Article 9 Competencies

• Article 9, concerning managing inappropriate behaviors, was adopted and approved on December 9, 2002.
• It was revised in October 2009, November 2012, March 2016, and January 2018.

Article 9 Competencies

• Article 9 competencies include identifying to whom Article 9 applies.
• Article 9 competencies include identifying 5 positive teaching techniques and strategies.
• Article 9 competencies include identifying when a team should consider developing a behavior plan.
• Article 9 competencies include determining when a strategy or technique must be reviewed and approved prior to use.
• Article 9 competencies include identifying and giving examples of prohibited techniques.
• Article 9 competencies include identifying the monitoring requirements for the implementation of a behavior plan.
• Article 9 competencies include identifying who must review and who must approve behavior plans.
• This includes techniques that require review and approval.
• Article 9 competencies include defining an emergency, an emergency measure, and when it can be used.
• Article 9 competencies include identifying the reporting requirements for an emergency measure.

Historical Perspective of Article 9

• In the mid-1980s, the Arizona Division of Developmental Disabilities (DDD) was deinstitutionalizing.
• At that time, there were three institutional facilities operating in the State.
• The Arizona Training Programs in Phoenix and Tucson had already begun relocating individuals into community-based services.
• The population at the Coolidge facility was also declining rapidly.
• Article 9 was written to address individual rights and the use of behavioral methods within DDD services.
• The Division drafted Article 9 in 1988 with representation from the advocacy community and service providers.
• Article 9 aimed to meet Federal requirements.
• Article 9 has had a significant impact on improving the quality of life for many individuals.
• Article 9 has shifted the role of the service provider from a controller to a partner in support of individuals.

Positive Behavior Support (PBS)

• Positive Behavior Support combines social, behavioral, and biomedical science.
• It applies this information at individual or systems level to reduce behavioral challenges and improve quality of life.
• PBS interventions are empirically documented and can be used by a wide range of support providers.
• PBS is based on the understanding, belief, application of knowledge, and conviction to move away from unpleasant events.
• An understanding that people don't control others, but seek to support others in their own behavior change process.
• A belief that difficult behavior has a reason, and people with difficult behavior should be treated with compassion and respect.
• People with difficult behavior are entitled to lives of quality and effective services.
• The application of knowledge about improving lives to reduce difficult behavior.
• A conviction to continually move away from the threat and/or use of unpleasant events to manage behavior.
• The threat and/or use of unpleasant events minimize the dignity of the other person, often provoke retaliation, and may cause physical and emotional harm.
• PBS involves a commitment to continually search for new ways to minimize the use of these approaches.

Why Do We Need Positive Behavior Support?

• People with difficult behavior have been misunderstood and mistreated throughout history.
• People with developmental disabilities have been subject to disrespectful, humiliating, and painful conditions.
• A growing body of research shows even the most challenging behaviors can improve with one or more approaches, called Positive Behavior Support.

Individual's Rights to Confidentiality

• All personally identifiable records, reports, and information of individuals served by the Arizona Department of Economic Security (DES)/Division of Developmental Disabilities (DDD) are confidential.
• Access to individual records and information is limited to specifically designated persons.
• Personally identifiable information may not be released without prior written authorization.
• The legally responsible person needs to give authorization, except as permitted by law, regulation, or policy.
• Employees should refer requests to their supervisor or DES/DDD support coordinator.
• DES/DDD District Human Rights Committees (HRC) may have access to records upon request.
• Health, safety, and emergency personnel may have access as necessary.
• All individual records should be maintained in an orderly, secure manner.

Individual's Rights to Consent

• The person signing must have the necessary information to make an informed choice when giving consent.
• The consent must be voluntary, without coercion involved.
• A person needing assistance in making an informed choice in granting consent shall be able to seek advice, counsel, or assistance.

Rights of Individuals with Developmental Disabilities

• Individuals with developmental disabilities have the same rights as all citizens guaranteed in the US and Arizona constitutions/laws.
• Protection from physical, psychological, verbal, or sexual abuse
• Publicly supported educational services
• Equal employment opportunities
• Fair compensation for labor
• Right to own, sell or lease property
• Presumption of legal competency
• Right to marry
• Right to petition
• Right to have placement evaluations
• Right to a written plan of services and supports [Individual Support Plan (ISP) or Individualized Family Service Plan (IFSP)]
• Right to notes documenting progress on the plan
• Right to participate in the planning process and placement decisions
• Right to be free from unnecessary and excessive medications
• Individuals in residential programs have rights to a humane environment, communication, visits, and personal property
• Individuals in residential programs have the right to live in the least restrictive alternative.
• Right to withdraw from services
• Right to be informed of their rights upon admission to services

Abuse and/or Neglect

• Abuse and/or neglect is prohibited in all services and programs operated or supported by DES/DDD.
• Anyone doing so is subject to dismissal and prosecution.
• Mistreating an individual by intimidating, degrading, or humiliating conduct is subject to dismissal and/or prosecution.
• This includes hitting, kicking, pinching, slapping, pulling hair, or improperly touching an individual.
• Abusive Treatment includes physical, emotional, and programmatic abuse.
• Physical abuse involves inflicting pain or injury.
• Emotional abuse includes ridiculing or demeaning an individual, derogatory remarks, or cursing.
• Programmatic abuse is the use of procedures or techniques not part of the support/service plan or prohibited.
• Neglect means a pattern of conduct without informed consent resulting in deprivation of basic needs.
• These needs include food, water, medication, medical services, shelter, cooling, and heating.
• Neglect also includes intentional lack of attention to physical needs such as toileting, bathing, meals, and safety.
• Neglect also includes intentional failure to report medical problems, sleeping on duty, abandoning work, or failure to carry out a treatment plan.
• Abuse or neglect of a DES/DDD eligible individual must be reported immediately to the appropriate entities (DCS, APS, law enforcement).

Positive Teaching Techniques and Strategies (Green Light Techniques)

• Anyone can use the following positive teaching techniques and strategies.
• Paid caregivers (agency staff, individually contracted providers) will use the guidelines of the Individual's Plan (Individual Support Plan or Individualized Family Service Plan) in applying these techniques and strategies.
• Active Listening: Assure attention to and understanding of communication by the person they support.
• Applied Behavior Analysis: Techniques and strategies based upon analyzing behavior.
• Chaining: Technique that breaks a task into smaller steps where each step acts as a prompt for the next step.
• Cues/Prompts: Signals to engage in behavior that naturally occur in the environment or are provided by support givers.
• Differential Reinforcement: Planned reinforcement of specific desirable behaviors, while not reinforcing other behaviors.
• Discrimination Training: Teaching a person to behave differently based upon the situation and environment.
• Environmental Manipulation: Creating environments that will make it more likely that the person will succeed.
• Fading of Cues/Prompts: Gradually reduces or withdraws the amount of assistance given to an individual.
• Generalization Training: Strategies to teach the person to display the behavior in all circumstances where it would naturally occur.
• Graduated Guidance: Starts with the guidance necessary to assist in completing a task and gradually provides less assistance.
• Incidental Teaching: Using naturally occurring situations as well as random and unplanned occurences.
• Modeling: Demonstrating the desired behavior to be imitated.
• Redirection: Instructed to a different area, activity, choice or focus in order to interrupt the current behavior.
• Reinforcement: Any event/item that immediately follows a behavior which increases the likelihood of the behavior occurring again.
• Relaxation Training: Strategies to help a person remain calm or use self-calming techniques in situations that otherwise produce stress and anxiety.
• Shaping: Reinforcing in a planned sequence closer steps to learning a skill.
• Token Economies: Reward systems where tokens (symbols) are given for positive behavior, saved and exchanged for items of larger value.
• Voluntary Time Out: Procedure where the individual chooses to go to an area away from others to allow time and space to deal with stressors.

Behavior Plan

• An individual needs a behavior plan for anyone prescribed a behavior modifying medication and/or techniques that require approval.
• These techniques may require the use of force, response cost, infringe upon rights, or involve protective devices.
• A team may consider developing a plan when an individual displays inappropriate behavior.
• This may include behaviors that interfere with learning, participation in the community, or if they place the individual or others at risk.
• The team must meet and consider writing a behavior plan when an emergency measure is used two or more times in a 30 day period.
• This applies if there is any identifiable pattern.
• Describe the target behavior in specific terms - label and define.
• Collect baseline data on various factors, including antecedents, precursors, and consequences.
• Examine the environment for contributing issues like space, privacy, health, communication skills, relationships, and ability to make choices.
• Look for the function of the target behavior.
• Determine the alternative behavior, how it will be taught, and write an alternative outcome to be taught.
• The plan should list strategies, reinforcement schedule, data collection method, what to do if the target behavior occurs.
• List the names and/or titles of the person/people who will train the staff that will be implementing the behavior plan and the person onsite monitoring.
• The responsible person's signature and approval must be attained prior to implementation and review of the plan by the Program Review Committee.
• The team needs to submit it for approval to the Program Review Committee and to the Human Rights Committee for review.

Techniques/Programs Requiring Prior Review and Approval by The Program Review Committee (PRC) (Yellow light techniques)

• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes techniques that require the use of force.
• This includes forced compliance and forced exclusion time out.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes the use of contingent observation, if force is required.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes logical consequences, if force is used.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes techniques that might infringe upon the rights of the individual.
• This includes excluding activities from withing the daily routine.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes paying back restitution for repairs.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes reinforcement procedures that earn indivudals necessities.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes taking reinforcements away as a consequence tool.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes limitations.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes medically reviewing behavior modifying medications by a physician.
• The ISP team shall submit to the PRC and Human Rights Committee for review any behavior plan, which includes protective devices used to prevent an individual from self-injurious behavior.

Training Requirements for People Implementing Behavior Plans

• Any person involved in the use of a behavior plan shall be trained by the Division or an approved instructor prior to such involvement.
• Initial training shall cover: provisions of law related to interventions, rights of individuals with developmental disabilities, confidentiality, and abuse and neglect.
• Training shall cover intervention techniques, treatment and services, addressing risks and side effects.
• Training includes the development, implementation, and monitoring of person-specific behavior plans.
• Training includes a general orientation to division goals and related policies.
• With respect to techniques, training shall include hands-on experience conducted by approved instructors experienced in the interventions.
• Physical management techniques shall only be used by those specifically trained in their use.
• Any person providing direct services to individuals who have the potential to exhibit inappropriate behaviors, which may require physical management and control, receive training in the use of interventions.

Prohibited Techniques (Red light techniques)

• Prohibited techniques include the use of seclusion (locked time out) rooms.
• Defined as placing a person in a room and locking/holding the door shut to stop them from leaving.
• Prohibited techniques include the use of overcorrection.
• Defined as a group of procedures where one has to repeat a behavior multiple times and or rebuild something.
• Prohibited techniques include the application of noxious stimuli.
• Defined as the utilization of a stimulus that is unpleasant including tastes, noises, odors, visual stimuli and textures. Prohibited techniques include physical restraints, including mechanical restraints, when used as a negative consequence to a behavior.
• Defined as limiting the movement of a person.
• The Rule prohibits the use of physical restraints, except in the case of an emergency
• Prohibited techniques include the use of behavior-modifying medications, except as specified in R6-6-909 in certain occasions, such as when dosages interfering with activites or behavior is not as per the behavior plans.
• "No psycho surgery, insulin shock treatment or electroshock or experimental drugs shall be administered by the Department to any individual, nor shall the Department license, approve, support any program or service which uses such treatments of drugs."

Individual Support Plan Team - Responsibilities

• The planning team must submit to the PRC and HRC committees any behavior plan which includes force, response cost, infringes on individuals' rights, involves behavior modifying medications, or uses protective devices to prevent self-injury.
• Upon receipt of the response from the PRC, the planning team must implement the approved behavior plan.
• All revised behavior plans must be re-submitted to the PRC for approval and the HRC for review and recommendation.
• No implementation shall occur prior to approval.

Monitoring Behavior Plans

• Each planning team shall specifically designate and record a member of the team who shall ensure the behavior plan is implemented as approved.
• The designeee will make sure that all persons implementing the behavior plan have received all the right training.
• The designeee will make sure that the behaviour record has all required details.
• The designeee will evaluate whether there is success or failures.
• The designeee will conduct reviews to look at whether the plan is effective and conduct tests.

Distinguishing between the PRC and the HRC Committees

• PRC (Program Review Committee) is a specially constituted committee meeting specific requirements.
• HRC (Human Rights Committee) refers to a committee established by the department.
• PRC is comprised of a DDD representative, habilitation services provider, behavioral techniques Division designee, a parent, a lay person, and someone with a disability.
• HRC comprised of Psychology, Medicine, Law, Parental advisory staff.
• PRC approves or disapproves individual plans with techniques using force, response costs, behavior-modifying medications, rights infringement, or self-injurious behavior protections.
• HRC provide independent oversight and review all aversive or intrusive behavior plans, the use of behavior modifying medications, research affecting individuals, and instances of abuse or neglect.

Reporting Emergency Measures

• An "Emergency Measure" is in the event that an individual engages in a sudden, intense, out of control behavior endangering the health or safety.
• It refers to the use of emergency physical intervention techniques and/or behavior modifying medication with a physician's order for specific one time emergency use.
• The team must meet and consider writing a behavior plan when an emergency measure is used two or more times in a 30 day period.
• Staff shall use the least amount of intervention necessary to safely manage the behavior.
• These techniques are included in Prevention and Support and shall be used appropriately by the trained individuals.
• When a physical management technique is employed to manage a sudden, intense behavior, the person employing that measure shall report the circumstances to the designated person and the responsible person.
• A written report needs to be submitted within one working day to the support coordinator and the district central reporting site.

Sanctions

• For programs operated, licensed, certified, supervised or financially supported by the Division, failure to comply with any part of this Article may be grounds for suspension or revocation of a license, termination of contract/employment, or applicable administrative/judicial remedy.
• Sanctions may be imposed for failing to comply with the Rule and associated Division Policies and Procedures.
• Sanctions may also be given out for failing on interventions.

Article 9 Managing Inappropriate Behaviors

• These rules apply to: all programs operated, licensed, certified, supervised, or financially supported by the Division.
• These rules apply to all habilitation programs and interventions included.
• The following are prohibited: The use of recluse and bad behavior technqiues.
• No one can implement behavior plans unless it part of the ISP and without approval.
• The ISP team shall submit to the PRC and Human Rights Committee any behavior plan which includes: -techniques that require the use of force.
• Programs which infringe upon the rights of the client .
• Behavior Plans need to be signed off by all staff and made sure to remain neutral.