NADD Bulletin Volume V Number 1 Article 1

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Optimizing Direct-Care Paraprofessionals’ Adherence to Behavioral Support Programs

Matthew N. I. Oliver, Gemma D. Skillman, Department of Psychology, University of South Dakota

Direct-care paraprofessional staff play an integral role in the behavioral support for individuals with developmental disabilities. While the development of behavioral support and treatment plans is often the responsibility of professional staff, paraprofessional direct-care staff are typically responsible for implementing these plans (Aylward, Schloss, Alper, & Green, 1995). Effective implementation of treatment, however, is dependent not only on the ability of professionals to clearly communicate procedures to direct-care staff (Morgan, 1990; Shaddock, Hattie, Edwards, Bramston, & Brummell, 1986), but also on the capability and motivation of paraprofessional staff to implement behavior support plans. Staff adherence to treatment protocol is important because failure to consistently implement behavioral treatments may adversely affect an individual’s mastery of skills necessary for community integration and greater independence (Aylward, Schloss, Alper, & Green, 1995). Consequently, understanding factors that impact staff adherence to treatment protocol is necessary for professionals to design effective behavioral support plans. This article focuses on four areas related to direct-care paraprofessional staff adherence to behavior support plans: staff training, staff stress, staff acceptance of support plans, and staff adherence evaluation strategies.

Direct-care Staff Training

Despite having limited training in behavioral interventions, paraprofessional staff are often expected to monitor consumers’ behaviors and provide corrective environmental contingencies. Unfortunately, because of limited training, direct-care paraprofessionals may overlook opportunities for problems to be prevented before they escalate. Moreover, staff may use ineffective and even dangerous interventions to stop problem behavior (Smalley, Certo, Goetz, 1997). Many clinicians working with direct-care paraprofessionals supporting persons with developmental disabilities have stressed the importance of training direct-care staff to use positive behavioral approaches for challenging behavior (Carr, Robinson, & Palumbo, 1990). Moreover, staff who understand why a particular treatment is likely to be helpful are more apt to consistently implement it. Critical points of positive behavioral approaches include basing treatment on functional assessment, emphasizing antecedent assessment and intervention, developing functionally equivalent alternative behaviors, and measuring quality-of-life gains in addition to behavioral change outcomes. Indeed, a direct-care paraprofessional training program focusing on positive behavioral support strategies was shown to reduce aggressive behavior (Allen, McDonald, Dunn, & Doyle, 1997). In addition to reducing consumers’ aggression, results suggested that positive behavioral support training reduced paraprofessionals’ use of physical restraints (62%), use of emergency medication (86%), staff injuries (75%), and client injuries (72%).

Paraprofessional Staff Stress

Adherence to behavioral support programs can also be hampered by work-related stressors experienced by paraprofessionals. Staff working in an emotionally charged atmosphere frequently express biases and distortions in their interpretations of consumer behavior (Worchel & Cooper, 1983). This can be particularly problematic when staff are responsible for developing behavioral support plans, because prescribed strategies may fail to consider the functionality of consumers’ behavior. That is, staff members’ perceptions of consumer behavior may become reactive and fail to appreciate the behavior’s environmental context (Karan, Harrington, & Broday, 1993). Moreover, frustrated staff have been found to attribute improvements in consumers’ behavior to changes within in the consumers rather than to their own influence (Purcell, Morris, & McConkey, 1999). If staff see their behaviors as irrelevant to consumers’ success, they may be less willing to consistently adhere to behavioral support programs. Therefore, addressing staff stress by using established training methods such as self-instruction training, problem-solving training, relaxation training, and stress-inoculation training (Keyes & Dean, 1988) may optimize staff adherence to positive behavioral support plans.

Staff Acceptance of Behavioral Interventions.

Even when interventions have been carefully designed and based on appropriate functional assessment, there is a wide range of barriers to the implementation of behavioral programs (Hastings & Remington, 1994). Recent attention has been focused on paraprofessional acceptance of behavioral treatments and how this factor influences treatment implementation (e.g., Elliot, 1988; Witt, Martens, & Elliot, 1984). Several factors related to staffs’ perceptions of treatment acceptability have been identified (Elliot, 1988). In general, support strategies considered to be positive (e.g., praise, stimulus control) are seen to be more acceptable than those (e.g., time out, contingent shock) considered to be reductive (Pickering & Morgan, 1985; Tarnowski, Rasnake, Mulick, & Kelly, 1989). Moreover, guided compliance, a major component of overcorrection and hand-over-hand instruction, has been rated as less acceptable than time-out in a number of studies (Miltenberger, Lennox, & Erfanian, 1989; Tarnowski, Rasnake, Mulick, & Kelly, 1989). Treatments requiring less labor and time were rated as more acceptable than those that did not (Witt, Martens, & Elliot, 1984). Furthermore, treatments depicted as having fewer or less problematic side effects were rated more favorably (Kazdin, 1981).

Direct-care paraprofessionals’ understanding of behavioral principles has not been found to be reliably related to their acceptability of different treatment interventions (Miltenberger & Lumley, 1997; Rasnake, Martin, Tarnowski, & Mulick, 1993). Some authors have noted that this suggests that the least-restrictiveness philosophy continues to permeate the thinking and decision-making of direct-care paraprofessional staff working with persons who have developmental disabilities (Kemp, Miltenberger, & Lumley, 1996). This also indicates that the functional approach to assessment and treatment embraced as best practice by behavior analysts (e.g., Iwata, Vollmer, Zarcone, & Rodger, 1993), may not be fully understood or accepted by direct-care paraprofessionals. Nonetheless, this finding is likely influenced by the common notion encouraged by administrators, advocates, and caregivers, that positive is “good” while intrusive is “bad” (Kemp, Miltenberger, & Lumley, 1996). Interestingly, research seems consistent with the recent trends toward limiting or eliminating interventions which are intrusive, restrictive, or aversive (e.g., Donnellan, LaVigna, Negri-Shoultz, & Fassbender, 1988; Sailor & Carr, 1994). Some researchers, however, have suggested that treatment decisions should be based not on the restrictiveness of the procedure, but on the degree to which treatment is functional (Carr, Robinson, & Palumbo, 1990). Nevertheless, if direct-care staff do not agree with an analysis or find an intervention strategy unacceptable, they may reject the intervention or at least adhere to it inconsistently.

Adherence Evaluation Strategies

While initial efforts to improve staff adherence to behavior programs focused on teaching paraprofessionals new skills (Reid & Whitman, 1983), more recent efforts have focused on evaluating staff behaviors in the actual work setting. These strategies have made perhaps the most substantial impact on improving staff adherence to behavioral support plans. Behavioral staff management techniques have been generally categorized into four types: 1) antecedent techniques, including instruction and modeling; 2) contingency management, such as reward and punishment procedures; 3) self-control approaches that involve staff in designing and implementing methods to alter their own behavior; and 4) multi-component approaches (Aylward et al., 1995; Reid & Whitman, 1983).

Antecedent procedures. Antecedent procedures typically include verbal or written instructions, modeling, and role-playing. These strategies are designed to ensure that staff know the duties expected of them and when they should be performed. Studies have demonstrated that, when used alone, these procedures are not generally successful in changing staff behaviors (Panyan & Patterson, 1974; Quilitch, 1975). In fact, some studies have demonstrated that even when staff knew the purpose of an inservice program, their behavior did not necessarily change. For example, Montegar, Reid, Madsen and Ewell (1977) found that the effects of an inservice training program were not maintained in the absence of supervisory feedback.

Contingency management procedures. Contingency management procedures focus on consequences of specific staff behaviors (Suda & Miltenberger, 1993). In general, behavioral support instructions alone have been found to be relatively ineffective in changing staff behavior. However, when a feedback mechanism is employed, staff adherence to behavioral programs is more likely to improve. Oral or written feedback and incentives (e.g., monetary gifts or performance lotteries) have been shown to be successful in changing staff behaviors (Anderson, 1987; Realon, Lewallen, & Wheeler, 1983). Feedback may also be presented individually, posted publicly, or observed from videotapes. When supervisors watched videotaped sessions with direct-care staff providing constructive feedback on target behaviors, staff performance improved (Dowrick & Johns, 1976). Because of the time and resources needed to use feedback effectively (Reid, Parsons, & Green, 1989), restructuring the monitoring system so that feedback is presented intermittently may offer a way to reduce costs and possibly result in staff behavior being more resistant to extinction (Anderson, 1987).

Self-management procedures. While there has not been a great deal of research investigating the effectiveness of staff self-management procedures, the results appear consistently positive. For example, although Doerner, Miltenberger, and Bakkan (1989) found that goal-setting alone, used by staff in a group home setting, did not result in an increase in positive interactions with clients, Burg, Reid, and Lattimore (1979) showed that goal-setting and self-monitoring resulted in a large increase in appropriate staff-client interactions (from 7% during baseline to 54% during the intervention phase). Furthermore, Richman, Riordan, Reiss, Pyles, and Bailey (1988) showed that staff self-monitoring increased engagement levels between staff and clients after in-service presentations had failed to do so. Hence, training programs that use self-recording may be more successful in facilitating direct-care staff adherence to treatment programs for consumers with developmental disabilities than training alone.

Multi-component training procedures. Although the use of individual training components (i.e., antecedent techniques, contingency management, self-control approaches) have been related to positive changes in staff behavior, multi-component training approaches tend to show the strongest and most enduring effects on direct-care paraprofessionals (Anderson, 1987). For example, Richman and colleagues (1988) found that the addition of feedback to self-monitoring procedures further improved the rate of social interaction between staff and consumers. Furthermore, when goal-setting, self-monitoring, self-evaluation, and self-reinforcement procedures were employed by paraprofessional staff in an institution, interactions between staff and children and adolescents with mental retardation increased by 40% (Burgio, Whitman, & Reid, 1983). Doerner and colleagues (1989) replicated these procedures in a community residential setting and showed that positive interactions with clients increased once self-management procedures were employed by staff. Suda and Miltenberger (1993), replicating similar procedures in a vocational setting, found that goal-setting and instructions alone were insufficient to change staff interactions with clients; however, when self-management strategies were implemented, positive staff/consumer interactions increased. However, using feedback and supervisory evaluation brought about the greatest improvement in staff performance.

Pyramidal training, in which the professional trains trainers, who in turn train direct-care staff, has been shown to be a viable method in improving paraprofessionals’ behavioral support performance (Page, Iwata, & Reid, 1982; Shore, Iwata, Vollmer, Lerman, & Zarcone, 1995). For example, brief instructions, even when supplemented with videotaped modeling, may be insufficient to teach complex interactional sequences to direct-care staff (Reid & Whitman, 1983). However, by using competency-based training established from task-analysis, direct staff supervisors were able to provide constructive feedback that resulted in noticeable improvements in both staff members’ and clients’ behavior (Shore et al., 1995). Although supervisor staff training is more labor-intensive than the typical approach to staff instruction, pyramidal training was found to be relatively effective and efficient. While no attempt was made to identify the single most effective components of staff training, it appears that three skills (i.e., implementing client’s program, training others on program implementation, and regularly monitoring the program) are important aspects of training and staff adherence to behavioral support programs (Shore et al., 1995).


Considering the potential impact of staff training, stress, acceptance of programs, and adherence evaluation strategies is crucial to optimize the adherence of paraprofessional staff to behavioral support plans. Professionals would do well to incorporate such considerations into behavioral designs in order to transfer best practices into the hands of the people directly responsible for supporting individuals with developmental disabilities. Because effective long-term adherence monitoring is likely to require multi-component evaluation procedures and increased resources, administrators, clinicians, and positive behavioral support teams need to collaborate to establish the behavioral need priorities and to secure appropriate resources.

While this paper primarily deals with technical considerations of behavioral programming, we cannot overstate the importance of agencies maintaining positive relationships with their direct-care staff. Staff want to be recognized and valued for their efforts. Agencies that frequently reward staff members for quality performance are likely to have higher levels of staff morale and agency affiliation. In contrast, the effectiveness of regular training and feedback is likely to be compromised if staff do not feel considered and do not share in the vision that such measures are necessary components of high-quality care. As agencies utilize effective methods to bolster staff adherence via staff training, professional/paraprofessional collaboration in developing support protocols, and feedback mechanisms, as well as striving to convey their vision of high standards in a personalized and genuine way, adherence to behavioral support plans will be improved, as will the support ultimately rendered to individuals with developmental disabilities.


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Authors’ Note: Portions of this paper were presented at the American Association on Mental Retardation Region VIII 2001 Annual Fall Conference, Des Moines, IA.

For further information:

Matthew Oliver
Department of Psychology,
University of South Dakota
414 East Clark Street
Vermillion, SD 57069