RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES

Recognizing Biologically- Based Problem Behavior and Effective Intervention Strategies Nina Kurfman University of Illinois at Urbana- Champaign

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES Introduction Ones quality of life can be enriched with good health, yet individuals with intellectual disabilities experience more health problems than those of the general population. Overall, health problems experienced by those with intellectual disabilities are comparable to those experienced by the general population, yet at a higher rate. In addition, individuals with more severe disabilities may not have the communication abilities to verbalize the health problems they may be suffering, leading to conditions

going untreated. In recent research there is developing evidence linking health problems and rises in problem behavior (May & Kennedy, 2010). Problem behaviors such as aggression, self-injury, and tantrums, can hinder ones inclusion in areas of education, employment, socialization, and community assimilation. Knowing the impact continued problem behavior can have on an individuals life, educators are urged to use behavior interventions based on variables that induce and maintain behavior. Still in question is how does an educator make the judgment when ones behavior is related to illness or pain, especially when the individual has limited communication skills. Research has yet to identify what steps classroom teachers take in determining when a student is displaying illness related behavior, or how they alter intervention plans to insure the problem behavior is not being reinforced. The authors May and Kennedy (2010) highlight how disregarding the reinforcement possibilities may give rise to problem behavior becoming strengthened when lacking a health condition. This was communicated through an example of a boy with an intellectual disability who began scratching his irritated skin caused by a skin allergy. Once the skin irritation was cleared, the boys scratching continued because his behavior was being reinforced through an

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES increase in positive attention. This would indicate that while health problems can affect the degree of problem behavior, the problem behavior may continue once the health problem has been cured. Literature Review Challenging Behavior Problem behaviors engaged in by individuals with intellectual disabilities have

been characterized in numerous ways. Regarding behavioral extremes is one respect that problem behaviors have been defined, including aggression, destruction of property, extreme tantrums, self-injury, and stereotypical. However, problem behaviors can also be associated with behavioral deficits, for example sleep problems, unusual fears, and eating disorders. The author Emerson (2001) defined problem behavior as, culturally abnormal behavior(s) of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behavior which is likely to seriously limit use of or result in the person being denied access to, ordinary community facilities (p. 3). Even though there are observable differences among the various definitions of problem behavior, there is an understanding relating the occurrence of problem behavior to an increase chance of individuals being vulnerable to physical restraints and being medicated. When the event of problem behavior has the potential of being harmful to others, the individuals inclusion of social, educational, and day services can be impacted, perhaps requiring residential care outside the family unit or long-term inpatient care. These factors act as key sources of stress on the family and could increase the probability of an abusive relationship forming from the caregivers.

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES Research has shown that individuals with intellectual disabilities are three to five

times more likely to engage in problem behavior than the typical population (Poppes, van der Putten, & Vlaskamp, 2010). Although this is known, little research has been done to gain information on the prevalence of problem behavior among individuals of this population, and there is a lack of literature regarding interventions and effects on problem behavior. To address these gaps in the research, Poppes et al. (2010) conducted a study to verify the prevalence, frequency, and severity of self-injurious, stereotypical, and aggressive behaviors among individuals with profound intellectual and multiple disabilities (PIMD), and studied the relationship concerning the occurrence of challenging behavior and the existence of sensory impairments and general health problems. In relation to this study, PIMD is defined as having an IQ of 25 or below and a diagnosis of a profound or severe motor disability and sensory impairments. The participants of this study consisted of 181 individuals from the Netherlands with profound intellectual disability and a profound or severe motor disability, the existence of sensory problems and other health problems were reported in some but not all participants. The mean age of participants was 35 years, ranging from 3-62 years of age, with 56% of the individuals being male and 44% being female. After gaining permission to conduct the study from the facilities, healthcare psychologists selected individuals with profound intellectual and multiple disabilities within those facilities through informed consent. Data were collected through the completion of questionnaires filled out by direct support staff that had known the individual for two months or more, and were provided written instructions on how to complete the forms.

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES In regards to this study, the term challenging behavior was defined using the

Dutch translation of the Behavior Problems Inventory (BPI) (Poppes et al., 2010). This is a behavior rating scale that applies to individuals of all ages with diverse intellectual disabilities that targets three types of behavior being self-injurious, stereotypical, and aggressive behaviors. When an individual displays a challenging behavior, the behavior is scored pertaining to two separate scales, frequency and severity. The individual must have engaged in the behavior at least once in the past two months from it to be scored. In addition to the completion of the BPI, a questionnaire was done for each participant by a direct support staff member to gain information on medical diagnosis, age, gender, health problems, and degree and prevalence of sensory problems. Out of the 181 participants, 166 individuals engaged in one or more type of challenging behaviors, with an average of nine behaviors being scored per individual, three concerning self-injurious behaviors, five of stereotypical behaviors, and one of aggressive behavior. On average, self-injurious behaviors were observed on a daily or weekly basis, stereotypical behaviors on a daily basis, and aggressive behaviors on once a week. The outcome of this study showed a high prevalence of problem behavior in individuals with PIMD. This study also discovered an association among having visual, tactile, or psychiatric problems with the existence of problem behavior. As stated prior, problem behavior can negatively effect ones quality of life by restricting the opportunities for community living, employment, and education inclusion, as well as presenting the individual as a hazard to self and/or others. This has lead to the importance of assessing the factors that predict and maintain problem behavior in current research. Studies have proven behavioral interventions based on functional assessment to

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES be more effective than those interventions that are not (Carr et al., 2003). Functional assessment strategies focus on recognizing the antecedents, or triggers, and consequences, maintaining factors, for problem behavior. When discussing maintaining variables, data illustrates that problem behavior can be maintained by attention from others, escape from an aversive task, escape of a social contact, access to preferred tangible items, positive sensory reinforcement, and escape from an aversive sensory stimuli. Functional Behavior Assessment

Problem behavior can have a negative effect on the learning and safety of students and educators, making educators accountable for implementing behavior plans that are effective in decreasing problem behavior. Amendments made to the Individuals with Disabilities Education Act in 1997 made it mandatory for schools to respect functionbased intervention plans for students with disabilities who displayed more severe behavior. Function-based supports encompass both assessment and intervention components. Functional assessment is termed a process of collecting information about a person and his or her environment. The end result of a functional behavior assessment yields record of events correlated to problem behavior, relating to the four-term contingency model. This model expresses all events and stimuli, both of the internal and external environments, that have the ability to shape behavior. It outlines setting events, antecedents, and maintaining consequences attached to problem behavior. Also, a functional assessment will highlight lifestyle concerns in need of addressing to improve ones quality of life. Data gathered through this assessment is critical in isolating

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effective and efficient ways to decrease problem behavior, strengthen desirable behavior, and confirm ones good quality of life. In order to create an effective and long-term behavior plan, the assessment must be comprehensive, consisting of multiple components and addressing all aspects of the persons life. Information gathered when conducting a functional assessment can be classified into two groups, broad information and specific information. Broad information includes major life events, health factors and physical issues, past interventions, academic performance, strengths, weakness, preferences, and general quality of life. Specific information takes in evidence on antecedents, events arising before a problem behavior in the direct environment; setting events, dealings that indirectly impact the role of antecedents and consequences connected to problem behavior; and maintaining consequences, events occurring after the problem behavior in the direct environment. The end result of the assessment offers a clear representation of the link between the environment and behavior, used to form hypotheses statements. The goal of a functional-based assessment is to create an individual behavior plan that offsets and removes variables that generate the problem behavior, instruct the student of a replacement behavior that will increase personal independence, and organize the environment to create consequences that promote desirable behavior and decrease problem behavior. Ingram, Lewis-Palmer, and Sugai (2005) conducted a study to inspect the effectiveness of function-based behavior interventions compared to non-function-based behavior interventions to decrease problem behavior. Participants of this study were two middle school boys who met the criteria of receiving no special education services,

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES displayed problem behavior(s) that affected their grades, and had not had a functional behavior assessment (FBA) prior to this study. A FBA was conducting regarding both students, including a teacher-directed functional assessment interview and a studentdirected functional assessment interview; hypothesis statements were formed using this

information. Direct observations during times with the problem behavior was most likely to occur and least likely to occur were done to confirm hypothesis statements. At this stage in the study, two separate behavior intervention plan were developed for each student, one function-based and one not. The function-based behavior plans were developed around the information gathered from the FBA, focusing on variables that maintained behavior and incorporating strategies that defused setting events, offset antecedents, and decreased the effectiveness of problem behavior by teaching a replacement behavior. Non-function-based behavior plans were developed maintaining consequences not backed by the hypothesis statements. The authors conducted an A-BA-B experimental design across both participants and results showed a decrease in problem behavior with both students when under the functional-based interventions. Ingram, Lewis-Palmer, and Sugai (2005) concluding the study by stating, ...First, interventions that are based on FBA information can be more successful in reducing student problem behavior than interventions that are not based on functional assessment information. Second, the FBA and BIP processes were useful in improving the social behavior of high-functioning students in the general education classroom. Finally, descriptive assessment procedures contributed to the development of effective function-based interventions. (p. 234)

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES

In a different study conducted by Trussell, Lewis, and Stichter (2008), the purpose was to assess the influence of FBA-based interventions and targeted classroom interventions in decreasing problem behavior of individuals with emotional/behavioral disorders in special education settings. Participants were three students enrolled in an alternative public school who displayed externalizing behaviors, including aggression. Centered on the direct and indirect assessment data, a hypothesis statement was formed for each individual. Targeted classroom interventions were founded on classroom literature and consisted of recommendations to enhance classroom structure, while the FBA-based interventions were founded around the individualized data gather during the FBA. At the conclusion of the study, results indicated, across all individuals, targeted classroom interventions decreased problem behavior, however individual function-based interventions were more effective at decreasing problem behavior. Successful implementation of FBA and intervention models is reliant on effective staff development, giving educators the ability to create comprehensive training programs, promote school-wide application, and encourage ongoing supports (Dukes, Rosenberg, & Brady, 2007). A study done by Duke, Rosenberg, and Brady (2008) was conducted to gauge the efficacy of a short-term training design for special educators to enhance their knowledge and skills relating to FBA. Participants were special educators of an urban school in the southeastern United States. Participants were divided into two groups, one to take part in the training program and one that would not. At completion of training program, participants were surveyed, asking them to read scenarios and answer questions relating to function and recommendations for intervention, and answer

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multiple-choice questions to assess their knowledge of function of problem behavior. To summarize the result, participants who took part in the training program revealed a higher level of knowledge of behavior function than those participants who did not, however there was no difference demonstrated among participants in ability to recommend behavior change methods. Illness or Pain Related Problem Behavior Research as shown that function-based interventions, focusing on the variables that maintain problem behavior, are more effective in decreasing problem behavior than those interventions that are not FBA (Trussell, Lewis, & Stichter, 2008). These variables can be environmental or biological (Carr & Blakeley-Smith, 2006). Environmental variables involve antecedent discriminative stimuli, for example demands of an academic task, and consequences that reinforce problem behavior, both positive and negative (Carr & Blakeley-Smith, 2006). Lately, the position biological variables, such as physical illness, have in intensifying problem behavior is gaining attention in research with knowledge that individuals with developmental disabilities are more likely to experience both chronic and acute physical illness than those in the typical population. A study led by Carr and Owen-DeSchryver (2007) was completed to develop a reliable method of assessing the presence of physical illness and pain of individuals with severe developmental disabilities who had minimal communication skills, and to determine the presence of a positive association between the level of pain and the level of problem behavior. The participants of this study were 19 individuals with developmental disabilities from community residences and schools whose problem behaviors seem to increase during illness, and relevant informants. The informants were supplied with a list

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES of common, observable and measureable symptoms of illness including: running nose, coughing, congestion, sneezing, tearing eyes, vomiting, diarrhea, repeated rubbing of

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nose, ears, eyes, presence of cuts or swelling, extensive bruising, three consecutive days without a bowel movement, and presence of fever. On a day when either an observable or measurable symptom was observed by the informant, a behavior questionnaire was completed. To promote generalization, observation data was taken across environments, both the school and home settings. The findings of this study concluded that on days that the individual was sick, the frequency and intensity of problem behavior was greater than on days the individual was not sick. Also, the higher level of pain suffered by the individual, the greater was the frequency and intensity of problem behavior. Research has proven that a link has been established among such conditions as urinary tract infections, otitis media, and allergies as functions to problem behavior (Carr & Blakeley-Smith, 2006). The development in which physical illness might have on increasing problem behavior has been defined relating to a setting event model (Carr & Blakeley-Smith, 2006). The term setting event refers to general variables that encourage the maintaining connection among discriminative stimuli, response, and reinforcing consequences. Corresponding to this model, pain and distress linked with physical illness make a range of home, school, community, and workplace requirements more aversive than normal, furthering supporting escape driven problem behavior. If escape from such an aversive demand follows problem behavior, then such problem behavior will develop more likely when companied by physical illness. In a similar situation, the setting event model can be weakened by treating the illness or by varying the makeup of the instructional framework. Other studies have been conducted, under different contexts,

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revealing the need for problem behavior intervention strategies to encompass biological setting events. A study done by Valdovinos & Weyand (2006) was performed to determine if a relationship exists among blood glucose levels and problem behaviors in a female individual with developmental disabilities. This study discovered when the students blood glucose levels surpassed the range or were on the higher end of the range, the rate of problem behaviors rose, compared to when the students blood glucose levels were within or below the appropriate range. It was also found that when the students blood glucose levels were above the normal range, self-injurious behaviors were lower possibly stating that the student was more sensitive to pain at this time. A separate study done by Carr et al. (2003) tested the link between menstrual discomfort and severe aggressive and self-injurious problem behaviors among females with developmental disabilities. The results indicated the frequency of problem behavior was increased during menses. Similar, another study linked increased rates of problem behavior to the presence of otitis media (OReilly, 1997). Carr and Blakeley-Smith (2006) conducted a study with purpose to explore the relationship between physical illness and problem behavior by verifying whether the addition of behavior intervention to typical medical intervention would be more successful than medical intervention alone in decreasing dangerous problem behavior in children with developmental disabilities within a school environment. Participants included twenty-one students with developmental disabilities in early intervention and elementary settings in Long Island, New York that appeared to experience an increase in problem behaviors when ill. The study was a group design where students were randomly assigned to either the medical intervention alone group or the medical plus

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behavior intervention group. Following school policy, students who appeared ill sought attention from the school nurse from either group. Students in the medical only group were sent to the nurse to receive medical attention when ill, including aspirin for headaches and a heating pad for a stomachache. In the experimental group, student received the same medical intervention, in addition to behavior interventions including behavior momentum, increased choice of and access to reinforcers, and escape extinction plus prompts. At the end of the 10 months, the behavior intervention was also delivered to the control group when ill for a 3-month period. Following intervention, students receiving medical and behavioral interventions showed significantly lower levels of problem behavior and completed more academic tasks than the control group solely receiving medical intervention. Research has demonstrated individuals with developmental disabilities have a three to five times greater probability of exhibiting problem behaviors then the typical population (Poppes et al., 2010). Such problem behaviors including self-injury, tantrums, and aggression regularly act as obstacles to successful inclusion in educational, employment, socialization, and community environments, thus hindering ones quality of life. Consequently, problem behavior has attracted much attention in the areas of intervention and assessment. Authors Bambara and Kern (2005) express the administration of a functional assessment is an essential component in the development of a behavior plan and intervention. The determining of an intervention plan is most valuable when the development is directed by assessment data that aid in clarifying why the student is displaying problem behavior. Understanding problem behavior involves recognizing the variables that control the behaviors rate, nonrated, and potential

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES probability. With this understanding, one should have the knowledge to foresee when, where, with whom, and under what conditions the behavior is likely to occur or not occur. However, these variables may not be so clear-cut when relating to biological

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setting events including illness or pain. Although current research has linked increases in problem behavior to biological- based functions, few studies have addressed the process and information used in determining such functions and how professionals are altering instruction and reinforcement to decrease the likely of problem behaviors being maintain after the subsiding of symptoms (Carr & Blakeley- Smith, 2006); (Carr & OwenDeSchryver, 2007); (Carr et al., 2003); (OReilly, 1997); (Valdovinos & Weyand, 2006). The purpose of this study is to investigate the steps taken or information used by professionals in determining the function of a students problem behavior; and how intervention is modified when the known function of the behavior is biological, including physical illness or pain.

Methods Participants Participants of this study include classroom teachers, certified behavioral analysis, and para professionals who provide direct support to students or clients with developmental disabilities in inclusive and/ or self-contained settings. Participants must have a target student or client who displays problem behavior and tends to present an increase in problem behaviors when ill or in pain (Carr & Blakeley-Smith, 2006). The communication skills for target students may range from non-verbal to verbal, but

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students must show the inability to clearly express symptoms or pain they undergo due to health conditions. Instrument Research questions will be answered through the collection of data in the form of an in person survey, allowing for the administrator to follow up with a clarifications or follow-up interview questions. The survey instrument was developed specify for this study and highlights three main topics including challenging behavior, illness/ pain related behavior, and behavioral interventions. The first section, regarding challenging behaviors, asks the participants to consider all the individuals they work with and identify the problem behaviors they observe. The participants are provided a chart and asked to verify the frequency of problem behaviors exhibit by individuals they work with through a five- point likert scale consisting of the following anchors; never, rarely, sometimes, often, and always. The behaviors listed within this chart range widely from selfinjurious, aggressive, stereotypically, and etc. This will allow for a general overview of the different types of problem behaviors being exhibited by individuals with developmental disabilities. The second section of the survey then asks participants to consider a student who displays problem behavior and has a known health condition or experiences frequent pain. If the participant does not have a target individual who meets this criteria, the administer will not ask any further questions in section two and move on to ask the questions presented in section three. Section two includes items targeting specific illnesses, symptoms, and behaviors observed when individuals are ill or in pain. Also, this section contains items directing to how the individual and others communicate the presence of an illness or pain. This section will be used to identify changes in

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frequency and intensity of problem behaviors of individuals when ill or in pain compared to when they are not. Also this section will be used to answer questions of how the presence of illness and/or pain is being communicated to professionals. The third section of the survey was developed to seek out information on the knowledge of participants regarding function- based behavior interventions and strategies used to decrease problem behavior in individuals when the function is illness or pain related. This section was created to reveal how participants determine function of behavior when behaviors are biologically based and how behavior interventions and reinforcement strategies are altered when behavior function is illness or pain related. Procedure Implementation of this study begins by targeting participants that meet the stated criteria and obtaining consent. Once consent has been received by participants, the study continues by the researcher setting up times to meet individually with each participant to administer the survey instrument developed for this study. The survey will be administered to participants in a face-to-face meeting. During the face-to-face meeting, the administer will follow the outline of the survey, deviating when further questioning or follow- up clarification is needed or requested. At conclusion of all participant meetings, the data will be analyzed and findings reported. Personal information on the participants included in the results will be coded to assure concealment.

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES Appendix A
Section I: Challenging Behavior

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1. To what extent do students in your classroom exhibit the following challenging behaviors?
Behavior Refusing food Banging head with hand or object Biting oneself Grinding teeth Screaming and shouting Repetitive hand movements Excessive fidgeting Pulling and grabbing others Pinching others Throwing objects Temper tantrum Physical altercation in the classroom Unwilling to engage (not disruptive, non participatory) Failure to complete classwork Frequent out of seat behavior Outright refusal to follow directions Frequent absences Never Rarely Sometimes Often Always

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Lacking motivation Emotional breakdown Other (Please specify)

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Section II: Illness/ Pain Related Behavior 2. Consider the students who most frequently display challenging behaviors. Do any of these students also have medical issues (illness) or experience frequent pain? Yes No (skip to question 15)

3. Lets talk about the top 3 challenging behaviors exhibited by this student.
Behavior Topography Frequency Duration Intensity

Topography (how it is performed) Frequency (how often it occurs per day, week, or month) Duration (typically how long it lasts when it occurs) Intensity (how damaging or destructive the behaviors are when they occur) 1- not at all a problem, 2- minor problem, 3- moderate problem, 4- serious problem

Continue thinking about this child. The next set of questions relate to the health issues your student is experiencing:

4. Over the past year, approximately how often has this student missed school due to illness? (Please check one) 1-2 3-5 6-10 11-15 16-20 21-25 Greater than 25

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5. Describe the illness and the types of symptoms the student displays?

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6. Source of information communicating student illness or pain level? (a) Parent report (b) Nurse report (c) Doctors note (d) Observed behaviors (e) Self-report by the student (f) Other (please specify) 7. What specific modes of communication does the individual typically use to indicate sickness or pain? (a) (b) (c) (d) (e) Verbal Sign language or gesture Picture communication system Pointing/ leading Other (please specify)

8. How frequently does your student display motor pain behaviors? (Facial grimacing, gritting teeth, repeatedly pulling ear, wincing, sensitivity to touch/ flinching, clenching jaw, holding and/or rubbing affected body part) 1 Never 2 Almost Never 3 Occasionally 4 Almost every time 5 Every time

Please describe the particular motor pain behaviors the student typically displays when ill or in pain.

9. How frequently does your student display vocal pain behaviors? (Sighing, whining/ sobbing, moaning, hacking/ gagging, groaning, screaming, or verbalizations: ow, ouch, hurts) 1 Never 2 Almost Never 3 Occasionally 4 Almost every time 5 Every time

Please describe the particular vocal pain behaviors the student typically displays when ill or in pain.

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10. What types of problem behavior does the individual typically display: (a) When he/ she is sick/ in pain?

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(b) When he/ she is not sick/ in pain?

11. When the student is sick or in pain, how frequently does he/she engage in problem behavior? 1 Never 2 Almost Never 3 Occasionally 4 Almost every time 5 Every time

12. When the student is not sick or in pain, how frequent does he/ she engage in problem behavior? 1 Never 2 Almost Never 3 Occasionally 4 Almost every time 5 Every time

13. When the student is sick or in pain, how intense are the problem behaviors which he/ she displays? 1 Mild 2 3 Moderate 4 5 Severe

14. When the student is not sick or in pain, how intense are the problem behaviors which he/ she displays? 1 Mild 2 3 Moderate 4 5 Severe

Section III: Behavior Interventions Now please switch your thinking back to more general terms. For the following questions, please state your level of agreement. 15. Which of the following behaviors might be indicative of a child experiencing pain or illness? Self- injurious behavior Aggressive behavior Stereotypical behavior

16. Environmental factors can have an influence the onset or increase of problem behaviors in individuals. 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree

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17. Biological factors can have an influence the onset or increase of problem behaviors in individuals. 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree

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5 Strongly agree

18. Physical illness or pain can make an array of home, school, community, and workplace tasks more aversive. 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree

19. If an individual is consistently allowed to escape a task following the onset of aggressive behavior, such behavior will become more likely over time in the presence of illness or pain. 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree

20. Providing medical intervention to individuals who are ill or in pain can decrease problem behavior. 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree

21. Delivering behavior intervention to alter the discriminative stimuli and response consequences associated with instruction can decrease problem behavior in individuals who are ill or in pain. 1 Strongly disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly agree

22. Please describe the behavior intervention you implement or have implemented in your classroom to decrease problem behavior in individuals.

23. What recommendations would you give to first year professionals to decrease problem behavior when the known function is illness or pain?

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24. What information would you communicate to first year professionals in determining illness of pain as a function of problem behavior?

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES Appendix B Adapted from Carr, E. G., & Blakeley-Smith, A. (2006); Carr, E. G., & OwenDeSchryver, J. (2007); & ONeill, R., Horner, R., Albin, R., Sprague, J., Storey, K., & Newton, J. (1997)

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RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES Reference

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Bambara, L. M., & Kern, L. (2005). Individual supports for students with problem behavior. New York, NY: The Guilford Press.

Carr, E. G., & Blakeley-Smith, A. (2006). Classroom intervention for illness-related problem behavior in children with developmental disabilities. Behavior Modification, 30, 901-924. doi:10.1177/0145445506290080

Carr, E. G., & Owen-DeSchryver, J. (2007). Physical illness, pain, and problem behavior in minimally verbal people with developmental disabilities. Journal of Autism & Developmental Disorders, 37, 413-424. doi:10.1007/s10803-006-0176-0

Carr, E. G., Smith, C. E., Giacin, T. A., Whelan, B. M., & Pancari, J. (2003). Menstrual discomfort as a biological setting event for severe problem behavior: Assessment and intervention. American Journal on Mental Retardation, 108, 117-33.

Dukes, C., Rosenberg, H., & Brady, M. (2008). Effects of training in functional behavior assessment. International Journal of Special Education, 23, 163-173.

Emerson, E. (2001). Challenging behaviour: Analysis and intervention in people with learning difficulties. Cambridge: University Press. Ingram, K., Lewis- Palmer, T., & Sugai, G. (2005). Function- based intervention planning: comparing the effectiveness of FBA function- based and nonfunction- based interventions plans. Journal of Positive Behavior Interventions, 7, 224-236.

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES May, M., & Kennedy, C. (2010). Health and problem behavior among people with intellectual disabilities. Behavior Analysis in Practice, 3, 4-12. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004690/. ONeill, R., Horner, R., Albin, R., Sprague, J., Storey, K., & Newton, J. (1997). Functional assessment and program development for problem behavior: A practical handbook. Belmont: Brooks/ Cole Cengage Learning. OReilly, M. F., (1997). Functional analysis of episodic self-injury correlated with recurrent ottis media. Journal of Applied Behavior Analysis, 30, 165-167. Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Patel, M. R., Katz, R. M.,

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Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 36, 187-204.

Poon, K. K. (2012). Challenging behaviors among children with autism spectrum disorders and multiple disabilities attending special schools in Singapore. Research in Developmental Disabilities: A Multidisciplinary Journal, 33, 578-582.

Poppes, P., Putten, A. J. J., & Vlaskamp, C. (2010). Frequency and severity of challenging behaviour in people with profound intellectual and multiple disabilities. Research in Developmental Disabilities, 31, 1269-1275. doi:10.1016/j.ridd.2010.07.017

Trussell, R. P., Lewis, T. J., & Stichter, J. P. (2008). The impact of targeted classroom interventions and function-based behavior interventions on problem behaviors of students with Emotional/Behavioral disorders. Behavioral Disorders, 33, 153-166.

RECOGNIZING BIOLOGICALLY- BASED PROBLEM BEHAVIOR AND EFFECTIVE INTERVENTION STRATEGIES Valdovinos, M. G., & Weyand, D. (2006). Blood glucose levels and problem behavior. Research in Developmental Disabilities, 27, 227-231. doi:10.1016/j.ridd.2005.02.002

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