MEANINGFULMedications may decrease crisis behaviors by altering the person’s response to stimuli...

Merrill Winston, Ph.D., BCBA-D PCMA, Inc.

MEANINGFUL RESTRAINT ELIMINATION

AND REDUCTION

1 Copyright 2011 PCMA, Inc.,

¡  Focusing too strongly on restraint reduction (which is a good outcome) takes our attention away from the problem of long-term treatment gains.

¡  Focusing on restraint reduction as a primary goal allows for too many ways to reduce restraints in ways that might be non-functional, misleading, dangerous, or not in person’s long-term clinical interest.

¡  Six categories of problems that often lead to high levels of restraint (loose restraint criteria, poor staff-client interactions, poor client skills in the face of even reasonable interactions, lack of reinforcers, client to client interactions, non-socially -mediated problems).

¡  The role of “non-compliance” in restraint usage. ¡  The danger of the language of “last resort” and how to replace it

with more functional, precise language that will better accomplish the intention of “last resort” language.

OVERVIEW


¡  Problems with facility -wide/state-wide restraint goals as opposed to individual goals.

¡  Administrative causes of restraint (policy issues including rules on restraint use and rules about teaching and treatment).

¡  Restraint reduction as the natural outcome of the selection of proper, long-term functional goals.

OVERVIEW


¡  Sometimes people focus on restraint reduction because the reduction is something that is “tangible.”

¡  We can “order” staff to stop using restraints, but unfortunately, we CANNOT order therapeutic gains for all our clients.

¡  It is far easier to tell staff what not to do than to tell them what to do. We need to de-emphasize proscriptive language in favor of prescriptive language

¡  Not in all cases, but in a majority of cases, restraint continues because behavior problems continue. Behavior problems continue because of treatment problems, staffing problems, medical problems and administrative problems.

¡  Do we use restraint on people with absolutely no behavior problems? That is, are restraints being used for people with no aggression, even when demands are placed on them?

¡  Do we use restraint for individuals who get an “F” on an exam or simply didn’t do their chores at the group home? Or do we push them to the point of aggression and THEN use restraint?

THE RIGHT RESULT BUT THE WRONG FOCUS


¡  Restraint is NOT the problem! ¡  Restraint is a symptom that is a result of a confluence of

variables (treatment, staff, medical, administrative). ¡  There is a tremendous dif ference between eliminating

restraint and eliminating THE NEED for restraint. ¡  Anyone can eliminate restraint, but can you eliminate the

need as well? ¡ When talking about restraint, I mean ALL FORMS not simply

floor restraint, or standing or walking. I mean the restriction of movement of some part of the individual and they are actively resisting against you.

¡  Holding a child by the hand, who is attempting to run into the street, and pulling away from you IS RESTRAINT! It’s just not what comes to mind with most people.

THE RIGHT RESULT BUT THE WRONG FOCUS


¡  If the goal is simply the reduction of restraint, (and no one is actually looking at the frequency of behavior problems, staff and client injuries, and the acquisition and maintenance of critical skills) then there are many, many ways to reduce/eliminate restraint!

¡  How is this accomplished? ¡  For behavior maintained by attention, provide constant 1:1

staffing. ¡  For behavior maintained by escape/avoidance eliminate all

demands. ¡  For behavior maintained by access to tangibles, allow access

to everything the person wants all the time, e.g., “It’s Chuckie’s CHOICE to eat 5 gallons of ice-cream and stay up until 3 a.m. on a school night.

HOW TO REDUCE RESTRAINT…LET ME COUNT THE WAYS…


¡  Now, these methods actually will reduce behavior problems and therefore reduce the need for restraint, but the method of behavior reduction is NOT a long-term therapeutic gain based on skill acquisition and personal growth.

¡  These methods are primarily antecedent manipulations and, as such, they do not teach new skills to staff or clients/students.

¡  There is nothing wrong with a few reasonable antecedent manipulations, but if they are taken too far they can actually make long-term, meaningful behavior change almost impossible.

¡  How else are restraints reduced? ¡  Medication, Medication Medication! ¡  Everyone is screaming about restraint reduction, but those same

individuals should be screaming about the dump trucks full of pharmaceuticals that are being pumped into people with disabilities every year.



¡ Medications may decrease crisis behaviors by altering the person’s response to stimuli that normally produce crisis behaviors.

¡  The individual never learns how to “cope” with these events, instead we are chemically removing the need for learning how to cope with dif ficulty.

¡ When the medications are removed or lose their efficacy the individual is no better off than they were prior to the initiation of medications and sometimes they are significantly worse.

¡  How else can we reduce restraints? ¡ MORE STRINGENT ADMISSION CRITERIA (cherry picking) ¡  GET RID OF OUR DIFFICULT CLIENTS!!! ¡  Call law enforcement! ¡  Do a room clear!



¡  We can create prosthetic physical environments: Lexan instead of glass, stucco interior walls, heavy duty door frames and steel doors (hardened homes).

¡  We can create Prosthetic social environments: Staf f are instructed to tolerate the intolerable. Staf f allow clients to hit them, destroy their personal property, destroy the property of the home/classroom and disrupt the entire treatment milieu in the name of avoiding restraint.

¡  We can create policy that bans restraint or certain types of restraint. This wil l in fact reduce restraint (at least it wil l reduce reports of restraint) but it wil l in no way af fect the need for restraint and is by far the worst way to reduce restraint, if the goal is a cl inically meaningful reduction.

¡  We can play definition games: “We don’t call it restraint if its less than two minutes” or “We don’t call it restraint if is only an escort.”

¡  We can play data games: “We only count 1 restraint for the entire episode even if the episode was an hour and they were restrained 15 separate times in the hour.”



¡  These categories are by no means exhaustive, they are more of a six point version of David Letterman’s “TOP TEN.”

¡  Although there are most certainly some topics that cannot be covered in the scope of this presentation, making progress in ANY of these six areas will SIGNIFICANTLY reduce restraint.

¡ Making progress in ALL of the categories will DRAMATICALLY reduce restraint as a result of altering the behavior of staff, the individual, and administrators in meaningful ways.

¡  Let’s take a look, shall we?

SIX CATEGORIES OF PROBLEMS THAT LEAD TO HIGH LEVELS OF RESTRAINT


¡  “Danger to self and others” can easily lead to overuse of restraint.

¡  Restraint is often used as a consequence of non-compliance when there is (initially) absolutely no danger is involved, e.g., a student refuses to get on the school bus or a client refuses to get on the van when the day treatment program is over.

¡  Noncompliance is definitely a problem, but it is seldom dangerous (a client refuses to move from the middle of a busy highway). Inappropriate physical prompting (pulling someone) in these cases could turn noncompliance into crisis that may result in restraint!

¡  Noncompliance should be dealt with programmatically and proactively, (more on this later) and not through the continued use of physical procedures.

¡  We at PCMA use the criteria of continuous aggression/self-injury/high magnitude disruption (CASH). However there are stil l situations in which judgments must made. No guideline can accommodate all situations.

¡  Non-continuous behaviors may be dangerous, but do not require restraint as they have already ended.

SIX CATEGORIES OF PROBLEMS: #1 LOOSE CRITERIA FOR RESTRAINT USE


¡  Individualized criteria for restraint will always be superior to general criteria, but must be based on data collection and analysis of the problem behavior. General criteria are good for unpredictable emergencies.

¡  Individualized criteria can prevent both the overutilization of restraint and the underutilization of restraint.

¡  Individualized criteria are based on recurrent, predictable behavior with which staff have a great deal of experience. Individualized criteria should be part of an individualized program. This is NOT the same as the “programmatic use” of restraint.

¡  The behavior may not be completely predictable in the sense of “the behavior will occur in 3, 2, 1…run away!!!”

¡  It may be predictable however in the sense that we expect that it will happen again and we know some of the circumstances that make it more/less likely.

SIX CATEGORIES OF PROBLEMS: #1 LOOSE CRITERIA FOR RESTRAINT USE


¡  There are two broad categories of crisis: ¡  Those that come and find you…you were in the wrong place at the

wrong time… ¡  Those that YOU produce yourself! Shame on you! ¡  In many instances, crisis behaviors are produced through coercive

interactions. ¡  Coercion means forcing someone to do something they don’t want to

do, in a particularly nasty way. This does not mean that the client has NO part in contributing to the problem. Most of us do not attack people and destroy things simply because we get “chewed out” by our bosses (a coercive interaction).

¡  People with disabil it ies however ( in most instances) do not have the same skil l sets for dealing with coercive interactions, or any sort of aversive for that matter.

¡  In the PCMA BehaviorTools Training, we focus on eliminating 12 dif ferent forms of coercive interactions. The focus here is on changing staf f behavior (which is sometimes harder than changing our cl ient’s behavior).

SIX CATEGORIES OF PROBLEMS: #2 POOR STAFF/CLIENT INTERACTIONS


¡  With almost all behavior problems, we usually know what the behavior is, but not the REAL problem!

¡  Problems usually involve some sort of skill deficit. ¡  Why is it that when we are denied access to reinforcers that we

don’t punch people? (well most of us don’t). ¡  We have numerous skills to help us get our needs met, and if one

doesn’t work we have a variety of others to choose from. ¡  If skill deficits are not addressed, there will be an over-reliance

on antecedent manipulations and some of those can be detrimental in the long run.

¡  We should focus on teaching individuals how to get their needs met in safe appropriate ways, AND focus on teaching coping skills.

¡  Coping skills are things we do when we can’t get what we want, are told something we don’t l ike, when we are disappointed, when we are exposed to unpleasant but necessary events and what we do to appropriately escape from and avoid unpleasant things that CAN be avoided.

SIX CATEGORIES OF PROBLEMS: #3 POOR CLIENT SKILLS


¡  Individuals who learn significant skills that help them get what they need and allow them to handle what they don’t like are just going to have fewer crises.

¡  If there are fewer crises there are fewer restraints. ¡  It is easy to reduce restraints in other (less productive) ways

yet the individual typically has learned absolutely nothing, and when (and if) that person transitions to a less restrictive setting they will in no way be equipped to deal with this new non-specialized environment.

¡  Remember, just because YOUR staff are non-coercive doesn’t mean someone else’s staff won’t be!

SIX CATEGORIES OF PROBLEMS: #3 POOR CLIENT SKILLS


¡  Many crisis behaviors are a direct result of demands. Even being asked to wait for a reinforcer is a demand. Even when staff are taught how make a request in the nicest possible way, some individuals will STILL display behavior problems.

¡  We cannot simply eliminate all reasonable requests, for this results in a person who makes no progress whatsoever. The elimination of all reasonable requests is in itself “unreasonable.”

¡  The motivation to escape plummets when reinforcement rises. ¡  The motivation to escape plummets when reinforcement rises. ¡  Nothing makes a bad job suck less like MO’ MONEY! ¡  You don’t have to pester someone to do a chore or start her job

or begin her schoolwork when you have good reinforcers and when those reinforcers are not (initially) dif ficult to obtain.

¡  When strong reinforcers are present people WANT to do things and are not doing things simply to make YOU go away!

¡  Naturally, you don’t need such strong reinforcers if you tap into your client’s interests, you just need to create the proper curriculum/treatment programs.

SIX CATEGORIES OF PROBLEMS: #4 LACK OF REINFORCERS


¡  Even if you find things your clients like, there will always be things you must ask them to do that they will not want to do.

¡  If powerful reinforcers are being used you typically do not have to compel people to do things, instead you can just give a subtle prompt instead of nagging or coercing the individual.

¡  It is true that even powerful reinforcers can cause their own problems, but that too comes back to skill deficits (learning how to give up reinforcers, how to accept alternatives, how to wait, etc.).

SIX CATEGORIES OF PROBLEMS: #4 LACK OF REINFORCERS


¡  You can have the best staff in the world and they may be non-coercive and they may use positive reinforcement in their interactions with all your clients but there stil l remains the problem of client to client interactions.

¡  Individuals with behavior problems can also cause behavior problems in their peers who ALSO have behavior problems and that’s a big problem!

¡  Sometimes a person’s behavior problem is that he specifically seeks out opportunities to cause behavior problems in his peers, and that too is a problem!

¡  If the individuals cannot be placed in dif ferent classrooms/treatment environments then there are three general avenues of action we can take:

¡  We can increase the “reinforcement value” that each individual sees in the other by making strong reinforcers contingent on cooperative tasks (they see each other as more useful).

SIX CATEGORIES OF PROBLEMS: #5 CLIENT TO CLIENT INTERACTIONS


¡  Sometimes one individual can be taught how to use a “non-reactive” response to another individual’s “junk behavior.”

¡  Sometimes we can teach social skills to the individual who likes to “set off” other clients.

¡  Ultimately there must be an analysis of the interactions between the two individuals to formulate a specific treatment plan, but the interactions must be addressed as well as the need for socially -related skill acquisition.

SIX CATEGORIES OF PROBLEMS: #5 CLIENT TO CLIENT INTERACTIONS


¡  Even in reasonable environments with reasonable staff members using non-coercive strategies to motivate and teach individuals there may still be behavior problems that are non-socially mediated.

¡  The individual’s behavior is caused and maintained by factors that don’t involve the actions of other people: 1) The internet doesn’t work, so a client smashes the mouse down and

destroys it. She then attacks the first person that walks by her (no one “did” anything to her, she just got agitated and agitation can greatly increase the chances of aggression).

2) An individual with an ear infection smashes her fist into her head repeatedly.

3) An individual finishes his soda and there is no more soda available (it happens) and he begins biting his hand repeatedly.

SIX CATEGORIES OF PROBLEMS: #6 NON-SOCIALLY MEDIATED PROBLEMS


¡  Although perhaps less frequent than socially -mediated problems, these types of behavior problems do in fact occur and, in many instances, can stil l be addressed through skill acquisition.

¡  People have to learn what to do when things break, how to stay calm, and how to make it work again. To do this we MUST contrive mildly upsetting situations in which things break and quickly show people what to do to fix those things.

¡  People have to learn how ask for alternatives when something is unavailable and/or how to ask for information about when something will arrive and how to wait and what to do while waiting. This is much more challenging with non-verbal individuals, but is stil l important.

¡  Medically -related problems, particularly in non-verbal individuals must be addressed through proper medical assessment and treatment. This can be particularly challenging when diagnosis requires verbal report by the patient (a real problem with medication side-effects).

SIX CATEGORIES OF PROBLEMS: #6 NON-SOCIALLY MEDIATED PROBLEMS


¡  Noncompliance is really a terrible concept. ¡  Noncompliance is really a terrible concept . ¡  It is an attempt to assign a label to a person, based on their

unwillingness to do what WE want them to do, e.g., “Johnny is VERY noncompliant!”

¡  Here’s how to get rid of noncompliance forever…ready? ¡  Rename it SELF-ADVOCACY! Problem solved! ¡  Noncompliance is not behavior. It is a description of poor

instructional control in which the blame for the lack of said control l ies with the student/client.

¡  Most people look at noncompliance as a failure to begin doing something (start working), but noncompliance can also be a failure to stop doing something (jumping off of tall furniture).

¡  When we desire to make people stop doing things it is better to say we need them to stop doing X instead of saying, “he’s noncompliant!” Continuing to do dangerous things can be considered a crisis and we must act accordingly.

THE ROLE OF NONCOMPLIANCE IN RESTRAINT USAGE


¡ When we want people to BEGIN doing something, when they aren’t really doing anything (sitting on the sofa), we can actually create a crisis.

¡ Many refer to these scenarios as “power struggles.” ¡ What do we do about this? ¡  First stop using the term noncompliant. If you don’t, then

you’re being noncompliant and you don’t want that label haunting you for the rest of your days do you? You’ll never get another job with that kind of reputation.

¡  Second, instead of saying “Jimmy is non-compliant” say “Jimmy doesn’t want to get out of bed” or “Janet doesn’t want to work at the table (be specific).

¡  Third, give Jimmy a damn good reason to get out of bed, and that reason cannot be, “Because I said so!” (which is the reason my father always gave me, and believe me, it was good enough for me).



¡ When people don’t want to do what we want them to there are two main things to investigate: 1) They hate doing THIS SPECIFIC THING. 2) They hate doing anything YOU WANT THEM TO DO, even if its

something they like.

¡  These are two VERY different problems. ¡  The first is addressed through an analysis of why they don’t

like what they don’t like and weighing the aversive nature of the task against the reinforcement that stands to be gained (it’s always a balancing act).

¡  The second is addressed through altering the staff reaction to the refusal to do something, because in this case the behavior is typically maintained by pleading, begging, cajoling, threatening, and anything else people can figure out to get the person to comply.



¡  This is a VERY common phrase in legislative bills, white papers, blogs, and policies all over the country and it can actually cause harm.

¡  If a child is smashing his head into a wall, restraint, of some form, is the first and only resort. Are you really going to try to “talk someone down” from smashing their head into the wall?

¡  True, you could try to “back away” from the person and maybe he will stop banging, but only if your presence caused the problem. It could also reinforce the head banging if the child wanted you to back off. ANY changes in your behavior, or to the environment as a consequence of crisis behaviors could make the behavior MUCH more severe and make it occur more often in the future!

¡  How many more head-bangs will occur before you realize that the less restrictive thing isn’t working? How many other non-restraint methods will you try? How many times does the child have to hit his head before you physically stop him?

¡  Remember restraint doesn’t necessarily mean holding someone in a horizontal position on the floor, restraint means restricting movement of some part of the person against his or her will .

THE DANGER OF THE LANGUAGE OF “LAST RESORT”


¡  The question is, are we using a formal restraint technique when there is already a crisis , or are we using some form of restraint for “noncompliance” (pulling a child by the arm who won’t leave an area or forcefully pushing him into a chair)?

¡  If someone refuses to leave the cafeteria, but is not exhibiting crisis behaviors, is restraint really even a consideration at all?

¡  Using the language of “last resort” may cause staff to believe that they should try as many things as they can think of, during a crisis, that may or may not stop the person as opposed to ABSOLUTELY stopping the person as soon as the crisis starts.

¡  If there exists a good general criterion for restraint use with unpredictable behavior, coupled with an individualized criterion for restraint use with recurrent yet somewhat predictable behavior, the language of “last resort” becomes altogether unnecessary.



¡  Additionally, if your staff know how to approach problems of “noncompliance” and if they understand the difference between naughty, socially unacceptable behavior and a true crisis, again, we won’t need the language of “last resort.”



¡  Global reduction goals are all too often handled in a global manner.

¡  The State: We must reduce restraint! ¡  The Administrator: That’s it! No more restraint! ¡  The State: Hurray!!! ¡  The Staff: I had to get 15 stitches from a bite! ¡  The Administrator: Doh! ¡  As mentioned, there are so very many ways to reduce restraint

that are merely quick fixes and not even very good ones. ¡  Even if we make goals for a 50% reduction in restraints, even

if focusing on real, meaningful skill acquisition for staff and and clients, a single new client with severe behavior problems can cause a very quick 50% increase!

PROBLEMS WITH FACILITY-WIDE/STATE-WIDE GOALS FOR RESTRAINT REDUCTION


¡ Why can we not focus on individuals? Aren’t we supposed to be all about “person-centered planning” and “individualized educational plans” and “individual support plans?”

¡  If your facility currently has 100 restraints per month and 50% of those restraints are caused by just two individuals…

¡  And you create meaningful behavior change and quality of life improvements for those individuals, thereby eliminating or nearly eliminating restraint for both of them…

¡  You now have nearly a 50% reduction in restraint use. ¡  However, if you get two new admissions with severe behavior

problems, until you can treat those individuals, you might get a 50% increase in restraints!

¡  Oh no! You’ve failed! You’re right back again to 100 restraints per month!!! Doh!

¡  Did you actually fail? Or did you change the lives of two people at your facility?



¡  If you could replicate this success on a person by person basis, sweeping through your organization, even if your restraint rates NEVER dropped below 100/month, but you constantly move individuals to less restrictive facilities as you treat them, is your organization a failure?

¡ What is wrong with abandoning goals for restraint reduction and instead saying, “James has the most severe problems, (and the most restraints) let’s focus our efforts on making him better!”

¡  If you can’t make James better, perhaps it will reveal problems in your treatment programs, medical services, staff skills, policies, or a variety of variables that can now be adjusted until behavior change can be achieved. Isn’t that ultimately more worthwhile than issuing proscriptive decrees?

¡  Think about it….are you done yet?



¡  This is not meant to “pick on” administrators. They have tough jobs too, but we can’t blame everything on our staff and we can’t blame everything on the behavior analyst (only most things). It isn’t good for morale and it is an incomplete analysis of the problem.

¡  EVERYONE PLAYS A ROLE IN THE USE OF RESTRAINT! ¡  Example: ¡  The air conditioning doesn’t work at the vocational center. ¡  Staff wish to keep the clients at home because they know

there will be behavior problems because of the heat. ¡  Administration: Clients can’t stay at home, it will go against

active treatment and our facility will be cited! We will send fans.

¡  The fans blow hot air on the clients. ¡  Crisis!

ADMINISTRATIVE CAUSES OF RESTRAINT


¡  A child with a disability does best with one teacher in particular and could easily spend the entire day with that teacher to meet her educational needs.

¡  Administration says that all the students must change classes ¡  The child has MANY more behavior problems with the other

teachers. ¡  Does the child really HAVE to change classes? ¡  A child has behavior problems in the lunchroom. ¡  The teacher is willing to allow the child to eat his lunch in the

classroom when the teacher eats his lunch. ¡  Administration says the teacher MUST take a break for lunch

(union rules) and he CANNOT have the child there.



¡  Are the administrators “bad people” or are they responding to pressure put upon them by laws, policies, or other administrators above them???

¡  Things can’t only come down the chain of command, they have to go up it as well!

¡  Administrators have to work with staff to reconcile their own needs with those of the individual client/student.

¡  Sometimes administrators are responding to other people who narrowly interpret federal, state or local guidelines and those individuals do not understand how their pressure on administrators might adversely affect restraint use.

¡  As an example, policies that ban the use of seclusion rooms (which can be used appropriately and safely) may actually INCREASE the use of physical (manual) restraint by removing a viable alternative.

¡  Banning the use of a “more restrictive” restraint, that might also be more effective at containing an individual quickly, might resort in an increased duration of less restrictive restraints.



¡  Laws, policies and procedures that are designed to help the masses are not by any means a guarantee that they won’t actually end up hurting individuals.

¡  Laws, policies and procedures are designed by very small groups of people to be used very with large groups of people, and very often are not written with enough “interpretive leeway” to allow for individual dif ferences.

¡  People at many levels need to be able use judgment so that persons with highly specific needs don’t suffer unduly.



¡  Restraint reduction is great. Everyone is for it, and no one (no one in their right mind) is against it.

¡  Is it the best goal? No. ¡  Is it a good goal? No. ¡  Can it divert our focus away from the REAL issues? Yes. ¡  Can we obtain restraint reduction without solving real problems?

Yes. ¡  Can we obtain restraint reduction and create new problems? Yes. ¡  Can we come up with better, more meaningful goals that target

real problems and suggest real, long-term clinically significant solutions? Yes!

¡  Will this have an OUTCOME of restraint reduction? Yes! ¡  Is restraint reduction a fantastic OUTCOME? Yes!! ¡  Did YOU find this presentation useful? Yes! (I hope).

RESTRAINT REDUCTION AS AN OUTCOME INSTEAD OF A GOAL


¡  You might find our Crisis Incident Risk Assessment and Root Cause Analysis Checklist to be useful in reducing restraint and crisis related adverse events in your program. You can get a free copy from our website!

¡  THANK-YOU for your participation! ¡  Questions???

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MEANINGFULMedications may decrease crisis behaviors by altering the person’s response to stimuli...

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