Association for Behavior Analysis International

Reinforcement-based interventions that are informed from a functional behavior assessment have been shown to significantly reduce severe destructive behavior in individuals with neurodevelopmental disabilities. These procedures are highly effective and empirically supported; however, additional behavior management strategies, such as restraint and seclusion procedures, may be warranted during emergent situations or when severe destructive behaviors prove resistant to reinforcement-based procedures alone (i.e., programmed as a punishment procedure). In this symposium, DeBrine and colleagues provide a concise review of the Applied Behavior Analysis International best-practice guidelines on the use of restraint and seclusion (2010). Salvatore and colleagues will discuss the use of function-based training to decrease the use of restraint procedures within a hospital setting. Moretti and colleagues review survey results examining behavioral practitioners’ (RBT, BCaBA, BCBA/BCBA-D) experiences with the use of restraint and physical intervention when working with neurodiverse populations. Romani and colleagues review data from an improvement project aimed at reducing staff injuries within a severe behavior program. Lastly, Dr. Alison Betz will provide comments related to best-practice pertaining to the contexts warranting inclusion of punishment, restraint, and/or seclusion practices.

This symposium is targeted at practitioners who specialize in severe destructive behavior disorders and/or neurodevelopmental disabilities within clinical and medical settings. In addition, this presentation is relevant for any RBT, BCaBA, BCBA, or BCBA-D that regularly encounters crisis situations involving restraint, seclusion, and/or physical interventions.

Physicians in hospital settings are treating an increasing number of patients with autism spectrum disorder (ASD) who also engage in severe behavior. Function-based treatments are widely studied and are documented as more effective in producing improved behavioral outcomes than non-function-based treatments. Although the behavioral literature has examined function-based treatment for increasing medical compliance, restraint is commonly used by physicians as a behavior management strategy when severe behavior occurs in hospital settings. Twenty-five physicians and medical trainees from an urban teaching hospital participated in discussions about experiences managing severe behavior in patients with ASD across the lifespan. Thematic analysis of participant transcripts indicated the critical need for physician training in function-based management of severe behavior. Despite moderate knowledge of ASD, participants identified a gap in knowledge specific to behavioral function and practical skills treating patients with ASD who engage in severe behavior, as evidenced by participants attributing severe behavior to internal (e.g., maintaining inner peace) and external (e.g., physical environment) factors and recommending restraint as a management strategy. We will discuss how principles of applied behavior analysis and function-based training may be incorporated into medical curriculum to decrease restraint implementation and promote effective behavior management for neurodiverse patients in hospital settings.

Restraint is often considered a last resort behavior management strategy to manage severe behaviors. The use of restraint is controversial, with research demonstrating that clients who had been restrained report feeling overpowered and helpless, and consider restraint a form of punishment and humiliation (Hawsawi et al., 2020). This study examines behavioral practitioners’ (RBT, BCaBA, BCBA/BCBA-D) experiences with and feelings about the use of restraint and physical interventions in their work with clients with autism. Participants completed a survey with open and closed-ended response on their experiences with physical and mechanical restraint and with physical guidance, including perceived clients’ reactions. Preliminary results with 94 participants indicate that 58.82% had implemented and 84.72% had observed a physical restraint within the past year. Of these participants, 71.88% managed challenging behavior at least weekly and 48.44% daily. A smaller percentage had implemented (27.69%) or observed (33.82%) mechanical restraint. The majority (88.52%) reported adverse responses from their clients to physical restraint, most commonly physical resistance (25%), vocal responses (23%), and emotional responses (20%). Most participants (71.15%) reported regularly implementing physical guidance, with 81.03% experiencing a client that disliked physical guidance. These results suggest the need for alternative behavior management strategies for clients with challenging behavior.

Youth diagnosed with neurodevelopmental disabilities are more likely to engage in aggressive behavior than their typically developing peers. Behavior technicians responsible for the management of these youth are often placed in risky situations that result in personal injury. This presentation will highlight research conducted on technician injury occurring on a psychiatric inpatient unit. To address technician injury, unit leadership supported implementation of a sweeping quality improvement project that affected staff-to-patient ratio, evidence-based staff training procedures on applied behavior analytic assessment/treatment, and use of behavioral personal protective equipment (B-PPE; e.g., Kevlar arm sleeves). The effect of training and addition of B-PPE resulted in a decrease in injuries reportable to the Occupational Health and Safety Administration from 6.6 per 1,000 patient days to 0.4 per 1,000 patient days. During a retrospective analysis of these data, we compared variables including technician-to-patient ratio and use of restraint and/or seclusion to technician injuries occurring from 2016 – 2018. Results showed significant relations between use of restraint/seclusion and injury and not significant relations between staff-to-patient ratio and injury. These data will be used to discuss both ongoing evaluation of and intervention for technician injury within severe behavior programs.