Behaviour Support Plan for Patrick (Part B 1-4)

Part B

Section 1 Assessment

1.1 Nature of disability/disabilities  

(Include level of intellectual disability, mental health status, medical, communication abilities, strengths and weaknesses)

Patrick is a 19 year old male who experiences Autism and Intellectual Disability. He has no diagnosed Mental Health challenges. Patrick is currently in very good physical health apart from small patches of Excema present on his chest and shoulders. His weight falls into the healthy range with his BMI calculated at 24. He communicates on an Intentional Informal level as assessed with the Triple C checklist. Patrick has experienced a traumatic childhood, allegations of physical abuse were made due to multiple fractures of his limbs, his family left Victoria, after they placed Patrick into state care, he has no family contact. Patricks incidence of broken bones has reduced to zero since being cared for by the State.

Patrick strengths are he is usually happy with an easygoing and calm nature/personality, he can learn, remember and recall the lyrics of a song easily, he participates in routines and chores such as making toast every morning, doing his laundry and cleaning his room. Patrick is able to walk long distances, he has good stamina and physical strength. Patrick has a strong relationship with his Foster Mother but he is currently separated from her due to her unexpected and serious illness.

Patrick’s weaknesses are based around his need for routine and a calm environment. He will display agitated states of emotion whenever people are yelling and behaving in a disruptive manner, and when his routine is disrupted. He is also prone to becoming bored whenever his preferred activity is not available, he is most likely to wander away and stimulate himself by finding items to flick and singing (humming) to himself. Patrick displays attachment skill deficits, he would like to have friends but they often do things that make him feel anxious and threatened.

1.2 Person’s goals  

(Include here all individual aspects about the person, in terms of work, school, recreation. What kinds of activities does the person enjoy?)

Continue the relationship with his foster mother in person.

Build or rebuild relationships with his birth family.

Develop opportunities for a relationship outside paid staff.

To have more sensory experiences available at Wunya (current day service).

To have more of Patrick’s preferred activities available across the week at Wunya.

To have a calm and predictable environment as much as possible.

To have a safe space and opportunities to spend time alone.

Go to football games, he is a Richmond supporter.

Go Bushwalking with his previously established group.

Develop alternative communication aids for Patrick to interact with his world.

Take photographs incorporating his bushwalking interest with photography.

Obtain his own set of cards for flicking.

Develop independent living skills.

Activities that Patrick enjoys are; bushwalking, walking, gardening, BBQ's, music, massage, painting, watching football games, making toast, humming and singing specifically the Richmond theme song), train travel, sensory experiences such as flicking Readers Digest magazines and photos, his recliner chair, looking at his reflection, looking at old family photos, holding small animals such as Mice, Guinea Pigs, Cats and Chickens, warm baths with eucalyptus oil and smelling eucalyptus oil, having his favorite "Teacher" at Wunya, one-on-one time with a support worker during chores time, touch and close interactions, repeating words of the people he likes, people visiting,  rewards and encouragement, smiles and hugs, copying hand gestures often the most inappropriate ones that get a reaction from others.

1.3 Behaviour/s of Concern

Based on Functional Behavioural Assessment:

1. Describe the behaviour/s of concern.

Patrick has been having violent outbursts where he has been noted to hit and pinch people. He will then usually bite himself. He usually pinches other residents. Other service users at Wunya have felt threatened by Patrick but have not been pinched or hit up to this date.

1. Briefly describe the impact of the behaviour on the person and others.

The impact of the behaviour of concern results in Patrick displaying very stressed and anxious behaviour, he appears to feel threatened, after being led to his recliner chair, Patrick will quickly withdraw from social contact and practice his observed self soothing behaviours. Patrick may spend as long as 1 hour in his chair while he is self soothing before he will appear to be functioning at his usual level of activity.

One service user in particular (a female resident aged 42 years) will yell at Patrick. She will yell whenever he moves toward her, she says she doesn't want to be pinched and she thinks that Patrick is about to pinch her and she yells at him to stop. This resident is the one who yells when Patrick starts to take the pictures off the timetable board.

Some staff have been known to yell at Patrick when he begins to remove pictures from the timetable board. There has been work practice counseling provided to these staff members.

Staff have been bitten by Patrick when they have tried to manually restrict Patrick from biting himself.

1. What are the predictors for the behaviour? (What are the situations in which the behaviour is likely to occur?).

In the early afternoons after returning from Wunya, and when Patrick’s choice of Television program is not showing, Patrick would usually be walking around the meal table in the dining room at Holley St,  he begins to make a low pitched "mmm" sound that rises in pitch and increases in volume before he moves toward the timetable board and removes the pictures to flick them. 

Patrick’s humming will usually attract the attention and presence of another resident who often follows Patrick from one room to another. The other resident will yell that Patrick is “Doing it again” and will point at him and wave her arms around When he is being yelled at he will sway back and forth and make a louder “Mmmmm” sound, he will turn away from the people who are shouting and shield the pictures with his body. He will grab at the photos if other people try to take off him. 

When Patrick’s behaviour escalates to hitting the other residents, Patrick will drop the pictures on the floor. He will start hitting people until a staff member holds his hands and leads him away from the situation. 

Patrick will usually bite his hands after his behaviour has escalated to hitting.

Patrick will bite the hands of a staff member who tries to manually restrain him from biting himself.

At mealtimes when Patrick is seated with other residents who are all eating a meal together  he will reach out and pinch someone. 

Patrick will also pinch some of the residents when they sit on the couch next to him to watch a TV program, some residents have never been pinched.

1. Frequency or intensity or duration of behaviour (daily, weekly etc).

Pinching, Frequency - once or twice every day. 

Intensity - Causes bruises on arms of other residents from pinches. 

Duration - Patrick will pinch another resident once which will happen up to twice a day, usually at mealtimes, or when he is watching TV.

Hitting, Frequency - Every day. 

Intensity -  The hitting is repetitive and Patrick may hit someone between 4 and 10 times before a staff member is able to intervene and remove Patrick from the situation.  Duration - Patrick will hit with his hands repetitively until a staff member intervenes, usually between 4 and 10 hits per incident which occurs every day in a period of 10 to 20 seconds. 

Biting, Patrick has been observed to bite his own hands, he will also bite the hands of a support worker if that worker tries to stop him biting himself. This happens when he has been involved in a hitting episode.

1.4 Observation and Analysis

a) Those who know the person well believe the behaviour of concern occurs because: (What is the function of the behaviour ie. to avoid something, to act out confusion, to gain intimacy).

Patrick may be looking for some one-on-one contact that mirrors his relationship with his Foster mother. it is likely that he feels lonely, missing the relationship he had with her prior to her illness. Patrick is looking for a friend to share things with.

Patrick may not like some of the people he lives with, especially because he is yelled at most days. 

Patrick's could be feeling scared of the other residents because they yell at him and wave their arms around near him. He shows a fight or flight response when he feels threatened. This is a consistent response for someone whose background includes experiencing physical abuse as a child.  

Patrick's wandering at Wunya and Holley St, may be due to boredom and his need for sensory stimulation could be exaggerated by boredom and lack of appropriate activity. 

Patrick may feel stress due to the itchiness of his excema, his condition is minor but if may cause an uncomfortable sensation that he would not be able to identify. 

He may be reacting to stress caused by the separation from his Foster mother. Patrick may be seeking his own set of photos for flicking.

Patrick may be seeking something that has value, the photo timetable board is looked at by people at all times of the day, therefore it has value to everyone. 

He may not like the sensory experience of eating with the group, the noise of everyone eating may be overstimulation.

Patrick enjoys sensory stimulation, he enjoys flicking and thumbing pictures and magazines because it provides a safe, familiar and controlled environment for him.

Biting his own hands can be a sensory reaction, the familiarity of the pain overrides the fear and stress of the yelling.

1. What environmental changes, structure and supports are needed to stop the person using this behaviour? (What changes need to occur with and around the person in order to remove the likelihood of behaviours of concern).

Develop plan for staff interactions with Patrick, the development of Active Support Strategies will enhance his opportunities for participation, presence, choice opportunities and respect during his life. The team also needs to spend some time developing and agreeing upon a consistent response for each time that Patrick begins to exhibit the concerning behaviour. Keep Patrick calm using his favourite music and lots of one-on-one time with staff, and spending time alone in his recliner chair with his magazines. Respond to Patrick at the point where he starts humming, ignore behaviour that is undesirable then give one on one attention so that he gets the positive reinforcement to remain calm instead of allowing his state of agitation to rise.

Make a leisure pack available to Patrick with some different sensory items that Patrick likes to feel, smell, touch and look at. Such as a rubber band ball, a bottle of bubbles, a surf dome, Readers Digest magazines, copies of old pictures of relatives (with their name written on them), some strength putty that he can squeeze, a rubiks cube, a eucalyptus nasal inhaler tube, slinky toy.

Getting some community request cards to use in the Community so that Patrick has the opportunity for positive interactions with people will enhance the likelihood he will be treated with respect. He can always carry them on him, possibly clipped to a belt loop and use them at Wunya. He then has immediate access to an appropriate personal possession that can be used for flicking and to satisfy his sensory need.

Provide more activity and stimulation  opportunities for Patrick. Offer walking activities to Patrick on a daily basis. Offer Patrick at least one other additional activity opportunity every day.

Provide extra support to the other resident that fears being pinched by Patrick. Staff need to focus on keeping Patrick and that resident separated, maybe the other resident could spend some time doing a special activity like a holiday or spending time with family or at a respite service for a short time

Install some sensory experience fittings in Patricks room, mirror ball, chimes and mobiles, interactive and age appropriate toys.

Rearrange the interior of Holley St so that there is a dining area in 2 locations, perhaps an outdoor area can be set up.
Remove the timetable board.

Provide a musical activity at Holley St. Patrick could learn to play tunes on a piano keyboard, it is possible that he could apply his great capacity to retain the melodies of his favourite songs to the development of skills required for playing the notes on a keyboard.

 Arrange day and time for Patrick to spend time with his foster mother, talk about her to him, display photos of her in his room.

Scan the old family photographs and reprint them or have them made into a photo book for Patrick to look at whenever he feels like it without fear of damaging them.

Get a chicken coop and chickens for Patrick to look after and develop relationship attachment skills. Patrick has expressed an interest in chickens, the next door neighbor at his Foster mothers home had a small flock and Patrick liked holding them. The chickens will also contribute eggs to the household and be used to recycle kitchen scraps and make compost for the vegetable garden. The chickens would be an item of value in everyones eyes.

Invite people to come and visit Patrick. Patrick's old next door neighbor may be able to visit Patrick and see his chickens and invite Patrick’s bushwalking club to come and visit him at Holley St, and possibly accompany him on an urbanwalk

Lobby Wunya to include chicken care into their activity/interest program, also negotiate with them to incorporate a more diverse arrangement of activities so that Patrick does not have the two boring days per week that he currently experiences.

Install a swing seat so that Patrick has an outdoor rocking/swinging location.

Patrick may have an undiagnosed medical condition, particularly due to the high incidence of fractures he sustained as a child, a full check up at the GP is overdue and should be attended to as a matter of urgency.

Follow up appointments with other specialists is also required, i.e. dentist, hearing services, dermatologist.

1. Critical alerts: Other behaviours to be aware of.

Patrick may be inclined to wander away from an activity if it is not his preferred activity.

SECTION 2: POSITIVE INTERVENTIONS

2.1 Alternative behaviours that meet the same need

1. What should the person be doing INSTEAD of the behaviour of concern? (How should the person get their needs met in an acceptable way?)

Learning to look after a pet,  A chicken coop and some chickens would be a great way to promote and develop attachment skills. Handling chickens would fulfill some of Patrick's sensory needs. 

Learning to play some music so sing to, Patrick could learn to play tunes on a piano keyboard, it is possible that he could apply his great capacity to retain the melodies of his favourite songs to the development of skills required for playing the notes on a keyboard.

Develop friendships with members of the community independent of paid staff and residents. Patrick could become an attendee at the local football club which plays in the Richmond colours, he could become involved by taking on a small helping role such as carrying the water bottles out to the players on the field.

Use the telephone to hear his Foster Mothers voice. The use of a shaping plan to assist Patrick overcome his fear of the telephone would be appropriate for developing this alternative behaviour.

Patrick can learn to use community request cards for his time at Wunya and in the community. He can also use these cards to flick whenever he feels the need for a sensory experience.

Teach Patrick how to get time to himself by using a time out card.

2.2 Positive strategies 

1. What strategies need to be developed? (ie. in order to teach an adaptive behaviour, what steps need to be taken?) Provide a summary of steps with reference to the person’s individual support plan or attach a copy of the strategies.

• Stimulus Satiation, make Patrick the person in charge of changing the pictures on the timetable board.
• Patrick would benefit from learning ways to manage his emotional state, in particular his  anxiety. He could benefit from a reward / reinforcement program to reduce the incidence of pinches.
• Give Patrick as much bread as he would like to turn into toast, offer toast making activities at other times of the day other than mornings.
• Behaviour scripts to help Patrick learn how he can interact with members of the local football team. Behaviour scripts should be fluid and dynamic changing with the level of interaction that Patrick experiences.
• Social stories can be used to help Patrick make sense of his immediate environment. A social story can be written to teach him why another resident yells whenever he is around. A social story can also be used as part of the shaping program to help Patrick use the telephone calmly.
• Communication skills, 
• Stress and Anger coping strategies. Mindfulness training has been proved to be a useful tool to help people to cope with their rising levels of anxiety, stress and anger. This may be a tool that Patrick could use easily and successfully.
• 
  
1. Who is responsible for implementing the program?

• Evelyn White who is the Team Leader at Holley St, is responsible for implementing the programs with Patrick. She has a good working knowledge of Patrick’s history and she likes Patrick and he likes her, Evelyn has nominated Sally Bearman as her accountabilty partner for implementing Patrick’s Behaviour Support Plan. All queries should be directed towards Evelyn and Sally on (03) 8770 7702.

SECTION 3: RESTRICTIVE INTERVENTIONS

3.1 Restrictive interventions

1. What restrictive interventions will be used? (List least restrictive first e.g., self-management prompt first, then to assistance etc.)

Patrick should be invited but not be expected to join the group at the dinner table. He should be allowed to choose the place that he would like to eat his meals.
Staff should focus on keeping Patrick and the resident that yells at him seperated, maybe the other resident could spend some time doing a special activity like a holiday or spending time with family or at a respite service.
Alternate between two activities very regularly throughout the afternoon and evening. With no more than 20 minutes before the activity is switched. The activities are; keep Patrick moving, take him for lots of walks, give him plenty of activity and stimulation. And; keep Patrick calm using his favourite music and lots of one-on-one time with staff and in his recliner chair with his magazines.
Respond to Patrick at the point where he starts humming, ignore behaviour that is undesirable then give one on one attention so that he gets the positive reinforcement to remain calm instead of allowing his state of agitation to rise. Ask Patrick if he would like some time alone when he starts humming “Mmmm” and walking around the table. 
Prompt Patrick to access his sensory items in his room, ask Patrick if would like to go for a walk with you, do some gardening with you, ask him if he would like a hug, offer Patrick an activity from his weekly opportunity plan, offer Patrick the toaster and some bread, sing the Richmond theme song to Patrick and ask Patrick to come into his room and show you some photos.
Move Patrick away from the area when other residents are expressing fear of being pinched, take him to his room to spend time in his chair, or take him outside with the bag of old (toasted) bread that he can use to feed the birds, do not lock the doors, do not tell him he has to stay outside.
Remove other residents from Patrick’s immediate area to the other living area, so that he has no-body to hit. Close but do not lock the connecting doors to the other half of the house. Open the doors to outside and to his room.
Take Patrick by the hand and lead him to outdoor swing seat and offer to make Patrick a warm Eucalyptus and honey drink to have outside.

Practice passive self defense, move away from Patrick, reduce talk. Move so that an object of furniture is between yourself and Patrick, wait for Patrick to stop feeling threatened before talking calmly to him.
Hold Patricks hands at his waist level so that he cannot bite himself. Walk with him towards his safe space in his recliner chair in his bedroom.

1. Why is the restrictive intervention being used?
For Patrick's personal safety. To prevent Patrick from biting himself and causing injuries.
1. Circumstances under which the restrictive intervention will be required.
When Patrick hits another person he will be restricted from the common indoor areas of Holley St. When Patrick bites himself he will be restricted from continuing to bite his hands until he begins to feel calm and at ease.
1. What measures will be used to monitor the effect of the restrictive interventions? 
Staff will keep Patrick under observation from a distance while he self soothes. A recording chart will be used to take note of how long it takes for Patrick to feel able to rejoin the group, the activity he uses to return to a calm state, the length of time he uses that activity. What interventions by staff are required to ensure that Patrick takes as much time as he needs to return to his his usual happy easygoing self. 
1. How and when is it to be reviewed?
The information will be reviewed weekly for the first month by Evelyn and Sally. Staff feedback  on the program will be incorporated in the review meetings. Adjustment and recommendations and feedback will be communicated to each staff member as the need arises. Evelyn will lead the team to develop and confidently agree upon a consistent response for each time that Patrick begins to exhibit the concerning behaviour.
1. Who authorises the restrictive interventions?
1. Evelyn White will authorise the restrictive interventions. 

SECTION 4:  REVIEW: EVALUATION OF INTERVENTIONS
4.1 Results of positive interventions
a) What works well in reducing behaviours of concern? (What evidence will be used to measure this? 
b) What doesn’t work well to reduce behaviours of concern? (what evidence will be used to determine this?)
4.2 Results of restrictive interventions
a) What was the effect of the restrictive intervention on behaviours of concern? (in the short term and in the longer term?)
1. What was the effect of the restrictive intervention on the person’s quality of life (might consider some of Schalock and Alonso domains: e.g., Physical Well-Being, Emotional Well-Being, Relationships with others, being included). 

3789 words