Helping Me to Help Myself: A Common Sense Approach to SelfRegulation Intervention

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Helping Me to Help Myself A Common Sense
Approach to Self-Regulation Intervention
Tim Feeney, Ph.D. Project Director New York State
Neurobehavioral Resource Project Southern Tier
Independence Center Binghamton, NY Clinical and
Executive Director School and Community Support
Services 17 British American Blvd Latham, NY
12110 tfeeney_at_scssconsulting.com 518-782-2100
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www.scssconsulting.org
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Grandma Masses Rules for Success The smart
guys are the guys who learn from the other guys.
Dont get all caught up in one thing everyone
believes their thing is the best thing and
theyre usually wrong. So, shut-up and listen
and learn and change. In order to be
successful youve got to be eclectic.
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More Grandma Masse

• Models collect dust on shelves.
• Dont fall in love with a particular approach
• ideally, youll/well
• create a framework for intervention (a working
  theory) that will evolve with experience and
  evidence

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• So, why is self-regulation so important?

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Socially Unacceptable Behavior
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Aggression
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Impulsive Behavior
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The Ultimate Result of Impaired Self-Regulation
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Context Relevancy How does this stuff apply
to the bigger world? adapted from Sailor, 1999
Useful Do the outcomes that were targeting
produce something useful to the individual in
long run? Desirable Does the individual
choose the outcomes for him/herself when given
the choice? Is the individual given thechoice
of outcome? Social Do the outcomes result
in behaviors that will increase interactions
with persons other than paid staff? Practical
Will the behavior be used in real contexts
without staff support? Adaptable Is there
a focus on developing skills that can/will be
used in a number of situations and without
staff?
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• Most of the stuff that works is conceptually
  simple but procedurally difficult.
• In many ways good intervention is really about
  the systematic application of common-sense.
• Unfortunately, common-sense is terribly
  uncommon. Mark Twain

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Three Beliefs That Will Affect the Likelihood
That Youll Be Successful

• Optimism Hope. Evident in the problems that are
  targeted and the language that is used when
  describing the individual and when interacting
  with the individual.
• Appreciating the Influences of Contextual Factors
  on Behavior. Requiring an understanding of the
  setting events (the distant events on an
  individuals behavior).
• Applied Pragmatism. Recognizing that there is no
  single right solution moving away from the
  notion of consistent use of a prescribed
  intervention strategy to concordance on the
  part of all involved.

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• Introduction to
• Intervention Ideas
• Conceptually Simple,
• Procedurally Difficult

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Why Do I Keep Making the Same Mistakes? Why
doesnt it Get Better?
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Communication
Cognition
Behavior
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COGNITION Organizatio
n Memory Info Processing Planning Procedural
vs. Declarative Non-strategic Self
Monitoring Implicit vs. Explicit Reviewing Self-
evaluating
BEHAVIOR Excesses Impulsiveness Aggressiveness Su
bstance Abuse Deficits Initiation
Impairments Insight Impairments
COMMUNICATION Efficiency Fluency/Articulation Dis
course Effectiveness Functional Apparent
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Success via Learning from Consequences Presuppose
s
Reasonable intactness of the neural networks
responsible for connecting Memory for the
factual aspects of past behavior and/or Memory
for the Somatic Markers, or the feeling states
associated with the consequences of those
behaviors
Without these connections in memory, past
rewards and punishments lack the power to drive
future behavior
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An impulse is not a choice
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• When choice is offered, of course, it is
  essential that the person being offered the
  choice have the information necessary for making
  a meaningful decision . . . without such
  information, being given a choice will feel more
  like a burden than a support for autonomy.
• Edward Deci, 1995
• Why We Do What We Do

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• Each waking day is a stage dominated for the good
  or ill, in comedy, farce, or tragedy, by a
  dramatis persona, the self. And so it will be
  until the curtain drops . . . Although multiple
  aspects characterize the conscious self, this
  self is a unity.
• - Charles Sherrington, 1946
• The Integrative Action of the Nervous System

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• Alliances are Critical to Success
• When working with others in a concordant manner
  the intensity, consistency, and duration of
  services improves.
• 2. There is an increase in the probability of
  generalization and maintenance of positive change
  (Browns Rule of Three Three people, three
  places, three times.)
• 3. There is a necessary infusion of reality,
  common-sense, and a functional focus of
  interventions.
• 4. All of us are smarter than any one of us.

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• Creating Alliances
• Three Rules of Thumb for Professionals
• Demonstrate respect all the time, especially when
  interacting with someone that you dont like (or
  who doesnt like you!).
• 2. Seek the insights of everyday people - find
  the hidden experts and use their expertise.
• 3. Keep your hat in your hand never forget you
  will always be a visitor in the life of the
  person with whom you are working.

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THATS WHAT I AM! THATS WHO I AM! RIGHT OR
WRONG, I CANT CHANGE THAT CARLITO (AL PACINO),
CARLITOS WAY
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Ive lived a very dysfunctional life, and I know
that that life has shaped and molded me into
the person I am today. I want to reshape
myself.
-
Lloyd K.
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Choice

• (Noun)
• 1 The act of choosing selection 2 the right,
  power, or chance to choose option 3 a person or
  thing chosen 4 the best or most preferable part 5
  a variety from which to choose 6 a supply that is
  well chosen 7 an alternative 8 purposive
  discernment.

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Impulse

• (Noun)
• 1 a) an impelling or driving forward with sudden
  force b) an impelling force sudden, driving
  force push thrust impetus 2 a) incitement to
  action arising from a state of mind or external
  stimulus b) a sudden inclination to act, usually
  without premeditation 3 sudden involuntary
  inclination prompting action.

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Functional Conceptions of Choice Free
choice Fixed choice Forced
choice Feeling the natural and logical
results of actions in the environment
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• For behavior-outcome linkages to serve as
  motivators, people must understand them, see them
  as relevant to their lives, and have the
  capabilities for utilizing them.
• Edward Deci, 1995
• Why We Do What We Do
• In other words People need to have both the
  strategies
• and capacities for attaining desired outcomes!

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The Three Big Things
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When we think of your future the next 10 years
we need to think about the 3 most
important things to work on the things that, if
you achieve, youll have a meaningful life.
The 3 Things tend to cluster around these
areas Behavioral regulation/self-regulation
Friendships/social-interaction Vocational
skills/meaningful engagement Self-help skills
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• Being intrinsically motivated has to do with
  being wholly involved in the activity itself and
  not with reaching a goal.
• -Edward Deci, 1995
• Why We Do What We Do

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Making the Big Things Real

• Creating personal maps or steps to attaining the
  personally meaningful goals.
• Articulated by the individual (with some help
  from staff, friends, family)
• Organized in a visual manner to assure clarity

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Step 55. Me the _______
Im good at I need to
Step 3.
Step 2.
Step 1. Me Now
Im good at I need to
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KEEPING A HOTTIE BOYFRIEND
EULAS STEPS TO SUCCESS
BEING A GOOD PERSON WITHOUT THINKING ABOUT IT
HANDLING MYSELF OUT OF CLASSES
DEALING WITH PROBLEMS /BEING IN CONTROL
HANDLING MYSELF IN CLASSES
LISTENING TO GOOD ADVICE/IGNORING BAD
IN THE RESOURCE ROOM
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HAVING A JOB, LIVING IN MY APARTMENT
PETERS STEPS TO SUCCESS
DONT FORCE IT
GET OUT OF IT BEFORE I GET INTO IT
FOLLOW MY PLAN WHEN IM OUT IN THEWORLD People,
Places, Things
MAKING PLANS BEFORE GOING OUT IN THE WORLD
DEALING WITH ASSHOLES POSITIVELY
MAKING MEETINGS PARTICIPATING IN THEM
MAKING MY PLAN TO STAY CLEAN EVERYDAY LETTING
PEOPLE KNOW
IN A TREATMENT PROGRAM
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A doctor
Toms Plan Toms Reality
An EMT
Be a helping person
In rehab
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• More Intervention Ideas
• Conceptually Simple,
• Procedurally Difficult

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PERSON
Language
Emotion
Volition
Behavior
MentalHealth
Cognition
Human beings are a collection of relatively
independent structures, processes, and systems
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Johns Cognition
Attention
Perception
Memory
Organization
Reasoning
EF
Sequence Categorize Associate Analyze Synthesize
Arousal Select Direct/ Filter Maintain Divide
Shift
Encode/Store/Retrieve Episodic/Semantic Explicit/I
mplicit Declarative/Procedural Involuntary/Strateg
ic Working Memory/ Knowledge
Base Remote/Recent Pro/retrospective Iconic
Inductive Deductive Analogical Divergent Convergen
t

• Goals for John - John will
• Increase duration of maintained attention
• Increase prospective memory from 3 to 5 minutes
• Increase category naming from 3 to 5 members per
  category

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Johns Mental Health
Axis I
Axis III
Axis II
Axis IV
Axis V
Personality Disorders Mental Retardation
General Medical Conditions
Global Assessment of Functioning
Clinical Disorders Other Conditions
Psychosocial And Environmental Problems

• Goals for John John will
• Participate in psychotherapy sessions without
  falling asleep
• Comply with his medication regimen as directed
• Follow the recommendations of the clinical staff
  to assure his safety
• Seek community services for his disorder and for
  his living
• arrangements

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Johns Behavior
John is the totality of his behaviors and the
systematic relationships among them
John
b1 b3 b12 b4 b1 b7 b62 b17 b17 b17 b4 b6 b9 b17
b12 b3 b8 b8 b5 b6 b17

• Goals for John John will
• Increase frequency of b3 and b12
• Decrease frequency of b17

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Alternative Understanding of Human Beings
Sarah
Pursuing personally meaningful goals
While participating in culturally valued
activities
In social, cultural, and historical contexts
Mediated as necessary by individuals with
greater expertise in that domain
Using cultural tools, such as language, category
schemes, mathematics, organizational supports,
domain-specific strategies
In the presence of varied context facilitators
and barriers
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Goal
Plan
Predict
Do
Review
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• Constructing an identity that is meaningful and
  sustainable is a primary goal of intervention

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The self is not something ready made but
something in continuous formation through choice
of action. - John Dewey
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SENSE OF SELF FOR INDIVIDUALS WITH CO-EXISTING
DISABILITIES

• Perplexity
• Unawareness or denial Retention of preinjury
  self-concept
• Fragmentation
• I am a victim (passivity depression)
• I refuse to be a victim (anger aggression)
• Ive changed Ive got my work cut out for me
  (resolve)

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IDENTITY MAPPING

• Identification of goals
• Identification of image, hero, metaphor
• Organization of identity description
• Creation of identity map
• Supported practice
• Modification of others support behavior
• Possibly meaningful project

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Reconstructing/Constructing Identity
An Identity Map
FEELINGS
How does this person feel?
FACTS
APPEARANCE
What has this person done?
What does this person look like?
POSITIVE IDENTITY METAPHOR
GOALS
PROCEDURES
What am I trying to accomplish?
What will I need to do?
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IDENTITY CONSTRUCTION

• Helping individuals with disability construct a
  sense of personal identity that is
• Satisfying/compelling
• Organized
• Adequately realistic
• AND that includes the hard strategic effort
  needed to be successful with a disability

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IDENTITY MAPPING

• Identification of goals
• Identification of image, hero, metaphor
• Organization of identity description
• Creation of identity map
• Supported practice
• Modification of others support behavior
• Possibly meaningful project

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Identity Mapping Cautions

• Professional competence
• Emotional fragility
• Professional imposition
• Cognitive prerequisites
• Meaningful language

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Identity Mapping Cautions

• Dangerous metaphors
• Negative use (e.g., nagging)
• Getting stuck flexibility
• Heroes and victims
• Time post injury

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Reasons Why People Dont Choose to Plan When
They Could Adapted from Ellis Siegler, 1997
Planning requires delay in attaining goals and
the impulse for immediate gain is stronger than
the choice to delay an action Planning
requires the suppression of currently
activated behaviors Individuals are often
overly optimistic about their success in the
absence of planning, reducing the perceived
need for planning Planning takes time, and
speed is often valued over accuracy
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A Community
Shared purpose
Recognition of individual needs
Ongoing articulation of purpose Identity(ies)/Role
s/ Places/Jobs
Procedures for managing situations when
participants are out of roles
Procedures for feedback from community members
Shared Projects
Community Meetings Staff Roles Leader,
supporter Participant Roles Leader, supporter,
facilitator
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The Importance of Community in Establishing an
Identity

• Communities help us to accomplish things.
• Communities are change agents.
• Communities are sources of meaning and belonging.
• Need to Belong (Baumeister Leary, 1995)
• The need to belong is a powerful, fundamental,
  and extremely pervasive motivation.
• A lack of belongingness constitutes severe
  deprivation and causes a variety of ill effects.
• Alone.... Uh, Im alone! I'm a lonely,
  insignificant speck on a has-been planet orbited
  by a cold, indifferent sun. -Homer Simpson
• The Belongingness Hypothesis A drive to form and
  maintain at least a minimum number of lasting,
  positive, and significant interpersonal
  relationships.

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Social Identity Theory

• People have an innate and strong tendency to
  mentally organize things and people into
  categories
• To the extent that we associate ourselves with
  communities (i.e. categorize ourselves), we have
  social identities
• Social identities (via our community memberships)
  are important aspects of how we define ourselves
• To the extent that we identify with communities
  that are valued (e.g., powerful, prestigious,
  high status, popular), well feel good about
  ourselves.

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Projects

• Personally meaningful goal product
• SENSE OF SELF AND MOTIVATIONAL THEMES
• Expert role helper/producer role
• Intrinsic motivation meaningful engagement
• Anti-egocentrism
• Relevance, anti-oppositionality
• Awareness of strengths and needs
• SOCIAL/BEHAVIORAL THEMES
• Meaningful context for practice of social/
  interactive competencies
• Meaningful context for practice of collaborative,
  cooperative effort and behavioral self-regulation
• COGNITIVE THEMES
• Deep processing
• Planning and organizing
• Meaningful context for practice of all cognitive
  and Executive Function processes
• G-O-P-D-R
• Compensatory strategies
• Integration of activity over time day to day
• Integration of several contexts

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SELF REGULATION DEVELOPMENTThemes

• Start early
• Develop slowly
• Continue into adulthood
• Influenced by biologic and environmental factors
• Variability Context (person, setting and task),
  motivation, culture

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SELF-REGULATORY DEVELOPMENTThe Role of
Experience

• Individuals are more likely to develop effective
  self-regulation if they
• Experience adequate social attachment
• Experience an organized and predictable world
• Receive authoritative/apprenticeship parenting,
  including effective modeling and verbal mediation
• Are rewarded for appropriate self-regulation and
  control by others who value self-regulation and
  autonomy

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Teaching a Learning How to Think
? Think out loud.? Think out loud a
lot.? Think out loud with the person reflect,
plan, problem solve, observe, organize,
evaluate, remember, review, create, etc.? Make
use of external supports when thinking diagrams,
photos, written routines, day planners, notes,
etc.? Present yourself as an image of
thoughtfulness. Help the individual to embrace
the notion that being thoughtful is a good and
great thing.? Think out loud in a way that
shows that you are fun and flexible and
experimental in your own thoughts.? Think out
loud in a way that captures metaphors, analogies,
similarities, history, etc.
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WHAT WEVE LEARNED OVER THE PAST 15
YEARSPRINCIPLES GUIDING THE DEVELOPMENT OF
SUCCESSFUL SELF-REGULATION FOR INDIVIDUALS WITH
CO-OCCURRING DISABILITIES
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PRINCIPLE ONGOING CONTEXT-SENSITIVE ASSESSMENT

• Functional behavior assessment
• Collaborative hypothesis testing
• Engagement of the person in the assessment
  process
• Assessment informs intervention/support informs
  assessment informs intervention/support

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Contextualized Collaborative Hypothesis-Testing
Whats the problem? (Using the two strangers in
the doorway rule)
Hypothesis Formulation (Why is s/he doing this?)
Hypothesis Selection (Begin with easiest to test
or most obvious)
Hypothesis Testing (Protocol for
experimentation Plan A - Plan B - Plan C Testing
time line)
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WHY TEST HYPOTHESES?

• Failure on any complex task is multiply
  interpretable
• Complex students can be supported in a variety of
  ways
• Test results do not necessarily indicate how best
  to achieve success on specific tasks

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WHY COLLABORATE?

• Increase observations and experiments
• Increase compliance
• Educate family, staff, others
• EF training for student
• Show respect

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WHY IN REAL CONTEXTS?

• Inconsistency
• Validity problems of standardized testing
• Impact of setting, person, activity
• Impact of stress
• Observe real-world initiation, inhibition,
  self-monitoring, problem solving
• Observe effects of real-world supports and
  routines
• Observe support behaviors of others

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PRINCIPLE POSITIVE BEHAVIOR SUPPORTS

• Environmental Focus
• Antecedent Focus
• Logical and meaningful consequences
• Skill Development

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Alternative Behavioral Paradigms
A B C
Tradition Behavior is a function of its
consequences
A B C
Positive Behavior Support Alternative Satisfying
behavior chains are created with everyday
antecedent supports
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Success via Learning from Consequences Presuppose
s
Reasonable intactness of the neural networks
responsible for connecting Memory for the
factual aspects of past behavior and/or Memory
for the Somatic Markers, or the feeling states
associated with the consequences of those
behaviors
Without these connections in memory, past
rewards and punishments lack the power to drive
future behavior
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Fluctuations in behavior are expected, the goal
of behavioral support is to make those
fluctuations manageable
High Risk/Unsafe/Unmanageable
Manageable Risk
Behavior
Low Risk
Manageable Risk
High Risk/Unsafe/Unmanageable
Time
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Fluctuations in behavior are expected, the goal
of behavioral support is to make those
fluctuations manageable
High Risk/Unsafe/Unmanageable
Manageable Risk
Behavior
Low Risk
Manageable Risk
High Risk/Unsafe/Unmanageable
Time
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PRINCIPLE THE PERSON IS THE CORE OF ALL
INTERVENTION AND SUPPORT EFFORTS

• Participation in goal setting and planning
• Case coordination
• Daily goal setting, planning, reviewing
• Participation in the assessment process
• Participation in selecting and managing staff
• Which person?? Helping the person to create an
  identity that is
• Stable
• Positive
• Nondisability oriented
• But inclusive of hard strategic effort

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Mature Person-Centered Organize supports
around goal- directed choices
Goal-Directed Identity
Synthesis Facilitate goal- directed choice
Shallow Person-Centered Whatever you Say!!
Medical/Expert Model I set your goals I make
your decisions
Anti-thesis Enable Impulsiveness
Thesis External Control
Apparently irresolvable conflict
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Which Person??Person-Centered Supports

• Person-centered does NOT mean never having to
  say, Thats not a good plan!! --- Thats not a
  choice thats just impulse!!
• Administrative challenges
• Who is authorized to help the person distinguish
  between choice and impulse?
• Who facilitates goal-directed choosing and
  planning?
• What are the scripts for other staff?
• Clinical challenge Mature identity construction

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PRINCIPLE INTERVENTIONS AND SUPPORTS ARE
ORGANIZED AROUND PERSONALLY MEANINGFUL ACTIVITIES

• In the absence of meaningful engagement in
  chosen life activities, all interventions will
  ultimately fail
• Option School, work, volunteer experiences,
  family responsibilities
• Option Preparatory skill development related to
  school, work, volunteer experiences
• Option Meaningful projects!!

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PRINCIPLE POSITIVE EVERYDAY ROUTINES ARE THE
CONTEXT FOR PURSUIT OF MEANINGFUL GOALS

• Collaborative design of successful everyday
  routines
• Recognition of adherence to routines and plans
• Ongoing reinforcement of planning, routine
  development, and maintenance of positive
  routines CELEBRATION of everyday success!
• Routine is despairs sly assassin

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PRINCIPLE FEEDBACK IS CONTEXT-SENSITIVE AND
MEANINGFUL

• GOAL OBSTACLE PLAN DO REVIEW
• Celebration of effective maintenance of positive
  everyday routines
• Celebration of special contributions
• Identification of what works and what doesnt
  work
• Frank constructive feedback in response to
  negative behavior delivered by a respected staff
  person

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Goal
Obstacle/Predict
Plan
Do
Review
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PRINCIPLE COMPONENTS OF LIFE MUST BE INTEGRATED

• People have an innate and strong tendency to
  mentally organize things and people into
  categories
• To the extent that we associate ourselves with
  communities (i.e. categorize ourselves), we have
  social identities
• Social identities (via our community memberships)
  are important aspects of how we define ourselves
• To the extent that we identify with communities
  that are valued (e.g., powerful, prestigious,
  high status, popular), well feel good about
  ourselves.

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A Community
Shared purpose
Recognition of individual needs
Ongoing articulation of purpose Identity(ies)/Role
s/ Places/Jobs
Procedures for managing situations when
participants are out of roles
Procedures for feedback from community members
Shared Projects
Community Meetings Staff Roles Leader,
supporter Participant Roles Leader, supporter,
facilitator
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PRINCIPLE BECAUSE THE DISABILITIES THAT FOLLOW
BRAIN INJURY ARE TYPICALLY CONTEXT-BOUND,
CONTEXTUAL SUPPORTS ARE CRITICAL TO SUCCESS

• Most critical to success
• Effectively trained everyday people
• Collaboration between
• Clinicians and support staff
• Natural and paid supports
• Participant and all supports natural and paid
• Elaborative supports
• Designed to expand domain of activity beyond
  disability supports
• Designed to improving thinking and decision
  making
• Feedback authentic and context-sensitive

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Components of Self-Coaching Self-Advocacy Videos

• The negotiation and agreements that led to the
  play (or script or identity map)
• For those with faulty recollection of the
  rationale for the play (or script or IM)
• Educational content about the persons injury and
  its effects
• For the individual and Everyday Partners
• Educational content about the social, vocational,
  or educational realities surrounding the play (or
  script or IM)

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Review of self-coaching in everyday life

• At least weekly
• Scripts feel ok??
• Meeting goals? Reducing problems?
• Celebrate everyday successes!!!
• Never failure if not working, try something
  else

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Goal of Self-Coaching

• General goal to improve planful goal-oriented
  and ultimately successful behavior while
  decreasing impulsive and reactive behavior
• Associated goal to facilitate construction of a
  positive sense of self based on effective
  self-regulation/self-coaching and ultimately
  successful social and vocational participation

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Why Self-Observation on Video?

• Repetition/habituation
• Context-sensitive automatization
• Particularly for those with limited processing
  resources and weak on-line decision making
• Self-monitoring/self-awareness
• Everyday communication partner self-observation
• Education
• TBI information
• Social information
• Other
• Concreteness and immediacy

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Self-Observation Cautions?

• Serious emotional vulnerability may rule out
  video self-observation
• Perception of self can be disturbing
• Perceived image may be distorted
• Negative emotional states may be exacerbated
• Protocol A relevant professional (psychologist,
  psychiatrist, social worker, other trained
  counselor) needs to authorize video
  self-observation in cases of emotional
  vulnerability.

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Goals of Self-Coaching Video

• Variable
• Participant or ECP Education about
  self-regulation
• Participant or ECP Education about TBI
• Participant or ECP Understanding of specific
  obstacles
• Participant Rehearsal of self-regulatory or
  social scripts
• ECP Negotiation and rehearsal of acceptable cues
  or other scripts

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PROCEDURES

• Origin of need for specific self-coaching scripts
  and video
• Participant
• Other participants
• Staff
• Family
• Other

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PROCEDURES (CONTD)

• Negotiation of self-talk script or social script
• With counselor individually
• In counseling-oriented group
• In self-coaching group
• Collaborative process, with experienced group
  leader guiding the process

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S-C Video Possible Components

• Introduction to concept of self-coaching
• Introduction to the participants specific issue
  ideally with the participant and calling
  attention to the brain injury-related issues
• Possibly brief vignette showing difficulty
  without use of S-C script
• Brief vignette showing success with S-C script
• With ECP or highly respected person
• Possibly brief discussion of need for practice
  and what will be evidence of success
• Possibly cheerleading from peers

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Some S-C Plays for Everyone

• The Big deal/little deal play
• Recognize/judge importance block anxiety
• The Lets think about that play
• Block impulsiveness encourage thoughtfulness
• The New play play (football audiblize)
• Encourage flexibility
• The Am I ready? play
• Block impulsiveness encourage readiness
• The Am I sure? play
• The What about you? play
• Block egocentrism
• The Hang in there play
• The Goal-plan-do-review play
• Encourage goal orientation and planfullness

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The self is not something ready made but
something in continuous formation through choice
of action. - John Dewey
97

• Constructing an identity that is meaningful and
  sustainable is a primary goal of intervention

98
IDENTITY CONSTRUCTION

• Helping individuals with disability construct a
  sense of personal identity that is
• Satisfying/compelling
• Organized
• Adequately realistic
• AND that includes the hard strategic effort
  needed to be successful with a disability

99
IDENTITY MAPPING

• Identification of goals
• Identification of image, hero, metaphor
• Organization of identity description
• Creation of identity map
• Supported practice
• Modification of others support behavior
• Possibly meaningful project

100
Reconstructing/Constructing Identity
An Identity Map
FEELINGS
How does this person feel?
FACTS
APPEARANCE
What has this person done?
What does this person look like?
POSITIVE IDENTITY METAPHOR
GOALS
PROCEDURES
What am I trying to accomplish?
What will I need to do?
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? Know that an event or activity will be
difficult? Establish reasonable goals (in some
cases these might be immediate)? Formulate a
plan to achieve the goal (or understand the
plan)? Initiate goal-directed
behavior? Refrain from actions that interfere
with the successful achievement of
goals? Attend to and evaluate how well they are
doing? Try another plan or strategy if things
are not going well
To Assure Long Term Success Individuals Need to
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Teaching Self-Regulation is Teaching People to
Think
? Think out loud.? Think out loud a
lot.? Think out loud with the person reflect,
plan, problem solve, observe, organize,
evaluate, remember, review, create, etc.? Make
use of external supports when thinking diagrams,
photos, written routines, day planners, notes,
etc.? Present yourself as an image of
thoughtfulness. Help the individual to embrace
the notion that being thoughtful is a good and
great thing.? Think out loud in a way that
shows that you are fun and flexible and
experimental in your own thoughts.? Think out
loud in a way that captures metaphors, analogies,
similarities, history, etc.
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ROUTINES Repetition
creating temporal structure to improve memory
about relevant past events Cognitive
predictions about what happens next Natural
occasions for promoting cognitive growth An
impetus for improvisation when trying to avoid
a negative outcome
are a necessary prerequisite for Planning
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Concrete Routines Picture Routines Written
Routines
Interaction Routines Language Routines
Activity Sequencing
Routines to Deal with Changes in Routines
What I do when what I expected to happen
doesnt happen
105
Key Executive System Concepts That Help
Individuals Learn Self-Regulation
Hard - Easy Big Deal - Little Deal Ready -
Not Ready Scary - Not Scary Like - Dont
Like Choice - No Choice
106
Interaction Scripts for Routines
Making Decisions About the
Goal Whatre you going to do? What are
we here for? How will we know were
done? Well know were done when it looks
like this . . .
107
Making Plans OK, so whats the
plan? Whatll you need to get this
done? How will you and I know youll need
help? What will help look like? Dont
tell me what you dont want, tell me what you do
want. OK, so what do you want me to do?
108
Making Decisions About Ease or Difficulty
Before Beginning Do you think this will be
hard or easy? If its hard, then whatll you
need? Have you ever done this before? What
happened? I dont think I could do this! How
do you know that you can? Whaddaya think?
Big deal or little deal?
109
Coaching Through Problems You look upset, is
there anything I can do? OK, youre not
ready. No problem just let me know when youre
ready. Ill know youre ready when you look
like this . . . Ill wait. You know
weve gotta figure this out, lets try . . .
I know its hard, but weve got to do
this.
110
Coaching in Context So, hows it
going? Is that helping you? Not
helping? Is there anything else you can
do? Is there anything I can do to help
you? So when are you going to start?
111
Review What Occurred So howd it
go? Howd you do? Tell me exactly what
happened . . . and then what? What do you
think other people thought? What were you
thinking when you . . . Next time you do
this, whatll you do differently? The
same? What helped? What didnt help?
112
PRINCIPLE REDUCTION OF SUPPORTS IS PART OF THE
PLAN

• Supports must be adjusted to fit needs and
  abilities
• Systematic reduction of supports is planned from
  day 1
• It is a goal of the waiver program to empower
  people to succeed with natural supports

113
COGNITION Organizatio
n Memory Info Processing Planning Procedural
vs. Declarative Non-strategic Self
Monitoring Implicit vs. Explicit Reviewing Self-
evaluating
BEHAVIOR Excesses Impulsiveness Aggressiveness Su
bstance Abuse Deficits Initiation
Impairments Insight Impairments
COMMUNICATION Efficiency Fluency/Articulation Dis
course Effectiveness Functional Apparent
114
Reasons Why People Dont Choose to Plan When They
Could

• Generating plans is no guarantee of success
  and
• lack of past success influences the current
  choice to plan
• An Individual may believe that s/he has no
  control
• over outcomes, even if s/he does plan
• Planning is often unpleasant because it is
  difficult or tedious or creates conflict
• An individual may assume someone else will
  make a plan for him/her
• Its often exciting NOT to plan

115
Helping People Choose to Plan
DO NOT plan on planning in situations that
have historical impulsive routines in
place Help individuals to connect the dots
make the outcomes associated with planning
explicit and the likely outcomes associated
with not planning equally explicit Show the
positive effects of planning for the
individual in the short term and long term
116
Helping People Choose to Plan

• Help the individual to make small/brief plans
• with immediate outcomes
• Create a culture of planning early and often
• Plan with the person, not for the person

117
SR CHECKLIST

• GENERAL CONSIDERATIONS
• Is intervention in the areas that fall under the
  heading "executive functions" structured around
  the individual's own meaningful goals?
• Is intervention infused into everyday activities?
  Are all everyday people oriented to how they can
  facilitate improved executive functions? Are all
  everyday people aware of the dangers of learned
  helplessness?
• Are everyday people aware of the strategies that
  the individual is being taught or is expected to
  use?
• Is successful performance in the areas grouped
  under this heading richly and naturally rewarded?
  Is the individual held responsible for effective
  strategic performance?
• Is the individual given ample opportunity to
  identify and solve his or her own problems (with
  guidance if necessary)?

118
SR Checklist (contd)

• For individual's who are young or very concrete,
  are executive function tasks structured around
  concrete physical activities (versus abstract or
  cognitive activities)?
• Do everyday people in the environment routinely
  model expert use of executive functions?
• Is the individual given sufficient practice so
  that strategic behavior becomes automatic?
• Are everyday people in the environment supportive
  of strategic or compensatory ways to accomplish
  tasks?
• Does the individual respect a strategic or
  compensatory approach to everyday problems? If
  not, is appropriate help/counseling provided?
• Are everyday people in the individual's
  environment fully aware of possible limitations
  in the individual's executive functions (esp.,
  initiation and inhibition) so that they do not
  misinterpret behavior?

119
Self-Awareness of Strengths and Needs

• Is the individual maximally engaged in
  identifying what is easy and hard to do, and what
  makes activities easy or hard?
• Is the individual given opportunities to compare
  performance when an activity is completed in a
  usual way versus when it is completed with
  special strategic procedures?
• Does the individual keep a journal in which
  strengths and needs are recorded?
• Is the individual given opportunity to identify
  strengths and needs in others, and strategic
  procedures that others may use (e.g., peer
  teaching)?
• Is the individual given appropriate informative
  feedback (e.g., peer feedback, video feedback,
  confrontational feedback if appropriate)?

120
Goal-Setting

• Is the individual routinely asked to predict how
  well he will do on activities?
• Are predictions recorded in journals and compared
  with actual performance?
• Does the individual maximally participate in
  rehabilitation/special education goal setting? Is
  adequate support provided if this is difficult?
• Are intervention activities structured around the
  individual's personal goals?

121
Planning

• Does the individual participate maximally in
  planning his or her intervention activities?
• Is a planning guide available, if needed?
• Does the individual begin the day by preparing a
  plan on a planning board or in a journal? Does
  the individual begin each activity by preparing a
  plan?
• Do therapy activities include attempts to plan
  meaningful complex events (e.g., parties,
  outings, etc.)?
• Does the individual participate maximally in
  long-term future planning? rehabilitation
  planning? IEP development

122
Self-Initiating

• Do everyday people give the individual
  opportunities to initiate and wait an appropriate
  length of time? Are signals available to remind
  the individual to initiate activities?
• Do the activities that the individual engages in
  make appropriate demands on the individual's
  ability to initiate (e.g., board games may
  require little initiation conversations may
  require much initiation)?
• Are all forms of institutional "learned
  helplessness" avoided?
• Are prosthetic initiators available if needed?
• If initiation cues are necessary, are they
  provided as much as possible by peers versus
  staff? Is nagging avoided?

123
Self-Inhibiting

• Do everyday people give the individual
  opportunities to inhibit that are realistic in
  their demands?
• Do the activities that the individual engages in
  make appropriate demands on the individual's
  ability to inhibit (e.g., unstructured and
  unfamiliar activities in a distracting
  environment require considerable inhibition)?
• If inhibition cues are necessary, are they as
  subtle as possible and provided as much as
  possible by peers versus staff? Is nagging
  avoided?

124
Self-Monitoring/Evaluating

• Do everyday people give the individual
  opportunities to self-monitor and evaluate
  performance? If cues are necessary, are they
  subtle? Is nagging avoided?
• Is the individual maximally involved in charting
  his own performance? keeping a journal in which
  performance is recorded? graphing performance?
• Is the individual routinely asked to fill in a
  form regarding his own performance What Works?
  and What Doesn't Work?

125
Intervention Goals

• Sarah will successfully complete ___ meaningful
  task, with ___ supports, possibly using ___
  tools/strategies, in ___ context (setting,
  people, activities), in order to achieve ___
  goal.
• Possibly focusing intervention attention on some
  specific aspects of cognition, communication,
  social skills, behavioral self-regulation, or
  educational/vocational skills aspects that are
  either particularly weak or particularly
  important for Sarah.

126
Teaching Positive Attribution

• UNHELPFUL ATTRIBUTION
• I cant do anything well
• Teachers dont like me
• Other kids are lucky
• Sometimes I get it sometimes I dont I dont
  know why

127
Teaching Positive Attribution

• HELPFUL ATTRIBUTION
• When I work hard and use my strategies, I do OK
  When I dont, I do badly
• Reading is harder for me than for other
  students, but I can get it if I give myself
  enough time and use my strategies.

128
Teaching Positive Attribution Procedures

• Product Monitoring
• Framing
• Self-Monitoring
• Hero Identification
• Procedures associated with learned optimism

129
EXPERIMENT ROUTINETHIS WAY OR THAT?

• Identify issue or conflict
• Try both ways
• Identify most successful
• General reassurance

130
EF SCRIPTSDELIVERY

• Conversational, non-threatening interaction
• Well-selected language
• Avoid boredom, irritation
• Mainly positive easy non scary not a
  problem not a big deal
• Massed and distributed practice (hundreds!!)
• Embedded in meaningful activity
• Across all everyday partners

131
PROBLEM-SOLVING SCRIPT

• Identify issue or conflict
• State the reason
• Generate a solution/strategy
• General reassurance

132
HARD TO DO/EASY TO DO SCRIPT

• Identify task as hard or easy
• State the reason
• Generate a strategy (if hard)
• General reassurance

133
BIG DEAL/LITTLE DEAL SCRIPT

• Identify the issue as a big deal or a little deal
• State the reason
• Generate a strategy (if a big deal)
• General reassurance

134
SCARY/NOT SCARY SCRIPT

• Identify situation as scary or not scary
• State the reason
• Generate a solution/strategy
• General reassurance

135
Problem Solving/Strategic Thinking

• Is the individual maximally involved in solving
  everyday problems as they arise? Are everyday
  people thoroughly oriented to the importance of
  problem solving?
• Is the individual maximally engaged in selecting
  strategies to overcome obstacles and achieve
  important goals?
• Is there an appropriate amount of external
  support for strategic thinking?
• Does the individual have a form that cues the
  appropriate kind of strategic thinking?
• Do everyday people in the environment expect and
  cue strategic performance?
• Do everyday people in the environment avoid
  learned helplessness, that is, do they resist
  solving all of the individual's problems?
• Is there consistency among staff and family
  members in how problem-solving tasks are
  presented and in the kinds of external
  problem-solving support that are provided? Is
  there consistency in reducing external support as
  the individual becomes increasingly independent
  in problem solving?

136
ROUTINES Repetition
creating temporal structure to improve memory
about relevant past events Cognitive
predictions about what happens next Natural
occasions for promoting cognitive growth An
impetus for improvisation when trying to avoid
a negative outcome
are a necessary prerequisite for Planning
137

• Routine is despairs sly assassin.

138
Concrete Routines Picture Routines Written
Routines
Interaction Routines Language Routines
Activity Sequencing
Routines to Deal with Changes in Routines
What I do when what I expected to happen
doesnt happen
139

• Much of our cognitive life may be the product of
  highly automated routines.
• - Gerald Edelman

140

• Steps to Organize Routines of Everyday Life
• 1. Identify successful and unsuccessful routines
• of everyday life. Whats working, whats not
• working?
• 2. Identify changes that have the potential to
• transform unsuccessful routines into
• successful routines (including changes in the
• environment and the behaviors of others.)
• 3. Identify how changes in routines include
• activities that are motivating to the individual
  
• and everyday people.

141
Steps to Organize Routines of Everyday Life

• 4. Implement needed supports to organize
• routines so that the individual experiences
• success and receives intensive practice in
• context.
• 5. Systematically withdraw supports and
• expand contexts as much as possible.

142
Goal
Plan
Predict
Do
Review
143
Key Executive System Concepts That Help
Individuals Learn Self-Regulation
Hard - Easy Big Deal - Little Deal Ready -
Not Ready Scary - Not Scary Like - Dont
Like Choice - No Choice
144
Interaction Scripts for Routines
Making Decisions About the
Goal Whatre you going to do? What are
we here for? How will we know were
done? Well know were done when it looks
like this . . .
145
Making Plans OK, so whats the
plan? Whatll you need to get this
done? How will you and I know youll need
help? What will help look like? Dont
tell me what you dont want, tell me what you do
want. OK, so what do you want me to do?
146
Making Decisions About Ease or Difficulty
Before Beginning Do you think this will be
hard or easy? If its hard, then whatll you
need? Have you ever done this before? What
happened? I dont think I could do this! How
do you know that you can? Whaddaya think?
Big deal or little deal?
147
Coaching Through Problems You look upset, is
there anything I can do? OK, youre not
ready. No problem just let me know when youre
ready. Ill know youre ready when you look
like this . . . Ill wait. You know
weve gotta figure this out, lets try . . .
I know its hard, but weve got to do
this.
148
Coaching in Context So, hows it
going? Is that helping you? Not
helping? Is there anything else you can
do? Is there anything I can do to help
you? So when are you going to start?
149
Review What Occurred So howd it
go? Howd you do? Tell me exactly what
happened . . . and then what? What do you
think other people thought? What were you
thinking when you . . . Next time you do
this, whatll you do differently? The
same? What helped? What didnt help?
150
An Important Goal of Intervention Learning to
Recognize Internal States

• Using some commonly understood method of
  communicating my mood/
• feelings/health, etc.
• - Red Yellow Green
• - A thermometer
• - Rating Scales

151
Recognizing and Communicating My Internal State
Im feeling great
Im feeling really lousy
152
Project Based Intervention

• Present a project in terms of helping others
  identify important information for transitions
• Provide a context to evaluate and plan for the
  big picture with Sarah and her family
• Provide a context to collaborate, as consultants,
  with the team (e.g., the aide, classroom teacher,
  vocational teacher, and parents).

153
Project ApproachRationale

• Organizational impairment
• Superior involuntary learning
• Weak elaborative encoding
• Need for situated learning
• Need for errorless learning
• Need for routine learning

154
Project ApproachRationale (contd)

• Internalization of mediated interaction
• Egocentrism
• Unawareness
• Intrinsic motivation
• Oppositionality
• Sense of self
• Self-esteem

155
Project Approach

• Meaningful goal product
• Deep processing
• Planning and organizing
• Meaningful context for practice
• Integration of activity over time
• Integration of several contexts
• Expert role
• Helper/producer role

156
AARONS RATING SCALE
Prior to, and following, each activity Aaron and
his staff will evaluate his general mood using
this scale. In addition, the scale can and
should be used during activities as a way of
helping Aaron recognize his mood changes, and the
causes for those changes.
Aarons Indicators
Red in the face Staring Lips clenched
Following directions Making eye contact
Quiet
Swearing
PERSEVERATION
Destructive Past the Red Line
Peaceful
Cool Zone Blue Zone
Yellow Zone
Red Zone
Use your strategies - take a break and move
away - talk about what your feeling - listen to
music
Stop and breathe

• Clear the deck
• Get somewhere else quiet

Staff Scripts

• Use the Hard Easy Script
• Aaron is this hard or easy?
• OK, if its hard, no problem
• Ill give you some help.

• Use the Ready Not Ready Script
• Aaron youre not ready to do this.
• Ill know youre ready when you look
• like ________.

157
The Job Help people to learn to develop, and
tell THE STORY Not simply report the news.
158
Four Lessons to Live by
Hope is an essential part of any successful
plan of support. Form follows function. Think
about what you need and then create a way for
that to happen in a flexible manner. The more
you try to force something or someone to change,
the more it (or he or she) changes you. When
all else fails, a sense of joy and a sense of
humor can get you through a whole lot!