Category Archives: Charting Progress

Active nursing – more than charts and labs!

May 1, 2014Charting Progress, JRC Experience, JRC ProgramDB

I have had the pleasure of being a nurse at JRC for 2 1/2 years.

I have worked in many other places such as hospitals and in-patient mental health facilities, and I have never had such a great work experience as I have had here at JRC. Unlike other facilities where I have worked, I feel I have the opportunity to get to know our students and clients and become an active and important part of their lives.

Each day, I look forward to interacting with our students and clients and ensuring their well being in a hands-on fashion instead of just through monitoring of charts, labs, vital signs, etc.

One of the greatest things about being a nurse at JRC is that I have the opportunity to see a student or client’s health and behavior improve as they receive treatment here at JRC.

This bag of psychotropic medications came to JRC with one student who was admitted. All of them were being taken daily! — This bag of psychotropic medications came to JRC with one student who was admitted. All of them were being taken on a constant basis!

One case in particular really stands out in my mind as a testament to this. We had a student come in at 256lbs and on three different psychotropic medications. She also was on oral diabetic medications and high doses of insulin twice daily. In a year she lost 86lbs and has been able to discontinue all of her psych meds and also is off all her diabetic medications. We don’t even need to check her blood sugars anymore!

To have the opportunity to watch the transformation of a student or client who has weaned off medications, and have her personality come out, and her eyes brighten as her body heals and the effects of the medication fade, is truly special.

Due to an outstanding chef, kitchen staff, and physical education departments, we have had the opportunity here at JRC to watch numerous clients and students lose weight and no longer be insulin-dependent and/or medication-dependent diabetics. In a world that is experiencing an obesity epidemic, this is truly an amazing feat.

One of the greatest rewards is not only to see how amazing the clients and students look and feel, but also to be able to speak to the parents and guardians and hear how grateful they are for the changes they see in their children. I greatly enjoy being able to interact and communicate with the parents and guardians of our students and clients, for I feel like this enhances the experience at JRC for the parents and guardians, students and clients, and myself.

At JRC we are a full-functioning nursing department that provides care for our students and clients on a 24 hour-a-day basis. We staff both LPNs and RNs, and we provide medical services in both the school and residences. We have two consulting physicians and also have close partnerships with many local hospitals and specialty offices to ensure our students and clients receive the best healthcare.

Nursing completes medication passes, first aid, sick visits, well checks, immunizations and body checks. Nursing also provides education in hygiene, sexual education, and health promotion. We also provide education to staff as to proper care of our students and clients, Emergency Medication Administration, and medication administration program (MAP) training.

Our goal as the Nursing Department to ensure that our students and clients are receiving the best medical care through a teamwork approach with all other specialties at JRC.

Need a Progress Monitoring Tool? Precision Teaching is the Tool for You!

April 28, 2014Charting Progress, Data, JRC Program, Special Education, Special Needs Programmingprecision teaching, progress, readingjh

What is Precision Teaching and how can you use it?

Precision Teaching is a measurement system that allows teachers to track what their students are learning and how they are performing. This is a great progress monitoring tool for all of you teachers out there!

This system puts the collected data onto a standard celeration chart, which gives the teacher a very clear learning picture. Teachers are trained to chart the data as well as how to interpret the data after it is placed on the chart. This allows teachers to make data-based decisions about their students’ learning.

By making these data-based decisions, the teachers can then determine if an intervention is needed and which one to use. This tool can be used in any area, for example: math facts; spelling; reading; writing; vocabulary; appropriate or inappropriate behaviors; running; toileting; smoking; daily living skills; vocational activities; and more.

In order for this system to work, a few things need to be set up:

First, you must identify what area you want to improve or change.
Second, the teacher must gather and arrange the materials needed.
Third, you must set the criteria; determine the length of time that will be set when measuring the behavior; and the aim (mastery criteria) you are looking for.

When taking data, the time can be set typically from 10 seconds up to 5 minutes when charting academic behavior. The data is recorded by frequency (how many times did this behavior occur in the time frame that was set).

An example

A sample standard celeration chart showing reading progress.

A student was working on reading decoding skills. The goal was to read at a rate of 250 words per minute at a 3^rd grade level. The student was given 3rd grade reading material. A timer was set for 1 minute; the student read for the entire minute. During this time the teacher collected the data on how many errors occurred and what specific words were incorrect.

Once the timing was done it was determined how many words were read correctly. The student read a total of 250 words and 6 were incorrect. The teacher then charted this data as 244 correct responses and 6 incorrect responses. Correct responses are marked by a dot and incorrect responses are marked by an x.

In the graph below you see two blocks of data for two different weeks. In the first block the date is marked 3/9/14. The students learning picture is very clear. The teacher set the goal for the child to read at a rate of 250 words per minute in order to move on to the next lesson.

In the first day we can see that the child was reading about 150 words per minute and had 6 incorrect responses. By the 5^th day there was 250 correct responses and 0 incorrect responses. This is GREAT!!! This is was we want to see. In this situation no intervention by the teacher is needed.

In the second week of data listed (I spaced it out so it is easier to read) we see a very different picture. It is clear that the student is struggling to reach the goal. The improvement rate over the week was very small and the reduction of incorrect responses was also very small.

On the first day the student is reading at a rate of 100 words per minute and has a total of 7 errors; by the 5^th day he is reading about 118 words with a total of 6 errors. So when we see this we intervene. (In our school we would actually make an intervention before day 5 but showing you all of these data points allows for my explanation to be a bit clearer.)

There are a variety of things that can be done here. One of which may be taking the words he is getting incorrect and doing a separate timing on those words specifically. Another reason this student is not making progress may be because the lesson is too hard, so he needs to move back to an earlier lesson. These are things we work with the teachers on determining; however this can be done at home as well. You can make an intervention and if it works, great – if not try something else.

I have used this method for myself in college. This is a great tool for when you need to learn a lot of terms. I can see where my errors are and I can go back and adjust the way I am practicing.

Resources

This is just the beginning of what precision teaching is and what it can be used for. There are some really great resources out there that can be used to further your understanding. Here are a few:

Kent Johnson and Elizabeth M. Street wrote an amazing book called Response to Intervention and Precision Teaching. You can also go to Kent’s website, Morningside Academy, and see what he is doing at the school he runs. He also has educational resources available to purchase on this site.
Another great resource is The Precision Teaching Book by Richard M. Kubina, Jr. & Kirsten K. L. Yurich.
Another useful guide is called Standard Celeration Charting 2002, by Steve Graf and Og Lindsley. This is a really tool that is a step by step guide on how to chart data and then read the data.
Lastly, https://celeration.org is an interesting site to join. It will allow you to see updated information regarding standard celeration charts and precision teaching.

Amazing Success Story

April 25, 2014Behavior Analysis, Charting Progress, JRC Experience, JRC Programmedication, skin shock, successrvh

I have been a clinician at JRC for over 20 years. People often ask me how I lasted for so long in such a controversial program. The answer is very simple. I have been a part of a team that has improved the quality of life of so many people. None of the negative comments or ridiculous misrepresentations of JRC has ever outweighed seeing a smile on a face that never smiled, or a “thanks for the help” from someone who entered the program full of anger. I’m in touch with many people who spent time here who we were able to help move on to other settings.

I remember one client, AS, who came to us years ago after 12 years of failed treatment. She spent nine years in 11 different residential or hospital settings in Massachusetts, but was expelled or transferred due to her serious aggressive and self-injurious behaviors. During this period she was treated with 14 medications, Paxil, Benadryl, Ritalin, Desipramine, Dexedrine, Trofranil, Trilafon, Lithium, Clonidine, Depakote, Klonopin, Haldol, Seroquel and Zyprexa in various combinations, without any significant improvement in her behaviors.

In AS’s last Massachusetts placement, she experienced 120 physical and 40 chemical restraints in a 28 week period. When all in-state placements were exhausted (I guess it was felt that JRC was too controversial) she was sent out-of-state where, again, medications and other treatments failed and, after 8 months, she was hospitalized in Boston. She was then finally referred to and accepted to JRC. (I like the fact that we don’t reject anyone because their behaviors are too intense.)

When AS entered JRC she was taking Klonopin, Prozac, Ritalin, Tegretol, Seroquel, Wellbutrin, Naltrexone and Lithium. No wonder she couldn’t control her behaviors! When she arrived at JRC she was in an ambulance and strapped to a gurney – they felt it was the only safe way to transfer her. I found her quite charming with a good sense of humor.

We immediately set up a behavioral program to help her reduce her dangerous behaviors. She did okay for a few days but then became highly assaultive and attempted to injure herself. The honeymoon was over.

custom composite chart — Our student’s chart shows her significant behavioral improvement.

Over the next month she had over 1,000 dangerous behaviors and required staff intervention to keep her and others safe. Staff injuries included broken ribs.

Given her extensive history of failed treatment and the fact that her dangerous behaviors were increasing steadily we discussed seeking court authorization for the use of contingent skin shock. She agreed that it was worth a try since nothing else had worked and she yearned for a more normal life. She wanted to live independently in the community someday.

She was appointed an attorney by the Court to represent her and she told her attorney that she wanted to give contingent shock a try. A hearing was held before a Judge in Probate Court who later authorized the use of contingent skin shock.

Success!

The first week AS received 8 contingent skin shocks for aggression and self-injury with 7 on one day. Over the next 52 weeks she received only 3 more. She was completely weaned off of all psychotropic medications and she was thrilled about that.

One of the biggest but immeasurable changes was her attitude. She went from rude and belittling to happy and social. Her self-esteem skyrocketed. The medications over the years had led to a large weight gain and she began to lose weight. She was clearly proud of her progress and actively participated in her educational program.

Due to her success we began to fade out the use of contingent skin shock after six months of treatment without any negative impact. She testified at the Boston State House against a bill to ban this form of treatment, telling the legislators how this treatment gave her back a life. She went out into the community weekly, which was not possible at all for the 12 years before coming to JRC.

AS was completely weaned off the contingent skin shock treatment within the first year and she was working toward her high school diploma. She did have one small set-back and the skin shock was reinstated for a short period, but in general she just continued to improve in all aspects of her life.

Over the course of her stay with us, about 27 months, AS was able to complete her education and receive her high school diploma. She took courses in a local vocational school. She started a paid in-house job in JRC’s Human Resource Department, and later a job at Friendly’s. (When she came to JRC the last place I could see her working was a restaurant where she would have to deal with many different people each day.)

She went out and got her learner’s permit as she prepared to live on her own. When she was ready to leave JRC, she moved to a group home and then later to independent living. She got married, divorced, remarried and had a baby. She trained to become a home health care aide.

I have kept in touch with AS over the many years since she graduated from JRC. Years after she left we asked if she’d like to speak at the State House again about her years of mental health treatment and how she’s done since she left JRC. She agreed to meet me in Boston, and I waited for her at the entrance to a nearby parking garage. I was brought to tears seeing her drive up in her large SUV. She looked like a confident businesswoman going to the office.

AS told the senators and representatives that day, that without JRC she would have died from her self-injury or been jailed due to her assaultive behaviors. To this day I get goose bumps every time I recount the story of first meeting her strapped to a gurney, and her subsequent progression up to seeing her driving into Boston in that large SUV. I still see her smiling face every day, as we have a picture on the wall of her working at Friendly’s.

And this is only one of the dozens and dozens of reasons that I continue to work at JRC.

Functional Behavioral Assessment at JRC

April 3, 2014Behavior Analysis, Charting Progress, JRC Experience, JRC Program, Special Needs SoftwareNL

The Applied Behavior Analysis (ABA) literature is consistent with regard to the value of thorough and precise assessment of the functions of dangerous/disruptive behaviors. Such assessment (whether experimental functional analysis or descriptive functional behavioral assessment) can help to form the development of a behavior intervention plan that is better tailored to the individual’s clinical needs.

At JRC, assessment of the functions of student problem behaviors is ongoing throughout the student’s JRC enrollment. When the student is first admitted to JRC, a reinforcer preference assessment occurs over the course of the student’s first week. Data are taken regarding which stimuli/events may serve as motivating rewards in the student’s BIP.

Simultaneously, the student’s JRC Clinician begins to collect data, across all environments, on the student’s positive and negative behaviors, as well as related triggers and consequences. Assessment methods include interviews and questionnaires administered to the student, family, and staff; collection and graphing of a broad range of behavioral frequency data 24 hours per day; and direct observation of the student across all natural environments.

JRC’s main video monitoring suite enables views of all JRC spaces.

Direct observation, a cornerstone of good ABA, is particularly easy to do at JRC because of JRC’s Digital Video Recording (DVR) system. Most environments (e.g., classrooms, group homes) are equipped with DVR cameras so that JRC Clinicians are able to observe their students’ behavior and related environmental antecedent and consequent events.

JRC’s specialized standard celeration behavior charting system, when combined with the direct observation capability provided by JRC’s DVR system, means that JRC’s Clinical staff are able to conduct ongoing and comprehensive functional assessment throughout the student’s enrollment at JRC. Such ongoing and comprehensive functional assessment is an improvement upon the once-per-year static and narrowly focused functional assessment that sometimes occurs at other settings. For more information regarding JRC’s functional assessment methods, please feel free to reply to this post.