Restrictive Procedures within Behavior Support Plans

All parents are perplexed by their children’s behavior from time to time. For parents of children with autism, it is even more difficult to understand their children’s behavior. Parents may ask, “Why doesn’t he play with toys like other children? Why won’t he ask for a cookie when I know he wants it?” In addition to deficits in communication and socialization, individuals with autism may also display aggressive and self-injurious behavior. “Why does he hit his sister for no apparent reason? Why does he bang his head on the floor?”

Safely and effectively treating and preventing these behaviors requires full knowledge of why and when they occur. Our understanding develops by systematically collecting information on the behavior’s frequency, intensity, and duration. We record 1) when these behaviors are likely and unlikely to happen, 2) if there are any triggers that seem to set them in motion (antecedents), and 3) how others respond to the behaviors when they are observed (consequences). Through comprehensive observations, data collection, and analysis, we analyze why the individual acts in a certain way. This process is formally known as a functional behavioral assessment. For example, a child may become frustrated during a work assignment. When he bites his hand, the teacher stops the instruction. Over time, this child may learn that biting results in escaping this difficult situation. Thus, intervention strategies that target the function of behavior (i.e., escape) rather than the form of the

behavior (i.e., biting) can be developed and implemented. For example, the teacher might be taught how to modify demands, reinforce verbal behavior that replaces hitting (e.g., requesting a break or help), and more effectively reward progress so that the child can tolerate the instruction and behave appropriately.

Individuals with autism sometimes exhibit aggressive or self-injurious behavior as a way to communicate their needs, desires, and dissatisfactions. It is the job of trained professionals, behavior analysts in this case, to work with parents, educators, and the individual to conduct the functional assessment procedures described above. The information that is collected is used to develop hypotheses regarding the function or motivation of the behavior. Professionals can then formulate a comprehensive plan to safely and effectively reduce the challenging behavior.

Best practice standards emphasize the identification, acquisition, and maintenance of more appropriate alternative behaviors so that the individual can express his/her needs, wants, and dissatisfactions (National Research Council, 2001). Teaching new adaptive skills is one component of what is known as a Positive Behavior Support (PBS) plan. These plans may also include environmental modifications in settings in which the individual participates, changes to instructional materials, and a high frequency of positive feedback. For the majority of individuals, these positive procedures are sufficient to decrease the inappropriate behavior. Not only does the maladaptive behavior diminish, but also the person’s repertoire of appropriate skills is expanded, providing him or her with the skills necessary to potentially engage in meaningful social interaction and other activities.

In some situations, however, the functional assessment and intervention may be insufficient to reduce some instances of problematic behavior. This is particularly troubling in the case of aggression or self-injury in which the individual remains in danger of severely harming him/herself or others. These behaviors unquestionably compromise health, safety, and quality of life. After exhausting all possible positive interventions designed to reduce the behavior and teach more appropriate replacement skills, other potentially more restrictive options may need to be considered.

The work does not end with the decision to use a restrictive procedure. Issues that must be continually addressed are: the effectiveness of the intervention, how best to fade and ultimately terminate the intervention, and to what extent has the individual’s quality of life benefited from the use of the intervention. The questions to be asked at this time include, but are not limited to: Has there been an increase, decrease, or no change in the frequency of the target behavior? Has the duration of target behavior decreased, increased or remained constant? Were there unintended side effects that impeded implementation and thus, effectiveness? When and under what conditions can the restrictive procedure be either faded or terminated?  Despite the use of a potentially restrictive intervention, is the individual now able to participate in meaningful learning experiences, acquire new skills, become more socially involved, and spend more time in the community because he or she

no longer engages in the harmful behavior? Is the individual’s health and safety secure?

Emergency situations also necessitate consideration and planning as these situations demand caregivers’ swift action to minimize and prevent harm to all individuals. Emergency situations may require the temporary use of restrictive procedures prior to conducting a functional assessment and implementing an intervention plan. The use of any restrictive procedure should be documented and reviewed by the treatment team. Crisis episodes should serve as an impetus for team discussion to determine the necessity of a more detailed plan to best serve an individual’s needs and promote quality of life.

Clearly, this process is a long and difficult one. Yet, this process is essential to best meet the needs of individuals who exhibit serious recurring aggressive, destructive, or self-injurious behavior. As previously stated, the majority of individuals with challenging behavior respond well to positive behavior support plans. In few cases, a temporary restrictive component within a positive behavior support plan may be necessary to effectively reduce a behavior that could cause serious harm to the individual or others.

In summary, COSAC is committed to the dignity, welfare and progress of all individuals with autism. COSAC supports the controlled use of restrictive procedures as a last resort and as outlined below. COSAC opposes the use of restrictive procedures when these conditions are not met.

 Adopted by the COSAC Board of Trustees on May 20, 2003