BehaviorImprovement,Safety&BehaviorManagementPlan

MACMH2011

DavidX.SwensonPhDLPPaulFleckensteinLCSWLCP

Howtheclientpresentedtheproblem&need

Howthetherapistunderstoodit

Howthecasemanagersummarizedit

Howcollateralsourcesviewedit

Howinsurancewasbilled Howitwassupported Whattheclientreallyneeded

HowtreatmentwasappliedHowtreatmentwasdocumented

Howthebillingagencyclassifiedit

Objectives

• understandkeyelementsinacomprehensivebehaviormanagementandsafetyplan

• Identifytriggersituationsandbehaviorsthatcanescalateintosafetysituations

• Identifybehaviorsthatcanbeusedtoreducesafetyriskandproblembehaviorsateachstageofescalation

• Identifystagesofbehaviorimprovementandreinforcementsthatcanbeusedtostabilizedesiredbehaviors

KeyIdeas:

• Clientinvolvement

• Usemultiplesources

• Focusonwhatworks

• Community‐basedsolutions

• Keepitconcise

• Behaviormonitoring

• Earlyintervention

• Customized

• Treatmentplanningisdynamic

• clientshouldbeinvolvedfromthebeginning.

• askaboutbehaviorstobeimprovedorwhatlifewouldbelikewithouttheproblemsortheconsequencesthathavebeenexperienced

• askwhatproblembehaviorshaveoccurredandhowtheyescalateintosafetyconcerns

• clientcanseethatabehaviordoesnot“justhappen,”butisaprogressionofbehaviors,eachofwhichbecomesadecisionpointtoredirect.

Clientinvolvement.

Multiplesourcesofinformation

• clientbehaviorsdonotdevelopinisolation

•manypeoplehaveimportantperspectivesonhowbehaviorprogressesandwhatworkstodefuseorrewardit

• alsoinvolvesthepeoplewhoshouldbemoreengagedinthetreatmentprocess

•whilethecasemanagerortherapistmaybetemptedtodothisalone,thattendstoleaveoutimportantcollaborators.

•whentreatingmentalandbehaviordisordersitiseasytobecomepreoccupiedwithpathology

•whatgetsattentiontendstopersist,includingsuchdysfunctionalbehavior

•morehelpfultoemphasizewhatworkstode‐escalatebehaviorearlybeforeitbecomesasafetyissue

• identifypositivechoicesthatcanbereinforced.

Focusonwhatworks.

• therapeuticinteractionscanoccurallthetimeandwithmanypeople

• planningshouldidentifyasmanysourcesofsupportforbehaviorchangeaspossible

• considermultipleoptionsinthecommunity(fosterplacement,extendedfamily,familyfriends,respitecare,etc.,)ratherthanmovingtooquicklytomorerestrictivetreatment.

Community‐basedsolutions

• plansshouldberelativelysimple,directandconcise

• abletobedescribedononeortwopages

• identifyspecificpositiveandnegativebehaviors

• listpossibleresponsesforeach

• simpleenough(orcanbereduced)tobetapedonarefrigeratordoor

“RefrigeratorDoor”Plan

• useasachecklisttokeeptrackofthefrequency,duration,orintensityofbehavior

• Ingeneral,foroppositional&conductproblems,moreeffortshouldbeexpendedonpositivethannegativebehaviors;aratioof4:1isrecommended.

Behaviormonitoring

• Byidentifyingtriggersituationsandbehaviorsthatcanescalateintosafetyissues,itispossibletoprovideearlierredirectionandpreventionefforts

• Staffandclientswillknowearlywarningsignsandhavemanychoicesindealingwiththebehavior.

Earlyintervention

• Everyplanisdesignedandadjustedforeachclient,withawarenessofcapacity,reasonablegoals,uniquerisks,andspecificreinforcerstowhichhe/sheislikelytorespond.

Customized

Howevercompleteaninitialplanis,ourunderstandingofaclientalmostalwaysbecomemorecompleteovertime.Theplanshouldberevisedasneededtobetterreflectwhatworks

Treatmentisdynamic

PrinciplesofReinforcement:Howtopottytrainapuppy

DON’T•Yell•Shame•Explain•Punish

DO•Makesuretheyaredevelopmentallyready•Buildapositiverelationship•Giveclear,simple,concretedirections•Iftoocomplex,breakintosmallerchunks•Rewardapproximations•Rewardthedesiredbehavior•Beveryconsistent•Generalizerewards

DesiredBehavior

ProblemBehaviors

StaffResponse/Reinforcers

Responses

+4

+3

+2

+1

‐1

‐2

‐3

‐4

SafetyPlan

BehaviorManagement

Plan

GraduatedBehavior

ImprovementPlan

••••••••••••••••••••••••

De‐escalateRisky

Behaviors

ReduceProblemBehaviors

IncreaseProSocialBehaviors

UndesiredBehavior StaffResponse/Reinforcers

‐1.IndividualDiscomfort:annoying,passive,inattention,silliness,leavingseat,fidgeting,withdrawal,emotionalwithself,preoccupied

•Ignore•Nonverbaldisapproval(eyecontact,expression)•Humor•Incentives•Redirect(“whatdoyouneedtobedoing?”•Helperrole;smallhelpfultask•“fidgetball”,physicalactivity•Staffmovecloser

‐2.Distraction:blurtingout,sidetalking,noises,outofseat,annoyingothers.Emotionalspilloverontoothersthatinterfereswiththeirwork

•Redirect/distractbehavior•Repeatbehaviorrespectfully•Relocateseating•Cleardirective•Individualattention•Inroomtime‐out•Askwhats/heneeds•Supportivepeerpressure

‐3.Disruption:defiance,teasing,repeatedredirection,rudeness,swearing,arguing,blaming,misuseofitems,lossofemotionalcontrol,mildselfinjuringbehavior(e.g.,picking,skinburn)

• Clear,concretechoices• Separationfrompeers• Cooldown/timeout,escort• Processingsheet• Physicalactivity• Pointoutprogress

‐4.Defiance:deterioratingcontrol,threatening,hitwalls,escalation,fighting,leavew/opermission

• Moveothersfromroom• Physicalhold• Parentalremoval• Nonegotiation• Contactpoliceforcontrol,arrest• Ambulancetransport&hospitalize

De‐escalation

Behavior

Managem

ent

Safety

DesiredBehavior StaffResponse/Reinforcers

4.Majorchange.Stableandconsistentperformanceoftargetbehaviors,discharge&mainstreamcriteria

•Reviewofprogress•“Graduation”awardfromprogram•Dischargefromprogram,mainstream•Transitionbacktoschool

3.Moderatechange.Effortfulbutwithoccasionallapses,admitsbehavior&correctswithminimalcoaching

•Increasedprivileges•Leadspecialactivity•Rolemodeltopeers•StudentoftheWeek•Increasesocialapproval•LeadsportionofM‐Teammeeting

2.Minorchange.Improvementwithinconsistenteffort,easilyderailedbutacceptsredirection

•Publicacknowledgementof+behavior•Identify&complimentdecisionpoints•Identifypositiveoutcomes&avoidanceofnegative

•Chooseactivityforthegroup

1.Neutralposition.Expressedchangebutmarginalevidenceofefforts,littleornomisbehavior,passivecompliance

•Helperrole•Callonforparticipation•Complimentcontributions•Encouragement•Pairwithcooperativepeer

GraduatedIm

provementBe

haviorIm

provem

ent&

Mainten

ance

DesiredBehavior

ProblemBehaviors

Reinforcers

Responses

+4

+3

+2

+1

‐1

‐2

‐3

‐4SafetyPlan

Behavior

Managem

ent

GraduatedBehavior

ImprovementPlan

••••••••••••••••••••••••

De‐escalateRisky

Behaviors

ReduceProblemBehaviors

IncreaseProSocialBehaviors

OtherApplications

Checkfrequency,durationorintensityofbehavior,andratioofpositivetonegativeresponses

Whatarethesituationsandtriggersthatelicitthesebehaviors?

Howcantheybereconditioned,modified,oravoided?

BehaviorManagementThresholds:Whatarethethresholdcriteriathatleads

totransfertothenextlevel?

Level4risk

Administration,policeliaison,

or911

BehaviorLab

ISS

OSS

OffCampus(Library)

Homebound

ClassroomBehavior

ManagementPlan

StudentName (1)IndividualDiscomfort:

distractible,poorconcentration,

forgetful,emotional,preoccupied

(2)Distraction:blurtingout,sidetalking,noises,outofseat,

annoyingothers.Emotionalspillover

(3)Disruption:disregarding

rules,challengeauthority,talkback,swearing

(4)Defiance:threatening,

throwingobjects,physicalcontact,

screaming,fighting

Outcome:Effectivenessofresolutionforeachstudent

acrossincidents

Outcome:Effectivenessoftheresolutionforeachlevelofbehavior

BehaviorLabWorksheet

RespectfulReferralProtocol

Reminder:centeringanddetachmentforthe

teacher

Acknowledgement:indicatingawarenessof

thedifficulty

Supportstatement:showingconcernfor

well‐beingandperformance

Behaviorsupport:referralforcalmingand

resolution

Followup:debriefingteacherreaction&welcomingreturnof

student

• It’snotaboutme• s/hemustbereally

frustrated[hurt,angry,afraid…]

• Iwonderwhat’shappenedtomakeher/himsotouchy?

• S/hedoesn’thavethecopingskillsmostkidshave

• Deepbreath;relaxfirst

• “Iknowyoudon’twanttobeheretoday…”

• “Youhavesomethingelsegoingon…”

• “You’rereallyfrustratedbythis…”

• “Iknowitshardtopayattention…”

• “It’shardtoconcentratewhenyoufeelthisway…”

• “Somethingiskeepingyoufromfocusing…”

• “Iwantyoutobeabletodowellonthetest”

• “I’dlikeyoutofeelmorerelaxedandcalm”

• “I’dlikeyoutobeabletoconcentratemore”

• “Letothersstayinvolvedwithoutdistraction”

• “Itwouldbehelpfulforyoutotakeatime‐out”

• “PleasegototheBehaviorLabtocooldownuntilyoucancomeback”

• “I’dlikeyoutocomebackwhenyoucanfocusmore.PleasegototheBehaviorLab”

• “Somethingiskeepingyoufromfocusing–SeeifyoucanyourfocusbackintheBehaviorLabandthencomeback”

• Talkwithcolleaguetocooloffyourself

• Getmoreinformationtounderstandwhathappened

• MediatedreturnwithBehaviorLabstaff

• Letitgowithnocomment

• “I’mgladyou’reback,how’sitgoingtoday?”

• “CanIhelpyouwiththatassignmentfromyesterday?”

• Eventone• Neutraltoconcernedexpression• Clear,simpledirections• Opengesture&postures• Positiveframing

• Don’tengageinpowerstruggle• “Please”and“thankyou”• Use“and”ratherthan“but”• Consistency• 4:1ratioofnotingpositiveto

negativebehaviors

Welcoming: Direction Update Assignment Followup

• It’snotaboutme• Mightstillbehypersensitive

• “I’mgladyou’reback”

• Simple,clear,singledirections

• “Pleasetakeyourseat”

• Bringuptodateonwhattheclasshasdonewhiletheywereout

• “Wehavecovered…andarenowworkingon…”

• Simple,clear,singledirections

• “Pleaseturntopage…andwearenowdiscussing…”

• Complimentappropriatebehaviorwhenpossible

• Decidewhetherthisisagoodtimefordebriefing

• Askstudentifnoworlaterwouldbebetter

RespectfulReturnProtocol

Do’s Don’t’s

• Bewarmandreceivinginthewelcome

• Giveshort,simple,cleardirectives• Checkunderstandingifyousensenotfollowing

• Reinforcepositivebehaviors

• Don’trequireapologies(itshamesinfrontofpeersorrequiresinsincereadmission)

• Don’tusealoud,orthreateningdemeanorortone

• Don’tlectureorwarnthem

Teacherstyle/demeanor

Directive Supportive

Studentdemeanor

Adversarial

Respon

sive

Poorfit,riskofescalation;avoidconfrontation

Courteousrequestifreadytotalknoworlater

Carefulnottoshameorundothestabilitybyconfrontation

Follow‐upwithdiscussionandreinforcement

Q/A

SafetyFirst