BEHAVIOUR MANAGEMENT PROGRAM Re: D.O.B.

: Date: John DOE September 8, 1994 February 13, 2012

___________________________________________________________________________________B ASIS OF REPORT: ____________________________________________________________________________________ The following program is based on: Mediator interviews, including parents, school staff and group home staff Review of client files/reports Direct observation Review of behavioural data Behaviour Assessment Report (BAR) completed by Pat Veleno, dated February 4, 2012

RATIONALE AND WORKING HYPOTHESIS: John Doe is a seventeen year old male with a diagnosis of autism and significant impairments in the areas of communication and social interaction. He lives at home with his parents and his younger sister. John has an older brother who attends university and does not live at home. John currently attends ABC secondary school and receives respite services from XXX Childrens Homes XXX Home facility. John has a longstanding history of behavioural difficulties, including problems especially with severe selfinjurious behaviour. John appears to have an obsessive-compulsive-like quality to his behavioural presentation such that he is largely routine-dependent, and will engage in repetitive, ritualistic behaviour intermittently throughout the day. He becomes quite anxious when events of the day do not unfold as he expects. This typically leads to outburst behaviours. Episodes of self-injurious behaviour, which can last several minutes at a time, appear to be cyclical with a patterned quality. This means that he may regularly repeat episodes of self-injurious behaviour at a specific time of day, or day of the week, if this behaviour has been established as a routine in the past. It appears that this routine can become entrenched after one behavioural episode, if not immediately interrupted and/or corrected. According to a recently completed behavioural assessment, dated February 4, 2012, there are a number of factors that serve to maintain the occurrence of Johns self-injurious behaviours. Some of his outburst behaviours are functional in nature and serve to escape demands, exert control or manipulate outcomes. Furthermore, John is likely to engage in self-injurious behaviours when presented with novel communication needs and other frustrating situations, such as being denied a request or access to a preferred item/activity, or being required to wait for a preferred activity or task.

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Results from the Questions About Behavioral Function in Mental Illness (QABF-MI) questionnaire, completed by Ms. Doe, suggest that his behaviours are multifunctional in nature, with the need to attain attention as a primary factor, followed closely by the need to escape demands or non-preferred activities, and finally, physical/sensory-related factors. Scores on the Durand Motivation Assessment Scale (MAS), completed by Ms. Doe, produced similar results. It is important that a consistent approach is implemented that incorporates elements of prevention, behaviour management, and behavioural skill teaching in order to give him the best chance of success. Further to this, a crisis plan must be put in place which safely addresses his severe outburst behaviour when less intrusive measures prove ineffective. This program also incorporates a positive reinforcement schedule where John will have the opportunity to earn regular rewards for meeting behavioural criteria. Finally, it is important to acknowledge the possible influence of biomedical and/or sensory factors in the presentation of Johns outburst behaviours. These variables must be further explored, in consultation with appropriate medical professionals, to properly and successfully address Johns behavioural presentation and improve his quality of life.

TARGET BEHAVIOURS AND OPERATIONAL DEFINITIONS: Johns behaviours of concern, which will be targeted for reduction, consist of the following: Self-Injurious Behaviours: John will strike his head and/or face area, often repeatedly, with an open fist with moderate to severe intensity, when agitated, anxious or upset

In order to adequately address his behavioural presentation, it is important that John is taught socially appropriate and effective replacement behaviours that serve the same function of the original, inappropriate behaviour. This is meant to build his skills and reduce the need to engage in inappropriate behaviours to have his needs met. Given that his self-injurious behaviours appear to be multifunctional in nature, John should be encouraged and reinforced for engaging in the following appropriate behaviours. These behaviours will be targeted for acceleration: Functional Communication: John will articulate his wants and needs clearly, with or without prompting, in the absence of selfinjurious behaviours

Accepting Choices: John will calmly accept choices provided to him by mediators in the absence of self-injurious behaviours, or attempts to self-injure John will successfully comply with mediator demands within two minutes of having heard and understood demands (provided that he is capable of doing so)

Hands Down: John will keep his hands down and will refrain from otherwise using his hands in an aggressive or self-injurious manner

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John will use his hands in a gentle manner General Support Guidelines: 1. 2. John will be required to follow his daily activity schedule. This is used to create structure and predictability in his day. It is important that John is encouraged to participate in positive and meaningful activities throughout the day to occupy him and increase the quality of his life. A visual schedule will be created and posted in an appropriate, high-traffic area. It will be reviewed with him on a regular basis throughout the day as he transitions from activity to activity. This will help ensure that he understands the expectations of the day, and will help promote consistency, predictability and structure. While it is important to incorporate predictability and routine into his daily functioning, it is also important to incorporate some element of unpredictability as a means of shaping flexibility for John. This can be done by altering the order of activities on his daily schedule on a day to day basis, while communicating the activities of the day by posting his activities in the To Do column of his schedule. Once his activities are completed, he will be required to move the PECS symbol representing the completed activity to the Done column. It is important to use first/then statements, in conjunction with visual cues, if appropriate, to convey appropriate messages to John. For example, if John approaches a staff person to request a snack, staff may respond by saying, John, first you need to eat dinner, then you can have your snack. This can be done using his visual schedule as well. John should be encouraged to participate in socially appropriate, active daily activities to release energy, i.e., going for regular walks, skiing, swimming, etc. whenever possible. These types of activities should be incorporated into his daily schedule. Past records have indicated that John does not cope well with being required to wait for expected activities. As such, whenever possible, activities or materials should be prepared ahead of time, or before he is prompted to participate in the desired activity. When this is not possible, John should be redirected to participate in some other, highly preferred activity to keep him busy until the originally scheduled activity is ready. If staff indicate that an activity will be ready at a certain time, he will fully expect this to occur at the time given. If not, this may prompt an outburst. Given that a percentage of Johns target behaviours appear to be an attempt to attain attention or to communicate with an individual within his environment, it would be of benefit to foster alternate, more appropriate means of gaining attention, i.e., by encouraging and expecting him to use clear and functional language to initiate interaction; using I want statements, etc. It is then important to increase the likelihood of the occurrence of these appropriate behaviours by reinforcing them at every available opportunity, initially. As these replacement behaviours become more entrenched, the rate of reinforcement can be gradually reduced. Mediators will not engage in power struggles with John when he becomes non-compliant or insistent. Rather, mediators will nonchalantly remind him of expectations, in a neutral, nonthreatening manner, one time only. Mediators will then break eye contact with him and wait quietly and patiently until he is ready to follow through with demands. Interactions with him will be minimized with him until then. Once John complies with the original staff request, he will be given lots of verbal praise for successfully doing so. It is highly recommended that Johns parents, and all others supporting John in a direct-care capacity, access appropriate training in a provincially approved crisis intervention program, including physical intervention techniques, and behaviour management principles, and must be familiar with the behavioural protocol in place for John before working with him in this capacity. All future staff working with John must be acutely aware of his triggers, behavioural patterns, signs of escalation, and behaviour management approach.

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10.

Given the complexity and range of Johns behaviour, it is necessary to pursue a full medical review to investigate and rule out any biomedical factors that may be contributing to his presentation. This should include examining all possible pain and/or sensory components that may precede outburst behaviour, while also considering medical and pharmaceutical options that may benefit John, especially considering his medical history.

Positive Reinforcement Schedule: Mediators working with John will be required to follow a daily reinforcer program. This means that mediators will be required to provide some sort of acknowledgement of appropriate behaviour. This should always include specific verbal praise, i.e., Youre doing a great job of keeping your hands to yourself, John. As well, alternate activity or edible reinforcement works well for him. John will be rewarded with a choice of special reinforcers daily at his home/group home for meeting behavioural expectations. This means that John will be offered a choice of special reward for successfully keeping his hands down, engaging in functional communication, and accepting choices on that day. Toward the end of the evening, prior to bedtime, John will be offered a snack, i.e. fruit or healthy snack, if possible, if he has been able to successfully meet demands. Give John a choice in this regard. Mediators will need to use discretion regarding what to offer John. Ideally, his reward should be powerful and motivating to him, and should not be otherwise offered or provided to him unless he earns it. There must be zero instances of episodes of self-injury at home/group home for him to have earned his reward, plus John must have displayed successful efforts to engage in functional communication and accept choices. Consideration should only be given to whether he was successful within his current environment, i.e., if John met criteria at home, but had a difficult time at school, he should still be offered a reward at home before going to bed. In the meantime, regular verbal praise should be offered throughout the day to him for meeting behavioural criteria. Functional Communication: John will articulate his wants and needs clearly, with or without prompting, in the absence of selfinjurious behaviours

Accepting Choices: John will calmly accept choices provided to him by mediators in the absence of self-injurious behaviours, or attempts to self-injure John will successfully comply with mediator demands within two minutes of having heard and understood demands (provided that he is capable of doing so)

Hands Down: John will keep his hands down and will refrain from otherwise using his hands in an aggressive or self-injurious manner

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John will use his hands in a gentle manner A daily schedule will be used to outline the expectations of the day. This will include identification of chosen reinforcers. 1. In order to promote consistency, predictability and structure, Johns daily schedule will remain relatively constant, with built-in opportunities for change and flexibility. 2. Upon completion of each task, John will be required to move his completed task PEC from the To Do column to the Complete column. Mediators supporting John will provide positive verbal feedback after each completed activity, and cue him regarding the next activity, i.e., Great job, John. Youve finished your bath. Now you have free time. 3. John will earn a reward for engaging in appropriate replacement behaviours, i.e., keeping hands down, using functional communication, and accepting choices. Mediators working with him will provide him with verbal praise for engaging in the appropriate target behaviours by saying, John, youre doing a great job of keeping your hands down, etc. This will help provide him with information regarding what he is doing correctly. 4. Prior to bedtime, Johns behavioural performance will be reviewed with him. John will have earned a small reward for zero instances of self-injury (plus successful efforts to accept choices and engage in functional communication). At that point, he can choose from a limited array of possibilities agreed upon by mediators. He should be able to access the reward immediately after he has earned enough tokens. Mediators should also provide him with verbal praise for this, i.e., Way to go, John. Youve earned your reward. What is your choice? (He will then be directed to choose from the approved list of possibilities.) Managing Self-Injurious Behaviours: John may engage in self-injurious behaviours (SIBs) when agitated, anxious or upset. Some of Johns triggers related to self-injurious behaviours include: When demands are made of him as a means of escape/avoidance When denied requests or preferred tangible items When he is seeking out sensory stimulation When there are changes in routines or expected outcomes There is a possibility that John may engage in SIB due to unidentified biomedical factors

1. Once John is initially noted to escalate, staff should immediately attempt to redirect him to a different activity or task, if possible, as a means of prevention. Signs of escalation include: repetitive questioning/unclear or unintelligible speech, changes in facial expression, whining, etc. 2. If John is noted to engage in repetitive questioning or unclear speech, provide a verbal prompt to him by saying, John, I want This will cue him to speak more slowly and clearly to communicate his needs. 3. If John responds appropriate to this prompting by rephrasing his comments slowly and clearly, reinforce his efforts by granting his request, if possible, and provide him with specific verbal praise, i.e., Great job using your words, John. 4. Instances of repetitive questioning should be dealt with by providing John with an answer or informative response to the original question, while addressing all subsequent repeat questions by saying, All done and breaking direct eye contact. Once a question has been answered, it should not be repeatedly answered. Maintain peripheral eye contact only to ensure his safety. Mediators are to remain neutral and are not to acknowledge Johns behaviours at this point.

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5. The following verbal behaviours should not be acknowledged in any way: a. Questions or comments ending with days of the week at the end of the sentence b. Questions or comments ending with the word yes c. Unorthodox questions or comments that would otherwise be difficult to understand by individuals who are unfamiliar with him d. Perseverative questions about activities that not currently occurring 6. If John begins to self-injure, two individuals will be required to address the situation effectively: a. One person, who will take the lead role, will remind him in a neutral voice, to keep his hands down, while avoiding direct eye contact with him at this point. A second person will quietly approach John from behind or from the side to block him from hitting himself, if necessary. No other communication will take place with him at this time. b. The lead person will prompt him to engage in the corrective procedures by asking him to go back and try it again. It is imperative that John return to the activity he was engaged in just prior to the episode of self-injury and re-do the action without engaging in selfinjurious behaviour. If he engages in self-injury during the process again, he will be redirected back to try it again until the sequence is completed in the absence of any attempt, successful or not, to self-injure. c. Once John successfully completes the sequence of events without engaging in selfinjurious behaviour, he will be given specific verbal praise, i.e., Good job keeping your hands down, John. d. John may make initially protest or make attempts to escape demands by requesting to go to the bathroom during this time. Mediators must not allow him to be successful in this regard. The expectation must be that he successfully completes the sequence of events calmly and in the absence of self-injury, before he is allowed to continue his day. e. John may attempt to run away from mediators who are attempting to block his selfinjurious behaviours. f. If attempts to self-injure continue for a period of 15 minutes or more, despite repeated attempts to redirect and block his behaviour, please consult the Mechanical Restraints Protocol section of this program. g. Remember that safety precedes all behavioural programming. 7. Once calm, mediators will direct John to continue to follow through with his regularly scheduled activities. This is done in order to ensure that John does not get inadvertently reinforced for escape-motivated behaviours. He must not learn to associate his SIBs with being able to get out of doing a non-preferred activity. Rather, staff must ensure that John recognizes that regardless of his behaviours, he will be required to follow through with staff demands/activities of the day, and that his must use his communication skills to request termination of activities or alternate programming options, etc. Mechanical Restraint Protocol The use of mechanical restraints is to be considered as a last resort only, and after all other means of appropriate intervention have been tried and have proven to be unsuccessful. A continuum of intervention procedures has been provided and should be considered as a general guide in response to high intensity outburst behaviours which result in a risk to the immediate safety of self or others: 1. Verbal De-escalation including redirection, setting limits, etc. 2. Removal from area to low stimulus area including bedroom, etc.

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3. 4. 5. 6.

Use of PRN medication, as prescribed and if appropriate Safe Management Group Crisis Intervention Techniques Mechanical restraints 9-1-1

When Johns safety or the safety of others within the area can no longer be adequately maintained, strong consideration should be given to the use of mechanical restraint. If needed, this will require a team approach, with at least 2 mediators directly involved to ensure overall safety. If required to do so, staff will follow the appropriate mechanical restraint protocol. It should be understood that prior to any use of mechanical restraint, the informed parental consent must have been given. Furthermore, consideration should be given to obtaining medical consultation regarding the use and safety of this mechanical restraint procedure. Simply put, this procedure must not be used unless these aforementioned steps have been met. 1. If John continues to persist in his attempts to engage in self-injury for a period of fifteen (15) consecutive minutes or more despite repeated attempts to block and redirect him, mediators will place heavy, cotton-padded gloves on his hands and secure temporarily them so that they cannot be removed. This is considered a form of mechanical restraint. 2. John is to be placed in mechanical restraints when in crisis, i.e., as a last resort only. This means that if his behaviour cannot be safely and effectively managed via the use of approved physical intervention techniques, and he is posing significant risk of injury to himself or others within his environment, mediators will then use mechanical restraints to manage him. At least two staff will be required to safely apply mechanical restraints. 3. At least two mediators will be required to participate in any mechanical restraint protocol involving John. 4. One staff person will be responsible for the lead role. This staff person will be the one providing verbal direction to John, and will assume leadership responsibilities within the team approach to the management of the crisis situation. 5. Mediators observing John throughout this process will not engage him in conversation and will avoid engaging him in any manner whatsoever other than to ensure his safety. 6. If John continues to attempt to self-injure, i.e., by slapping his face or head area, for a period of 5 consecutive minutes subsequent to the application of the padded mitts, a protective helmet, with face guard will be placed on his head and securely fastened. 7. At least two staff must be present to observe John while mechanical restraints are in use. The lead person will assume responsibility for monitoring physiological cues to ensure overall well-being. 8. Mediators need to ensure that John is appropriately monitored while mechanical restraints are in use, and appropriate documentation is completed, i.e., observational data is to be logged every 5 minutes, as required. 9. Following a period of 5 consecutive minutes of calm behaviour, John must be released from any and all restraints. Mediators may determine calm behaviour by observing Johns rate of breathing, level of vocalization, and physical activity levels. 10. Restraints are otherwise required to be released after a maximum of 30 minutes of consecutive use. 11. Remember to engage in appropriate post-restraint procedures, including appropriate documentation, consultation with appropriate supervisory staff and staff to staff debriefing. 12. Remember that safety precedes all behavioural programming. Consideration must be given to contacting 9-1-1 should Johns behaviours become unmanageable and his safety or the safety of anyone else within the vicinity become compromised. 13. A review of progress regarding the use of mechanical restraints will take place every 4-6 weeks to problem solve and determine next course of action, as necessary.

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14. Implementation of this behaviour management program (BMP) is not recommended unless (unnamed psychological practice) are involved in the training and implementation of the protocols outlined. 15. This level of programmatic intrusiveness requires the involvement of a behaviour therapist to assist with parent and staff training, and ongoing monitoring. 16. If the aforementioned duties are taken over by an alternate agency or individual, (unnamed psychological practice) takes no responsibility in resultant outcomes. School: 1. If school board policy does not allow for the use of mechanical restraints within the school environment, this protocol will be modified to exclude the use of mechanical restraints, in favour of approved emergency physical restraints, where applicable. Consult the aforementioned escalation intervention continuum for further review. 2. Should emergency physical restraints prove ineffective in managing John`s behaviour, consideration should be given to contacting 9-1-1 to ensure overall safety. DATA COLLECTION: 1. 2. Data will be collected on Johns target behaviours (frequency data) and token-economy program. Incident reports should be written for all physical aggression, property destruction behaviours.

APPROVALS:

Approvals:

_________________________ Ms. Barbie Doe Parent

___________________________ Mr. Ken Doe Parent

_________________________ Pat Veleno, B.Sc. (Specialist) Behaviour Consultant

___________________________ Dr. BL, Ph. D., C. Psych. Consulting Psychologist

Reviewed and Understood by:

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I have fully reviewed and understood the program outlined and agree to implement the program, as written: ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________