals:
- what the student is doing that is problematic (observable
behaviors).
- to what extent (e.g., frequency) these behaviors are
occurring.
- what broad goals the team hopes to achieve through intervention.
II. Gather relevant information.
Members of the behavioral support team gather information
through a variety of sources:
- review of existing records.
- interviews of support providers.
- direct observation of patterns, antecedents, contexts,
and consequences.
III. Develop summary statements.
The team uses the information to create statements that describe
relationships between the student's behaviors of concern and
aspects of the environments. These statements include:
- when, where, and with whom the behavior is most/least
likely to occur.
- what happens following the behavior (what they get or
avoid).
- other variables that appear to be affecting the person's
behavior.
IV. Generate behavioral support plan.
A plan is developed, based on the summary statements, to address
the behavioral concerns and fit within the environments in
which it will be used. The behavioral support plan (for students
who have IEPs this may also serve as the Behavior Intervention
Plan (BIP) includes:
- adjustments to the environment that reduce the likelihood
of problem.
- teaching replacement skills and building general competencies.
- consequences to promote positive behaviors and deter
problems.
- a crisis management plan (if needed).
V. Implement and monitor outcomes.
The team works together to ensure that the plan is implemented
with consistency and is effective in achieving the identified
goals. The team identifies the training and resources needed,
determines who is responsible for monitoring implementation,
evaluates outcomes (via continued data collection), and communicates
periodically, making adjustments in the plan, as needed.
How
should goals for Tertiary Prevention be determined?
Individualized positive behavior support focuses not only
on decreasing specific behaviors of concern, but also building
adaptive (and replacement) skills, and improving the individual’s
overall quality of life. Goals should be based on a positive,
long-term vision for the student developed with input from
the student, the student’s family, and the support team. An
excellent mechanism for determining broad goals for behavioral
intervention is person-centered planning.
Person-centered planning (PCP) is a process for learning about
an student’s preferred lifestyle. It involves creating goals
that will assist students in achieving their preferred lifestyle
within a collaborative team context. Most PCP plans are created
with the goal of:
- increasing participation and presence in the school and
community;
- gaining and maintaining significant relationships;
- expressing and making choices;
- experiencing respect and living a dignified life; and
- developing personal skills and areas of expertise.
How do we
know when an individual plan is effective?
Effective tertiary interventions produce measurable changes
in behavior and improvements in a student’s quality of life
(e.g., participation in integrated activities, improved social
relationships, independence and self-sufficiency). Individual
BIPs include objective methods for evaluating these outcomes,
and determining adjustments that might be warranted when progress
does not occur within a reasonable time frame.
What should be done when there
is a crisis situation?
Tertiary Prevention is a process that takes time to be effective.
When severe episodes of problem behavior occur, it is important
to provide a rapid response to ensure the safety of all involved
and produce a rapid de-escalation of the behavior. To support
Tertiary Prevention, therefore, safe crisis management procedures
are needed and should be planned thoroughly in advance. It
is important to remember that the goals of crisis management
procedures are to ensure the safety of the student and all
others, and to de-escalate the problem as rapidly as possible.
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