Positive Behavior Support Training

1. Positive Behavior Support Training What we Can & Can’t do!

2. Behavior Support Interventions Part 1 • Positive Behavior Supports • Used to improve difficult behavior with an approach based on the belief that there are reasons behind the difficult behavior • They should still be treated with compassion and respect • The individual’s input should be sought when setting up a behavior support plan

3. 1)Positive Behavior Support Strategies **BEHAVIOR CHANGE IS NOT TO BE PURSUED FOR THE CONVENIENCE OF STAFF!** There could be medical reasons why the individual is acting out. We should always assess the situation first. Here are some steps: • UNDERSTAND HOW AND WHAT THE INDIVIDUAL IS COMMUNICATING • Don’t just assume. Asking questions is the best way to get answers. For this, you must be patient and understanding. This will help the individual become more open to answering questions. • UNDERSTAND THE IMPACT OF OTHERS • Their Presence - The individual may act out when a certain person is around. • Their Voice/Tone - Sometimes it’s not what you say, it’s how you say it • Their Words - You want to make sure that you are encouraging good behavior, not punishing them for the bad • Their Actions and Gestures - Words aren’t the only thing that can be hurtful. Your facial expressions (rolling your eyes, smacking your teeth, looking uninterested) and hand gestures (waving the conversation off, “talk to the hand”) can alter an attitude. • SUPPORT THE INDIVIDUAL IN COMMUNICATING CHOICES AND WISHES • You want your consumer to make their own decisions, so when they ask you a question that you know they should be able to answer, you ask them what they want to do. Giving options is different than telling them what to do.

4. Positive Behavior Support Strategies cont…. • SUPPORT WORKERS TO CHANGE THEIR BEHAVIOR WHEN IT IS DETRIMENTAL • It’s not always the individual. Sometimes you have to look within yourself to see if it’s something you’re doing to cause the behavior. You may also see or hear a co-worker talking negatively, or they show negative actions that are wrong. Letting your Team Leader know about these situations isn’t telling on that person, it’s helping both the co-worker and the individual get a better understanding of each other. • TEMPORARILY AVOID SITUATIONS WHICH ARE TOO DIFFICULT • If you know that a certain situation is going to upset your consumer, hold off on doing it until you find another way of approaching it. Know you’re not alone. You have your Team Leaders to go to in these situations. You don’t have to solve the situation by yourself. • TEACH COPING, COMMUNICATION AND SELF-REGULATION SKILLS • Although these skills come naturally to most, our consumers think differently than we do, and it’s our responsibility to guide them through life situations that may seem simple to us, but very difficult for them. Again, patience and understanding is key. • Anticipate situations that will be challenging and assist the individual to cope or calm. • OFFER AN ABUNDANCE OF POSITIVE ACTIVITIES • Physical Exercise • walking in the park or around the corner, going to a exercise class • Relaxation • Taking a nice long shower/bath, meditating, reading a book, watching a favorite show/movie. Whatever they enjoy doing to relax. Removing stressors (light, noise etc. may assist in fixing the behavior. Sometimes it’s not the person, it’s the place.

5. 2)Manipulation of Rewards SOMETIMES IT MAY BE NECESSARY TO CONTROL ACCESS TO REINFORCEMENT TO ASSIST IN BEHAVIOR CHANGE. THIS IS NOT A PREFERRED METHOD BECAUSE IT GIVES THE CAREGIVER CONTROL OVER THE INDIVIDUAL. IF THIS METHOD IS GOING TO BE USED AS PART OF A BEHAVIOR SUPPORT PLAN, THESE CONDITIONS MUST BE IN PLACE: • An assessment of what is currently maintaining the behavior must be conducted • Who, What, Where, When and Why • The manipulation must be natural and not deliberate (on purpose) • The provider shouldn’t be using this because they don’t feel like dealing with the consumer. This should be used to help, not harm. • Must be time-limited • The manipulation should not go any longer than 1 hour. Control over the situation should then go back to the consumer. As long as the consumer attempts to change their behavior, and it’s better than when you started, control should return to them. **PROVIDERS OF INPEL MUST SPEAK TO THEIR IMMEDIATE SUPERVISOR BEFORE DOING THIS SUPPORT STRATEGY. IT SHOULD NOT BE DONE WITHOUT PRIOR AUTHORIZATION.

6. 3) Psychiatric Medications THESE DRUGS ARE PRESCRIBED TO STABILIZE OR IMPROVE MOOD, MENTAL STATUS OR BEHAVIOR . SOMETIMES THESE DRUGS ARE CALLED “PSYCHOTROPIC” OR “PSYCHOACTIVE” MEDICATIONS. WHEN PSYCHIATRIC MEDICATIONS ARE PRESCRIBED, AND THE PERSON IS SUPPORTED BY WORKERS PAID WITH DS FUNDS, A PSYCHIATRIC MEDICATION SUPPORT PLAN IS REQUIRED. • This plan should be developed and updated by the team, together with the prescribing Physician. It should incorporate both the medication and Positive Behavior Support. • Medications cannot cure behavioral or emotional disorders. They can help improve specific symptoms. CATEGORIES OF PSYCHIATRIC MEDICATIONS: • ANTIDEPRESSANTS - Celexa (Citalopram), Paxil (Paroxetine), Prozac (Fluoxetine) • ANTIANXIETY - Ativan (Lorazepam), Klonopin (Clonazepam), Valium (Diazepam) • ANTIMANIC AGENTS (Mood Stabilizers)- Depakote (Sodium Divalproex), Lithium, Tegretol • ANTIPSYCHOTICS - Risperdal (Risperidone), Seroquel, Clozaril (Clozapine) • STIMULANTS - Ritalin, Adderall (Amphetamine), Concerta

7. 4) Restrictions of Rights “RESTRICTIONS OF RIGHTS” ARE ACTIONS BY WORKERS PAID BY DS(Developmental Services) FUNDS WHICH USE THE CAREGIVER’S AUTHORITY OVER THE INDIVIDUAL AND INTERFERE WITH AN INDIVIDUAL’S AUTONOMY(doing what you want to do), RIGHTS, ACTIVITIES OR PRIVACY IN WAYS WE USUALLY FIND UNACCEPTABLE IN CONSENTING RELATIONSHIPS. • A restriction of rights may be needed to protect the emotional or physical health or safety of the individual or others. • Contact with family members may be restricted for the safety of the individual or the family member. • Restrictions of rights must not be used as rewards or punishments to change behavior. There is a fine line between reasonable safety precautions and a limitation of autonomy • Restricting contact with family because the individual is noncompliant, and allowing contact when he is compliant • Locking up chemical cleaners or prescription drugs vs. locking up kitchen cabinets and the refrigerator • Using the phone for no more than a ½ hour at a time vs. not using the phone because your room isn’t clean • Locking a person in his/her room is never permitted • It is the responsibility of the individual and his/her guardian and other ISP team members to identify measures that are restrictions of rights and continuously reassess the need for any restrictions.

8. 5) Restraints RESTRAINTS ARE ACTIONS THAT LIMIT A PERSON'S VOLUNTARY MOVEMENT FOR THE PURPOSE OF KEEPING THE PERSON FROM DOING SERIOUS HARM TO THEMSELVES OR OTHERS. RESTRAINTS MAY NOT BE USED FOR THE PURPOSE OF TRAINING OR CHANGING BEHAVIOR OR FOR THE CONVENIENCE OF STAFF. THERE ARE FOUR TYPES OF RESTRAINTS: • PHYSICAL RESTRAINT • When using physical restraints, the minimum amount of force necessary should be used • Excessive use of physical restraint may be considered abuse • Workers who use physical restraints must be trained in • Emotional self-regulation (Strategic Self-Regulation) • Positive behavior supports and de-escalation techniques (Safety Awareness Training) • The restraint specific to the person Safety Mechanics) • PROHIBITED RESTRAINTS - These restraints are prohibited under any circumstances: • Restraints in which the individual lies face down • Restraints that have the individual lying on the ground or in a bed with a worker on top of the individual • Restraints that restrict breathing (head lock, choke hold) • Restraints that hyper-extend a joint • Restraints that rely on pain for control • Restraints that rely on a takedown technique in which the individual is not supported and allows for free fall as he/she goes to the floor (tackling) GENTLE PROMPTS OR PHYSICAL GUIDANCE USED AS PART OF A TEACHING ACTIVITY OR OTHER ACTIVITY OF DAILY LIVING ARE NOT CONSIDERED RESTRAINTS (bathing, dressing, toileting, physical support of an unsteady person)

9. Restraints...cont. • CHEMICAL RESTRAINT • Chemical restraint is the administration of prescribed medicine when all the following conditions exist: • The primary purpose of the medication is a response to problematic behavior • The prescribed medicine is a drug or dose that would not otherwise be administered as part of a regular medication regimen • The prescribed medicine impairs the individual's ability to do or accomplish his/her usual activities of daily living MEDICATIONS THAT HELP A PERSON SLEEP DURING HIS/HER REGULAR SLEEPING HOURS ARE NOT CONSIDERED CHEMICAL RESTRAINTS. • MECHANICAL RESTRAINT • Any items worn by or placed on the person to limit behavior or movement and which cannot be removed by the person • Mittens, straps, arm splints, harnesses, restraint chairs, bed rails, bed netting and helmets • OTHER RESTRAINT OF MOVEMENT • Locked Perimeter Exits • Used to secure the exits during waking hours to protect the individual from causing severe injury to themselves or others • Exception: Locked perimeter doors at night to protect the individual and staff while asleep • Safety Shields in cars & Locking Seat Belts • Metal barrier or locking seat belt in a vehicle to prevent an individual’s movement in the front seat • Exception: Age-appropriate child safety restraints.

10. Restraints used in a medical context THE USE OF RESTRAINTS IN A MEDICAL CONTEXT AND MECHANICAL SUPPORTS ARE NOT COVERED BY THE GUIDELINES ABOVE. NO MUI INCIDENT REPORT ARE REQUIRED FOR THE FOLLOWING: • Sedation prescribed by a physician or dentist prior to a medical or dental procedure • Restraints used to control the movement of a person during a time sensitive, necessary medical or dental procedure. • Time limited restraints to promote healing following a medical procedure or injury • Devices prescribed by a physician, physical therapist or occupational therapist to maintain body alignment or otherwise support or position a person • Devices normally used for safety reasons (car seats or seat belts) • Helmets, when they are used to protect a person from injury during a fall or seizure • Helmets are restraints when used to prevent a person from touching or hitting his/her head • Bed rails when used to keep a person from rolling out of bed • Bed rails are restraints when used to prevent a person from getting out of bed when they want to • Wheelchair brakes, unless used for the purpose of interfering with a person’s mobility • Mechanical restraints needed to protect an individual known to be at risk of severe injury due to frequent loss of consciousness

11. Emergency Restraints THE USE OF LISTED RESTRAINTS TO BRIEFLY CONTROL BEHAVIOR THAT POSE A RISK OF SEVERE INJURY WHEN THOSE BEHAVIORS WERE NOT ANTICIPATED. THESE RESTRAINTS MAY BE USED IN AN EMERGENCY SITUATION PROVIDED THEY ARE USED: • On a time limited basis for the purpose of protecting the safety of an individual or others • To prevent serious property destruction • After less intrusive attempts to achieve safety have failed • If there is no time to attempt less intrusive methods. IF THE BEHAVIOR REOCCURS, THE INDIVIDUALS TEAM SHOULD MEET TO CONSIDER ALTERNATIVES TO THE EMERGENCY INTERVENTION ANY EMERGENCY USE OF A RESTRAINT MUST BE REPORTED IN A MUI INCIDENT REPORT. IF RESTRAINTS ARE USED AS EMERGENCY PROCEDURES ON MORE THAN 2 DAYS WITHIN A 6 MONTH PERIOD, THE INDIVIDUAL’S IPS TEAM MEMBERS SHOULD MEET TO REVIEW THE PERSON'S NEED FOR SUPPORT.

12. Procedural Requirements for Behavior Supports Part 2

13. Consent • AN INDIVIDUAL AND HIS/HER GUARDIAN (IF ANY) MUST BE INVOLVED IN DEVELOPING A PLAN FOR ANY BEHAVIOR SUPPORT UNLESS THE PLAN IS COURT ORDERED. • Court orders do not require consent of the individual or guardian. A copy of the court order must be in the person’s record. • IF THE PERSON HAS A GUARDIAN, THE PLAN MUST BE EXPLAINED TO THE INDIVIDUAL EVEN THOUGH THEIR CONSENT ISN’T REQUIRED. ALL OTHER ISP TEAM MEMBERS SHOULD ALSO BE INVOLVED IN DEVELOPING THE PLAN. • All ISP team members should agree to the plan • THERE MAY BE TIMES WHEN AN AGENCY WILL REQUIRE A BEHAVIOR SUPPORT PLAN, RESTRICTION OF RIGHTS, OR PLAN FOR RESTRAINTS AS A CONDITION OF PROVIDING SERVICES. • If the individual or guardian wish to receive services, but does not agree to the plan or intervention, the plan must be in writing and must be reviewed by the Professional Review Committee. • If approved by the committee, the individual/guardian must decide if he/she will accept the services, including the plan • HUMAN RIGHTS COMMITTEE • A Human Rights Committee reviews and prior approves or rejects all behavior support plans. The committee ensures that the rights of the individual are protected • The committees are formed by the county board or those formed by the provider

14. Planning for Behavior Supports • FUNCTIONAL ASSESSMENT • The foundation of a behavioral support plan. • May be informal and focus on a particular setting or situation • May be formal and comprehensive. The team will need to determine how comprehensive the functional assessment needs to be based on: • The dangerousness of the behavior • The history of past behavior change with the individual • The restrictiveness of the interventions being used • The cost of services addressing the behaviors • A comprehensive assessment is always required when restraints are part of the plan • APPROVAL BY PROFESSIONAL REVIEW COMMITTEE • Committee members should have the knowledge and experience in evaluating approaches to ensure the use of the least restrictive alternatives • If chemical restraint is part of a plan, the committee shall include a physician, nurse or pharmacist • Committee members include • professionals, people with developmental disabilities or family members who are not part of the agency

15. Planning for Behavior Supports...Cont.. IF A PLAN IS PRESENTED TO THE PROFESSIONAL REVIEW COMMITTEE, THE PERSON AND HIS/HER GUARDIAN SHOULD BE INVITED AND ENCOURAGED TO BE PRESENT ANY PLAN THAT INVOLVES THE USE OF RESTRAINTS SHALL BE SENT TO THE STATE HUMAN RIGHTS COMMITTEE FOR REVIEW. IT MUST ALSO BE REVIEWED AT LEAST EVERY THREE MONTHS BY THE INDIVIDUAL’S TEAM AND SOMEONE WITH APPROPRIATE TRAINING AND SKILLS IN POSITIVE BEHAVIOR SUPPORTS. THE RESULTS OF THE REVIEW MUST BE SUMMARIZED AND DOCUMENTED IN WRITING. ANY USE OF RESTRAINTS, INCLUDING AN EMERGENCY RESTRAINT, MUST BE REPORTED IN A MUI INCIDENT REPORT. ANY WORKER WHO LEARNS THAT AN INDIVIDUAL WITH DEVELOPMENTAL DISABILITIES HAS BEEN SUBJECTED TO A PROHIBITED PRACTICE SHOULD REPORT THE SITUATION. WORKERS ARE MANDATED REPORTERS AND MUST REPORT ANY SUSPICION OF ABUSE TO THE MUI DEPARTMENT (ADULTS) OR CHILDREN SERVICES (CHILDREN)