RBT Task List – Behavior Reduction (D-06)

We’re moving into a very critical area of behavior reduction ensuring safety when challenging behaviors escalate.

Having covered proactive antecedent strategies (D-03), the power of differential reinforcement (D-04), and the principles of extinction (D-05), we now address how RBTs must be prepared to respond in more acute situations where immediate safety is the primary concern.

Let’s do a comprehensive exploration of:

D-06: Implement Crisis/Emergency Procedures According to Protocol

This task is paramount for client and RBT safety. It underscores the absolute necessity for RBTs to be thoroughly familiar with and prepared to implement specific, pre-approved plans when a client’s behavior poses an immediate risk of harm. There is no room for improvisation when safety is on the line.

What Defines a Crisis or Emergency in ABA Services?

In the context of ABA services, a crisis or emergency situation refers to instances where a client’s behavior poses an immediate and significant risk of harm to:

• Themselves (e.g., severe self-injurious behavior like intense head-banging, deep scratching or picking that causes tissue damage).
• Others (including the RBT, other clients, family members, or staff; e.g., intense hitting, biting that breaks the skin, hair pulling that removes hair, throwing heavy objects).
• The environment (e.g., high-intensity tantrums that involve significant property destruction, creating unsafe conditions).
• Or situations like elopement into dangerous areas (e.g., running towards a busy street, leaving a safe area without supervision).

This task item (D-06) requires RBTs to be able to implement pre-planned and approved crisis/emergency procedures exactly according to protocol. These protocols are:

• Highly individualized to the client and the specific crisis behavior.
• Designed by the supervising BCBA/BCaBA, often in consultation with other professionals (like psychologists, medical doctors) and caregivers.
• Focused on prioritizing safety above all else.
• Aimed at de-escalating the situation, preventing injury, and returning the client to a calm state as safely and quickly as possible.

Crucially, RBTs do not create crisis plans. Your role is to:

• Be thoroughly familiar with any existing crisis/emergency protocols for each client you work with.
• Receive specific training on these protocols from your supervisor. This training may include didactic instruction, modeling, role-playing, and, if physical management is involved, specialized certification (see important note below).
• Implement the procedures with absolute fidelity (exactly as written and trained) when a crisis occurs.
• Document the crisis accurately and objectively, and report it to your supervisor immediately.

A Critical Note on Physical Management and Restraint:
It is absolutely critical to understand that RBTs should NEVER implement any physical management or restraint procedures unless they meet ALL of the following conditions:

• They have received specific, hands-on training and certification from an approved crisis management system (e.g., Professional Crisis Management (PCM), Crisis Prevention Institute (CPI), Quality Behavioral Solutions (QBS), Safety-Care).
• The procedure is explicitly written in the client’s approved Behavior Intervention Plan (BIP) and crisis plan.
• It is permitted by agency policy and all applicable local, state, and federal regulations.
• It is used only as a last resort when less restrictive measures have failed and there is an imminent risk of serious harm.
  Standard RBT training does not qualify an RBT to use physical restraints.

Essential Components of a Written Crisis/Emergency Protocol

You need to be able to identify and understand these components from the client’s plan:

• Clear Definition of What Constitutes a “Crisis” or “Emergency” for That Client:
  • The plan must specify exactly which behaviors, at what intensity or duration, trigger the activation of the crisis protocol. Not all challenging behavior rises to the level of a crisis.
  • Example: “Crisis is defined as: (a) Any instance of head-banging against a hard surface lasting more than 3 seconds, OR (b) Any attempt to bite another person that makes skin contact.”
• Immediate Safety Procedures (Priority #1):
  • These are the first steps to ensure the safety of the client, the RBT, and any other individuals present.
  • Examples:
    • Removing other clients/individuals from the immediate area.
    • Removing potentially dangerous objects from the environment (e.g., scissors, heavy items).
    • Positioning oneself to block access to hazards (e.g., blocking a doorway if elopement is the crisis behavior).
    • Using protective equipment if specified and trained (e.g., padded mats for head-banging, arm guards for staff if severe biting is a persistent risk this is rare and highly specific to the plan).
• Specific De-escalation Strategies:
  • These are techniques to try and calm the individual and reduce the intensity of the behavior once immediate safety is addressed. These strategies should be highly individualized and, where possible, function-based, even in a crisis.
  • Examples:
    • Minimizing verbal interaction (remaining calm, using few, simple words).
    • Redirecting to a highly preferred calming activity (but only if the client is receptive and it won’t reinforce the crisis behavior).
    • Providing space (if the behavior is exacerbated by proximity or feeling crowded).
    • Using a calm, neutral tone of voice.
    • Removing demands temporarily (if the behavior is escape-maintained and it’s safe to do so as a de-escalation tactic, with a clear plan to reintroduce demands later when calm).
• Physical Management/Intervention Procedures (IF APPLICABLE AND TRAINED/CERTIFIED):
  • This section will only be present if the agency and BCBA have deemed it necessary and ethical due to imminent risk of serious harm, and if staff are specially trained and certified in an approved system.
  • It would detail specific, approved physical escort or restraint techniques, including:
    • When to use them: Only as a last resort when there’s immediate risk of serious harm and less restrictive methods have failed or are inappropriate.
    • The exact holds/procedures to use: As taught in the specific crisis management certification.
    • Criteria for releasing the hold: Based on the client’s behavior and safety.
    • Monitoring procedures during the hold: Critically important (e.g., for breathing, signs of distress, circulation).
  • Again, RBTs MUST NOT implement these without specific certification and explicit authorization in the client’s plan.
• Notification Procedures:
  • Who to contact immediately: (e.g., supervisor, on-call BCBA, other designated staff members).
  • When and how to contact emergency services (e.g., 911): Under what specific circumstances.
  • Procedures for notifying parents/guardians: As per agency policy and legal requirements.
• Post-Crisis Procedures:
  • These are the steps to take once the immediate crisis has de-escalated and the client is calm.
  • Examples:
    • Allowing the client a cool-down period in a safe, quiet space.
    • Re-engaging in simple, preferred, and successful activities.
    • Briefly reviewing the incident (if appropriate for the client’s developmental and communication level, this is often done by the BCBA).
    • Ensuring the environment is safe and restored.
• Documentation Requirements:
  • The plan will specify which forms to fill out (e.g., incident report, crisis documentation sheet).
  • It will detail what information to include: clear antecedents to the crisis, specific behaviors observed (topography, intensity, duration), actions taken by staff, duration of the crisis, any injuries to anyone, and notifications made.
  • This documentation is crucial for the BCBA to review the incident, assess the effectiveness of the crisis plan, and make any necessary modifications to the BIP or crisis protocol.

Your Responsibilities as an RBT When Implementing Crisis/Emergency Procedures

• Know the Protocol Inside and Out: Before a crisis occurs, you must have studied and understood the specific protocol for each client.
  • If you work with multiple clients, you need to know each individual plan. Ask questions if anything is unclear.
• Remain Calm (As Much As Possible): This is very difficult but absolutely critical. A calm RBT is better able to think clearly, make good decisions, and implement the plan effectively.
  • A panicked RBT can inadvertently escalate the situation. Deep breaths and focusing on the steps of the plan can help.
• Prioritize Safety Above All Else: The absolute first priority is to prevent harm to the client, yourself, and others.
  • This may mean an RBT needs to remove themselves or others from a dangerous situation if they cannot safely manage it alone, while simultaneously calling for help as per the protocol.
• Implement with Fidelity: Follow the steps of the protocol exactly as written and trained. Do not improvise or use unapproved techniques, especially if any form of physical management is involved.
• Use the Least Restrictive Intervention Necessary: The goal is always to use the minimum level of intervention required to ensure safety and de-escalate the situation.
• Communicate Clearly (If Part of the Protocol): If other staff members are involved or need to be alerted, clear, concise communication is essential (e.g., using a pre-determined code word or phrase to request assistance).
• Do Not Try to “Teach” or “Reason” During the Peak of a Crisis: When a client is highly escalated, they are typically not receptive to teaching, lengthy explanations, or logical arguments. Focus on safety and de-escalation first.
• Document Immediately and Accurately After the Crisis: As soon as it is safe to do so and the client is calm and supervised, complete all required documentation thoroughly and objectively.
  • Memories fade quickly, and details can get lost.
• Report to Your Supervisor Immediately: Even if the crisis plan was followed perfectly and the situation was resolved, your supervisor must be informed of any crisis incident as soon as possible, according to agency policy.
• Participate in Debriefing: After a crisis, the BCBA will likely debrief with the RBT(s) involved to review what happened, how the plan was implemented, what went well, and if any changes are needed to the plan or to staff training.
  • Honest and open participation is key for continuous improvement.
• Self-Care: Dealing with crisis situations can be emotionally and physically draining. RBTs should engage in self-care practices and seek support from their supervisor or agency if they are feeling overwhelmed, stressed, or experiencing any negative effects after an incident.

Real-World Example: David Implements a Crisis Protocol for Alex

• RBT: David
• Client: Alex (10 years old)
• Crisis Behavior (Defined in Alex’s Plan): Intense Head-Banging – “Alex forcefully hitting his head against hard surfaces (floor, wall, table) repeatedly for more than 2 consecutive hits.”

Snippets from Alex’s Crisis Protocol (Simplified for this example):

• Immediate Safety: If head-banging on floor, place provided padded mat under head. If towards wall/table, attempt to guide Alex to a padded area or use a soft blocker (e.g., cushion) between head and surface. Remove hard objects nearby. Call for assistance from another staff member if available by saying “Assistance needed in Room 3.”
• De-escalation: Minimize verbalizations. Use a calm, neutral tone. If receptive, offer a highly preferred calming item (e.g., squishy ball) after head-banging stops for 5 seconds. Do NOT provide social attention (e.g., soothing talk, excessive eye contact) during head-banging episodes.
• Physical Management: (This plan has NO physical restraint for this behavior, only protective blocking measures).
• Notification: Inform supervisor (Jane BCBA) immediately via text once Alex is calm and safe.
• Documentation: Complete Crisis Incident Report form within 1 hour of the incident.

Scenario: Alex is working on a task and is told he cannot have more iPad time right now. He immediately drops to the floor and starts banging his head on the hard tile floor.

David’s Actions (Following Alex’s Protocol):

• David immediately retrieves the nearby padded mat and quickly, calmly slides it under Alex’s head while simultaneously saying, in a clear but not alarmed voice, “Assistance needed in Room 3” (as another RBT is in an adjacent room).
• He quickly scans the immediate area and removes a small toy truck that was close to Alex’s head.
• David stays near Alex, observing closely for safety, but minimizes eye contact and talking directly to Alex during the head-banging, as per the de-escalation plan.
• The head-banging continues for about 30 seconds, then Alex stops and begins to cry. David waits 5 seconds after the head-banging has completely stopped.
• David calmly says, “Alex, I see you’re upset. Here’s your squishy ball if you want it.” He places it nearby, within Alex’s reach but not forcing it on him.
• Alex takes the squishy ball and begins to squeeze it. The head-banging does not resume. The other RBT arrives to offer support if needed.
• Once Alex is calm for a few minutes and engaged with the squishy ball, David sends a text to Jane BCBA: “Alex had head-banging incident, now calm. Followed protocol. Will doc.”
• As soon as Alex is settled in a safe and supervised activity, David completes the Crisis Incident Report form, detailing the antecedents (denied iPad), the specific behavior (head-banging on floor), the actions he took, the duration of the incident, and that no injuries occurred.

Key Vocabulary for Crisis/Emergency Procedures

• Crisis/Emergency: A situation where behavior poses immediate, significant risk of harm.
• Protocol: The specific, written plan detailing steps to take during a crisis.
• De-escalation: Techniques used to reduce the intensity of a crisis and help the individual regain calm.
• Physical Management/Intervention: Physically guiding, escorting, or holding an individual to ensure safety. Requires specialized training and certification.
• Restraint: A specific type of physical intervention that restricts an individual’s movement. (Many types exist: e.g., physical/manual, mechanical, chemical – RBTs are primarily concerned with potential involvement in physical/manual restraints, and only with proper certification and as a last resort).
• Seclusion: The involuntary confinement of an individual alone in a room or area from which they are physically prevented from leaving. This is generally NOT a procedure RBTs would implement and is subject to very strict regulations and ethical considerations.
• Incident Report: A formal document used to record the details of a crisis event.
• Fidelity (of crisis plan implementation): Implementing the plan exactly as written and trained.
• Last Resort: Physical interventions are almost always considered a last resort, to be used only when less restrictive measures have failed or are inappropriate to prevent imminent serious harm.
• Debriefing: A post-incident discussion, usually led by the BCBA, to review what happened, how the plan worked, and how to improve responses or the plan in the future.

Common Mistakes & Misunderstandings Regarding Crisis Procedures

• Not Knowing the Protocol: Being unfamiliar with the specific steps for a particular client when a crisis occurs. This is a major safety risk.
• Panicking or Becoming Overly Emotional: While understandable, this can escalate the situation or lead to poor decision-making. Training and practice can help build confidence.
• Implementing Unapproved or Untrained Physical Interventions: This is a major ethical and safety violation, with potential legal consequences. Never use physical management unless specifically trained, certified, and it’s in an approved plan.
• Deviating from the Protocol: Trying techniques that “worked with another client” or that are not part of the approved plan for this client in this situation.
• Trying to “Reason” or “Lecture” During the Peak of a Crisis: This is usually ineffective when someone is highly emotionally escalated and not in a state to process language.
• Failing to Prioritize Safety: Focusing on other aspects (like completing a task) before ensuring the immediate safety of everyone involved.
• Incomplete or Delayed Documentation: Not filling out incident reports accurately or promptly. This information is vital.
• Not Notifying the Supervisor Promptly: Supervisors need to be aware of all crisis incidents as soon as possible.
• Failing to Call for Help When Needed: Trying to manage a serious crisis alone when backup is available or should be summoned as per the protocol.
• Viewing Crisis Management as Separate from the BIP: Crisis procedures are an integral part of a comprehensive behavior plan when needed. Ideally, effective BIPs, consistently implemented, reduce the need for crisis procedures over time by teaching alternative skills and modifying antecedent conditions.

Implementing crisis/emergency procedures according to protocol is a non-negotiable responsibility for RBTs when working with clients who have behaviors that can escalate to dangerous levels.

It requires preparedness, calmness under pressure, and strict adherence to approved plans, always prioritizing safety above all else. Understanding these protocols thoroughly is critical, and any questions or uncertainties should be directed to your supervisor before a crisis occurs.

This provides a very comprehensive look at D-06. We’ve emphasized the critical nature of following protocols, prioritizing safety, and the strict conditions under which any physical management might occur (requiring specialized training).

Punishment procedures like time-out and response cost are generally considered under the umbrella of “implementing behavior reduction plans” and would be detailed within a specific client’s BIP if used, falling under the consequence interventions section we discussed in D-01.

Therefore, it would be most aligned with the current RBT Task List to proceed to D-07: Report other variables that might affect the client. This is a crucial aspect of an RBT’s role in providing holistic information to their supervisor.