Safeguarding Behavioral Supports

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DDS Office for Human RightsOctober 28, 2013

Safeguarding Behavioral Supports

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Who Should Review This Module:

Human Rights Coordinators Human Rights Committee Members Other Interested Parties

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Presentation Goals

Give an overview of what one needs to know to safeguard behavioral support programs.

Teach the principles and highest standard of care and requirements under the current Behavior Modification Regulations.

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The Right to Habilitative Care and Treatment

For decades supports took the shape of warehousing people, not caring for them, or tending to even some of their basic needs. Expose’s of horrid conditions led to changes in law requiring more humane care and treatment.

Courts took over when pressed by families and advocates using these new laws, and declared a right to habilitative care and treatment, as one response to the broad principles governing these legislated improvements.

This gave rise to the fundamental right to habilitative care and treatment that helps eliminate barriers to a more full life, and maximizes a person’s participation in community activities that are meaningful to that person. Such treatment empowers each person to reach for a life that is satisfying and achieves their fullest potential. Laws required such programming be safeguarded by well informed outsiders, including a Human Rights Committee.

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Understanding Current Context

For many years the Department has worked with a program for addressing behavioral challenges of individuals called Behavior Modification.

In the years since the adoption of this system many advances have occurred in the science associated with this program.

It is based upon Applied Behavioral Analysis and tries to identify the reasons why persons exhibit the behavior they do. What is the function of the behavior and what is being communicated?

It attempts to identify positive skills that can be taught to the person to address the needs previously being met by the inappropriate behavior and replace these with the socially appropriate skills.

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Context (Continued)

As practices have improved more efforts have been taken to identify these dynamics occurring at an earlier point and providing preventative measures and attacking antecedents to the inappropriate behaviors.

In the same spirit, these efforts have led to going beyond understanding the simple functional consequence that maintains the behavior to include the environmental conditions and triggers that cause it. This means understanding that although a person may hit someone to “escape” a task (consequence), he or she may have been aggressive because of frustration over not being able to complete the task in the first place (antecedent).

Now we may want to know if there were signs earlier that the person was tired, or a specific part of the task was particularly frustrating because it required abilities they don’t have.

Context (Continued)

Now we must do more work to understand what it is about the task they may want to escape. While simply teaching appropriate ways to communicate their frustration with the task is helpful, addressing the cause of the frustration with the task may be more helpful. Maybe both can be done, so the communication strategy may be applied to different situations.

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Context (Continued)

All of this is designed to know more about why the behavior occurs and what the truly least restrictive approach can be to helping the person get their needs met without expressing behavior that can cause harm to their selves or others for any reason.

This presentation will guide you through a step by step process for understanding what you should be seeing in plans you review and how to think about what you do see.

Context (Continued)

Plans are classified by level of intrusion, Level II plans must be approved by a Human Rights Committee before implementation.Level I plans pose no more than a minimal degree of risk, intrusion, restriction on movement, or possibility of physical or psychological harm.Level II plans carry more than a minimal degree of such risks, intrusiveness or restriction.

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Safeguarding Treatment

ISP Teams, Peer Review Committees and Human Rights Committees all act as a safeguard to ensure that all the required components of planning have been properly included in each behavior support plan, and the thinking is whole.

Comprehensive planning is important to successful treatment and each of these groups plays a unique role in support of this.

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Safeguarding Treatment (continued)

Human Rights Coordinators provide a critical role in getting the plans to the Human Rights Committees in a timely manner and either ensuring clinical staff are present at the meeting, or that obvious questions are addressed before the meeting. They serve as the liaison between the committee and the administration.

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Each step in safeguarding puts a different set of eyes with a unique focus on the behavior support plan and allows it to be fully vetted.

This presentation looks mostly through the lens of the Human Rights Committee, but many of the questions are the same for each role in safeguarding.


The HRC has the perspective of people who are outside the day to day operations of the program, but who have direct experience with individuals like those now supported.

The HRC has perspective as well from an array of roles, advocate, family member, clinician, health care professional, legal and as a person with intellectual disabilities, and therefore valuable knowledge of the context of the lives of people with disabilities.13


These different perspectives and sets of experiences can help the committee see circumstances differently and can sometimes help find different solutions. They can also see problems with proposed solutions that may not have been anticipated.

Finally, the HRC can see if something was missed by the clinical team.

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Who Writes the Plan

All plans are overseen by persons knowledgeable of and practiced at Applied Behavior Analysis

Persons without full training, but proper clinical supervision may qualify to write such plans.

One person may write the plan, but all such persons work as part of a team in which each member has some knowledge of the person and the setting in which the behavior occurs.

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What Needs to be in a Behavior Modification Support Plan?

I. Background Information: This includes some basic facts about the person, their age, height and weight, abilities, disabilities, medical and psychological diagnoses and legal status

It also includes facts about the person writing the plan and the treating clinician, or Qualified Clinician” if different.

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What Needs to be in a Behavior Modification Support Plan? (Cont.)

Individual’s support providers, residential, vocational and/or day programs and how they, or sometimes family, participate in the plan’s implementation.

Other treatment the person may be receiving, counseling, psychiatry, etc., and how this is integrated with the behavior plan (should always include list of medications when this includes psychiatric care).

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These elements give a framework for the person’s environment and the setting and players involved in the planning. These contribute to the context for the number of considerations that may be present for this person. It also says who is writing a plan to those safeguarding it.

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II. Clinical Elements:

Individual’s strengths, skills, learning style, or other personal attributes that will help in development of replacement behavior or alternative behaviors, and that may lead to work, personal or other success

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History of individual’s problem behavior and if relevant related mental illness and key events, such as personal trauma or significant family events or changes that may be leading up to the person’s current clinical status.

What un-intrusive, or less intrusive interventions have been tried, what were the results?


The next component is the core of ABA science. This is the performance of a comprehensive Functional Behavior Assessment (FBA).

This is performed using a number approaches, including a record review, observations, interviews, and/or use of standard ABA analytic tools, like ABC, or FAST assessments.

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The plan should describe the approaches used to perform the FBA.

The plan should then identify and describe the results of the FBA, such as: the antecedent events that may at times trigger the behavior; the setting events such as hunger, mood states, or predictable pattern of interactions that are likely to lead to a problem behavior.

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It isn’t until the clinician can put together the factors that seem to maintain the behavior with the factors that may have originated the individual’s needs for the behavior that they can have all the information needed to then start to devise a solution. The solution or solutions may meet at several points along the series of events that can lead to the behavior.

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The other result to identify are outcomes or consequences that may be maintaining the problem behavior. This can include both immediate and more distant consequences (actions that come immediately, or predictably down the road) that seem clearly to be maintaining the problem behavior.

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What Needs to be in a Behavior Modification Support Plan? (continued)

Brief introduction of the target behavior and an analysis of factors that may be contributing to the occurrence of the target behavior.

These can include stressful life circumstances, like loss of a friend or less-preferred living setting, or other environmental factors, like disruptive work mate.

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Organic, medical or psychiatric conditions which may be contributing to the problem behaviors or interfering with the learning of adaptive skills.

If the person has the ability to communicate their wants or discomforts.

Responsiveness of person’s support staff to their efforts to communicate.

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The clinician has the job to make the plan make sense. It is important to

understand what the behavior is and how the person is guided by these factors to respond as they do.

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Getting to Solutions:

The next set of sections of the plan will focus on interventions to solve the problems. This will include behaviors to increase, many of which are targeted to replace the need for the inappropriate behavior (replacement behavior) and some improving competence in their environments. Others work to reduce the targeted behavior.

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Section on behavior or behaviors to be taught, maintained and/or increased.

Include an operational definition of the replacement behavior (some behaviors to increase may not be “replacement behaviors” as noted in last slide, however for every target behavior to decrease, there must be a corresponding replacement behavior).

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There needs to be a rationale based on the findings of the FBA for why each replacement behavior was selected.

It needs to identify a specific method of measurement for each replacement behavior.

Baseline data needs to be presented for each replacement behavior as deemed clinically appropriate.

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The clinician needs to be able to explain why these are going to be the successful solutions to the problem. Having data will allow the committee and others, over

time, to measure the course of treatment.

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For each instructional procedure to teach, maintain or increase the replacement behavior there must be a description of the instructional procedure;

A description of how the potentially reinforcing consequences were chosen and why you believe they will work for this individual.

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What Needs to be in a Behavior Modification Support Plan? (Cont.))

A description of the proposed schedule for reinforcement supporting the procedure.

A description of how the instructional procedure will be used; structured teaching sessions, incidental teaching opportunities, and/or in the context of the person’s day to day milieu.

This can be matched up with learning style information to build confidence in procedure.

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For Behavior to Decrease there must be clear operational definitions of each such behavior to decrease.

There needs to be a specific method of measurement for each behavior to decrease.

If behavior to decrease occurs infrequently it may be necessary to consider complementary or indirect measures for use in valid evaluation of the progress.

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Baseline data judged as clinically appropriate in relation to the behavior being addressed must be reported in the plan.

Baseline data using the chosen method for measurement are needed to allow all to measure the course of treatment over time.

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For each proposed intervention designed to decelerate the behavior to decrease there needs to be a description of the intervention and it needs to be determined whether it is a Level I or II intervention.

There needs to be a rationale for each intervention to decelerate a behavior to decrease based on the FBA and a statement on why this intervention was chosen.

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What less restrictive or intrusive interventions have you considered prior to those proposed in this plan? Why were they not tried?

There is an obligation of the plan, to limit interventions to the less restrictive or

intrusive intervention possible to achieve the goal.


The plan must detail for each intervention: how it will be implemented, the conditions under which it will be employed, the duration of the intervention per application, the conditions/criteria under which an application of each intervention will be terminated.

This allows the reader to understand the true level of intrusion, aversion or restriction

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The plan must detail in measurable terms the expected behavioral outcome from the use of each intervention.

It must include criteria that defines success of each intervention and the plan as a whole.

It must include criteria defining the need to revise the plan, and other criteria showing the need to terminate the plan.

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The plan must include success criteria that are related to a specific date or number of trials after which the plan will be evaluated and may continue to run as is, be modified, or discontinued, based on the outcomes to that point.

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As you can see, the clinician has a tall order to show that they understand the person and their behavior and they can forecast how long it would take to succeed with these behaviors.

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Plan must include an assessment of what psychological or physical harm, if any, could result from the implementation of the proposed interventions and how likely this is to occur

Clinician must detail plan for periodic review of records on behaviors to increase, decrease, reinforcement delivery, application of interventions and safety checks.

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Clinician must demonstrate how these record reviews will be documented.

Plan must specify staff training procedures for each specific procedure of plan, who will do this training, how modifications or updates to plan shall be trained, and who will be authorized to implement the intervention.

Before implementation a physician needs to sign off that a Level II plan is not medically contraindicated.

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These final criteria for the plan ensure it will be well monitored according to reasonable standards of care.

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Other Terms to Know

Interventions may either be: Positive Reinforcement, meaning an action or

reward for exhibiting a replacement behavior, or some alternative, or any socially acceptable behavior other than the inappropriate target.

These positive practices may include differential reinforcement of other (DRO = increased access to rewards for a desired response other than that targeted), differential reinforcement of incompatible (behaviors you can’t do and while exhibiting inappropriate behavior) and/or alternative (specific targeted) behaviors (DRI or DRA), Satiation (saturation exposure that causes state of “feeling full”), or Token point gains.

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Other Terms to Know (Continued)

Aversive, unpleasant conditions or stimuli which may elicit a negative response to convince the person to not exhibit a specific behavior.

Deprivation, meaning to withdraw or delay goods, services or social reinforcement that are rewarding to the individual as a “response cost,” or consequence for exhibiting the target behavior

Aversive and deprivation procedures can have a varied risk or level of intrusion, or restrictiveness. The goal is to use the least restrictive and most effective strategy possible to help a person change their behavior. These are punishment strategies.


Time Out “means socially isolating an individual by removing the individual to a room or an area physically separate from, or by limiting the individual’s participation in, ongoing activities and potential sources of reinforcement, as a suppressive consequence of an inappropriate behavior.”

115 CMR 5.14 (2) Time Out

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Level I time out could be moving a person to another area of a room, but in plain view; removing material or activity or positive reinforcement for a given period; or moving to a room for no more than 15 minutes, with the door open and with staff present.

Level II time out has the person in a room with the door closed and staff able to observe for no more than 15 minutes.

Any time out requiring an escort with force over resistance to get to time out is also a Level II plan.

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When a Level II time out proceeds to 15 minutes, the person must be given the clear earnest opportunity to leave. Multiple time outs that exceed 15 consecutive minutes are not allowed. They must end and the program must use a different strategy.

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What to look for in reviewing behavior support plans

In the current scheme all Level II plans, along with Level I plans that have some associated restriction, must be reviewed by the Human Rights Committee of an agency, who gets to approve or disapprove of Level II plans and weigh in on the need for restrictions in Level I plans.

Such reviewers don’t need to all be clinicians, but to apply the “reasonable person” perspective on whether the rationale and the strategies make sense, is the plan coherent, does the data and internal logic of the plan match up and therefore qualifies as the least restrictive approach as required by regulations?

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Reviewing Behavior Support Plans(continued)

The reasonable person’s standard is simple. Do the judgments in the plan match up with the interventions chosen?

The clinician says the person is engaging in dangerous behavior of grabbing people to get attention. The replacement behavior rationale says it isn’t dangerous and teaching to shake hands will suffice. Does this mean the punishment procedures to decelerate the target of grabbing are necessary?


Do the target behaviors to decrease really reflect a compelling problem the person needs to have addressed? Are the restrictions in the plan necessary?

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Does the data show the plan is working, because the frequency or intensity, or both, of the behavior to decrease is decreasing and the data for the frequency of replacement behavior increasing?

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If there is a mismatch in the data, for instance, where behavior to increase is rising, but so is the behavior to decrease. There should be an explanation for this before you approve the plan.

One example might be that a major life event, such as the death of a family member occurred and interfered with the course of treatment.

Good clinical leadership should have an answer for data problems.

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Reviewing Behavior Support Plans (Continued)

If it is a new plan is there baseline data to express the frequency and intensity of the problem? What do they expect to happen?

What less restrictive things have been tried, and how did they work out? Is there anything more positive and less restrictive that could be tried?

Have less restrictive procedures included changes to an environment that may pose problems for the person, or otherwise address the context in which the behavior occurs? Is the context clear?

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Do the replacement behaviors make sense according to the rationale for them, or do they simply seek to obtain compliance from the individual?

Does the plan speak to the person’s strengths, and their vision, making it more likely the plan will be more meaningful and therefore successful for this person?

Does the rationale clearly discuss communication deficits and do interventions reflect their role in the behavior?

Does the plan speak to medical complications the person may experience?

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If the plan is being renewed from a prior year, does the data on targets to decrease show decrease, and the targets to increase show the data increases? This would indicate the program is working.

If not, ask why the plan is being continued, or what leads the clinician to believe that the plan still has merit? Were there circumstances that interfered with treatment in the past year?

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Never just take someone’s word for the outcomes, data must be available to explain the course of treatment, though sometimes data and narrative are needed together to tell a complicated story, both are helpful.

If the inappropriate behavior targeted for decrease is maintained by escaping a task, is it a task that is meaningful to the person (goes to rationale)? Does it require skills the person doesn’t have (fine motor skills, for instance)?


If the target behavior to decrease is reinforced by internal stimuli, such as endorphins from self-inflicted pain, is there a strategy to address this?

Have all possible medical conditions that could be causing discomfort for the person been ruled out as a cause for the behavior?

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How do the risks associated with particular interventions weigh against the potential benefits from the procedure? Are the risks clear?

What is the system for training staff about the procedures in the plan and for taking data on the various parts of the plan? Are they planning on collecting the right data?

Does the plan seem to fit the person as known to the committee, if known?

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Actions for HRC review: Approve plan. Approve plan until next meeting with specific

supplemental parts to be reworked. Disapprove of plan with specific problems

spelled out, identifying lead person who can “informally resolve” the problems with clinician.

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Other Considerations Regarding Behavioral Supports and Treatment

When committee or others see behavioral problems in incident reports or restraints

they also review, what can they do? If the problem hits two times in a week on more than

one day, or three times in a month ask if the team has been convened to discuss why this has happened and what might be able to be done to better support the person. There should be a clear answer that the team is scheduled to meet, or provides the determinations of the treating clinician.

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Other Considerations (Cont.)

What is the context it is occurring in? Is it always during certain times of the day, days of the week, during specific tasks or activities, or when certain staff are on shift?

Committees and others looking at restraints and incidents should look for places where problems may be occurring. What are the antecedents (sequence of events and behaviors prior to the emergency)?

Is the duration of restraints high (longer than 15 minutes?

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Sometimes the problem may be the effect of one individual on others. What is the program doing to assist others affected?

The program’s obligation isn’t just to help the person having difficulty, but also to help those who may be traumatized by the behavior of a fellow resident.

This requires programs to anticipate, or to be thoughtful about how to handle these situations.

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When looking at behavioral support needs all hands should be on deck, along with all eyes, ears and observational capacities of direct care staff. These are all needed to best understand the dynamics of behavior so that the best and least restrictive or intrusive solutions can be found.


In the end, review of restraints and incident reports should focus on preventing their recurrence and providing more supportive environments to improve the quality of life for persons involved.

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Conclusion

For more information contact your Human Rights Specialist. On your internet browser type in

mass.gov/dds and in the top of the left column click on “Human Rights.” You will find the list of Human

Rights Specialists on this page. Otherwise call:

Tom Anzer, DDS Director for Human Rights

617-624-7738

Documents

Safeguarding Behavioral Supports