+ Evidence Based Practice University of Utah Training School Psychologists to be Experts in Evidence Based Practices for Tertiary Students with Serious Emotional Disturbance/Behavior Disorders US Office of Education K H325K University of Utah: High Incidence Grant Joe Viskochil

+ Crisis Management: Seclusion And Restraint Protocol Oregon Intervention System (OIS): 2000 Behavior Support and Intervention in the Community version 2.6 CCI: Center for Continuing Improvement © Oregon Technical Assistance Corporation, and Oregon Office of Developmental Disability Services

+ OIS Description Provides training in Positive Behavior Support Grounded in the understanding and assessment of the "meaning" of the behavior. Designed for people who intervene physically or non- physically to keep individuals from harming self or others. Based on a proactive approach that includes evasion, deflection and escape from holding.

+ OIS Philosophy  Respect for individuals comes first and is a requirement in any transaction between people.  People who provide support to those who have challenging behavior must receive support as well.  Behavior is a form of communication.  Understanding of the causes and context of the behavior can aid the individuals to develop alternative, and often very creative, approaches to situations.  Alternatives are always based on positive approaches-- aversive or punishing approaches are never used.

+ OIS Training and Certification Training: 2 day (16 Hour) workshop emphasizes Understanding the underlying causes of behaviors How to avoid situations that may result in physical aggression How to avoid physical injury if such behavior occurs. Cost ranges from $ for each registrant Trainees Learn skills to prevent challenging behavior and avoid injury Earn certificates of completion given demonstrated their skills Can be anyone: Families, vocational staff, educators Trainers Certified by CCI/OIS CCI continues to provide oversight and review of the trainers Trainers and staff must be recertified every 2 years

+ OIS Competencies Skills, attitudes and temperaments necessary for people who provide support To recognize and avoid abusive behavior and instead promote caring and supportive behavior To maintain self control in crises and stressful situations How to analyze behaviors, contributing factors and functions of the behavior To build behavior supports and develop an effective plan for positive behavior intervention Physical methods of keeping people safe in the event of potentially unsafe behavior

+ Legal Liabilities: Overall OIS is approved and regulated through the state Senior and Disability Services office and its contractor, Center for Continuous Improvement/Oregon Intervention System(CCI/OIS). Approved by the Oregon Mental Health and Developmental Disabilities Services Division (MHDDSD) Follows framework of intervention strategies outlined in Oregon’s Administrative Rules

+ Legal Liabilities: Interventions Written Policy: The program shall have and implement a written policy concerning intervention procedures Implementation: A decision to implement a program to alter an individuals behavior shall be made by the Individual Support Plan (ISP) team and the program described fully within the individuals ISP Documentation: Documentation regarding the behavior program shall include documentation of Informed consent of individual, guardian and ISP team All programs and methods used to develop an alternative behavior A functional analysis of the behavior Oregon Administrative Rule

+ Legal Liabilities: Physical Restraint Restraint: Restricting the movement of an individual or restricting the movement or normal function of a portion of the individuals body Physical restraint is only employed: As part of an Individual Support Plan intended to lead to less restrictive means of intervening As an emergency measure if necessary to protect the individual or others from immediate harm As a health related precaution prescribed by a physician if necessary for a specific medical or surgical procedure Oregon Administrative Rule

+ OIS Interventions Prohibits: OIS prohibits the use of physical intervention in situations other than protection from immediate harm Any form of punishment in any intervention is also prohibited Abusive Techniques: outside parameters of good practice Humiliate or deliberately cause pain or discomfort Abuse of Techniques: correct techniques applied inappropriately Unnecessary, too long, unauthorized restraints or interventions

+ OIS Interventions Requires: Physical Preparedness: appropriate attire and mobility Self Control: use a preplanned response to avoid overreacting Behavior Plan: ISP must be developed and agreed upon Any possible interventions to be used must be Documented Explained Monitored Functional Assessment: must accompany the Behavior Plan Consider nature and meaning of behavior Close observation of antecedents, behavior and consequence Appendix of training manual includes OIS 2000 Functional Assessment

+ Interventions: Strategies Plan A: The Pro-Active Plan Quality of life issues, person-centered thinking, daily living skills Replace problem behaviors with alternatives Plan B: Reactive Response Plan Make needed changes based on early warning signs Reduce the likelihood of escalation and resume Plan A Plan C: Crisis Intervention Any restraints to maintain health and safety Use only if the individual is at risk of harming themselves or others and after all other efforts have failed Must be approved, documented and reviewed Plan A, Plan B and Plan C

+ The Crisis Cycle

+ Crisis: Stress Cycle Interventions Phase 0 (Current Status): Observe and minimize triggers Use Plan A strategies Routine Supervision Phase I (Triggering): Redirect or emphasize self-control Plan B Strategies Close Supervision Phase II (Escalation): Crisis communication Simple and Direct communication Constant Supervision

+ Crisis: Stress Cycle Interventions Phase III (Crisis): Potential evasion and restraint All intervention efforts must be specified in Plan C Constant, multiple supervision Phase IV (De-escalation): Continue crisis communication Do not discuss consequences Plan C component Close supervision Phase V (Depletion): Remove restraint, active listening Close supervision for SIB, suicide or running away Positive supports outlined in Plan B Phase VI (Stabilization): Reinstate Plan A activities and supervision

+ Crisis: Reasonable Responses SETTING/EVENT REASONABLE RESPONSE Intimidation/Threats -No physical restraint -No physical intervention -Only physical contact to separate Physical Contact Made For non-serious injury -Evasive maneuvering, covering and deflecting attack For serious injury -Whatever is reasonable to maintain safety (restraint, 911) Self Injurious Behavior Threat: redirection techniques Non-serious contact: non-restraint Serious contact: manual restraint Reasonable response is just enough intervention to prevent injury, and no more than necessary

+ Crisis: Intervention Standards 1. Self Control: develop and practice self control plan 2. Observe and Identify: signals, setting events and triggers 3. Communication: Keep It Simply Stated (KISS) 4. Timing: use intervention strategies only when appropriate 5. Patience: even if strategies seem ineffective 6. Spontaneity: be able to modify or individualize techniques

+ Crisis: Principles of Evasion 1. Be patient: the episode cannot last forever Most crises will be over in less than 3 minutes 2. Control yourself: avoid excessive force and poor judgment 3. Maintain personal space: crowding increases risk for both 4. Maintain communication: use names and brief directives e.g. “JOE!! Stop! Sit Down!” 5. Stay out of the way: stay out of striking distance 6. Move with the attack: move away in circular patterns its easier to deflect than block an attack

+ Principles of Evasion (cont.) 7. Get out of the way: stay balanced and move smoothly Continue to communicate 8. Cover up: cover vital areas while moving away 9. Deflect blows and kicks: physical contact is momentary Make no attempts to hold or control individual Close the attack by deflecting blow across middle of individual, but do not plant your feet and push 10. Escape holding attacks: move toward point of contact Do not attempt to use pain to escape Individual may not perceive pain; sets a bad example; is abusive 11. Call for help

+ Crisis: Stances STANCE Back straight Chin up Weight balanced on balls of feet Feet shoulder width, one foot a few inches back Knees flexed to 135 degrees (sitting on object) CROUCH Forearms in front of chest Fingers on sides of chin, palms out Elbows tucked into ribs Feet more than shoulder width, one several inches back Knees flexed to 90 degrees (sitting on chair

+ Crisis: Movements and Steps PIVOT (ex: left foot pivot) 1. Keep left foot still 2. Pivot on ball of left foot 3. Move in circular sweep 4. Move backwards FRAMING 1. Arms outstretched, elbows bent 2. Hands perpendicular to floor 3. Hands six inches apart (forming a window) 4. View attack through window, deflect BACKSTEPS 1. Move rear foot back 2. Maintain balance 3. Slide front foot back 4. Back straight and chin up SIDESTEPS (ex: move to right) 1. Pull left foot into right 2. Push right foot out 3. Keep feet close to floor/slide 4. Back straight and chin up

+ Crisis: Team Stances, Steps STEP 1. Stand shoulder to shoulder 2. Face slightly outward 3. Feet 200% of shoulder width 4. Inside foot forward 5. Inside knee more flexed BACKSTEP 1. Move rear feet backward 2. Slide front feet back 3. Keep feet close to the ground 4. Move in unison KNEEL 1. Separate legs as far as possible, maintaining comfort and balance 2. Lock inside hands 3. Kneel down on inside knee 4. Touch floor with locked hands 5. Keep back straight and chin up at all times

+ Restraint: Principles Manual restraint is only appropriate when: Responding to very challenging and potentially injurious behavior The behavior can be controlled with restraint The intervention care-givers are sufficiently trained and can reasonably expect to achieve safe control

+ Restraint: Application Principles 1. Master evasion techniques 2. Master control techniques 3. Get a grip (grab clothing, if possible) 4. Use weight, not strength 5. Avoid pain 6. Use only a reasonable response 7. Maintain a proper ratio (at least 2:1) 8. Be a team player (one leader communicates and directs) 9. Select least intrusive restraint position 10. Monitor breathing and circulation (no pressure on bones, joints, lungs)

+ OIS Manual Restraint Positions BALANCE CONTROL One hand grasps belt, other grasps clothing between shoulder blades Never grasp directly on the spine and always move backwards ONE AND TWO ARM SUPPORT One arm is held close to the chest with caregivers arm laced inside the elbow and holding the individuals same side arm away from the wrist Other arm is free (one arm) or held by another caregiver (two arm) COUCH RESTRAINT Two staff hold individual on a couch Less danger of falling or being knocked down

+ OIS Manual Restraint Positions ESCORT POSITION Individual is held in standing position and forcibly walked Individuals may calm during brief restraint, remove force WALL RESTRAINT Individual is held with their back to the wall if escort is not possible Individual can slide down wall into couch restraint PRONE FLOOR RESTRAINT Only used if all other restraints have failed Individual is held face down on floor, limiting large major muscles Use of a supine position allows larger muscles to be used Recommended only for obese, pregnant, and sexually abused Must be authorized by the OIS Steering Committee, in writing, before its implementation

+ Resources Training Media None Websites Not very relevant Defines OIS Includes training opportunities ge.html ge.html Brief description Program philosophy Contact info Article Search Google Scholar: None ERIC: None PsycINFO: None PsycARTICLES: None Psychology and Behavioral Sciences Collection: None

+ Contact Kelley M Gordham, Director Oregon Intervention System Director, Special Projects Center for Continuous Improvement 900 Main St, Suite 200 Oregon City, Oregon , ext 27 fax