When it comes to the treatment or reduction of challenging,
disruptive, dangerous problem behaviors, regardless of the setting or
populations served, this will often be referred to as “Crisis Intervention”.
This concept is far broader than ABA, as many institutions
and facilities will create, monitor, and implement crisis interventions whether
anyone on site has received ABA training, credentialing, or licensure, or not
(examples: police, schools, daycares, residential settings, prisons, etc.).
Being such a broad topic, that can look about 10,000
different ways depending on the setting and availability of highly trained
specialists, it should come as no surprise that crisis behavior scenarios
frequently result in injury or even death. If you do some online searches for
news stories related to seclusion and restraint, regardless of the setting, you
will see what I mean.
This issue is also larger than disability.
Yes, most of the horror stories we see on the news where
someone was seriously injured during a restraint DO involve people with
disabilities (whether it was known at the time, or not). But in the absence of
disability or mental health issues, crisis management can still lead to serious
injury or death. That could be for the person(s) responding to the crisis, or
to the person(s) having the crisis.
This is a very weighty and complex topic, and I can’t
possibly cover everything anyone should know about crisis intervention. However,
due to the seriousness of crisis scenarios and the increased risk of harm
(again, for the person intervening, the person or having a crisis, or even both
of those people), I very much want to share some resources and information about managing behavioral crises.
First, some terms. Here is my favorite definition of a
crisis:
A time of intense difficulty, trouble, or danger; a time
when a difficult or important decision must be made.
During a behavioral crisis, the individual is having intense
difficulty or trouble. They are having a hard time (not giving you a hard
time). Decisions must be made, not just regarding what to do RIGHT NOW, but in
the future, in case this happens again. Which, without the proper supports in
place, the crisis event is highly likely to happen again.
Viewing a crisis through this lens takes the responsibility
off of the individual having the crisis, and onto the supports in place (or
lack thereof). When a crisis event occurs, ask yourself these questions:
1. 1. Does this individual know how to safely
de-escalate during a crisis event?
2. 2. If yes, then why are they not using that tool?
Truly individualized and effective de-escalation tools are
best understood as the means by which an individual in a crisis state can
identify they are approaching a crisis state, select a de-escalation method,
implement the method, and lastly evaluate how well the method worked once they
are calm again.
Depending on the setting, availability of support help, and
the understanding of de-escalation (or lack thereof), this “returning to
neutral” process can take minutes, hours, days, or may not occur at all. It may
involve a team of people, a caregiver or support person, or happen independently.
When it doesn’t occur at all, that typically results in emergency room visits
or admittance into an inpatient facility.
I do not know your work setting, the populations you serve,
or your job title, but if you are reading this post I have to assume you have
either experienced a crisis event with a client/student/etc. or want to be
equipped if it should happen.
Right here I have to point out a very common myth, that can
be quite dangerous when people believe it: In the field of ABA, clients who
exhibit (or have a history of exhibiting) highly violent or dangerous problem
behaviors may be classified as exhibiting “severe behavior”. It is a myth that only severe behavior clients can have
crisis events. That is not true at all. Clients with non-violent or
less disruptive problem behaviors, under the right set of combined circumstances,
could have a behavioral crisis. For example, what if their home routine is significantly
disrupted, they are ill, dealing with a change of medication, and also recently
started puberty? These setting events when combined, could trigger a
crisis event. For this reason, it is important for professionals and practitioners
to be properly trained and equipped for crisis conditions, far before they are
needed.
Now I want to speak specifically to ABA implementers (RBT’s,
paraprofessionals, etc.) who work directly with clients: If you are working with clients where you are regularly
responding to crisis events or working with clients with a known history of
crisis events, you should be following the policies of the physical management
training you received. If you have not received any physical management
training, then you should not be working with those clients. It is dangerous for
you, and dangerous for them.
Again, crisis events could potentially happen at any time,
with any client/student/etc. It would be unwise to think “Oh I don’t work with severe
behavior individuals, so this doesn’t apply to me”. For ANY of us (disabled or
not, mental health issues or not) the right set of circumstances could trigger
a crisis event.
If you were in the midst of a crisis event, who would
you want helping you? Someone reacting on impulse or instinct, or
someone who has been thoroughly and properly trained on safe de-escalation?
So what can be done? Glad you asked.
Research shows that in the absence of individualized,
evidence- based crisis interventions, individuals will contact injury to self
and others (Burke, Hagan-Burke, & Sugai, 2003), receipt of medications with
serious side-effects that rarely correct the causes of the behaviors (Frazier et al, 2011),
receipt of intrusive, ineffective interventions that are punishment-led (Brown et al, 2008), and increased negative interactions (Lawson & O’Brien, 1994).
Be cognizant of crisis needs and function when designing a behavior plan for students with crisis behaviors, and operationally describe steps to be taken for each phase of escalation. When describing these steps, be aware of the behavioral function. Change the quality of reinforcement delivered between appropriate and inappropriate behavior, and prompt appropriate behavior before providing access to calming activities. Train staff to competence on the intervention strategies (which most often includes role play scenarios during training, not just discussion/lecture).
*Recommended Resources (please share!):
~Find the number for the mental health crisis/emergency
support services in your state, and save it in your cell phone
~For caregivers, if your child is on medication the Physician/Psychiatrist
will likely have an after-hours or emergency help desk. Save that number in
your cell phone
https://crisisintervention.com/
https://www.pcmasolutions.com/
https://www.marcus.org/autism-training/crisis-prevention-program
https://qbs.com/safety-care/
Crisis Intervention Strategies
Handbook of Crisis Intervention and Developmental Disabilities
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