Informational Bulletin On Positive Behavioral Supports A Guide for Agencies Implementing Positive Behavior Supports Department of Developmental Services October 2013 1
From: Commissioner Elin Howe Date: October, 2013 Informational Bulletin on Positive Behavioral Supports I. Background: More than a year ago, a Positive Behavioral Supports Advisory Committee was convened to explore and develop a framework for the implementation of Positive Behavioral Supports (PBS) throughout the DDS system. The Advisory group has been a collaborative effort between DDS, providers, family members, a self-advocate, the DD Council, an array of external and internal clinicians, and an educational consultant all versed in PBS. From that group a number of sub-committees were created to develop PBS practices and trainings. The information provided in this Informational Bulletin is a by-product of the Advisory work and will shape the promulgation of new regulations to replace the current behavior modification regulations currently found in CMR 115, 5.00 in 2014. DDS will eliminate the current behavior plan Level system I and II and replace it with Positive Behavioral Supports 1. This Bulletin alerts providers to the upcoming changes and supports the adoption of PBS principles and work in advance of these regulatory changes. II. Purpose: The purpose of this informational bulletin is to share with the DDS community the Department s upcoming implementation of Positive Behavioral Supports. The key goal of PBS is an improved quality of life for all individuals and includes teaching positive, pro-social alternative behavior(s) for individual exhibiting challenging behaviors. A physical and social environment that is safe, humane, and responsive to a person s needs and interests is a necessary building block for effective supports. Problems or shortcomings in the living and working environment must be addressed first since effective behavioral support is not likely to occur without an environment that accommodates an individual s needs and preferences (i.e. is functional for the person). Positive behavioral supports emphasizes prevention of problem behavior and when problem behavior exists and must be addressed uses development of positive, pro-social functional alternative behaviors to replace problem behaviors as a key intervention strategy. The ongoing effectiveness of PBS interventions is evaluated using objective data and DDS remains committed to this level of evaluation. DDS remains committed to assuring that individuals it serves will be free from any serious physical and psychological risk of harm and to supporting health and safety at all times. The Department intends to implement Positive Behavioral Supports as the foundation upon which all programs and individual support plans are developed. III. DDS Definition of PBS: Adopted by the Advisory Committee on 10/13 Positive Behavioral Supports is a systematic, person centered approach to understanding the reasons for behavior and applying evidence based practices for prevention, proactive intervention, teaching and responding to behavior, with the goal of achieving meaningful social outcomes, increasing learning and enhancing the quality of life across the lifespan. 1 The current Level III regulations will remain in place. 2
IV. What differentiates the PBS Approach from what we do now? The Department s focus on Positive Behavioral Supports is both a move toward furthering a more holistic way of understanding individuals and their environments and a move away from a focus on behavior management. PBS is an organization wide approach to creating living and learning environments for all the people supported by DDS that is operationalized as a commitment to: a) Improving the quality of life of all individuals supported; b) Promoting and providing individuals with choice and control; c) Teaching skills that will help individuals avoid the burden of challenging behavior; d) Reducing and eliminating challenging behavior; e) Focusing on the role that the environmental context plays in challenging behavior in order to, when possible, address the roots of those behaviors; f) Making sure clinical work is evidence and value based, considers the individual as a whole person, recognizing his/her strengths, weaknesses and needs and avoids coercive interventions; g) Building on existing practices, training and managing staff to work as part of a caring team that supports individuals to achieve happy, healthy lives while pursuing their life goals; h) Emphasizing the treatment integrity of all PBS work; and i) Incorporating a systems approach that includes data based decisions with the goal of improving outcomes for individuals over time. V. Philosophy: Positive Behavioral Supports recognizes that people exhibit challenging behavior because it serves a useful purpose for them in their current situation. People exhibit challenging behavior for many different reasons ranging from poorly arranged contingencies, to irritability related to depression, to frustration related to boredom, to relief from uncomfortable thoughts and feelings arising from a history of trauma. Positive Behavioral Supports focuses on prevention of challenging behavior and only when prevention is not enough is a highly individualized plan developed. The focus of PBS begins with environments that help prevent challenging behaviors. We will ask providers to focus on creating environments and patterns of support that makes the challenging behavior irrelevant, ineffective, or inefficient. Procedures used to insure safety, while necessary and important, should not be misunderstood to substitute for procedures that provide positive behavioral supports. If prevention efforts are insufficient, PBS work proceeds to the delivery of quick Targeted responses to individuals at risk of developing significant challenging behavior. PBSS includes highly individualized Positive Behavior Support Plans (P-PBS) for a few individuals when in depth 3
support is needed. Those plans are based on a thorough understanding of the person including his/her history, physical and mental health issues and the function of the challenging behavior. Once a person is understood and it is known why the challenging behavior occurs, procedures can be developed to prevent the occurrence of the challenging behavior and the teaching and promotion of alternatives to the challenging behavior. The end goal is not just to eliminate the undesirable behavior but also to improve the quality of the individual s life as when relevant skills are learned. VI. Overview of PBS: There are four (4) basic elements of PBS. a) PBS emphasizes operationally defined and valued outcomes for all individuals. b) PBS is based on established behavioral and biomedical sciences that can be applied to address problem behavior. c) PBS emphasizes research-validated practices to achieve goals and outcomes. Data are used to guide the selection of practices to achieve those goals/outcomes. d) PBS gives priority to systems that support the effective and efficient selection and implementation of practices by agencies. 2 VII. Scope: When full implementation occurs, PBS will apply to all providers of services to individuals with intellectual and developmental disabilities who receive funds either directly or indirectly from the Massachusetts Department of Developmental Services. Embedding PBS into the DDS community is a long term effort which will likely occur over a number of years. VIII. Components of DDS Positive Behavioral Supports Framework: The Massachusetts Department of Developmental Services Positive Behavioral Support Framework will emphasize the prevention of problem behavior and improvement of the quality of life for individuals it supports. PBS is evidenced-based, system-focused, function-based, teachingfocused, and culturally responsive. PBS emphasizes a preventive approach. Three tiers of support are identified: Universal, Targeted, and Intensive. a) Universal (primary) interventions which always are available for all individuals. In order to prevent problem behaviors, considerable effort is dedicated to ensuring individuals are in positive, proactive and responsive environments, i.e. ones in which they are less likely to engage in problematic behavior due to lack of access to preferred activities boredom, frustration, lack of an effective communication system or an unrecognized health problem. Problems or shortcomings in the basic environment must be addressed since effective behavioral support is not likely to occur without an environment that meets the needs and desires for the person. b) Targeted (secondary) interventions which are put in place quickly and are for anyone at risk of problem behavior designed and implemented by a Team in consultation with a qualified clinician for an individual who needs additional support beyond universal interventions. Targeted interventions may involve intensive work teaching skills, as well as focusing on reinforcing 2 Rob Horner and George Sugai- Grant from the Office of Special Education, US Department of Education. 4
replacement behavior. The goal of Targeted interventions is to prevent a (potential) problem from becoming a big problem via quick action. And, c) Intensive interventions which are put in place only for those few individuals who need support beyond Universal and Targeted interventions. Intensive interventions are used with individuals with the most complex behaviors who require a well-developed comprehensive Positive Behavioral Support plan; all such plans will require a Functional Behavioral Assessment. A Functional Behavioral Assessment looks beyond the behavior itself for the cause of the behavior (the function). It is the process of gathering and analyzing information about an individual and their behavior in order to determine the purpose or intent of the actions. (See Attachment for Details on Universal, Targeted and Individualized Interventions) IX. Role of Leadership Team in PBS: PBS implementation is team-based. Each provider agency and DDS state-operated program will need to create a Leadership Team to oversee the implementation of PBS. The Leadership team at a minimum should consist of the following types of personnel: a) an individual in an executive leadership position who has the authority to make change, and b) a senior level qualified clinician with experience in developmental disabilities with at least a master s degree and experience in Applied Behavioral Analysis, Special Education, Psychology or a related discipline, and c) family member of an individual receiving service, d) an individual receiving services and d) other personnel from within the agency that represent different functional units such as IT, Division Directors, Clinicians, Human Rights Coordinator etc. The Leadership Team will be charged with the overall implementation of PBS at all levels of the agency. Leadership will need to determine how it will implement the three tiers of support of PBS and how many teams it will need to accomplish these tasks. The Leadership Team meets regularly. The Leadership Team will determine the key agency goals that support PBS. Leadership Team will assess agency readiness. The Leadership Team will specify a set of behaviors that are measurable, distinctive and mutually exclusive and the procedures to be used to enter, summarize, retrieve and display the data. The Leadership Team will develop an implementation plan and a method to communicate among the various components and implementers of PBS. X. Training Consultation and Technical Supports: DDS intends to provide multiple training opportunities and is exploring ways to provide consultation to providers as PBS implementation unfolds. DDS also is developing technical supports in the form of: (a) trainings that will help orient all staff and other interested parties to the key ideas of PBS including on-line materials, and (b) An on-line library of professional articles and chapters of PBS that cover its conceptual and research bases. http://ddslearning.com XI. Developing Positive Behavior Support Plans: DDS will provide guidance about the criteria to be used to categorize current plans shortly. Providers in collaboration with DDS personnel may need to differently categorize individual behavior support plans under this new system. 5
The Department s plan is to provide a standard template for both a functional behavioral assessment and a positive behavioral support plan. DDS will require that a Positive Behavioral Support plan be developed based on the outcome of a functional behavioral assessment. The plan itself should be evidence-based and use data to inform decision-making. DDS will look for plans that have clearly defined goals and outcomes that result in improved quality of life and competent strategies and activities to assist individuals in developing new skills while minimizing or reducing challenging behavior. Providers will have the option of using their own template for both a Functional Behavioral Assessment as well as a Positive Behavioral Support Plan provided that all required elements noted below are met. A. Functional Behavioral Assessment: A Functional Behavioral Assessment looks beyond the behavior itself for the cause of the behavior (the function). It is the process of gathering and analyzing information about an individual s behavior in order to determine the purpose or intent of the actions. It should include not only an assessment of the antecedents and consequences, but also take into consideration the individual s history paying special attention to factors that may have contributed to this behavior. The Functional Behavioral Assessment will include the following information: a. Identifying Information b. General Background Information c. Specific History d. Current Supports e. Functional Behavior Assessment i. Problem Behavior ii. Indirect Assessment Procedures iii. Direct Assessment Procedures iv. Experimental Functional Assessment Procedures v. Strengths Assessment vi. Skill Deficit Contributions vii. Contributing Environmental Factors viii. Safety Concerns ix. Possible Reinforcing Stimuli x. Findings f. Summary and Recommendations (See Attachment for Detail) B. Elements of a Positive Behavior Support Plan: As described above, all plans begin with a Functional Behavioral Assessment (FBA) as a necessary first step in the development of an intervention plan. The Plan will be based on the assessment and includes understanding the strengths, preferences and interests of the individual. The Plan shall consist of the most efficient, fewest, positive, proactive interventions and support strategies possible coupled with reinforcement. Success will be measured by the increase of desired behaviors, a reduction of challenging behaviors and improvements in quality of life. The Positive Behavioral Support Plan will include the following information: a. Identifying information b. Relevant Background Information c. Competing Pathway d. Behaviors to Increase e. Behaviors to Decrease 6
f. Preventative Interventions g. Teaching Procedures h. Consequential Procedures i. Procedures for Measuring Key Behaviors and Evaluating Progress j. Procedures for Training, Supervision, and Maintaining Integrity of Interventions (See Attachment for Detail) C. Proposed Positive Behavioral Support Plan Author Qualifications: The qualified clinician will be fluent in both PBS, ABA and organizational strategies. Any individual given the responsibility to develop a Positive Behavioral Support Plan for an individual will at a minimum meet the following qualifications: a. at least a Master s Degree in a relevant discipline such as Applied Behavioral Analysis, Psychology, or Special Education b. Substantial clinical background in Developmental Disabilities, including a combination of professional experience, class work, formal training, and/or supervision by a licensed or certified professional c. Qualified behavioral clinicians will have ABA competencies but do not need to hold Board Certification as a Behavior Analyst (BCBA) d. Exhibit sound clinical judgment e. Work to continuously expand clinical knowledge and skills about Positive Behavioral Supports. The qualified individual will be able to provide PBS training, coaching, and oversight to staff within the organization. D. Individual Emergency Protocol: In most situations staff trained in an approved DDS standardized Restraint curriculum can manage the behavior of individuals who exhibit severely aggressive or destructive behavior directed at self or others. However, there are some individuals who have unique conditions such as exceptional medical or traumatic issues that preclude the safe use of acceptable procedures. The Department is planning on introducing an Emergency Protocol for these situations. E. Restraints and Holds: In the future DDS intends to eliminate the distinction between restraints and holds. Restraints will not be considered part of a PBS plan and will not constitute treatment. This will be a topic of future communication. XII. Impact of PBS on Other DDS Systems A. Peer Review: DDS intends to revamp its Peer Review process as it moves to implement PBS. This will be a topic of future communications. B. Role of Licensure & Certification: In FY 14 DDS will continue to use the current Licensure and Certification process as it pertains to behavior plans. The Department will revisit this issue again once PBS is operational in FY 15 and may revise its Licensure and Certification tool. 7
C. Human Rights: DDS is currently exploring ways to revamp Human Rights processes to support PBS implementation by simplifying the process of advocacy and focusing on promoting human rights by providing direct support to programs to help individuals realize and exercise personal control in daily life. 8