Reinforcement and Crisis

Remember to reinforce what you only really want to reinforce.  Remember, “what we focus on, increases.”  This is not an invitation to bury your head in the sand.  Take care of safety, urgent issues quickly and efficiently, but find ways to reinforce the positive.

          Understand and effectively use:

1.     Redirection  

2.     Choices (3 is usually best and make them real choices)

3.     Consequences

Tantrums:

1.               Assure safety if there is a real potential safety hazard.

2.               Don’t over react.

3.               Allow children to lean they can self-calm

4.               Teach children appropriate ways to communicate and meet needs

5.               Teach delayed gratification

Parsimonious checklist for Family Centered Planning

For almost any child, the family is the first context within which all development occurs.

After family, typical comes school, religious organizations and support (for some), peers, culture, and environment.

To assure you are optimizing the context within the family, consider:

1.       Was information gathered about the child/youth in context of the family?  This would include the natural environment and natural routine.  Observation may be included if possible, but understand, behavior often changes when being observed.  Be aware of the “Hawthorne Effect.”

http://weight-lossnewsandresearch.blogspot.com/2018/06/hawthorne-effect.html (Behavior often changes while being observed.)

2.       Have you, are you carefully, and demonstratively listening to: comments, concerns, and observations, by parents/guardians? 

Understand that sometimes, in somethings, parents can be right and know more about their child than you.

3.       Are plans, goals, objectives, written in language easy for the parent/guardian to understand?

4.       Is the family a full partner in the plan?

5.       Whenever possible is the child/youth a full or to the degree possible, partial and active partner in the plan?

6.       Are outcomes meaningful and practical for the child/youth and family?

7.       Even when there is a behavior you wish to diminish or eliminate, have you included what you want the child/youth to do?  What is the replacement behavior?

8.       Be careful about ascribing motivation to parents/guardians.  Sometimes we do not even fully understand our own underlying motivations.  You can collect data, you can work to influence, but understanding “why” can be very elusive.

9.       Be a good partner with everyone involved.  Be considerate.  Don’t assume.

This book, like a well written objective, was meant to be parsimonious.  Hopefully, like a well written objective, it is also helpful.

Foundational Setting Events

I always appreciate good, thorough, meaningful assessment, if it informs and enhances good intervention/treatment.  Don’t shortcut assessment.

Evidence based interventions primarily fall into one of two categories: Developmental and Behavioral.  Over the past 10 – 20 years, these two approaches have come closer together. 

Typically, when looking at the “why,” or reason for a behavior, a good BCBA (behavioral) will look at the function of the behavior.  Is the child trying to avoid/escape/release, get something, or is it to fill a sensory need?  Skill and performance deficits will be considered.  Antecedents, Behavior, and Consequences, will all be considered, and they are all crucial and critical elements of an effective plan.

Developmental interventions work in a similar vein.  The interventionist and/or parent coach create the opportunity for the child to develop foundational developmental skills and then build upon those skills. The Greenspan Floortime ApproachTM is a good example.  Building upon the work of Dr. Greenspan, Dr. Richard Solomon developed The PLAY Project. See:  Autism: THE POTENTIAL WITHIN, The PLAY Project Approach to Helping Young Children with Autism. Richard Solomon, MD.  https://www.playproject.org/  (PLAY is an excellent evidence based and low-cost intervention for autism for many children and families. PLAY can significantly extend capacity for services for children with ASD at a relatively low cost.  It is not for all, but for some it can be a great boon.)

Therapists, educators, parents, should never underestimate the critical importance of fundamental, developmental building blocks and experiences.  Too often we attribute the lack of progress to a lack of motivation, or even simple skill building, when other critical issues are at play and must be addressed. 

Setting events will be considered as mentioned previously.  However, this appendix will take a much broader view of setting events, some of which are often overlooked or neglected, but which are fundamental for anyone, whether or not they have a disability or social/emotional difficulty.  Do not disregard the foundations of: physical, emotional, social, and mental health.

Let’s start with Maslow.  Almost anyone in the social sciences or education is familiar with Maslow’s Hierarchy of Needs.  It is something we learn about in Psychology or Social Work 101 and then we often forget it exists.  If the child, any child (or adult), does not have his/her basic physiological and safety needs met, you are unlikely to change or improve outcomes or behavior.  The same could be said for that child’s parent.  If you want to influence the parent as a partner for the good of the child, do not forget the parent also has basic needs.

For my purposes here, I only want to focus on the bottom three layers of Maslow’s Foundation.  Physiological includes physical needs (shelter, food, clothing, etc.), health and medical needs.  Safety would include adverse childhood experiences, which will be discussed next.  Safety also includes stability.  It is difficult to feel safe in instability.  Love and belonging are also essential and will be discussed after adverse childhood experiences.

For more information on Maslow’s Hierarchy of Needs, you can find resources here:  http://weight-lossnewsandresearch.blogspot.com/2018/04/maslows-hierarchy-of-needs.html

Adverse Childhood Experiences

 https://www.samhsa.gov/capt/sites/default/files/images/adverse-childhood-experiences-pyramid-lg.jpg

This model from the U.S. Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/  refers to a large research project, the Adverse Childhood Experiences Study, sometimes referred to as ACES.  You can learn more about this study from many resources, including: https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences

While this is an over simplification, the study found that the more adverse childhood experiences a child had (risk factors) the more likely they were to have social, emotional, & cognitive impairment.  This in turn increases the likelihood the child/adult will become involved with health-risk behaviors.  This in-turn increases the risk of disease, disability, and social problems, and ultimately early death.  However, well before early death, is poor quality of life.

What this pyramid does not demonstrate is the importance of protective factors.  Many people who have adverse childhood experiences go on to thrive.  Quite often the difference is the presence of protective factors, strength, or developmental assets.  You can learn about developmental assets which help children thrive here: https://www.search-institute.org/our-research/development-assets/developmental-assets-framework/

Though this may differ slightly from Maslow’s model, I always put safety first and immediate.  Resolving urgent, significant, immediate, safety concerns is always the priority.  In this context, I expect Maslow would agree.  While removing risk factors is important when possible, it is impossible to remove the past.  Inserting protective factors or developmental assets, especially those which fit the interest and/or need of the child can help ameliorate risk and reduce the negative effects of adverse childhood experiences. 

Additional intervention/therapy may also be needed.  Some children can benefit from trauma informed therapy and/or play therapy (not to be confused with P.L.A.Y.) provided by a well-trained, effective therapist able to build a positive rapport with the child and parent/guardian.

Please also consider the following pyramid model.

This is only part of The Pyramid Model from the Technical Assistance Center on Social Emotional Intervention for Young Children.  For more information go to: http://challengingbehavior.fmhi.usf.edu/do/pyramid_model.htm

Consider this pyramid, what do you think the outcome would be for the child and family if only the top and bottom levels of this pyramid were present?  The point of this model is the necessity of addressing each layer from the bottom up, before providing intensive individual intervention for the child, whenever possible.  While there may be some urgent situations where an immediate intervention may be warranted, in most situations, for most children with social-emotional needs, building the foundation can lessen or even resolve the need for intensive individual intervention.

Here’s another.  The Foundation for Personal, Optimal, Health.

          It can be very difficult to think clearly, feel well, and behave your best, when your body is fueled by crap and void of essential nutrients.  It is similar for a lack of sleep, exercise and/or significant chronic stress.

Our internal chemistry, how we think and how we feel is fueled or disrupted by what we put into our bodies; by the chemicals, liquids, and nutrients. Do not underestimate the importance of this fact.

Personal Optimal Health

          Food Security is not about getting enough food to eat.  It is about getting the essential nutrients.  This is about getting all the nutrients your mind and body need to function well.  If you are food insecure, you will crave food.  Even if you were to eat a gallon of macaroni and cheese every single day, even two gallons of macaroni and cheese every single day, if that was all you ate, you would be food insecure.  I had a college roommate who tried that.  He became so sick he had to have vitamin shots to regain his health.  He was lucky, it could have been much worse.  For some it is.

          According to the World Health Organization, and perhaps for the first time in history, there are now more people in the world who are malnourished and obese than malnourished and underweight.  (See: http://weight-lossnewsandresearch.blogspot.com/2018/05/food-insecurity-paradox.html)

          Some believe it is too expensive to eat healthy, that is a myth, for most.  It is cheaper to eat healthy, and be healthy, even on food stamps, IF you know how.  Many can even eat more than they usually eat and still lose weight, if needed.  This is not something that can be remedied in one meal or one day.  If you or a child are seriously food insecure, it will take many weeks/months of good, well-balanced meals to rectify significant damage previously done.  In some cases, it may require medical intervention.  Occasionally it may be too late, but still important for personal optimal health, whatever that may be.   See: Food Addiction, Binge Eating, Addiction Recovery: Choose: Health, Life, and Love (with recipes) CR Petersen M.Ed.

          While only discussing a few aspects, all the pyramid is essential for anyone’s personal optimal health.

http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30003-2/fulltext "With irrefutable evidence that children in low- and middle-income countries can be expected to develop optimally as long as basic needs for nutrition, safety and stimulation are met, policy makers and political leaders can now turn their attention to making it happen." https://www.theguardian.com/global-development/2018/mar/21/health-wealth-child-development-study https://www.facebook.com/DeliciousNutritionStealthHealth/

All of this speaks to the old metaphor comparing the fence at the top of the cliff to the ambulance at the bottom.  While we will always need the ambulance, these pyramids or foundations, bring attention to the need for a good strong fence.

Examples:

Many cases of autism and developmental disabilities can be prevented with nutrition before and during pregnancy. http://weight-lossnewsandresearch.blogspot.com/2018/05/prevention-of-autism-and-developmental.html Exercise and depression http://weight-lossnewsandresearch.blogspot.com/2018/05/exercise-and-depression.html This does not mean that exercise will eliminate depression.  In very few cases will it do that.  However; in many cases, it will ameliorate depressive symptoms.  Consult with your physician, take medication as needed. http://www.dailymail.co.uk/health/article-5526813/Stopping-exercise-worsens-depression-little-three-days.html Nutrition and mental illness http://weight-lossnewsandresearch.blogspot.com/2018/05/nutrition-and-mental-illness.html Again, good nutrition is not likely to eliminate mental illness, but in some cases, it may ameliorate symptoms. Consult with your physician, take medication as needed. One other interesting article: The road to Alzheimer's disease is lined with processed foods https://qz.com/1234901/the-road-to-alzheimers-disease-is-lined-with-processed-foods/

According to the researchers at Vitalsmarts https://www.vitalsmarts.com/, we are influenced by both motivation and ability, and for both, at the levels of personal, socials, and environment.  At the personal motivational level, we might include: sensory needs, wanting something, and escaping from something.  These may include motivators pertaining to health, and internal feelings such as pain.   Personal ability may include other aspects of physical health and disability, as well as other areas of personal ability.

          Hopefully you are now well beyond only thinking about the basic motivators of avoiding or escaping, getting something desired, or sensory needs.  Those are important, even critical, but they are not the whole story. 

          You may be asking yourself how you can know about all these levels in multiple pyramids.  While not a complete answer, the CANS or The Child and Adolescent Needs and Strengths http://weight-lossnewsandresearch.blogspot.com/2018/05/the-child-and-adolescent-needs-and.html  can fill in many of the pieces which may missing and where you can build on strengths.

Not only will it provide an assessment, but it will tell you of specific needs which may need to be addressed, and areas of strength which can be further ameliorated.  These strengths can be used to minimize the impact of some needs.  This does not mean that some serious and significant needs do not need to be addressed with urgency.  Urgent needs, especially around safety and stability, must often be addressed immediately.

Many years ago, I was a MANDT http://www.mandtsystem.com/

instructor.  At the time I was a clinician in a mental health agency.  It was common on average, on a weekly basis, that we would restrain and put at least one youngster in time out.  I know practically nothing about MANDT now, but at that time, while physical restraint was taught, avoiding the need and prevention, were emphasized.  Quite often, when foundations are created as demonstrated in the foregoing pyramids, crises are adverted.  While the MANDT training did not address anywhere near everything addressed here in this appendix, it addressed enough to make a substantial difference.  After going through the training, myself, and then training the staff at the agency, as I remember, we only had to physically restrain one child, one time, during the following year and a half.  That is a substantial improvement over doing it weekly.

More on diet, health, and weight-loss

Working with parents and guardians

“There’s no such thing as a resistant client, only inflexible therapists.”  Becoming Solution-Focused in Brief Therapy 1st (first) Edition by Walter, John L., Peller, Jane E. Published by Brunner/Mazel Inc. (1992)

Why this quote?  Many therapists feel competent working directly with the child, but so much more is often required than “fixing the child.”  Many children lack the essential building blocks which they need to thrive, or even achieve their personal, basic, optimal health.  Expanding capacity for intervention almost always requires partnership with a parent/guardian.  This is the child’s first and often most important teacher.

Sometimes environments need to be altered, relationships need to be improved, basic needs need to be met.  Sometimes communication and interactions need to be adjusted or improved.  This does not necessarily mean that a parent is a bad parent, but the needs of some children are different from others.  Sometimes talents, strengths, assets, resilience, and interests, need to be developed.  Sometimes we forget to apply fundamental developmental information known for years, decades, generations, and in some cases, millennia.  This may require more than basic Interventional skills.  You may need to relate to, influence, and even teach a parent.

This may require flexibility, creativity, excellent communication skills, the ability to relate, demonstrate real empathy, as well as additional skills and knowledge not always common to the beginning or even many experienced therapists, interventionists, and/or teachers.

One must be very careful about telling a parent s/he is doing it “all wrong,” or that s/he must make substantial changes, unless there is a significant safety issue, to include those which must be reported to proper authorities.  Almost always the best way to help parents/guardians create healthier environments and more therapeutic supportive interactions for their children with special needs, is to praise what they are doing right, and give them slight nudges towards change.  Overtime this approach will almost always be more beneficial for both the parent/guardian, and the child.  Milton Erickson, a famous 20^th century psychiatrist believes we are all in trenches pertaining to the way we think and behave.  It can be very difficult for many of us to see or act outside the deep trenches in which we are traveling.  His very effective practice was not (in almost all cases) to try to force people to make significant changes or see things completely differently, but to help them make very moderate changes.  This would allow them to make more healthy adjustments once they were outside their deep trenches.  Often the initial change was very slight.

In what I believe was his first professional position in the field, Milton Erickson worked in a psychiatric hospital.  There was a man who had been there many years and who believed he was Jesus Christ.  Many had tried to convince him he wasn’t.  Erickson said to the man, ‘I understand you are Jesus Christ.’  The man responded, “Yes.”  ‘I understand you used to be a carpenter.”  The man responded, “Yes.”  ‘I understand you like to help others.’  The man responded, “Yes.”  ‘Well,” Erickson asked, ‘they need help in the carpentry shop, would you be willing to help?’  What could the man say, but “Yes.”  Within about six months the man was released from the hospital.  Erickson’s entire career was filled with these types of interventions.  (See: Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson, M.D. by Jay Haley) 

A little respect and positive rapport with a parent/guardian, the right amount of positive feedback, and gentle nudges in the right direction, along with patience, can usually go a long way.  Generally, you do not even need to make direct suggestions.  Well-crafted questions can be even more effective, most of the time.  How do you think you could???  What have you done in the past that has???  What has worked in the past???  What have you seen others do to???  What do you think might work???  And the last question, what do you think about trying???

Many years ago, my wife and I purchased a new car.  Repeatedly, part of the electrical system would short out.  We took it into the dealer and they would replace a fuse and try to figure out why it was shorting.  This continued for months.  The mechanics could not find the source of the problem.  Finally, on one visit a mechanic discovered a set of spare keys we kept in the ashtray.  Once the keys were removed, the electrical shorts stopped occurring.  Often, it is the same with setting events.  Once an underlying issue is resolved, the maladaptive or inappropriate behavior stops or is easily replaced with more appropriate, healthy behaviors.

The following is intended to only give you a glimpse of some of the fundamental, developmental, and general health needs of every child (and adult).  ALL the following CAN be significant setting events.  Some is essential, much is crucial… for optimal health and development.

More on Goals

Goals

Remember, a goal is where you want to go, objectives are how you are going to get there… or the steps to help you reach the goal.

Consider:

1.     Needs which need to be met.

2.     Issues which need to be resolved.

3.     Developmental stages which need to be met or achieved.

4.     Behaviors which need to be changed, developed, or replaced.

5.     Strengths and interests which can be developed or augmented.

6.     Setting Events, for child/family.

How to write a SMARTERR goal Specific (with a baseline) Measurable Achievable/Attainable Results-Focused Time-Bound Evaluate/Enhance/Adjust Reporting/Accountability & Reinforcement/Reward

Plan Implementation Template

Plan Implementation Template

Name of Child/Youth:	Diagnosis:
DOB:	Goal related to this objective:

Is this objective contextually mediated within the child/youth/family’s natural routine and natural environment (either current or desired)?   Yes ☐ No ☐

If this is not a natural environment/routine, how and when will this intervention be transitioned into this child/youth/family’s natural environment/routine?

Why can this not be accomplished in the child/youth/family’s current or desired natural environment/routine at this time (if applicable)?

Has consultation/collaboration occurred with other therapists involved with this child and have they had input on this plan?  I.e. Speech, OT, PT, Behavior, Teacher?

Yes ☐ No ☐  If yes, please include name and discipline. 

Objective number/letter:	What is the type of environment where this will occur? Home     Community     Center (Circle all that apply) What is (are) the specific location(s) where work on this objective will occur?
Start Date for Objective:
What behavior is the child/youth to do?	If this is a replacement behavior, what (problem) behavior is this replacing?
What cue will tell the child/youth it is time to do the behavior listed just above?  (Please include additional prescribed prompts when applicable.)	If applicable, how will problem behavior be measured?
What is (are) the specific criteria for the child/youth to successfully meet/accomplish this objective?  (Please include specific prompts and allowable time between cue and desired behavior if applicable.)	Target Date for Completion of Objective (not to exceed one year):
The initial baseline for goal: (When first assessed)	Current baseline for this objective:

Written instructions to staff to include needed supplies, schedules, charts, environmental preparation, and/or child preparation:

What reinforcement will be used when this child/youth completes the behavior as prescribed?

Is this an arbitrary (contrived) reinforcement?  Yes ☐  No ☐  If yes, is there a plan to transition to a natural reinforcement Yes ☐      No ☐  If yes, how?

How will setting events be modified (if applicable)?

How will immediate antecedents be modified (if applicable)?

Any additional strategies to prevent the problem behavior (if applicable).

Crisis (Safety/Risk) plan (if applicable).

(Remember: avoid subjective outcome/objective terms such as:

Improve

Better

Feel

Believe

Try

(While there is value in measuring a parent’s subjective experience, self-efficacy, and stress reduction, objective outcomes/objectives for children/youth should always be used.  Use objective (active) outcome terms which are observable and measurable as mentioned previously.)

Adjust all plans as often as needed.  Every two weeks is not unreasonable in some cases.  Plans should be reviewed at least every 90 days.

Appendix A: Possible considerations for a Crisis/Safety/Risk Plan

You will want to retype what is appropriate for your situation, add anything additional that may be needed, and add sufficient space to complete the plan.

Safety/Risk Plan and Risk Reduction (Always make it applicable to the needs of the individual.  These are only a few things to consider.  Adapt and add according to individual needs. Recreate according to individual needs and fill in the blanks.  Assure that necessary supplies/resources are available.  Post on the fridge or where it can be easily and frequently seen if applicable.)

De-escalation (Note: be careful not to reward or reinforce escalation, crisis, or other inappropriate behavior.  Remember: attention, touch, time, tangibles, can all be a reward or reinforcement.  Provide more appropriate ways for the person to receive desired and appropriate rewards/reinforcements prior to inappropriate or unhealthy behavioral escalation.  Helping/teaching the child/adult to identify the beginning of their own escalation is important.  Helping/teaching the child/adult to appropriately self-regulate can be essential.  Appropriate reinforcement/reward for appropriate early identification and self-regulation is appropriate.)  Aerobic exercise, deep breathing, blowing big bubbles, stretching, stretching while deep breathing, yoga, can all be helpful.

Distraction/Redirection (Divert attention to something different.)

Cross talk (Speak about the person in a quiet voice, but not to the person.  Sometimes, someone in a crisis may not want to hear what you have to say to them, but if you are speaking with another close by, they may want to hear what you are saying about them.)

Consequences (Have consequences prepared in advance.  Present/remind of appropriate, safe, consequences of inappropriate behavior. Follow through.)

Call parent or another appropriate adult.

Alternative behaviors (Present and reinforce alternative behaviors.  This is different than a simple redirection.  This is repeatedly practiced prior to any escalation or crisis.  Best if used at the very beginning of escalation.  Taking a walk in a safe place, going to a sensory room are examples.)

Writing or art (Ask the person to write or draw about their frustrations.  Tell them they can share/explain to the appropriate person.)

Use stories or fables (These should also be familiar and have been told and perhaps acted out previously.  These provide healthier resolutions to a typical escalation or crisis.)

3 choices (These should also be written down in advance.  Provide the person with alternative choices.  Three is more than the typical, “yes or no,” “do this or do that.”  When there are three choices, the person must self-calm enough to consider the three.)  Make them viable positive choices, not just: do this or else…!

Learn the signs of stress and an oncoming crisis, this may be quicker movements, quicker or slower speech, change in behavior, change in volume, the sound of a dry mouth, reports of hallucinations, threats, concerning self-talk or with imaginary entity, etc.  Provide supports and use de-escalation without rewarding inappropriate behavior.

When a child/youth escalates into a crisis, it is often easy to escalate with them.  As the situation becomes more stressful, it can be difficult for almost anyone to remain completely calm.  Remain calm as much as possible.  Know and stick with the plan.  If unable to remain calm and if possible, trade with another fresh adult who has not escalated at all with the child/youth.  Such trading may need to occur more than once.

Children in crisis may resort to fight, flight, or freeze.  They may use one strategy for one situation and another in a different situation.  ALL require de-escalation.

Remember, de-escalation often requires a physiological change, which initially, may be best accomplished with a physical aerobic activity such as walking.  After physical activity, the child/youth may be better prepared to process the events that led to the crisis.

Do not transport on your own if you cannot safely do so.  Do not take the child/youth for a walk if you cannot safely do so.  If the child/youth needs to be transported to an emergency room, if you do not feel confident you can do so safely, call for appropriate assistance according to your local area, i.e. Law Enforcement, Ambulance, etc.

If you believe anyone is in imminent danger, call Law Enforcement immediately.

Process crises with others, to include crises averted and then adjust as necessary.  Celebrate/reinforce positive outcomes to include self-soothing and self-regulation and de-escalation before the crisis occurs with the child/youth.

Remember, confrontation and physical intervention can be dangerous for everyone involved.  In some extreme situations it may be necessary for safety.  Before using physical intervention in a crisis, become trained and certified in an approved (according to your location) technique.

First listen and demonstrate you are listening.  Empathize and demonstrate empathy, agree to solutions, partner or collaborate with the child/youth.

Specific known triggers Things that can cause or precede a crisis or escalation of dangerous behavior.  List: _________________

Respite plan for parent or child/youth.  Where can either go to safely get a break? 

Child/youth ___________   _______________ ______________

Parent ____________ _____________ ____________

How can the:

Child/youth access (or notify of the need for) break/respite? ___________

Parent access (or notify of the need for) respite? ____________

What supports/resources are needed to make this happen? __________

Diagnoses for individual List: ____________________

For child, parent, and other members of the household

Stress Reduction (which sometimes may reduce risk)

Take a walk (where: _________________

Take a walk with a friend (who: ________________

Another exercise (what: ______________

Call a friend or support person (who: ___________________

Blow big bubbles

Deep slow breathing

Stretching

Listen to calming music (what: _____________

Talk with a friend (who: ______________ _______________ _________

Art work or create something, make sure you have the tools/resources on hand (what: ___________

What has worked in the past? List: ________________________ Which are still viable? ______________________

Limit screen time.  Encourage activity, supervise and provide structure as necessary.  Provide meaningful developmentally appropriate chores.  Teach and train for success.

(See: Tools For: Food Addiction, Binge Eating, Addiction Recovery, for more information on stress reduction.  CR Petersen)

Safe environment… remove or lock up.

Firearms and ammunition

Knives, box cutters, razors, scissors, other sharp objects

Car keys

Medication, both prescription and non-prescription.  Some supplements may also need to be locked up.

Matches/lighters

Pornographic and/or violent print or media (games, movies, etc.)

Alcohol, illegal drugs, related paraphernalia

Tools, any on the property.  Be aware of and minimize risk of tools or other items near the property where the person resides.

Chemicals and cleaning supplies.

Belts, ropes, shoelaces, cords, etc. (anything that could present a significant danger)

Supervision provided by ___________________ ______________ How close/frequent does the supervision need to be? Frequency ________________ (may need to be constant) How close ___________________ (does the person supervising need to remain within arm’s reach?)

Minimize environmental stressors, such as noise, lights, specific people.  Use systematic desensitization as appropriate.

http://weight-lossnewsandresearch.blogspot.com/2018/06/systematic-desensitization.html

Safe environment – (What can be added to make the environment safer?  Consider nature sounds or soft music.)

Alarms on windows/doors (where) _________________

Tracking system such as ankle or wrist (can be very useful for children with ASD or other conditions and who may run.)

Plexiglass for windows

Secure but accessible first aid

Other safety equipment _____________________

Medications

Sometimes medications for the child/youth are necessary not just because of the needs of one individual, but for the benefit and even safety of other members of the family or community. 

A lot has been written, and there has been a great deal of research about over medicating both children and adults for various diseases as well as mood and behavioral difficulties.  There is a time and place for medication.  Sometimes there is a chemical imbalance which requires medication.  Sometimes there is another health condition where just the right amount of the right medication will make all the difference in the world.  Sometimes medication can make learning and behavioral change easier or even possible for some.  Sometimes medication is required to sustain life or enjoy any degree of quality of life.

Caution:  Do not neglect the many foundations of physical and emotional health as discussed in the appendixes.  Do not over-medicate or use medication as an excuse to avoid the sometimes more difficult, but still essential aspects of safety, intervention, learning, development, and behavioral change.  Consult with a qualified physician or psychiatrist when needed and use appropriate medications when they will provide benefit and improve the quality of life for the individual.

You can find research on the dangers of over medicating at this URL: http://weight-lossnewsandresearch.blogspot.com/2018/05/over-medicating.html  Remember though, medication may be necessary.  Consult with a physician or psychiatrist.

List medications being used: ____________________________________

Restraint:

Sometimes and for some children/youth, a gentle but firm squeeze (such as on the arm) or appropriate hug, may help them calm and de-escalate.  This is not the same as a restraint.  A hug or gentle squeeze lasts only if the other individual is welcoming of this contact and not a second longer.

Restraint of a child should only be used as a last resort.  When used, it should be reviewed and approved by a licensed psychologist, psychiatrist, or other professional legally authorized to make such approvals.  The person using the restraint should be trained and certified in a medically recognized safe restraint intervention and used according to training.  In most situations, if environment and other setting events are appropriately addressed, and de-escalation techniques appropriately used, restraints will rarely if ever be needed.

Go to the link below for more resources on de-escalation techniques.

http://weight-lossnewsandresearch.blogspot.com/2018/05/de-escalation-techniques.html

Reasons for living, and natural supports.

Family _______________ _______________

Friends ________________ _______________

Pets _________________ _______________

Teacher/Mentor/Religious leader ____________________

Goals ___________________

Other _________________

Safety is first.  Always call law enforcement, protective services, the local emergency room, or other appropriate agencies if you believe someone is in danger to self or others or gravely disabled.

Help/Resources

Therapist/Counselor __________________

Crisis/emergency # i.e. 911 _________________

Law Enforcement ______________

Hospital ___________________

Suicide/Suicide/another hotline ____________________

I agree to follow this plan as written: (print name and sign)

Child ___________________

Adult _________________

Parent _____________________

Support ______________

Clinician/Therapist _________________

Date ______________________

Additional risks

List additional risks for the child or family __________________

List 3 alternatives on how each of the risks can be mitigated _____

_______________