Where It All Starts…
Your child’s treatment plan is the foundation of moving things in the right direction and seeing progress in your child’s behavior. It’s vital that you’re a large part of this process (of preparing the plan), in identifying the primary concerns that need to be targeted and to ensure that the goals are clear, concise, and achievable. In that respect, this post will target the creation of clear baselines, and writing achievable objectives.
What To Be Looking For To Create An Effective Treatment Plan:
You want there to be a clear indication of the problem behavior, how the problem behavior is manifesting (the baseline), and an objective that will show progress by the end of the treatment period (usually 3-6 months). The ‘treatment period’ is simply a period of time to assess progress, it does not refer to discharge. There can be many ‘treatment periods’ before discharge occurs.
Goals vs Objectives
These terms are often used interchangeably, but the goal is often broader and vague, while the objective is very specific.
So, what’s the Formula?
There are 5 steps to this formula – will review them now.
Step 1: Target the Issue(s):
What are the typical issues that cause difficulties in the home? Almost invariably, they include a child having problems with:
- Aggression or being oppositional
- Social Deficits
Step 2: Determining Vague vs Measurable Behaviors
Your child’s therapist will operationally define the ‘issue’ into measurable and observable ‘behaviors’. Once you know the issue(s), the next step is to transform the issue into an identifiable and concise behavior as clearly and specifically as possible - in measurable and observable terms, which means you can actually observe the behavior, and measure it. In that regard, “emotional”, which is far too vague, is operationalized into specific ‘behaviors’ that can directly be observed and measured, so we can assess over time and see if there is progress. So, here are some examples of vague vs specific:
Specific Terms (Observable and Measurable):
yells and screams/whines/cries/runs off
hits mother on the arm/throws things/gestures…
yells ‘no’/ignores/says will do it, but does not
Time-sampling or permanent product/task completion:
- Off-task 3/5 minutes- three, 5-minute time-samplings
- Fails to complete 3/8 classroom assignments per day
- Fails to complete 5/8 assignments on time.
avoids social interactions / “socially awkward” is too vague, instead – stands too close, monopolizes…
Step 3: Quantifying Behavior:
Once the measurable and observable behavior is identified, the next step is to quantify the extent of the behavior so the behavior will be seen in ‘measurable’ terms. For example:
- how many times per day, or per week (e.g. 3x per day)
- How many times per opportunity or # of prompts (3/5)
- how often within any given occurrence (hits 5x per occurrence, or works at a particular rate to accomplish a chore)
- how long the behavior persists per-episode
- degree of force (aggression – leaves a bruise, red mark…)
- The time between prompt and task initiation
Step 4: Establishing a Baseline:
Your child’s therapist will then create the ‘Baseline’ by combining the specific problematic behavior with the measurable term. The Baseline is the extent to which the behavior is seen before treatment begins. A baseline can be written in lots of different ways, whether how many times the behavior is seen, or how often seen in a number of opportunities…
Baseline Examples when a child is oppositional:
- Michael yells and resists when directed to task 50% of the time.
- When directed to task, Michael yells ‘NO’ 5x per day, (or 3 of 6 occurrences).
- When directed to task, Michael yells ‘no’ and screams, at an ear-piercing level, 5x per day.
- When given a direction, Michael says ‘NO’ and refuses to comply 4x per day (before the 5th prompt/or 4 of 5 opportunities).
- When given a direction, Michael ignores and does not comply 70% of the time (or 7 of 10 occasions).
- When given a direction, Michael waits an average of 15 minutes before beginning the task.
- When given a direction, Michael needs 5-6 prompts to comply, at least 60% of the time (6/10 opportunities).
Baseline examples when a child has lots of emotions:
- Michael has yelling episodes 3x per day - persists for 20 minutes each time.
- Michael yells for at least 10 minutes, 3x per day.
- Micheal screams, in an ear-piercing manner, for 15 minutes, 3x per day.
Examples of baselines for a child struggling with distractibility:
- The therapist will target on-task behavior, or what’s referred to as “permanent product” or the outcome of the assignment (completing a worksheet, or completing the chore).
- Mary completes 1/5 assignments per day.
- Mary needs 5 prompts every 10 minutes to complete a task.
- Mary needs 10-15 prompts to get through the morning routine.
- Mary is off-task 50% of the time during time-sampling (a time-sampling is when a therapist measures, for example, whether the child was on-task when observed every minute for 10 minutes, for a one-hour period of time, 3x per day).
Is the baseline truly measurable and observable? We use the two-person test: would two people agree on what the behavior looks like?
Step 5: Creating Objectives for Effective Treatment:
Next, we create the objectives (based on the baseline). You and your child’s therapist decide what is realistic to be achieved by the end of the treatment period, and use the same behavior and measure as what was used in the Baseline.
Examples of baseline and the subsequent objectives targeting compliance or following directions:
Baseline: Michael yells and resists, for upwards of 10 minutes, when directed to a task 50% of the time.
- Objective: Michael will comply with directives, with only mild sulking (defined) that will persist for no more than 5 minutes, 60% of the time, and will comply otherwise.
- Objective option 2: Micheal will comply with the second prompt and remain calm (define calm).
Baseline: When directed to his chore, Michael yells ‘no’ 5x per day, (4/5 occurrences).
- Objective: When given a direction, Michael will remain calm, and comply 3/5 occurrences per day.
- Objective Option 2: Michael will complete his chores (define) by 5:00 PM daily, 4/5 days per week.
Baseline: When directed to task, Michael yells ‘no’ and screams, at an ear-piercing level, 5x per day.
- Objective: When given a direction, Michael will demonstrate no more than minor sulking (define) 2x per day and will comply otherwise.
Baseline: When given a direction, Michael says ‘no’ and refuses to comply 4x per day (needs 6-8 prompts).
- Objective: Micheal will comply by the 3rd prompt no less than 3x per day.
Baseline: When given a direction, Michael ignores and does not comply 70% of the time (7/10 times).
- Objective: Michael will respond and comply with directions 60% of the time.
Baseline: When given a direction, Michael needs 5-6 prompts to comply, at least 60% of the time.
- Objective: Michael will comply before 3rd prompt 50% of the time.
Example of baseline and subsequent objective targeting emotions:
Baseline: Michael has yelling episodes (define yell) 3x per day - persisting for 20 minutes each.
- Objective: Michael will exhibit yelling episodes no more that 1x per day, for 5 minutes per episode.
Baseline: Michael yells at a severe level (define “severe yell”) for at least 10 minutes, 3x per day
- Objective: Michel will exhibit a mild level of emotion (define) no more than 3x per day, for 5-minute episodes.
Baseline: Micheal screams, in an ear-piercing manner, for 15 minutes, 3x per day.
- Objective: Michel will exhibit mild emotional episodes (define), 1x per day, for 10 minutes per episode.
Examples of baseline and subsequent objective targeting attention to task: (assessing on-task behavior, or using permanent product).
Baseline: Mary completes 1/5 assignments per day (this is using permanent product).
- Objective: Mary will complete 4/5 assignments per day
Baseline: Mary needs 5 prompts every 10 minutes to complete a (specific) task (tough to monitor).
- Objective: Mary will complete a task with less than 4 prompts.
Baseline: Mary needs 10-15 prompts to complete the morning routine (define morning routine).
- Objective: Mary will complete the morning routine with less than 6 prompts.
Baseline: Mary is off-task 50% of the time during time-samplings (define time-samplings - how, where, when).
- Objective: Mary will be on-task 75% of the time during time-samplings.
A few more examples of baselines and short-term objectives: sometimes there are shorter-term goals that can build off of known baselines:
Objective Goal: Mary will comply with parental directives within 2 prompts in at least 4 out of 5 presented opportunities.
- Known Baseline: She is able to comply with parental objectives in 3/5 instances with 3-5 verbal prompts.
Objective Goal: Mary will improve self-control as evidenced by no aggressive, destructive, or self-injurious acts at least 5 out of 7 days a week.
- Known Baseline: She engages in aggressive and destructive acts 4 days per week.
Objective Goal: Sally reduced controlling behaviors (telling others what to do or being bossy, attempting to negotiate, etc.) to 2 out of 5 times by the end of the treatment period.
- Known Baseline: She becomes controlling during interactions in 4/5 instances
Objective Goal: Johnny will decrease physical aggression to once per week or less by the end of the treatment period.
- Known Baseline: He becomes aggressive with his mother and siblings 3 days per week
Objective Goal: Neal will learn and use appropriate coping/anger management skills (taking deep breaths, hitting a pillow, counting to 10, etc) when upset in 3 out of 5 instances by the end of the treatment period.
- Known Baseline: He uses coping skills independently 1/5 instances
Objective Goal: Nelson will improve problem-solving skills as evidenced by using his words and refraining from acting with violence in 3 out of 5 situations by the end of the treatment period.
- Known Baseline: He is unable to use problem-solving skills at this time (0/5 instances)
The Key to Effective Treatment:
The key to effective treatment plans is a careful process - and one that involves observations by both the family and the therapist. So there you have it; this general overview of how we prepare measurable and observable baselines and objectives so that the treatment process is more targeted and ultimately it’s easier to assess progress over time. Hope you found that helpful. Feel free to reach out with any questions at DrCarosso@aol.com. God bless you and your family.