Positive Behavioral Redirection, De-Escalation and Intervention

Foundational Principles

What You Will Learn

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Positive intervention for dangerous behavior begins with these foundational principles.

Function: All behavior whether adaptive or maladaptive, desirable or undesirable, has a function, or purpose. It is an effort to meet a need. Look for the function and teach individuals skills to meet their needs in positive ways.

Compassion and Empathy: Dangerous behavior, even directed at you, is not personal. Avoid the urge to be angry, rather understand the individual's confustion, or frustration, fear or anxiety that is precipitating the behavior.

Proactivity: Look for triggers, warning signs, and precursor behaviors that indicate dangerous behavior could be imminent. Respond.

Environment: Look for potential triggers in the individuals's environment and eliminate them. Eliminate objects from the environment that can become weapons. Provide safe, cozy space for calming. Set up the environment for optimal success.

Replace: Consistently teach, encourage, reinforce and reward desirable behavior to replace the undesired.

Ignore and Redirect: We do not use punishment to extinguish undesired behavior. Ignore it whenever possible. Redirect it when necessary.

Creativity: Sometimes behavior can be redirected by distraction - an unexpected, but not frightening or alerting, change in your own behavior, for example.

Escape and Avoidance: When dangerous behavior is directed at you, can you move away? Can you position yourself behind or move objects between you and the individual (furniture, cushions, chairs, tables, for example) while you verbally redirect?

Restraint is the Last Resort: The goal is always to avoid involutary restraint. Use restraints for children only to prevent serious harm to the child, yourself, or others in the environment. Restraints are prohibited for adults.

De-Escalation Training:

Functional Behavior Assessment

Functional Behavioral Assessment is a method for identifying the function of a behavior and alternatives for teaching the child skills to meet needs in positive ways. It follows a simple formula and should be used anytime a pattern of maladaptive behavior is evident.

Whenever you intervene with an involuntary hold, you'll be asked to complete a report on that hold. One key element of that report is an A-B-C analysis. We recommend that you also document in this manner in your Progress Note when you believe you have successfully redirected precursor behaviors that might have led to dangerous behavior, preventing the need for a hold.

A-B-C Analysis

Antecedent

Antecedent refers to all of the conditions that existed prior to the problem behavior you are trying to understand. This includes:

• Conditions in the environment
• Other people in the environment and their behavior and activities
• The individual's activities and behavior just prior to the problem behavior, including known
  precursorsPrecursors:
  behaviors that reliably precede the problem behavior
  .
• What provider staff did, or asked the individual to do, just before the problem behavior occurred
• How staff intervened to redirect, distract, calm the individual when (if) precursor behaviors were exhibited
• Anything else remarkable in the environment

Behavior

• Describe the problem behavior in objective, measurable and observable terms. Describe only what you can detect with the five senses. Leave out opinions or judgements.

Consequence

• Provider interventions in detail, including a detailed description of any hold used
• What happened after the problem behavior ended...
• What did the individual do?
• What did provider staff do?
• What did others in the environment do?

During a debriefing following any use of a hold, we will use this information in part to determine if we can identify the function of the behavior. The debriefing is also used to identify alternatives that might have worked to successfully redirect, or prevent, the behavior without the need for a hold.

Functional Behavior Assessment is not limited for use only when a hold occurs. It can be used as a tool in planning proactive treatment and interventions for known maladaptive or dangerous behavior.

Involuntary Holds and Restraints

Restraints Prohibited for Adults

For adult services restraints, aversive or deprivation procedures are prohibited as behavior modification techniques. Limited emergency restraints are allowed for children only to prevent serious injury.

Responses allowed by this policy are as follows:

• Any physical support not objected to by an individual
• Brief physical interventions to prevent an accident (e.g. falling, stepping into traffic)
• Ending a session when feeling threatened
• Exiting an unsafe environment and escorting others to safety when feeling threatened
• Declining to provide services to an individual who has exhibited threatening or dangerous behavior (seek guidance from a supervisor if unsure)
• Declining to provide services to an individual in certain environments that seem unsafe
• Self defense and defense of others (when possible) to prevent serious injury

Restraints Allowed For Children Only In Emergencies

What is Serious Injury?

Serious injury is injury that requires examination and potential treatment by a physician. Minor scratches, bruises or emotional injuries (hurt feelings) do not adhere to this definition.

Restraint is allowed only in an emergency, where it is necessary to prevent serious harm. Restraints are not allowed to prevent property damage.

Restraint as a behavior modification technique or consequence for behavior is strictly prohibited.

Any involuntary hold must be released immediately when the child or others are out of danger.

The following do not constitute an emergency:

• Property damage
• Verbal aggression
• A person's refusal to receive or participate in treatment or programming on his/her own

Allowed Holds

When necessary, the following types of involuntary holds are allowed. They are listed in order from least to most restrictive. Choose the least restrictive hold possible to prevent harm.

• Briefly holding the arm, hand, waist, clothing or shoulders of a child to prevent them from accidental harm (falling, or walking into traffic, for example).
• Briefly holding a child's arm, hand, clothing or shoulders to prevent them from seriously harming others, accidentally or on purpose. This type of restraint should last no more than seconds, until the person at risk of harm is able to move away, or the threat is otherwise eliminated. (Example, a child is about to swing a hard object at a sibling. You hold the child's wrist to prevent them from hitting the sibling and then take away the object, or the sibling moves out of harm's way.)
• Escorting the child while holding him or her by the hand or wrist, and arm wrapped over the shoulders, out of an unsafe situation.
• If necessary to ensure the safety of the child or others, the above methods implemented by two staff members.
• Brief (under 30 second) hug restraint by trained staff members with small children restricting violent or destructive behavior, releasing as soon as the child is calm.
• A basket hold used by trained individuals only for larger children or young adults only in cases where you have been trained in the use of this restraint.
• Other situations might occur in which some form of restraint that falls outside these definitions might be necessary to prevent serious harm or death to a child or others. In these extreme circumstances, restraint will be reviewed by the agency in the context of the situation and intentions of the staff member.

Exceptions

The following are exceptions to restrictions on seclusion:

• Safety gates (such as on stairways) intended to prevent young children from falling.
• When parents use time-out as a response to behavior, and the parents are present while services provided, and they choose to implement this consequence during service provision.
• When a children voluntarily remove themselves (upon suggestion) from a room or situation as a calming method (self time-out) but are not required or forced to do so.
• Time-out that consists of taking a break from an activity or group, and sitting or standing aside, within view of the activities/group, as a calming technique or in response to problem behavior is not considered seclusion.

Documenting Holds and Debriefing

At any time you use a restraint, you must

• use the add-on to the progresss note Involuntary Hold Report Filed;
• report it fully in an Behavioral Intervention report, found in: assessments > incidents and reports > Behavioral Intervention; and
• meet with your Clinical Supervisor or Treatment Director to debrief on the incident within 48 hours or before the individual is seen again whichever comes first.

The Debriefing

The provider who implements the hold completes the ABC Report section of the Involuntary Hold report and contacts a supervisor to schedule a debriefing. The supervisor completes the Debriefing section and approves the report.

Debriefing after each hold is a supportive process. Even if we determine during the debriefing that less restrictive techniques might have been successful, we will consider this a learning opportunity, not a disciplinary action.

Document the debriefing meeting using the service type Incident Debriefing found in the Other Notes category.

Successful De-Escalation

You may encounter situations where children exhibit potentially dangerous behavior and require de-escalation. When in your judgement, de-escalation is successful in averting the need for an involuntary hold, use this add-on to indicate this on your progress note.

We can learn from success. At any time you beleive you have successfully de-escalated a situation where involuntary hold may have been needed, it is strongly recommended that you describe the incident and debreif as for an involuntary hold as follows:

• use the add-on to the progresss note Successful De-Esclation;
• describbe it fully in an Behavioral Intervention report, found in: assessments > incidents and reports > Behavioral Intervention; and
• meet with your Clinical Supervisor or Treatment Director to debrief on the incident within 48 hours or before the individual is seen again whichever comes first.

Threats of Harm to Self or Others

Credibility, Means, Plan

Threats of harm to self or others must meet the standards of: Credibility, Means, and Plan.

Credibility

Credibility means how believable the threat is. It can be difficult to determine this based on your relationship and knowledge of the client. If ever you have concerns about whether a client's threat to harm self or others is credible, seek guidance immediately.

Means

Means is the method by which the individual intends to commit harm to self or others (weapons, pills, etc). Exploring means is also part of establishing credibility of the threat.

Plan

Plan goes also to credibility. If a client expresses a specific plan to harm self or others, with means, and with a specific plan for how to do it, this completes the threat. Seek guidance immediately.

Duty to Warn

What is a Tarazoff Warning? (Duty to Warn)

Tarasof Warning refers to this California Supreme Court decision, finding a psychologist and the psychologist's employer at fault for failing to warn the potential victim of a threat.

"Tatiana Tarasoff was a student at Merritt College in Oakland. In 1968, when she was 18, she met 22-year-old Prosenjit Poddar, a graduate student at UC Berkeley. They dated, but Tarasoff told Poddar that she was seeing other men, and he was crushed, becoming increasingly depressed. He eventually began therapy with Lawrence Moore, a psychologist at the student health service. Poddar told Moore that he intended to kill Tarasoff by stabbing her. In response, Moore informed campus police and recommended that Poddar be civilly committed for treatment of paranoid schizophrenia. Police detained Poddar but released him because he appeared rational. Neither Tarasoff nor her parents received any warning directly. A few months later, Poddar stabbed and killed Tarasoff, carrying out the plan he had confided to his therapist.

"The family sued the university, leading eventually to two important California Supreme Court decisions, referred to as Tarasoff I and Tarasoff II. In Tarasoff I, the court ruled that doctors and psychotherapists have a legal obligation to warn a patient’s intended victim if that person is in foreseeable danger from the patient. Warning the police or other authorities is not good enough. This is a concept known as the "duty to warn."

"In Tarasoff II, a rehearing of the case, the court added the concept of “duty to protect.” This duty requires providers to take whatever steps are necessary to protect the intended victim. You can warn them, but you can also protect the intended victim by, for example, placing the patient on an involuntary psychiatric hold. This option has the advantage of not breaching patient confidentiality."

Credit: Carlat Publishing 2022, Tarasoff: Making Sense of the Duty to Warn or Protect

Following this case, California and other states passed laws regarding "Duty to Warn. Minnesota law contains similar statutes.

Report Credible Threats of Harm

Regardless of statute, at Accend, we beleive that credible threats to others must be reported. If you believe that someone you serve has made a credible threat, with means and a plan, report this to and seek guidance from your supervisor immediately. Actions we may take might include contacting police or the intended vicitim, or other interventions depending on circumstances.

Other Incident Reporting

Finally, when other incidents occur that fit the definition of incident in our policy, complete an Incident Report. When you file an Incident Report, flag your Progress Note with the add-on: Incident Report Filed.

Feedback or Questions about this Chapter

This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Please send us your thoughts about anything in this chapter by tapping on the link below.

Updates to this Chapter

November 15, 2022: Prohibition on restraints for adults added. Language changes to apply the policy/procedure to both adults and children. Headers and navigation updates.

Threats of Harm section added.

February 2, 2023 Added De-Escalation Powerpoint Training.