One Cannot Prevent Meltdowns By Using Restraint

A Theoretical Aside

This post comes from my experiences the last few weeks. I have been working with a number of students that have been a danger to themselves and others. As such, I have had to use physical restraint to ensure maintained safety of students and others around them.

Fewer people were injured because I used restraint methods, but I still feel terrible for having to use MANDT restraints after my preventative strategies proved ineffective. I have found that school teams often have difficulty in understanding why I feel like an abject failure whenever I have to restrain students. To the untrained eye, the intervention worked-and it is hard to understand why I am so disappointed.

This post is my explanation.

The Escalation / Crisis Cycle

escalation

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I start with two diagrams to show that escalation is not an all or none phenomenon. We all go through several steps.

  1. Calm or Baseline Phase
  2. Triggered or Stimulation Phase
  3. Agitated/Acceleration or Escalation Phase
  4. Peak or Crisis
  5. De-Escalation Phase
  6. Recovery or Stabilization/Post Crisis Phase

The important components of this post are as follows:

The Calm or Baseline phase is not the same for everyone. In fact, in my experience, there are a surprisingly large number of children that do not have the luxury of having a true baseline level. If they have a hard home life, trauma in their past, or some conflict with and adult or other students, they may actually start the day at the Triggered phase.

The Triggered phase of the crisis cycle is deceptively named. For most people who start at a Calm baseline, the Triggered phase does not involve outward signs of agitation or stress. When a child is triggered, this sets the stage for responses to stimuli that are of a much greater amplitude than they would be had the student not been triggered.

The Agitated phase is when the child moves beyond simply being Triggered and begins to show outward signs of stress and annoyance. The child will become intolerant to stimuli they would otherwise tolerate. This is actually the phase most children are in when we erroneously say they have been Triggered.

The Acceleration phase is when the Agitated phase starts to self-perpetuate.

The Peak or Crisis stage is, in my opinion, by far the most  misunderstood stage. At this stage the child is disconsolate. Meaning there is NO WAY anyone can intervene to “bring them down” – and yet this is the stage most adults start to intervene.

The De-Escalation phase is deceptively tricky. Most adults do not  realize that a student fresh off a Crisis are very easy to re-escalate back into Crisis.  The De-Escalation Phase is oftentimes even closer to Crisis than the Acceleration phase.

Recovery is a refractory period between Crisis and Calm. It is only at this phase that it is appropriate for an adult to intervene and discuss the Crisis with the child.

How Should We Handle a Student in Crisis?

Optimally, we don’t let things escalate this far. We back off earlier in the escalation or crisis cycle, either by anticipating the Trigger or recognizing the Agitation phase for what it is.  The easiest way to do this is to back off. Give the child space. Most of the time your help is not actually  helpful at this point.

That said, backing off is not an option if a student uses violence or aggression during their Agitation, Acceleration, or De-Escalation phases. In these cases, intervention is unavoidable. Below I will explain how we can intervene. But first, I will cover how our interventions are often the coup de grace or straw that breaks the camel’s back that sends the child into full-blown crisis.

What Do We All Do Wrong

The diagram below describes the cycle that adults and children get into when there is a conflict. As adults, we often fail at taking the perceptions and feelings of others into account when we work with them.

why-conflicts-escalate

When a student is Agitated or in the Accelerating phase of the crisis cycle, they perceive intervention from an adult as a threat rather than as help. Because the child perceives a threat, the child either goes into a fight or flight mode or else they get angry. This means the student will react to the adult as an enemy rather than a friend-regardless their relationship 5 minutes or even 5 seconds earlier.

Well, because as the adult we fail to account for this side of the cycle, we react to the student’s reaction by getting escalated ourselves, and we go through the same behavioral cycle as the child. This turns into a vicious feedback cycle that results in both the adult and the child saying and doing things they will later regret and would not normally do.

How Do We Do It Right?

I distinguish the above cycle of conflict of serial reactions to stimuli from an adult taking a step back and responding appropriately. My operational definitions for these words are reaction = acting upon stimulus without prior thoughts. Response = acting upon stimulus with prior consideration of multiple options and antecedents.

When we find a student that has been Triggered, we need to take a step back and ask ourselves some questions.

  • Did I just do something that triggered the student?
  • Did something happen to the student at school today that might have triggered them?
  • Did something happen in the student’s home life that might have triggered them?

If we do not know the answer, there are two things we can do. We can – I know this is revolutionary – ASK THE STUDENT how they are feeling. If they are unable or unwilling to answer, that is why we have phones. Reach out and communicate with the child’s family or other teachers/paraprofessionals that may have some information.


If this proves fruitless, we move onto the next step. If the student is triggered or agitated, we can still engage them in a dialogue. Importantly, the adult must take care to not take a dictatorial tone. The adult is on a fact finding mission, not on a quest to solve any problems. In fact, if an adult tries to impose a solution on the child at this point, it will likely be interpreted as either unfair, controlling, or demanding…and the child will escalate toward the Accelerating phase.

If, however, we let the student talk (and this does often involve a fair amount of cursing and swearing), they often can de-escalate themselves or else discover their own trigger. Since they are in control, they can be receptive to an adult guiding them to a Calm state. Letting the child express themselves in a free and safe environment will often naturally guide them into a Calm state, but if you, as the adult, impose yourself and try to correct their language or minimize the child’s emotions, you are not recognizing how the child feels and they will likely escalate.


Let us assume we cannot help at the Agitation phase. If a student is at the Accelerating phase (or the De-Escalation phase as they are handled the same way), BACK OFF. Literally. BACK OFF. Give the child as much space as possible and do not bother them. You can only make things worse at this point. Even proximity will result in further acceleration toward a crisis.

Sometimes body blocking is necessary, so we do it. But it is obligatory we KEEP OUR MOUTHS SHUT. If we have to take something away from the student, we do so SILENTLY or just say with a flat affect, “Not an option”. Nothing more. Even this runs a major risk of driving a student toward crisis. We cannot give any emotional fuel to the hell fire in potentia.

If the student has an option of a safe space, dark spot, or quiet corner, this is a good time to remind a student (REMIND, never demand), that they have the option of separating themselves into their special space. Again, if we demand the student do this or tell them to go over there to cool off, we probably just ticked them off. The Accelerating phase is typified by a defiant attitude and self-preservation – not taking advice.


Now to the hard part. Crisis. What do we do when there is crisis. I wish I could say, “Run away”, but that is not always an option.

monty-python-run-away-o

So, if running away and giving oodles of space fails, we are left with one of the hardest things we can do. KEEPING A CHILD IN CRISIS SAFE. Most of the time this takes the form of clearing the classroom or else getting the student to a safe space where they cannot hurt anyone.

Amazingly, that is the easy part.


If the above fails, we have another responsibility-and this is the hardest bit-we have to make sure the student does not hurt themselves or others. This is where restraint methods come in. And the probability of both the adult and the child getting seriously hurt goes off the scale.

Restraint is not to be taken lightly and is the absolute last resort in any crisis situation. Touching a student in crisis is often not a great idea and is almost always dangerous, both to the adults and to the child. This is why every other option needs to be employed prior to even considering restraint. In fact, even grabbing a student’s hand or using an arm to prevent an elopement can cause problems.

I say backing off and letting the kid blow off steam is the easy part because it does not involve a physical interaction, Whenever a child is escalated, even if they are in the Accelerating or De-Escalating phase, touch will often send them from 0-100 in a microsecond.


This video below shows one of my behaviorist heroes, Cesar Milan, making a mistake of touching an animal in crisis. Everyone was safe until he touched the dog. Cesar carefully took the dog through the escalation cycle from Calm, to Triggered, to Agitated, to Acceleration, to Crisis, and to De-escalating phases. However, even though it was during the De-escalating phase, as soon as Cesar touched the dog, everything became complicated. I particularly like this video because it explains the dog behavior along the Escalation/Crisis cycle.

I Feel Terrible When I Lose Control Of The Situation

Whenever I restrain a student, I lose. They lose. We all lose. The student ends up a sweaty mess of emotions and snot, and I often end up bruised and bitten. I have to use restraint, I feel like Cesar in the above video explaining to the people around him how he screwed up and missed something. Then Cesar had to walk away and lick his wounds. Additionally, the dog learned nothing from the experience other than he was able to bite Cesar (which will increase the probability of it happening again).

I feel terrible for all the reasons displayed in this video. Cesar missed something because he was distracted and it resulted in injury to himself and complete loss of control of a situation. I always ask myself, “What did I miss? What could I have done to prevent this? Where did I screw up?” immediately followed by an, “is the student okay? Are they hurt? Are they still freaking out? DO they understand what just happened?”. Then I ruminate and perseverate on the experience for a few hours.

EVERY. SINGLE. TIME. I have to use restraint methods I am able to find something that I missed during the escalation/crisis cycle that would have prevented further escalation. There is always something I did not notice. Some tone of voice I missed. Some frustration I accidentally projected.  Some accidental sarcasm on my part. An eye roll. A smirk. A mistake. An oversight. A lack of control over my surroundings that resulted in an additional trigger.

How Do I Do Better?

I have spent a lot of time mulling over in my mind what I can do better to help de-escalate kids when they are not in control of themselves. By applying my background as a behaviorist to the situation, I have a few notes for myself – and I hope they will be helpful to others. When one has to restrain or seclude students for their own or other’s physical safety:

  • Never invalidate a student’s emotions. They are feeling what they are feeling, there is no point telling them they are wrong or shouldn’t feel a certain way.
  • Never hover over a student. If a student is on the floor or in a chair, do not use your mass to intimidate them. It is intimidating.
  • Never repeatedly bring up a student’s mistake. Move on. You are only going to make them self-conscious and reduce their self-esteem.
  • If a student asks for space, GIVE IT TO THEM so long as it is safe.
  • Do not chase/run after a student if they elope. Follow SLOWLY and at a distance. Catching the student does not earn any prizes.
  • Watch your tone of voice. The student is paying attention. They know if your tone is aggressive they are unsafe.
  • Never use sarcasm. If words do not match the tone of voice, you are confusing the student.
  • Never dictate terms. The student will balk at orders when escalated and become defiant on principle.
  • Never lie to the student. They will call you on it. They will remember. They will hate you for it.
  • Never talk about the student in a negative way in front of them to another teacher. In fact, this is NOT the time to give an update on behavior unless you are handing off responsibility for the student to a specialist.
  • Never give ultimatum. These never work, less so when a child is escalated.
  • Never give an emotional response to swearing or physical aggression. The student is not entirely in control of themselves and trying to get the adult to move away from them, by whatever means necessary.
  • Never argue with the student. They will contradict and defy you. Don’t take the bait.
  • In fact, Never try to start a conversation. This will not end well. There is nothing you can say that will fix the situation.
  • Never touch the student to calm them down (pat on back, etc.). This will be misinterpreted.
  • Never distract yourself with a phone, etc. You will miss important signs.
  • Never show frustration, anger, etc. Your emotions are not helpful. They do not contribute anything other than fuel to the already highly combustible situation.
  • Never, Ever, under any circumstances retaliate against any of the violence committed by a student being restrained. I wish this went without saying. It doesn’t. I am saying it. We are the adult. We MUST act like it.

Some of these may seem counterintuitive, but they are all important. The best advice I can have for anyone is to avoid restraint or seclusion as consequences for behavior.

The solution is for us to focus on prevention instead. Help the student meet their needs before we turn the escalation cycle into an escalation spiral.

Moving Beyond ABA: How to do a Functional Analysis…

#Ooh Ooh Ooh! They Finally Did It!

“In all my years of doing Functional Analysis and treating problem behavior, I have never once, not once, been thanked by a parent for effecting a long-lasting, socially relevant change. None of them have been able to tell me I long-term changed their children’s lives for the better” – Greg Hanley, BCBA-D, Ph.D.

I recently went to a conference about critical issues impacting children and adolescents. I was hopefully optimistic that because the conference was in Utah there would not be too strong a focus on Applied Behavioral Analysis (ABA) as a primary treatment measure for autism.

Alas, I was slightly disappointed when I saw the presenter information and noticed Greg Hanley, Ph.D., BCBA-D was the keynote speaker and teaching all the sessions I was interested in. Anyone following this blog knows I do not put much stock in ABA as a science, which means I have a particular disdain for a rather large proportion of the methods used in ABA and have not shied away from being vocal about it. However, in speaking with my colleagues in the district office that are working toward their BCBA, I found out Dr. Hanley has a “unique and somewhat controversial approach” to functional analyses and the treatment of problematic and dangerous behaviors in autism, and that they were interested to see the “other side” of the debate among BCBA regarding treatment methods.

As a scientist and teacher, I do try to keep an open mind and I try very hard to give everyone the benefit of the doubt, so I took a deep breath, left my prejudice at the door (mostly), and focused on the science of what was being presented. All that being said, I am ecstatic I attended the conference as well as the fact I attended all of Dr. Hanley’s presentations. I enjoyed the presentations immensely and I left hopeful that the methods being used in ABA-based therapy are starting to evolve and treatments are becoming more humane – or at least some precedent is being laid down to justify such a movement.

I will refer the reader to the following links to get information about Dr. Hanley’s works I am speaking about. The first is his website outlining his methods. Under the presentations tab if you look at November 2-5, 2016 there are the powerpoints and handouts from the conference I attended. Relevant papers can be downloaded Here and Here (please contact me if you cannot get these or any articles I link to in this post, I have them and am very happy to share the science).


What is a “standard” Functional Analysis?

Before I dive further in, I do not mean to infer that all functional analyses are standardized tests. They aren’t. I use the term “standard” functional analysis in the same way Dr. Hanley does in his manuscripts. This means any functional analysis that isolates attention, escape, or tangibles as motivators will be referred as a “standard” functional analysis.

Rather than try to give an explanation of a functional analysis, I will give a pseudo-textbook definition and then explain quickly what it means. I leave deeper conversations regarding functional analyses, their validity, and methodology to others.

From Wikipedia:

A functional analysis is the most direct form of functional behavior assessment, in which specific antecedents and consequences are systematically manipulated to test their separate effects on the behavior of interest. Each manipulation of the antecedent and consequence in a particular situation is referred to a condition. In a functional analysis, conditions are typically alternated between quite rapidly independent of responding to test the different functions of behavior. When data paths are elevated above the control condition (described below) it can be said that there is a functional relation between that condition and the behavior of interest. Below, common examples of experimental conditions are described. A standard functional analysis normally has four conditions (three test conditions and one control):

Attention

In this condition, the experimenter gives the individual moderately preferred items and instructs them to go play. After that initial instruction, the experimenter pretends to act busy and ignores all bids for attention from the individual. If the individual engages in the behavior of interest, the experimenter provides the individual with attention (commonly in the form of a reprimand). Behaviors that occur more frequently in this condition can be said to be attention maintained.

Escape/Avoid

In this condition, the experimenter instructs the individual that it is time to work. After the initial instruction, the experimenter delivers a series of demands that the individual is typically required to complete (e.g. math problems, cleaning up, etc.). If the individual engages in the behavior of interest, the demand is removed and the child is allowed to take a break. Behaviors that occur more frequently in this condition can be said to be escape maintained.

Alone

Normally referred to as tangible condition. In this condition, the child is left alone with a variety of items to engage with. If the child engages in the behavior of interest, no programmed consequences are delivered. Behaviors that occur more frequently in this condition can be said to be automatically maintained.

Control (play)

In this condition, the child is allowed to engage with a variety of items during the session. No demands are placed on the child throughout the duration of the session. The experimenter provides attention to the individual throughout the session on any behavior that is not the target behavior. If the target behavior occurs, the experimenter removes attention until the behavior has subsided. This session is meant to act as a control condition, meaning that the environment is enriched for the purpose of the behavior not occurring. Said another way, by meeting environmental needs for all possible functions, the individual is not likely to engage in the behavior of interest. This condition is used as a comparison to the other conditions. Any condition that is elevated to a large degree form the control condition, shows a higher degree experimental control indicating the functional relationship between the specific environmental conditions and the behavior of interest.

In essence, a functional analysis is an experiment. The researcher, teacher, or behavioral analyst forms a hypothesis regarding the function of the behavior – or why the child engages in a certain behavior. They then place the child in a controlled environment and test their assumptions by repeatedly offering the child challenges by removing what they hypothesize the child wants and recording the responses. To preserve experimental replicability, the tangibles used in a standard analysis are held relatively constant across functional analyses, as are the escape and attention contingencies (where to escape and/or scripted attention).

The standard functional analysis can take hundreds of trials and takes a significant amount of time. If everything goes as predicted, the child will respond with a behavior when the experimenter removes the hypothesized contingency (attention, escape, or tangible), whereas removing the other contingencies will not result in similar flare-ups of behaviors. The standard functional analysis also interspersed free-play conditions they consider a control or no task condition. This differential effect is called “differentiation” and is the hallmark result of a behavioral analysis.

What is this new thing I am talking about (IISCA)?

What Dr. Hanley proposed in 2014 was a new way to perform a functional analysis. The quote I started this post with was what Dr. Hanley said as his motivation for changing how he does his functional analyses. He spent decades performing standard functional analyses and designing behavioral treatments based on the results of those analyses.

In his presentations, Dr. Hanley belabored a point I agree with entirely. He suggested it as a motivation for developing the IISCA and relying on open-ended rather than standardized interviews.

[F]rom a clinician perspective, it does not matter whether or not we can characterize the function of a behavior; just so long as we can identify the topography of the behavior and use our identified synthesized contingencies to turn the behavior on and off. If we can do that, then we can help the child or young adult. We get too bound up as BCBA and ABA therapists on characterizing the behavior that we forget that our goal is to help the child overcome problematic or dangerous behaviors. We get too bound up in positive and negative reinforcements and other definitions that we lose sight of our mission.

IISCA stands for Interview-Informed Synthesized Contingency Analysis. They chose to go with the clumsy acronym IISCA because it captures two procedural differences between this method and the traditional, “standard” functional analyses. The first is that the specific contingencies (and combinations thereof) assessed and materials used in the sessions are derived from the interviews, thus the analysis is interview informed rather than experimenter driven.

The first part of the IISCA is the open-ended interview (you can download the actual template here). This is important for two reasons: First, checklists like those commonly used by BCBA to interview parents tend to limit responses to multiple choices and thus can actually guide responses rather than allow parents or caretakers to report their experiences. And B, open-ended questionnaires take a lot less time to perform. Often, the checklist questionnaires take 60-90 minutes to perform, whereas the open-ended interviews take 30 minutes. Sometimes, parents even take the forms home, talk to their family, and return it at their leisure.

The second part that I will emphasize for the IISCA, and why I like it as a method, is that it accepts that reality is complicated. What I mean is that I have never met a child misbehaving for something as simple as “attention” or “escape”. I have never seen a student try to get out of doing work and being contented with fleeing from work to a corner of the room to do nothing. I also have never seen students seek any attention I am willing to give. They want a certain type of attention. Ditto for a tangible. Only rarely do children respond to any tangible-they prefer certain ones over others.

The IISCA method emphasizes the use of so-called “synthesized contingencies”. By “synthesized contingency”, Dr. Hanley (and I) is referring to the phenomenon that children tend to escape from tasks to play with toys while seeking attention from a preferred adult (i.e.,  escape to attention + tangible). Some children escape to predictability (i.e., they flee from unpredictability or transition to force the typical schedule). Others are rewarded by what is called “mand compliance”, or having adults comply with verbal demands. This is clearly a form of attention seeking, but it is qualitatively different enough that it needs its own category. Interestingly, in his presentations Dr. Hanlkey makes a point I agree with entirely:

The IISCA procedure also emphasizes using the specific reinforcers that the child responds maximally to. Oftentimes, they use whatever stimuli the parents bring with the child. The assumption is that there is a reason why the family brought those items: that reason is that those items sooth and calm the child.

Also, the IISCA emphasizes focusing on what are called precursor behaviors to the major problem behaviors. In other words, if a child always growls or yells prior to physically aggressing, then the experimenter or analysis terminates trials when the child growls or yells, rather than waiting until they engage in physical aggression.

Of interest is that the average IISCA takes approximately 30 minutes for the open-ended interview and then 30 minutes for the functional analysis. There are three 5-minute control sessions wherein the child is given access to reinforcers (even if that is adult attention, iPad, etc) regardless their behaviors. There are then three 5-minute sessions wherein the child is given demands and separated from the reinforcers. Once the child shows precursor behaviors the reinforcement is returned and the data are taken. Since the IISCA is only evaluating the synthesized contingency, there are only 2 conditions (control, experiment) and if there is differentiation, the IISCA is finished quickly (in one report Dr. Hanley suggests an IISCA can be performed in 5 minutes).

Another cool part with the IISCA, it has been shown to be easy enough a protocol that parents and teachers can replicate the findings of the experimenters, with only minimal training and assistance through Skype (manuscript here).

Is the IISCA really better?

Yes. Much better. In pretty much every way you can imagine.

I say this because the treatment informed by the IISCA is functional communication training (FCT). This means training the child to use communication to get reinforcement rather than using misbehavior to fulfill needs. Based on the literature, using the information obtained from the IISCA results in faster, more efficient, and longer lasting FCT than using information obtained through a standard functional analysis.  Below is a figure from a Master’s thesis showing that treatment based on standard functional assessments are much less reliable than those informed by an IISCA.

Basically, what this shows is that the kids are much more willing to use FCT to get their needs met if they are offered the entire reward (i.e., the synthesized contingency) rather than isolated attention, escape, or access to a tangible. They can even be taught to tolerate being told, “No” and tolerate rather long delays before receiving rewards because the reward is so salient when it is finally presented.

Conclusion

Overall, I am excited to see this new direction in the ABA community and I hope it will be implemented in the larger ABA community. For my part, I have already used the IISCA method twice this month and it works. It is basically the method I was using before to “figure out what is making this kid tick” as I put it, but it is nice to finally have a formalized method to follow so I do not have to keep justifying my methods that always appear at odds with what other people are doing. I can vouch for the rapidity of the method and the validity of the data. The kids also seem to have much more fun during this type of functional analysis compared to the standard functional analysis.

In my opinion, although Dr. Hanley’s ideas are new and novel, we can and should begin to use them in schools to help our kiddos overcome behavioral challenges to access their education. This will improve these students’ quality of life greatly, and in the end that is all we are after.