Professional Documents
Culture Documents
(2nd Edition)
Prepared by psychologists:
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Trevor Mazzucchelli Lisa Studman Paul Wilson Matthew Dunsire Lara Harmsworth Andrew Adlem
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Skills Training and Behavioural Strategies Including Aversive Procedures for Children with Developmental Disabilities
Foreword
FOREWORD
The Disability Services Commission has produced the Behaviour Support Guidelines for Children with developmental disabilities as best practice standards for anyone supporting a child with a disability. The document is based on contemporary literature and practice, and was developed following extensive consultation with a range of external agencies, non-government organizations, carers and families. Meeting the needs of children with difficult behaviour can be highly demanding and challenging. These guidelines document contemporary approaches and standards for the management of such behaviours. I recommend that all people who work with and care for children take the time to familiarise themselves with these guidelines. It is important that parents and carers consult with relevant health professionals for advice and or assistance if they are experiencing challenges implementing the behaviour support guidelines.
The authors thank Ritu Campbell, Antoinette Casella, Lois Lowe, Ellen Lee and Kate Smith for their contributions to the first edition of this document. We gratefully acknowledge the staff from the following agencies that have provided feedback on the first edition: Activ Foundation, The Centre for Cerebral Palsy, Department for Child Protection, Department of Education, Disability Services Commission, Identity WA, Lady Lawley Cottage, Mofflyn, Playgroup WA, Rocky Bay, State Child Development Centre, Resource Unit for Children with Special Needs, and Therapy Focus Inc. We also thank Deb Tedeschi, Debbie Lobb and Mia Huntley for their contributions to the second edition of this document. We thank all the parents who read earlier drafts and provided very useful feedback. Finally, we greatly appreciate the assistance of Lu Le Petit Ecolier.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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ACKNOWLEDGEMENTS
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Feedback on this document would be welcomed and can be provided to the Clinical Psychology Supervisors from the Commissions Individual and Family Support Program on either 9301 3800 or 9329 2300.
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Further copies of this document can be obtained from the Disability Services Commission Web Site: www.disability.wa.gov.au.
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Contents
CONTENTS
1. Introduction........................................................................................5 2. Developing a behaviour support plan....................................................6 3. Lifestyle interventions that promote child development and independence ...................................................8 3.1 Develop positive relationships ......................................................8 3.2 Find a way to communicate ....................................................... 10 3.3 Set up environments ................................................................. 11 3.4 Encourage cooperation and participation..................................... 12 3.5 Reinforce desirable behaviour .................................................... 13 3.6 Teach new behaviours............................................................... 13 4. Reducing problem behaviour.............................................................. 19 4.1 Constructive approaches to reduce problem behaviour ................ 20 4.1.1 Functional communication training ................................... 20 4.1.2 Redirection ..................................................................... 20 4.1.3 Teaching coping skills ...................................................... 20 4.1.4 Active listening................................................................ 21 4.1.5 Problem solving............................................................... 22 4.2 Punishment and aversive procedures: Issues to consider............. 22 4.2.1 Safeguards when using punishment ................................. 23 4.3 Punishment procedures ............................................................. 24 4.3.1 Reprimands..................................................................... 24 4.3.2 Blocking.......................................................................... 24 4.3.3 Escape extinction ............................................................ 25 4.3.4 Overcorrection ................................................................ 25 4.3.5 Time-out......................................................................... 26 4.3.5.1 Planned ignoring ............................................... 26 4.3.5.2 Response cost ................................................... 27 4.3.5.3 Brief interruption ............................................... 27 4.3.5.4 Contingent observation ...................................... 28 4.3.5.5 Quiet Time ........................................................ 28 4.3.5.6 Time-out ribbon................................................. 28 4.3.5.7 Exclusionary time-out ........................................ 29 4.3.5.8 Facial screening................................................. 30 4.3.6 Restraint, including the use of medication ......................... 30 5. Management of emergency situations ................................................ 33 5.1 Antecedent control strategies..................................................... 33 5.1.1 Removing seductive objects ............................................. 33 5.1.2 Removing unnecessary demands and requests.................. 34 5.2 Interrupting the behavioural chain and counter intuitive strategies ................................................................................................ 34 5.2.1 Stimulus change.............................................................. 34
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Contents
5.2.2 Diversion ........................................................................ 35 5.2.3 Capitulation..................................................................... 35 5.3 Restraint................................................................................... 36 5.3.1 Interpositioning............................................................... 36 5.3.2 Seclusion ........................................................................ 36 5.3.3 Physical restraint ............................................................. 36 6. Child Abuse ...................................................................................... 38 6.1 Actions which do not meet the Commissions standards and are not to be used ................................................................................ 38 Bibliography...................................................................................... 40 Appendix A: Behaviour Support Diary ................................................. 41 Appendix B: Emergency Management Procedures ............................... 42 Appendix C: Resources...................................................................... 44
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Introduction
1.
INTRODUCTION
These guidelines have been produced to inform and guide those who care for or teach children with developmental disabilities up to 18-years-of-age. They may be considered best practice for anyone supporting a child with a disability, including parents, carers, teachers, and support workers. Parents of children with developmental disabilities may also expect all the Commissions employees are familiar with and adhere to them. The guidelines are applicable to children with any kind of disability including physical, sensory, neurological, cognitive, intellectual and autism spectrum disorders. The information in this document is based on the most recent literature and extensive experience in the support and development of children with disabilities. There has also been extensive consultation with direct care staff, supervising staff and families. The document introduces behaviour support plans, and provides details on ways to promote child development and independence, and ways to reduce problem behaviour. It also outlines techniques that do not meet the Commissions standards and should not be used. It is not intended to be a training document. For further information on appropriate training and materials, see the resource sections in this document.
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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The goal of behaviour support is to achieve long-lasting, meaningful improvements in childrens behaviour. Success is measured not only in terms of reductions in problem behaviour, but also by increases in the performance of alternative skills and improvements in the child and familys quality of life. Behaviour support plans consist of multiple interventions or support strategies that emphasise lifestyle enhancement, alternative skill training, and environmental adaptations. The four key components of behaviour support plans are outlined below: Lifestyle interventions that aim to provide a supportive child focused home, school and recreational environment. This might include providing a rich variety of activities that the child can choose from, helping the child participate in after-school activities of his or her choice, and teaching the childs peers to understand the childs communication system.
Developing a behaviour support plan begins with understanding why a child engages in problem behaviour. To develop such an understanding a functional assessment is typically required. The basic steps of such an assessment include: Collecting broad contextual information about the child: skills and abilities, preferences and interests, general health and quality of life. Collecting specific information that will pinpoint the conditions that are regularly associated with the problem behaviour and identify the function or purpose of the childs behaviour. Developing hypotheses that summarise the assessment information by offering logical explanations for problem behaviours. These statements guide the development of behaviour support plans.
This document outlines strategies and ideas that can be used to develop a comprehensive behaviour support plan.
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Deciding how to respond after the problem behaviour occurs. Possible responses include using an instruction to tell the child what to stop doing and what to do instead, using planned ignoring, or in the case of an emergency situation, moving to a safe place.
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Eliminating or modifying specific events that leads to problem behaviour. Examples of these modifications might include providing a favourite activity during a high-risk time, stating clear expectations for desired behaviours, and giving attention before problems arise.
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Teaching alternative means for achieving desired outcomes. Examples of this component might include teaching a child how to ask for help, to selfinitiate activities using an activity schedule to keep occupied, and / or to relax during stressful events.
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For Parents
O'Neill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R., Storey, K., & Newton, J. S. (1997). Functional assessment and program development for problem behavior: A practical handbook (2nd ed). Pacific Grove: Brooks/Cole Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis. New Jersey: Prentice.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Sanders, M. R. (2004). Every Parent: A positive approach to children's behaviour. Camberwell: Penguin. Sanders, M. R., Mazzucchelli, T. G., & Studman, L. J. (2003). Stepping Stones Triple P Family Workbook. Milton, Queensland: Triple P International
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A lifestyle intervention that promotes child safety, development and independence is the basis of an effective behaviour support plan. When considered thoroughly, lifestyle interventions can prevent the development or persistence of problem behaviour. When children and teenagers have a well structured, nurturing and engaging lifestyle with an effective way of communicating and solving problems, problem behaviour is less likely to occur. All children need warm, safe and responsive interaction with others in a variety of environments such as home, community, education and work settings. They also need opportunities to learn how to:
Children with disabilities need additional support or teaching in some or all areas of development. They also need consistent support to participate fully in all or some environments. This chapter provides ideas on how to set up healthy balanced lifestyles for children and teenagers with disabilities. 3.1 DEVELOP POSITIVE RELATIONSHIPS Children are more likely to develop to their potential within the context of secure relationships that are warm, positive and predictable. When these relationships are formed with parents and carers, especially in the early years, children are less likely to develop behaviour problems. To develop secure relationships parents and carers need to be sensitive and responsive to children. Interactions to facilitate secure relationships include: Facial expressionshowing a child a calm, relaxed facial expression with lots of gentle and direct eye contact. Parents and carers need to be 8
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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To solve problems. questioning needs to be options, make choices everyday problems such who to see.
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Be as independent as possible with appropriate levels of support from others. This involves keeping busy and engaged in play or other activities without constant adult attention, developing as much mobility as possible, and learning everyday tasks such as dressing, eating, and using the toilet. Their curiosity, interest, understanding and encouraged. Children need to learn to consider or decisions and think about alternatives to as what to wear, what to eat, what to do and
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Regulate their emotions. They need to find ways to express feelings in ways that are not harmful to themselves and others, to control aggressive impulses, to develop positive feelings about themselves, their families and others and to accept rules and limits.
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Communicate and get on with others. This includes expressing ideas and needs, asking for help when needed, cooperating with adult requests and taking turns to share with other children.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Joint decision makingas children grow older and can participate in family discussions and decisions, hold regular meetings or gatherings where everyone in the family or house can contribute their ideas. Set an agenda so that everyone knows what topics are going to be discussed. It could be that the group needs to decide how to spend holiday time together, what house-rules to have, or to plan the housework roster for that week. Another topic could be to develop a plan so that a teenager can safely participate in a social event that has some risks. Keep the meeting brief (about 15 minutes) and focused on achieving a definite solution or plan. Having some rules for the meeting can help it run smoothly. Rules may include: speak calmly, only one person speaks at a time, everyone has a turn, and ask permission if you need to leave.
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Pacing of turnstiming interactions on the basis of signals or cues from the child to create rhythmical turn-taking. That is, giving a child time to make a response and encouraging their attempts by waiting and looking expectant for instance by, raising eyebrows, opening the mouth, and nodding. It also involves actively supporting a childs play or a teens activities by being interested, watching, commenting and approving.
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Expressions of affectionaffection can be expressed vocally, visually or through touch, such as stroking, hugging, and smiling. Parents and carers need to be responsive to child cues about how much physical affection is wanted. That is, it is important not to intrude into a childs personal space when they do not like it. Appropriate forms of physical affection changes with the childs age and stage of development. For example, trying to hug a child when they are angry and pushing an adult away or saying, stop, I dont like it, would not serve to develop a secure relationship.
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Signing - this involves the use of a formal set of signs, or signs which are particular to an individual. Signing is useful to help children to understand language and to express ideas to others who can use signs. Photos, drawings, objects and picture symbols - these are used to represent words in a visual way to assist the child to understand language and express themselves. For example, visual timetables, choice-making boards, Picture Exchange Communication System (PECS), communication displays, topic boards can all be used to assist children to communicate effectively. The symbols used are interactive and encourage both receptive language and opportunities for the child to make requests, comments and use social language. Chat books - these are books that may contain photos, pictures, symbols, words and messages about a child and their interests, e.g. pictures of family, pets, school, favourite places or activities may be included. Children who have difficulty with verbal communication use chat books to initiate social conversations with those around them. Speech generating devices these are computers that can be programmed to speak a message when a particular button, or sequence of buttons, are pressed.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Natural Gestures this involves general or natural communication methods such as pointing, gestures, eye-pointing, mime, facial expressions and body language.
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Social reinforcement (e.g., "Good work!", thumbs up, a pat on the back) is the most available and potentially useful of all reinforcement. When using social reinforcement it is important to be enthusiastic and genuine. When tangible reinforcement (e.g., juice, chocolate, stars) or activity reinforcement (e.g., a push on a swing, a drive in a car, reading a book) is used, they should be given at the same time or just after social reinforcement. Another way to reinforce behaviour is to allow a child to do or have something that they are not usually permitted at that time if they have behaved well (e.g., extra time on the computer than usual, extra time to stay out and socialize with peers, or even uninterrupted time to engage in self-stimulatory behaviours such as looking at lights or spinning wheels on toys). When a person uses reinforcement often and shares preferred activities with the child, it will encourage that child to associate that person with feeling good and it will be much easier to encourage appropriate behaviour. 3.6 TEACH NEW BEHAVIOURS All children need to learn new behaviours at every stage of development. Some children with disabilities need more opportunities and extra support to learn these. When teaching a new behaviour show or tell the child what to do, help them to do it and provide reinforcement for doing it.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Reinforcement will be most effective in encouraging appropriate behaviour when given immediately after that behaviour. As the behaviour is learned, it should be reinforced only every now and then.
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REINFORCE DESIRABLE BEHAVIOUR Reinforcement happens when an event or object follows a behaviour making the behaviour more likely to occur again. Reinforcement is essential to teach children new skills and to maintain existing skills and development. For example, Wendy is told she is doing a good job when she puts her plate in the sink and this results in her doing it in the future without having to be prompted. Or Eddie gets a stamp on his chart every time he puts a piece in a puzzle and over time this leads to him working on the puzzle on his own. Finding the most powerful and socially acceptable reinforcement for each individual child is important. Never assume that what is reinforcing for one child will be reinforcing for another or what is reinforcing one day will be reinforcing the next. There are several ways of finding out what is most reinforcing for a child. These include asking the child or carers, completing inventories, or offering items to the child and seeing what they reach for or resist having taken away.
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For Parents
Baker, B. L., & Brightman, A. J. (1997). Steps to independence: teaching everyday skills to children with special needs. Baltimore: Paul H. Brookes. Protective Behaviours o Feel SafeAn intervention for teenagers and adults, available through Disability Services Commission. o People 1st Programme: Corner of Roe Street and Lake Street, Northbridge. www.people1stprogramme.com.au Safety products o Kidsafe WA Child Accident Prevention Foundation: Godfrey House, Princess Margaret Hospital, Corner of Roberts Road and Thomas Street, Subiaco. www.kidsafewa.gom.au o Also, see hardware stores (e.g., Bunnings) and baby specific stores (e.g., Baby on a Budget) Ralph, A., & Sanders, M. R. (2002). Teen Triple P Group Workbook. Milton, Queensland: Teen Triple P Group Workbook. Sanders, M. R. (2004). Every Parent: A positive approach to children's behaviour. Camberwell: Penguin. Sanders, M. R., Mazzucchelli, T. G., & Studman, L. J. (2003). Stepping Stones Triple P Family Workbook. Milton, Queensland: Triple P International
Alternative and Augmentative Communication www.aacinstitute.org Frost, L., & Bondy, A. (2002). The Picture Exchange Communication System: Training Manual. Newport: Pyramid Educational Consultants Lutzker, J. R. (1998). Handbook of child abuse research and treatment. New York: Springer. McClannahan, L. E., & Krantz, P. J. (1999). Activity schedules for children with autism: Teaching independent behavior. Bethesda: Woodbine House. PECS Training Pyramid Educational Consultants of Australia www.pecsaustralia.com Overview of strategies Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis. New Jersey: Prentice. Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, 16
Western Australia: Author.
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Behaviour does not occur in a vacuum, it always occurs within a context. No matter how difficult or unusual a problem behaviour may appear, certain conditions give rise to and trigger it and the consequences of the behaviour maintain it. In this way the behaviour is said to serve a function. Four functions of problem behaviour are to: avoid or escape an event or situation (e.g., misbehaving at the dinner table to avoid having to eat disliked food), gain more social interaction (e.g., interrupting adult conversations by screaming), obtain some tangible item or activity (e.g., snatching toys from other children), obtain a sensory reward (e.g., rubbing eyes hard to get visual shadows and light distortion). The same behaviour, such as a tantrum (screaming and rolling on the floor), depending on its context, may serve a different function for the child. In the context of sitting at the table in front of a plate of tripe the tantrum may serve the function of having the meal removed. In the context of an adult conversation that the child cannot follow, the tantrum may serve the purpose of interrupting the conversation and gaining attention. In the context of the supermarket, the tantrum may serve the function of gaining access to a bag of lollies. In the context of an uninteresting room, the tantrum may serve the function of gaining interesting sensory stimulation. At times it can be difficult to determine the function of behaviour within particular contexts, and a thorough assessment may be required. Information about triggers and what function a particular behaviour may serve can be obtained through functional assessments such as structured interviews, checklists, rating scales or questionnaires with people who are very familiar with the child (e.g., teachers, parents, carers or the person themselves). Functional assessment can also be done by recording what happens before the behaviour (e.g., he was watching TV and I told him to turn it off for dinner) and after the behaviour (e.g., I let him eat dinner in front of the TV). This is called Narrative ABC (Antecedent-BehaviourConsequence) recording. Behavioural assessment can vary in complexity from asking carers what seems to trigger and maintain certain behaviours to more scientific approaches, such as functional analysis. Functional analysis is usually done by a psychologist and involves generating and testing hypotheses about why a particular behaviour occurs.
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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4.1.3 Teaching Coping Skills Everyone needs to use specific skills to cope with difficulties they come up against on a daybyday basis. Children often need to cope with situations they find unpleasant such as waiting, accepting unexpected changes in routine, and noisy environments. Keeping children busy and engaged can help them learn to cope. For example, a parent could prompt their child to select a book in the doctor's surgery when they notice that they are looking bored or agitated. Parents could also teach their child how to relax by breathing slowly, and then remind them to use this skill in situations that they find distressing. Another way to promote positive coping is to teach children how to express how they feel. You can start to teach a child to label their basic feelings such as happy, sad, angry and scared from a young age. Do this by commenting Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, 20
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4.1.2 Redirection This involves getting the childs attention before the behaviour becomes a problem and redirecting them to another task or activity. It is useful when it is anticipated that a child may misbehave or that a situation could get out of hand. For example when a child is holding a crayon and walking towards a wall, get their attention and give an instruction, "Kate, draw on paper", while pointing to the paper on the table. If necessary physically guide Kate to the table and help her to begin. When Kate is drawing on the paper, provide reinforcement, "Good drawing Kate".
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Functional communication is often addressed by joint behavioural and speech pathology intervention.
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Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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As stated in section 2 of this document, parents / carers and agencies working with a child should agree on the specific procedures that may be used as part of a childs behaviour support plan. 4.2.1 Safeguards When Using Punishment It is good practice to monitor the strategies used and the behaviours to be changed, this will indicate whether the plan is working or whether it needs to be modified. If punishment is being used constantly to manage a problem behaviour, it is a sign that there may be something wrong with the overall behaviour support plan. For example, there may not be enough emphasis on teaching new behaviours. If there is no improvement in the childs behaviour over a 2-week period review the plan and consider seeking assistance from a psychologist. A sample monitoring sheet for keeping track of the use of behaviour change strategies is provided as Appendix A.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Despite these problems, there is a case for the use of mild forms of punishment as part of a behaviour support plan. Punishment can result in a rapid decrease in problem behaviour, but should be combined with reinforcement procedures to teach the appropriate behaviour and promote longlasting behaviour change. For example, taking a toy from two children who are fighting over it would make it less likely that they would fight over it again. However, they would still need to be taught how to share the toy appropriately. In this way, punishment is used to discourage fighting and then reinforcement is used to teach new behaviours.
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4.3.2 Blocking This involves physically interrupting a childs behaviour momentarily to prevent its completion. Some examples include placing a hand in front of a child's mouth to stop them from biting their own hand, or quickly moving your hand to prevent one child from hitting another. Blocking should be combined with other strategies to teach appropriate behaviours.
ADVANTAGES
Is usually a natural response to prevent dangerous behaviours. Prevents instances of the problem behaviour from occurring. Has been used effectively for reducing rates of self-injurious and repetitive behaviours.
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A socially acceptable minimally aversive procedure. Can tell the child what the unacceptable behaviour is. When combined with an instruction telling the child what to do instead, gives the child an opportunity to learn appropriate behaviour.
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DISADVANTAGES
If a child is seeking attention, a reprimand may reinforce problem behaviour. Can be easily overused. Can trigger other problem behaviour.
DISADVANTAGES
Requires close physical proximity to the child. Can lead to a tussle and injury to the person blocking. May accidentally lead to the problem behaviour being reinforced.
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4.3.4 Overcorrection Overcorrection has two components, restitution and positive practice. Restitution involves restoring the environment to the state it was in before the problem behaviour, and perhaps to a state improved on what it was before the problem behaviour. Positive practice requires the child to repeatedly demonstrate a relevant prosocial alternative to the problem behaviour. For example, after drawing on the wall with a crayon, a child may be first required to wash the wall (restitution), including an area of the wall not marked by crayon, and then guided to use crayons on drawing paper (positive practice).
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ADVANTAGES
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Can produce a rapid reduction in the problem behaviour and an increase in adaptive behaviours. Can be effective for serious problem behaviours including selfinjury. One of few procedures useful for behaviour motivated by escape or avoidance.
Can be a very intensive and complex procedure to implement. Can result in a temporary increase in attempts at problem behaviour. May require additional support to implement depending on the size of the child or the intensity of the behaviour. Risks associated with blocking are also relevant for escape extinction.
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DISADVANTAGES
Child may be unwilling to complete tasks during the restitution and positive practice process. Child may not understand how the positive practice is related to the problem behaviour and may learn to perform both the problem behaviour and the positive practice in the future.
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DISADVANTAGES
Planned ignoring may lead to a brief increase in the rate and intensity of the behaviour. More severe problem behaviours, such as aggression, may also be exhibited. Because it can lead to an escalation in the behaviour it can be difficult for parents and carers to stay calm and continue using the procedure.
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4.3.5.2 Response Cost This involves taking away reinforcers following a problem behaviour, for example a toy is removed when the child is using it destructively. This form of response cost could also be termed a logical consequence because it is logically related to the misbehaviour. Other examples of response cost might include having water instead of a soft drink for shaking up the bottle, or receiving less pocket money for not completing chores. If the reinforcer was logically related to the problem behaviour it would usually be reintroduced after a short period to provide the child with another opportunity to learn how to behave with it. Children may need a reminder or support to use it appropriately. For example, the TV is switched off for five minutes when children are arguing over what channel to watch. Then it is turned on after the set time and assistance is given to the children to come up with an agreement about to watch. Response cost works best when it is carefully planned, immediately follows the problem behaviour, and is carried out every time the problem behaviour occurs.
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ADVANTAGES
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Care should also be taken when selecting consequences. The procedure should not restrict learning or social opportunities. For example, stopping a child from attending a birthday party when they are rarely invited to one is not appropriate.
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4.3.5.3 Brief Interruption Brief Interruption involves a period of interruption (10 seconds to 2 minutes) in response to disruptive behaviour such as self-injurious, repetitive or destructive behaviours. If the child engages in disruptive behaviour the parent or carer blocks their behaviour and instructs, or if necessary, guides their hands downward to their lap where they remain for the required amount of time. If the child is not calm at the end of the required amount of time, the duration of the interruption is extended until they are calm for a few seconds. For a more complete description see Azrin et al. (1988).
DISADVANTAGES
Requires being in close physical proximity to the child. Can lead to a tussle and may inadvertently lead to the problem behaviour being reinforced.
The child can be maintained in the situation and consequently may be effective for behaviours that are maintained by escaping or avoidance.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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DISADVANTAGES
May make childrens behaviour worse in the shortterm when the reinforcer is removed.
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DISADVANTAGES
Negative peer attention and instructions from carers during the observation period can reinforce the problem behaviour.
ADVANTAGES
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4.3.5.6 Time-out Ribbon In this procedure, all children in a group are given a ribbon or button to be worn. With the ribbon in place, a child receives positive reinforcement in response to appropriate behaviour. As the child is receiving this reinforcement, the appropriate behaviour is described and the fact that the ribbon is present is commented upon. Over time, this consistent pairing of the ribbon with reinforcement helps the child understand that wearing the ribbon is a prerequisite for delivery of positive reinforcement. Thereafter, a non-exclusionary time-out can be put into effect by removing the ribbon for a set period of time, such as 3 minutes, whenever the child demonstrates a targeted problem behaviour. During the interval in which the ribbon is withdrawn, all forms of social interaction are removed. If the problem behaviour still occurs after the time period, the interval is extended until the behaviour stops. At this point, the ribbon is replaced and the caregiver looks for an opportunity to provide positive reinforcement for acceptable behaviour.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Can be used to address a variety of problem behaviours, both in group settings (e.g., refusal to share or take turns) and when the child is alone with the carer (e.g., not following an instruction).
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4.3.5.5 Quiet Time Quiet time involves removing the child from the activity in which a problem occurred and having them sit quietly on the edge of the activity for 1 to 5 minutes. During this time they are not given any attention. Once they have remained quiet for the set time, they can rejoin the activity. If a child does not sit quietly during quiet time a back-up strategy such as exclusionary timeout would need to be used in the short-term.
DISADVANTAGES
The child may learn to delay or avoid certain activities by displaying problem behaviour. Becomes less age appropriate as the child gets older.
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DISADVANTAGES
May require a long period before becoming effective. Removal of ribbon may lead to aggression toward the caregiver or a temporary escalation of other behaviours such as tantrums or property destruction. Children may have difficulty understanding why the ribbon is removed at the end of the class. Potentially stigmatising to children involved in such a programparticularly if it is only used with children who have a disability or worn out in the community.
Because of the risk of inadvertently reinforcing problem behaviour, it is recommended that the use of exclusionary time-out is monitored. Each use of exclusionary time-out should be recorded as well as how long it takes before the child is quiet for the set time. If effective, the child should become quiet more quickly and time-out should be needed less often. A sample recording sheet of monitoring the use of time-out (and other strategies) is provided in Appendix A.
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4.3.5.7 Exclusionary Time-out Exclusionary time-out involves removing the child who misbehaves from "timein" to a secluded time-out area. The time-out area should be uninteresting, yet safe, with good lighting and ventilation. Misbehaviour and calling out while the child while in the time-out area is ignored. Time-out is over when the child has remained quiet in time-out for a specified period of time, usually 5 minutes or less. At this time, the child is returned to timein and the caregiver looks for an opportunity to praise the child's alternative appropriate behaviour. It should be emphasised that time-out will not be effective if timein is not sufficiently reinforcing for the child. For specific procedural guidelines on the use of exclusionary time-out, see Sanders and Dadds (1993).
Can send a clear message to the child that unacceptable behaviour has occurred. Provides an opportunity for both the child and the parent to calm down. Can help children learn to manage feelings of anger and frustration.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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DISADVANTAGES
Child can receive reinforcement while being taken to the time-out area. The child can delay or avoid the required task during time-out (and consequently be reinforced for the problem behaviour). There is a risk of dangerous or destructive behaviour by the child during time-out. Carers can be reinforced for using timeout and may leave the child in time-out for too long or use time-out too frequently.
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4.3.5.8 Facial Screening Facial screening involves applying a face cover, usually a soft cloth, a blindfold, or the caregiver's hands, to block out visual input for about 5 to 15 seconds following each occurrence of the unwanted behaviour. Because of issues concerning the acceptability of this strategy it should only be used in circumstances where the risk to the child outweighs the social costs of using this procedure. Less intrusive procedures should be used in preference.
ADVANTAGES
Has been successful with a variety of selfinjurious and repetitive behaviours.
DISADVANTAGES
A tussle can occur should the child try to remove the screen. The procedure may be devaluing to the person. May not be socially acceptable to members of the public.
4.3.6 Restraint, Including the Use of Medication Restraint involves a variety of mechanisms used for the purpose of restricting the free movement or decision-making abilities of another person. There are four main types of restraints: 1. Physical Restraintincludes any manual methods to restrict, subdue or prevent the movement of any part of a persons body, and involves physically holding the person against their will. 2. Mechanical Restraintinvolves the use of any devices, equipment or materials to restrict, subdue or prevent the movement of, or access to, any part of the persons body. This could include (but is not limited to): seat belts (other than those required by law), wheelchair lap belts, wheelchair tray tables, clothing that the person cannot remove (e.g., mittens, overalls), or placing a person in chairs or in beds that they cannot get out of. It can also include not helping someone with a disability move when he or she wants to. 3. Chemical Restraintinvolves the intentional use of medication to control a persons behaviour when no medical condition or psychiatric disorder has been diagnosed or is being treated. 4. Seclusionincludes locking a person in a room or any other location, or locking them out of an area The use of restraints to manage problem behaviour is questionable because it not only stops the problem behaviour, but can restrict other behaviours as well. For example a restraint to prevent a person from sucking their hands can also prevent that person from learning to feed themselves or from playing. For this reason a thorough assessment should be conducted and a behaviour support plan incorporating alternative strategies developed.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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DISADVANTAGES
On their own, restraints do not teach the child more appropriate behaviours and can result in the emergence or escalation of other problem behaviours Restraints are particularly susceptible to overuse. The extended use of restraints can result in physical injury to the person by reducing circulation, causing welts, and muscle and bone wastage. Restraints typically deprive the child from participating and interacting with their environment. When applying restraints, a tussle may occur. Children can grow to like or expect the restraint and the restraint can be difficult to eliminate or fade out. May result in the loss of dignity for the person wearing them. May not be socially acceptable.
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MORE INFORMATION AND RESOURCES: Baker, B. L., & Brightman, A. J. (1997). Steps to independence: teaching everyday skills to children with special needs. Baltimore: Paul H. Brookes. Sanders, M. R. (2004). Every Parent: A positive approach to children's behaviour. Camberwell: Penguin. Sanders, M. R., Mazzucchelli, T. G., & Studman, L. J. (2003). Stepping Stones Triple P Family Workbook. Milton, Queensland: Triple P International
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disabilities. In E. Cipani (Ed.) The treatment of severe behavior disorders: Behavior analysis approaches (pp. 37-58). Washington DC: AAMR. Van Houten, R. (1980). How to use reprimands. Austin, Texas: Pro-ed. Restraints Disability Services Commission (2006). Use of Restraints Policy. Perth, Western Australia: Author.
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5.
There can be occasions where carers are faced with scenarios, which have not been planned for, and there is a need to resort to emergency management procedures, such as those listed in Appendix B. Although the aim should be to provide adequate support to prevent problem behaviour, children can still have behaviour outbursts which can place themselves or others at risk of serious injury. Examples might include a child who begins to threaten other children and carers with a cricket bat, a child who runs towards a busy road ignoring a carer's calls to stop, or a child who punches herself in the face. Having strategies which carers can use in situations where preventative measures have not succeeded is essential in any behaviour support program. There are a number of strategies that can be used to defuse emergency situations, such as distraction and redirection, active listening, facilitating relaxation and selfcontrol, and giving the child what they want. The main purpose of these strategies is to diffuse the situation as soon as possible and protect the individual and others from further harm. This has the increased risk of accidentally reinforcing the problem behaviour. Emergency management strategies should be embedded within a broader plan that supports the individual to develop other more appropriate ways of having their needs met. If emergency management strategies are used regularly, the behaviour support plan should be reviewed. When carers use emergency procedures the incident should be documented and the incident should be discussed with the child's parents afterwards. At this time steps to prevent such a scenario from occurring in the future can be discussed and how to manage any similar incidents in the future can be agreed upon. It is not the place of this document to cover all these emergency strategies (for a comprehensive list see Willis & LaVigna, 1996). For severe assaultive / destructive behaviour, the following strategies may be appropriate, often in combination with other emergency strategies. 5.1 ANTECEDENT CONTROL STRATEGIES 5.1.1 Remove Seductive Objects Particular objects or materials can act as a cue for a child to approach and engage the object which can then result in a potentially serious situation. By removing the object, or by eliminating access to the object, a potentially serious episode might be avoided. Examples of this strategy might be to lock the front door to prevent a child from leaving the house unattended, putting away small objects that might be swallowed, or not giving a child a particular toy because they will refuse to participate in all activities from that time on.
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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DISADVANTAGES
If objects are not re-introduced, the child is not given opportunities to learn how to manage their behaviour in their presence.
Prevents occurring.
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When used in isolation, the effect of stimulus change is only temporary. The more often the same novel event is used, the less effective it is likely to become. A wide repertoire of novel things to do and to say may be needed. Stimulus change may be a useful short term strategy until a comprehensive assessment and a behaviour support plan can be implemented.
ADVANTAGES
Works quicklyif stimulus change works at all, it works immediately. Provides opportunities for use of alternative strategies (e.g., reinforcing of other behaviour). Disability Services Commission (2008, June). Behaviour
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5.2
INTERRUPTING THE BEHAVIOURAL CHAIN AND COUNTER INTUITIVE STRATEGIES 5.2.1 Stimulus Change Stimulus change involves presenting an unexpected stimulus or altering environmental conditions when the child is beginning to escalate or at the time of an incident. This can interrupt the course of the escalation and result in the problem behaviour lessening in intensity or even stopping. Examples of stimulus change might include performing an outrageous dance, bursting into laughter, turning on classical music, or turning out the lights.
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If requests are not re-introduced, the child is not given opportunities to learn how to cope when given such requests. Child can learn to escalate behaviour in order to avoid other demands / requests.
DISADVANTAGES
Effect on behaviour is temporary, especially if used in isolation. If used repeatedly, children may learn to disregard such changes. May accidentally reinforce the problem Support Guidelines for Children. Perth, 34
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5.1.2 Remove Unnecessary Demands and Requests Children sometimes become physically aggressive and destructive when presented with demands or are pursued for compliance. In these situations, removing or making easier requests is likely to reduce many serious behaviour episodes. At the same time, the child can be reinforced for cooperating with related demands and requests. For instance, if a child is known to bang his head on the floor when told, Do this puzzle, caregivers may choose not to make that request. Instead, the child might be encouraged for following instructions to participate in other activities. Puzzles may be reintroduced later, starting with ones that the child enjoys and is able to complete successfully.
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5.2.3 Capitulation Capitulation involves giving the child what they want in order to bring a problem behaviour under rapid control and prevent injury to the child or others around them. This is an approach used when other strategies have not yet been put in place. For example, if a child is banging her head on the door, wanting to go outside at an inappropriate time, capitulation would involve allowing the child to go outside in order to avoid further escalation and risk of injury.
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May quickly bring the problem behaviour under control Does not involve physical contact between the carer and the distressed child, reducing the risk of injury to either party. Provides opportunities for use of alternative strategies (e.g., reinforcing of other behaviour).
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May quickly bring the problem behaviour under control. Does not involve physical contact between the carer and the distressed child, reducing the risk of injury to either party.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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May accidentally reinforce the problem behaviour. Effect on behaviour is temporary, especially if used in isolation.
DISADVANTAGES
May accidentally reinforce the problem behaviour.
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5.2.2 Diversion Diversion involves redirecting or diverting a child to an activity or event that is compelling or strongly attractive. For example, suppose a child loves milk and has a history of dropping everything and going to the kitchen when you say, lets get some milk. This might be used to divert a child in an emergency situation. For instance, if the child picked up a screwdriver and threatened to hurt another child with it. This strategy is counterintuitive in that it has the strong potential to reinforce the problem behaviour and increase its future occurrence. Given this, safeguards should be incorporated such as teaching the child how to ask for milk appropriately so that threatening behaviour is not the only way to get access to milk. Diversion should be used as early in the behavioural chain as possible. Also, in high-risk situations, appropriate behaviour should be prompted and reinforced.
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DISADVANTAGES
May accidentally reinforce the problem behaviour if it turns into a game.
ADVANTAGES
Protects others from injury and gives the child space and the opportunity to calm down
5.3.3 Physical Restraint Physical Restraint includes any manual methods to restrict, subdue or prevent the movement of any part of a persons body, and involves physically holding the person against their will. Physical restraint involves the use of handson contact through the placement of the carer's body weight in such a manner as to briefly prevent the childs movement. It does not involve the use of restraining devices (see section 4.3.6). Physical restraint may be used when a persons behaviour becomes so uncontrollable that it presents a clear danger to the child or others. Examples of physical restraint include holding the child's wrists to prevent them from hitting others, wrapping arms around the child, bringing them down to ground level, holding them until they are calm, and physically taking the child to another area while holding their arms. These strategies involve physical risk to the people involved therefore carers should be fully trained in their quick and safe implementation.
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Can quickly bring the incident under control, protect the child and others from danger, and can minimise property damage.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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DISADVANTAGES
Can increase the risk of injury to those involved. Can result in an escalation of the behaviour. Can be resource intensive to implement effectively.
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5.3.2 Seclusion Seclusion involves taking the child to a specified area or removing yourself and others from an area and locking the door.
DISADVANTAGES
May lead to an escalation of the disruptive behaviour. There is risk of injury to the child and carer if physical contact is involved. May accidentally reinforce the problem behaviour if the child avoids a disliked activity.
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Child Abuse
6.
CHILD ABUSE
Child abuse is anything which individuals, institutions or processes do, or fail to do, which harms children or damages their prospects of a safe healthy development into adulthood. Physical abuse includes bruising, burning, shaking or beating children. Emotional abuse includes depriving a child of love, warmth and attention; yelling or "picking on" a child. Neglect includes failing to provide basic necessities of lifeadequate diet, medical care, clothing. Sexual abuse includes incest, rape, fondling, "flashing" and other sexual activity. 6.1 ACTIONS WHICH DO NOT MEET THE COMMISSIONS STANDARDS AND ARE NOT TO BE USED The Commission considers the following methods of punishing behaviour unacceptable. They may be considered maltreatment and result in concerns being raised about the child's welfare and further investigation.
Threateningverbal threats of dire consequences. Refusing to provide or withdrawing meals without replacement.
IF YOU HAVE CONCERNS Anyone with concerns about the practices used with a child should raise the issue with those involved. Often problems are resolved through discussion with the person closest to the issue that is of concern. If this action does not immediately resolve the issue the next step may be to speak to this persons supervisor. If your concerns are still not resolved, a complaint can be lodged. If there is an agency involved, contact them and ask how to lodge a
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Introducing foul tasting or harmful substances such as chilli or tabasco sauce. Shouting or screaming at a child. Electric shocks or prods. Spraying substances at children such as water, lemon juice or ammonia.
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Child Abuse complaint. The Commission has a complaints procedure and may also be able to assist in having concerns resolved with other agencies. If you are worried that a child you know is being hurt it is important to trust your instincts. Talking to your doctor, child health nurse, Department of Child Protection officer, or Disability Services Commission staff member can be an important step in keeping a child safe from further harm and in getting help for the child, family and the person hurting the child.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Bibliography
BIBLIOGRAPHY
Axelrod, S. (1987). Doing it without arrows: A review of LaVigna and Donnellan's Alternatives to punishment: Solving behavior problems with nonaversive strategies. The Behavior Analyst, 10, 243-251. Axelrod, S. (1990). Myths that (mis)guide our profession. In A. C. Repp & N. N. Singh (Eds.) Perspectives on the use of nonaversive and aversive interventions for persons with developmental disabilities (pp. 59-72). Sycamore, IL: Sycamore Publishing company. Azrin, N. H., Besalel, V. A., Jamner, J. P., & Caputo, J. N. (1988). Comparative study of behavioral methods of treating severe selfinjury. Behavioral Residential Treatment, 3, 119-152. Bambara, L. M., & Knoster, T. (1998). Designing positive behavior support plans. Washington DC: American Association on Mental Retardation. Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimental analysis and extinction of selfinjurious escape behavior. Journal of Applied Behavior Analysis, 23, 11-27. LaVigna, G. W., & Willis, T. J. (1997). Severe and challenging behavior: Counterintuitive strategies for crisis management within a nonaversive framework. Positive Practice, 2 (2), 1, 10-17. ONeill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R., Storey, K., Newton, J. S. (1997). Functional assessment and program development for problem behavior: A practical handbook. Pacific Grove: Brooks/Cole Publishing Company. Sanders, M. R., & Dadds, M. R. (1993). Behavioral family intervention. Boston: Allyn and Bacon. SulzerAzaroff, B., & Mayer, G. R. (1991). Behavior analysis for lasting change. Fort Worth: Holt, Rinehart and Winston. Zarcone, J. R., Iwata, B. A., Vollmer, T. R., Jagtiani, S., Smith, R. G., & Mazaleski, J. L. (1993). Extinction of selfinjurious escape behavior with and without instructional fading. Journal of Applied Behavior Analysis, 26, 353-360.
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Appendix A
BEHAVIOUR
(e.g., list the desired or problem behaviour)
STRATEGY USED
(e.g., descriptive praise; exclusionary time-out)
OUTCOME
(e.g., he giggled and kept working; length of exclusionary time-out)
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Appendix B
2.
3.
4.
5.
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When the child calms down, set them up in an appropriate activity and reinforce them for their appropriate engagement. Finally: Take care of anyone who was hurt, including the child involved in the incident. Inform the child's parents and other relevant support staff (e.g., at school or day care) as soon as possible. Record what was done and why. Consider emotional support and trauma debriefing to anyone who may be seriously affected by the incident. Ensure that a review of the incident is undertaken. The review should include an assessment of the incident and how to prevent 42
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Appendix B
this occurring again. A psychologist could be consulted to help plan any intervention and to help determine how to avoid such incidents.
Disability Services Commission (2008, June). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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Appendix C
APPENDIX C: RESOURCES
Disability Services Commission Head Office ............................................................................ 9426 Joondalup Office ..................................................................... 9301 Myaree Office ......................................................................... 9329 Accommodation Services ......................................................... 9426 Country Services ..................................................................... 9426 Complaints ............................................................................. 9426 9200 3800 2300 9200 9200 9200
Department for Child Protection Crisis Care ...................................................... 9223 111 or 1800 199 008 Family Helpline ..............................................9223 1100 or 1800 643 000 Parenting Line ................................................9272 1466 or 1800654 432 Department of Education and Training Check phone book for your District Education Office Centre for Inclusive Schooling.................................................. 9426 7111 Communicare 9251 5777 Resource Unit for Children with Special Needs (RUCSN) ............ 9221 5616 Independent Schools Check phone book for appropriate school
Therapy Focus ..................................................................... 9478 9500 Department of Health Check phone book for your local Community Health Service Centre State Child Development Centre............................................... 9481 2203 Psychiatric Emergencies ..................................9224 8888 or 1800 676822 Ngala Family Resource Centre Administration ........................................................................ 9368 9368 Police Check phone book for local police station Training in Implementation of Physical Restraint Professional Assault Response Training .............................(03) 9870 1249 Triple PPositive Parenting Program (parent and practitioner training) Contact your local Disability Services Commission office, community health service centre, or the Parenting Line Triple P International............................................................ (07) 3367 1212
Disability Services Commission (2008, July). Behaviour Support Guidelines for Children. Perth, Western Australia: Author.
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