Once the initial ground work is laid and you are able to develop a sound hypothesis regarding the function of a person's behavior, you need to develop your behavior program. Typically called a Behavior Support Plan (BSP), although sometimes referred to as an Intensive Behavior Plan, Behavior Intervention Plan, and several others, the behavior program is where the analysis part of the work will take place. Before we get too far into the structure of your BSP though, I want to establish a couple of unspoken rules I have learned from my experience in the field and from more experienced clinicians than I. These unspoken, but widely known rules include:
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Write for your audience. You may think it is wonderful that your college professor thought you wrote like a Ph. D level clinician, but the staff who are implementing the plan don't care. Use short sentences and keep the jargon to a minimum.
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Don't write an approach you're not comfortable with. Believe me, there is a time and a place for a punishment procedure, but not when the behavior is non-compliance with picking up a bedroom. You may run into parents, other team members, other clinicians, etc. that want you to do something you don't feel is ethical given the circumstances. When this happens stick to your guns, because in the end, you're the author of the plan, and you don't want your name on something you're not in support of.
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Remember The Law of Parsimony/Occam’s Razor/Keep is Simple Stupid. Usually the simplest explanation is the correct explanation. It can be tempting at times to dig into the depths of our brains and come up with an awesomely unique explanation for someone's problematic behavior, and sometimes this awesomely unique explanation is right, but most of the time, and I mean like 99% of the time, it's the easy explanation that wins out in the end.
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Don't keep the same behavior plan in place for years. I have seen this time and time again, and it's not usually due to lazy clinicians, people's caseloads grow to unmanageable sizes and it's just easier to keep that reinforcement plan in place for, eh, one more year. This leads me to my final and most important point;
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DO NOT TAKE ON MORE THAN YOU CAN HANDLE. This is pretty self-explanatory, but is important to bring up. Unless you are super-human, every person has a limit to the amount of work they can handle while still maintaining an acceptable level of quality. If you feel like you aren't designing good behavior programs for all your clients, take on less and focus on the ones you already have.
The behavior Support Plan format I included is just one of the many possible formats out there; this one just works well for me. However, all behavior plans need to have some semblance of order and parts, as the information needed to run a behavior program is not really that abstract. Regardless of the format you use remember that a good plan will contain a brief summary of why the services are being provided, the behaviors being targeted for reduction, the behaviors being targeted to increase (or replacement behaviors), the hypothesized function of the problematic behavior(s), a functional assessment (antecedents, establishing operations, reinforcers, precursor behaviors), approaches (analysis), and administrative requirements, i.e. physical restraint training, and data collection requirements. I have also included two other formats I sometimes use for very specific reasons. The Environmental Restrictions Plan is ideal if you are working with a person (usually an elderly person) whom for one reason or another (dementia, stroke, etc.) will always require Environmental Modification (Restrictions) to keep them safe. Some environmental modifications I have put into place using this plan format are door locks, alarms, bed rails, locks on refrigerator and freezer, etc. My personal feeling is that there is no need to "modify" a 73 year old man's behavior who has dementia and an intellectual disability; at this point the focus should be on quality of life, not learning replacement behaviors (I know some may disagree with me on this or their employer's policy may not allow for this type of plan, but I still wanted to mention it). The third type of plan I occasionally utilize is a Crisis Plan. Useful during transitions from one environment to another, during complete dysregulation, and/or during the initial months of services the Crisis Plan gives staff active and reactive approaches to utilze while you do assessment work. The whole idea of the Crisis Plan is that it is intended for brief (three months maximum) environmental control to decrease the danger the person poses to themselves or others. The Crisis Plan focuses only on active and reactive staff approach as well as environmental restrictions and/or medical (PRN) and physical restraint use. |
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Functions of Behavior (Think M.E.A.T.S.) or;
Medical - Internal triggers that may lead to the onset of specific behaviors. The most common medically based functions of behavior are typical illnesses, i.e. stomach aches, Urinary Tract infections, constipation, etc. Other medical causes that are not as immediately thought of are medications (especially anti-psychotics), mental health D/O, organic brain D/O, i.e. Alzheimer's and Traumatic Brain Injuries, and Seasonal Affective D/O. As a general rule of thumb, you should always encourage that a medical cause of behavior be ruled out prior to starting a behavior program.
Escape - To get away from an unwanted environmental variable, i.e. people, places, and things.
Attention - To get from another person within the environment, i.e. staff, parents, strangers, peers, etc.
Tangible - To gain access to a preferred physical item, i.e. food, preferred toy, etc.
Sensory - Engaging in behavior because of the physical sensation the behavior provides, i.e. rocking, head banging, etc.
Functional Assessment
Antecedent - An environmental variable that is known to trigger a specific behavior or set of behaviors (also referred to as a class of behaviors). Good behavior programs seek to minimize the significance a particular antecedent has at causing a behavior to occur.
Precursor - Also referred to as a warning sign behavior, precursor behaviors are noticeable verbal and/or non-verbal changes in your client's mannerisms. Some people have very common precursor behaviors, e.g. pacing, raised voice volume and/or rate, or cursing, and some people have unique precursor behaviors, e.g. asking for milk minutes before breaking items, or hiccups. Knowing these behaviors will allow you to write your plan from a more active standpoint instead of just reactive.
Reinforcer - Items, events, people, etc. that the person finds rewarding. You will want to identify the stronger reinforcers and utilize them as reinforcing agents within the behavior program.
Establishing Operation - Also referred to as setting events, the establishing operation (E/O), is a variable, either external or internal that causes a person to behavior in an unusual way to usual events. Some E/O that often come up with clients are holidays, anniversaries (especially the death of a loved one), Seasonal Affective D/O, birthdays, etc.
Consequence Management
Positive Reinforcement - When something is added to the environment to increase the occurrence of a behavior, e.g. giving the child positive verbal praise for assisting the teacher set up for an activity.
Negative Reinforcement - When something is removed from the environment to increase the occurrence of a behavior, e.g. taking the child out of time-out 5 minutes early because the child did not yell while in time-out.
Positive Punishment - When something is added to the environment to decrease the occurrence of a behavior, e.g. adding 10 minutes of timeout each time the child has an outburst.
Negative Punishment - When something is removed from the environment to decrease the occurrence of a behavior, e.g. taking away the child's preferred toy for 10 minutes when he hits a peer.
Response Cost - A combination program of positive reinforcement and negative punishment. Typically used in conjunction with a token economy, the individual is rewarded for the presence of the socially positive behavior (sitting at desk for 5 minute) with 1 token (positive reinforcement), however, the student has one token taken away every time he leaves his seat (negative punishment). Another aspect of response cost is the fact that it provides opportunity for both short-term and long-term reinforcement. So, for the child that is working on staying in his seat, he is reinforced every 5 minutes by his teacher with a token and verbal praise (short-term) and 15 minutes of play time for the last 15 minutes of every hour if he can earn 5 tokens.
NOTE: It is not recommended that physical restraint be utilized as a behavior modification intervention. I have seen the effects of this type of approach on children and the impact is noticeable. While some may respond to this type of punitive intervention, many others 1) become overly combative towards staff; 2) are not taught replacement behaviors; and 3) struggle in adult services where physical restraint is not used for this reason. This is only my experience and others may have seen positive results from this but I have never seen a case where punishment procedures alone where more effective than positive approaches. I am not saying that punishment does not work, but I would never rely on it solely to bring about a desired behavior change.
Staff Approaches
Proactive - environmental and/or personal approaches that are known to reduce the likelihood of problematic behavior occurring by accounting for triggers present within the environment while seeking to maintain overall quality of life.
Active - Approaches that are known to de-escalate a person who is reacting to a stimulus in the environment in a negative way. Often times if the person has been working on learning coping skills, e.g. deep breathing, going for a walk, etc. this is when staff would prompt the person to use this skill. The most effective way to actively handle an environmental trigger is to remove the trigger or the person from the environment where it is present.
Reactive - If the person does not respond to the above approaches and escalates to the point where they are engaging in the identified problematic behavior (physical aggression, verbal aggression, self-injurious behavior, etc.) the plan's intervention will be presented. The intervention can be any number or things ranging from a physical restraint to ensure the safety of the client and others in the immediate area, to a contrived consequence (losing free time, access to a preferred item, etc.).
Target Behavior
The target behavior (problematic behavior, maladaptive behavior, socially inappropriate behavior) is the problematic behavior the person displays either too much or not enough. The approaches in the plan should either reward or punish the absence of this behavior or punish the presence of this behavior, respectively.
Replacement Behavior
The replacement behavior (socially appropriate behavior) is the identified behavior you want the person to engage in instead of the target behavior. The replacement behavior should be as easy if not easier to perform than the target behavior that serves the same function. Often times staff will be puzzled as to why a client continues to scream and spit at staff when he has to use the bathroom instead of just hitting the bathroom icon on his Dynavox. It's because it is still easier for the person to scream and spit - if this behavior is still positively reinforced, i.e. staff eventually take him to the bathroom, there is no need for the client to change his behavior.
Environmental Considerations
Environmental considerations fall into two categories in the plans I write; restrictive (see below) or proactive. Typically if it is necessary to put an environmental restriction into place it is because the client has demonstrated in the past to need the restriction in order to be safe. Some common environmental restrictions include door locks, alarms (or any monitoring device for that matter), locked refrigerator and freezer, etc. The problem with these types of restrictions is that it limits your ability to write a plan to teach the person appropriate skills; often environmental restrictions are put in place because the risk to the person's safety is too great.
The second category of environmental considerations are proactive measures taken by the team to ensure the person is not in an environment that is aversive to them, or one that historically leads to problematic behavior. If you are new to the person, getting this information from more knowledgeable team members through an FAI or other interview will be helpful.
Restricting a Person's Rights
This is one area where the regulation difference between child and adult services differs greatly. I cannot speak to this matter indefinitely, but it is my understanding that for children a behavioral approach that is restrictive in nature, e.g. physical restraint, time-out rooms, etc. can be put into place without the prior authorization from a Human Rights Committee (HRC). I do know however that all restrictive approaches used on people once they age of child services must be approved by an independent committee of people. Typically, a well-built plan will leave no question as to why a certain approach is being identified for use. You may find that the HRC requests that you try a less restrictive intervention first before they approve the intervention you presented; this could be seen if you write a BSP with response cost as the primary method of consequence management and the HRC wants you to try just positive reinforcement first.
Accounting for Extraneous Variables
Training - One of the ways we ensure our plans are carried out as intended is to train the staffs implementing the behavior program.
Observation - Although we cannot be everywhere at once, it never hurts to stop in unannounced and see how the client is doing (and the staff). It is best to observe from a hidden vantage point as your presence may impact the client's behavior and will definitely impact the staff's behavior.
Write simple plans - We may sometimes want to write very detail oriented, sophisticated behavior programs, and if the staff implementing the plan can handle them, then great! However, sometimes you need to break down the work for the staff into simpler steps; the client's progress may not be as great or as fast, but they will make progress none the less.
Improper data collection - We need to have reasonable expectations of our hard working direct support staff. They balance a lot every day, and although we may think the behavior program is at the top of the heap in terms of importance, usually there are several other plans (I.E.P., I.S.P. medical needs plan, etc.) Because of this we cannot expect the staff to know exactly how many times the client engaged in finger flapping if the client engages in finger flapping constantly (see more about this in data tracking). We need to set our data up in a way that is intuitive and quick, otherwise the data will be half-@$$ed and you won't have any idea what's going on.
