Essential Elements of Comprehensive Behavior Support Plans That Include a Restrictive Procedure
COSAC believes that restrictive procedures should be implemented only in accordance with the following conditions:
1. The individual’s basic needs are met on a continuous basis. These include a nutritious diet, satisfactory living space and accommodations, frequent and positive social interaction, therapeutic services, preferred leisure activities, and opportunities to be a valued and productive member of society.
2. The target behavior has the potential to cause harm to the individual or others.
3. The frequency, severity, and/or duration of the behavior has not been sufficiently reduced or eliminated by positive interventions. These positive interventions must be comprehensive, implemented by trained personnel, documented, and have failed to reduce or eliminate the behavior.
4. The individual, parent, or legal guardian provides informed consent following a clinician’s thorough explanation of the objectives and limitations of the proposed option and alternative options. This explanation must be delivered in a developmentally appropriate and culturally sensitive manner. Any modifications to the plan also require consent prior to implementation.
5. Review and approval of all planning and oversight committees are provided.a. An interdisciplinary team
b. A behavior management committee – appropriately credentialed master- and doctoral-level behavior analysts and psychologists, who review behavioral treatment plans for clinical appropriateness and technical accuracy.
c. An independent human rights committee – a group of community members who also evaluate behavioral plans from an ethical standpoint. Individuals should be knowledgeable about autism and effective treatment.6. The individual has no known physical or medical conditions that would contraindicate the procedure. Medical personnel document their assessment and approval for the procedure.
7. A qualified behavior analyst or psychologist, with expertise using functional behavioral assessment and in developing positive behavior support plans, creates and supervises the assessment and intervention in accordance with professional and ethical standards.
8. A clear and specific definition of the behavior for which the procedure is provided.
9. Pre-intervention data are collected on the frequency, severity, and/or duration of the behavior to determine if the behavior constitutes a danger to self or others.
10. A functional assessment is conducted and documented to determine the environmental and/or biological factors that maintain the behavior.
11. The intervention chosen:a. Is based on the Principle of the Least Restrictive and Effective Alternative, that is, less aversive procedures must be considered and/or tried before more aversive procedures are considered and/or tried. Other untried procedures would result in unacceptable danger to the individual (e.g., the use of extinction for self-injurious behavior that could result in significant harm to the individual before it was effective). Deviations from this principle must be justified, documented, and guided by informed consent.
b. Teaches the individual more adaptive, functionally-equivalent behaviors.
c. Has empirical support from well-designed research studies.12. All appropriate parties are provided with ongoing training regarding how and when to use the procedure and to recognize signs of distress that may warrant terminating the procedure.
13. Data are collected to monitor treatment fidelity to ensure that personnel are implementing the procedure as planned.
14. Data are collected to monitor changes in the target behavior and other relevant behaviors.
15. Procedures to facilitate maintenance and generalization of the behavior change are documented and implemented.
16. If continuous monitoring shows that the target behavior is not improving at the desired rate, the intervention must be reviewed and changed or terminated as necessary. Any change to the plan requires informed consent, medical clearance as appropriate, and committee approvals.
17. The procedure is effective and systematically faded or terminated as soon as the behavior is satisfactorily modified.
18. A primary focus in evaluating the success of the intervention must be the direction and extent to which the target behavior has changed as planned and agreed to in the assessment process.
19. A secondary focus in evaluating the success must be an assessment of the other aspects of the individual’s functioning, that is, the extent to which the intervention has resulted in other positive changes.
20. An assessment of the individual or guardian’s satisfaction with the intervention must be undertaken.
21. All outcomes of the intervention must be thoroughly documented.
22. The restrictive procedure is one component of an individualized and comprehensive behavior support plan designed to increase adaptive behavior, independence, and participation in meaningful relationships and activities.
Some of the elements listed above have been adapted from the Guidelines for the Use of Aversive Procedures issued by The Australian Psychological Society.