John Pokrzywinski, M.A. & Richard Powell, Ph.D.
A great deal of time and money is expended each year for services to treat challenging behaviors of individuals who have developmental disabilities. These behaviors include aggression, self-injury, pica, property destruction, polydipsia, rumination, extreme noncompliance to social and instructional requests, and others. Even if behavior support plans may be technically sound and well-designed, they may be poorly implemented, not adhered to over time, or simply filed away without ever being used (Albin, Lucyshyn, Horner, & Flannery, 1996).
There is a growing body of literature regarding the proficient implementation of and adherence to behavior support plans (Albin et al., 1996; Burgio, Whitman & Reid, 1983; Everson & Reid, 1999; Oliver & Skillman, 2002; Reid, 1998; Reid & Parsons, 1995b; Reid & Parsons, 2002; Sprague, Flannery, O'Neill, & Baker, 1997). In fact, an entire issue of the Journal of Organizational Behavior Management was dedicated to the role of organizational behavior management in developmental disability services. These articles were co-published simultaneously in book form (Reid, 1998).
The best developed behavior support plans will not be successful if they are not implemented proficiently and in a consistent manner. Sprague, Flannery, O'Neill, and Baker (1997) stress the importance of reviewing and observing implementation. Regular observations and constructive feedback should improve the adherence to behavior support plan procedures and assist in the identification of the need for additional training, environmental changes, re-assigning staff, or even disciplinary action, if necessary. Table 1 contains some common problems associated with behavior support plan adherence.
Few plans utilize a systems-level analysis of resources and commitments prior to plan implementation. Frequently, such issues are only addressed after a plan is implemented and it becomes apparent that either implementation or adherence is inadequate or the plan is not effective in producing any positive change in behavior. The purpose of this brief review is to identify and discuss the major issues confronting adherence to behavior support plans, given they are technically sound and potentially effective.
Contextual Fit and Effective Behavior Support Plans
Freeman, Baker, Horner, Smith, Britten, and McCart (2002) suggest that behavior support plan effectiveness is dependent on technical soundness and contextual soundness. A systems-level assessment provides the team with important information needed to ensure contextual fit (Freeman et al., 2002). Contextual fit refers to the congruence, or compatibility, that exists between specific features and components of a behavior support or support plan and a variety of relevant variables relating to the individuals, their environments, and their support staff (Albin et al., 1996). When developing a behavior support plan, it is important to pay attention to variables that might increase or decrease the contextual fit between the plan and the implementation team. Albin et al. (1996) identify three general classes for these variables. They include: (a) characteristics of the person for whom the plan is designed, (b) variables related to the people who implement the plan, and (c) features of the environments and systems within which the plan will be implemented. These are the basis for the following discussion. The organization of this discussion and some of the accompanying tables are adapted from Freeman et al. (2002).
Developing Effective Behavior Support Plans
There is a wealth of literature documenting advances in the design of behavioral procedures to successfully treat challenging behaviors. The four major components for developing positive behavior support plans, as identified by Freeman et al. (2002), are contained in Table 2.
Functional Behavior Assessment
Central to the development of effective behavior support plans is the functional behavioral assessment (FBA). The goal of functional behavior assessment is to develop an intervention specific for that function and the individual, and to replace the challenging behavior(s) with positive behaviors that results in similar reinforcement (O'Neill, Horner, Albin, Sprague, Storey, & Newton, 1997). Table 3 is a simplified explanation of FBA provided by Repp (1999).
FBA identifies the function, or functions, that different challenging behaviors serve for the individual in question. More simply put, why is the individual performing challenging behaviors? By identifying these functions, the behavior support plan can be designed and implemented to teach, or increase, positive behaviors that replace the challenging behaviors (Freeman et al., 2002; Iwata, Vollmer, Zarcone & Rodger, 1993). In addition to identifying the functions of a challenging behavior, a functional assessment can aid in the identification of motivational factors (Horner, Day, & Day, 1997; Iwata, Smith, & Michael, 2000; Vollmer & Iwata, 1991) and environmental variables that might interact with the challenging behavior (McCord, Iwata, Galensky, Ellingson, & Thomson, 2001).
Functional assessments can also identify antecedent conditions that can be modified to produce changes in the challenging behavior (Asmus, Wacker, Harding, Berg, Derby, & Kocis, 1999; Luiselli & Cameron, 1998; Mueller, Wilczynski, Moore, Fusilier & Trahant, 2001; Ringdahl & Sellers, 2000; Van Camp, Lerman, Kelley, Roane, Contrucci, & Vorndran, 2000). A good functional analysis should reduce the reliance on procedures such as planned ignoring, redirection, or non-contingent reinforcement, which do not teach new behaviors.
Designing Effective Behavior Support Plans
It is not the intent of this paper to discuss effective behavior support plan design in detail. Please refer to Bambara and Knoster (1998), Carr and Wilder (1998), Demchak and Bossert (1996), and Horner, Sugai, Todd, and Lewis-Palmer (2000) for more detailed information.
In our own practice, we have emphasized the need to utilize functional replacement behaviors, especially functional communication training (FCT) (Carr & Durand, 1985; Doss & Reichle, 1989; Reichle, 1993; Reichle, Davis, Freeman & Horner, 1999; Reichle & Johnston, 1993). We discuss the use FCT in promoting mental wellness at length in Powell & Pokrzywinski (2003).
We also advocate using three to four replacement behaviors for each challenging behavior. Many challenging behaviors may serve multiple functions. Additionally, the above mentioned ratio helps increase positive interactions compared to the rate of corrective interventions. We also feel that no restrictive interventions, including psychotropic medications, should be included unless there are provisions for the systematic fading of those interventions (Pokrzywinski, 2001).
Behavior Support Plan Implementation
The variables related to data collection systems, resource availability, and administrative systems are crucial to the successful implementation of and compliance to the plan. In order to be successful, implementation procedures have to identify and control for relevant variables. This requires true interdisciplinary collaboration.
Ongoing Assessment & Adaptation
We have observed and reviewed many behavior support plans that continue for months, and even years. Frequently the only changes seen in the rate of occurrence of the challenging behaviors appear to be related to changes in medical or environmental conditions. Behavior support plans must be reviewed regularly and data analyzed to determine treatment trends.
Additionally, we have found that behavior analysts file monthly progress reviews and behavior graphs without discussing them with direct support staff or other team members. Horner, Thompsen, and Storey (1990) examined the effects of case manager feedback on the quality of individual habilitation plan objectives.
Implementation Team Analysis
Skill Level & Experience
The primary variables associated with implementation team analysis are contained in Table 4. It is important to remember that each implementation team member has a unique history of reinforcement in dealing with challenging behaviors (Freeman et al., 2002). Experience and skill level play a large part in a team member's attitude toward an individual's behavior. Some direct-support staff may have a very positive attitude and view the individual's challenging behavior as a challenge to their skill. Others may view the behavior support plan procedures with a great deal of fear and trepidation due to past experiences, a lack of confidence in their own skills, or a combination of both.
It appears necessary to be able to identify the team members' skill levels and experiences as they relate to the individual's challenging behavior. For example, observations by the residential home manager may identify specific situations where a particular staff member needs to "unlearn" old techniques that may unintentionally reinforce the behavior (Gersten & Brengleman, 1996). Such observations may indicate that some staff members have a conceptual understanding of how the person's behavior is maintained, but have little awareness of how their actions directly reinforce the individual's behavior (Freeman et al., 2002). Such observations may also be useful in identifying key direct-support staff members who are more successful and more confident than others in dealing with the individual's challenging behavior. Such individuals can take a lead role in the behavior support environment by modeling positive-based interactions.
Values & Beliefs
Even if a behavior support or intervention plan is appropriate for the individual, it is essential that all caregivers perceive it as being acceptable to them. For the plans to be accepted by direct-support staff, it is important to ensure their acceptability to the supervisors of the staff and other team members. Without a consensus of procedural acceptability, adherence to a plan becomes more unlikely. It is necessary to assess the deeply ingrained assumptions or beliefs that might influence the team's performance and which can hinder or enhance a behavior support plan. A systems-level analysis could identify staff values and beliefs that would likely cause discordance between team members (Freeman et al., 2002).
To increase adherence to support plans, it is important to determine the acceptability of the behavior support procedures to direct-support staff (Kemp, Miltenberger & Lumley, 1996; Miltenberger, Lennox & Erfanian, 1989; Oliver & Skillman, 2002). Direct-support staff understanding of behavioral principles has not been found to be reliably related to the acceptability of different behavior support interventions (Miltenberger & Lumley, 1997; Rasnake, Martin, Tarnowski, & Mulick, 1993). Studies indicate that the functional assessment approach to behavior support plans may not be fully understood or appreciated by direct-support staff (Iwata, Vollmer, Zarcone, & Rodger, 1993).
Sprague, Flannery, O'Neill, and Baker (1997) provide a Support Plan Acceptability Rating form to assess staff satisfaction with the plan. However, Reid and Parsons (1995a) obtained results that suggest that traditional questionnaire evaluations may not be sufficiently sensitive measures of acceptability relative to choice measures.
Bambara, Gomez, Koger, Lohrmann-O'Rourke, and Xin, (2001) utilized in-depth interviews to examine team members' perceptions on their guiding values, struggles and barriers to implementing positive behavior supports. They were also asked their feelings on ways to support team members, the importance of staff relationships, and key elements of their direct support. Bambara et al. (2001) concluded that their findings depicted an overall culture of support consisting of interrelated layers of social context.
The Effects of Stress on Staff Members
Adherence to behavioral support programs can also be hampered by work-related stressors experienced by direct-support staff. Individuals working in a crisis situation frequently exhibit biases and distortions in their interpretations of consumer behavior. Direct-support staff members' perceptions of challenging behaviors may become reactive and fail to appreciate the behavior's environmental context (Oliver & Skillman, 2002). Frustrated staff have been found to attribute improvements in challenging behavior to changes within in the individual rather than to their own influence (Purcell, Morris, & McConkey, 1999). Conversely, staff experiencing stress may attribute behavior support failure to some characteristic of the individual rather than a systemic variable. In ether case, if staff members view their behavior as irrelevant to behavior support success or failure, they may be less willing to consistently adhere to behavior support plans. Oliver and Skillman (2002) suggest, addressing direct-support staff stress by using established stress-reduction techniques such as self-instruction training, problem-solving training, relaxation training, and stress-inoculation training (Keyes & Dean, 1988) to optimize staff adherence to behavior support plans.
In a recent study (Oliver, Leimkuhl & Skillman, 2003) analyzed the ratings of direct-support staffs' ratings of various work-related and behavior-related stressors, and job satisfaction. Their results suggest that managers need to take a progressive and continuous approach in considering the training needs, stress, and job satisfaction of direct-support staff. They conclude:
"Essentially, agencies who use leadership to involve their direct-care staff in policy development, support innovation, and who recognize the efforts of their staff create a community context wherein all parties can benefit." (p. 6)
Resources, Management & Training Analysis
Freeman et al. (2002) state that identifying the social network as a unit of analysis might provide important information that can useful to improve the quality of services to all individuals in the behavior support environment. Environmental variables that can affect challenging behaviors are the physical characteristics of the environment, the number of people in the environment, and how they interact (Albin et al., 1996). Please refer to table 5.
Management & Resources
The majority of staff management procedures that have been reviewed in the literature have been located in institutional settings (Oliver & Skillman, 2002; Reid & Whitman, 1983). Several books have been published that cover management procedures in developmental disability settings in depth (Reid, 1998; Reid & Parsons, 1995b; Reid & Parsons, 2000; Reid & Parsons, 2002; Reid, Parsons, & Green, 1989).
Antecedent management procedures appear to be the least effective, while contingency management procedures, including performance feedback procedures and multi-faceted procedures appear to be the most effective (Reid & Parsons, 1995b; Reid & Whitman, 1983). Harchik, Sherman, Sheldon, and Strouse (1992) demonstrated that after mini-workshops that improved staff behavior skills, performance was maintained by the provision of observation and consultation. However, continued observation and consultation appeared to be necessary to maintain performance at high skill levels.
Studies indicate that it is equally important to train supervisors in both the behavior support plan procedures and how to use behavior management principles to motivate direct-support staff to carry out that program (Green, Rollyson, Passante, & Reid, 2002; Methot, Williams, Cummings, & Bradshaw, 1996; Parsons & Reid, 1995; Williams & Lloyd, 1992). Green, Reid, Perkins, and Gardner (1991) were able to demonstrate an increase in the quality of habilitative services for persons with profound handicaps by applying a structural analysis to staff management. The results of a study by Parsons, Cash, and Reid, (1989) indicated that a behavioral management program was accompanied by consistent and durable decreases in resident nontherapeutic activity as well as increases in specifically designated habilitative activity. Their results provided support for the successful incorporation of behavioral management technology into human service settings on a large-scale, long-term basis.
Behavior support plan training procedures typically include verbal or written instructions, modeling, and role-playing. Studies by Panyan, Boozer, and Morris (1970) and Quilitch (1975) have demonstrated that these procedures alone are not generally successful in changing staff behaviors much beyond the initial training; In fact, some studies have demonstrated that even when direct-support staff knew the purpose of behavior support procedures, their behavior did not necessarily change. For example, Reid and Parsons (1995b) suggest that the effects of a behavior support plan training procedure are not maintained in the absence of supervisory feedback. Page, Iwata, and Reid, (1982) discuss the large-scale use of pyramidal training with institutional staff.
The Rehabilitation Research and Training Center on Positive Behavior Support has implemented a national inservice training model that may serve as model for related inservice applications. This model is discussed in length in Dunlap, Hieneman, Knoster, Fox, Anderson, and Albin (2000). Table 6 contains their five key features.
It appears essential to train supervisors in behavior analysis procedures for individual with challenging behaviors and in organizational behavior management procedures for use with direct-support staff (Parsons & Reid, 1995; Reid & Parsons, 1995b; Reid & Parsons, 2002; Reid, Parsons, Rotholz, Braswell, & Morris, 2003; Reid, Rotholz, Parsons, Morris, Braswell, Green, & Shell, 2003; Williams & Lloyd, 1992).
Summary & Conclusions
This brief review of the literature identifies the concerns regarding systems-level issues and behavior support plan adherence. Discussion related to individual variables briefly reviewed the functional behavior assessment process and other best practice procedures. The literature suggested that a goodness-of-fit analysis is essential in dealing with team variables. These include behavior support plan acceptability, the perceived role of team members, stress-related issues, and team member values. Management issues consist of the social network, provider resources, staff management procedures, and staff development training.
It appears that incorporating the assessment of all variables discussed is essential to improving adherence to behavior support plans. This may especially be true when looking at team values and contextual fit. Additionally, providing direct-support staff alone competency-based training in the behavior support procedures is not sufficient to ensure plan adherence. The works of Reid an his colleagues (1995b, 2002, 2003, 2003) strongly suggest the need to train supervisory staff in the behavior support procedures and in how to deliver performance management procedures such as direct feedback.
Finally, much of the work reviewed here was done in institutional settings where systems-level issues can usually be addressed by one agency, the institution itself. In community settings, behavior support plans involve several agencies which can complicate dealing with system-level issues (Zukotynski, 2002). Further work needs to be done to demonstrate successful systems-level approaches where multiple community-based agencies are involved.
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