Crisis Prevention and Management Planning

Consider escalating behavior problems as symptoms and not as disorders in themselves. Escalating behavior problems that build to a crisis may be the best or only way that a person with IDD can communicate a need and that something is wrong.

Understanding what is underlying the behavior problems is the key to preventing and managing these problems.

When a person has already experienced a behavioral crisis and there is a risk of recurrence, debrief and develop a Crisis Prevention and Management Plan.

1. Debrief after the crisis with the patient, caregivers, and team. Identify what may have contributed to or caused the crisis, and which interventions used were effective or ineffective. Make recommendations regarding preventing and managing possible future crises.

  • Identify and treat underlying conditions that caused or contributed to the crisis behaviors.
  • Review medications, particularly psychotropics, and any medication changes made in the Emergency Department.

2. Develop a Crisis Prevention and Management Plan

  • A case manager or behavior analyst is often the most appropriate person to coordinate the care planning meeting and to take the lead in developing the Crisis Prevention and Management Plan.
    –In Tennessee, an adult with an intellectual disability should qualify for TennCare and have access to services from a behavior analyst. (Eligibility for case manager or behavior analyst services may vary in other states.)
    –Other options might include seeking assistance from a local mental health  center or a mobile crisis team.
  • Meet as a team with the patient, appropriate caregivers, and interdisciplinary team (e.g., residential caregivers, psychiatrist, nurse, behavior therapist, service coordinator, if possible). If indicated, include Emergency Services (ED, police, ambulance services).
  • Inclusion of the patient and caregivers in development of the plan will help to promote consistency in responses to escalating behavior problems and will provide a shared way to document stages of escalation for treatment and evaluation.
  • In the first column of the onclick=”eventClick(‘PDF’, ‘click’, ‘Crisis Management Plan’)” Crisis Prevention and Management Form, identify what the patient’s behavior looks like at each stage. Identify signs of escalation to Stage B (Escalation Stage) and Stage C (Crisis Stage). Early identification of signs of anxiety or agitation provides opportunities for interventions to keep the patient and others safe and, if possible, to prevent the situation from reaching a crisis.
  • In the second column of the onclick=”eventClick(‘PDF’, ‘click’, ‘Crisis Management Plan’)” Crisis Prevention and Management Form, identify usually successful de-escalation or intervention strategies that caregivers can use. Include when to use them, for how long, how often, and where to record them.
    – Clearly identify when to administer “as needed” (PRN) medication.
    – Clearly identify the circumstances under which the patient should be taken to the Emergency Department.
  • Identify the care provider most responsible for regularly reviewing and updating the Crisis Prevention and Management Plan.
  • Develop a schedule with the patient and caregivers from all environments for a regular, patient-centered review of the individual and his/her needs, the behavior problems, the escalation continuum, and corresponding interventions.

 

 Overview of Behavior Stages and Recommended Responses 1

Stage of Patient Behavior Recommended Caregiver Responses
Typical, calm behavior Use positive approaches, encourage usual routines

  • Structure, routines
  • Programs, conversation, activities, antecedent interventions, reinforcement
Stage A: Prevention (Identify early warning signs that signal increasing stress or anxiety.)Anxiety may be shown in energy changes, verbal or conversational changes, fidgeting, sudden changes in affect, attempting to draw people into a power struggle. Be supportive, modify environment to meet needs

  • Encourage talking, be empathetic, increase positive feedback, offer choices.
  • Use calming object or usual calming approach (e.g., deep breathing)
  • Use distraction and environmental accommodation (e.g., reduce noise stimuli, increase personal space).
Stage B: Escalation (Identify signs the patient is escalating into possible behavioral crisis.)Increasing resistance to requests, refusal, questioning, challenging, change in tone and volume of voice, sense of loss of control, increasing physical activity, loud self talk, swearing to self. Be directive (use verbal direction and modeling), continue to modify environment to meet needs, ensure safety

  • Use verbal intervention techniques, set limits, remember distance. Use visual aids, if helpful.
  • Reassure, discuss past successes, show understanding.
  • Describe what you see, not your interpretation of it.
  • If the patient is able to communicate verbally, identify his/her major feeling state (angry, frustrated, anxious), provide answers to questions,  state facts, ask short clear questions.
  • For a nonverbal patient, adjust responses to him/her.
Stage C: Crisis (Risk of harm to self, others, or environment, or seriously disruptive behavior)Threats of aggression:

  • Swearing at people
  • Explosive behavior
  • Using threatening gestures to others or self

 

Physical aggression to self or others:

  • Hurting self
  • Kicking, hitting, scratching, choking, biting
  • Using objects to hurt self or others

 

 

Use safety strategies

  • Ensure your own safety, safety of others, and safety of individual.
  • Use personal space and supportive stance.
  • Remove potentially harmful objects.
  • Use clear, short, calm and slow statements.
  • Remind the patient of pre-
    established boundaries; remind him/her about the consequences of his/her behavior but do not threaten him/her.
  • Get assistance to keep safe.

Use crisis response strategies

Everyone should agree on a plan for what happens at the time of a crisis and the follow-up. For example:

  • Phone 911
  • Call the local Mobile Crisis Unit
  • Have caregiver accompany distressed patient to Emergency Department

Take the patient to ED with the following:

  • List of medications from pharmacy
  • Essential information for Emergency Department
  • Crisis Prevention and Management Plan
Stage R: Post-crisis resolution and calming

  • Stress and tension decrease
  • Decrease in physical and emotional energy
  • Regains control of behavior
Re-establish routines and re-establish rapport

  • Attempt to re-establish communication and return to “calm” and normal routines.

Management of crises and abnormal behavior may be different for patients with IDD than for patients in the general population.

Patients with IDD may behave atypically or unpredictably. For example, attempts to
de-escalate the situation verbally may worsen the patient’s agitation.

Approaches to interviewing adapted to patients with IDD generally help to engage them and avoid further escalation. (See Communicating Effectively.)

At each stage of your interaction with the patient, make use of the caregivers’ knowledge and experience of the patient. Caregivers often have a protocol and recommendations for managing out-of-control behavior, and protocols may be tailored to specific individuals. Ask about these and apply them if this can be done safely.

See also: 

Initial Management of Behavioral Crises
Behavioral Problems and Emotional Concerns-Providers Checklist

1 Based on Nonviolent Crisis Intervention ® Training (NVCI) from Crisis Prevention Institute – www.crisisprevention.com. Accessed September 2016.

Original tool: © 2011 Surrey Place Centre.
Developed by Bradley, E, Drummond, C & Developmental Disabilities Primary Care Initiative Co-editors.

Modified with permission of Surrey Place Centre. This tool was reviewed and adapted for U.S. use by physicians on the Toolkit’s Advisory Committee; for list, view here.

 

 

 

 

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