Functional Behavior Assessment

Report of Findings and Recommendations

Month 00, 0000

Student: AAA Date of Birth:
School: Age:
District: Classroom: SID/PID Self-Contained
Teacher/Case Manager:
Behavior Analyst:

Dates of Assessment:

• Observation and work with student and classroom staff: January 10, 20, 27,
February 10, March 2, 9
• Teacher interview: January 10 and throughout (including paraprofessional staff)
• Parent Interview: February 17, 2017

Problem/Functional Assessment

AAAA, “AA” is an nine-year, six-month old boy in Ms. BBBBB’s classroom at Atha
Road Elementary. His classroom serves students with severe and profound intellectual
disabilities. AA has a diagnosis of autism spectrum disorder, severe intellectual disability
and speech language impairment. He also has a seizure disorder; Mrs. CCCCC, AA’s
mother and Ms. BBBBB reported there was a period of increased frequency of seizures in
2013/2014 resulting in a lengthy hospitalization, and reported declines in behavioral
functioning.

AA was referred for a functional behavior assessment (FBA) of his challenging behavior,
which includes self-injurious (SIB), tantrums, aggression and property destruction. SIB,
which includes head hitting and banging, and biting self (typically his hands) is the most
severe and dangerous of the behaviors with events often occurring between 50% and 60%
of observation intervals during a school day. The behavior has caused a permanent
swelling or hematoma on his forehead and ears (“cauliflower”). He has also injured his
nose, eyes and hands. More severe or lengthy behavioral episodes result in tissue
reddening, “fresh” or additional swelling, abrasions and lacerations. These episodes
require the use of protective equipment (helmet with partial face guard, Rifton® chair
and splints, all approved via physician order), and while the equipment is being applied
AA often becomes aggressive including hitting, kicking, pinching and biting others. On
the other hand, AA engages in mild head hitting that may occur independent of other
target challenging behaviors and appears to be stereotypic or, possibly, a habit. In fact it
often occurs just prior to or while his falling asleep.

In addition to the aggressive behavior that occurs with episodes of SIB, AA engages in
aggression that appears to be more “random” including reaching out and hitting another
or pulling someone’s hair as he ambulates from one location of the classroom to another.
Property destruction also occurs concomitant with SIB, and less frequently, independent
AABBBB FBA/BIP Addendum 3/14/17 page 2

of SIB. This includes swiping items from tables, throwing objects, pulling an adult’s
hair. AA tantrums include any combination of SIB, crying, screaming, and falling to the
floor. Lastly, he displays non-aggressive spitting (placing his tongue between his lips
and blowing), drooling and hand mouthing; these behaviors were not the subject of this
assessment.

AA was enrolled in the Marcus Autism Center, approximately 2013 (report was not
available) where he participated in an 18-week program of functional analysis and
followed by the design and initial implementation of an intervention. Further, he has was
admitted to Laurel Heights Hospital’s acute treatment unit for 18 days in April, 2016, for
behavioral treatment, leaving with a behavior plan for the home and community.

SIB, tantrums, and aggression were the primary focus of this functional assessment. The
assessment included teacher and parent interview, observation of AA during several
activities yielding descriptive (e.g, antecedent, behavior, consequence) information; trials
of simple, possible initial intervention procedures; and assistance in intervening during
tantrums, including the noted severe SIB. In addition the Functional Analysis Screening
Tool and the Questions about Behavioral Function were used, both designed to pinpoint
possible functional variables, or events in AA’s environment, related to his challenging
behavior.

Teacher and Parent Interviews

Ms. BBBBB

Information from the interview with Ms. BBBBB is referenced throughout the report
where relevant. Prior to any work by this clinician and working with Ms. BBBBB, she
summarized her assessment of AA’s behavior as related to several variables including:
escape from demands, tangible items (their removal or presentation), not doing what he
wants when he wants, and pain or discomfort.

Mrs. CCCCC

Mrs. CCCCC reported that AA has many health challenges related to his developmental
disabilities. These include disordered sleep, which has been effectively treated with
Clonidine (now used only as needed), and digestive problems—most notably,
constipation. He has been hospitalized related to constipation and receives MiraLax each
day. Mrs. CCCCC reported AA’s hearing is good and that he has astigmatism, though
the impact on his vision is unclear. AA is allergic to some medications (Zofran, Haldol).
He eats finger foods and will use a fork or spoon with hand over hand guidance to
prevent throwing.

Mrs. CCCCC’s assessment of AA’s challenging behaviors is consistent with much of Ms.
BBBBB’s assessment. She shared the following:
• AA’s SIB, and other challenging behaviors are related to pain, either unidentified
(e.g., headaches, constipation, gas), or as caused by the SIB
AABBBB FBA/BIP Addendum 3/14/17 page 3

• AA’s challenging behavior is worse when he doesn’t sleep well

• The behaviors are more likely and more intense when he has a cold
• He prefers to play and avoids demands, and will display challenging behavior
when required to engage in a non-preferred task (e.g., diaper change)

Mrs. CCCCC shared that the previously mentioned evaluation at the Marcus Center
showed his challenging behavior to be related to multiple variables, and that the treatment
outcomes from the clinic based treatment was short-lived due to difficulty replicating the
procedures at home. As noted, a report was not available.

AA was admitted to the hospital over the Thanksgiving 2016 break to begin a change
of course in his medications, including the psychotropic and antiepileptic medicines he
had been taking for many years. On November 20, Fentanyl was initiated, due to Mrs.
CCCCC’s and the pain management team’s assessment that AA’s SIB and other
behavioral challenges are related to pain. At the same time the following medications
were tapered, with all fully discontinued by January 9, 2017: Seroquel, Clonidine,
Neurontin, Trazodone, Valproic acid and Trileptal.

AA currently receives:
• Fentanyl 12 mcg/hr (via transdermal patch)
• Scopolamine (to treat excessive drooling, via transdermal patch)
• Miralax (to treat constipation)
• Clonidine, as needed for sleep

Mrs. CCCCC reported that AA’s behavior has improved substantially through the
medication adjustment process. His SIB and tantrums were reported as less
frequent and intense/severe, and, that he is much easier to redirect.

Mrs. CCCCC’s primary goal for AA is that he “have the best quality of life possible.” In
addition, she wishes others understood his communication as she does and would
like to see his skills improved in this area. Lastly, she reported that AA has “issues
with food sensitivity and acceptance” and consumes five cans daily of Pediatric
Complete formula. She would like to see him learn to accept more foods and
decrease the use of formula.

Classroom Observations, Descriptive Functional Assessment and Interview

Findings

I observed AA during several classroom activities including arrival, morning group

activity, breakfast, 1:1 instruction, and less structured times in the classroom. The
observations included a descriptive functional assessment (possible setting events, and
antecedents and consequence variables related to target behaviors). As reported above,
there was a dramatic decrease in AA’s challenging behavior just as this assessment was
beginning. The data below suggest this change is related to recent, significant,
adjustments to AA’s medication regimen (discussed in detail in the Data Discussion
section). Ms. BBBBB reported that, in addition to decreased rates of the behaviors there
AABBBB FBA/BIP Addendum 3/14/17 page 4

was also a significant decrease in intensity or severity of behavioral events. Thus the
initial part of the assessment included many periods when AA was happy (smiling,
“relaxed”) and calm, and he participated in classroom activities in the absence of the
reported behaviors. This allowed for observation of AA’s performance in instructional
activities with limited disruption, while other parts of the assessment included low to high
severity target challenging behavior. Observations during classroom activities were as
follows:

Morning group/song

AA was physically prompted to sit as the morning song began. The classroom staff sang
along and clapped. AA clapped 2-3 times independently. When a switch (a simple
assistive communication device) was presented AA readily touched the “hi” switch, then
touched his picture on two consecutive trials.
• He dropped a container holding beads continually throughout this activity, which
may have helped him participate. Dropping objects that make noise is reportedly
a highly preferred, perhaps reinforcing activity.
• Following his turn to say “hi”, AA dropped from his chair to the floor and began
lifting (tilting) and dropping the chair leg, which appeared to be maintained by the
noise made by the dropping.
• I moved the chair away, and requested a “high five”; when AA responded I
dropped the bead container. Several trials were repeated. This simple instruction-
response-reinforcement contingency (“high five” – hand slap exchange – noise)
appears very effective with AA at times of low rate challenging behavior.
• He then responded to the instruction “stand up.”

AA participated in a diaper change in the absence of SIB, aggression tantrums and

property destruction. These behaviors are reported as being highly likely during diaper
changes, prior to the recent period of improved performance.

One-to-one instructional activities:

I observed Ms. Cheryl Johnson’s speech session with AA. He is working on an early
phase of a picture communication system, making an exchange of a generic (blank)
picture card for his fork, allowing him to take a bite of breakfast. His hands are
shadowed or held down between trials to minimize grabbing items on the table or staff.
When AA receives the fork he is physically guided to take a bite. I offered a suggestion
on how to position oneself in relation to a student when physically guiding—with one’s
body and guiding hand oriented the same as student’s body and hand. I also suggested
offering a bite of food, rather that the fork, contingent on the picture response, so that
reinforcement (if in fact food is reinforcing) follows the communicative response
immediately. This may lead to faster skill acquisition.

During Ms. BBBBB’s 1:1 session with AA, she worked on stacking various colored
shapes onto pegs. AA participated for 10 minutes. He began dropping the wooden
shapes, again, seeming to enjoy to the noise. I demonstrated how to use this as a
AABBBB FBA/BIP Addendum 3/14/17 page 5

reinforcer during the teaching session, by first requiring that a shape be placed on a peg,
followed by giving AA a peg for dropping/spinning. He completed several trials in this
fashion. This session ended with AA falling to the floor, appearing uncomfortable, or in
pain. He began to whine, and then cry (with tears). He then began drooling, banged his
head on his hands several times, and hit staff when they attempted to block. His helmet
was applied and splints were considered but not needed. He then lay on a beanbag chair
and fell asleep. Ms. BBBBB described this event, particularly the crying, as “not
typical.” The episode appeared to be related to discomfort or fatigue; it is possible that
one or the other made him more sensitive to the instructional demands, following several
successful trials.

Arrival

During an observation of AA’s arrival to school in the morning, he was falling asleep
(“dozing”). When in the classroom he was removed from his chair. He fell to the floor
and began banging his head against his forearm, though with limited force. Nevertheless,
his forehead and nose became red. His helmet was applied—he then moved to the
beanbag chair and fell asleep. The helmet was removed once he was asleep. Being
moved from a preferred (chair and dozing) to less preferred activity/location precipitated
the self-injury. In addition, he was fatigued, likely a setting event to many of AA’s
difficult behavior—i.e., when tired he is more likely to respond adversely to
environmental events such as moving from a preferred to a less preferred
activity/location.

On another arrival occasion, while still in his chair, AA was given a toy octopus (a
favorite toy). He repetitively dropped the toy, followed by spitting (“raspberries”).
When I removed the toy, he began to hit his head. He later began chewing on a strap
from his chair; when removed, he began to head hitting. On one occasion, I blocked the
response and following a moment of no attempts re-presented the desired toy. This
sequence suggests SIB is related to the removal and presentation of favored objects, or
tangible reinforcement. Following the removal of the object, AA may begin SIB, which
may be immediately followed by the presentation of a toy or favored object, reinforcing
the self-injury.

Less Structured Activities

AA was observed on several occasions in the “sensory” room, which is equipped with a
swing, objects for visual stimulation on the wall, therapy balls, etc. He prefers this
location when he is not involved in direct instructional activities, and at times, during
instructional activities. A severe episode of SIB and aggression occurred on one occasion
when AA, had difficulty either entering or removing himself from the swing. He was
assisted to leave the swing and once free from the swing began to bang his head. I
attempted to return him to the swing, which he resisted and led to increased SIB and
aggression. The episode escalated to the pointed where AA and staff were injured. The
helmet, Rifton and splints were used. After a struggle to apply the equipment he calmed.
It is possible that protective equipment serves to reinforce the problematic behavior. Not
AABBBB FBA/BIP Addendum 3/14/17 page 6

all episodes end in this manner—so the equipment is used intermittently, and if it is
reinforcing, this can lead to behavior that is highly resistant to change.

Related, AA left the general classroom following morning group, breakfast and
individual instructional activities. He went into the sensory room, which is not available
during the morning. He lay on a mat and began banging his head. To assess for attention
as a potential reinforcer, I approached AA on each of several successive head bangs and
offer a common attention response. For example, “AA you’re going to hurt yourself”, or
“AA, stop banging your head.” On each of several trials, AA looked at me and stopped
banging, resuming after 15-20 seconds, at which time this pattern continued. Under these
circumstances, attention appeared to be a controlling variable.

The attention trials were followed by a test of tangible reinforcement or, possibly “alone”
as a variable maintaining SIB and AA’s other challenging behaviors. This was conducted
by prompting AA to leave the sensory room, first verbally and then with physical
guidance. When he would attempt to fall to the floor, a blank “pictorial” icon was placed
in his hands by Ms. BBBBB, which I removed while stating “my turn”; and “oh, AA, you
want more turn in the room, sure.” We repeated this on several trials with AA resisting
less on subsequent trials. This suggests the following: 1) the sensory room may be
controlling variable of challenging behavior, and/or 2) time alone or away from others
may be functioning to reinforce the tantrums, 3) AA can learn a simple request (“mand”)
response to access desired items.

After several trials of the picture exchange procedure, AA’s tantrum/SIB escalated. It
was discerned that he had had a BM, so was taken for a diaper change. He lay still for a
diaper change, after which all challenging behavior ceased. This again suggests AA may
be responding to discomfort with attenuation of the discomfort possibly reinforcing the
tantrum that preceded it. For example, AA becomes constipated, engages in target
challenging behavior, is changed and feels better (reinforcer).

Functional Analysis Screening Tool and Questions About Behavioral Function

Findings

The Functional Analysis Screening Tool (FAST) was completed by Ms. BBBBB as part
of the current assessment, prior to my work with she or AA. The FAST is designed to
identify or pinpoint variables that influence the target challenging behavior; in this case
Ms. BBBBB completed the tool for SIB. She endorsed items related to “automatic
reinforcement” (sensory stimulation) most frequently, suggesting the behavior is
reinforced by positive sensory reinforcement and occurs independent of environmental
events. Social reinforcement in the form of escape (e.g., from demands or other
stimulation aversive to the student) was the second most frequently rated category.
Social reinforcement in the form of attention and automatic reinforcement in the form of
pain attenuation were third and forth, respectively, in the ranking of variables considered
important.
AABBBB FBA/BIP Addendum 3/14/17 page 7

The Questions About Behavioral Function (QABF) is similar to the FAST in that it is
useful as an indirect assessment of the function of an individual’s behavior, and can serve
as one tool in the FBA process. The results of the QABF, also completed by Ms.
BBBBB, scored items in the categories escape from demands, environments, others, and
physical variables yielding the highest scores available for number of items endorsed and
severity. Non-social variables, such as those described above as automatic reinforcement
(sensory) also scored high in both categories.

Preferences/Reinforcers

Preferences were assessed through the interviews, classroom observation and direct work
with AA. All reported or observed the reinforcing properties of noise produced by
dropping hard objects—this was directly illustrated in the “high five” interaction and
stacking shapes on pegs activities described above. Social attention, hugs or chest
squeezes, coke (and carbonated beverages generally) and time alone, particularly in the
sensory room, were also identified as preferences, and may have value as reinforcement
during instructional trials and interventions targeting reduction of challenging behavior.

Data Collection Considerations

The data collection used by the classroom staff included a 30-minute partial interval
recording tool for SIB, tantrums, and property destruction, with frequency recording for
aggression (data from this tool are displayed later in this report and the primary data
considered in this functional assessment). Aggression was recorded during the same
intervals as the other behaviors—as a more conservative, and likely more accurate index,
aggression is also considered as percentage of 30-minute intervals.

Following interview of AA’s teacher Ms. BBBBB, and review of the data using the tools
in place, the high rates of the target challenging behavior suggested that a momentary
time sampling (MTS) tool may be more efficient. The MTS would allow for data entry at
five minute intervals with recording only when the behavior was observed at the moment
the five-minute interval ended. However, as reported below, a dramatic decrease in AA’s
challenging behaviors occurred just following the beginning of this assessment. Thus,
Ms. BBBBB and I agreed, leaving the current tool in place would be sufficient.

The MTS tool was initiated following a recent (early March, 2017) uptrend in the
behavior. After a morning of use, Ms. BBBBB reported the MTS approach was resulting
in many incidents of challenging behavior being unrecorded. Therefore, the data
collection method was changed to five-minute partial interval recording, wherein the
behaviors are recorded if they occur at any time in an interval.

Following this clinician’s most recent interaction with AA when engaged in a tantrum
and SIB, the Self-Injury Trauma Scale (SITS) was initiated and will be completed at
arrival and departure. The SITS will provide a measure of tissue damage/physical injury
and serve as a secondary measure of SIB during assessment and intervention processes.
AABBBB FBA/BIP Addendum 3/14/17 page 8

Finally, a record of each bowel movement (BM) at school is being kept to allow
evaluation of the relationship between constipation/BMs and the target challenging
behavior.

Behavioral Definitions

Classroom data collection tool:

SIB: Biting self, hit hitting with open or closed hand.

Aggression: Biting, pinching, hitting, kicking others, digging fingernails into other’s skin
(includes attempts)
Tantrums: Crying with or without dropping to the floor/wiggling around floor, lasting for
at least five seconds.
Property destruction: throwing things, swiping items off table, climbing on furniture,
digging into garbage.

Five Minute Partial Interval Recording Tool

SIB: Head hitting, banging head, biting self, or attempts.

Aggression: Head butting, biting others, kicking, scratching or attempts
Tantrums: Any combination of self-injurious behavior, falling to the floor, and
screaming.

Classroom Data

The following figures show AA’s behavior as sampled using the 30-minute partial
interval tool that was ongoing when the assessment was initiated. The figures show a
baseline period (or period prior to the most recent medication changes), the period when
the medication Fentanyl was introduced and the other medicines were tapered, and lastly,
the period with AA receiving only Fentanyl, Scopolamine, and Clonidine as needed for
sleep.
AABBBB FBA/BIP Addendum 3/14/17 page 9

Percentage Intervals SIB

100 +Fentanyl 12 Fentanyl 12 mcg/hr;
* mcg/hr; Scopolamine; Miralax;
90
Scopolamine; Miralax; Clonidine prn (sleep)
80
Clonidine prn (sleep)
70 •w/tapering of * until
60 1/9/17
50
40
30
20
10
0
4-Nov
9-Nov
14-Nov
19-Nov
24-Nov
29-Nov

3-Jan
8-Jan

2-Feb
7-Feb
12-Feb
17-Feb
22-Feb
27-Feb
4-Dec
9-Dec
14-Dec
19-Dec
24-Dec
29-Dec

4-Mar
9-Mar
14-Mar
19-Mar
24-Mar
29-Mar
30-Oct

13-Jan
18-Jan
23-Jan
28-Jan
Day

Figure 1: Percentage intervals self-injury during FBA with ongoing medication change.
*Seroquel – 200 mg TID; Clonidine – 0.1 BID; 0.2; Neurontin – 100 mg BID, 200 mg HS;
Trazodone – 50 mg HS; Valproic acid 180 TID; Trileptal; Scopolamine; Miralax

----------

Percentage Intervals Tantrums

100 * +Fentanyl 12 Fentanyl 12 mcg/hr;
90 mcg/hr; Scopolamine; Miralax;
Scopolamine; Miralax; Clonidine prn (sleep)
80
Clonidine prn (sleep)
70 •w/tapering of * until
60 1/9/17
50
40
30
20
10
0
4-Nov
9-Nov

2-Feb
7-Feb

14-Mar
19-Mar
24-Mar
29-Mar
30-Oct

14-Nov
19-Nov
24-Nov
29-Nov

3-Jan
8-Jan
13-Jan
18-Jan
23-Jan
28-Jan

12-Feb
17-Feb
22-Feb
27-Feb
4-Dec
9-Dec
14-Dec
19-Dec
24-Dec
29-Dec

4-Mar
9-Mar

Day

Figure 2: Percentage intervals tantrums during FBA with ongoing medication change.
*Seroquel – 200 mg TID; Clonidine – 0.1 BID; 0.2; Neurontin – 100 mg BID, 200 mg HS;
Trazodone – 50 mg HS; Valproic acid 180 TID; Trileptal; Scopolamine; Miralax

----------
AABBBB FBA/BIP Addendum 3/14/17 page 10

Percentage Intervals Aggression

100 +Fentanyl 12 Fentanyl 12 mcg/hr;
* mcg/hr; Scopolamine; Miralax;
90
Scopolamine; Miralax; Clonidine prn (sleep)
80
Clonidine prn (sleep)
70 •w/tapering of * until
60 1/9/17
50
40
30
20
10
0
4-Nov
9-Nov
14-Nov
19-Nov
24-Nov
29-Nov

3-Jan
8-Jan

2-Feb
7-Feb
12-Feb
17-Feb
22-Feb
27-Feb
4-Dec
9-Dec
14-Dec
19-Dec
24-Dec
29-Dec

4-Mar
9-Mar
14-Mar
19-Mar
24-Mar
29-Mar
30-Oct

13-Jan
18-Jan
23-Jan
28-Jan
Day

Figure 3: Percentage intervals aggression during FBA with ongoing medication change.
*Seroquel – 200 mg TID; Clonidine – 0.1 BID; 0.2; Neurontin – 100 mg BID, 200 mg HS;
Trazodone – 50 mg HS; Valproic acid 180 TID; Trileptal; Scopolamine; Miralax

----------

Percentage Intervals Property Destruction

100 +Fentanyl 12 Fentanyl 12 mcg/hr;

* mcg/hr; Scopolamine; Miralax;
90
Scopolamine; Miralax; Clonidine prn (sleep)
80 Clonidine prn (sleep)
70 •w/tapering of * until
60 1/9/17
50
40
30
20
10
0
4-Nov
9-Nov

14-Mar
19-Mar
24-Mar
29-Mar
30-Oct

14-Nov
19-Nov
24-Nov
29-Nov

3-Jan
8-Jan
13-Jan
18-Jan
23-Jan
28-Jan
2-Feb
7-Feb
12-Feb
17-Feb
22-Feb
27-Feb
4-Dec
9-Dec
14-Dec
19-Dec
24-Dec
29-Dec

4-Mar
9-Mar

Day

Figure 4: Percentage intervals property destruction during FBA with ongoing medication change.
*Seroquel – 200 mg TID; Clonidine – 0.1 BID; 0.2; Neurontin – 100 mg BID, 200 mg HS;
Trazodone – 50 mg HS; Valproic acid 180 TID; Trileptal; Scopolamine; Miralax
AABBBB FBA/BIP Addendum 3/14/17 page 11

Data Discussion

Figures 1-4 display AA’s SIB, tantrums, aggression and property destruction presented as
percentage intervals he engages in the behaviors on school days using the measurement
tool described. The behaviors all decreased some upon the initiation of Fentanyl, with
further reductions seen when the tapering process for many of the other medications was
complete on January 9, 2017. Figure 1 shows that SIB decreased less than the other
behaviors, however, though the rate of occurrence was slightly lower, the classroom staff
and AA’s mother reported the behavior was much less intense and severe. Finally, at the
end of each figure, a clear and immediate upward trend in the percentage intervals the
behaviors occurred increased substantially, and the events were reported, and observed
by this clinician to be more like those seen prior to medication changes.

The data suggest that Fentanyl and the tapering of several (listed in figure notes)
medications are related to significant behavioral improvement during the period between
approximately January 17 and the end of February, when an upward trend in the
behaviors began. However, this analysis does not allow discernment of which variable(s)
are most important, since Fentanyl and tapering were simultaneous—it is possible that
AA’s improvement was also, or solely, related to the withdraw of one or more of the
discontinued medicines. Similarly, the recent uptrend in target behaviors, particularly
with increased intensity including new tissue damage, may be related to acclimation to
the Fentanyl dosage, or again, a delayed response to the withdraw of one of the other
medicines that may have had some therapeutic benefit, though this was not evident before
the introduction of Fentanyl. Lastly, it is possible this is a brief “relapse” (at the time of
this writing) unrelated to medication changes.

FBA Summary and Recommendations

The FBA was unique due to AA’s significant behavioral improvement as the assessment
began. Nevertheless, the information gathered provides sufficient initial information
regarding the variables related to AA’s challenging behavior. The increase in target
behaviors in early March allowed direct observation and interaction with AA during
episodes of severe SIB, and aggression. Further, though limited, the recurrence of the
severe episodes allowed direct assessment trials of functional variables and tests of
potential intervention methods.

AA’s challenging behavior appears to be influenced by several variables, including

physiological variables and medical (medication) intervention.

The behaviors are more likely to occur under the following physiological conditions
which may serve as setting events, or variables that make AA more sensitive to the
environmental events that are also related to his behavior (described below). For
example, when he is physically uncomfortable, he may be more likely to display SIB
when a demand is presented compared to when he is feeling comfortable. The variables
include:
AABBBB FBA/BIP Addendum 3/14/17 page 12

• When constipated or following 2-3 days without a BM (this time period can be
better specified when more data on BMs are gathered)
• When he displays symptoms of illness/cold symptoms.
• When his sleep is disturbed. This is by parent report. Data on sleep and its
relationship to challenging behavior will better ascertain this and how and when
to intervene with regard to his sleep routine.
• Pain without an identifiable source (reported by Mrs. CCCCC and Ms. BBBBB
based on facial expressions, crying, SIB in the absence of other circumstances that
may make the behavior more likely).

The behaviors appear more likely under the following conditions:

• When he cannot access a desired object/activity or event, or tangible
reinforcement -- the behavior may occur because of a history of being given
access to the desired object/activity following the behavior.
• When demands are presented. AA’s behavior often results in escape from
demands, particularly when the episodes require use if protective equipment.
• When he is alone, or specifically, alone in the sensory room and his “alone” time
is terminated.
• When attention is made available when problem behavior occurs.
• When alone—however, target behaviors typically only occur when he is alone
and appears in pain or discomfort, or is sleepy/fatigued.

The effects of the medication interventions are difficult to precisely discern for the
reasons detailed in the Data Discussion section. Additional data collection will provide
more, important information, regarding the benefit of the current medication regimen.

Ongoing and Additional Assessment Recommendations

1) Trial-based functional analysis: this is a relatively short running assessment

where behavioral function can be ascertained in direct and controlled fashion.
The assessment has been shown to yield reliable findings of behavioral function,
similar to more traditional, lengthy, functional analyses. Further, it is appropriate
for students with dangerous behavior because a session stops on the first
occurrence of the behavior. A behavior analyst (BCBA) with training and
experience with experimental functional analysis of self-injury should
conduct/oversee this analysis.
2) A more direct assessment of C’s preferences and reinforcers may reveal items
useful for both skill acquisition and behavior intervention programming.
3) The five-minute partial interval recording tool should continue as the primary data
collection instrument.
4) Begin to note dates when symptoms of illness are apparent on the interval
recording data sheet.
5) AA’s sleep and its relationship to behavioral episodes should be more thoroughly
evaluated. Sleep should be measured either as precise hours slept, or using a scale
based on family best approximation (e.g., 8-10 hours, 6-8 hours, 4-6 hours, <6
hours).
AABBBB FBA/BIP Addendum 3/14/17 page 13

Considerations for Intervention

A behavior intervention plan should follow this assessment and include the following
procedures with precise details for implementation:

Skill acquisition

1) Use noise from dropped hard objects (e.g., toy octopus with plastic feet, bead
shaker, shape sorter, wooden pegs) as a reinforcer contingent on accurate
responding, even when prompted. Prompt fading and increasing the criterion for
reinforcement should occur as AA begins to respond more reliably and with less
resistance.
2) Since most of AA’s instruction requires hand over hand physical prompting, it is
very important that the instructor orient their body such that they are positioned
the same way as AA. The instructor’s right hand should be used to prompt AA’s
right hand from his right side, without obscuring his vision.
3) The picture communication system should continue to be pursued with an
increase in the number of daily trials and trials across several environment. A
modified version of the Picture Exchange Communication with touch rather than
a picture exchange seems appropriate.

Problem Behavior

1) Continue current use of protective equipment. The need for detailed

documentation of each application of the equipment should be evaluated with the
school nurse and special education administration.
2) Two, and some times, three adults should assist with diaper changes to maintain
AA’s safety and the safety of those changing him.
3) AA should receive non-contingent attention every 2-3 minutes at a moment when
he is not displaying challenging behavior.
4) A behavior analyst (BCBA) with skills and experience evaluating medication
efficacy using behavioral data should conduct ongoing assessment, including
collaboration with medical professionals when necessary (e.g., data sharing)
5) When AA displays any of the following, instructional and classroom routine
demands should be minimized and the rate of reinforcement increased:
a. Appearance of sleepiness; if dozing, he should be allowed to rest in his
chair or on a beanbag chair (unless otherwise indicated, for example as
part of a sleep intervention).
b. When his mother reports that his sleep was limited the previous night
c. Appearance of illness: red or puffy eyes and rubbing eyes, nasal.
discharge, weepy or crying without other target behaviors.
d. Two to three days with no BM – current data collection will help make
this more precise.
6) When low-intensity SIB occurs, such as very light head hits/taps, or tapping his
helmet on the floor, do not respond and delay the delivery of any reinforcement
for at least 30 seconds of the absence of the behaviors.
AABBBB FBA/BIP Addendum 3/14/17 page 14

7) Require a simple mand (request) as AA indicates he wants something, such as

access to the sensory room, or a toy. This can include a point toward the desired
object/room, a hand off or touch of a blank picture card. This should be done
throughout the day.
8) When AA engages in SIB or aggression occurs: a minimum of two adults should
be available to block attempts of both behaviors, use Crisis Prevention and
Intervention or similar crisis management techniques (if trained and certified) if
necessary, followed by use of protective equipment, if the episodes escalates to
the point that AA can no longer be protected with blocking.
9) Injuries should be evaluated and treated by the nurse.

In addition to the recommendations above, a session-by-session function and skill-based

intervention should be considered. This type of session should be run multiple times
daily and continuously evolve as AA’s skills develop, requiring very close oversight.
One example of this type of procedure is in the description in the Classroom
Observations, Descriptive Functional Assessment and Interview section above, where a
simple communicative exchange yielded an opportunity for AA to access or remain in a
favored location and receive a favored item on multiple repeated trials. By handing the
blank card to the clinician, AA “asked” for “my turn” with the favored objects, or to
access the sensory room. This was done whether or not challenging behavior occurred.
Repeated administration of such an intervention will be required to build this
communicative replacement behavior. Given the dangerous and highly complex nature
of AA’s challenging behavior, this procedure should be developed and initiated by a
senior level behavior analyst with extensive experience in the functional analysis and
treatment of severe self-injury. The sessions should run with two people: the behavior
analyst should work with Ms. BBBBB and/or a Registered Behavior Technician (RBT), a
direct therapy level behavior analyst technician, training and implementing the
procedures together. When the team is running the procedures with consistent
proficiency under direct supervision, daily training in the absence of the supervising
clinician can begin.

Please feel free to contact me with any questions.

_______________________
First Last, AbC, BCBA
Title/Role
Affiliation