Tertiary Level

Tertiary Level

What is Tertiary Prevention?

Tertiary Prevention was originally designed to focus on the needs of individuals who exhibited patterns of problem behavior. Research has demonstrated the effectiveness of PBS in addressing the challenges of behaviors that are dangerous, highly disruptive, and/or impede learning and result in social or educational exclusion. PBS has been used to support the behavioral adaptation of students (and other individuals) with a wide range of characteristics, including developmental disabilities, autism, emotional and behavioral disorders, and even students with no diagnostic label.

Tertiary Prevention is most effective when there are positive primary (school-wide) and secondary (classroom) systems in place. In addition, the design and implementation of individualized supports are best executed when they are conducted in a comprehensive and collaborative manner. The process should include the individual with behavioral challenges and people who know him/her best all working together to promote positive change all working as a behavioral support team (BST). Support should be tailored to people's specific needs and circumstances. It should involve a comprehensive approach to understanding and intervening with the behavior, and should use multi-element interventions. The goal of Tertiary Prevention is to diminish problem behavior and, also, to increase the student's adaptive skills and opportunities for an enhanced quality of life.

Tertiary Prevention involves a process of functional behavioral assessment (FBA) and a support plan comprised of individualized, assessment-based intervention strategies, including a wide range of options such as: (1) guidance or instruction for the student to use new skills as a replacement for problem behaviors, (2) some rearrangement of the antecedent environment so that problems can be prevented and desirable behaviors can be encouraged, and (3) procedures for monitoring, evaluating, and reassessing of the plan as necessary. In some cases, the plan may also include emergency procedures to ensure safety and rapid de-escalation of severe episodes (this is required when the target behavior is dangerous to the student or others), or major ecological changes, such as changes in school placements, in cases where more substantive environmental changes are needed.

What differentiates tertiary (individual) intervention from other systems of positive behavior support?

The main difference between tertiary and other levels of positive behavior support is the focus of the interventions. The defining features of Tertiary Prevention (i.e., identification of goals, data collection and analysis, summary statements, multi-element plans, and a monitoring system) address the needs of individual children. It is support that is focused on meeting individual needs; and the characteristics of individual students and specific circumstances related to them (e.g., differences in the severity of behavior, complexity of environment) dictate a flexible, focused, personalized approach. This means that Tertiary Prevention allows teams to vary features of the process (e.g., data collection tools used, breadth of information gathered, specificity and number of hypotheses generated, extent of the behavioral support plan, and degree of monitoring) to provide the most individualized behavior support possible.

When should a program of Tertiary Prevention be implemented and who should be involved?

Mandates provided by educational and human services agencies define conditions in which individual systems should be used to address concerns related to behavior. For example, IDEA requires that a functional behavioral assessment (FBA) be completed and a behavioral intervention plan (BIP) be implemented when disciplinary sanctions result in extended periods (i.e., the first removal beyond 10 cumulative days and every change in placement) in which a student is removed from an environment or suspended (34 C.F.R. 300.520 (b) (c)). Individual systems of support are warranted in other circumstances as well (e.g., when problem behavior is interfering with educational progress).

Who should be involved in functional behavioral assessments and behavioral intervention planning?

Tertiary Prevention is most effective when approached as a collaborative (rather than expert-driven) process. Support teams including the student's family, educators, and/or other direct service providers should be involved in assessment and intervention. It is also helpful to include people who have specific expertise in applied behavior analysis and intervention design. In general, support teams should include people who know the student best, have a vested interest in positive outcomes, represent the range of environments in which the student participates, and have access to resources needed for support.

How can we address the needs of individuals within group environments?

Individual systems and other levels of positive behavior support are complementary in that well-structured group applications (e.g., classroom management systems) provide a foundation for effective individualized support. Often, the need for individual systems is minimized by these broader systems; however, some people require a greater degree of individualization and support. It may be necessary to adapt features of group applications (e.g., physical arrangement, routines, types of rewards) to meet the needs of individuals within certain settings.

How is Tertiary Prevention implemented?

Tertiary Prevention interventions are implemented through a flexible, but systematic, process of functional behavioral assessment and behavioral intervention planning. The following outline illustrates the general steps of the process.
I. Identify goals of intervention.
Based on the available information, the team identifies the specific concerns and goals:

  1. what the student is doing that is problematic (observable behaviors).
  2. to what extent (e.g., frequency) these behaviors are occurring.
  3. what broad goals the team hopes to achieve through intervention.

II. Gather relevant information.
Members of the behavioral support team gather information through a variety of sources:

  1. review of existing records.
  2. interviews of support providers.
  3. direct observation of patterns, antecedents, contexts, and consequences.

III. Develop summary statements.
The team uses the information to create statements that describe relationships between the student's behaviors of concern and aspects of the environments. These statements include:

  1. when, where, and with whom the behavior is most/least likely to occur.
  2. what happens following the behavior (what they get or avoid).
  3. other variables that appear to be affecting the person's behavior.

IV. Generate behavioral support plan.
A plan is developed, based on the summary statements, to address the behavioral concerns and fit within the environments in which it will be used. The behavioral support plan (for students who have IEPs this may also serve as the Behavior Intervention Plan (BIP) includes:

  1. adjustments to the environment that reduce the likelihood of problem.
  2. teaching replacement skills and building general competencies.
  3. consequences to promote positive behaviors and deter problems.
  4. a crisis management plan (if needed).

V. Implement and monitor outcomes.
The team works together to ensure that the plan is implemented with consistency and is effective in achieving the identified goals. The team identifies the training and resources needed, determines who is responsible for monitoring implementation, evaluates outcomes (via continued data collection), and communicates periodically, making adjustments in the plan, as needed.

How should goals for Tertiary Prevention be determined?

Individualized positive behavior support focuses not only on decreasing specific behaviors of concern, but also building adaptive (and replacement) skills, and improving the individual's overall quality of life. Goals should be based on a positive, long-term vision for the student developed with input from the student, the student's family, and the support team. An excellent mechanism for determining broad goals for behavioral intervention is person-centered planning.
Person-centered planning (PCP) is a process for learning about an student's preferred lifestyle. It involves creating goals that will assist students in achieving their preferred lifestyle within a collaborative team context. Most PCP plans are created with the goal of:

  • increasing participation and presence in the school and community;
  • gaining and maintaining significant relationships;
  • expressing and making choices;
  • experiencing respect and living a dignified life; and
  • developing personal skills and areas of expertise.
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