Northern Virginia Training Center

The purpose of behavioral treatment is to help a person acquire strengths and learn functional skills that will increase self-determination, independence, and social integration. Effective behavioral treatment is responsive to a person's strengths, needs, differences, and preferences, and ensures: 1) a therapeutic environment, 2) services that promote a person's welfare, 3) treatment by competent professionals with appropriate qualifications, 4) programs that teach functional skills, 5) behavioral assessment and ongoing evaluation, and 6) the most effective treatment procedures available (Van Houten, Axelrod, Bailey, Favell, Foxx, Iwata, & Lovaas, 1988). Such treatment provides opportunities for decisions, choices, and activities that facilitate learning.

Purpose & Overview

The foundation of behavioral treatment is functional assessment or analysis of existing behavioral patterns and ecological assessment of relevant physical, social, and treatment/learning environments.

Behavioral treatment procedures must be empirically validated and may include procedures to enhance strengths, to teach functional skills, to produce changes in relevant environments, and to reduce or eliminate problematic behaviors.

Behavioral treatment procedures are not delivered in isolation from or instead of other treatment modalities relevant to a person's overall needs. Rather, these services are developed and delivered as part of an interdisciplinary treatment plan integrating relevant assessment and diagnostic information and treatment procedures.

Terminology contained in this manual is consistent with terminology and definitions in the scientific and clinical literature. To preserve the integrity of this manual and the practices that arise from it, in those circumstances in which a term has both a scientific or clinical connotation, and a social connotation, the scientific or clinical connotation is used.

Access to Treatment

Functional and Empirical Basis. All behavioral treatment programs are based on a clear understanding that behavior serves complex functions for each person, and is controlled by a variety of social, physiological, and ecological variables. Understanding the behavior's function with respect to relevant variables, and the maintaining contingencies of which it is a part, is crucial for designing effective treatments.

Behavioral treatment programs are designed to help all service participants to live, work, play, learn, and receive services in contexts that are as free as possible of undue constraints on their liberties.

The goal of behavioral treatment is optimal use of functionally least restrictive, most effective procedures and supports that produce beneficial results for the person. Exposing a person to any procedure is unacceptable unless it can be demonstrated that the procedure is necessary to produce safe and clinically significant behavior change. It is equally unacceptable to expose a person to less restrictive procedures if assessment results or available research indicates that other procedures would be more effective, or would produce an effective outcome significantly more rapidly.

Professionals who design and monitor implementation of behavioral treatment procedures are trained in behavior analysis, and in ethical and legal principles related to providing such services. The Ethical Principles of Psychologists and Code of Conduct developed by the American Psychological Association (American Psychological Association, 1992), and statement on the Right to Effective Behavioral Treatment published by the Association for Behavior Analysis (Van Houten, et al., 1988) provide the basis for such ethical treatment, as do ethical guidelines found in licensure and certification guidelines for service providers.

Persons who implement behavioral treatment programs are trained in basic techniques of behavior analysis and other forms of treatment relevant to the person, as well as in the procedures specified in the written program for the person. It is acknowledged that there are other empirically validated methodologies related to behavior analysis (e.g., cognitive behavioral therapy and dialectical behavioral therapy), and that these methodologies have appropriate uses, but that they are beyond the scope of this manual.

The careful analysis and arranging of a person's environment as a therapeutically safe, humane, responsive, socially enriched, and pleasant atmosphere for learning is a necessary prerequisite for effective interventions. Improvements in lifestyle such as increasing the opportunities to make choices; and experiencing a variety of activities, people, places, and things, contributes significantly to the therapeutic environment.

Personal preference is assessed and is taken into consideration when designing treatments and therapeutic environments.

Behavioral treatment programs develop skills and contribute to a person's lifestyle as a strategy to reduce problematic behaviors. Analysis of individual need and circumstances, however, determines whether such interventions are appropriately delivered in concert with or exclusive from procedures that directly address problematic behaviors or symptoms. This approach and analysis produces constructive, efficient, durable results with social validity and potential for prevention of future problems.

Procedures are chosen not only on the basis of careful functional and ecological analysis, but also on consideration of ethical issues, such as: the speed with which the behavior can or must be brought under control; the risks associated with the behavior; the risks and benefits of the treatment; and the generalization of effect across responses, other stimuli, and other conditions across time. Regarding the latter, it is acknowledged that some efficacious procedures may require additional procedures to enhance external validity.

As early as possible in planning, the client, along with the client's family, guardian, and Interdisciplinary Team (IDT) members should be collaboratively involved in decisions about the procedure.

Treatment is provided and generalized in those settings in which the person must ultimately function (when appropriate) and is likely to be continued in the natural environment. It is acknowledged, however, that initial acquisition of treatment effects may require delivery of services under more contrived conditions, with generalization of treatment effects to more natural environments explicitly programmed afterwards.

Treatments should not only be evaluated on immediate improvements in the priority behavior, but also long-term behavioral changes that are documented by outcomes showing fuller participation in meaningful daily lifestyles.

Evaluation of treatment efficacy is continuous, and incorporates procedures appropriate to the treatment modality. Reliability of measures and integrity of implementation are regularly assessed, and these indices are considered along with behavioral treatment data when evaluating efficacy. When reliability and/or integrity assessment indicates that behavioral treatment data are unreliable or that behavioral treatment procedures are not being implemented with integrity, steps are taken to improve reliability and integrity, and improvements are reflected in subsequent reliability and integrity data.

Treatments take into account possible health difficulties. It is acknowledged that persons with mental retardation are more likely than the general public to evidence psychopathology (Matson & Barrett, 1982), and that general and acute health difficulties in persons with mental retardation and/or mental illness can influence their behavior. Psychiatric and medical difficulties are assessed and treated using standard techniques adapted to the person's unique needs. When such treatment can impact a client's behavior, appropriate consultation and collaboration is made between medical and psychological providers, and will ensure relevant data collection to assess effects of medical treatment on the client's behavior.

Data-Based Decision Making

Behavior is influenced by a wide variety of variables, crossing social, ambient, physiological, and other domains. Delivering effective behavioral services by necessity involves consulting and collaborating with across disciplines. While professionals are expected to work within the scope of their education, training, and experience, it is expected that all dimensions of a client's behavioral difficulties will be assessed by relevant disciplines, and that resulting treatment programs will be comprehensive, integrated plans which incorporate relevant findings and recommendations across disciplines. It is also expected that treatment decisions will be made following consideration by all disciplines serving a client with regard to a particular issue. All decisions, however, must be made on the basis of programmatic data. It is further expected that all disciplines involved in a client's behavioral treatment will regularly collect data pertinent to their involvement in the client's treatment, and will regularly assess and report on reliability of data collection and integrity with which treatment is provided.

Functional Assessment or Functional Analysis Basis

The first step in treating problematic behavior requires a detailed and systematic analysis of the situation in which the behavior occurs, the circumstances of the person exhibiting the behavior, and the behavior itself. This analysis includes a functional assessment of the problematic behavior, and possibly a functional analysis of that behavior, as well.

Functional assessment is a process by which hypotheses regarding the function of a behavior (i.e., the maintaining contingencies of which the behavior is a part) are determined. Functional analysis is a process by which conditions under which a behavior may or may not occur are varied, and data collected on that behavior, such that contingencies of which the behavior is a part are demonstrated. Information gained through both functional assessment and functional analysis is then used prescriptively to develop treatment procedures to address particular behaviors, as well as to identify alternative behaviors that may better serve the client. Contingencies identified may involve external, environmental stimuli and events; medical/physical factors; social and familial variables; and other factors that either immediately precede or follow the behavior (i.e., discriminative stimuli, reinforcers, etc.), or are more distally related to the behavior (i.e., establishing operations).

The behavioral treatment program should identify factors contributing to the behavior and describe the methods used to reach this conclusion. If results of a functional assessment are sufficiently inconclusive to preclude development of hypotheses that result in logical development and implementation of treatment procedures, functional analysis is conducted and/or appropriate external consultation is secured.

Separate functional assessments or analyses are conducted for each targeted problematic behavior.

Functional assessment and analysis should include consideration of psychiatric problems, particularly when psychotropic medications are used.

All behavioral treatment programs must document the functional assessment or functional analysis procedures conducted to identify contingencies maintaining the behaviors addressed. Functional assessments must consist of the following procedures:

Review of the person's social history
Review of the person's medical history, current medical status, and medication regimen
Structured interviews, such as the Questions About Behavioral Function; Functional Analysis Screening Tool; O'Neill, Horner, Albin, Storey, & Sprague (1990) interview; Functional Analysis of Psychopathology; Rumination Assessment Scale; etc.
Systematic observation and data collection and analysis

Assessment of preference relevant to the target behavior

Adaptive behavior or social skills assessment

Assessment of mental status, or screening for psychopathology using an instrument such as the Diagnostic Assessment for the Severely Handicapped (Second Edition), Reiss Screen, Psychopathology Inventory for Mentally Retarded Adults, Depression Rating Scale-DD Version, DSM-IV checklists, etc.

In addition to considering these procedures, functional analysis also involves:

Manipulation of potentially relevant environmental events in naturally occurring settings, and/or

Manipulation of potentially relevant environmental events under analogue conditions.

Analogue functional analysis is a method for assessing variables that do (and do not) contribute to a person's problematic behavior. This methodology has been developed over nearly two decades' research, and has been proven repeatedly in the behavior analysis literature during this time to be superior to other methods of functional assessment in determining which variables influence a person's behavioral difficulties (Carr, 1994; Horner, 1994; Mace, 1994; Repp, 1994).

Analogue functional analysis involves examining a person's behavior under a set of randomly ordered, controlled conditions. The conditions that are developed and conducted mirror those that the person experiences in her or his daily life. These conditions may include variations on consequences that follow (or do not follow) problem behaviors, antecedents that do (or do not) precede problem behaviors, or both. Data collected on the behavior under these varying conditions lets the psychologist state definitively, in many cases, which types of environmental events influence the person's behavioral difficulties, and which types don't. Having this precise knowledge then lets the psychologist develop treatment procedures, make environmental modifications, and make changes to caregiver practices that specifically target those events that have been proven to influence the person's problem behavior. These practices, procedures, and changes, in turn, can more effectively and rapidly remedy the person's behavioral difficulties. These changes also typically result in reduction and elimination of restrictive interventions.

Alternatives to analogue functional analysis currently exist. Most notably, indirect and descriptive methods of functional assessment are often very useful in determining which variables are likely to (and unlikely to) influence a person's problematic behavior. These methods were developed, by and large, on the basis of analogue functional analysis. That is, analogue analyses were conducted, common outcomes were found from similar procedures, and series of questions or observation and review procedures were developed that produce, in many cases, findings that were very similar to those obtained from analogue functional analysis.

Indirect and descriptive methods of functional assessment sometimes present clear advantages over analogue functional analysis. First, these procedures can be completed much more easily and more quickly than an analogue analysis. When working hypotheses can be generated quicker, treatment can be developed and delivered sooner. Second, given that indirect and descriptive methods are conducted in the person's natural environment, the resulting treatment procedures may be readily applicable to those environments. Third, given that indirect methods typically involve only interviewing, they pose little to no risk to the person whose behavior is being considered.

Although indirect and descriptive methods of functional analysis do have some strengths over analogue functional analysis, there are clear limitations. First, information obtained from indirect methods can be highly subjective, since what the informant is reporting is his or her impressions on the person's behavior. These methods can also have poor reliability and questionable validity. Given these constraints, the findings of indirect or descriptive procedures may be insufficient for treatment development or may lead to development of ineffective treatment procedures. Second, descriptive methods are based on direct observation of behavior, so there is some potential risk to persons, but no more than would be natural in the person's typical environments. Third, observations conducted during descriptive analysis may not be give a representative picture of the person's behavior and circumstances, despite their being conducted in the natural setting. As a result, the conclusions drawn from the observations may be flawed. Fourth, both indirect and descriptive methods only indicate apparent correlations (or lack of correlations) between behaviors and events, and not demonstration of causation between events and behavior, and so there is potential for treatments to be developed on the basis of correlations between behaviors and events that aren't actually related.

In some cases, analogue functional analysis presents clear advantages over indirect or descriptive methods. First, only this method permits the psychologist to definitively state whether a particular set of variables influences a person's behavior. This can be crucial to developing treatment procedures for a person whose problematic behavior has resisted other treatment efforts. Second, analogue functional analysis allows a closer examination of the circumstances under which the behavior does (and does not) occur. This examination permits the psychologist to draw clearer conclusions about the relationship between the person's behavior and environmental events than is possible with other methods. As a result, more precise changes can then be made to the natural environment, to practices of caregivers, or to other variables that are demonstrated to influence the person's behavior. Third, given that analogue functional analyses are often conducted in specially designed environments, and only following assessment of risk and development of strategies to minimize risk, it is likely that analogue functional analysis places the person at less risk of injury than might observation under more typical circumstances, such as in descriptive analysis procedures.

It is essential that the most appropriate procedure be selected and conducted. When it is the case that indirect methods of functional assessment can produce working hypotheses from which effective treatments can be developed and implemented, these procedures should be used. When it is the case that descriptive procedures are needed to augment indirect methods in order to develop effective treatment procedures, these can be used. When it is the case that neither indirect nor descriptive methods of assessment yield hypotheses from which effective procedures can be developed, analogue functional analysis procedures should be used. Use of analogue functional analysis is also advised when there are repeated treatment failures, when those treatments have been based on indirect or descriptive assessment procedures, and when treatment integrity data indicate that the procedures were implemented as planned but were nonetheless unsuccessful.

Guidelines for Conducting Analogue Functional Analysis

Proposal for conducting an analogue functional analysis may originate from the client's psychologist, or from any other member of the client's interdisciplinary team. Regardless, the proposal will be developed only on the approval of the ID Team, and following approval for development, the proposal will be forwarded to the BTRC only after the ID Team has approved of the procedures contained therein.

Proposals for conducting analogue functional analysis will be reviewed by the Behavioral Treatment Review Committee (BTRC) prior to conducting the analyses. No analogue functional analysis will proceed without prior approval from the BTRC.

Outcomes of analogue functional analyses will be reviewed by the BTRC at the first meeting following completion of the functional analyses.

Informed consent for the analogue functional analysis will be obtained from a client's parent, guardian, or authorized representative prior to conducting the analysis. This informed consent will comply with guidelines set forth in the AEthical Principles of Psychologists and code of Conduct of the American Psychological Association.

Analogue functional analysis sessions will be of durations no greater than 15 minutes.

More than one session may be conducted in the same day. However, a client must be permitted a break period between assessment sessions.

Particular analogue functional analysis conditions developed will be devised from descriptive analysis procedures, such that they closely mirror those conditions encountered by the client during the normal course of his or her day.

Prior to conducting the analogue functional analysis, the psychologist will discuss the functional analysis conditions with the client's physician, and the physician will determine physical risks the procedure may pose to the client. The psychologist and physician will devise steps to minimize these risks, as well as any behavioral criteria for terminating a session prior to reaching the session end time. Description of the risk assessment, the risks identified, steps to minimize risk of injury, and behavioral criteria for terminating the session will be included in the proposal submitted to BTRC.

Prior to conducting a session, the client will be assessed by a nurse to determine whether conducting the planned session would be contraindicated for the client at that time, or whether the client evidences any medical condition at that time that may have an adverse influence on that session.

Whenever possible, medications will not be adjusted during the period of time when a client is participating in analogue functional analysis.

When the psychologist determines that conducting the analogue functional analysis in the client's natural environments would not permit sufficient control over environmental events so as to yield useful results of the procedure, or when the psychologist and physician determine that use of a specialized room would minimize risk of injury to the client during the procedure, sessions will be conducted in a room that is away from ongoing activity. The room will be constructed such that potential for injury is minimized. Observation through a one-way mirror will be conducted throughout the session for purposes of data collection and to assure client safety.

When analogue functional analysis procedures will be conducted in a specialized room, they will be reviewed by BTRC and gain BTRC approval prior to conduct. When analogue functional analysis procedures will be conducted in the client's natural environments, the BTRC Chair will be informed of the proposed procedures, and may determine, at his discretion, for the proposal to be brought before BTRC for approval prior to conduct.

No behavioral topography that has been determined by the client's physician and psychologist to pose such risk that every response must be blocked, will be examined using analogue functional analysis.

If, during the conduct of a session, a client demonstrates that he wishes to leave the assessment area, initial efforts will be made to redirect the client back to the ongoing task. However, if the client persists in indicating the wish to leave, the session will be terminated.

Following completion of a day's sessions, the client will be assessed by a nurse to determine whether injury has been sustained.

Following termination of a session upon meeting the medically-psychologically determined termination criteria, the client will be assessed by a physician and/or nurse.

The guidelines published by Hagopian, Fisher, Thomspon, Owen-DeSchryver, Iwata, and Wacker (1997) for use in interpreting analogue functional analysis outcomes will be followed in all cases.

Local Rights Committee Review:

The LHRC will be informed monthly of clients with whom the Psychology Department is planning to conduct analogue functional analyses.
When discussion between the Psychologist and Physician (as specified in Guideline 8, above) has revealed potential risk factors for the client, the LHRC will be notified prior to conducting the analogue functional analysis of the client for whom the procedure is planned, the behaviors to be assessed, the functional analysis conditions proposed, the potential risk factors for the client, and the steps to be taken (determined jointly by the client's Physician and Psychologist) to minimize risk during the assessment (to include behavioral criteria for terminating the session).
When a proposed analogue functional analysis will include at least one condition in which the door of the analogue room will be locked while the client is in the room, the LHRC will be notified prior to conducting the functional analysis.

Data Collection

A large body of literature has demonstrated that one's verbal reports or impressions of one's own, or another's, behavior are often inaccurate (Sidman, 1960/1988; Johnston & Pennypacker, 1980; Poling, Gadow, & Cleary, 1991; Miller, 1997). It has also been said that clinical application of a procedure or a medication is, in actuality, an experiment (Poling et al., 1991). It has further been said that clients have a right to effective behavioral treatment (Van Houten et al., 1988). Given that verbal reports or impressions regarding behavior tend to be inaccurate, it stands to reason that persons receiving treatment have a right to effective data gathering procedures with which to evaluate the efficacy of that treatment, whether behavioral or pharmacological.

Behavior analysis is characterized by reliance on direct observation procedures for purposes of data collection, and subsequent clinical decision making based on those data. Likewise, methodological collection of data on symptoms of psychopathology treated with psychotropic medication, and the utility of basing treatment decisions on such data has been described (Poling et al., 1991). Such data based decision making represents current best practice in both fields, and helps to ensure the effective treatment to which recipients have a right.

In all cases other than emergent use of a procedure or psychotropic medication, baseline data will be collected on relevant dimensions of the behavior or symptomatology prior to implementation of a treatment or medication. Measures will be selected that are appropriate to the behavior or symptom under study, assess relevant dimensions, and are feasible given the conditions under which data will be collected. Staff responsible data collection will be trained to competency by the Psychologist or Psychologist's Assistant responsible for reporting the data. Reliability checks will be conducted, and data will be considered reliable and used for assessment and treatment purposes once a minimum of 80% interobserver agreement has been reached. Assessment of reliability (i.e., interobserver agreement) will continue throughout treatment, and interobserver agreement figures less than 80% will trigger retraining on data collection for individual staff members achieving the deficient scores. Persistent failure to achieve 80% interobserver agreement on reliability checks will result in consultation with appropriate supervisory staff to ensure resolution.

Functional assessment or analysis, and other assessment will be conducted prior to selecting a medication or developing a treatment program. However, treatments will be selected, in part, on the basis of consideration of the baseline data, and treatment efficacy will be evaluated based on comparison of data collected using identical procedures to those used in baseline, during the treatment phase.

Goals and Objectives of the treatment program will be developed, in part, with reference to the dimensional aspects of the behavior or symptoms revealed during baseline data collection, and will be expressed in the same measurement units as those used in the data collection.

Whenever possible, direct observation data will be collected. However, under some conditions, indirect measurement procedures (e.g., self-report or informant-based symptom checklists or measurement scales), when empirically validated, may be appropriately used. When using previously validated indirect measures, it remains essential to periodically assess reliability of those collecting the data.

Behavioral Treatment Program Components

A behavioral treatment program is developed and written by a psychologist after the interdisciplinary treatment team agrees that such a program is necessary to meet the person's needs. The behavioral treatment program is an integral part of the person's interdisciplinary treatment plan. The behavioral treatment program must specify the behaviors to be addressed, the procedures to be used, the data to be collected, and the responsibilities of staff. When intrusive procedures are used, the program includes justification for use of those procedures. The review and approval requirements for a program depend on procedural restrictiveness. Those requirements are listed for each level of restrictiveness under Behavioral Procedures.

Behavioral treatment programs must include the following information:

Pertinent demographic information, to include the client's full name; registration, record, or hospital number; date of birth; and identification of residential living area;
Problem identification, described further in the client's record, that the program is designed to address;
Goals, and objectives to meet those goals, for adaptive and problematic behaviors, as well as symptoms, addressed by the program. Goals and objectives are written such that they are measurable and objectives are time limited.
Operational definitions of all adaptive and problematic behaviors, and symptoms of psychopathology targeted by the treatment procedures;
Identification of parties responsible for implementing the treatment and data collection procedures;
Identification of parties responsible for developing, monitoring, evaluating, and revising the treatment and data collection procedures;
A summary of relevant client biographical information pertinent to development, and to etiology of the problem addressed by the treatment program, to include multiaxial diagnoses and general medical diagnoses;
A summary of baseline and/or comparative data taken on the target adaptive behaviors and problematic behaviors and symptoms addressed by the treatment program, including graphic display;
A summary of previous treatments to address the problem, including identification of particular procedures and medications used, dates of implementation, outcome of implementation, and reasons for revision or discontinuation;
Description of functional analysis or assessment procedures used in developing current treatment procedures, as well as outcome;
Description of risks or implications of the targeted problematic behaviors or symptoms, as well as benefits that might be expected from program procedures;
A concise, step by step description of treatment procedures, to include:

Preventive procedures. This section will include, when applicable, a description of medical or other therapeutic procedures to be followed if determined that the person is experiencing pain, discomfort, or illness which is influencing the person's behavior;
Adaptive Behavior Training and therapy procedures. When these procedures are developed and implemented by another discipline, they will be identified and briefly described in the treatment program, and the data collection procedure used by that discipline will be described as well. The Psychologist will assist the other discipline in ensuring that reliability and integrity measurement is in place for these procedures.
Interdisciplinary training procedures pertinent to the problem addressed by the program
Reactive procedures
Schedule of implementation of training procedures, and schedule of other pertinent therapies

Description of potential adverse reaction of nonpharmacological and pharmacological treatments, including potential medication side effects, plan for monitoring and managing side effects, laboratory studies indicated and schedule of conduct; and options to be considered if side effects occur;
Description of documentation procedures for adaptive and problematic behaviors, and target symptoms, as well as frequency of data collection and parties responsible for data collection;
Description of program evaluation procedures, including schedule of data summarization and review by relevant psychology and psychiatry staff; identification of data reporting schedule and parties responsible for reporting data; identification of review schedule for the entire plan by the client's ID Team, the Psychology Department, by the Psychiatrist in conjunction with Psychology and the ID Team, by the BTRC, and by the LHRC;
A listing of nonspychotropic medications the client receives, dosages and dosing schedule, and indications;
Medical assessment that proposed restrictive procedures are not contraindicated, given the client's medical condition (where applicable);
A schedule of staff training, reliability checking, and treatment integrity checking; as well as descriptions of these procedures, and identification of parties trained and parties responsible for training;
Signatures and titles of program authors;
Signatures and dates of approval (or notification by Facility Human Rights Advocates or LHRC) for parties approving (or notified of) the program;
Informed consent of relevant parties.

Behavioral Profiles

Each behavioral treatment program will be summarized on a behavioral profile. The behavioral profile will include brief descriptions of the following components:

Pertinent demographic information, to include the client's full name; registration, record, or hospital number; date of birth, and identification of residential living area;

Operational definitions of all adaptive and problematic behaviors, and symptoms of psychopathology targeted by the treatment procedures;

Identification of diagnostic information, including multiaxial diagnoses and general medical diagnoses;

Identification of psychotropic medications used (where applicable);

Description of outcome of current functional assessment or analysis procedures;

Concise descriptions of treatment procedures, to include:

Preventive procedures;
Adaptive behavior training procedures;
Reactive procedures;
and general interaction guidelines, where applicable.

Behavioral profiles will be maintained together with data recording forms in all areas where these forms are kept for data recording purposes.

Clinical trials

The procedures described in these guidelines have been demonstrated effective in treating behavioral difficulties in the professional literature. However, it may not be possible to predict their effects in an individual case on an a priori basis. Clinical trials may provide information on a procedure's feasibility and potential effects. Thus a Clinical trial may be employed if the Interdisciplinary Team agrees that a behavioral issue warrants a formal treatment plan, and if, in the professional judgement of the Psychologist, development of a viable treatment can only be derived from actual experience with the treatment.

The proposal for a Clinical Trial will contain the following information:

Rationale for Clinical trial;

Description of target behaviors, to include operational definition; baseline measures of frequency, duration, and intensity; risks and implications of target behaviors;

Setting and Schedule for Treatment, to include procedures to be implemented; data collection instructions; description of reliability and integrity measures to be taken; description of evaluation procedures to assess efficacy;

Interim approval is required for Clinical Trials adding or changing psychotropic medications, or changing dosages to greater than the previously approved maximum dosages, in training centers. Interim approval is needed for addition of Level III procedures, or extension of Level III procedures to additional target problematic behaviors.

Interim approval must be obtained first from the Client's ID Team Chair, Director of Psychological Services (for Level III procedures), and Authorized Representative. Clinical trials of psychotropic medication must be approved by the facility Medical Director must also give interim approval. Next, interim approval must be obtained from the BTRC Chair, and the LHRC will be notified in a manner consistent with the LHRC policies, prior to implementation of the Clinical trial.

Interim approval is given only until the next scheduled BTRC meeting, following which a program should be written and submitted for appropriate approval within 30 days if treatment efficacy has been demonstrated. In that program, the results from the various procedures implemented during the Clinical trial will be summarized under APrevious Interventions.@ If treatment efficacy has not been demonstrated within the 30 day approval period, the procedure will be discontinued.

Any staff member, or any member of LHRC or BTRC may request to have the procedure stopped and fully reviewed by calling a special team meeting. Staff will be trained as in other programs and will be identified as trainers in the Clinical trial proposal.

Behavioral Profiles

Each behavioral treatment program will be summarized on a behavioral profile. The behavioral profile will include brief descriptions of the following components:

Pertinent demographic information, to include the client's full name; registration, record, or hospital number; date of birth, and identification of residential living area;

Operational definitions of all adaptive and problematic behaviors, and symptoms of psychopathology targeted by the treatment procedures;

Identification of diagnostic information, including multiaxial diagnoses and general medical diagnoses;

Identification of psychotropic medications used (where applicable);

Description of outcome of current functional assessment or analysis procedures;

Concise descriptions of treatment procedures, to include:

Preventive procedures;
Adaptive behavior training procedures;
Reactive procedures;
and general interaction guidelines, where applicable.

Behavioral profiles will be maintained together with data recording forms in all areas where these forms are kept for data recording purposes.

Clinical trials

The proposal for a Clinical Trial will contain the following information:

Rationale for Clinical trial;

Description of target behaviors, to include operational definition; baseline measures of frequency, duration, and intensity; risks and implications of target behaviors;

Behavioral Procedures

Although these procedures may be employed during mealtime, and although a body of literature exists documenting efficacy of a number of these procedures in promoting improved intake and relevant mealtime behavior (Allison, 1995; Babbitt, Hoch, Coe, Cataldo, Kelly, Stackhouse, & Perman, 1994; Hoch, Babbitt, Coe, Krell, & Hackbert, 1994), these procedures should not result in unplanned alterations in the amount of food a client normally consumes. If, on occasion, use of one or more of these procedures does result in delaying offering the meal, the meal will be maintained in a safe, hygienic manner, and offered to the client after termination of the procedure. If the meal should become unsuitable for consumption as a result of this delay, an alternative meal will be provided.

When a procedure is part of a client's behavioral treatment program, only staff trained to implement that program with that client may implement that procedure. Documentation will be maintained by pertinent discipline staff and forwarded to the Training Department.

Level I procedures may be used as part of a behavioral treatment program, as part of a program developed by another discipline, or independently of a program. Level II and III procedures may only be used as part of a behavioral treatment program.

If a client is injured during implementation of a procedure, a nurse and the on-site supervisor will assist in monitoring the client, determine whether to release the client, and determine (in consultation with the Psychologist) which alternative behavioral procedure will be used during and following medical treatment prior to release.

If time limits indicated for particular procedures listed below need to be extended, if an unusual incident occurs during conduct of a procedure, or if the form of the procedure or the client's response to it is questionable, the on-site supervisor must notify a Psychologist or other staff member (following procedures for contacting a back-up Psychologist) to obtain approval to continue the procedure.

Prohibitions: The Commonwealth of Virginia specifically prohibits use of:

Corporal punishment (slapping, hitting, spanking, etc.) and verbal abuse (shouting, screaming, swearing, name calling, threatening, and demeaning gestures or any other act that would be damaging to an person's self-respect).
Seclusion (e.g., placing a person alone, in an unmonitored or key-locked room).
Totally enclosed cribs.
Situations in which persons served discipline other persons served, except as part of an organized self-government program that is conducted in accordance with written policy. Written house rules devised by clients' agreement is an example of a self-government program that is not prohibited.
Any procedure implemented primarily for the convenience of staff, family members/guardians, etc, or as a substitute for providing appropriate supervision and/or habilitation by appropriately trained staff.
Denying meals, breaks, sleep, or the opportunity to maintain personal hygiene. Under certain specified conditions, however, temporary delay may occur.
Forfeiture of money or personal property, except as part of an approved plan wherein the client is asked to replace property which the client is known to have damaged intentionally.
A staff person violating any of these prohibitions will receive disciplinary action according to the standards of conduct for state employees.

Level I: Unrestricted Procedures

Usage. The procedures listed in this section are considered nonrestrictive and may be used incidentally, as need arises, programmatically, or may be incorporated by other disciplines in their treatment or teaching procedures. Special considerations may exist for use of some of these procedures in some circumstances, and are described in the Definitions section. Finally, these procedures may also be incorporated into programs that contain procedures of higher levels.

Required approval. When used programmatically by Psychology or other disciplines, must be part of a written plan, and requires ID Team approval.

Required documentation and evaluation. When used as part of a behavioral treatment program, data for the target adaptive or problematic behavior will be collected on a regular basis to evaluate the effects of treatment. In some cases, however, indirect measurement (i.e., use of checklists to assess current level of symptoms) may be appropriate. The data must be reviewed monthly by the psychologist responsible for the program, and an entry made in the client's record. The data will be reviewed at minimum semi-annually by the Director of Psychological Services, and monthly by the ID Team.

Supervision. The professional(s) responsible for the program will train relevant staff in implementation of the procedure and in data collection procedures, and will monitor the use of the procedure, including regularly assessing treatment integrity and reliability of data collected. ID Team and Departmental reviews of the program will include consideration of reliability and integrity data.

Level I procedures are listed below.

Backward Chaining
Caregiver Management
Chaining
Contingency Contracts (involving only Level I procedures)
Differential Reinforcement
Discrimination Training
Environmental Management
Environmental Restitution or Restoration (which does not include property replacement)
Extinction
Fading
Graduated Guidance
Non-egress-prevented Exclusionary Time Out
Nonexclusionary Time Out
Positive Reinforcement
Prompting
Redirection
Relaxation Training
Response Blocking (not to exceed 60 seconds of continuous physical contact)
Response Interruption
Shaping
Total Task Training

Level II: Procedures Restricted to use in Behavioral Treatment Programs

Usage. Procedures in this section may only be used when part of a written behavioral program. Although the following requirements must be met to obtain approval for all procedures listed below, special considerations are placed on use of some, and are described with the procedures in the Definitions section. Level II procedures are intrusive procedures.
Required review. All Level II procedures require review and approval by the ID Team, BTRC, and Client/Guardian/Authorized Representative, and notification of the Facility Human Rights Advocate prior to implementation, and yearly thereafter. Approval will be contingent on documentation of severity of the problem, lack of success or lack of probable success (based on consultation with relevant clinical literature) of less intrusive alternatives, consideration of the risks associated with the procedure, technical adequacy of the plan, and proper consideration of the client's rights. A procedure may be temporarily approved by the BTRC Chair, Facility Director, and Client/Guardian/Authorized Representative, and the Facility Human Rights Advocate notified absent of BTRC approval, but approval is in effect only until the procedure is reviewed at the next regularly scheduled BTRC meeting.
Required documentation and evaluation. Data pertaining to target behaviors and to implementation of these procedures must be collected using procedures approved by the BTRC (or BTRC Chair in the event of temporary approval). Data must be reviewed at least monthly by the Psychologist responsible for the program, and an entry made in the client's monthly progress note. Data must be based on direct observation of targeted adaptive and problematic behaviors, although indirect measurement (i.e., use of rating scales or checklists to rate level of symptoms) may be appropriate. Additionally, treatment integrity and data reliability will be assessed regularly. Target behavior and symptom data, and integrity and reliability data will be considered by the Psychologist and the ID Team monthly, the Director of the Psychology Department semi-annually, and the BTRC annually to evaluate treatment efficacy. When such evaluation indicates that the particular procedure is not effective, steps will be taken by the Psychologist and ID Team to enhance potential for efficacy, or to re-evaluate the problem and revise procedures. These steps will be documented in a progress note, and changes will be made in a timely manner.
Supervision. To ensure proper conduct of these procedures, the written program will specify the particular competency based staff training procedures, as well as treatment integrity and data reliability assessment procedures to be used. The Psychologist or Psychologist's Assistant will maintain documentation of staff trained, and of integrity and reliability measures. When integrity falls below 100% for a particular staff member, or reliability below 80%, that staff member will be retrained in pertinent components of the program, and this training will be documented. Should a staff member repeatedly demonstrate integrity or reliability less than these criteria, the Psychologist will inform the supervisor of the staff member. The supervisor will then be responsible for taking remedial or administrative action.
Level II procedures are listed below.
Contingent Effort
Egress-prevented Exclusionary Time Out (maximum duration of less than 30 minutes)
Extinction or Differential Reinforcement (in which the topography on extinction is determined by the interdisciplinary team to have serious potential for injury to the client or to others)
Preferred Equipment
Protective Equipment
Response Cost (periods of less than 30 minutes)
Social Disapproval

Level III: Procedures Requiring BTRC Approval and LHRC Notification

Usage. The procedures listed in this section may be employed on a regular basis when they are part of a written program. Although the following requirements must be met to obtain approval for any of the procedures listed below, special restrictions are placed on use of some, and are described along with the definition of the procedure in the section so named.
Required review and approval. Approval signatures must be obtained from the following: Psychologist, Chair of Psychology Department Peer Review Committee, Director of Psychological Services, QMRP/QMHP, Team Physician, Psychiatrist (when involved), Client/Guardian/Authorized Representative, and BTRC Chair, and signatures indicating notification and review by the Facility Human Rights Advocate and LHRC Chair. In addition, all authors of the program must sign the program in the section so named. Approval will be contingent on documentation of the severity of the problem, lack of success or lack of probability of success of less intrusive procedures (based on review of relevant clinical literature), consideration of risks associated with the procedure, technical adequacy of the plan, and proper consideration of the client's rights. Approval and notification must be documented prior to implementation of the program, and the program will be reviewed for approval by the BTRC quarterly, and will be presented to the Facility Human Rights Advocate and LHRC quarterly, as well.
Required documentation and evaluation. Data collected regarding targeted adaptive and problematic behaviors and symptoms must be collected in accordance with data collection procedures described in the approved program. Data must be based on direct observation, although some indirect measures (i.e., checklists or rating scales to measure symptoms) may be appropriate. In addition, treatment integrity and data reliability will be assessed regularly. Behavioral and symptom data will be reviewed by the Psychologist and an entry made in the client's record no less than monthly. Target behavior and symptom data, and integrity and reliability data will be considered by the Psychologist monthly, the ID Team monthly, Director of the Psychology Department quarterly, and the BTRC quarterly to evaluate treatment efficacy. When such evaluation indicates that the particular procedure is not effective, steps will be taken by the Psychologist and ID Team to enhance potential for efficacy, or to re-evaluate the problem and revise procedures. These steps will be documented in a progress note, and changes will be made in a timely manner.
Supervision. To ensure proper conduct of these procedures, the written program will specify the particular competency based staff training procedures, as well as treatment integrity and data reliability assessment procedures to be used. The Psychologist or Psychologist's Assistant will maintain documentation of staff trained, and of integrity and reliability measures. When integrity falls below 100% for a particular staff member, or reliability below 80%, that staff member will be retrained in pertinent components of the program, and this training will be documented. Should a staff member repeatedly demonstrate integrity or reliability less than these criteria, the Psychologist will inform the supervisor of the staff member. The supervisor will then be responsible for taking remedial or administrative action.

Level III procedures are listed below.

Aversive stimulation
Egress-prevented Exclusionary Time Out (maximum duration of greater than 30 minutes but less than 60 minutes)
Isolated Time Out (durations less than 60 minutes)
Physical Restraint, Partial Mechanical Restraint, and Full Mechanical Restraint
Programmatic use of mechanical or physical restraint
Response Cost (for periods greater than 30 minutes)
Restitutional or Restorational Property Replacement

Use of Psychotropic Medications

Psychotropic medications will be used only to treat symptoms of psychiatric disorders diagnosed by a psychiatrist, physician, or licensed psychologist. A behavioral treatment program will be developed whenever psychotropic medications are used, which integrates pharmacological treatment with behavioral therapy, treatment, and/or training procedures; and data collection procedures specific to the particular symptoms targeted, adaptive behaviors to be established or improved, and problematic behaviors to be reduced or eliminated.

Behavioral treatment programs incorporating psychotropic medications must be approved and reviewed by the client's Psychologist, Chair of the Psychology Department Peer Review Committee, Director of Psychological Services, QMRP/QMHP, Team Physician, Psychiatrist, BTRC Chair, and the Client/Guardian/Authorized Representative, prior to implementation. The Facility Human Rights Advocate and Local Human Rights Committee must likewise review the program prior to implementation, and the Facility Human Rights Advocate and Chair of the Local Human Rights Committee must sign the program, indicating that they have received notification of it, prior to implementation. In addition, all authors of the program must sign the program in the section so named. Approval will be contingent on documentation of the severity of the problem, demonstrated clinical suitability for treatment of the symptomatology with the proposed medication regimen, consideration of risks associated with use of the medication, technical adequacy of the plan, and proper consideration of the client's rights. Programs incorporating psychotropic medications and only Level I or Level I and Level II procedures will subsequently be reviewed by the BTRC for approval yearly, and by the Facility Human Rights Advocate and LHRC annually, as well. Programs incorporating psychotropic medications and Level III procedures will be reviewed for approval by the BTRC quarterly, and by the Facility Human Rights Advocate and LHRC quarterly, as well.

Data regarding targeted adaptive and problematic behaviors, and targeted symptoms must be collected in accordance with the data collection procedures described in the approved program. Data must be based on direct observation or on use of a measurement system validated for use in measuring the symptoms of the client's diagnosed disorder. In addition, treatment integrity and data collection reliability will be assessed regularly. Behavioral and symptom data will be reviewed by the Psychologist and an entry made in the client's record no less than monthly. Behavioral and symptom data will be reviewed jointly by the Psychologist and Psychiatrist and an entry made in the client's record no less than quarterly. Target behavior and symptom data, and integrity and reliability data will be considered by the Psychologist monthly, the Psychologist and Psychiatrist Quarterly, ID Team and Director of the Psychology Department quarterly, and by the BTRC and LHRC yearly, to evaluate treatment efficacy. When such evaluation indicates that the particular medication or dosage of the medication is not effective, steps will be taken jointly by the Psychologist and Psychiatrist, along with the ID Team, to enhance potential for efficacy, to reconsider use of the particular medication regimen; or to re-evaluate the problem and revise procedures. These steps will be documented in a progress note, and changes will be made in a timely manner.

To ensure proper conduct of various programmatic procedures, the written program will specify the particular competency based staff training procedures, as well as treatment integrity and data reliability assessment procedures to be used. The Psychologist or Psychologist's Assistant will maintain documentation of staff trained, and of integrity and reliability measures. When integrity falls below 100% for a particular staff member, or reliability below 80%, that staff member will be retrained in the pertinent components of the program, and this training will be documented. Should a staff member repeatedly demonstrate integrity or reliability less than these criteria, the Psychologist will inform the supervisor of the staff member. The supervisor will then be responsible for taking remedial or administrative action.

Only a psychiatrist or other licensed physician may prescribe psychotropic medication. Psychotropic medication may only be administered by a physician, nurse, or qualified medication aide. Regarding the other procedural components of the program, however, staff trained to use the remaining components of the program with the specific client (documented on training records maintained by the psychologist and forwarded to the Training Department) may conduct those procedures. Non-medication related components of such programs must be written by a Psychologist.

Procedural Definitions and Special Considerations

Level I Procedures

Backward Chaining refers to development of specific sequences of behavior by initially reinforcing the last response in the desired sequence. Earlier responses are then trained in a reverse sequential fashion such that the final link trained in the behavioral chain is the first response in the natural sequence. In this procedure, the entire chain may be performed on each trial through guidance; however, instruction, including prompting, prompt fading, and reinforcement begins on the last step and proceeds to an established criterion before training is initiated on the next previous link in the chain. Special Considerations: None.
Caregiver Management refers to analysis and modification of reactional, interactional, supervision, or other aspects of caregiver behavior, based on consideration of potential functional relations between caregiver behaviors and client adaptive and problematic behaviors, which lessens probability of problematic client behaviors and increases probability and opportunity for adaptive behaviors. Special Considerations: None.
Contingency Contracts involve a written contractual agreement between a client and staff in which occurrence of targeted behaviors (adaptive, problematic, or both) will result in application of specific consequences (desired and undesired). Special Considerations: Contingency contracts that involve only Level I procedures will be considered Level I procedures. Those involving Level II (but no Level III) procedures will be considered Level II procedures. Those involving Level III procedures will be considered Level III procedures. Included in the contract are the identification of specific target behaviors, staff and client expectations, consequences of targeted problematic behaviors, and performance criteria leading to fulfillment of the contract. The contract is written in a manner that the client understands. The client demonstrates understanding of the contract on questioning.
Differential Reinforcement refers to a contingency in which one behavior or topography is reinforced, and behaviors or topographies other than the specified behavior or topography are extinguished. When any behavior other than a specified problematic behavior is reinforced, and the specified problematic behavior is extinguished, the procedure is termed differential reinforcement of other behavior (DRO), or Omission Training. When a behavior that is physically incompatible with a particular targeted problematic behavior is reinforced and all other behaviors (including the problematic behavior) are extinguished, this procedure is termed differential reinforcement of incompatible behavior (DRI). When a particular adaptive behavior is reinforced and all other behaviors (including the problematic behavior) are extinguished, this procedure is termed differential reinforcement of alternative behavior (DRA). Alternatively, a contingency in which behaviors that exceed or are lesser than a particular frequency or intensity are reinforced, while all other instances of the targeted behavior are extinguished. The former procedure is termed differential reinforcement of higher rates of behavior (DRH), and the latter is termed differential reinforcement of lower rates of behavior (DRL). Special Considerations: The extinction component of differential reinforcement should not be partially applied. When the extinction component is used, the reinforcer must be withheld completely following the response for a period of time long enough to eliminate the response. A minimal delay of several seconds to several minutes must elapse before access to the reinforcer is again available. Extinction frequently produces an initial increase in responding and must not be used without adequate monitoring and protection for self-injurious or aggressive behavior. When Extinction is used as a treatment component for aggressive or self-injurious behavior which could likely result in injury to self or others, then the procedure becomes a Level II procedure.
Discrimination Training refers to a differential reinforcement contingency in which one behavior or topography is reinforced in one or a specified set of circumstances (i.e., locations, times of day, in the presence of particular people, etc.), and that same behavior or topography is extinguished under all other circumstances. Special Considerations: The extinction component of differential reinforcement should not be partially applied. When the extinction component is used, the reinforcer must be withheld completely following the response for a period of time long enough to eliminate the response. A minimal delay of several seconds to several minutes must elapse before access to the reinforcer is again available. Extinction frequently produces an initial increase in responding and must not be used without adequate monitoring and protection for self-injurious or aggressive behavior (Alabama Department of Mental Health and Mental Retardation, 1998). When Extinction is used as a treatment component for aggressive or self-injurious behavior which could likely result in injury to self or others, then the procedure becomes a Level II procedure.
Environmental Management refers to analysis and modification of an person's living, working, or leisure environment on the basis of client capabilities and preferences, resulting in lessened probability of problematic behavior and increased opportunities and probability of adaptive behaviors, Special Considerations: When modifying a living, working, or leisure activity which will be simultaneously used by other persons, rights and needs of those people will be considered along with those of the target person.
Environmental Restitution or Restoration without Property Replacement refers to contingent return of an environment to its pre-problematic behavior condition following occurrence of a problematic behavior which alters the environment. Special Considerations: Environmental restitution or restoration which does not require a client to replace damaged property through use of the client's own property or funds may be classified as a Level I procedure. Requiring replacement through use of the client's own property or funds results in classification as a Level III procedure.
Extinction refers to disruption of a previously operative reinforcement contingency, such that the reinforcement that previously followed a particular behavior no longer follows that behavior; or such that the reinforcement that previously followed a particular behavior now is delivered noncontingently, irrespective of that behavior. The latter procedure is sometimes termed noncontingent reinforcement. Special Considerations: Extinction, not involving noncontingent reinforcement, should not be partially applied. When extinction is used, the reinforcer must be withheld completely following the response for a period of time long enough to eliminate the response. A minimal delay of several seconds to several minutes must elapse before access to the reinforcer is again available. Extinction frequently produces an initial increase in responding and must not be used without adequate monitoring and protection for self-injurious or aggressive behavior. When Extinction is used as a treatment component for aggressive or self-injurious behavior which could likely result in injury to self or others, then the procedure becomes a Level II procedure.
Fading refers to gradually modifying antecedent stimuli or stimulus schedules so that a response that originally tended to occur only in presence of one set of stimuli will eventually be occasioned by a different set of stimuli (Alabama Department of Mental Health and Mental Retardation, 1998). Special Considerations: None.
Forward Chaining refers to development of specific sequences of behavior by initially reinforcing the first response in the desired sequence. Training on later responses is added in a forward fashion so that the final link added to the behavior chain is the last response in the sequence. In this procedure, each step in the chain may be completed each trial. However, training begins on the first step and proceeds to an established criterion before training is initiated on the next link in the chain. Special Considerations: None.
Graduated Guidance, also called Three Step Guided Compliance, refers to a prompt hierarchy in which a person is prompted to engage in a particular activity first with a verbal prompt (with engagement reinforced), next with a verbal and gestural/visual prompt (with engagement reinforced), and next with a verbal and physical prompt (with engagement not reinforced), with level of prompting increasing in response to the client's response to the prior prompt. Special Considerations: Ample time must be given following a prompt for the person to reasonably initiate the prompted behavior.
Non-egress-prevented Exclusionary Time Out refers to verbally or verbally and gesturally directing a person to a different, open location contingent on emission of a targeted problematic behavior, with return to the original environment contingent on termination of the problematic behavior, or termination of the problematic behavior plus achievement of a prespecified calm criterion. Total duration may not exceed 30 minutes. No measures are taken to prevent egress from the alternative location. Special Considerations: Verbal instruction to move to the alternative location may not take the form of a threat, or any other type of statement that would be contrary to the person's civil liberties.
Nonexclusionary Time Out, also called Local Time Out, refers to temporary withdrawal of social attention by a person or group of people from a person, contingent on occurrence of a targeted problematic behavior by that person. Does not involve relocation of the person to another area. Social attention is returned following elapsing of a specified period of time, subsiding of the target behavior, or when the person has achieved a prespecified calm criterion. Special Considerations: Although social attention is temporarily withdrawn, the person must remain under supervision of the staff person/people present. Nonexclusionary time out is most effective when all present withdraw social attention contingent on the behavior. Nonexclusionary time out will most likely not be effective for behaviors that are not maintained by social attention they produce. Nonexclusionary time out is not indicated for behavior maintained by a negative reinforcement contingency. See special considerations under Extinction.
Positive Reinforcement refers to response contingent presentation of an object or event that results in an increase in the frequency, duration, intensity, or another dimension of that behavior. Special Considerations: When used programmatically, positive reinforcers will be most effective when identified empirically. Use of food or drink as reinforcers must be approved by the Interdisciplinary Team, including the client's physician and dietitian. Use of food or drink must also comply with the client's prescriptions made by the facility's Nutritional Management Team.
Prompting refers to temporary provision of an artificial antecedent stimulus including verbal, visual, and physical cues that increase the probability of a target behavior. Special Considerations: None.
Redirection refers to instructing or requesting a person to engage in an alternative activity, to terminate the original activity or to prevent occurrence of a problematic behavior. Special Considerations: None.
Relaxation Training is a procedure by which a person is first taught to achieve muscular relaxation, and then stimulus control of this procedure is transferred to anxiety or other arousal inducing circumstances, such that the person learns to relax under conditions which previously induced anxiety, agitation, or a similar state. Special Considerations: The nature of the condition inducing the state must be considered. In some cases, treatment may involve altering those conditions.
Response Blocking refers to placing a barrier between a portion of a person's body and an object, between a portion of a person's body and another person, or between one portion of a person's body and another portion of the person's body such that a response may not be completed, contingent on initiation or attempted initiation of the response. Special Considerations: If the person whose behavior is being blocked tries to continue with the action being blocked, then the person blocking the action may only apply resistance sufficient to prevent continuation of the action being blocked. That is, the person blocking the action must not counteract the resistance of the person whose behavior is being blocked in any way other than to provide equal resistance so as to hold that person stationary until resistance is lessened. The person blocking the action must use an open hand, or an approved object that will be unlikely to cause injury to the person. The person blocking the action may not in any way grasp the person whose behavior is being blocked. The risk of making problematic behavior worse must be monitored and considered whenever this procedure is used (Alabama Department of Mental Health and Mental Retardation, 1988). Response blocking involving holding for longer than 60 seconds will be considered physical restraint.
Response Interruption refers to termination of a sequence of responses by directing the person to an alternative behavior early in the sequence. Special Considerations: Response interruption will be most effective if the Alternative behavior to which the person is directed is one that is either explicitly reinforced or which produces automatic reinforcement for the person. To minimize probability that this procedure will lead to indirect reinforcement of incipient forms of problematic behavior, or that incipient forms of problematic behavior may come to have mand function, noncontingent access to reinforcing activities and events must otherwise be readily available in the person's environment.
Shaping refers to differential reinforcement of successive approximations toward a target behavior, with extinction of previously reinforced approximations. Special Considerations: The extinction component of differential reinforcement should not be partially applied. When the extinction component is used, the reinforcer must be withheld completely following the response for a period of time long enough to eliminate the response. A minimal delay of several seconds to several minutes must elapse before access to the reinforcer is again available. Extinction frequently produces an initial increase in responding and must not be used without adequate monitoring and protection for self-injurious or aggressive behavior.
Total Task Training involves reinforcing response in each link of a chain of behaviors from the first to the last on each trial.

Special Considerations: Total task training should only be used when there is clear evidence that backward or forward chaining are inappropriate training methods for the person learning the skill and when specific steps are taken to prevent the person from becoming dependent on within-task verbal prompts (e.g., when the "wait, ask, say, do" method of prompting is used to minimize prompt dependence) (Alabama Department of mental health and Mental Retardation, 1998).

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Procedural Definitions and Special Considerations