Plan
Implementation Template
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Name
of Child/Youth:
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Diagnosis:
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DOB:
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Goal
related to this objective:
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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.
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Objective
number/letter:
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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?
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Start
Date for Objective:
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What
behavior is the child/youth to do?
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If
this is a replacement behavior, what (problem) behavior is this replacing?
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What
cue will tell the child/youth it is time to do the behavior listed just
above? (Please include additional
prescribed prompts when applicable.)
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If
applicable, how will problem behavior be measured?
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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.)
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Target
Date for Completion of Objective (not to exceed one year):
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The
initial baseline for goal: (When first assessed)
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Current
baseline for this objective:
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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.
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.
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 _____
_______________
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