Abstract ensure the behaviour analyst acts within the client’s

 

 

Abstract

Ethics
is a vital part of any caring profession, in particular for the behaviour
analyst working with vulnerable clients. The use of restraint procedures on
clients who exhibit self-injurious behaviour is an intrusive but at times
necessary intervention implemented by behaviour analysts. The use of an
intrusive procedure requires ethical protocol which is set out in the
guidelines set by the BACB and the ABAI, which guides safe practice and
implementation. 

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Introduction

Behaviour
Analysts are bound by a set of ethical protocol which governs decisions regarding
doing the right thing, doing what is worthwhile for the clients and being a
good behaviour analyst (Cooper, Heron & Heward, 2014). The aim of the
behaviour analyst is to improve the welfare of the client, and acting within
the ethical guidelines (BACB, 2017) will help to produce significant behaviour
change which is of social importance to the client (Hawkins, 1984).

The
ethical guidelines (BACB, 2017) ensure the behaviour analyst acts within the
client’s best interest, whilst maintaining the integrity of the field and being
a positive representation of ABA to the public. The beliefs and values of a
community, the law, the individual’s personal beliefs and philosophies will
shape the ethical code (Bailey and Burch, 2011). The ethical decision can be
reached by asking what is right, what is worth doing and what does it mean to
be a good BCBA (Cooper, Heron & Heward, 2014).

Behaviour
analyst often work with vulnerable client populations and as a result will
encounter different ethical dilemmas throughout their career (Bailey &
Burch, 2011). It is important that the behaviour analyst carries out their
ethical decisions keeping in mind what is the best for each individual client,
ensuring that all behaviour modification is functional for each client and most
importantly is that the behaviour analyst does no harm (Cooper, Heron &
Heward, 2014). Good ethical practice can be difficult as predicting the full
extent consequences of a selected intervention is not possible. It is important
that the chosen intervention is the most effective and least intrusive for the
individual. It is also interesting to look at how this intervention can be faded
in the future, so the client can achieve further independence.

The
best practice and least restrictive procedure is an important component of
ethical behaviour. The intervention should be designed, applied and evaluated
scientifically. This evaluation will show the progress made by the client,
allowing for the eventual fading out of the intervention. However, in the
circumstance where the client does not make progress, it is essential that the
data is reviewed, and modifications are made to the intervention. The
collection of data in behaviour analysis is paramount in every aspect of the
field as it will ensure the client’s best interests are upheld (Bailey &
Burch, 2011)

Discussion

Challenging
behaviour can present in the form of self-injury, which can pose a serious risk
to the client depending on the severity of the behaviour. The use of physical
restraint over the years has raised concerns regarding the restrictive nature
of the practice (Vollmer, et al. 2011). The social acceptance of physical restraint
increases with the severity of the behaviour (Witt & Elliot, 1985).  

The
behaviour analyst has a responsibility to the client to use the most effective
but least intrusive behaviour interventions (BACB, 2017) (Cooper, Heron &
Heward, 2014). The guidelines for implementing a punishment procedure advise
the behaviour analyst should first attempt to utilise reinforcement procedures,
however in the case of serious problem behaviour it can require immediate use
of punishment procedures, such as restraint (BACB, 2017).

The
use of restraint to physically prevent the individual from causing significant
harm to themselves or to others should only be considered for behaviour which
would cause serious physical harm to the individual or those around them.
Behaviours which occur in an unpredictable manner or behaviour which persists
after the implementation of alternative procedures have been unsuccessful or
insufficient in reducing the behaviour. (Vollmer, et al. 2011)

The
decision regarding a restraint procedure should be made by the professional
team, the client (if possible) and the guardians of the client. The use of
restraint should be decided by a professional team with previous knowledge or
experience of the procedure, with the information provided by research the current
research the team can make an informed decision as to whether the
implementation of restraint is in the interests of the client. The interests of
the client should also be paramount in the decision-making process.

Informed
consent is required for all behaviour modification programmes, and due to the
restrictive practice in restraint interventions, it is vital that the client
and their guardians are a part of the decision-making process. With a previous
client who had very complex challenging behaviour, her guardian consented for
us to perform the restraint procedure at the clinic, but her guardian did not
wish to undergo training to perform the procedure at home. The guardian was
aware of our requirement to keep the client safe, but felt she could manage the
behaviour less restrictively in the home environment. The guardian had the
right to make this decision and it was important ethically that we respected
this decision.

In
a previous work setting, team teach holds were implemented for clients who
engaged in high levels of self-injury. 
It was decided to use the holds because of the high-risk to the clients,
regardless of the antecedent. However, in some individuals it became apparent
the hold was becoming reinforcing as a form of escape, for example a child
would engage in self-injurious problem behaviour when the response effort was
higher, which would then result in them being placed in a hold in a separate
part of the classroom until the client was no longer aggressive, which
facilitated escape from the demand, the table for what could be upwards of an
hour.

Whilst
working with the client I found that the intensity of the self-injurious
behaviour had decreased dramatically, for which I felt the team teach hold (a
seated, double elbow hold) was unnecessary and unethical as the behaviour was
not causing a huge detriment to the client. I also found that the client would
engage in the problem behaviour and then prepare for the hold by grabbing
either myself or a colleague, suggesting that he was finding the hold
reinforcing through the escape of the demand.

After
speaking to my supervisor and the BCBA responsible for the program she agreed
that we should attempt to remove the hold and instead block the self-injury, by
guiding the client to clasp his hands. This was consented to by the client’s
mother as she did not implement the hold at home and would prefer a less
intrusive method. At first the behaviour had an extinction burst, where the
client engaged in challenging behaviour against other clients and other members
of staff. However, the behaviour gradually reduced to a rate lower than when we
had been implementing the hold.

This
allowed for a greater quality of life for the client as he was no longer being
physically restrained and the procedure at both school and home was identical,
and manageable for his guardian.

The
disadvantage of implementing the restraint procedure is that it can potentially
mask the function of the behaviour (Borerro, et al, 2003) In my former work
place what we found was that while initially the hold would be implemented to
prevent harm to the client, it was difficult to then move beyond the hold and
attempt to find a different, effective treatment. As a client grows older, and
consequentially stronger, it becomes more difficult to implement a hold safely,
which is why it is so essential to find an alternative, effective treatment
before this occurs.

According
to the Association of Behaviour Analysts International “procedures which
involve the use of restraint or seclusion should only be continued if they are
demonstrated to be safe and effective: their use should be reduced and
eliminated when possible” (Vollmer, et al. 2011). This would imply that whilst
we are implementing restraint procedures we should be taking data and ensuring
the quality of the procedure, whilst aiming to decrease and remove the
restraint. The collection of data on how often, under what antecedent and the
length of each restraint should be collected and used to make viable decisions
about the procedure.

After
speaking to ABA professionals regarding the removal of a restraint procedure,
there seems to be no ethical or agreed upon protocol for carrying this out. It
was suggested to me that if there was a reduction of time in a hold,
consequentially this could cause an increase in the target behaviour which
would then make the previous, for example five-minute hold, restraint procedure
ineffective and would then require an increase in the duration of the hold. The
difference between this professional’s background and thus what governed their
ethical practice is that in their country it is legal to restrain an individual
over the age of eighteen, whilst in the U.K. and Ireland it is a more
complicated grey area, which is a legality that should govern the ethics of
professionals.

In
the case of another client who had team teach hold implemented for high
intensity self-injury, they became to strong to physically restrain, even in
the presence of five qualified professionals and the decision was made to
remove the hold. Unfortunately, due to the effectiveness of the hold whilst the
client was younger, no further intervention had been made regarding the problem
behaviour and the client was still on a variable ratio of one for simple
natural environment targets. In this scenario, it became apparent that the hold
had been used for convenience to staff rather. Whilst it was important to keep
the client safe, it was convenient for staff which meant that they did not seek
further behaviour intervention or support for this individual.

During
my professional placements it has been an ethical issue for me implementing
holds, particularly for children who are engaging in low intensity, but however
still self-injurious behaviour. Ethically, we are bound to protect our clients
from harm, but we should also be seeking a less intrusive method of keeping
them safe (Cooper, Heron & Heward, 2014) There have been numerous cases
where physical restraint has proved useful and slowly been faded out, and the
use of emergency physical restraint is essential in terms of protecting our
clients from self-injury. However, in most adult placements there is a
reluctance and often a legal inability to use a physical restraint, which means
we are potentially leaving our former clients in a precarious situation when
they move on from an ABA school or clinic.

Conclusion

The
use of physical restraint to prevent injury to the client when other procedures
have proven ineffective is the ethical decision to make (Vollmer, et al, 2011).
However, it is important that when the initial use of emergency restraint is
made during the assessment of a client, that the professional attempts to move
towards a less intrusive practice. It is important that the rights of the
individual are respected and their consent, or the surrogate consent of a
parent or guardian, is sought before the implementation of a physical restraint
procedure. Ensuring the restraint procedure is at all times under review of a
behaviour analyst and only implemented by those trained in the restraint system
(e.g. Team Teach, PCM Crisis Management).

Overall,
restraint procedures should only be implemented if proven to be efficient and safe
for the client (Vollmer, 2011).  It is
suggested that when possible, the use of such procedures should be reduced if
not completely eliminated. The suggestion that long term use of restraint
procedures could become reinforcing (Favell, et al. 1978) is another factor in
why the continued collection of accurate and relevant data to guide the use of
restraint procedures is essential for the welfare of clients.