Leadership and program support - foundation

Clinical participation - meds, side effects

Supervision and post crisis response

Training and competency standards

Documentation and incident monitoring and feedback

Setting Conditions

5 components

Any thing that makes challenging behavior more or less likely to occur

-Organizational culuture (control oriented, poor communication)

-Environment (hot, crowded)

-Program related (routine, staffing, activities)

-Personal (individual, illness, medication, trauma)

-Relationship-based (excessive controls, "us versus them" culture)

-Being aware of personal goals, values, and beliefs

-Understanding cultural and ethnic differences and each other's worldview

-Demonstarting self-regulation skills

-Knowing personal triggers

Stress Model of Crisis

1.) A crisis occurs when...

2.)  Goals of crisis intervention

3.) Describe the model

4.) Recovery Phase

1.)  A young person's inability to cope results in a change in behavior

2.)  SUPPORT:  support environmentally and emotionally to reduce                            stress and risk.

      TEACH:  teach children better ways to cope with stress (LSI)

3.)  Precrisis = Baseline

      Triggering event = agitation

      Escalation phase = aggression

      Outburst CRISIS = violence

      Recovery = baseline

4.)  Higher (Educateur)

      No change (fire fighter)

      Lower (abuser)

Skills Building Pyramid

1.) Purpose?

2.) Levels

1.)  Skills for building co-regulation strategies in TCI

2.)                                         LSI

                                  Crisis Co-regulation

                                   Emotional First Aid

                             Behavior Support Techniques

                     Active Listening Crisis Communication

                           Self-Awareness Four Questions

1.) What am I feeling now?

2.)  What does this young person feel, need, or want?

3.)  How is the environment affecting the young person?

4.)  How do I best respond?

-Provide environmental support by managing the environment to neutralize potential triggers.

-Provide emotional support by engaging the young person.
-Exercise self-control over own feelings. 

1.)  What am I feeling now? (3)

2.)  Effects of anger?

1.)  -Anger can undermine objectivity

-Anger is an emotional and physical state

-Cognitive abilities are reduced

2.)  -"When we are at our angriest, we are out our stupidest."

Knowing the Child

1.)  Iceberg

2.)  Assessing Behavior

3.)  Pain-based Behaviors

4.)  Identifying a young person's needs.

1.)  Behaviors are on the surface but many more feelings and needs        lie below the surface.

2.)  All behavior has meaning.  

      Behavior reflects needs.  

       Trauma affects how children behave.

3.)  Impulsive outburts, aggression, running away, self-injury, defiance,       inability to regulate emotions, trauma re-enactment.

4.)  What is this individual child's baseline behavior?

      Is this normal for a young person of this age?

      Does this behavior reflect the child or family's worldview?

      Is this a pain-based behavior related to past trauma?

      What feeling is the child expressing?

Managing the environment

1.) Examine Physical Setting

2.)  Activities and routines

3.)  Agency Policy and Procedure

1.)  Possible weapons, stimulating lights or noise levels, crowding.               Chaotic, messy, disorganized messages.

2.)  Causing frustration, boredom, anger?

      Inadequately resourced so that children can not fully participate?

      Conducted in areas without enough space or equipment?

      Building on children's strengths or pointing out their weaknesses?

      Allowing individuals (adult or child) to agitate others?

3.)  Clearly written, Communicated, Understood, Applied. 

Crisis Communication and Active Listening

1.) Nonverbal Techniques

2.)  Meaning in emotional communication

1.)  Silence, nods, facial expression, eye contact.

2.)  55% Facial Expression, 38% tone of voice, 7% words.

1.)  Encouraging and eliciting techniques

2.)  Understanding responses

3.)  Active listening

4.)  Active listening is NOT

1.)  -Tone of voice

      -Minimal encouragements "uh-huh"  "go on"  "I see"

      -Door openers "I'd like to hear more"  "Tell me about that"

      -Closed questions "Do you like your teacher"

      -Open questions  "How did you respond?"  "What happened next?"

2.)  -Reflective responses "You feel uncomfortable when your friends talk about       school"  "You are angry about your visit being cancelled, I'd be upset too"

      -Summarization "Here is what I hear you saying"

3.)  Identifies and validates feelings, reduces defensiveness, promotoes change, communicates that we care and understand, is an effective co-regulation strategy, helps young people "talk out rather than act out" 

4.)  Throwing up roadblocks (not taking the time to deal with it), Arguing or blaming, Giving permission (its ok to have feelings but not the behavior), Giving advice or solving the problem for the child, Necessarily time consuming.

Behavior Support Techniques

8

-Managing the enviroment

-Prompting

-Caring gesture

-Hurdle help

-Redirection and Distractions

-Proximity

-Directive statements

-Time away

Emotional First Aid

1.)  Adults can help children by...

2.)  Goals of emotional first aid

3.)  Strategies

4.) The child should understand that the worker...

1.)  -Seeing the incident from the child's perspective

      -Helping children see the connection between feelings and                  behaviors

      -Encouraging children to be responsible for their actions

2.)  -Provide immediate help and support to reduce emotional intensity (co-regulation)

      -Resolve the immediate crisis

      -Keep the child in the program/activity

3.)  -Drain off emotions

      -Clarify events

      -Maintain the relationship and lines of communication

      -Remind the child of the expectations and mediate the situation if necessary

4.)  -Believes the child has the abliity to successfully participate in the activity

      -Will have time later to talk again, if needed. 

The conflict cycle

1.) Describe

2.)  We can avoid the conflict cycle by...

1.)  Stressful situation ->  Young person's feelings ->  Young person's behavior -> Adult's response -> back to stressful situation in a circle

2.)  -Using positive self-talk

      -Listening and validating feelings

      -Managing the environment (eg removing others)

      -Giving choices and the time to decide

      -Redirecting the young person to another positive activity

      -Appealing to the youn person's self-interest

      -Dropping or changing the expectation

Managing Aggressive Behavior

1.)  Two types of Aggressive Behavior

2.)  Proactive Aggression Model

3.) Immediaonste respe Priorities for each type

4.)  Ongoing response priorities for each type

5.)  Individual Crisis Management Plan (ICMP)

6.)  Nonverbal communication/behaviors

1.)  Reactive Aggression:  Affective or expressive aggresion, Loss of            control and emotional flooding, emotions are dominant.

      Proactive Aggression:  Instrumental or operant aggression, goal              oriented, cognitions are dominant.

2.)  Emotional arousal signs are subtle and during irritation phase.             Behavior escalation is sharp peak in aggression phase.

3.)  Reactive = Safety, Understanding and support, Remove or reduce stimulus

      Proactive = Safety, containment and negotiation, engagment and reasoning

4.)  Reactive =  Teach coping skills, Teach self-regulation skills, Anger management

      Proactive =  Teach appropriate thinking, values, and social skills, Reward socially           appropriate behavior, not anti-social behavior.

5.)  Functional analysis of high risk behavior, Strategy for intervening tailored for the           young person, periodic review and update.

6.)  Eye contact, Body language, Personal Space, Heigh differences, Gender                       differences, Cultural differences

1.)  4 elements of a potentially violent situation

2.)  Remove the potential trigger to violence by...

3.)  Remove the target by...

4.)  Avoid the weapon by....

5.)  Decrease thel evel of stress or motivation by....

1.)  A potential trigger to violence, A target, A weapon, Level of stress or motivation (Reactive vs Proactive)

2.)  Never touching an angry and potentially violent person, Avoiding any aggressive moves and provocative statements, Avoiding the conflict cycle and counter aggression, Removing others who might trigger the violence, Body language is critical.

3.)  Asking the targeted person to leave, if it's you reminding the young person of your relationship or leaving the situation and asking for "neutral" staff, target may shift.

4.)  Discreetly removing objects, Maneuvering away from weapons, staying a safe distance away.

5.)  Using your relationship, actively listening to identify feelings, removing the audience, using co-regulation strategies (reactive aggression), Offering alternative, nonaggressive ways to achieve goals (proactive aggression).

1.)  Objective of crisis co-regulation

2.)  What to think (self awareness)

3.) What to do (nonverbal strategies)

4.) What to say (verbal strategies)

5.)  What to do when it's over

1.)  To provide support in a way that reduces stress and risk.

2.)  Ask yourself the four questions, use positive self-talk.

3.)  Take a deep breath, use protective stance, step back, give the situation time, sit down if appropriate, remember the importance of body language and facial expression.

4.)  Very little, Understanding reponses, remember the importance of tone of voice.

-"I can see..." (validate feelings)

-"When you.." (encourage positive behaviors)

-"I know we..."  (emphasize desirable outcomes)

-"I am sorry..."(offer an apology)

5.)  It's over when the outburst ends but not back to baseline, Prepare to discuss the situation in a LSI.

The Life Space Interview (LSI) 

1.)  Definition and quote.

2.)  5 Goals of LSI.

3.)  Steps to the LSI.

1.)  -A therapeutic, verbal strategy for intervening with a young person.  

       -"The clinical exploitation of life events." - Fritz Redl

2.)  -Return the young person to normal functioning.

      -Clarify events.

      -Repair and restore the relationship.

      -Teach new coping skills.

      -Reintegrate the young person back into the program.

3.) I ESCAPE

      I - isolate the conversation

      E- Explore young person's point of view

      S - Summarize the feelings and content

      C - Connect feelings to behavior

      A - Alternative behaviors discussed

      P - Plan developed/Practice new plan

      E - Enter young person back into the routine

Choosing a Safety Intervention

1.)  5 Options to handle phsyical violence

2.)  The goal of physical intervention

3.)  Defintion of physical restraint

4.)  Physical restraint should only be used when...

5.)  Physical restraint is NOT used to...

6.)  Basical principals of physical intervention

1.)  Eliminate one of the elements of a violent situation,  Make a directive statement that clearly communicates the violence must stop, Use releases and maintain a safe distance with a protective stance,  Leave the situation and get assisstance, Employ physical restraint techniques (if indicated on the ICMP.)

2.)  To ensure safety.

3.)  -Physical restraint:  The use of trained staff members to hold a young person in order to contain acute physical behavior.  

      -Acute physical behavior:  Behavior likely to result in physical injury.  

      -The young person, other clients, staff members, or others are at imminent risk of physical harm.

4.)  -(All three criteria must be met)  

      -Agency policies and state regulations approve restraint.

      -The young person's individual crisis management plan indicates it.

      -Our professional dynamic risk assessment indicates it.

5.)  Demonstrate authority, enforce compliance, inflict pain or harm, punish or discipline.

6.)  *A maximum amount of caring and a minimum amount of force with the goal of de-escalating the situation by reducing stimulation.

States what is expected of the young person.

Is directed by the team leader.

Is supportive of the young person.

Safety Concerns and Documentation

1.)  Do not use physical restraint when...

2.)  Define asphyxia and positional asphyxia.

3.)  Predisposing risk factors?

4.)  Warning signs of asphyxia.

1.)  We cannot control the young person safely, we are not in control or are too angry, sexual stimulation is the motivation, we are in a public place, young person has a weapon, young person's medical condition prohibits it, young person has emotional problems risking retraumatization, young person is on medication(s) that affect his or her system.

2.)  Asphyxia:  the deprivation of oxygen to living cells

      Positional asphyxia:  fatal respiratory arrest in which the ability to breathe is                   compromised by the positioning of the body in relationship to its immediate surroundings.

3.)  Obesity, alcohol or drugs, prolonged violent physical agitation, underlying natural disease (enlarged heart, asthma, sickle cell trait, hypertension, diabetes), hot humid environments, certain types of medication.

4.)  Due to neck compression:  goes limp and ceases to breathe spontaneously.

      Due to respiratory interference:  states that he or she can't breathe, respiration is labored, rapid or abnormal, may make grunting noises, vomiting or turning a dusky purple color, especially of the face, goes limp and ceases to breathe.

5.)  Things to monitor during restraints.

6.)  Recommendations to reduce the risk of injury or death.

7.)  Documentation.

5.)  Position of child and staff, skin color, respiration, level of conciousness, level of agitation, range of motion and/or swelling in extremities.

6.)  Never...place weight on a young person's chest or back, put puressure on the young person's neck, place the head in a position that cases the neck to be compressed, allow a young personal to stay in the prone or supine position once he or she is no longer a safety risk-get them up to seated position, place a young person's arms behind his or her back when that person in in a prone position, bend a child forward in the small child or seated restraint, place anything over or near the young person's face, mouth, nose that can be inhaled or conform to the contours of the face, ignore any of the warning signs of pending asphyxia, fail to take immediate action if there is a need for emergency medical treatment, restrain a child in the prone position on a mattress or surface that can conform to the contours of the face, use these restraint techniques on children under five years of age.

7.)  Who, what, when, where?  What did the staff do to de-escalate the situation?  If physical contact, who did what?  How long did the restraint last?  Staff/child injuries?  Medical attention?  What plan was developed in the LSI?  Debriefing of staff?  Was follow-up needed?  Was the family notified?

Young person refuses to talk

     -convey calm support and sanction silence

     -ask a focused question

     -reschedule LSI

Young person gets off subject

     -allow exploration and relate it to incident

     -focus on issue at hand

Worker or young person wants to just "fix it"

     -don't interrupt young person's thought process

     -don't develop the plan for young person