Behavior Support Plans Research Articles

Trauma-Informed Care on CAMHS ID Unit. Case Study of a Child with Neurodevelopmental Disorder and Self-Injurious Behaviour

AimsCrystal House is a specialist CAMHS ID inpatient 5-bedded unit based in the Kingswood Centre, North West London - for children aged between 13 and 18 years with primary diagnosis of Intellectual Disabilities with or without additional concerns that warrant admission to hospital for purpose of assessment and management. Reporting this case, we wanted to highlight complexities of management of children presenting with neurodevelopmental conditions and history of trauma.MethodsThis is a case of a fourteen-year-old girl with established diagnoses of Moderate Intellectual Disability, Childhood Autism, Foetal Alcohol Syndrome and childhood trauma. She was admitted to our CAMHS ID Assessment and Treatment Unit with a nine- year history of self-injurious behaviour, suicidal ideation and voice-hearing experiences – after failed treatment in the community and in-patient treatment (including under restrictions of long-term segregation) on generic CAMHS unit. Her current treatment includes a person-centred Trauma- Informed Positive Behaviour Support Plan; individual and family therapy psychology sessions based on the principles of trauma-informed care and consultation with staff on trauma-informed care. She also undertook ADHD assessment, and we are in the process of optimising ADHD medication.ResultsTrauma-Informed Positive Behaviour Support Plan was a new concept for the team. Therefore, this was supported by training and consultations with staff. The latter was introduced to create a psychologically oriented environment using trauma-informed care principals and helping the team understand what trauma means and how it affects the individual. ADHD assessment confirmed the diagnosis of ADHD which was followed by optimising ADHD medication.ConclusionSystemic and a person-centred approach is used for this child with concerning presentation and history of neurodevelopmental disorder and childhood trauma.

Including Students With Significant Support Needs in the Development of Behavior Support Plans

Students with significant support needs (SSN) are often at an increased risk of demonstrating challenging behaviors compared with their peers without disabilities. As a result, students engaging in these behaviors typically experience fewer opportunities for inclusive education, strained relationships with educators, and increased likelihood of exposure to intrusive and harmful practices (e.g., restraint and seclusion), thus providing increased support for the use of effective behavioral interventions. Although research has shown that function-based interventions are more effective in addressing challenging behavior and these practices should be implemented for SSN who engage in challenging behavior, unfortunately these supports are often planned without involvement from the student. All students, including those with SSN, should have input in the selection and design of the supports they receive. Therefore, the purpose of this article is to provide educators with strategies for including student voice in the functional behavior assessment process and when developing a behavior support plan for students with SSN. We describe in detail methods for (a) gathering student input during the indirect assessment interview process, (b) administering direct preference assessments, and (c) increasing accessibility of these methods for students with SSN.

Needed independent and dependent variables in multi-element behavior support plans addressing severe behavior problems

Ethically, behavior analysts are required to use the least aversive and restrictive procedures capable of managing behaviors of concern. This article introduces and discusses a multi-element paradigm for devising support plans that include ecological, positive programming, and focused-support proactive strategies for reducing the frequency of problem behavior occurrence. It also includes reactive strategies, i.e., separate independent variables. In this paradigm, reactive strategies are aimed solely at getting rapid, safe control over the incident, thereby reducing measured and quantified episodic severity. Behavior analysts who publish in mainstream behavioral journals do not always make it explicit how they, in fact, successfully employed non-aversive reactive procedures to achieve rapid/safe control over the severity of a behavioral incident. Three examples of published studies in the behavioral literature which successfully, though only implicitly, used non-aversive reactive strategies (NARS) to reduce the severity of the behaviors of concern are described. The multi-element paradigm discussed in the present article is illustrated by the support plans that address the challenging behavior of three children in a pre-school setting, using both proactive and reactive strategies. Reactive strategies were used for the purpose of reducing episodic severity (ES) and proactive strategies were aimed at reducing the frequency of occurrence. Following a comprehensive functional analysis and assessment (CFA) and the implementation of a multi-element behavior support (MEBS) plan, results show successful outcomes without the need for any aversive or restrictive procedures. When addressing severe behaviors of concern, in addition to reducing behavioral occurrence, safety should also be improved by reducing ES as a measured outcome and as a function of the reactive strategies employed, including in many cases, the use of strategic capitulation, i.e., providing the identified reinforcer for the target behavior.

Clinical Safety and Treatment of Severe Aggression: Behavioral-Pharmacological Intervention Evaluation in a Young Adult With Autism Spectrum Disorder

This case study concerned clinical safety and behavioral-pharmacological intervention with an 18-year-old man who had autism spectrum disorder and high-frequency aggression toward care providers at a specialized school. A multicomponent behavior support plan included antecedent, differential reinforcement, environmental modification, and physical management procedures subsequently combined with psychotropic medication (aripiprazole). Clinical safety components emphasized comprehensive care provider training, continuous supervision, function-based treatment, and prevention-focused strategies. The behavioral-pharmacological intervention eliminated implementation of aggression-contingent physical restraint and was associated with increased transition compliance during the school day. Throughout the 7.5 months duration of the study, there were no injuries to the participant or other students and a single injury was sustained by one care provider. Intervention effects were long-standing, and care providers rated their training, implementation fidelity, and therapeutic outcome favorably.

Addressing Race and Implicit Bias in the Functional Behavior Assessment Process: A Pilot Study of Preservice Teacher Training Modules

ABSTRACT Despite decades of research and reform, exclusionary discipline remains disproportionately used with minoritized students and students with disabilities (SWD). The present study investigates how functional behavior assessment (FBA) and Positive Behavior Support Plan (PBSP) procedures can be taught in conjunction with an explicit focus on achieving equitable outcomes for minoritized SWD. Specifically, researchers created modules for preservice teachers focused on racial and cultural bias within the FBA and PBSP processes. In this manuscript, we will detail the development, delivery, and preservice teachers’ perceptions of modules, directly and explicitly challenge color-evasive FBA and PBSP practices, and consider how PBSPs can be culturally responsive. We present results of social validity surveys and the School Record Analysis (SRA), a tool used to measure preservice teachers’ implicit racial biases. Exploratory results suggest the modules provide a promising and necessary step for using behavior analysis to address disproportionate use of exclusionary discipline for minoritized SWD.

Implementing a program to reduce restraint and seclusion utilization in a public-sector hospital: Clinical innovations, preliminary findings, and lessons learned.

The Alternative to Restraint and Seclusion State Incentive Grant was a national initiative to reduce restraint and seclusion use in psychiatric hospitals and community based mental health settings sponsored by the National Association of State Mental Health Program Directors. This initiative was implemented in a large public sector psychiatric hospital. It involved the use of a restraint and seclusion prevention project team and a Patient-Staff Steering Committee collaborating on violence prevention. It also entailed systematic data collection and case reviews, staff-training on trauma-sensitive care and other relevant topics, employee recognition, as well as the use of specific restraint prevention tools including sensory modulation, positive behavioral support plans, comfort rooms, Wellness Recovery Action Plans, modified restraint orders, and new debriefing protocols. Compared with a 4-year baseline period, a 4-year implementation phase showed a reduction in annual restraints hours by 89%, annual staff injuries by 18%, and annual Workmen's Compensation medical costs by 24%. The findings illustrate the value of implementing systemic evidence-based practices to reduce restraint use, enhance the quality of care in tertiary care settings, and promote a new, patient-centered and recovery-oriented institutional culture. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Including people with intellectual disabilities in the development of their own positive behaviour support plans

Purpose People with intellectual disabilities are not routinely involved in the assessment of their behaviours that challenge, as this is often completed by a proxy respondent and the health-care professional. This is contrary to guidance stating that everyone should be involved in the planning of their care. This paper aims to show how health-care professionals can support people with intellectual disabilities to engage in the assessment of their behaviours that challenge and the subsequent development of their own positive behaviour support (PBS) plans. Design/methodology/approach A non-systematic review of the existing literature on improving the engagement of people with learning disabilities in health-care planning, and specifically PBS planning, was undertaken. Appropriate papers were included in this paper. Findings There are several evidence-based methods to improve people’s engagement in the assessment of their own behaviours that challenge and then the development of their PBS plans. These methods are discussed in terms of their application to supporting people to communicate and involving them in the process of developing a valid and meaningful PBS plan. This is a relatively new focus within the literature, and further research should focus on increasing engagement in the process, as well as monitoring how co-production affects PBS outcomes. Originality/value This paper summarises some of the approaches used to support people with intellectual disabilities to engage in the assessment of their behaviours that challenge and the development of their own PBS plans. This should encourage health-care professionals to consider how to use alternative and augmentative communication strategies to facilitate co-production in their own clinical practice.

Commentary on “Including people with intellectual disabilities in the development of their own positive behaviour support plans”

Purpose The purpose of this paper is to broaden the discussion on some of the barriers and solutions for co-production in positive behaviour support (PBS) planning as identified in the paper “Including people with intellectual disabilities in the development of their own Positive Behaviour Support Plans”. Design/methodology/approach Drawing on the literature associated with co-production in PBS planning, this commentary will reflect on the wider systems and culture needed to enable successful implementation of this way of working. Findings Co-production in PBS planning is recommended as part of best practice guidelines. However, there is limited research in the area of co-production with regards to PBS and use of augmentative and alternative communication methods. Collaboration among speech and language therapy and PBS practitioners is an important factor for co-production to achieve the best outcomes for people with learning disabilities who display behaviours of concern. Along with identifying a range of communication tools/strategies needed for PBS assessment/planning, it also requires a whole systems approach and culture shift to ensure the necessary foundations are in place. Originality/value Co-production in PBS planning remains an under practiced way of working. This commentary builds on the barriers and solutions identified for co-production and provides further insight into what might be needed to achieve this in health and social care settings.

Multiple Stimulus Without Replacement Preference Assessment for Students With Emotional and Behavioral Disorders

Students with emotional and behavioral disorders (EBD) generally have behavior support plans that are based on a functional behavioral assessment. This article provides educators practical guidelines for conducting a multiple stimulus without replacement (MSWO) preference assessment to rank order preferred activities that will align with the function of behavior for use in behavioral interventions. The use of highly preferred reinforcers to reduce student problem behaviors can enhance educational outcomes for the student.

Comprehensive Assessment of Triggers for Behaviours of Concern Scale (CATS): Initial Development.

Challenging behaviour displayed by people with intellectual disabilities (ID) can be difficult to manage if caregivers do not understand the reasons for the behaviour. Identifying the contextual variables/triggers for the behaviour is likely to help undertake a functional analysis leading to a person-centred positive behaviour support plan. Currently, a limited number of checklists are available for trigger assessment and none were developed using an interview with the family caregivers. This article describes the development and contents of the comprehensive assessment of triggers for behaviours of concern scale (CATS). CATS was developed in two stages. Stage 1 used a ‘bottom-up’ approach, in which caregivers of adults with ID who show aggressive behaviour were interviewed to identify the triggers for aggression. In stage two, using a ‘top-down’ approach, a comprehensive literature review was conducted to gather items from existing trigger checklists. Trigger items from both stages were combined and the duplicates were removed. The final list in CATS consists of 333 contextual triggers categorised under five main domains and 12 subdomains. CATS can be used by caregivers to identify triggers or antecedents of challenging behaviour. Further work is needed to test its psychometric properties, utility, and acceptability.

Risperidone in non‐epileptic attack disorder and chromosome 15q deletion syndrome

Chromosome 15q11.2 microdeletion is an emerging syndrome identified in individuals with Prader‐Willi syndrome and Angelman syndrome but also found in isolation. Here, the authors present a case of a 19‐year‐old woman with chromosome 15q11.2 microdeletion and her successful treatment with risperidone, a tailored positive behaviour support plan and with staff training around non‐epileptic attack disorder.

Chronicity of Challenging Behaviors in Persons with Severe/Profound Intellectual Disabilities Who Received Active Treatment During a 20‐Year Period

AbstractBackgroundEvidence of the chronicity of challenging behaviors in individuals with intellectual disabilities (ID) and autism spectrum disorder while receiving active treatment over long periods is limited. Analysis of the chronicity of these behaviors and the corresponding intensity of treatment has important implications for clinical practice and provision of services.Specific AimsThe aim was to examine chronicity of challenging behaviors in individuals with ID receiving residential treatment over a 20‐year period addressing the following questions: (1) What is the prevalence of challenging behaviors requiring a Behavior Support Plan (BSP) within the population of the facility during the study? (2) Is there a significant decline in frequency of challenging behaviors of these persons with ID over time? (3) Is there a significant decrease in intensity of intervention targeting challenging behaviors of these persons with ID over time?MethodsThe treatment records of 216 persons with ID were examined to identify individuals for whom challenging behaviors required a Behavior Support Plan. The chronicity of five categories of challenging behavior and associated treatment interventions over a 20‐year period was analyzed through repeated measures analyses.FindingsA significant decline was found for the frequency of Physical Aggression, and Physical Disruption over 20 years, but not for Self‐Injury, Verbal Disruption, and Program Refusal. There was a corresponding significant reduction of intervention intensity for Physical Aggression and Physical Disruption, however, the need for interventions persisted over time for all challenging behaviors.DiscussionResults demonstrate that rates of challenging behaviors are chronic, but remain relatively low in the repertoire of persons with ID. Parallel findings on interventions suggest that comprehensive treatment programs are needed to maintain low rates of these challenging behaviors with implications for provision of services for persons with ID, as well as planning and policy implications for managing challenging behaviors.

A systematic review of training methods to increase staff's knowledge and implementation of positive behaviour support in residential and day settings for individuals with intellectual and developmental disabilities.

Behaviour support plans (BSPs), if accurately implemented, have been found to increase skills and decrease challenging behaviour of individuals with intellectual and developmental disabilities. Training is essential for staff to acquire the skills necessary for accurate implementation. The aim of this systematic literature review was to evaluate procedures used to train staff in Positive Behaviour Support (PBS), on both knowledge of PBS and implementation of BSPs. Systematic searches of 4 databases identified 18 studies as meeting criteria. Findings indicate that description alone was not consistently effective in increasing knowledge and should be used in combination with other training strategies. Staff’s implementation of BSPs were increased by different combinations of the following training components: description, feedback, modelling, role-play, monitory incentive, and escape contingency. To identify evidenced based practice when training staff on BSPs, it is necessary to evaluate active and feasible training components from current training models.

Are the rapid tranquilisation nice guidelines adhered to, in patients with agitated/aggressive behavior? a QIP

AimsTo explore whether the NICE guidelines for rapid tranquilisation are adhered to in the Psychiatric intensive care unit (PICU/ Tryweryn).MethodData were collected by core trainees. Standards were taken from NICE guidelines NG10. All patients who had received rapid tranquilisation, that were in PICU from August 2019 to February 2020 were considered in this a.ResultDuring the first PDSA, we discussed with the staff in the ward regarding the protocol. Prior to actually starting the second audit, the adherence was noted to be low. However following persistence and having created a protocol jointly with the ward manager, we could see the difference. The staff were appreciated for their efforts in maintaining 100% adherence. The same was intended to be continued with some positive reinforcement from the auditing team. Over the first 2 months, 12 patients received Rapid Tranquilisation. Out of these 12, we randomly selected 4 patients to find the adherence of the NICE guidelines to be 100 per cent. The predictions regarding the adherence to protocol showed that the PDSA was successful.During the second PDSA, the adherence was 100% again. The adherence to the protocol has been followed for not just the sample that was selected, but for the entire set of patients who received the Rapid Tranquilisation. Following this QIP, we formatted the proforma which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and response to medication.ConclusionThe utilisation of de-escalation techniques and behavioural support plans that was person-centred in turn brought down the rate of Rapid Tranquilisation successfully. Thus placing our PICU as having the least restraints in the UK in 2019 (Second least 3/ month). Our PICU was awarded the prestigious Nursing Times Team of the Year Award for their pioneering work.Following this QIP, we then formatted the proforma for Rapid Tranquilisation which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and patients response to medication. The PICU will continue to maintain this 100% standard and we would then consider extending the Audit to both Open wards and PICU in entire North Wales.

Alignment of Supplementary Aids and Services With Student Needs and Placement.

Trends in the supplementary aids and services (SAS) written in individualized education programs (IEPs) for students with significant disabilities (a) in different educational placements, (b) with and without behavior support plans (BSP), and (c) with and without complex communication needs (CCN) are examined using multivariate analysis of variance. Results show no significant differences in SAS for students across separate, resource, and inclusive placements. Students with BSPs had significantly more collaborative and behavior SAS than those without BSPs. Students with CCN had significantly more social-communication SAS than those whose IEPs indicated little to no communication support needs; however, 51.1% of students with CCN had no social-communication SAS. Findings raise concern around the extent to which SAS are considered before placement decisions, the high frequency of paraprofessional support for students with BSPs, and the low frequency of social-communication SAS written for students with CCN. Implications for policy, practice, and future research are provided.

The characteristics of patients requiring readmission to an Australian forensic psychiatric intensive care unit

IntroductionPsychiatric intensive care units (or PICU’s) emerged to manage high acuity patients outside the justice system. Studies have sought to better understand characteristics of those admitted to forensic or civilian PICU’s. Few, in contrast, have explored the frequency and contributors to readmission. The following study was conducted on Apsley unit, a Forensic PICU based in Melbourne, Australia, and seeks to understand the differences which would allow early identification of patients likely to require readmission and the provision of targeted interventions.ObjectivesExamine rates of and contributors to forensic PICU readmission over a 6-month period.MethodsA retrospective audit was conducted to collect clinical, problem behaviour (and strategies to manage), forensic history and demographic information for consecutively admitted patients to an 8-bed forensic PICU between March-September 2019.ResultsData analysis is ongoing. Interim analysis found that 96 patients were admitted during the 6-month study period: 74 (77.1%) had a single admission; 22 (22.9%) required readmission. Almost all were admitted from prison (96.9%), most had a psychosis diagnosis (80.2%) and substance abuse history (96.9%), and many had a personality disorder (24.0%) and history of adolescent antisocial behaviour (46.5%). Patients requiring readmission were significantly more likely to have been previously under compulsory mental health treatment (95.5% vs 75.3%, p=.039) and have a Positive Behaviour Support Plan developed during admission (85.7% vs 54.8%, p=.010).ConclusionsInterim analysis highlighted the multicomplexity for forensic PICU patients alongside the occurrence of problem behaviour during admission and history of compulsory treatment as indicators of increased risk for re-admission.

Real-Time Telehealth Treatment Team Consultation for Self-Injury by Individuals with Autism Spectrum Disorder.

ObjectivesSelf-injurious behavior (SIB) refers to any repeated self-directed, non-suicidal, behavior that may cause or has the potential to cause physical harm to the person’s body. Behavioral interventions provide the standard evidence-based treatments for SIB by people with autism spectrum disorder (ASD) and intellectual disabilities (ID). Translating the proven effectiveness of behavioral interventions to treatment of self-injury in community settings by clinicians and caregivers has not been totally successful. The aim of the present study was to advance translational research by providing real-time telehealth consultation to a treatment team at a community-based mental health agency that provided inpatient and outpatient services to individuals with ASD and ID.MethodThe participants of this single-case experimental study were three adolescents with ASD who had been referred for services because of their increasingly unmanageable SIB both at home and at school. The telehealth consultant provided real-time assistance to the treatment team within a translational model of care in the development and implementation of a behavior support plan and an informal mindfulness-based Soles of the Feet (SoF) program.ResultsBoth visual and statistical analyses demonstrated reductions in the frequency of SIB for all three adolescents, with overall clinically significant reductions only with the SoF intervention.ConclusionThe results of this translational study suggest that telehealth consultation might be a viable technological alternative in situations which preclude face-to-face consultation. Telehealth consultation could be one method of supporting people with behavioral difficulties during pandemics, such as COVID-19.

Reducing restrictive practice: a pertinent issue for children's services.

The reduction of restrictive practice has gained momentum in mental health services and it is now becoming evident in mainstream adult services. There remains confusion as to the definition of 'restrictive practices' across all sectors of health care, including the difference between 'restrictive practices' (such as attitudes of control, limit setting and unnecessary ward rules) and 'restrictive interventions' (including physical, chemical or mechanical restraint). This article highlights the relevance of restrictive practice to children's nursing and argues that the principles apply across all health provision. Acts of restrictive practice may result in challenging behaviour, or even restrictive interventions, strategies to minimise both restrictive practice and subsequent acts of challenging behaviour are explored. Behavioural support plans adopting a bio-psycho-pharmaco-social approach have been shown to be effective in both mental health and adult nursing and are recommended for use in children's nursing.

Effects of Training on Knowledge Acquisition in Designing Behavioral Support Plans Based Functional Behavioral Assessment for Teachers at Special Needs Schools

Effects of Training on Knowledge Acquisition in Designing Behavioral Support Plans Based Functional Behavioral Assessment for Teachers at Special Needs Schools

Disciplinary and Nondisciplinary Outcomes of School-Based Threat Assessment in Colorado Schools

Threat assessment involves evaluating and intervening with individuals who make threats of violence. This study examined the resulting actions and outcomes of threat assessment cases in three Colorado school districts. A particular focus of the study was on potential disparities. The sample consisted of 253 threat assessment cases reported by participating school districts for the 2014–2015 academic year. In addition to disciplining students, schools implemented a variety of nondisciplinary actions in response to threat assessment, including mental health services, behavior support plans, and referrals for a special education evaluation. Analyses found no disparities in any outcomes, including disciplinary actions among Black, Hispanic, and White students receiving a threat assessment. There were also no significant differences between students with and without disabilities. These findings are promising in light of documented exclusionary discipline disparities and have implications for both the use of threat assessment as a violence prevention strategy and school discipline reform. Impact Statement Findings of the current study indicate that more than half of Colorado students who received a threat assessment were subsequently disciplined in some way. Most students also received nondisciplinary actions such as mental health counseling. No differences in threat assessment outcomes were observed based on race/ethnicity or disability status.