Prevention of Crisis Behavior: Steps to Take Prior to an Emergency

Objectives

  • Define and recognize crisis situations before they occur
  • Understand the goals of the crisis
  • Review and understand client rights
  • Understand why problem behavior may occur
  • Develop a session plan for clients that engage in challenging behavior
  • Review stances and techniques to prepare for possible crisis situations
  • Review preventative strategies to use before a crisis occurs
  • Understand what to do if the preventative strategies do not work
  • Understand the importance of debriefing the client, the clinical team, and the parents/guardians

Definitions

Preventative Intervention: Intervening with the client to attempt to de-escalate them before a crisis behavior occurs

Crisis Behavior: Can include aggression towards self to towards others, and property destruction

Emergency Interventions: Intervening with a client that is in a crisis situation; they may hurt themselves or others

  • Examples of Additional Crisis Behaviors (That warrant immediate intervention):
    • Eloping to a dangerous situation (running into a parking lot or a road)
    • Throwing chairs and desks at people (If it were not at people, it may not need an emergency intervention)

Why do Problem Behaviors Occur?

4 Basic common functions of behavior (Antecedents and Consequences)

  • Escape (From a task, demand, etc)
  • Attention (negative or positive attention)
  • Tangible (gaining a desired item or activity)
  • Automatic (immediately reinforcing in and of themselves for the individual)

Additional Factors that Contribute to Problem Behaviors

  • Medical reasons
    • Specific types of seizures
      • Particularly Frontal Lobe Seizures
    • Any types of “aches”
      • Headaches
      • Toothaches
    • Medicine Changes
    • Traumatic Brain Injury
    • Psychiatric conditions
    • Allergies
    • etc.,
  • Historical Reasons
    • Abuse of Client
      • Sexual
      • Physical
    • Witnessing Abuse
      • Fear it may happen to them
    • PTSD (Post Traumatic Stress Disorder)
  • Mental Impairments
    • Deficits
      • Cognition
      • Executive Function
      • Communication
  • Environmental Conditions
    • Clutter
    • Loud/annoying noises
    • Smells
    • Unpleasant visual stimulation
    • Ambient temperature

Goals

  • The goal of preventative intervention is to stop the crisis behavior from occurring
  • The goal of crisis intervention is NOT to restrain the client; physically, mechanically or chemically. It is to prevent ahead of time and then teach, if you can, appropriate behaviors…

Client’s Rights

  • Client’s Have the Right To:
    • Be free from restraint
      • Clients should not have to be held down or have their movements restricted
      • Clinicians should assist in teaching clients how to meet the function of the behavior in a more socially acceptable manner
      • Restraint is only in emergencies and only conducted by those trained
    • Be free from abuse or harm
      • The use of restraints with clients can lead to clinicians feeling more powerful over the client; thus leading to:
        • Restraints when the client is not in danger of hurting themselves or others
        • Restraints being used for longer periods than regulations state
      • By doing any of the above, it is abuse of the client
    • Be informed about their treatment (informed consent)
      • Client’s have the right to know what behavior is being treated and accept or deny the treatment
      • Some clients may not be able to comprehend the treatment due to cognitive limitations and in those situations parents/ legal guardians then should agree with or deny treatment prior to the implementation of any behavior plan
    • Be in the least restrictive environment
      • IDEA defines Least Restrictive Environment to be:
        • “to the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are not disabled, and that special classes, separate schooling, or other removal of children with disabilities from regular educational environment occurs only when the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and in services cannot be achieved satisfactorily.
      • This requires that students are given the supplementary aides to assist them in learning the skills needed to be educated with their peers
        • Following LRE
          • By teaching clients replacement behaviors for their socially unacceptable behaviors
        • Not following LRE
          • Restraining a client and placing them in seclusion without teaching them replacement behaviors

The Importance of Planning for a Session

As clinicians that work with aggressive or potentially aggressive clients, we always need to be prepared for a problem behavior to occur that could lead to a crisis. There are things that can be done to plan and prepare for potentially aggressive situations to reduce harm that may be caused to the client or the clinician.

Areas of potential preparation:

  • Know your client
    • What are your client’s problem behaviors?
      • Is there a BIP in place for each of those behaviors?
        • Have you been trained on each one? Have you seen them in action?
    • What are their triggers?
      • Do loud noises bother them?
      • Do messy areas bother them?
  • Organize the therapeutic environment
    • Remove objects and liquids that can be used as weapons
      • Hot coffee
      • Scissors (and other sharps)
      • Pens/Pencils
      • Sporting sticks for gross motor activites
    • Is there an available exit?
      • Do not block exits/entrances
      • People to come in and help
      • Ability to exit
    • Scan the environment every 20 seconds to ensure there is still an exit in your immediate environment
      • Don’t put yourself in a corner
  • Communication with others
    • Other people in voice range to hear you call for help
      • Caregiver
      • Therapist/other staff
    • Use a code phrase working within a center-based/school-based program
    • Access to a cell phone to call 911
    • Double staff an aggressive client if possible
      • Attain approval from the funding agency
  • Dress for problem behaviors
    • Wear athletic sneakers/shoes
      • You may have to run
      • Fast footwork to evade
      • Less likely to hurt the client or themselves
    • Eliminate items around your neck
      • Lanyards
      • Scarfs
      • Necklaces
      • Ties
        • These items can become a noose and be used against a staff member *as can headbands
    • Choose specific clothing
      • Dress to cover and protect skin
        • Wear clothes that cover as much as possible
          • Long sleeve  shirts
            • Possibly sweaters or sweatshirt materials
              • Equals more protection
          • Long Pants
            • Denim is more sturdy
              • Equals possibly more protection
  • Miscellaneous Problematic Items:
    • Shirts with hoods
    • Any jewelry
      • Body piercing
      • Dangling earrings
      • Provocative clothing
      • Cargo pants/shorts
      • Hair accessories
      • Chains
  • Protective Gear may be needed if the client is aggressive (Extreme circumstances)
    • Shin guards
    • Gloves
    • Face shields
    • Arm guards
  • Be aware of staff/self behavior
    • Do not engage in a power struggle with the client
    • Be aware of body language
      • Crossed arms
      • Hands clenched
    • Demonstrate respect towards client
    • Promote dignity towards client
    • Be aware of facial expressions and gestures
      • Use a “poker” face
      • Act neutral

Stances and Techniques

There are body positions that can be used to prepare for aggressive behaviors that assist in protection:

Protective Stance: To be used when working with a known aggressive client; a client who is beginning to escalate. There are two different stances, one for working with children or sitting adults and another for working with adolescent to adult clients that are standing (may be younger, it depends on their height):

Low Protective Stance
Child/Seated Adult/Small Adult:

  • Hands are placed down low to be ready to protect
    from being hit or kicked in the stomach or private area
  • Hands are not in fists or in a way that is provoking to the client
  • Can walk around the client in this position observing what they are doing
  • Hands can move into a defensive stance easily
  • Should be 1-2 arm/leg lengths away from the client

High Protective Stance
Adolescent/Standing Adult:

  • Hands are placed up higher near the chest to be ready to protect from being hit in the face or chest
  • Hands are not in fists or in a way that is provoking to the client
  • Can walk around the client in this position observing what they are doing
  • Hands can move into a defensive stance easily
  • Should be 1-2 arm/leg lengths away from the client

Reasons for Use: To ensure your hands can protect specific areas of your body QUICKLY. To avoid “power” positions (i.e, crossed arms, body facing straight on towards the client)

Check-In: To be used when a client is known to be aggressive and may possibly be aggressive but is not being aggressive at this time. They may be exhibiting precursor behaviors.  *It may be beneficial to alert the client that you may touch them, prior to actually using a check-in strategy

Check-In

  • Keep a straight rigid arm
    • To be able to stop the client from possibly hitting the clinical staff
  • Keep a cupped hand
    • Where the thumb should be pressed against the other fingers and not wrapped around the arm
  • The check-in should be on the forearm and not on a joint
  • Clinical staff’s body should be sideways to the client and facing away for a quick escape if need be

Reasons for Use: To get closer to a client who may be agitated or has the potential to be aggressive or who may have recently been aggressive

Defensive Stance: To be used when a client has escalated and prevention strategies have not worked. There are two different stances, one for working with children or sitting adults and another for working with adolescent to adult clients that are standing (may be younger, it depends on their height):

Defensive Stance
Adolescent/Standing Adult:

  • Keep elbows in to protect chest
  • Hands are in front of the face
  • Fingers and thumbs are squeezed together
  • Hands are not place in provoking positions, like fists, karate, etc.
  • Weight is balanced on both feet and separated
  • Knees are bent to balance

Defensive Stance
Child/Seated Adult/Small Adult:

  • One hand is to protect the chest and face, the other to protect the stomach and private area
  • Bottom hand is palm down and parallel to the floor
  • Fingers and thumbs are squeezed together
  • Hands are not placed in a provoking position
  • Weight is balanced on both feet and are separated
  • Knees are bent

Reasons for Use: To ensure your hands can protect specific areas of your body. To avoid “power” positions (clenched fists, “karate hands”). To evade an aggressive client.

General Positioning

There are some general positioning strategies that may assist in reducing injuries from a client or from evading a client

  • Mentioned previously:
    • Know the exits
    • Do not get backed into a corner
  • Additional tips:
    • Know who is behind you
    • Stay out of arms/leg reach of the client
    • Don’t cross the client’s midline
    • Maintain balanced footing

Body Positioning For Biting

There are not any good strategies to get out of a bite, therefore, it is all about preventing a bite

  • Stay away from the bite zone
  • Know where the client’s mouth is at all times
  • Do not reach in the client midline area
  • Avoid hugs and times when the client’s mouth can be near a body part
    • This is during reinforcing activities as well
  • Planning for biters
    • All staff should be aware of a client has a history of biting
      • Fill-ins and make-ups as well
    • As previously discussed:
      • Wear clothing that covers the body
      • Clothing may need to be heavy and thick
    • Human bites are dangerous and staff need to seek immediate medical attention

Understand that aggression can occur at anytime with any client!
Always be prepared!!

Preventative Strategies

Preventative intervention is intervening with the client to attempt to de-escalate them, prior to the client engaging in a crisis behavior.

Frequent Reinforcement

  • Reinforce clients frequently
    • 4 times more frequently than the problem behavior is occurring
  • Use behavior specific reinforcement
    • “Nice job writing with your pencil!”
    • “I love how your feet are on the floor!”
  • Pair it with a tangible if need be
    • Depends on the functioning level of the client
  • Do NOT praise the absence of the problem behavior
  • Conduct regular preference assessments
    • Client’s desires change
    • Avoids satiation
      • it can cause problem behavior in clients

BCBA Involvement

  • The clinical staff should be informing the BCBA of problem behaviors in between BCBA observations or clinics
  • BCBAs should be conducting functional behavior assessments (FBA) and creating behavior intervention plans (BIP) as needed
  • BCBAs should be guiding the clinical staff on teaching replacement behaviors

Be Observant of Precursor Behaviors

  • Precursor behaviors are any behaviors that immediately occur prior to a severe problem behavior
    • These should be listed in the BIPs, if client’s engage in precursor behaviors
    • This is when the preventative strategies should be implemented
    • Precursor behaviors are client specific but may include:
      • Angry voice
      • Slamming objects
      • Pacing
      • Self-talk
      • Rocking

Functional Communication Training (FCT)

  • If a client is escalating and is unable to express their needs
  • Assist them in saying what they need:
    • Use icons
    • Written text
    • Echoics
    • Leading Questions
  • If it is appropriate at that time give the client the item or what they need
  • If it is not appropriate at that time, tell them when they can have it
    • If they do not understand the concept of when they can have it, use strategies they are familiar with to help them with the concept
  • If a client requires assistance in communicating their wants and needs, so that they do not engage in problem behavior, the BCBA of the program should implement an FCT lesson for that client

Change of Environment

  • If precursor behavior to a known aggressive behavior occur, it may benefit the client and alter the behavior to change environments:
    • Be sure to continue the demands that were being placed prior to the precursor behaviors beginning
    • Do NOT bring the client to a reinforcing environment
      • Play ground/Play set
      • to watch a movie
    • This may not always be possible or appropriate (It’s a situational decision)

Change of Staff

  • If precursor behaviors to a known aggressive behavior occur it may benefit the client to change staff:
    • Clients and staff do not always match well
      • Most people can avoid or reduce contact with specific people if they realize they do not get along well with specific other people
      • However, clients that are assigned clinical staff many times do not have a choice of who works with them, staff should be aware and possibly change staff if it could benefit the client
      • If you opt to change staff for a brief period of time during a session, to attempt to reduce precursor behaviors;
        • Be sure the client isn’t just “requesting” another staff person by engaging in problem behaviors
        • The client should have a means of requesting people other than by engaging in problem behaviors

Change in Activity

  • If precursor behaviors to a known aggressive behavior occur it may benefit the client to change the activity
    • If this is done, be sure to continue the demand situation if possible
    • Do not change to a reinforcing activity

Allow for Choice

  • Choice can be allowed in all programs
    • This does not mean the client chooses what is and is not completed during a session
      • Forced-choice: clinical staff selects activities for the client to choose from
        • Perceived control of the client
        • targeted tasks of the clinical staff can be completed

Differential Reinforcement of Incompatible Behaviors (DRI)

  • DRI is reinforcement provided for one behavior that is incompatible with another behavior
  • Attempt to have a client engage in behaviors that are incompatible with their problem behavior
    • Throwing objects = have client clap and reinforce clapping behavior
    • Spitting = have the client drink from a cup and reinforce the drinking
  • By engaging in DRI it allows for reinforcement to be delivered to the client, which may reduce the likelihood of the problem behavior continuing

Wait Out the Client

  • If any of the other preventative strategies are not working to decrease or eliminate the problem behavior AND the behaviors have not escalated to the point where they are going to harm themselves or others…. WAIT!
    • Don’t engage with the client
    • Don’t ignore the client, ignore the behavior
    • Reinforce any reduction in the problem behavior if any appropriate behavior occurs
  • When a client begins to de-escalate and the problem behavior has reduced enough, begin to place demands on the client again
    • Use DRI to allow for reinforcement to be delivered
    • Eventually fade back to the original demand, if possible
  • Waiting may seem like doing nothing, but it is actually one of the hardest things to do, And
  • If an emergency intervention is avoided, than this is a step in the right direction!

Preventative strategies may not always stop a client from engaging in severe problem behavior…

WHAT DO YOU DO THEN?

If Preventative Strategies Do Not Work:

  • Call for help
    • Parents/Caregivers
    • Other clinical staff
    • Administrative personnel
    • Siblings
      • Allow them to assist you
      • Helpers should follow your instructions
      • Sometimes clinical staff cannot de-escalate clients on their own, it is ok to ask for help
  • If Extra help is not effective or not available
    • The aggression continues to escalate to the point where the client is hurting themselves or others:
      • Call 911
        • It is the clinicians job to keep the client safe
      • Double check to ensure that all dangerous objects have been removed
        • Keep the client and clinical staff safe

IF YOU HAVE NOT BEEN TRAINED IN EMERGENCY SITUATIONS AND SPECIFIC USE OF RESTRAINTS YOU ABSOLUTELY CANNOT DO SO. SPECIFIC TRAINING AND AUTHORIZATION IS REQUIRED

  • If anyone is hurt
    • Client
      • Inform the parent/caregivers of the injuries
        • Refer them to a doctor
        • Call ambulance if needed
    • Staff
      • If severe, call 911- take ambulance to hospital
      • Always call the appropriate office staff for guidance
      • Fill out the appropriate forms through Human Resources
      • Human Resources will refer the employee to a physician

Debriefing

Communication

  • Document the behaviors so other clinical staff are aware
  • Inform the BCBA of the behaviors as soon as session is over
  • BCBAs may need to
    • Conduct an FBA and write a BIP or adjust a current BIP
      • Training on the BIP needs to occur for all
        • Staff
        • Parents
        • Others
          • As funding source allows