State Supported Living Centers Statewide Policy & Procedures. Behavioral Health Services Department

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1 State Supported Living Centers Statewide Policy & Procedures Policy Number: Effective: DRAFT ( / /2013) Replaces: POLICY: PURPOSE: Behavioral Health Services Department The purpose of the policy is to ensure that the services provided by the behavioral health service department to individuals residing in state supported living centers (SSLCs) and the ICF-IID component of Rio Grande State Center (collectively, state centers ) are consistent with current, generally accepted professional standards of care. APPROVED BY: Joseph Vesowate Assistant Commissioner State Supported Living Centers APPLIES TO: All state center employees and contractors involved in providing or ensuring the provision of psychological and behavioral services. DISTRIBUTION: The state center must ensure the policy, exhibits, and forms are distributed to applicable staff, contractors, and agents; and to any individual or legally authorized representative (LAR) requesting a copy. CONTACT: Eric Moorad Policy/Rules Coordinator (512) EXHIBIT AND FORMS: EXHIBIT A: Hierarchy of Behavioral Interventions REFERENCES: 40 Texas Administrative Code (TAC), Chapter 5 Texas Health and Safety Code (THSC), Chapters 591 and 592 Settlement Agreement (SA), Section K Health Care Guidelines to the SA, Section III

2 I. State Center Responsibilities Each state center must ensure that: 1. A qualified director of the behavioral health services is responsible for a consistent level of behavioral health services that meet acceptable standards of care within the state center; 2. A demonstrably competent service provider or a service provider supervised by a demonstrably competent service provider provides behavioral health services; 3. The demonstrably competent service provider for a positive behavioral support plan (PBSP) is a board certified behavior analyst; 4. Psychologists, counselors, and board certified behavior analysts provide services based upon generally accepted professional standards of practice and adhere to their discipline specific codes of ethics; 5. Assessments are performed in a timely manner in response to interdisciplinary team (IDT) requests to complete an assessment due to changes in an individual s status; 6. The annual behavioral health update is completed on time and approved recommendations by the IDT are carried out; 7. A tracking system is developed and implemented to track the status of each individual s assessments as addressed in this policy and actions to respond to this need; 8. Treatments and interventions are timely and clinically appropriate based upon assessments and diagnoses; 9. PBSPs are reviewed at least annually and anytime there is a change in status (e.g., changes in psychiatric symptoms or target behaviors that represent an increase in risk or distress, such as increased levels of dementia or increased use of restraints; an increase in adaptive skills; or an achievement of important developmental milestones), and revised as needed; 10. State center procedures describe peer review procedures including the mechanism to track follow-up to recommendations arrived at in the review; 11. Staff implementing counseling, psychiatric support and PSBPs are trained to competency prior to implementation. Their implementation is monitored to maintain treatment integrity, data integrity, and interobserver agreement at levels of 80% or better; 12. Behavioral health services are based upon current research, are integrated with other disciplines, and follow the least restrictive alternative that produces effective results as measured by clinical indicators; 2

3 13. In developing interventions, input from the individual, the individual s family, legally authorized representative (LAR), and direct support professionals (DSPs) must be considered and incorporated as appropriate, to enhance effectiveness; 14. Behavioral health services are responsive to peer review and behavioral service committee (BSC) and human rights committee (HRC) input, as applicable; 15. Plans are data based and progress on the goals of a plan is reviewed and documented monthly. If the individual is not meeting expectations, the relevant assessments and the plan are reviewed and recommendations for adjustments in the plan are presented to the IDT for review and approval; 16. Implementation of plans includes the measurement and report of treatment integrity, data integrity, and inter-observer agreement; 17. Competency based training is required for staff assigned to implement PBSPs, psychiatric support plans, the methods for generalization of skills acquired in counseling, and restraint instructions; 18. All necessary approvals, consents, and authorizations are obtained prior to the implementation of a plan; and 19. A database is maintained to support quality assurance and corrective action as needed. II. Specific Behavioral Health Services Provided A. A psychological assessment identifies and analyses the following information: 1. The individual s strengths, adaptive ability, and any delayed development in specific functional areas, with a focus on building on strengths and capacities, providing effective teaching and interaction strategies, and suggesting meaningful activities, including work, leisure, and relationships. 2. Emotional, behavioral, and trauma issues that may impact the individual s ability to benefit from treatment and programs; 3. Psychiatric and personality issues that may impact treatment and behavioral indices of psychopathology as applicable; 4. Individual preferences, strengths, and needs for the IDT to consider in developing the individual support plan (ISP); B. Each individual must have a complete and current psychological assessment, and if the individual engages in challenging behaviors that constitute a risk to the health or safety of the individual or others, or serve as a barrier to learning and independence or community integration, a structural and functional assessment will be completed. 3

4 C. A psychological assessment is incomplete until it contains all of the following elements: 1. A standardized assessment or review of intellectual and cognitive ability; 2. A standardized assessment of adaptive ability, in addition to the Inventory for Client and Agency Planning (ICAP); 3. A baseline screening for psychopathology, emotional, and behavioral issues, including a Reiss screening; 4. A review of biological, physical, and medical status as relates to psychological functioning; 5. A Review of personal history; and 6. A structural and functional assessment for those individuals whose record reflects behavioral disturbance or psychopathology. D. A current psychological assessment contains an annual behavioral health update with a review of intellectual and adaptive functioning, relevant biological, physical, and medical status, and the most current results of the ICAP, Reiss screen, comprehensive psychiatric assessment, and structural and functional assessments. The update must summarize progress and any recommendations regarding supports, and provide input to the IDT regarding whether the most recent documents in the complete psychological assessment are still valid or a new assessment must be completed for one or more components. E. For an individual under 18 years of age, a psychological assessment must be completed every three years as part of the individual s annual behavioral health update or sooner, if the IDT recommends the assessment in response to a change in status. F. If at the completion of the annual behavioral update or in response to a relevant change of status at any time, one or more of the components of a complete psychological assessment are recommended to the IDT by the behavioral health service provider,the assessment must be completed no later than 45 days after the IDT approval. G. For a new admission, a psychological concurrence report is completed within the first 30 days to review and verify that the Determination of Mental Retardation (DMR) assessment previously completed remains valid, and a psychological assessment is not necessary. If the validity of the previous tests is questioned, or the psychological assessment does not contain all the components, an assessment is scheduled and completed within 45 days. H. Structural and Functional Assessment 1. If there are challenging behaviors of concern, if the individual s record or assessments reflect behavioral disturbance or psychopathology, or if behavioral and/or psychopharmacological interventions are being considered, a review of the 4

5 individual s current structural and functional assessment is completed to determine if a new structural and functional assessment is needed. If a new structural and functional assessment is needed, one is completed by a board certified behavior analyst. 2. The structural and functional assessment provides information on the behavioral health need, case formulation, and recommended approaches to meeting the behavioral need. Direct observation, indirect assessment such as interviews with staff, and as needed, functional analysis is completed to provide the following information: a. A description of the individual s challenging behavior, including the intensity and risk level of the challenging behavior, the behaviors that typically occur together, the order in which they typically occur, and identification of any precursors to the challenging behaviors; b. Setting events (such as health, psychiatric, environmental, psychosocial, sensory issues) that afford conditions favorable for challenging behavior and motivating operations that impact the value of the reinforcers of the challenging behavior; c. Antecedent events and current consequences relevant to the behavior(s); d. Functions of the challenging behavior, including the derivation of the behavior and, if possible, differentiation between learned and biologically based behaviors. Identify learned behaviors that appear to be sensitive to environmental changes or are likely to be responsive to environmental changes and other behaviors that appear to be primarily biologically based; e. Functional replacement behaviors and other competing responses currently in the individual s behavioral repertoire or, lacking such, functional replacement behaviors or alternative behaviors that can be taught; f. Preferences and potential reinforcers for teaching new behaviors to be used as functional replacement behaviors or alternative behaviors or for teaching new coping and tolerance behaviors; g. Current behavioral data, including frequency, intensity, or latency of the challenging behavior that may be used as preintervention data; current behavioral trends; and the response to previous and current treatment strategies; h. Specific recommendations and justification for the development of an effective, least restrictive approach for increasing positive behaviors and reducing challenging behaviors. Recommendations may include supports, services, or specific treatment in a PBSP, psychiatric support plan, or a counseling plan or a combination of plans; 5

6 i. If a PBSP is recommended, baseline or preintervention data to be used to evaluate treatment efficacy is presented the interventions are described the treatment expectation and timeframes are written in objective, observable, and measurable terms and the data collection system is described. The proposed schedule for treatment integrity, data integrity and independent observer agreement (IOA) measurement is summarized; and integration with any other behavioral health support plans is discussed; j. If a psychiatric support plan is recommended, the psychiatric behavioral indicators, the data collection procedures, the schedule for review of the data and treatment integrity and independent observer agreement (IOA) measurement, and integration with any other behavioral health support plans is discussed; and k. If a counseling plan is recommended, the role of the plan, its integration with any other behavioral health support plans, and accountability measures are discussed. 3. The assessment must be reviewed and considered for revision, when the current behavioral interventions are ineffective, when behavioral data indicate the functions of the target behaviors may have changed, when new targets emerge that are not a part of the response class, when a relevant change of status has occurred, when part of the recommended in of the annual behavioral health update, or as a recommendation of the IDT. If the decision is that the assessment remains valid, and no revision is needed, the rationale for this determination must be documented in the record. I. Restraint instructions are described in detail in the current statewide policy 001 Use of Restraint. J. Consultation services within the state center are provided in response to a request for information from the IDT, or assistance from other disciplines at the state center. This service may include reviewing behavioral data in case formulation with psychiatry, developing strategies to reduce pretreatment sedation, assisting with skill acquisition plans, or working with residential services to improve engagement and reduce restraints. K. Behavioral Health Service Plans The behavioral health services department provides PBSPs, counseling plans, and psychiatric support plans. 1. These plans are derived from clinical assessments used by the specific service provider (e.g., the structural and functional assessment for a PBSP). The assessment includes recommended measurable treatment objectives, a method for measuring progress, clinical indicators for discontinuation, and measures of accountability, such as treatment integrity; 6

7 2. These plans are written in a manner that is useful in the real world setting in which staff are carrying out the plan; 3. Progress is assessed and reported monthly, and if there is a lack of progress within the period of time indicated benchmarked in the progress note, the plan is presented to the IDT for review and possible revision; 4. All plans have a schedule for measurement of accountability of plan implementation. For a PBSP, it is treatment integrity, data integrity, and interobserver agreement. The author of the PBSP must determine the schedule of these measurements, according to the phase of implementation and complexity of the plan; and 5. PBSPs, counseling plans, and psychiatric support plans are implemented as soon as possible, but no later than 14 days after the assessment and all approval processes have been completed. If a plan takes more than 14 days to implement after all approval processes have been completed, staff must document a reason for the delay. L. Positive Behavior Support Plans (PBSPs) Requirements 1. A PBSP is considered as a treatment approach when there are behaviors that constitute a risk to the health or safety of the individual or others, when there are behaviors that are a barrier to learning, independence, or achievement of the person s goals, and previous attempts to change behavior have been resistant to less formal approaches, such as staff behavioral guidelines. 2. If there is no PBSP in place for reducing or eliminating the circumstances that lead to restraints, a PBSP is developed when there is a restraint pattern in which an individual is placed in crisis intervention restraint more than three times in a rolling thirty day period and if there already is a plan in place, the IDT convenes and the plan is reviewed for its effectiveness. 3. The least restrictive and intrusive interventions that are effective and are consistent with the hypothesized function of the behavior described in the structural and functional assessment are applied in a PBSP. 4. PBSPs containing no restrictive interventions are reviewed and approved by the IDT, including the individual and the legally authorized representative, processed through the internal peer review process and approved by the behavior support committee. 5. PBSPs containing restrictive interventions are reviewed and approved by the IDT, including the individual and the LAR, require consent, are processed through the internal peer review process, and approved by the behavior support committee and the human rights committee. 7

8 6. In cases of an emergency need due to the risk level of the behavior, staff instructions that do not contain any restrictive interventions may be put into place, while the structural and functional assessment is completed as soon as possible. 7. Each PBSP has a data collection system for reviewing progress and treatment decision-making, including graphs of target behaviors and replacement behaviors. Graphs are clearly displayed and delineate changes in interventions, psychotropic medications, and other significant medical or environmental factors. 8. A new or a revised PBSP is implemented in no more than 14 days after the necessary approvals or consents are received.. 9. The PBSP contains the following components written in clear, readable language that can support the consistent application of the interventions: a. The purpose or objectives of the plan and the operational definitions of target and replacement behaviors; b. Provision of positive reinforcement sufficient for strengthening desired behavior; c. Staff instructions that include how to teach, as needed, and reinforce desired replacement behaviors and the what to do to reduce undesired behaviors; d. Instructions addressing antecedents, setting events and motivating operation issues, as applicable; e. Staff instruction on data collection procedures; and f. The signature of the author of the plan and the name(s) of who to contact for questions about the plan. 10. State center procedures for internal peer review are designed to review PBSPs with low treatment efficacy for elements that are not meeting generally accepted professional practice and to make recommendations to improve treatment efficacy. a. The behavior health department director or designee selects the PBSPs to be reviewed at weekly internal peer review prior to the scheduled expiration date of PBSPs. The selection must prioritize plans with low level of treatment efficacy as the first priority for review. b. The behavioral health department director or designee ensures that documentation of the review is completed and that there is timely follow-up to any recommendations. c. The behavioral health department director or designee may choose to select other PBSPs or other products of the department for processing through a peer review. 8

9 d. Any product reviewed must include a checklist template in which the criteria for evaluating the product are operationally defined. The peer review must include the completion of the checklist template. e. Internal peer review may be integrated into the BSC meeting, but only the BSC has the responsibility for a formal approval of all PBSPs. Internal peer review must emphasize plans with low treatment efficacy, especially restrictive PBSPs for highrisk individuals. 11. State center procedures for external peer review are designed to review PBSPs with low treatment efficacy and for carrying out reliability measurement in relationship to the internal peer review findings. At least one PBSP is reviewed monthly, and at least one reliability check completed quarterly. a. At least once per quarter, the behavioral health department director or designee must supply the list of PBSPs reviewed in all the peer review sessions for that period without identifiers and the external peer reviewer must randomly select one or more plans to carry out a reliability check with the internal peer review findings using the review template. The reliability measures that fall below 80% must be discussed with the behavioral health department director or designee and necessary action taken to maintain an inter-reviewer reliability of at least 80%. b. The behavioral health department director or designee ensures that documentation of the review is completed and that there is timely follow-up to any recommendations. 12. The behavioral health services director or designee must monitor the internal and external peer review process, ensuring that the reviewers understand the purpose of the review and the minutes summarize the clinical discussion, any recommendations, and follow-up. 13.Competency-based training is necessary for implementing PBSPs correctly and consistently across settings and to meet established goals. All training results must be logged in a training tracking system. a. Training must include procedures to reduce target behaviors and procedures for teaching new, and/or reinforcing existing replacement behavior. b. Competency-based training is required prior to a staff person being assigned responsibility for implementing the PBSP with the individual. All staff that implement the PBSP must be trained to competency at 100%. Training includes presentation of the plan, practice, and demonstration of the skills by participants as well as on-the-job assessment of skill level. The author of the plan trains on the plan and may train others as trainers of the plan. c. On-the-job assessment and instructional feedback supports the generalization and maintenance of staff skills from the training setting to the natural setting. Treatment integrity, data integrity checks, and inter-observer agreement checks are carried out to assess on-the-job staff performance and, as needed, 9

10 instructional feedback is provided. The author of the PBSP must determine the scheduling of these on-the job integrity checks within the following guidelines. i. All PBSPs must have a schedule that describes the frequency for onthe-job integrity checks, including interobserver agreement and treatment integrity. The schedule will vary depending upon the complexity of the PBSP, the risk level presented by the behaviors, the newness of the plan or changes in the plan, the rate of the behaviors, and the effectiveness of the plan in producing behavior change. ii. iii. iv. For PBSPs that include restrictive interventions, treatment and data integrity checks must be completed at least monthly by a board certified behavioral analyst designated staff. As the data indicates a consistent level of acceptable performance, and risk levels decrease, adjustments in the schedule must be considered. Input from internal and external peer review may be beneficial in decision making regarding the schedules. Changes in the schedule must be documented in the monthly progress note and the rationale explained. Integrity checks must yield at least 80% correct implementation for the on-the-job staff performance and must be recorded in the monthly review of progress and entered into the training tracking system at the state center. If the person is less than 80% correct in performance, instructional feedback is provided and the person is brought to a level of 100% competency. d. Substitute staff and float staff must be trained on the PBSP prior to being assigned to the individual. The author of the plan may train others as trainers to assist in the timely training of substitute staff and float staff. M. Psychiatric Support Plans Requirements 1. The psychiatric support plan is a non-pharmacological support for those receiving psychotropic medication that provides measurement of psychiatric behavioral indicators to aid in the assessment of the treatment efficacy of the psychotropic medication and to minimize the need for psychotropic medication to the degree possible. It is based upon case formulation from the comprehensive psychiatric assessment and the structural and functional assessment. 2. The psychiatric support plan contains the following components: a. A description of the purpose of the plan; 10

11 b. A description of the psychiatric behavioral indicators or other measurements developed jointly by the psychiatrist and the board certified behavior analyst; c. Instructions to staff on how to record the occurrence of behavioral indicators or a description of the rating scales and when ratings will be collected; d. Staff behavioral guidelines or education on how to respond to the behaviors indicative of the psychopathology when they occur; and e. Data is displayed in graphical form and/or tabular form, including details on any psychotropic medication changes. 3. The IDT and the psychiatrist must review the case formulation, psychiatric assessment, and structural and functional assessment to determine the least intrusive and most positive interventions that meet the behavioral needs of the individual receiving psychotropic medication. Developing a psychiatric support plan does not prohibit the development of a PBSP or other non-pharmacological approaches, such as skill training of a communication skill or a relaxation technique. 4. Staff are trained on the definitions of psychiatric behavior indicators and how to record their occurrence. They are also trained on the staff behavioral guidelines that instruct them on what to do when the psychiatric behavior indicators occur. a. The training includes didactic, demonstration, and in-vivo sessions. Treatment integrity and data integrity checks are carried out to assess on-thejob staff performance and, as needed, instructional feedback is provided. The frequency of checks should be higher when the plan is first introduced. Treatment and data integrity checks must be provided at least quarterly for all psychiatric support plans and the checks should yield at least 80% correct implementation for the staff performance measured. b. All training and performance measures must be entered into a training tracking system. N. Counseling Plan Requirements 1. An individual may be referred for a counseling plan by the IDT when one or more of the following factors are present: b. A stated need or request for counseling by the individual, LAR or IDT; c. Significant life or personal changes, such as personal loss, traumatic changes in relationships, conditions, or environment; d. A serious health problem or having to experience intrusive treatments; 11

12 e. A psychiatric disorder for which counseling may be beneficial, such as personality disorder, major depressive disorder, or anxiety disorder; significant changes in usual mood or behavior, such as anxiety or depression; f. References to suicide or suicidal behavior; g. Physical complaints for which medical causes have been ruled out; h. Concern about living arrangements or options; i. Victim of abuse, neglect, or other trauma; and j. Serious challenging behaviors for which self-monitoring, self-regulating, compensating, problem-solving, and coping skills can potentially be developed or improved through counseling in conjunction with the PBSP. 2. Counseling plans include the following: a. Goals and treatment expectations to respond to the behavioral need; b. Services to be provided as per the treatment plan, including number of sessions and targets for intervention; c. The measurable counseling objectives to be used to evaluate treatment efficacy; d. Clinical indicators, including indicators that trigger review and revision of interventions or discharge criteria for lack of treatment efficacy (fail criteria); e. A description of any group interventions or psychoeducational groups; f. Plans for generalization and maintenance of skills learned; g. Identification of staff providing the services and their qualifications, based on specialized training, license, certification or supervised practice; and h. As applicable, identification of staff that assist or supervise homework or other activities outside of the counseling session and their training to carry out the activities. 3. Progress on the counseling plan is documented monthly. 4. Review of the implementation of the counseling plans must occur at least quarterly. The review must include the percentage of therapy sessions provided, the integrity of the data collection system and a measure of adherence to the counseling plans. 12

13 5. If staff are involved in the generalization and maintenance of skills trained in the counseling sessions to the natural environment, staff must be trained to competency and treatment integrity and data integrity checks completed at least once per quarter. 13

14 Exhibit A: Hierarchy of Interventions The interventions listed in this hierarchy are classified as either nonrestrictive or restrictive interventions. Nonrestrictive interventions involve environmental strategies that teach, train, increase behavior, or maintain desired behaviors. In some cases, the procedures involve mild forms of negative feedback, such as social disapproval. Restrictive interventions involve procedures that are designed to decrease or weaken a target behavior. The definitions listed below are intended to be examples of nonrestrictive and restrictive behavior interventions and terminology may be slightly different depending upon the scientific sources. As advances occur, the list may be modified through a process coordinated by the State Office Discipline Coordinator. As needed, a behavioral health service provider may consult with the State Office Discipline Coordinator regarding the categorization of a particular procedure. Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Anger Management Training Antecedent Exercise Antecedent Adjustments Apology Definition A procedure in which an individual is trained to use calming techniques (e.g., taking slow breaths or counting) to replace inappropriate responses to situations the individual finds frustrating or challenging. The training occurs when the individual is in a calm state and not exhibiting inappropriate behaviors. The individual is encouraged to identify the times when these techniques might be useful to the individual, is cued to use them when behaviors begin to escalate, and is positively reinforced when the individual uses one or more of the learned techniques instead of exhibiting a target behavior. Opportunities to engage in exercise in the form of walks, jogging, swimming, aerobics, exercise machines, to reduce or prevent challenging behaviors that may be related to anxiety, tension, or high levels of energy. Making adjustments in the activity or stimulus that precedes or accompanies a behavior so that it may affect the behavior. Example: If an individual s behavior becomes aggressive when in a noisy work environment, the state center would find an alternative setting that would be quieter, resulting in far less aggression when presented work in the quiet environment. A procedure which requests an individual who has done something that violates or infringes upon the rights of another individual to apologize in an appropriate manner to the offended party. The apology must be given voluntarily, and the individual is reinforced if the apology is provided. 2013

15 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Backward Chaining Behavior Contracting Behavior Momentum to Encourage Cooperation Behavioral Rehearsal Chaining Coping Rehearsal Comfort Statements Contingent Reinforcement Continuous Reinforcement Definition An instructional procedure in which the individual is put-through all the steps of the training sequence except the last one, which is trained. Training is started at the last step in the task analysis chain and proceeds to the first step. For those individuals who have the capacity to understand the agreement, a procedure in which an individual makes a contract with the interdisciplinary (IDT) to meet a behavioral goal, upon which a special exceptional (i.e., above the regularly scheduled activities) reinforcing event is provided. A method of teaching individuals to comply to requests by making one to three simple, high-probabilityof-compliance requests, followed by the targeted request, in an attempt to increase compliance to requests made by staff. Reinforced practice of a skill under simulated conditions. Role-playing is one form of behavioral rehearsal. Role-playing is the performance of a sequence of responses to simulate the action of another individual or the same individual under other circumstances. An instructional procedure in which the first task analysis step is taught and then linked to the second so that reinforcement is presented after the completion of steps one and two. This process proceeds through the various training steps until the task is completed or the individual reaches his/her maximum level of competency. A procedure in which appropriate behavior for a specific, or type of situation is discussed and/or practiced. The event is described, and appropriate coping responses are discussed and/or rehearsed. Telling an individual in a calm and reassuring voice, that they are safe and you are there to assist them. Discrete trial training that combines positive reinforcement, cues and prompts to teach a task or set of tasks. A schedule of reinforcement in which every occurrence of a behavior is reinforced. 2013

16 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Desensitization Training Differential Reinforcement of High Rates of Behavior (DRH) Differential Reinforcement of Alternative Behaviors (DRA) Differential Reinforcement of Incompatible Behavior (DRI) Differential Reinforcement of Low Rates of Behavior (DRL) Definition A procedure in which an individual learns to cope with fear or anger-provoking situations through controlled exposure to the precipitating stimuli, while an adaptive response is prompted and reinforced. While this procedure deals with some aversive variables (e.g., fear of dental procedures), correct implementation would require treatment to begin with variables that are not, or at most mildly, aversive (e.g., watching a video tape of the dental office and later, visiting the dental office when no procedure is done) and proceed from there. Consequently, the individual should encounter only variables that are mildly fear evoking. If the individual is exposed to the full intensity of the stimulus, this procedure is a restrictive procedure. Delivering reinforcers for engaging in progressively greater rates of adaptive behavior. It is used when a behavior is occurring, but not as much as desired (i.e., production in a workshop). Delivering reinforcers for engaging in a specific appropriate/alternative behavior other than the target behavior. Delivering reinforcers for engaging in a behavior that is physically incompatible with the target behavior. Delivering reinforcers for engaging in progressively lower rates of a behavior, until it is at a tolerable level. DRL is indicated when the behavior should be reduced, but not eliminated (i.e., answering questions in class). 2013

17 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Differential Reinforcement of Other Behaviors (DRO) Discrete Trial Teaching Embedding Environmental Adaptation Escorting Definition Delivering reinforcers contingent on the absence of the target behavior. Reinforcement is delivered if the behavior is not occurring at the moment, or if it has not occurred for a specified period of time. An instructional technique in which training trials having a distinct beginning and ending are used. Training trials are generally delivered within a training session, defined by a period of time or a specific number of trials. This is placing requirements in a positive context. The main idea behind embedding requirements in a positive context is to identify stimuli that evoke behaviors such as smiling, laughing, and being attentive and enthusiastic that would indicate that the individual is in a good mood. It can include placing preference assessment procedures within daily activities and offering choice opportunities across daily routines. A procedure that makes minor changes to the environment to prevent the occurrence of a maladaptive behavior or to increase the probability of engagement in appropriate behaviors. Some examples are changing seating arrangements, turning down the volume of radio or TV, cooling a room when too hot, going outside, using special wall board or plexiglass windows, or using assistive technology. Providing physical assistance while moving a cooperative individual from one location to another. The distance moved is not a factor in defining escorting. The defining feature is that the individual is cooperative. That is the individual does not object to being moved and is fully cooperative. 2013

18 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Extinction of Behavior Maintained by Positive Reinforcement Fading Forward Chaining Functional Communication Training (FCT) Hand-Over-Hand Physical Guidance Incidental Teaching Definition This procedure is the withholding of the positive reinforcer(s) that have been identified as maintaining a behavior. This procedure should be applied in conjunction with a procedure that reinforces an alternative to the behavior for which the reinforcer is withdrawn. This procedure is not escape extinction, which is a restrictive procedure. In using this procedure, consideration must be given to the quality of the data that is used to identify the positive reinforcers maintaining the behavior, the abilities of the plan mediators to carry out the procedure consistently and to avoid reinforcing the target behavior intermittently, and the risk/benefits of the procedure, considering possible extinction bursts and spontaneous recovery. One example of an extinction procedure used for a maladaptive behavior maintained by the social positive reinforcement of staff attention would be: a differential reinforcement of an alternative behavior procedure which uses attention to reinforce an alternative behavior to the maladaptive behavior, while attention for the maladaptive behavior is withheld.. The gradual and systematic removal of prompts (the trainer s help or assistance in completing a task or a task analysis step). An instructional procedure in which training begins with the first task analysis step and proceeds to the last. In contrast, see backward chaining. A type of differential reinforcement of alternative behavior procedure in which a communication response is reinforced to replace the problem behavior. An instructional procedure in which the trainer takes the individual s hands and physically guides the individual through the task. For example, the trainer takes an individual s hands and puts them through the various movements associated with turning a water faucet on and off. To be considered nonrestrictive, the individual must be fully cooperative. Using naturally occurring or unplanned opportunities to teach a specific task or skill. 2013

19 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Intermittent Reinforcement Positive Reinforcement Problem Solving Prompts Motivating Operations Negative Reinforcement Redirection Definition A schedule of reinforcement in which some, but not all, occurrences of a behavior are reinforced. The process of providing an item or activity immediately on the occurrence of a behavior that increases the probability of the behavior s occurrence over time. A procedure that calls for the individual and staff to develop appropriate strategies for resolving problem situations. This procedure involves discussing alternative responses that may occur in the future. This procedure may only be conducted by personnel trained in the procedure specific for the individual. An instructional procedure, in which the individual cooperates, that provides help or assistance in completing a task or a task analysis step. Verbal prompts may range from complete instructions or directions to a vocal sound. Physical prompts may range from complete hand-over-hand assistance to a simple gesture such as tapping the table or raising the eyebrows. Modeling of the desired response may also be used as a prompt. Changing the environment to alter the effectiveness of some object or event as reinforcement. In establishing operations, the changes in the environment make the reinforcement more potent and thus the behavior that produces the reinforcer more likely to occur. An example might be changing a task so that it is easier or more interesting to increase engagement behaviors and reduce negative behaviors. In abolishing operations, the changes in the environment make the reinforcement less potent and thus the behavior is less likely to occur. An example might be, providing an extra snack to an individual, with the effect that it reduces the likelihood of food stealing. A procedure that helps the individual use appropriate behaviors to remove an unfavored stimulus by carrying out a specific response. Examples: An individual who has been working a long time can remove himself or herself from the task by telling the supervision that he or she needs a break. An individual has pain, goes to the nurse and points to the area where it hurts, and the nurse is able to relieve the pain. This procedure utilizes the least prompt sequence to displace an individual away from an inappropriate behavior toward a more appropriate or desirable behavior. 2013

20 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Nonrestrictive Behavioral Interventions or Procedures Procedure Response Blocking Restoring the Environment or Simple Correction Role Playing Self-Monitoring Stimulus Control Training Task Analysis Token Reinforcement Verbal Prompt to Stop Definition Preventing the occurrence of a maladaptive behavior by interposing with a protective pad or with one s own limb(s) or body. This procedure is intended to be used when the behavior is mild or moderate in intensity and its frequency (the number of blows or the number of attempts) is relatively low or is of short duration. A procedure requesting an individual to restore, to its original condition, the affected area or object. The individual may be requested to clean or pick up items in the disturbed area, replace any stolen article, or otherwise demonstrate socially responsible behaviors which make up for the disruption caused by their behavior. Having the individual practice appropriate means of responding to problems. It is used to facilitate the effectiveness of problem solving. Also having an individual perform a behavior in a contrived interpersonal situation which is similar to the everyday circumstances under which behavior occurs. This training may only be conducted by personnel who have received training in the procedure. Teaching an individual to observe, record, and evaluate his or her behavior. Changing the circumstances under which a behavior occurs by reinforcing it in the presence of one stimulus and not another. Breaking a specific task into a number of smaller or simpler training steps or components. A generalized reinforcer that serves as a medium of exchange for other reinforcers such as objects or activities. Tokens should be appropriate to the individual s age and functioning level. Tokens typically are used in the context of a behavior contract or token economy where the tokens are used to bridge the time delay between the desired behavior and receiving reinforcement. The individual must have the capacity to understand the relationship of his or her behavior to the receipt or delay of tokens. The tokens must be used for exchange for objects or activities that are above and beyond what is already required to be provided to the individual. Telling an individual in a calm, but firm voice, to stop. This should not be used repeatedly/in rapid succession and is most likely inappropriate when the function of an individual s challenging behavior is attention. 2013

21 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Restrictive Behavioral Interventions or Procedures Procedure Contingent Observation Escape Extinction Definition A procedure in which the individual is allowed to remain in the environment and observe other individuals engaging in reinforcing activities. A type of non-exclusionary timeout from positive reinforcement. A procedure in which a challenging behavior no longer produces cessation of the task requirements. The antecedent stimulus no longer predicts negative reinforcement after the challenging behavior is carried out resulting in the antecedent stimulus eventually failing to evoke the challenging behavior. It is important to use this procedure with a procedure to reinforce a socially appropriate behavior to terminate the task demand. This procedure does not allow the use of physical holding to prevent the individual from leaving the area. Positive Practice Reparation of Property or Restitution Response Cost A procedure in which the individual is required to practice appropriate behaviors following the occurrence of target behavior. The plan must set a limit to the number of times or length of time the behaviors are repeated. A procedure that requires an individual to pay for all or part of stolen or broken property of another individual. The challenging behavior of stealing or property destruction needs to be observed and documented by staff. This procedure requires an approved written plan describing how repayment will occur. Consideration of the individual s ability to understand the concept of paying for the damage and the amount of payment based on available funds must be given before deciding to use this procedure. This procedure must not be used to reimburse staff or the Center. A procedure in which items such as points or tokens are lost contingent on target behavior. Fines represent a common form of response cost. 2013

22 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Restrictive Behavioral Interventions or Procedures Procedure Response Effort Adjustments Restriction of Environmental Access Restriction of Mobility Search Definition One method of treating automatically reinforced behavior is to alter the parameters of either the automatic reinforcement or the reinforcement available for alternative behavior. In this regard, response effort can be increased. The response rate of the behavior being automatically reinforced can be decreased by an increase in response requirements. A sufficiently high response effort changes an establishing operation. Increasing the response effort required can increase the potential reinforcement value of less favored types of reinforcers. A variety of procedures that make a change in the normal work or living environments. These procedures are usually designed to prevent or detect maladaptive behaviors. Examples include locked living areas, locks on food or storage cabinets, and special alarms. A procedure in which the individual s movement inside or outside of the facility is restricted because of a maladaptive behavior. This procedure does not apply to mobility restrictions associated with the provision of supervision due to skill deficits, cognitive difficulties, medical issues, and/or encouragement to keep an individual in a specific location to enhance participation in an activity. An inspection of an individual or the individual s property to ascertain the presence of any item found to pose a risk of injury to the individual or others. A search procedure may also be conducted to ascertain the presence of stolen property. Inherent to the search procedure is the removal of any inappropriate items found. There must be sufficient documentation of behaviors that would justify use of this procedure. 2013

23 Exhibit A: Hierarchy of Interventions Hierarchy of Interventions: Restrictive Behavioral Interventions or Procedures Procedure Suspension Talk Time Timeout From Positive Reinforcement- Exclusionary Timeout - Nonexclusionary Timeout Ribbon Definition Not allowing an individual to attend a scheduled activity for a specified period of time due to the occurrence of maladaptive behavior. The individual is returned to the regular scheduled activities as soon as the behavioral situation is resolved. a. An individual may be restricted from work on the basis of a workplace disciplinary policy which is universally applied to all employees and which the individual has accepted as a condition of employment. b. An individual may be restricted from a scheduled activity or activities to assess the circumstances of a serious behavioral episode. The duration of the investigation should be as short as possible. c. An individual may be prevented from attending a scheduled activity if that individual is exhibiting a targeted inappropriate behavior at the time the activity is to begin. The individual s participation may also be interrupted if the individual begins to engage in maladaptive behaviors during the activity. A procedure of giving extra special scheduled social periods with staff during which the individual has complete choice over the topic of conversation. This is used for an individual whose perseveration on certain issues becomes problematic, who is overly demanding of staff attention, or who is highly motivated by periods of special attention. It can be helpful in teaching the individual to tolerate delays and situations in which staff social attention is distributed across several others. A procedure in which the opportunity to earn reinforcement is removed or reduced for a specified period of time, contingent upon a target behavior. During exclusionary timeout, the individual is removed from the immediate area (e.g., into the hallway or to their bedroom). Doors are not locked. There are no Time-Out Rooms. A procedure in which the opportunity to earn reinforcement is removed or reduced for a specified period of time, contingent upon a target behavior. During non-exclusionary timeout from positive reinforcement, the individual remains in the same room, and is not visually separated from ongoing activities A variation of non-exclusionary timeout from positive reinforcement in which a ribbon becomes a discriminative stimulus for receiving reinforcement. Contingent upon inappropriate behavior, the ribbon is removed and all forms of reinforcement are stopped for a specified period. 2013