Restrictive Practices. Ethics. Introduction THE WAITING POTENTIAL FOR PBS TO REDUCE THE USE OF RESTRICTIVE PRACTICES 3/12/18

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1 THE WAITING POTENTIAL FOR PBS TO REDUCE THE USE OF RESTRICTIVE PRACTICES Introduction Behaviors exhibited by adults and children, can be of concern if they put them, their families, their support staff, and/or the community at risk. Gary W. LaVigna, Ph.D., BCBA-D APBS Conference San Diego, March 2018 Out of a duty of care, it is recognized that in these circumstances restrictive practices may be necessary to keep everyone safe. Restrictive Practices Ethics Physical Management Mechanical Restraint Seclusion PRN s Etc. Restrictive practices are to be used as a last resort 1

2 ABAI BACB The Association for Behavior Analysis International (ABAI) and its members strongly oppose the inappropriate and/or unnecessary use of seclusion, restraint, or other intrusive interventions Behavior analysts review and appraise the restrictiveness of procedures and always recommend the least restrictive procedures likely to be effective APBS Background Practitioners use techniques that do not cause pain or humiliation or deprive the individual of basic needs Linear vs. nonlinear ABA 2

3 Linear Behavior Analysis A B C Definition: Behavior is understood in terms of a three part contingency relationship between the antecedents that precede it and the consequences that follow it. Linear Behavior Analysis A B C Examples: 1. When staff are talking with another client, he tantrums and staff pay attention to him. He is doing this for attention. 2. When he is asked to do something, he engages in self injury and staff reactions include withdrawing the demand. His self injury is his way of avoiding undesired activity. Nonlinear Behavior Analysis (Goldiamond & Thompson, 1967; 2004; Goldiamond, 1974; 1975) Comprehensive Functional Assessment < Definition: Behavior is understood in terms of variables beyond the behavior and its consequences and antecedents, that may themselves differentially affect the three part contingency. For example: Potentiating Variables (Establishing Operations) Rules (instructional/abstractional) History Alternative Sets (behavioral repertoires) Constant Stimuli Aimed at understanding behavior within this complex context, concluding with a nonlinear, personal understanding rather than with a linear understanding, e.g., Car Resistance Vs. Why Don t You Understand What Happened to Me? 3

4 Resulting in nonlinear, multielement support plans that proactively employ aimed at: Ecological Strategies (Establishing Operations), e.g., Interactional Style Density of Preferred Events/Activity Schedule Visual Schedule Increased Choice Other Services (e.g., Mental Health; Medical; Supported Living) Positive Programming (Alternative Sets/Target Repertoire), i.e., teaching General, Functionally Equivalent & Related, & Coping/Tolerance Skills Focused Support (Nonlinear/Linear) Strategies for Prevention, e.g., Schedules of Reinforcement - (Cont.;Instructional/Abstractional Rules) Stimulus Satiation (Abolishing Operation) Antecedent Control (Linear) Improving the person s quality of life (clinical validity) Eliminating behaviors of concern (barriers) Generalizing results across time and settings Consent for plan s methods/objectives (social validity) Avoiding negative side effects Nonlinear, multielement support plans reactively employ ABAI, 2010 strategies that are effective in producing rapid, safe situational management including restrictive practices if necessary. The effectiveness of a non-aversive reactive strategy as well as a restrictive procedure, if used, should be evaluated by its measured effects on the Episodic Severity of the behavioral occurrence. Efficacy with respect to treatment programs refers to a reduction in the rate of the specified target behavior and/or reduction in the Episodic Severity of that behavior. 4

5 Episodic Severity Episodic Severity (LaVigna & Willis, 2005) A quantified measure of the intensity or gravity of a behavioral incident measures include, e.g.,! Duration! Cost of repair and replacement! Degree of harm or injury! Topography! Severity ratings based on categories or scales of each incident. Resolution To resolve an event: nonlinear, multielement support plans reactively employ The reactive presentation or withdrawal of a stimulus or event which results in the immediate reduction of the likelihood of response continuation or escalation. Nonaversive reactive strategies (NARS): Function based Non-function based Restrictive procedures To reduce Episodic Severity 5

6 Ethics and policy Non-aversive Reactive Strategies NARS restrictive procedures are to be used as a last resort. First resort reactive strategies Function Based NARS Function Based NARS The Elephant in the Room 6

7 Sigafoos & Saggers, 1995 Function Based NARS Discrete Trial Functional Analysis Attention/Tangible Functional Analysis Client 1 Aggression stopped 100% of the time. Client 2 Aggression stopped 95% of the time. Function Based NARS Function Based NARS Functional Analysis Strategic Capitulation Functional Analysis Strategic Capitulation Examples 7

8 Establishing/ Abolishing Operations Non-Function Based NARS The Elephant Behind the Elephant in the Room Non-Function Based NARS Non-Function Based NARS Establishing/abolishing operations Establishing/abolishing operations Redirection to another preferred activity 8

9 Non-Function Based NARS Non-Function Based NARS Establishing/abolishing operations Redirection to another preferred activity Redirection to obsessive compulsive behavior Establishing/abolishing operations Redirection to another preferred activity Redirection to obsessive compulsive behavior Stimulus change NARS Can establishing/abolishing operations allow resolution w/o reinforcement using NARS? The Elephants in the Room A B C A B C A B R This is the biggest challenge from mainstream, linear thinking 9

10 Establishing/abolishing Operations* Two Variations: Function Based and Non-function Based Nonaversive Reactive Strategies * Alternative Sets - Goldiamond,1993; Density of Preferred Events - Diorio and Konarski, 1989; FB-NARS NFB-NARS A1 B1 C1 A1 B1 C2 Noncontingency; Rules; Doody, 2009; Spicer & Crates, 2016 History; etc. *Jack Michaels,1993 Competing Contingencies The apparent (linear) problem: FB-NARS NFB-NARS A1 B1 C1 A2 B2 C2 A1 B1 C1/ 2 10

11 Establishing/abolishing Operations - The nonlinear solutions: Establishing/abolishing Operations - The nonlinear solutions: A1 B1 C1/ 2 A1 B1 C1/ 2 A3 B3 C 1/ 2 Non-contingenc y (Satiation) Establishing/abolishing Operations - The nonlinear solutions: Establishing/abolishing Operations - The nonlinear solutions: A1 B1 C1/ 2 A1 B1 C1/ 2 A3 B3 C 1/ 2 Ax Bx C x A3 B3 C 1/ 2 Ax Bx C x Ay By C y Non-contingenc y (Satiation) Alternative sets - PP GS Non-contingenc y (Satiation) Alternative sets - PP GS Alternative sets Density of Pr ef er r ed Events FES FES FRS FRS C/T C/T 11

12 Establishing/abolishing Operations - The nonlinear solutions: Establishing/abolishing Operations - The nonlinear solutions: Az Bz C z Az Bz C z: Az Bz C z Az Bz C z: Focused Support, e.g., DROP History History History History A1 B1 C1/ 2 A1 B1 C1/ 2 A3 B3 C 1/ 2 Ax Bx C x Ay By C y A3 B3 C 1/ 2 Ax Bx C x Ay By C y Non-contingenc y (Satiation) Alternative sets - PP GS Alternative sets Density of Pr ef er r ed Events Non-contingenc y (Satiation) Alternative sets - PP GS Alternative sets - Density of Pr ef er r ed Events FES FES FRS FRS C/T C/T Establishing/abolishing Operations - The nonlinear solutions: Evidence Base Az Bz C z History Focused Support, e.g., DROP Az Bz C z: History A1 B1 R A3 B3 C 1/ 2 Ax Bx C x Ay By C y Non-contingenc y Alternative sets - PP Alternative sets - Density (Satiation) GS of Preferred Events FES FRS C/T Strategically capitulating or introducing a competitive preferred event can resolve without reinforcing behavior! 12

13 Resolution Without Reinforcement Resolution Without Reinforcement Slocum & Vollmer, 2015 For escape: problem behavior continued to produce escape MacDonald, Hume & McGill, 2010 Potter, 2016 Even so, problem behavior was reduced. Hughes & Huerta, 2016 Using NARS specifically to reduce measured Episodic Severity Results of Multielement PBS on Occurrence and Episodic Severity Using NARS Crates & Spicer, 2016 Situational Effects of Different Reactive Strategies Spicer & Crates,

14 IABA Use of Restrictive Procedures July 1, 2016 June 30, 2017 Aversive Events RP 1-3* # of RP 4** # of Recipients Times Recipients Times Adult Day Service (229) Supported Living (81) Child/Adolescent (173) Crisis Response (13) A.Unnecessary for reducing occurrence (ABA Ethics). B.Increases Episodic Severity (Opposite of desired outcomes). Infant Development (39) Total ( 535 clients) *RP Physical mgt./mechanical restraint/seclusion; **RP 4 - PRN Malott, Whaley & Malott, 1997 LaVigna & Willis, 2012 Spicer & Crates, 2016 Targeted Counter-intuitive Research Template More research is needed. As measured by Episodic Severity, introducing preferred events can resolve without reinforcing behavior! 14

15 The payoff 15

16 The Waiting Potential for PBS to Reduce the Use of Restrictive Practices Gary W. LaVigna, Ph.D., BCBA-D APBS Conference, San Diego; March 2019 Selected References ABAI Statement on Restraint and Seclusion, ABAInternational.org APBS Standards of Practice, APBS.org BACB Professional and Ethical Compliance Code for Behavior Analysts, BACB.com Crates, N. & Spicer, M. (2016). Reactive strategies within a positive behavioural support framework for reducing the episodic severity of aggression. International Journal of Positive Behavioural Support, 6(1) (pp ). Diorio, M. S., & Konarski, E. A. (1989). Effects of a freely available response on the schedule performance of mentally retarded persons. American Journal on Mental Retardation, 93(4), Doody, C. (2009). Functionally based reactive strategies, an argument for the use of positive and negative resolution strategies in the reactive element of the MEBS model. Paper presented at the IABA International Conference, Brisbane, Australia. Goldiamond, I. (1974). Toward a constructional approach to social problems: Ethical and constitutional issues raised by applied behavior analysis. Behaviorism, 2, Goldiamond, I. (1975). Alternative sets as a framework for behavioral formulations and research. Behaviorism, 3(1), Goldiamond, I. & Thompson, D. (1967, reprinted 2004). The blue books: Goldiamond & Thompson s the functional analysis of behavior. P. T. Andronis (Ed.) Cambridge, MA: Cambridge Center for Behavioral Studies. Hughes, E. C., & Herta, E. (2016). Reducing episodic severity of challenging behaviours in public school setting using the multi-element behavioral support plan. International Journal of Positive Behavioural Support 6(2) (pp ). Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3-20, 1982)

17 LaVigna, G. W., & Willis, T. J. (2003). Counter-intuitive strategies for crisis management within a non-aversive framework. In D. Allen (Ed.), Behaviour management in intellectual disabilities: Ethical responses to challenging behavior (pp ). Kidderminster: British Institute of Learning Disabilities. LaVigna, G. W., and Willis, T. J. (2005). A Positive Behavioural Support Model for Breaking the Barriers to Social and Community Inclusion. Learning Disability Review, LaVigna, G. W., & Willis, T. J. (2005). Episodic severity: An overlooked dependent variable in the application of behavior analysis to challenging behavior. Journal of Positive Behavior Intervention, LaVigna, G. W. & Willis, T. J. (2012). The efficacy of positive behavioural support with the most challenging behaviour: The evidence and its implications. Journal of Intellectual and Developmental Disability, Michaels, J. (1993). Establishing operations. The Behavior Analyst, 16, MacDonald, A., Hume, L., & McGill, P. (2010). The use of multi-element behaviour support planning with a man with severe learning disabilities and challenging behaviour. British Journal of Learning Disabiltities, 38, Potter, G. (2016). The impact of situational management strategies on episodic severity, International Journal of Positive Behavioural Support, 6(1) (pp ). Sigafoos, J. & Saggers, E, (1995). A discrete-trial approach to the functional analysis of aggressive behavior in two boys with autism. Australia and New Zealan Journal of Developmental Disabilties, 20(4), Slocum, S. K. & Vollmer, T. R. (2015). A comparison of positive and negative reinforcement for compliance to treat problem behavior maintained by escape. Journal of Applied Behavior Analysis, 48 (3) Spicer, M., & Crates, N. (2016). Non-Aversive reactive strategies for reducing the episodic severity of aggression. International Journal of Positive Behavioural Support, 6(1), (pp ).