Proc R38
QUALITY LIFE CONCEPTS, INC.
Procedure
on
Behavioral Support
The strategies are represented in a hierarchy of increasing restrictiveness, with the least
intrusive and least restrictive presented first. This order, by no means, suggests that
each “must” be used prior to movement to the next. Some behaviors may escalate to
emergency proportions within a few seconds. Rather, the order of these strategies
should act as a reminder to try to use the “Least Restrictive or Intrusive Alternatives”
first. The definition of least restrictive or intrusive is (a) a procedure that is not more
restrictive or intrusive than is necessary to prohibit the individual from inflicting harm to
him/herself or others; and (b) that is applied to no longer than necessary to prevent or
contain the dangerous behavior.
A.
B.
POSITIVE PROGRAMMING
1.
The first emphasis of behavior programs to manage behavior problems
(e.g. aggression, property destruction, etc.) is to provide a rich schedule of
positive programming to develop the consumer’s functional
communication, domestic vocational, recreational, social, spiritual, and
community living skills. It is within this context that efforts directed toward
reducing the individual’s undesired behavior problems can occur. To the
extent that he/she develops and exhibits a rich repertoire of daily living
competencies that are incompatible with the undesired, these problems
should occur less often, if they occur at all. Thus, positive programming
may in itself reduce the frequency, duration, intensity and array of
individual and group behavior problems, assuming that programming is
provided consistently.
2.
It is extremely important that consumers are provided with frequent
contingent attention, praise and constructive assistance for appropriate
interactions with other consumers, materials and staff. Additionally,
attention should be provided frequently in non-contingent social
interactions (i.e. primarily for the purpose of providing attention). It is
expected that the provision of a high level of interaction among staff,
families and others and consumers will be effective in preventing or
lessening the frequency and intensity of many occurrences of aggression
as well as other behaviors before they become problems. As a rule,
others working with consumers should plan to provide interactions “at
least” every 15 minutes for each consumer.
ENVIRONMENTAL/SURFACE MANAGEMENT STRATEGIES FOR BEHAVIOR
PROBLEMS
In spite of the clear provision of positive, constructive programming, consumers
may continue to manifest severe behavior problems that may represent a
potential threat to themselves, to others, and to property. In the sections below,
a variety of strategies are presented as methods of preventing, or lessening the
likelihood of a full-scale outburst. These procedures should not be construed as
treatment. Rather, they are designed to allow individuals and those interacting
with them to manage the behaviors until positive programming can have the
opportunity to effect desired change.
1.
Environmental Redesign
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2.
1.1
This group of procedures involve the removal or elimination of
events, objects, or situations that may “set off”, “cue” or “set the
stage” for the occurrence of behavior escalation. It is important that
others interacting with consumers always seek ways for the
consumer to be included rather than excluded from events and
activities.
1.2
Remove known antecedent objects. Frequently, objects or
materials in a setting are cues for a consumer to approach and
engage the object. For example, for one consumer, an open
cabinet may be a cue (invitation) to sneak food and to gorge
himself. For another consumer, pictures on a wall may be a cue to
pull the pictures down. These instances are likely to require staff
intervention to correct, redirect, and to prevent their occurrence. By
eliminating the known antecedents, the undesired behaviors are
likely to be avoided and the need for staff intervention unnecessary.
1.3
Relocate people. Quite often, we observe that certain consumers
simply do not get along with others. At the table, they touch, push,
grab, and pull at each other. Other consumers attack others as
soon as they come into close proximity with them. By
acknowledging and honoring individual preference and not having
the individuals together, you can reduce the possibility of issues
before they occur. Friction with potentially hazardous
consequences may be prevented or lessened until positive
programming can affect change.
1.4
Remove unnecessary demands/requests. Consumers sometimes
react angrily with assault and property destruction when they are
presented with demands, or are pursued for compliance. Do not
make demands of individuals. By always treating every individual
as a person with dignity and respect, you can often times avoid
upsetting folks.
1.5
Change the location and time of activities. Certain consumers
manifest serious behavior problems at specified times. For
example, hitting may occur only in the dining room, but not in the
kitchen; resistance might occur during activities presented just
before lunch. By changing the location and/or time of the activities
the behavior may not present themselves.
1.6
Rearrange the environment. Many undesired behaviors are tied to
specific arrangements of furniture in select situations. For example,
a consumer yells, screams and hits others only when she sits in a
specific chair that is pointed in a specific direction. By changing the
chair and her position, it may be possible to eliminate many
outbursts outside the confines of structured treatment.
Interrupting the Behavior Chain
Severe behavior issues are frequently a part of a “behavioral chain” which
progresses from less to more severe. For example, assaultive behavior
(e.g. hitting others) may begin with verbal protests, whining and crying. It
may be possible to prevent “assaultive” behavior by eliminating early
elements in the behavior chain. Early members of the chain may be
eliminated, or chain may be interrupted using the following strategies:
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2.1
Proximity Control. In some cases, we might observe that a
consumer is “less likely”, if at all, to manifest serious behavior
issues when a staff person is present or in “Close proximity”.
Under such circumstances, simply “moving closer” to the consumer
when he appears agitated may be sufficient to “prevent” a fullblown episode. Other examples might include placing a firm hand
on the individual’s shoulder, moving closer to the consumer at the
dinner table or in group settings.
2.2
Interject humor. Sometimes, consumers appear sullen, grim or
irritable just prior to initiating serious undesired behaviors. In other
words, they appear distressed. It may be possible to prevent
continued escalation through the interjection of playful, joking
mannerisms, to include a funny story you know or discussing
something humorous on TV. However, considerable caution needs
to be exercised to ensure the humor isn’t wrongly construed as
ridicule or sarcasm.
2.3
Instructional Control. Instructions include verbal, written and
gestural events. Instructional control is said to occur when
instructions reliably result in a change in behavior to conform to the
contexts of the instructions. Many consumers with whom you come
into contact indeed are able to change their behavior to conform to
instructions. In such instances, instructions may be used to divert
the consumer into more appropriate activities to stop ongoing
activities, etc. Some specific examples where instructional control
may be used are described below:
a.
b.
c.
d.
e.
f.
2.4
A consumer who masturbates indiscriminately might be
instructed as to where it is appropriate to masturbate. Be
sure your mannerisms and vocal tone do not demean.
Asking a consumer who is about to hit himself or others if
he’d (she’d) like to pound some clay.
Asking a consumer who is agitated and escalating toward
aggression if he’d like to go somewhere else.
Telling a consumer who is running toward the street to
“stop”.
Telling the consumer who is hitting his head to “stop”.
Handing an individual a sign that cue’s them to stop.
Communication Facilitation. Many of the consumers with whom we
work, either lack communication skills entirely, or these skills are
not firmly developed to communicate desires, anger, frustration and
wants. Thus, efforts to assist the consumer to express himself may
effectively reduce the likelihood that severe problems will appear.
More importantly, attempts to do this at the time when the
consumer is quiet may head off more severe problems.
2.4.1 When a consumer begins to show signs of agitation and
frustration, when he shows the early signs of escalating to
more severe behaviors, ever effort should be taken to
determine the consumer’s problems to encourage the
consumer to express himself. Some more specific questions
might include:
a.
Do you need something?
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b.
c.
d.
e.
f.
Do you have a problem?
Do you need help?
What is wrong?
Can you show me where it hurts?
How are you feeling?
2.4.2 To assist the consumer to express himself at the time a
combination of “active listening” and “best guessing” may be
used. For example:
Consumer’s Behavior
a.
The consumer is pacing
and becoming progressively more
upset as the time for dinner
approaches
b.
The consumer is crying
and agitated while completing a
task.
Staff Reaction
a.
I know you are hungry,
dinner will be ready in 10
minutes. Do you want to help me
while you wait?
b.
I know you want to
It gets you angry when you have
to work. But you’re almost done.
Good!
Some phrases that might assist in encouraging the consumer to
communicate include “tell me what is wrong”. “Tell me about it…”
Many consumers are simply unable to talk and have limited nonverbal expression skills. However, a “best guess” approach may be
helpful during crisis time. For example, an 18-year-old young lady
is yelling and screaming for no apparent reason. However, you
know that she is about to or is having her period. One reaction
might be: “…you don’t feel good. Your stomach is hurting. I’m
sorry. Would you like to lay down?” In a second case, a 24-yearold lady who is not able to communicate has just had an altercation
(fight) with another consumer. She is grabbing, pulling at anyone
and anything around her. One approach might include: “
, you
have a scratch on your face. I’ll bet that hurts. Let me help you.
Let’s go the bathroom and fix it.” For young children, a favorite
song maybe sung, an offering of color crayons and paper asking
them to draw how they feel or holding and soothing them may
diminish the undesired behavior.
2.5
Facilitated Relaxation.
This is another special form of
“instructional control procedure”. If the consumer continues to be
upset, agitated, self-abusive or destructive, then instructions to
relax should be used. The following guidelines are presented to
assist the consumer in the process of learning and engaging in
relaxation:
a.
b.
c.
Acknowledge that the consumer is upset; “I know you are
upset… You seem to be upset… You are angry about…”
Instruct the consumer to calm down: “You will feel better if
you calm down… Relax.”
Instruct the consumer in activities that promote relaxation:
“Take a deep breath… Let the air out slow… Now take a
deep breath…”
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If instructions are not effective in de-escalating the situation, the
consumer should be encouraged to go to a place that is conducive
to him/her “gaining control”.
a.
The “quiet place” should be away from others and offer the
consumer the opportunity to be undisturbed while he “gains
control”. Some possible locations include:
-a sofa or chair in an unoccupied room
-at the kitchen table when there is little or no activity
-in the consumer’s room
b.
c.
d.
e.
f.
g.
Once the consumer has arrived in the designated area, he
should be encouraged to sit or to lay down – in other words
to get comfortable.
The consumer should be assisted in getting comfortable; he
should be instructed to loosen tight clothing. The consumer
should be promoted to place his hands in a resting position
by his sides, resting on the arms of a chair or in his lap.
These positions should be identified as “relaxing positions”.
The entire situation should be of “encouragement”, not
forced compliance.
The voice tone during these instructional periods should be
given in a calm and even “monotonous” manner. The voice
should always convey an air of support.
The consumer should be encouraged to calm down.
Instructions should be given to “relax” select parts of the
body. For example, as body parts are identified, and as
relaxation is instructed, the statement should be
accompanied by tactile “stroking” of the targeted area (i.e.
arm, neck, forehead). Another approach is to have the
consumer shake his hands and fingers, since continued
shaking may lead to fatigue and a feeling of relaxation.
Statements that might assist in the process of relaxing might
include: “limp as a rag doll”, “melt into the floor”, “float like a
feather”.
The consumer should be instructed to take a deep breath,
hold it, and let it out slowly while the instructor says the
words “relax”, “calm down”. This breathing should be
repeated up to five (5) times in a given session.
Once the consumer has achieved a “calm” relaxed state for
from one (1) to five (5) minutes, he should be asked “Are you
calm?” or “Do you feel better?” If the answer is yes, and his
appearance is one of calm, he should be instructed to take a
few deep breaths (three to five), to stretch his arms
overhead, and then ask if it’s okay to leave him alone now.
If he is not calm, an additional one (1) to five (5) minutes
should be allowed.
It should be remembered that the relaxation procedure is not
designed as a punishment (i.e. a time out). Rather, it is
designed (1) to prevent escalation to more severe behaviors,
(2) to reduce the severity and duration of an ongoing
incident, and (3) to provide the consumer with an alternative
coping strategy.
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2.6
Stimulus Change. If instructional control methods, communication
attempts and relaxation methods are not effective, and if selfinjurious behavior, aggression, or destructive acts continue to
present a serious danger to the consumer, to others, and to
property, a “stimulus change” strategy should be attempted.
2.6.1 This strategy involves the “non-contingent” delivery of a
sudden addition of a novel stimulus or the alteration of
incidental stimulus conditions.
2.6.2 This method involves introducing something entirely new
(novel stimulus) or making slight changes in the existing
situation (alter incidental stimuli) as a way of temporarily
managing or stopping a behavior.
2.6.3 This procedure has the usual effect of decreasing all
behaviors, including the target behavior.
2.6.4 The momentary response reduction is only temporary. The
stimulus change is likely to become ineffective with repeated
usage.
2.6.5 The particular method may be useful as (a) a consumer is in
the process of attacking, (b) as aggressive destructive acts
are imminent or are already occurring, and (c) in situations
where serious behavior is occurring in a seemingly unending
chain. Of course, it may take considerable exploration to
identify stimuli that have the desired disruptive properties.
2.6.6 Some examples of stimulus change methods include:
a.
A consumer is approaching to assault you, or has
already begun the assault. Possible staff, family,
respite providers, etc. reactions might include:
-go completely limp
-point and speak of something behind the person
-sing
b.
The consumer is either preparing for or is actively
engaged in property destruction. Some possible
reactions include:
-asking for help with a task
-shall we go for a run?
c.
C.
Other potential novel stimuli might include: singing,
jumping up and down, giving ridiculous instruction,
telling all the other consumers to jump up and down,
laughing hysterically. Remember to avoid any type of
power struggle.
GEOGRAPHICAL CONTAINMENT
Typically, caregivers know certain aspects of the consumers behavior that gives
cues or clues to what precipitates before an individual acts out.
1.
This procedure involves the use of the immediate environment to minimize
or to eliminate the consequences of assaultive/destructive behavior. One
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purpose is to reduce or to eliminate the need for physical contact with the
consumer.
2.
Geographical containment should be used only when the other
procedures described above have not been effective. It is an emergency
procedure to eliminate and/or to reduce severe aggressive and destructive
actions.
3.
Geographical control procedures should be accompanied by instructional
methods as described in the previous section.
4.
Examples of this procedure for a variety of incidents are described below:
Consumer’s Behavior
Consumer is rushing toward
a.
you.
b.
Consumer rushes out of the
room and outside of the house.
c.
Consumer rushes toward living
room window to kick it.
d.
Consumer jumps up and
rushes to hit another consumer.
e.
Consumer kicks at window in
van.
f.
Consumer is angry, frustrated
and thrashing self around, attempting
to hit others.
Procedure
Step behind a table or chair.
Position yourself between the
consumer and the door.
Position a piece of furniture in the
consumer’s path.
Position yourself in a manner that
may make it difficult for them to get to
the other person.
Have consumer hold something in lap.
Instruct consumer to go to a hallway,
kitchen, and prevent access to the
other consumers by placing yourself in
a position between them. Get others
away from the upset person. Try to
direct the person to an area where the
behavior is unlikely to cause damage
or injury.
Most often, the procedure comes before the behavior, based on the preestablished caregiver knowledge of the consumer.
D.
EMERGENCY PHYSICAL CONTAINMENT
1.
In the event that a consumer’s behavior becomes so uncontrollable that it
presents a clear danger to the consumer and/or to others; and in the event
that preventative methods, and geographical containment methods have
not been effective, “Emergency Physical Restraint” may be used as an
“EMERGENCY PROCEDURE ONLY”.
2.
“Emergency Physical Containment” involves the use of “hands on” contact
through the placement of your body position in such a manner as to briefly
prevent the consumer’s movement. It does not involve the use of
restraining devises such as “soft ties”, “posey restraint”, seat belts, etc.
3.
Examples of Physical Containment include the following:
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a.
b.
c.
d.
e.
f.
g.
4.
Holding a consumer’s hands to his/her sides to prevent selfinjurious head banging or head slapping.
Holding a consumer’s hands to prevent the hitting of the caregiver
or other consumers.
Redirecting or deflecting, blocking techniques; Mandt one or two
arm sitting or standing restraint (if properly trained).
Placing your hands on the shoulders of a consumer to prevent
him/her from getting up to pursue assault and/or destruction.
Holding a consumer’s legs so that he/she cannot kick.
Escorting the consumer to a place while holding his hands or arms.
Preventing a consumer from leaving an area by body positioning.
Avoid using physical containment unless there is clear and present danger
of physical injury to the consumer or to others. Physical altercations are
dangerous whenever they are used for both the consumer and staff
members. This should be a last resort. However, a time may arrive when
you have no choice but to use physical containment. Before considering
using physical containment, as the consumer is escalating to an
impending crisis, you should ask yourself a number of questions:
a.
b.
c.
d.
e.
f.
Am I physically able to manage this consumer?
If not, is help available?
How will I get help if I need it?
Am I wearing anything that will possibly injure the consumer or
myself? This includes rings, watches, glasses, long hair, earrings,
ties, etc. In addition to this question is whether you are wearing
something of great value, that if damaged would cause you to lose
your temper.
How can I get away if I need to?
What is the consumer likely to do when he/she is physically
contained?
The answers to these may help prevent injury to the consumer or to the
staff.
5.
Remembering that physical containment is a “last resort” technique, a
number of guidelines should be observed:
* CAUTION: Avoid physical contact in escalated situations. Only as a last
resort consider physical restraint techniques.
a.
b.
c.
d.
When approaching the consumer, assume a non-threatening but
prepared posture. Do not yell, scream and reprimand. This will
only heighten the behavior for which containment is deemed
necessary.
Maintain eye contact with the consumer at all times while speaking
and instructing in a calm, reassuring voice. As described above,
continue to talk to the consumer in an effort to de-escalate the
situation.
If it necessary to grasp the consumer, and there is a choice, always
grasp the consumer by the clothing rather than by the flesh. In
addition to affording a better grip, there is less likelihood that the
consumer might be hurt and the incident escalating further.
If it is necessary to grasp body parts, grasp limbs at points just
above the joints. In addition to offering a better grip, it is likely to
minimize joint damage.
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e.
f.
6.
Physical containment should be gradually decreased as the consumer
shows signs of calming, relaxing and gaining control. This may be
accomplished in the following ways:
a.
b.
c.
d.
e.
Gradually lessen muscle tension.
Gradually move from restraining to shadowing (i.e. simply having a
hand on the consumer).
Gradually reduce the intensity and nature of the containment
contact.
Increase the space available to the consumer by moving away.
Gradually decrease the number of staff involved.
7.
As the consumer appears to have a greater calm, he should be asked
“Are you calm?”, “Are you under control?”, “Do you feel better?”.
8.
Each incident in which any form of “physical containment” is used should
be documented in the Incident Report. The particular events that need to
be documented include the following:
a.
b.
c.
d.
e.
f.
g.
h.
9.
E.
When containing a consumer from hitting, do not force the
consumer. Do not force the consumer’s arm down. Apply only the
level of strength that may be sure to stop the blow.
Throughout the containment procedure, the consumer should be
reassured and encouraged to calm down.
The place and date of the incident.
The time of day of the incident.
The total amount of time spent in containment.
The events that lead up to the need for containment.
The strategies used by staff to avoid the use of physical
containment.
An exact description of the activities taken by staff during
containment (e.g. position, number of staff, location).
The outcome of containment, including injuries and property
destroyed.
How the incident was eventually resolved.
In addition to the documentation described above, each occurrence of
physical containment should be reported, immediately and verbally to the
CSS Director, CSS on-call or Resource Coordinator. In NGD, the incident
is reported to the Director. In Home Based Services, the employee will
document the incident only if witnessed. Other caregivers are encouraged
to keep a record of such incidents for future review/follow-up
INDIVIDUALIZED INTERACTION PROTOCOLS
1.
For each consumer residing in a Quality Life Concepts, Inc. residential
setting, where a review of records or experience shows that the potential
exists for the repeated behavior that could be harmful to the consumer or
others, an individual plan of emergency management strategies should be
prepared and the techniques provided. This individualized plan should, at
a minimum, include the following:
a.
Operational Definition. Each behavior should be clearly defined,
giving (1) a detailed description of the behavior; (2) the cycle of the
behavior, i.e. when it starts and stops; and (3) the delimiters, such
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b.
c.
as hitting versus boxing during a boxing match; (4) a description of
the consumer behavior as it escalates to a serious level.
Antecedent Conditions. The conditions that “set off”, “cue” or
initiate behaviors should be described. This should include
persons, time of day, demand styles, times of the month, etc. This
information is necessary for staff so that they are not caught off
guard or unprepared.
Emergency Management Strategies. A list of suggested
procedures should be presented. Basically, this should include
procedures like those described above and a list of “do’s” and
“don’ts”.
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