3.16 – Behavior Support Strategies and Plans

Hierarchy of Interventions

The development of behavioral support strategies following a thorough assessment of an individual’s needs may involve a number of interventions. The primary focus of behavior support strategies is the proactive creation of supportive environments that enhance an individual’s quality of life by understanding and respecting their needs and expanding opportunities for them to communicate and exercise choice and control through identification and implementation of positive measures. These strategies should encourage positive skills and proactive strategies chosen to promote growth and development while minimizing the health and safety risks of maladaptive behaviors. The following areas outline the range of behavioral support strategies as they increase from low risk/low restrictiveness to high risk/aversive.

Development of Positive Behaviors

A key aim of the Behavior Support Plan (BSP) is to help the individual develop positive behaviors to use in replacement of the undesirable behaviors that the plan is trying to decrease. If it is difficult to figure out what positive behaviors you wish to increase then consider revisiting your functional assessment and/or conducting a motivational assessment. These assessments should help identify the potential driving forces for the undesirable behaviors. Once we know the motivating forces that information can be useful in finding behaviors that help the individual expand their behavioral repertoire and develop more adaptive behaviors. Although, strategies will have much information about the reactive pptions to utilize when faced with undesirable behaviors the most important part of the plan will be creating positive opportunities for the individual to develop and learn more effective ways of coping with their environment and learning new behaviors that can achieve the same motivational ends.

Many of the positive skill/behavior strategies target one of the following three goals:

1. Reinforce and teach alternative behaviors that serve the same function or meet the same need as the target behavior.
2. Assisting the individual in altering the problem situation by learning new interpersonal or social skills.
3. Using teaching opportunities to model and teach the individual how to cope with difficult and possibly avoidable situations.

General Intervention Strategies/Behavior Support Strategies:

General intervention strategies are an essential component of a positive culture in that they are a primary means of supporting positive growth and development. General intervention strategies have a positive influence on the experiences of an individual by addressing lifestyle and ecological factors as well as social relationships which relate to otherwise detrimental behaviors. These strategies may, as needed, be implemented in a proactive or reactive manner.

General intervention strategies are instructional or preventative procedures, which may be used to prevent, increase, decrease, generalize and/or maintain behavior and that involve minimal risk. When these strategies are employed, formal oversight by the behavior support and human rights committees are usually not required. However, if there are indications that a person is adversely affected by an intervention or there is a concern about it, then further assessment may be indicated followed by the appropriate level of committee review. Proactive strategies are used non-contingently to address target behaviors.

Environmental Interventions

Modifying the physical environment to foster learning and avoid provoking maladaptive behavior. Examples:

• Assigning a seat where the individual faces a view with relatively few distractions but has freedom to turn around to gain attention or observe
• Errorless Learning – setting up the situation so that no or few error responses occur o Giving all the necessary cues, prompts, instructions, etc. that are necessary to get the target or desired behavior to occur o Intercepting inappropriate behavior.
• Minimizing disruptions, distractions and noise, including offering commercially available sound mufflers for individuals whom are or may be agitated by noise.
• Minimizing distractions. This could include the use of the following provided that implementation is non-contingent, the individual does not resist its use, and implementation is never used as punishment for undesirable behavior : study carrels
• Proactive General Intervention Strategies including room dividers for individuals with required assigned seating
• Providing adequate play or leisure materials and activities
• Providing adequate adaptive equipment
• Providing furniture which fits the individual
• Seating two individuals apart who distract each other
• Setting up the environment or occasion for the specific response for which you are looking.
• It is appropriate for staff to provide additional assistance when needed on and off vehicles to assist with safety.  This includes allowing individual to hold onto staff’s hands or arms to provide extra support.

Schedule/Routine/Activities

Modifying routines and schedules to prevent or minimize undesirable behaviors and to increase desirable behaviors or the situations that provoke them. Examples:

• Arranging for adequate gross motor outlets
• Alternating simple and complex activities
• Meeting individual’s basic needs (including the need for varied and interesting activities, opportunities for exercise, “breaks” etc.)
• “Orchestrating” interesting experiences
•  Positive Behavioral Contract – A program in which an agreement or contract is made between the person who wishes change and the person whose behavior is to be changed. The contract specifies the relationship between behavior and the consequences and includes specified goals and rewards for appropriate behavior.
• Providing choices
• Providing developmentally appropriate activities and expectations
• Varying body position by scheduling a standing activity, then a seated activity, then a gross motor activity

Social/Interpersonal

Modifying the style and the way that one interacts with the individual to prevent or minimize undesirable behaviors and to increase desirable or adaptive alternative behaviors. Examples:

• Consistent and calm intervention with a caring attitude
• Developing a positive courteous and supportive atmosphere
• Developing good rapport (for example, developing a good first impression, greeting the individual with a smile, and being sensitive to what is being communicated)
• Distraction/redirection – the individual is directed to a more appropriate task or area using prompts.
• Graduated guidance, including physical prompts which do not involve the use of force and which may help the individual understand what you want. Also known as hand-over-hand or physical guidance.
• Holding an individual’s hand during transportation.
• Modeling appropriate behavior, role playing, rehearsal techniques – a procedure where the individual observes a demonstration of the desired behavior and then matches the behavior.
• Proximity control – A process in which a staff member moves closer to an individual whose behavior is problematic or becoming so. Proximity can also be achieved by having the individual bring something to the staff member.
• Relaxation or calming techniques. For instance, taking an individual who is agitated for a walk (verbal or gestural indication that a particular behavior which has just occurred is undesirable).
• Self-management techniques – Self-management includes any of a variety of activities designed to encourage the individual to participate in reflecting upon, monitoring, regulating, and providing feedback on their own behavior.

Positive reinforcement and other principles of learning

Applying the principles of learning to reduce undesirable behaviors and to increase desirable behaviors. Examples:

• Schedules of reinforcement – using a positive consequence to increase a behavior (edible, activity/privilege, sensory, social, tangible).
• DRO (differential reinforcement of other behavior) – Delivering reinforcement when the target behavior is not emitted for a specified period of time. Reinforcement is contingent upon the nonoccurrence of a behavior. Behaviors other than the target behaviors are specifically reinforced.
• DRI (differential reinforcement of incompatible behavior) – A procedure in which reinforcement is carefully arranged so it only follows one or more behaviors chosen because they are fully or partially incompatible with engaging in a behavior judged to be inappropriate and, therefore, targeted for reduction.
• Behavior Chaining (Forward/Backward) – A procedure in which reinforcement is initially given following the first step in the chain and is subsequently shifted to follow the first step plus successively longer portions of the chain (forward), or a procedure in which reinforcement is initially given following the final step in the chain and is subsequently shifted to follow the last two steps, the last three steps, and so on until the entire chain is required for reinforcement (backward).
• Extinction procedures – A procedure in which the reinforcer that has been sustaining or increasing an undesirable behavior is withheld. RBSC approval is recommended for extinction procedures when applied to behaviors injurious to self or others. o Fading – The gradual removal of prompts, reinforcement. The goal is to have the individual do the task independently.
• Sensory extinction (excludes anything an individual would wear).
• Shaping – In this procedure a new behavior is developed by immediately reinforcing successive approximations to the desired behavior in a systematic way. Successive approximations are responses that increasingly resemble the desired behavior.
• Token Economy – A system in which token reinforcers (symbolic objects exchangeable for a reinforcer of value to the individual) are earned. Note The use of a consumer’s own funds for reinforcement of desirable behavior is prohibited. It is not appropriate for an individual to re-earn something that is already theirs.

Reactive interventions

Contingent responses to maladaptive behaviors that involve minimal risk to the individual. Examples:

• Voluntary Change of Environment
• One-on-one supervision
• Response interruption, including Blocking, Brief Hands Down (no risk of physical harm; brief duration of 10 seconds or less; lack of clear physical force; no evidence of struggle)
• Simple Self-Correction – In this procedure, an individual is required to repair any damage that they did to their environment. This should not require the repair or cleaning of anything that the individual did not disrupt.  Also physical prompts should only be to assist with the task if necessary, not to overcome resistance. This does not include financial restitution.

Restrictive Interventions

While maintaining an utmost respect for the promotion of self-determination and community inclusion, behavioral strategies are often utilized to insure the welfare of individuals by ensuring the availability of appropriate choices and utilizing necessary means to limit the potential risks of known behavioral difficulties. Restrictive interventions are used as a last resort, which include limiting an individual’s access to typical activities, possessions, experiences, or freedoms for the purposes of either preventing harm or minimizing the risks associated with a known or current behavior.

Proactive/Preventative Restrictions

Procedures utilized non-contingently to minimize or prevent risks to health and safety due to a known history of behavioral or mental health problems which represent a threat to health and safety. Such interventions may either be part of the individual’s IPP or BSP. These restrictions require review by the Human Rights Committee.

Contingent Restrictions

Specific implementation of restrictive procedures (i.e. loss of privilege) which are implemented only following display of target behavior or specified criteria. These types of restrictions are part of a formal behavior support plan and require documentation of implementation as well as review by Behavior Support Committee and Human Rights Committee. Note: When determining if an intervention represents a restriction of an individual’s rights, the abilities and needs of the individual must be considered. Individuals with extensive or pervasive support needs may require levels of supervision and/or environmental supports that, when applied to a person with more limited needs, may appear restrictive. However, if implemented in response to the individual’s lack of developed safety skills, such interventions may not constitute a restriction. Example: Securing of an individual’s medications would not be considered a restriction for an individual who has been assessed as unable to safely self-medicate or manage his or her prescribed medications Example: An individual with pervasive support needs may not be appropriate to receive unsupervised alone time in the community as he may not be able to anticipate and respond to unanticipated safety risks. However, should such strategies be applied to an individual due to more volitional behavioral choices, then such strategies should be recognized as restrictions and reviewed as appropriate.

The following list (while not inclusive) identifies those procedures that constitute a restriction:

• Alone time restrictions
• Cameras in the home
• Cigarette restrictions
• Dietary restrictions
• Level Systems which delay or withhold the individual’s access to preferred or routine items and activities contingent upon behavior
• Locked doors/windows; door/window chimes
• Access to money restrictions
• Motion sensors
• Phone access restrictions
• Restricting access to community
• Restricted access to parts of home/items in home (sharp knives or objects, etc)
• Restricting access to types/listening time/volume of music
• Restricting family visits
• Searches of personal property, space, or person
• TV watching limitations/restrictions
• Non-contingent wearing of protective clothing that restricts access (but not fine/gross/functional motor abilities)  In most cases, such cases of restrictive clothing will involve individuals with significant cognitive disabilities in situations where there are habitual, high frequency behavioral concerns that are predominantly motivated by sensory factors rather than those that are clearly willful in nature.

Aversive Intervention Strategies

It is recognized that there is, at times, a need for interventions which have the potential to be experienced as undesirable or aversive by an individual. Such needs arise when the health and safety of individuals are at risk. The emphasis on creating a positive culture for individuals requires that such interventions are developed only in response to serious risks to well-being and after a lack of success with a variety of positive and less restrictive interventions. Note: Aversive interventions are never to be used for retaliation, staff convenience, or as a substitute for active treatment.

The following list (while not inclusive) identifies those procedures that constitute an aversive intervention:

• Chemical Restraint
• Involuntary Change of Environment
• Manual Restraint (physical crisis intervention)
• Mechanical Restraint
• Monetary Restitution
• Response Cost – involves the loss of previously earned reinforcers following a target behavior.
• Suspension (from work or money making activities due to behavior)
• Emerging Methods Note “Emerging methods” refers to new methods of restraint or seclusion that create possible health and safety risks for the individual, including methods or technology that were not developed prior to the development of the Behavior Support Rule (OAC 5123:2-1-02(J). Such interventions require prior approval from the director of DODD.

The following sections provide critical information, definitions, and implementation criteria for the use of specific aversive interventions as required in the State of Ohio Behavior Support Rule.

Change of Environment

The individual loses access to reinforcement by virtue of leaving, or being removed from, the area/activity. Change of Environment can be considered either a voluntary/nonaversive (self initiated or posed clearly as a voluntary option by staff) or involuntary/aversive (through a staff directive or actual use of physical redirection) intervention.

• Voluntary Change of Environment: The use of Voluntary Change of Environment indicates that the individual themselves initiated the act of removing themselves from the area or were given a clearly voluntary option by the staff to leave the area. There should be no aversive implications, however subtle, as it relates to the individual’s perception and experience of the change of environment intervention. Voluntary Change of Environment is not considered an aversive or restrictive intervention.
  • Example: After a housemate steals her cookie from the dinner table, Susan becomes agitated and attempts to hit the housemate. Verbal redirection is not successful and despite separating the individuals, Susan remains upset and physically aggressive towards staff. As Susan has learned relaxation skills in previous counseling sessions, staff remind her that she can use these skills to calm and that she can choose to go to her bedroom until she feels better and desires to return to the living room. Susan agrees and spends the next 15 minutes alone in her bedroom.
• Involuntary Change of Environment indicates that the individual is directed by staff to leave the area either by verbal demands and/or physical intervention. Involuntary Change of Environment is presumed to be aversive to the individual and thus requires appropriate oversight and review by the RBSC and HRC.

Change of Environment Restraint

This means restricting the free movement of, normal functioning of, or normal access to a portion or portions of an individual’s limbs, head, or body through manual or mechanical means as a part of a systematic, planned behavioral intervention.

Behavioral Restraints

These are used primarily for the reduction or elimination of a dangerous behavior and are never to be used for the convenience of staff or as a substitute for positive programming. They are to be used in a way that will not cause physical injury to the individual and result in the least possible discomfort. Such use must be approved by an interdisciplinary team that includes medical staff and, as appropriate, a physical and/or occupational therapist.

Guidelines for Use of Restraint:

• Restraint should be used only as a last resort in a systematic, planned, and positively focused plan
• Restraint shall be used only when clearly necessary to protect health and safety.
• Restraint may be used as an emergency procedure, but MUI guidelines must be followed. If a restraint occurs on a regular basis, implementing a behavior support plan incorporating those techniques should be considered.
• Restraint should only be used with behaviors that are destructive to self or others, and only when all other conditions listed above are met.
• An OT/PT assessment may be required as part of the development and approval process for plans incorporating manual and mechanical restraints.
• Use of restraint shall be discontinued if it results in harm or injury to the individual or does not achieve the desired results as defined in the behavior support plan.

Types of Restraint:

Manual behavioral restraint means physically holding an individual to inhibit control or limit the movement or normal function of any portion of a person’s body.

Open Door trains all employees during orientation and refresher training annually on “Responding to a person in Crisis” training module.  This course provides staff training on Non-violent intervention techniques that may only be used as a last resort after all verbal means of managing the situation have been exhausted, and there is no other way to protect the individual and others from injury and/or to prevent major property destruction. Each plan must clearly outline the technique for staff intervention specifically.

Examples of situations which may necessitate physical interventions include the following:

• Refusing to leave a building during a fire drill.
• Lying down in the street.
• Blocking a fire exit during a fire drill.
• Sitting or lying on the floor or sidewalk in a place of high traffic or during a period of high traffic
• Attempting to strike someone in a manner that could cause an injury.
• Severe self-injurious behavior presenting significant risk of harm to the individual.
• Moving an individual away from a dangerous violent individual.
• Moving an individual away from an immediately dangerous situation (for example, individual attempting to put something in an electric socket or biting an electrical cord that is plugged in).

NOTE: The use of restraint is not appropriately used as an intervention for property destruction where there is no risk to health and safety of the individual or others.

Mechanical Restraints

Mechanical restraint means those devices used to inhibit, control, or limit the movement or normal function of any portion of a person’s body applied for the purposes of behavior support, excluding the following: mechanical supports, medical restraints, and seatbelts on buses, cars, and cabs.

Mechanical restraints are most typically restraints that the individual cannot remove easily. Mechanical restraints may include easily removable restraints that the individual is not permitted to remove, or which are put back on upon their removal. Restraints are designed and applied with concern for good body alignment and comfort of the individual. All use of mechanical restraints should be utilized keeping the individual’s comfort and cooperation in mind, and should the individual react negatively, all steps should be taken to minimize or eliminate this reaction. The interdisciplinary team should be notified of these situations and meet as needed.

Mechanical restraints may include:

• easily removable wrist bands applied to prevent self-biting and reapplied when the individual takes them off
• harnesses/vests used on buses
• helmets that are tied or affixed in such a manner that removal cannot be easily accomplished by the individual
• a jump suit used reactively for situational control of a low-frequency behavior
• soft ties
• tie jackets
• use of a splint to prevent self-injurious behavior or self-stimulation while facilitating movement in some way
• use of a Velcro strap to prevent an ambulatory individual from getting out of his seat or to prevent an individual who is non-ambulatory from willfully trying to get out of his wheelchair
• locking of a wheelchair, or disabling a power wheelchair, to prevent willful behavior that endangers an individual  

NOTE: If there is a physician’s order for the use of a mechanical device, its purpose must be clarified. Use of a device for medical/therapeutic purposes does not require the development of a behavior support plan.

Devices intended to prevent an individual from engaging in a known harmful behavior must be incorporated into a BSP and reviewed by BSC and HRC. Exception: Use of car seats, booster seats, vests, or seat belts that are necessary for the safety of individuals because of their size.

Medical or Therapeutic Restraint

Medical or therapeutic restraint is a type of restraint the involves using items or measures to inhibit, control or limit the movement or normal function of any portion of an individual’s body to permit medical treatment, promote healing, or prevent an infection in order to protect the individual from injuring himself/herself.

Medical restraints are not considered mechanical restraints. In general, medical restraints are those restraints used to promote healing or prevent injury in individuals who do not have an ongoing behavior problem as the source of the medical problem (for example, individual who must wear a helmet while walking or seated due to seizures). Use of medical restraints must be determined and monitored by the interdisciplinary team with nurse or physician consultation.

Chemical Restraint

Chemical restraints are subject to oversight per the Ohio Department of Developmental Disabilities (DODD) and as indicated in the Ohio Administrative Code 5123:2-1-02(J). As with mechanical and manual restraints, they require review and approval by the behavior support and human rights committee prior to implementation, and notification to DODD within five working days of the approval, and all other requirements associated with the use of aversive procedures.

The Ohio Administrative Code 5123:2-06 (C)1 means the use of medication in accordance with scheduled dosing or pro re nata (“PRN” or as needed) for the purpose of causing a general or non-specific blunt suppression of behavior (ie: effect of medication results in noticeable difference in individual’s ability to complete activities of daily living) or for the purpose of treating sexually offending behavior. A behavior support strategy may include chemical restraint ONLY when an individual engages in a precisely-defined pattern of behavior that is very likely to result in risk of harm.

“Chemical restraint” does NOT include the following:

• Medications prescribed for the treatment of a diagnosed disorder as found in the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM);
• Medications prescribed for the treatment of a seizure disorder. In our experience, it is necessary to have additional guidelines beyond this definition to determine if a given prescription for psychotropic medication constitutes a chemical restraint. For purposes of making this determination for county board funded situations, the following criteria apply: Conditions for which a prescription will NOT be classified as a Chemical Restraint (all must be present)
• The individual is diagnosed with an illness or condition per a current version of the DSM or ICD.
• Per the prescribing physician, the medication is prescribed to address symptoms or behaviors associated with the diagnosis or condition.
• The medication is taken at the dosages specified by the physician Medical/ Therapeutic Restraint Chemical Restraint
• There is no evidence of over-medication as evidenced by an interference with the person’s ability to participate in services or an observable generalized reduction in alertness or level of consciousness, nor is there an over reliance on the medication as evidenced by high frequency use (as determined by the physician). • Psychosocial and environmental supports are in place.  These include an emphasis on both prevention of the symptom, as well as non-pharmacological support during symptom expression

PRN Medication

Because of the potential for misuse, questions pertaining to the classification of PRN medications as chemical restraint receive additional scrutiny. In general, the following guidelines should be noted in regards to psychotropic PRN use:

• Referral for a Psychotropic PRN Review should be made to the physician
• Orders for PRN psychotropic medication that clearly specify that the medication is to be given only at the request of the consumer will not be considered a chemical restraint.  
• Orders for PRN psychotropic medication prescribed for addressing anxiety or related symptoms prior to or during medical appointments will not be classified as chemical restraints

For all other psychotropic PRN orders, the order will NOT be classified as a chemical restraint only if each of the following criteria in addition to those given above are met:

• There are clear instructions from the physician as to the conditions under which the PRN is offered to the consumer. These instructions should describe the symptoms and the duration for which they should be present prior to administration of the PRN.
• There is no evidence that the medication is being used for staff convenience, to compensate for poor staff training, or as an alternative to sound psychosocial planning and supports.
• Consistent with medication administration requirements, each administration of the PRN is documented and there is a procedure in place for documented supervisory review of the PRN use (at least once per month).

Many of these same standards may apply even when a psychotropic medication is used that does not employ chemical restraints:

• There must be evidence that a Registered Nurse or other appropriately qualified health care professional has reviewed the use of the chemical restraint, including possible adverse side effects.
• There must be documentation of ongoing communication between the prescribing physician and a member of the person’s team.
• There should be a description of the type of data that will be used to evaluate the need for chemical restraint. In practice, this will often involve some measure of the frequency and/or intensity of the target behaviors for the medication. The target behaviors should be identified via collaboration with the BSC/HRC.

Guardian/individual involvement

A strategy that contains a chemical restraint, manual restraint, or time out must specify how and when the guardian wishes to be notified of the use of restraint. The provider must maintain a record of Restrictive Measures and share the record with individual and guardian whenever the strategy is being reviewed or reconsidered. The individual or guardian may seek recommendations. The individual or guardian is to be notified 72 hours in advance of the HRC meeting and has the right to present information to HRC. An individual or guardian may seek reconsideration of HRC rejection of a restricted measure by submitting a rationale for reconsideration within 14 days of the decision. IF dissatisfied with behavior support strategy, the individual or guardian may appeal to the specially constituted committee if a resident of ICF or may seek administrative resolution through the county board.

Prohibited Actions/Interventions

Prohibited Interventions or actions that are potentially harmful to an individual’s health or safety, mental and emotional well-being, or personal dignity and self-esteem are expressly prohibited by Open Door.  Such actions include, but are not limited to, the following:

• Any physical abuse of an individual such as striking, spitting on, scratching, shoving, paddling, spanking, shaking, squeezing, pinching, and corporal punishment. Any abusive action to inflict pain or the intent to cause harm.
• Any psychological, verbal, or gestural abuse such as threatening, ridiculing, or using abusive or demeaning language that causes the individual to feel devalued. Includes swearing or yelling, although in an emergency yelling may be used to obtain an individual’s attention to immediately stop the individual from injuring himself or another, or from being injured. This includes implying threat via non-verbal communications such as physical proximity, glaring, or verbal tone is prohibited.
• Any sexual interaction with an individual.
• Allowing an individual to discipline another individual.
• Total elimination of room illumination.
• Subjecting the individual to damaging or painful sound, including excessive music volume
• Squirting an individual with substances, including room temperature water mist, as a consequence for a behavior.
• Aversive tickling
• Loss of meal or routinely scheduled snack (NOTE: denial of snacks or beverages is permissible for an individual with diagnoses of primary polydipsia or a compulsive eating disorder such as Prader-Willi Syndrome when denial is based on specific medical treatment of diagnosed condition and approved by HRC).
• Use of time out rooms
• Medication for behavior control, unless it is prescribed by and under the supervision of a licensed physician who is involved in the interdisciplinary planning process.
• The use of behavioral restraints (manual, mechanical, or chemical) when not in compliance with CBDD’s Behavior Support Procedures Manual (includes fastening an individual in a wheelchair with a seatbelt because they won’t stay in the wheelchair or guiding an individual by placing your hand around or at the neck area in the absence of written monitored programs).
• The use of Prone Restraint is banned by the Department of Ohio Developmental Disabilities as of November 5, 2008. Prone restraint is defined by DODD as a method of aversive behavior intervention where an individual’s face and or frontal part of his body is placed in a downward position touching any surface. Prone restraints are not to be written into Behavior Support Plans that may or may not be components of any person’s Individual Services Plan. Prone restraints are not to be utilized at any point in time, including as a behavioral intervention in any crisis situation.
• Electroconvulsive therapy prescribed by a physician to treat a diagnosed medical condition and administered by a physician or a credential advanced practice registered nurse is permissible.
• Any other aversive procedure that qualifies according to the introduction of this section.

Informed Consent

The State of Ohio Behavior Support Rule requires that the person or the guardian must provide informed consent prior to the implementation of a behavior support plan containing aversive or restrictive measures. These rules also require that informed consent must be updated on an annual basis, if the same behavior support plan is still being implemented.

When a behavior support plan containing aversive measures is proposed for a person aged 18 or above and that person does not have a guardian, the informed consent assessment should be administered.

Annual Update of Informed Consent;

• If a person has been determined to be incapable of providing informed consent during a previous assessment of the capacity to consent to aversive behavioral interventions, the assessment does not need to be repeated as it will generally be assumed that the incapacity persists. Rather, guardianship should have been pursued or the aversive should have been discontinued.
• If a person was determined to be capable of providing informed consent during a previous assessment, the assessment does not need to be updated unless: a. The behavior plan has changed significantly, meaning that a new aversive has been added, OR b. The person’s condition has changed or is suspected to have changed, so that there is a concern that the person may no longer be competent to provide consent.

In addition, several other considerations apply:

• Any member of IPP team may request a re-assessment of the person’s ability to provide informed consent if there is a concern or a need
• Disclosure of the nature of the procedure, risks, benefits, etc. should be provided on an annual basis to all persons (or guardians) receiving aversive behavioral interventions on an annual basis, or more often, if procedures change significantly during the course of the year.

Levels of Review

Person Centered plans (OISPs) may require levels of review beyond individual consent when they contain restrictions to an individual’s rights or aversive interventions.

• The following strategies may be incorporated into the consumer’s Individual Plan (OISP)
  • Rights Restrictions not related to behavioral supports: These may be restrictions imposed by external factors such as the courts, medical prescriptions, or factors of the environment. Rights restrictions require HRC review and approval.
  • Behavioral Guidelines/Support Strategies: Intended to promote the maintenance or development of positive behavior. These are often considered preventative in nature.  Guidelines are not considered to be treatment and do not require documentation of specific behavioral incidents, responses to strategies, or specific monitoring of the procedures. Specialized training is not required, but Open Door includes this training during individual specific training with employees.
  • Person-Centered Behavior Support Strategies are intended to both promote the development of positive behavior (skill development) and reduce the frequency, intensity, or duration of maladaptive behaviors. They may include positive, restrictive, and aversive interventions. Behavior Support Strategies are treatments and prescribe specific responses to negative or maladaptive behavior; they are intended to result in a measurable impact on the individual’s behavior. Behavior strategies require data collection procedures to assess the impact of the intervention on the frequency/intensity/duration of the behaviors and the frequency of the implementation of the interventions. Strategies which include the use of proactive strategies, contingent restrictions (such as response cost), and aversive interventions require individual/guardian, IPP team, behavior support committee, and human rights committee approval. 
  • All aversive measures must be reported to DODD through RMN report within 5 days after HRC approval and before implementing the plan.
  • Behavior Support Strategies may be reviewed every 90 days and should consider changes in severity of behavior, new skills developed by individual, frequency of behavior, and reports from natural supports and staff regarding their well-being
  • When Manual Restraints are used in past 90 days, the review should include perspectives from staff and individual involved in the use of the manual restraint regarding why it occurred, and what could be done differently to prevent from using in future.
  • Analysis of the aggregate strategies must be compiled and analyzed annually by March 15th including number of strategies by type of restrictive measures reviewed, approved, rejected, implemented, and discontinued and reason for their discontinuation by ICF and county boards. The patterns and trends regarding restrictive measures should be used to determine ways to enhance risk reductions efforts and outcomes to reduce frequency of these measures.

Last Revised: 9/30/2022