Toileting Branch Design #3 Overview of Client Selection, Intake Forms & Pre-Treatment Assessments
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This guide provides an overview of client selection, intake forms & pre-treatment assessments.
What are the prerequisite skills to starting SBT?
You might be thinking about this when working on client selection. However, in general, being able to establish and maintain HRE, and some way to communicate the FCR (either vocal or physical) are the only true prerequisites!
I’m not aware of any published, however in practice with very complex and older learners with long learning histories we have found at my practice that the building trust/relationship stage is essential and may take a month or more. We have seen this across half a dozen clients so far who have complex profiles. When we dive in to sFCR with these learners too soon before that is established and he have SOLID HRE we have to go back to the start anyway – so it’s been better to work that in to treatment from the beginning. We are also defining and establishing boundaries during this stage and teaching assent and withdrawal of assent.
–Melisa Santacroce
What are some common barriers or red flags to look for that signal the client is not the best fit for SBT?
Other considerations include…
- Inability to design a condition at leads to HRE
- Older teens/adults with advanced verbal skills
Are there any specific diagnoses or behaviors that SBT would NOT be recommended for?
If you can’t turn on and off the EO reliably, I’d consider if this is the right fit. I don’t think there is a list of what specific diagnoses, but for example — schizophrenia might not be a good fit if you cannot control the client’s internal EOs. I don’t think we could say DEFINITELY NOT to any particular diagnosis because everyone is so unique….. but you really have to consider — can we do this safely? Can we adequately control the EOs?
-Jacqui Wunderlich
Is there a list of prerequisite skills a learner needs in their repertoire prior to beginning “my way”?
Not necessarily a permanent barrier, but definitely a signal that you need to do some investigating: you struggle to design an HRE condition that virtually eliminates the referring behavior.
–Bethany Creech
Sometimes older learners with a lot of verbal skills aren’t the best fit- enhanced choice model or collaborative problem solving are things I consider for that profile.
–AnnaMarie Stoudenmire
Should I use SBT with learners that fit an ODD/PDA profile?
I have, but I don’t do it with this profile anymore. I have found that Collaborative & Proactive Solutions does a much better job of building the more complex skills these learners need.
-Bethany Creech
Are there any other considerations I should think through?
I want do move forward with SBT…how much time should I spend in treatment?
Check out these resources on how to determine the amount of SBT that your client may need.
Treatment Determination Tool (TDT)
SBT at a Glance
Additionally, here are some threads about SBT dosage! Generally the answer is…
How long should I run SBT with a full day client?
It really depends. I always say to start by developing a really solid BAU context with a nice boundaries protocol and target emotional regulation. From there, you can determine how frequently R1/R2 are occurring and better decide programming time
-Megh Moloney
Second for developing boundaries protocol, and having a Universal Protocols set up – which really focuses on programming to be assent based and supporting BAU in a way that shows empathy, enriches the environment, following students behavior, and limiting non-essential demands, as well as reinforcement of precursor behavior.
–Brit Baulere
Are there recommendations for how long you should run SBT trials with a learner each time? And how long in Boundaries as Usual?
For me, it depends on if I am able to work on skills outside of SBT or if I am spending that time trying to keep interfering behaviors turned off.
I stopped being ok with forcing a client to give up their activity and transition if it meant the client was not consenting and actively participating in the transition. If we could work on NET, we would do that and then work on relinquish and transition during SBT.
For SBT, make sure practice sessions are productive. If too many trials back to back is aversive, space it out with other tasks or longer periods in SR. If other tasks are too aversive, leave them out and focus on teaching them as a branch in SBT.
-Cindi Kennedy
When running SBT all day (heavy dosage) do you only run in practice room (honouring when student chooses to leave practice area) or do you follow the student’s lead and work in whatever space the student wishes (hall, class, outside)?
If the client is HRE then yes we may continue running trials.
We might also see what they’re seeking and try to bring it with us back to ur designated space if possible.
If they are not HRE- then we will work on meeting their needs to get them back to HRE.
Additionally, we scaffold “unavailable” around some of this. If we know a client is going to vote with their feet, or maybe we don’t know and then it happens, we game plan around what amount of that is okay.
For example- we have a student in school who we allow to vote with his feet. But there are areas, activities, and actions that we cannot allow when he is voting with his feet. This has been an evolution. But we are giving enthusiastic access to walk around areas of campus. But when it comes to going into other classrooms, approaching other people, climbing into areas- we adhere to a strict unavailable consequence. And unfortunately as a part of that we do have to deal with some fall out in terms of escalated behavior.
I tell staff to cast a wide net. Make as much available as you can so when the unavailable happens, it’s not as big! If you have enough available vs unavailable the client should allocate their responding to where their behavior gets the most reinforcement. It can take time to get to that place!
-Hillary Laney
What number of trials should we have in an SBT session?
FTF suggests for a minimum of 120 trials to be done weekly as well. So if you are doing three hours a week that would be a goal of 40 trials done per hour.
This might not be reasonable depending on your learner and the average length between trials. Just something to keep in mind when deciding on dosage.
-Logan Waggoner
Right, based on the changes Dr. Hanley’s team implemented, the process is not time-based anymore, but rather we progress based on the learner’s progress. We let the learner lead the number of trials based on them being HRE. That is what should dictate when you run the next trial, so it will vary greatly. Otherwise, you may find yourself running trials when the learner hasn’t reached HRE yet (i.e. “too soon”). You also need to be careful with not running enough trials though!
-Monica Meija
Does a more frequent lower intensity of sessions (1 hr, 3-5 times a week) have outcomes similar or better than that of high intensity (9-15+ hours a week)?
I’m not too sure about funding and what not, but I always concentrate on parent training. I make sure the parent is competent to implement and has the rationale behind what we are doing. This allows for generalization into the home environment and more practice through the day and throughout their lives. Parents have to be dedicated… I work with military families and I want to make sure they are prepared to run programming for months/year before they get services again when they change duty stations… I don’t know if that helps.
-Letesha Driskell
Additional resources for client intake, selection and assessment
What do I need to do before starting treatment? The Behavioral Health Index (BHI) provides a way to track quality of life over time. The Personal Inventory of Values Informing Treatment (PIVIT) allows you to more easily prioritize the values of the family when selecting goals.
Behavioral Health Index (BHI)
Also available in… Russian!
Behavioral Health Index (BHI) in spreadsheet form!
BHI Class Profile Example
Get some ideas of Initial Intake Questions from Tropical Behavioral Services
Jessel et. al’s Questionnaire of Concern for Problem Behavior
Client Ratings Living Document
Consider Activities Meaningful to the Person (AMPs)
Uncover family values and perspectives with PIVIT
You’ve made it to the end of this guide, but this is only the beginning! These tools and resources are a great starting point, but you can also utilize our other guides, resources, mentors, and partners to help you along your PFA & SBT journey. Didn’t see your question answered? Want to connect with others? Come join us on our FaceBook community by clicking here. (And don’t forget to answer the membership questions when you join! 😉)