RBT: Prevention of Crisis Behavior/ Steps to Take Prior to an Emergency

What is not an example of a behavior specific reinforcement:

"Susie, way to go" not describing what they are doing appropriately

After Preventative Strategies do not work:

- Call for help (parent, staff member, etc.) - Allow to assist - Sometimes, Clinical staff cannot de-escalate client - If extra help is not available or effective: + Call 911 + ensure dangerous objects have been removed ( aggression continues to escalate to the point when the client is hurting themselves or others) If anyone is hurt: - Client (inform parents of the injuries, refer to doctor, etc.) - Staff (document)

Importance in Planning for a session:

- Know your client: Understanding their needs (reinforcement) - Organize environment to reduce risk of harm - Dress for problem Bx - Staff training (preventative strategies)

When in a Protective or Defensive Stance, clinicians should be _____________ away.

1-2 arm/leg lengths

Why do Problem Behaviors Occur? 4 Basic Common Functions of Behavior

1. Escape - very common (hitting, tantrum, etc. to escape from demand/antecedent) 2. Attention (lack basic communication skills) 3. Tangible (gaining a desired activity/item) 4. Automatic (occur because immediately reinforcing - stereotopy) (lack basic functional communication)

A clinician should scan the environment every _________ seconds, to ensure there is an available exit and know the client's whereabouts.

20 seconds

What is a precursor behavior?

A Bx that occurs before a client escalates into a crisis Bx.

Client's Rights:

Be free from: - restraint (only in case of emergency) - abuse or harm Be informed about their treatment (informed consent) Be in least restrictive environment (LRE) - requires that students are given supplementary aides to assist them in learning the skills needed to be educated w/ their peers. +Following LRE: teaching replacement Bx +Not following LRE: restraining a client & place in seclusion w/o teaching replacement Bx IDEA: Least restrictive environment defined "to maintain extent appropriate, children w/ disabilities, including children in public or private institutions or other care facilities, are educated w/ children who are not disabled, and that special classes, separate schooling, or other removal of children w/ disabilities from the regular educational environment occurs only when the nature or severity of the disability is such that education in regular classes w/ the sue of supplementary aids and services cannot be achieved satisfactorily."

Body placement for biting:

Body placement - know where their mouth is at all times - avoid hugs and times when their mouth can be near a body part - during reinforcing activities as well (sensory related issue) - appropriate clothing - human bites: are dangerous

A clinician has a locked arm, cupped hand that is placed on the forearm of a client, and fingers and thumbs pressed together are all characteristics of a good ____________________.

Check-in

It is important to conduct regular preference assessments so that the ___________________.

Client does not become satiated

Differential Reinforcement of Incompatible Behaviors (DRI)

DRI: reinforcement is provided for one behavior that is incompatible w/ another behavior Attempt to have a client engage in Bx that are incompatible w/ their problem behavior - Throwing objects: have them clap and reinforce clapping - Spitting: have the client drink from a cup and reinforce them for drinking ++ redirect behavior++ By engaging in DRI allows for reinforcement t be delivered to the client, which may reduce the likelihood of the problem Bx continuing.

Debriefing:

Debriefing: Communication - document Bx so other clinicians are aware - inform the BCBA of the Bx as soon as session is over BCBA may need to - Conduct an FBA and write BIP or adjust a current BIP

Common preventative strategies are:

FCT DRO Wait for client to de-escalate

Hugs are the best reinforcer to use w/ a client that bites. True or False

False

Defensive Stance should be used when trying to implement preventative strategies: True or False

False Use preventative stance Defensive is only when client becomes aggressive

In either High or Low Protective Stance, a clinician's hands should not be _______________.

Fists

Preventative Strategies: Frequent Reinforcement

Frequent Reinforcement: Reinforce frequently - 4 times more frequently than the problem Bx occurs Use specific reinforcement - Nice job writing - Pair w/ a tangible if needed Do not praise absence of the problem Bx Conduce regular preference assessments - desires change BCBA involvement (if new Bx occurs) - conduct functional Bx assessment - teach staff how to handle Observant of precursor Bx - any Bx that immediately occurs prior to severe problem - BIP - Client specific + angry voice, pacing, self talk, etc.

Preventative Strategies: Functional Communication (FTC)

Functional Communication Training (FTC) - Client is escalating and is unable to expire their needs - Assist them in saying what they need: + use icons + Written text + Echoics + Leading questions - If appropriate give client the item or what they need - if NOT appropriate at that time, tell them when they can have it (if don't understand, use strategies they are familiar w/) If assistance is required in communicating their wants, BCBA should implement FTC program

Preventative Strategy: Wait out Client

If other preventative strategies are not working to decrease or eliminate the problem Bx and the Bx have not escalated to the point where they are going to harm themselves or others ..... WAIT! - Dont engage w/ the client - Dont ignore the client, ignore the Bx - Reinforce any reduction in problem Bx and any appropriate Bx When a client begins to de-escalate and the problem Bx has reduced enough, begin to place demands on the client again - use DRI to allow for reinforcement to be delivered - Eventually fade back the original demand, if possible Waiting may seem like the clinical staff are doing nothing If emergency intervention is avoided - that is a step in the right direction!

Preventative Strategies: Change in Activity & Choice

If precursor Bx to a known aggressive Bx occurs it may benefit the client to change the activity - If this is done, be sure to continue the demand situation if possible - Do not change the reinforcing activity - Always switch back to the original Bx to complete that activity Choice: - can be allowed in all programs (allowing to make reasonable & appropriate choices) + Perceived control of the client + targeted tasks of the clinical staff can be completed

Preventative Strategies: Change of Staff

If precursor Bx to known aggressive Bx occurs if may benefit client to change staff: - Clients and staff do not always match well - OPT to change staff for a brief period of time during session, to attempt to reduce precursor

Preventative Strategies: Change Environment

If precursor Bx to known aggressive Bx occurs it may benefit the client and alter Bx to change environment + Be sure to continue the demands that were being placed prior to the precursor Bx beginning + Do not bring to a reinforcing environment - play ground, play set, watch movie May not always be appropriate or possible

Emergency Interventions:

Intervening w/ a client that is in a crisis situation; they may hurt themselves or others to include: Eloping to a dangerous situation (running into a parking lot) Throwing chairs and desks AT PEOPLE (it it were not at people, then would not be emergency)

Preventative Intervention:

Intervening w/ the client to attempt to de-escalate them before a crisis behavior occurs to include: Aggression - towards self - towards others Property destruction

General Positioning Strategies:

Know Exits & who is behind you Don't get backed in a corner Stay out of arm/legs reach of client Don't cross the client's midline Maintain balanced footing ++ Understand that aggression w/ a client can happen++

Check-in should always include:

Locked arm cupped hand fingers and thumb together

Factors that contribute to problem behaviors:

Medical reasons - specific seizures (frontal lobe) - any types of "aches" (physical pain = toothache, headache) - Medicine Changes - Traumatic Brain Injury - psychiatric conditions - allergies - and more...... Historical reasons - Abuse of the client (sexual & physical) - witnessing abuse (fear may happen to them - PTSD Mental impairments - Deficits (cognition, executive function (regulate own Bx), communication (cannot mand for basic needs)) Environmental Conditions - Clutter - Loud/annoying noises (increased sensitivity) - Smells - Unpleasant visual stimulation - Ambient temperature (too hot/cold)

Preventative strategies should occur prior to or during ___________________.

Precursor behaviors + frequent preference assessment + functional communication

Stances & Techniques prepare for aggressive behaviors:

Protective stance - used when working w/ known aggressive client - client beginning to escalate - 2 stances: + Low Protective stance: working w/ children or sitting clients 1-2 arm/leg lengths of client hands down low (not fist) + High Protective stance Hands not in fists or provoking posture Hands placed higher up near chest 1-2 arm/leg length of client working adolescent to adult clients that are standing may be younger (depends on height) - Reasons for use: + ensure your hands can protect specific areas of your body, QUICKLY + to avoid "power" positions (crossed arms, body facing straight on to the client)

Which is not a type of technique or stance that was reviewed?

Provoking (never want to do this)

Check-in Strategies:

Reason for use: Get close to client that may be exhibiting precursor Bx or a client that has the past history of being aggressive - Keep straight rigid arms + be able to stop the client from hitting clinical staff - Keep a cupped hand - The thumb should be pressed against the other fingers and not wrapped around the arm BAD example: Clinical staff facing student, thumb around arm, body faced toward individual

Defensive Stance:

Reasons for use: Ensure your hands can protect specific areas of your body Avoid "power" positions - clinched fists - Karate hands Evade an aggressive client To be used when: A client has escalated Preventative strategies have not worked Different stances: working with children or sitting clients working w/ adolescent to adult clients that are standing - depends on height - Elbows in to protect chest - Hands are in front of the face - Fingers and thumbs are squeezed together - Hands are NOT placed in a provoking position; like: Fist , Karate pose - Weight is balanced on both feet and are separated - Knees are bent

Goal for preventative intervention:

Stop crisis from occurring NOT to restrain client, prevent ahead of time - then teach appropriate behavior

What should occur if a clinician is using DRI w/ a client? Differential Reinforcement Intervention

The behavior the clinician is asking the client to engage in should cause the client to not be able to engage in the problem Bx, if they comply. clapping / not biting

What is the goal of FCT? Functional Communication Training

To ensure the client can express their wants and needs in a more functional and appropriate manner. communication through: pics, ASL, etc.

If a client gets hurt during a session w/ a clinician, the clinician should recommend or in sever enough cases insist upon medical treatment. True or False

True +make sure staff are safe++

A clinician that is trained in assaultive behavior management can restrain a client if they are in danger of hurting themselves or others. True or False

True All preventive strategies have failed - protect safety of staff and client

Preventative Strategies may not always.....

stop a client from engaging in sever problem Bx