Head Hitting After Lunch
Jonah is 14 and has profound intellectual disability, a seizure disorder, and a gastrostomy tube. He does not speak and moves with a wheelchair. For six weeks, staff have recorded open-hand head hitting 8–12 times per day, up from 1–2 times per day. The behavior occurs most often during transitions from the sensory room to the classroom and 20–30 minutes after tube feedings. The school's behavior specialist proposes a plan that removes transition demands and provides a preferred vibrating toy contingent on 'calm hands.' Jonah's mother reports he has been constipated and that his neurologist increased one seizure medication two months ago. The nurse is on campus one day per week; the teacher is asked to start the plan tomorrow. Staff also note that he has been refusing his morning tube feeding and has had two episodes of vomiting. The IEP includes communication goals but Jonah has no consistent yes/no system.
1. What should happen before the team implements a behavior intervention plan, and why?
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Before a behavior plan, the team must rule out medical and physical causes. Jonah's head hitting increased over six weeks, occurs after tube feedings, and the parent reports constipation and a recent medication change; staff also report feeding refusal and vomiting. Pain, constipation, reflux, seizures, dental problems, or medication side effects can produce self-injury. A behavior plan that removes transitions and gives a vibrating toy may reinforce the behavior or miss the cause. The team should: (1) contact the parent and school nurse; (2) request medical review from his physician, including seizure activity and medication side effects; (3) review feeding tolerance and bowel patterns; (4) screen for pain and observe during and after feeds; (5) continue safety measures and comfort care; and (6) begin an FBA by collecting ABC data. This is both ethically and legally important: a behavior plan must be based on a functional assessment, and the school cannot ignore a known medical condition. If the behavior is painful, the plan should change the environment and medical treatment, not just consequences.
2. Design an FBA that is feasible in the classroom and explain the hypotheses you would test.
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Feasible FBA: (1) Indirect measures-open-ended interview with parent and staff and a motivation assessment scale. (2) Descriptive data-ABC recording during transitions, meals, and leisure for two weeks. (3) Scatterplot to identify temporal patterns such as time of day, after feeds, and medication schedule. (4) Structured observation with partial-interval recording of head hitting, antecedents, and consequences. Hypotheses to test: (a) escape from nonpreferred transitions; (b) pain or discomfort after tube feeding or related to constipation; (c) access to sensory stimulation or attention; (d) communication of 'stop' or 'help.' The team should compare conditions across routines-if head hitting is high after feeds regardless of demands, a medical or pain hypothesis is stronger; if it is high only during transitions, escape is plausible. A functional analysis may be contraindicated if self-injury is severe; use descriptive and indirect data first. The FBA report should link each hypothesis to environmental changes and a communication replacement.
3. How should the team address the teacher's instruction to start the plan tomorrow before the nurse is available?
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The teacher should not implement an unapproved behavior plan merely because the behavior specialist proposes it. The teacher should: (1) keep Jonah safe using approved crisis procedures and comfort measures; (2) contact the principal and nurse immediately; (3) document the instruction and the nurse's unavailability; (4) request an emergency IEP or team meeting; (5) explain that the plan requires parent consent, staff training, and medical clearance; and (6) ask for a written emergency plan. If the principal directs implementation, the teacher should ask for the direction in writing and express concerns. The teacher should not ignore the behavior or punish Jonah. The ethical principles are nonmaleficence, respect for parental consent, and scope of competence. The team should also consider that the mother's report of constipation and the staff reports of vomiting are relevant and may require immediate medical follow-up. The teacher's role is to advocate for a safe, data-based plan, not to diagnose or prescribe.