Behavior Intervention

1. Chemical restraints
2. Mechanical restraints
3. Manual restraints
4. Time out
5. Seclusion
6. Any other aversive or deprivation procedure

In summary, we do not do these things.  Not only do they make people unhappy, they generally do not work well to help people appropriately get their wants and needs met. Prohibited procedures may stop a behavior, but they do not teach a person what to do differently the next time. Prohibited procedures may also make a behavior worse. In addition, prohibited procedures can result in mental or physical injuries. 

We have better options for you, so please keep reading. We will cover the things you can’t do first and end with the good stuff, positive supports. 

Here are the simplified and technical definitions of prohibited procedures along with some and examples. 

1.    Chemical restraint:

• A chemical restraint is giving someone a drug or medication that has not been prescribed by their doctor to treat the behavior you are trying to avoid.  
•  An example of chemical restraint is giving a person Xanax when they start yelling so they don’t become physically aggressive but Xanax is prescribed for the person to take when they have panic attacks. If Xanax is given for physical aggression and not a panic attack, this would be a chemical restraint. 
• Technical definition: The administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s medical or psychological condition. 

2.    Mechanical restraint:

• A mechanical restraint is using an object to limit or stop a person from freely moving a part of their body or have access to a part of their body
• An example of a mechanical restraint is taping gloves onto a person’s hands so they cannot scratch themselves, but they would not choose to wear the gloves on their own. 
• Mechanical restraint does not include the following:  (1) devices worn by the person that trigger electronic alarms to warn staff that a person is leaving a room or area, which do not, in and of themselves, restrict freedom of movement; or (2) the use of adaptive aids or equipment or orthotic devices ordered by a health care professional used to treat or manage a medical condition.
• Technical definition: The use of devices, materials or equipment attached or adjacent to the person’s body, or the use of practices that are intended to restrict freedom of movement or normal access to one’s body, to prevent injury with a person who engages in self-injurious behaviors, such as head-banging, gouging, or other actions resulting in tissue damage that have or could cause medical problems resulting from the self-injury. Mechanical restraint also includes the use of practices that are intended to restrict freedom of movement or normal access to one’s body or body parts, or limits a person’s voluntary movement or holds a person immobile as an intervention precipitated by a person’s behavior. 

3.    Manual restraint:

• A manual restraint is using your body to limit another person’s ability to move their own body.
• An example of a manual restraint is pinning someone to the ground to stop them from going somewhere. 
• Technical definition: Physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint. 

4.    Seclusion:

• Basically, seclusion is making a person go somewhere or leave somewhere against their wishes and then not allowing them to leave. 
• An example of seclusion is forcing a person to be separated because they were pinching the staff by putting them in a locked room while attending a birthday party. 
• Technical definition: Removing a person involuntarily to a room from which exit is prohibited by a staff person or a mechanism such as a lock, a device, or an object positioned to hold the door closed or otherwise prevent the person from leaving the room; or otherwise involuntarily separating a person from an area, activity, situation, or social contact with others and blocking or preventing the person’s return. 

5.    Time out:

• A time out is making someone go to an area and it is experienced as a negative consequence. It differs from seclusion in that the person is not stopped from leaving the area they were sent to, but it is still not allowable for a staff to tell a person receiving services that a consequence of their behavior/actions is that they have to go to a designated area. 
• Time out does not mean voluntary removal or self-removal for the purpose of calming, prevention of escalation, or de-escalation of behavior; nor does it mean taking a brief break or rest from an activity for the purpose of providing the person an opportunity to regain self-control.
• An example of a time out is sending a person to their bedroom after an argument, when they do not want to go. Another example is requiring someone to sit on a chair for a specified amount of time, but not physically forcing them to stay in the chair. 
• Asking someone to ‘take a break’ to ‘cool down’, but not requiring them to do so, is not considered a time out. 
• Technical definition: The involuntary removal of a person for a period of time to a designated area from which the person is not prevented from leaving. 

6.    Any other aversive or deprivation procedure:

• Aversive procedure: An aversive procedure is doing or saying something during or right after a behavior that will cause a strong feeling of stress, anxiety, dislike or disgust in order to get the person to stop or reduce the behavior. 
•  An example of an aversive procedure is to wash someone’s mouth out with soap if they swear in the hope that they will not swear again. 
• Technical definition: The application of an aversive stimulus based upon the occurrence of a behavior for the purposes of reducing or eliminating the behavior.
• Aversive stimulus: Typically, an aversive stimulus is an unpleasant thing that punishes or limits a person. The thing that is used to try to stop the behavior is the aversive stimulus. The thing or situation itself does not have to be aversive on its own. It can be how it is used that it becomes aversive to the person. 
• Examples of aversive stimulus are heat, cold, noise, a food or an event that is unwanted or unpleasant that is presented to stop someone or suppress a behavior.   
• Technical definition: An object, event, or situation that is presented immediately following a behavior in an attempt to suppress the behavior.  
• Deprivation procedure: A deprivation procedure involves taking away or not allowing someone to have something or do something they like, want, or need in order to get the person to stop or reduce the behavior.
• An example of a deprivation procedure is to take away someone’s dinner because they hit someone or not allow the person to go to the dance because they hit themselves. 
• Technical definition: The removal of a positive reinforcer following a response resulting in, or intended to result in, a decrease in the frequency, duration, or intensity of that response.  Often times the positive reinforcer available is goods, services, or activities to which the person is normally entitled. The removal is often in the form of a delay or postponement of the positive reinforcer.

The things we can only do in certain circumstances (also known as restricted procedures)
A restricted procedure is something that should not normally be done, but may be allowed in very specific circumstances if it is done properly and for acceptable reasons. Some restricted procedures include:

1.    Procedures identified in a positive support transition plan 
A positive support transition plan is developed by the person’s expanded support team to implement positive  support strategies to: 

• Eliminate the use of prohibited procedures 
• Avoid the emergency use of manual restraint and 
• Prevent the person from physically harming self or others
• Phase out any existing plans for the emergency or programmatic use of restrictive interventions that are prohibited. 

Employees working with a person who has a positive support transition plan receive training before working unsupervised. In Minnesota, Mains’l develops a positive support transition plan on the forms and in the manner prescribed by the commissioner of DHS for a person who requires intervention in order to maintain safety when it is known that the person’s behavior poses an immediate risk of physical harm to self or others.  The positive support transition plan forms and instructions will supersede the requirements in Minnesota Rules, parts 9525.2750; 9525.2760; and 9525.2780.  

2.    Emergency Use of a Manual Restraint: 

• Emergency physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint.
• This means using a part of your body, such as your arms, hands, legs, or your entire body to stop the movement of another person. 
• An example of an emergency use of a manual restraint is to use a wrist side hug procedure to move a person away from someone they are trying to assault. 

 A restricted procedure (one approved in a positive support transition plan or an emergency use of a manual restraint) cannot:
1.    Be implemented with a person in a manner that is sexual abuse, neglect, physical abuse, or mental injury.
2.    Be implemented in a manner that violates a person's rights.
3.    Restrict a person's normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, necessary clothing, or any protection required by state licensing standards or federal regulations governing the program;
4.    Deny the person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;
5.    Be used for the convenience of staff, as punishment, as a substitute for adequate staffing, or as a consequence if the person refuses to participate in the treatment or services provided by the program;
6.    Use prone restraint, which means the use of manual restraint that places a person in a face-down position. Prone restraint does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, if the person is restored to a standing, sitting, or side-lying position as quickly as possible;
7.    Apply back or chest pressure while a person is in a prone position;
8.    Be implemented in a manner that should not be used (contraindicated) for any of the person's known medical or psychological limitations;
9.    Be implemented by a staff that has not completed training on the proper techniques to do an emergency manual restraint. 

The things that we can do (also known as permitted actions and procedures)
While these are not the first choice, or what we want to regularly have happen, the following can be used on an intermittent basis. Additionally, if addressed in a person service and support plan, these things can be done on a continuous basis. The reason for continuous use is to be included. 

1.    Physical contact or instructional techniques must use the least restrictive alternative possible to meet the needs of the person and may be used:

• To calm or comfort a person by holding that person when they show no resistance to being held.
• To protect a person known to be at risk of injury due to frequent falls as a result of a medical condition; 
• To facilitate the person's completion of a task or response when the person does not resist or the person's resistance is minimal in intensity and duration;
• To block or redirect a person's limbs or body without holding the person or limiting the person's movement to interrupt the person's behavior that may result in injury to self or others with less than 60 seconds of physical contact by staff; or
• To redirect a person's behavior when the behavior does not pose a serious threat to the person or others and the behavior is effectively redirected with less than 60 seconds of physical contact by staff.

2.    Restraint may be used as an intervention procedure to:

• To position a person with a physical disability in a manner specified in the person’s service and support plan. 
• Assist in the safe evacuation or redirection of a person in the event of an emergency and the person is at imminent risk of harm.  
• Allow a licensed health care professional to safely conduct a medical examination or to provide medical treatment ordered by a licensed health care professional that is necessary to promote healing or recovery from an acute, meaning short-term, medical condition.

3.    Use of adaptive aids or equipment, orthotic devices, or other medical equipment ordered by a licensed health professional to treat a diagnosed medical condition do not in and of themselves constitute the use of mechanical restraint.

The things that you should do (positive supports)
Positive approaches should be used first and be the most commonly used approached to intervening in another person’s behavior. Positive support approaches include:

1. Showing is often more effective then telling. Act the way you want them to act.
2. Take the time to understand what the person is trying to 
3. communicate with an inappropriate behavior and then teach                  
4. appropriate behavior so they can get what they want or need.    
5. Follow the guidance in the person’s Services and Support Plan, 
6. their Person Centered Plan and if they have one, their Behavior Plan. 
7. Shift a person’s focus by talking with them about a different activity or topic. 
8. Reinforce appropriate behavior. When someone does the right thing, point it out!
9. Offer choices, based on the person’s preferences, including activities that are relaxing 
10. and enjoyable to the person.
11. Give regular and specific positive feedback.
12. Listen carefully to what the person is telling you and  validate their feelings;
13. Create a calm environment by reducing sound, lights, and other factors that may bother a person.
14. Speak calmly with reassuring words; consider volume, tone, and non-verbal communication.
15. Simplify a task or routine or discontinue until the person is calm and agrees to participate.
16. Respect the person’s need for privacy or physical space.

By using positive support approaches, we show respect and honor the dignity of people. We are also more likely to see decreases in the behaviors we don’t want to see and increases in the behaviors we do want to see.  

Responding to a challenging behavior
When a person begins to engage in escalating disruptive behavior and it becomes obvious that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of self or others if not redirected, implement the following steps:

1.    If appropriate or possible, remove all people, whose safety is threatened, from the immediate area of the threatening person.
2.    Attempt de-escalation techniques.  De-escalation techniques include restructuring the environment (noise, crowding, proximity), maintaining calm posture and body language, re-direction, positive verbal praise, active listening, and/or prompting (verbal and gestural).
3.    If applicable, review the use of the person’s PRN (as needed) medication to address target mental health symptoms.
4.    If the person’s behavior continues to be disruptive, ask the person to remove themselves from the ongoing activity to a location where they cannot observe the ongoing activity – this is a voluntary time out.
5.    Follow through with the encouragement of the person’s absence from the ongoing activity with verbal prompts. Do not use physical intervention!
6.    Monitor the person’s behaviors while they choose to be in a voluntary time out. 
7.    When the person stops the disruptive or threatening behavior, ask them if they want to return to normal activities.
8.    If immediate intervention is needed to protect the person or others from physical injury or to prevent severe property damage that is an immediate threat to the physical safety of the individual or others, call 911.    
9.    If a behavior intervention that includes the police, PRN medication to stop a behavior, or , the staff who implemented the intervention: 
•    Notifies their manager immediately;
•    Calls the on-call administrative personnel to report the incident as well as the on-call nurse (if they have one) if there is an injury;
•    Completes the Behavior Intervention Reporting Form (BIRF), and submits it to the manager before they leave work;
•    If a PRN medication is given for target behaviors rather than mental health symptoms, staff completes the BIRF.
10.    If 911 was called, the staff responsible at the time of the incident:
•    Completes an incident report and the BIRF.
•    Calls the on-call administrative personnel to report the incident;
•    Notifies the manager who notifies the case manager and the legal representative of the incident within 24 hours.

The procedures listed above are not used to respond to challenging behavior with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated for a person. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning process.

Staff Training

a. Before having unsupervised direct contact with a person receiving service and annually thereafter, all employees who provide direct support receive instruction on prohibited procedures that address the following:

1.    what constitutes the use of restraint, time out, seclusion, and chemical restraint; 
2.    staff responsibilities related to ensuring prohibited procedures are not used; 
3.    why such prohibited procedures are not effective for reducing or eliminating symptoms or undesired behavior; 
4.    why prohibited procedures are not safe 

b. For the limited situations where the emergency use of a manual restraint may be allowed, before those staff may implement manual restraints on an emergency basis they must also be trained on the following within 60 days of hire:

1. alternatives to manual restraint procedures, including techniques to identify events and environmental factors that may escalate conduct that poses an imminent risk of physical harm to self or others;
2.  de-escalation methods, positive support strategies, and how to avoid power struggles;
3. simulated experiences of administering and receiving manual restraint procedures allowed by the program on an emergency basis;
4. how to properly identify thresholds for implementing and ceasing restrictive procedures;
5. how to recognize, monitor, and respond to the person’s physical signs of distress, including positional asphyxia;
6. the physiological and psychological impact on the person and the staff when restrictive procedures are used;
7. the communicative intent of behaviors; and
8. relationship building.
9. the safe and correct use of manual restraint on an emergency basis