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Handbook of Crisis Intervention and Developmental Disabilities pp 367–391Cite as

Treating Severe Problem Behavior Within Intensive Day-Treatment Programs

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Part of the book series: Issues in Clinical Child Psychology ((ICCP))

Abstract

Intensive day-treatment units are settings with some distinct advantages, and some limitations, when it comes to treating severe problem behavior. Such settings represent a median between more intensive and costly clinical models and less intensive but potentially less comprehensive ones. The current chapter discusses issues that can lead to the effective use of this setting to treat such behaviors as aggression, self-injury, and other destructive behaviors when they are exhibited by individuals with developmental disabilities. In particular, ensuring the appropriateness of referrals, an effective intake and evaluation process, use of appropriate functional assessment methods, and incorporating caregivers in treatment planning are recommended and discussed.

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Authors and Affiliations

  1. The Marcus Autism Center and Emory University School of Medicine, Atlanta, GA, USA

    Nathan A. Call, Natalie A. Parks & Andrea R. Reavis

Authors
  1. Nathan A. Call
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  2. Natalie A. Parks
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  3. Andrea R. Reavis
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Correspondence to Nathan A. Call .

Editor information

Editors and Affiliations

  1. , Dept. Applied Behavioral Science, University of Kansas, Sunnyside Avenue 1000, Lawrence, 66045, Kansas, USA

    Derek D. Reed

  2. , Dept. Applied Behavioral Science, University of Kansas, Sunnyside Avenue 1000, Lawrence, 66044, Kansas, USA

    Florence D. DiGennaro Reed

  3. May Institute, Pacella Park Drive 41, Randolph, 02368, Massachusetts, USA

    James K. Luiselli

Appendices

Appendix 1: Problem Behavior Severity Assessment

Therapist should collect all referral, intake assessment, indirect assessments, and medical record information that is possible. Refer to the Client Summary Sheet (CSS), the Descriptive Assessment Summary Sheet, or the Brief CSS in the client’s e-folder to gain access to most of this information. All answers should be based on the primary referral behavior(s). For example, if the primary concerns are aggression and self-injury but pica and elopement also occur; this scale should be completed based upon the results of the aggression and self-injury together, but should not consider the pica or elopement.

Note: This assessment is not designed to be used as a questionnaire. Answers should be based upon compiled data, not caregiver driven.

Topography of Primary Problem Behavior(s): ____________________________

Current State of Problem Behavior

Complete the following questions based upon compiled data and reports that reflect the current state of problem behavior (i.e., within the past 6 months). Scores should be based upon instances that have actually occurred, not the probability reported.

  1. 1.

    How has the behavior problem affected the family’s current daily routines?

    1. a.

      Does not interfere.

    2. b.

      Changes have been made to family routines (e.g., changes in mealtime, bedtime, always leave TV on or never turn it on).

    3. c.

      Child or the family no longer engages in certain activities outside of the house (e.g., going to restaurants, shopping malls, movie theaters, church).

    4. d.

      Structural modifications have been made to home/school (e.g., changing the location of door locks, installing shatter proof windows, changing the arrangement of the classroom, installing alarms).

    5. e.

      Resulted in more restrictive educational or residential placement (e.g., child has been moved to school other than home school or self-inclusive classroom [due to problem behavior, not educational delays] or 1-on-1 paraprofessional is required due to problem behavior, foster care, emergency respite, hospitalizations, residential/group home).

  2. 2.

    Has the behavior problem caused any physical harm to the individual or others?

    1. a.

      No physical damage to self or others

    2. b.

      Soreness, redness, or surface scratches without bleeding

    3. c.

      Bruising, minimal broken skin (with bleeding and/or scabbing), callusing, or damage to teeth and gums (bleeding or enamel erosion)

    4. d.

      Any damage requiring medical attention such as broken bones, stitches, infection, or damage to internal organs that could be addressed by medications (e.g., taking medication to address esophageal damage)

    5. e.

      Permanent damage to either the individual or others such as loss of sight or hearing, permanent deformities, or damage to internal organs that require medical procedures (e.g., surgery of any kind)

    6. f.

      Required outside personnel to gain control of the situation (e.g., emergency calls to police, emergency hospitalizations, residential placement) or to treat physical damage (24 h or more in hospital)

  3. 3.

    Has the behavior problem caused any damage to property?

    1. a.

      No damage

    2. b.

      Ripping paper, hitting or kicking walls and floors without denting or breaking holes, destroying school materials such as pencils, crayons, etc.

    3. c.

      Throwing, pushing, or knocking over large objects (e.g., small appliances)

    4. d.

      In less than 50  % of all occurrences, resulted in broken windows, doors, furniture, or dents or holes in walls

    5. e.

      In more than 50  % of all occurrences, resulted in broken windows, doors, furniture, or dents or holes in walls

    6. f.

      In more than 85  % of all occurrences, resulted in broken windows, doors, furniture, or dents or holes in walls

  4. 4.

    What is the highest level of intensity of current intervention used to manage or decrease the behavior problem?

    1. a.

      Behavior problem is ignored, blocked, or redirected; a verbal reprimand is given; or items or extra attention is given to the individual to manage behavior problem.

    2. b.

      Interventions that may include a time-out procedure, the removal or restriction of a preferred item/activity, or corporal punishment.

    3. c.

      Behavioral intervention plan which does not require additional individuals to implement. For example, token economies, multiple schedules, or any intervention that can be implemented by one individual while also engaging in other activities simultaneously. If restraint has been implemented, it was safely implemented by one person.

    4. d.

      Individual requires one-on-one monitoring in any location; individual cannot be left alone for any period of time; child has been moved to school other than home school or self-inclusive classroom (due to problem behavior, not educational delays). If restraint was implemented, it required two or more people to safely implement.

    5. e.

      Individual requires two or more individuals to safely manage behavior problems at all times, the individual is ever placed in total seclusion (to protect others from harm), or protective equipment (e.g., helmet, arm splints, arm guards) is ever used to protect either the individual or those working with the individual.

Potential State of Problem Behavior

Complete the following questions based upon compiled data and reports that reflect the potential state of problem behavior (i.e., what is projected or expected) for the next 6 months. Scores should be based on what might happen in the next 6 months should no new interventions be implemented and the current trend in problem behavior continues. Scores should not be based on any projected changes or trend in problem behavior beyond 6 months (e.g., in the next 12 or more months).

  1. 5.

    If problem behavior continues to follow its current trend for the next 6 months, how would the family have to change its routines?

    1. a.

      No changes.

    2. b.

      Changes in daily routines within the house (e.g., changes in mealtime, bedtime, always leave TV on or never turn it on).

    3. c.

      Child or the family would not be able to engage in certain activities outside of the house (e.g., going to restaurants, shopping malls, movie theaters, church).

    4. d.

      Structural modifications would need to be made at home or school (e.g., changing the location of door locks, installing shatter proof windows, changing the arrangement of the classroom, installing alarms).

    5. e.

      Changes to more restrictive educational or residential placements may be made, including additional individuals to manage the individual, change in classroom placement to self-inclusive classroom, transition from home to foster care, emergency respite residence, or residential setting.

  2. 6.

    If problem behavior continues to follow its current trend for the next 6 months, what harm may be caused to others or the individual?

    1. a.

      Less than 20  % chance

    2. b.

      More than 80  % chance that soreness, redness, or surface scratches without bleeding will occur

    3. c.

      More than 80  % chance that bruising, minimal broken skin (with bleeding or scabbing), callusing, or damage to teeth and gums (bleeding or enamel erosion) will occur

    4. d.

      More than 80  % chance that broken bones, infection, or the need for stitches or other medical attention will occur

    5. e.

      More than 80  % chance that permanent damage to either the individual or others such as loss of sight or hearing, permanent deformities, or damage to internal organs that require medical procedures (e.g., surgery of any kind)

    6. f.

      More than 80  % chance that outside personnel will be called to gain control of the situation (e.g., emergency calls to police, emergency hospitalizations, residential placement) or to treat physical damage (24 h or more in hospital)

  3. 7.

    If problem behavior continues to follow its current trend for the next 6 months, what damage to property may occur?

    1. a.

      Less than 20  % chance

    2. b.

      More than 80  % chance that minor damages to the environment will occur including ripping paper, hitting or kicking walls and floors without denting or breaking holes, destruction of school materials including breaking pencils and crayons

    3. c.

      More than 80  % chance that property damage such as throwing, pushing, or knocking over large objects (e.g., small appliances) will occur

    4. d.

      More than 80  % chance that windows, doors, and furniture will be broken or dents and holes will be put in walls but in less than 50  % of all occurrences of problem behavior

    5. e.

      More than 80  % chance that windows, doors, and furniture will be broken or dents and holes will be put in walls in more than 50  % of all occurrences of problem behavior

    6. f.

      More than 80  % chance that windows, doors, and furniture will be broken or dents and holes will be put in walls in greater than 85  % of all occurrences of problem behavior

  4. 8.

    If problem behavior continues to follow its current trend for the next 6 months, what interventions will be necessary if intervention does not occur immediately?

    1. a.

      Others can ignore, block, redirect, or verbally reprimand problem behavior or provide items or extra attention to the individual to manage problem behavior, but no formal intervention.

    2. b.

      Informal behavioral interventions such as time-out, removing or restricting access to items, or corporal punishment would be necessary to keep the individual or others safe.

    3. c.

      A formal behavioral intervention plan that does not require additional individuals to implement such as token economies, multiple schedules, or any intervention that can be implemented by one individual while also engaging in other activities simultaneously would be necessary to keep the individual or others safe. In addition, should restraint be required, only one person would be necessary to implement.

    4. d.

      One-on-one monitoring would be necessary in any location, the individual could not be left alone for any period of time, or the individual would be moved to a school other than his/her home school or placed in a self-inclusive classroom (due to problem behavior, not educational delays) to keep the individual or others safe. If restraint should be required, two or more individuals would be necessary to implement.

    5. e.

      Any behavioral intervention would require at least two individuals to implement in order to keep the individual or others safe, total seclusion may be necessary to ensure the safety of others, or the use of protective equipment for the individual or others may be required for safety.

Appendix 2: Standardized Interview Questions

  1. 1.

    What are the specific forms of the problem behavior you are observing at home or school? (Be sure to discuss specifics, not just SIB, but head hitting, face slapping, etc.)

  2. 2.

    When did it start?

  3. 3.

    What is its current frequency (h/day/week)?

  4. 4.

    What is its intensity (typical vs. most severe instance caregiver can recall)?

  5. 5.

    Has anyone gotten hurt?

  6. 6.

    Has he/she hurt himself/herself?

  7. 7.

    Has he/she broken any furniture, windows, etc.?

  8. 8.

    What is the typical duration of the target behavior (e.g., lengthy tantrum vs. specific instance of behavior)?

  9. 9.

    Are there any predictable times or events that take place that precede the behavior?

  10. 10.

    In what settings does the behavior occur?

  11. 11.

    With whom does the behavior occur?

  12. 12.

    If there was one specific thing that I could do that would result in the behavior occurring, what would it be?

  13. 13.

    What do you do when the behavior happens?

  14. 14.

    How does this work?

  15. 15.

    What does he/she do when you do this?

  16. 16.

    Have you tried responding differently in the past?

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Call, N.A., Parks, N.A., Reavis, A.R. (2013). Treating Severe Problem Behavior Within Intensive Day-Treatment Programs. In: Reed, D., DiGennaro Reed, F., Luiselli, J. (eds) Handbook of Crisis Intervention and Developmental Disabilities. Issues in Clinical Child Psychology. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-6531-7_21

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