This testimonial discusses the need for PPE when undertaking Applied Behavioral Analysis based care to ensure staff are protected from behaviours that challenge, a huge thank you from Patterns Behavioral Support for their invaluable insight. We are also happy to say that they will be reviewing:
How does Applied Behavior Analysis assist in preventing challenging behaviors?
Applied Behavior Analysis seeks to determine the “function” of challenging behaviors. Typically, the four functions of challenging behavior can be categorized by the acronym S.E.A.T. This acronym stands for sensory, escape, attention and tangible. When a challenging behavior occurs, the behavior can either be strengthened or decreased by various ABA interventions. Prior to developing an intervention, a Board Certified Behavior Analyst (BCBA) or Board Certified Assistant Behavior Analyst (BCaBA) conducts an assessment to determine what potential function(s) serve as reinforcers to the problem behavior. Once the function(s) have been identified and consent for treatment has been obtained, a behavior analytic intervention is introduced to decrease the challenging behavior. It’s important to know that behaviors may be reinforced by a combination of functions at one time. This is called a “synthesized contingency” of reinforcement.
Various behavior analytic interventions seek to change the environment and reinforcement contingencies that are in place which cause challenging behaviors to continue. Oftentimes, this means that ABA does not prevent challenging behaviors, rather our interventions provide alternative replacement behaviors that serve the same function as the challenging behaviors. Challenging behaviors typically arise from a lack of communication or the ability to effectively communicate within an environment.
ABA teaches alternative forms of communication and other prosocial, functional behaviors to reduce challenging behaviors which prevent individuals from interacting or communicating within their environment. While ABA teaches alternative forms of behavior for better communication, it can also teach alternative replacement behaviors that serve the same function. An example of this would be an individual who is in pain and can’t communicate with a loved one. The individual may become aggressive or self-injurious to communicate their pain. An ABA intervention would be to teach the functional replacement behavior of saying “I’m in pain” or to touch a card that signals they need help.
What are your thoughts on challenging behaviors as a way of communicating unmet needs?
For many individuals, challenging behaviors serve as their primary form of communication. Communication can be shaped in ways that are not harmful to self or others. The shaping process can take time and generally may include events of challenging behaviors which may occur more frequently. Although difficult to manage, the increase in challenging behaviors does not typically continue for a long time. Once the individual contacts the reinforcement contingency of additional forms of communication (pointing, ASL, pushing a button on a speech-generating device, touching a picture) the new form of behavior is strengthened. During the process of shaping the new communication response form, challenging behaviors are no longer reinforced while new communication forms are reinforced. This is called differential reinforcement of alternative behaviors (DRA) and uses the principles of reinforcement and extinction. Extinction is the process of no longer providing reinforcement to a previously reinforced behavior.
Have you ever directly experienced challenging behaviors in your role? Have you/a colleague ever been injured as a result?
Yes, several times. I personally have five different scars on my body from six different biting incidents from one individual. I have a scar on my leg that is not only medium to large in size but also very noticeable. There have been other staff members that have been bitten by the same individual and have some form of a scar or permanent marking from the incident. If protective clothing were implemented from the start of the individual getting services, it would have been more likely that the scars that I have from the previous bites could have been reduced or eliminated.
In addition to the biting example, I have experienced a variety of challenging behaviors. In the role of supporting individuals with disabilities, it’s typical to see that many individuals haven’t received intensive forms of intervention to address the function of their challenging behavior(s). Challenging behaviors can range in intensity from mild to severe and may include self-injury, aggression and property destruction. Aggression may take many forms including hair pulling, biting, kicking, scratching, hitting, etc. Staff members who support these individuals require intensive training and protective equipment to thoroughly intervene during the intervention and teaching process.
The field of Applied Behavior Analysis is not well understood by others and BCBAs are often called for consultation when challenging behaviors occur at intensive levels. It’s imperative that replacement behaviors are taught throughout the intervention process. Without teaching functional replacement behaviors, challenging behaviors will continue. The process of reducing challenging behavior is symbiotic with teaching new skills. One can’t occur without the other. Protective clothing is required throughout the process to ensure the safety of the staff and individual.
Do you think staff are adequately protected when performing necessary manual handling of people who are prone to these behaviors?
No. Staff members require better training on how to manage these difficult and emotional situations. Staff can be better supported with the introduction of more training and the assistance of having protective clothing and safety materials. With the introduction of protective clothing, staff and other stakeholders will benefit in the following ways:
- More protective physical support after receiving the proper training on behavior management and de-escalation techniques
- Increased confidence when working with high-risk individuals
- Risk mitigation of damage to the skin and other soft tissue areas of the body
- Risk mitigation of skin infections and/or communicable diseases
- Companies benefit by the reduction of workman’s compensation and liability claims paid to employees
- Individuals will remain in programs that have typically turned away high-risk individuals which will allow them to receive continued intervention and continuity of care.
What is your opinion on protective clothing as a means of increasing confidence when providing care?
For staff who serve individuals with developmental disabilities, there can be many factors that contribute to the stress of the job. One of these factors can be the anticipation of intervening with challenging behaviors. As previously mentioned, challenging behaviors can range from physical aggression towards staff, property, self, and peers, to biting self, staff, and peers, to forms of self injurious behavior. The field of ABA has an extremely high turnover rate. In their 2018 annual report, The Behavioral Health Center of Excellence (BHCOE) published that approximately 50% of direct care staff leave within one year of employment (BHCOE, 2018).
Protective clothing will assist with the management of these behaviors. Having bite proof clothing or other forms of protection can help staff with mitigating the risk of broken skin with bites. Individuals can also benefit from protective clothing by preventing the self-injurious behavior of biting arms, legs, and other parts of the body. Further, having a layer of protection on skin reduces the risk of broken skin which may lead to superficial infections and/or communicable diseases. Bite proof protective clothing can help staff to receive protection from injuries, protect individuals from self injurious behaviors, and to protect peers who may be injured during various forms of challenging behaviors.
In closing, we would like to advocate on behalf of the field of Applied Behavior Analysis to receive more protective clothing to support the individuals that we serve. The field of developmental disabilities has grown at exponential rates over the last decade. With the addition of the increased rates of autism spectrum disorder (ASD) diagnoses, paired with the autism insurance mandates in all 50 states, the need for workers is at an all time precedented high. The more protection that staff have to prevent the risk of injury and to feel more confident with behavior reduction techniques will ultimately produce better individual and staff outcomes to this growing field.
ALLY DUBE - M.S, BCBA, LABA
Licensed & Board Certified Behavior Analyst
Vice President of Clinical Services
Pattern Behavioural Services