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CASE STUDY 

 

Questions

1.   How would you ensure TJ’s rights are upheld?

 

2.  As TJ’s support worker, how would you implement his plan on a daily basis?

 

3. Identify any actions/activities you would implement to promote independence and informed decision making for TJ.

 

4. Identify any potential or actual risks for TJ within his environment and detail how you would address these.

 

5. Briefly discuss the impact of medication on TJ’s behaviour.

 

6. As a support worker, what would your role be in ensuring TJ’s plan stays current?

 

About the Person

  Description

 

 

 

 

 

History

 

TJ is 19 years old.  He has a great sense of humour.  He likes being busy and once he starts something he likes to finish it well.     He has a great memory and will remember dates, times and people easily.  He prefers writing to communicate and asks lots of questions.   He loves footy and barracks for Hawthorn.

He has a mild intellectual disability and autism.

Until the age of 17, TJ lived at home with both parents, but he physically injured his mother on several occasions by kicking her.

His parents tried many different strategies to stop him from kicking, including prescription of medication.  His parents’ health suffered and they decided to move him into supported accommodation.  When TJ first came to live at his current home, he was on 3mg Risperidone per day and was having PRN Zyprexa on average once per week.  This has since been slowly reduced.

He goes to Flinders Disability Services every day on the service bus which he dislikes because it’s noisy and takes an hour.  When he gets home, it’s good to let him have time alone to cool off.

 

 

 

 

Health

TJ is in good health most of the time but he can get ear infections about once per month.   When he gets ear infections (will bang his ear or rub it) information can be found in his health plan, for details on how to manage ear infections.

He can be exhausted after his day placement especially after the bus journey and if it’s been a hot day.  The best way to get him going the next day is to give him a cup of tea in the morning.

Mental health: It is reported that TJ was traumatised at school where he was punished by being locked in a ‘time out area’.

He is sensitive to heat.  Have cool drinks ready on a hot day.

 

 

 

 

Communication

A communication assessment (23 April 2018) showed that:

TJ can speak well but:

He uses a notepad because he prefers written language rather than spoken.        He finds the sounds of people’s voices irritating;
It takes time for TJ to understand information;
He has difficulty changing attention from one topic or activity to another.

   

 

 

 

 

 

 

 

 

Likes/Dislikes

Likes:

He only wants to be called TJ
Listening to music is his favourite activity
He likes to be occupied; he prefers to do things on his own
He loves praise especially the ‘thumbs up’ sign
He likes to know when everything is happening, and be able to choose
He likes to visit his family

Structure and predictability are important to TJ.  If plans need to change, let him know in writing through the use of daily planners.

 

Dislikes:

He really dislikes being called by his Christian name
Hot days
He doesn’t like noise; especially high pitched voices
To sit still for long or having to wait (depending on the day he can sit or wait for up to 10 mins before needing to move)
Things that make him unhappy are any changes to his routine; especially if it is what has been agreed to in his daily plan
Dogs barking or children shrieking in the park
The bus to day placement

 

 

 

Sensory

Will seek to avoid the sounds of voices

Needs his iPod for car or bus travel or when in close confines with others

TJ would benefit from a sensory assessment.  An appointment has been made and the plan will be updated once the assessment is completed and the report received.

 

 

 

Goals and Aspirations

TJ wants to have friends

TJ uses a computer at day placement and wants his own iPad (currently shares the house iPad)

TJ would like to learn to catch the train to his day placement

TJ would like to have more money of his own and a job

TJ would like to move into his own flat with a support worker who had their own space (see PCP)

 

 

Behaviour Harm to Others

 

Behaviour Description

TJ can kick people in the legs with enough force to cause bruising and swelling.   This can happen about eight times a day.  The behaviour can last for up to 10 seconds.  This behaviour was noted by his parents to have occurred at home and at school and has continued since moving into his new home 3 months ago.

 

Triggers and Setting Events:

 

 

 

Communication

Behaviour: Kicking

Trigger 1: Staff calling him by his Christian name instead of TJ

Setting Event 1: Staff being unaware of forgetting to TJ

 

Trigger 2: Staff only using verbal communication to him rather than predominantly writing or visual communication (his preferred way to communicate)

Setting Event 2: Staff using verbal instead of written language.

 

 

Physical environment

Trigger:   When the is very noisy – TJ doesn’t like noise

Setting Event:  Most incidents occur around 3pm to 4pm when all residents are returning home from their day placements and there is increased noise.

 

 

Routine

Trigger:   Sudden changes to his routine or what had been agreed to in his daily plan, e.g. change of staff, not doing as he requests or an unavoidable time delay make him very unhappy.

 

Other

Setting Event:  TJ is more likely to kick others when he has an ear infection.

 

Functions: Description
Protest, Avoidance or Escape

Function 1:

TJ kicks others to communicate his protest against being called by his Christian name.  He only wants to be referred to as “TJ”

 

Function 2:

TJ kicks others to protest against when people don’t communicate with written and/or visual communication.

 

Positive Behaviour Support: Description:

 

 

 

Address triggers and setting events

Behaviour:   Kicking

 

Trigger 1 and setting events – His name is TJ.  Do not use any other name

Trigger 2 and setting events – Staff to communicate with TJ in written or visual form

 

Other:

 

Staff will monitor TJ’s health to avoid recurring ear infections

Provide cool drinks and suggest a shower on hot days.

 

 

 

 

 

 

 

Replacement behaviour and skill teaching

Replacement Behaviours

 

TJ is being taught by CA to use cards to communicate.  These cards will also be used by TJ to inform staff of his preferred name/preferences for written or visual communication and to protest if his preferred name or ways of communicating are not used.

 

Every time TJ uses his cards, give him “thumbs up”, and get him what he wants.

 

Skill Teaching:

Take a shower after returning from day placement to help calm him down is now part of his daily routine.
Waiting – Staff praise TJ when he has had to wait for a short time for something without getting upset.
Independence – nothing has been done about his travel arrangements as yet.        (He would like to travel with the train rather than the bus).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Communication

Communication cards, iPad and notepads are used instead of words

 

It takes time for TJ to understand information – when you have asked a question or given him some information, count to 20 slowly in your head, then prompt TJ to see if he has understood, or needs more time to plan his response and repeat information if necessary.

 

Give him time to understand any communication

 

Staff should also carry a spare notepad in case one is lost.

 

Speak gently, softly and in a low tone around and to TJ as he responds better to this and only in conjunction with his preferred communication methods.

He has difficulty changing his attention form one thing to another (activity, conversation or setting) – always gain TJ’s attention via gesture and gently speak his name (TJ).

 

Give TJ time to finish what he is doing

 

Give him warnings or prompts that the activity, conversation or setting will change and provide him a timeframe (e.g. 5 minutes).

 

Direct his attention to his planner so that he is aware of what is happening next.

 

TJ NEEDS TO KNOW WHAT IS HAPPENING AT ALL TIMES:  DAILY PLANNER – STAFF ROSTER

Make sure daily planner is updated every day.

Make sure TJ has his smaller planner he carries with him

A ‘Who’s on’ staff roster is put on the wall in the house with pictures and names of the staff for that day.

Always let TJ know of any changes to staff before the day if possible.  Use change and sorry cards if needed.

 

 

 

 

 

 

Physical and Mental Well-being

Feeling Anxious:

 

SUGGEST HE LISTEN TO HIS MUSIC – HAVE MUSIC AVAILABLE AND ENSURE THAT HIS IPAD IS CHARGED (sensory calming activity)

 

Waiting to see a psychologist who does internet counselling.

 

TIREDNESS AFTER DAY PLACEMENT:

Offer TJ a cool drink that he can make himself in the kitchen

Having a shower immediately on return from day placement works well (sensory calming activity)

 

ROUTINE CHEMICAL AND PRN USE SIDE-EFFECTS:

Observe TJ for side-effects of use including drowsiness, dizziness, etc.

 

Goals and Objectives: Description

 

 

 

 

Replacement Behaviour and Behaviour Reduction

Goal for increasing the replacement behaviour:   When TJ wants to communicate or protest; he will give the correct card to staff without kicking for ¾ of the time for three consecutive weeks within three months.

 

Goal for decreasing the behaviour of kicking:   Reduce kicking within two months from eight times a day to two times a day.

 

Other Goals:

 

Counselling – counselling to be arranged for TJ within the next two months

 

Other:  Ear infections are monitored regularly

 

 

 

 

De-escalations: Description

 

 

 

 

Assess Safety

Check everyone is safe

Check in with TJ after returning from day placement

If he is unhappy (either by showing you his ‘unhappy’ card or by facial expression (glaring, frowning and eyebrows drawn together, or his body language – moving quickly without seeming to settle, muscle tension evident across shoulders and arms, fists may clench).  Ensure safety by keeping everyone 2 metres from TJ if possible.

 

If TJ has used his ‘unhappy’ card, give him a ‘thumbs up’.  Use gestures to ask TJ to follow you away from the others.   Ensure you stay out of his kicking range.

 

Prompt the replacement behaviour

Offer him the card that says:

‘are you ok TJ’

‘use your cards to tell me what’s wrong’

 

Each staff should have one of these cards on them at all times.

 

Other

If TJ uses his cards:

 

Get him what he wants as soon as possible and reward him with a thumbs up sign.

If TJ has signs of being unhappy or is agitated (e.g. yelling) because of a staff issue (daily planner not updated/’who’s on’ board not completed), say sorry and ask TJ for help with finding out what’s happening.

 

Then suggest something relaxing (shower/music/computer) as TJ can stay upset for a while after the problem has been solved.  Make sure to check in with him regularly for the rest of the shift and let him know when new staff arrive.

 

If TJ indicates “NO”, that he either would not like to talk to you about it or use his cards:

 

Ask him (by offering the choice through cards) if he would like a shower (‘would you like a shower?’), a cold drink (‘would you like a cold drink?’) TJ will usually take you up on one of these offers as it is part of his usual routine.

 

If TJ does not take you up on one of the options presented to him, encourage TJ to go to his room and listen to music until he calms down (no longer glaring, open relaxed body language, able to smile and engage).  carry out this by using the ‘bedroom and music’ card or by pointing to his room.  Check on him in 10 minutes to see if he is feeling less upset and if he would like to complete his usual routine.

 

If TJ attempts to kick:

 

Hold up your hand (palm) out to signal “STOP”.  Remove yourself and any others from TJ’s reach and give him some space.

Check in on him using 5 minute intervals.  If TJ has not calmed after 20 minutes, offer him PRN Olanzapine 5mg.   Continue to monitor until PRN takes effect (usually in 20 minutes time – TJ will appear calmer and slightly drowsy).

 

Offer him a cool drink and the chance to go lie down and listen to some music.

 

If the behaviour occurs outside the home:

When he is in the park:

Follow ‘assess safety’, ‘prompt replacement behaviour’ and ‘if TJ uses his cards’ above. (Substitute iPod for shower when out in the community).

If this is not working, encourage TJ to sit in the bus on his own until he calms by using the ‘bus’ card or prompting.  Check in on him in 10 minutes to see if he is feeling less upset and if he would like to re-join the activity.

If he doesn’t want to continue  this, move everyone away from him and give him space.

Follow ‘if TJ attempts to kick’ above, should he attempt to kick while in the community.

 

Use PRN Chemical Restraint:

If TJ has kicked someone and will continue to kick them and they cannot escape or;
If all of the above steps have been tried and it is certain TJ will kick someone, follow the PRN Chemical Restraint Guidelines dated 21/02/2017.
If the PRN is needed to be used more than twice within a 7 day period, the BSP should be reviewed and an appointment made with the GP for a medical review and a review of the PRN.

 

Post incident debriefing

Program or a referral to the Critical Incident Response Management Team for group support.

Inform the other staff

When he is calm, use the cards to ask him to discuss the incident, privately.

Discuss with other staff/manager if immediate changes to strategies and the BSP are necessary.

Discuss incident for next team meeting

 

Restrictive Interventions: Administration Type:  
Routine Chemicals

Risperidone 1mg tablet orally at night.   The prescribing doctor indicates that this medication is to address ‘anxiety’ (as indicated by incidents of behaviours of concern and distress over changes which leads to behaviours of concern).  The benefit for TJ is intended that he will be more able to engage with others and more able to achieve his goals of living independently if he is not engaging in behaviours of concern.

 

A review with a potential planned further reduction will commence in two months’ time when TJ has had more time to learn to use the card system developed with him, the BPS strategies are being implemented consistently and there has been a noted decrease in frequency, intensity or duration of behaviours of concern.

PRN Chemicals

Zyprexa, 5mg oral, Max does 20mg in a 24hr period, if used more than twice per week, a review is indicated.   Used to sedate TJ, this is only used in an attempt to prevent certain physical harm to others when all other least restrictive strategies have been followed so that TJ and others are not put in a position where they may be hurt.  The benefit for TJ is intended that he will be more able to maintain relationships with others and more able to achieve his goals of living independently if he is not engaging in behaviours of concern.

PRN chemical restraint has not been needed since the BSP has been implemented.  Its need will be reviewed in two months.  If it has not been needed, discussion will be held with the doctor regarding it being removed from his treatment.

 

Who has been involved in preparation of the Plan and what are their responsibilities?

 

Name Agency Role Relationship
TJ Holgate Family    
Ray and Julia Holgate Family   Parents
Nick Holgate Family   Brother
Clare Adams Southern Cross Services Inc. Key Worker House Staff
Jan Arnold Southern Cross Services Inc. House Supervisor House Staff
Bruce Apway Flinders Disability Services Staff member Staff member

 

Team Co-ordination and review: List how the team will co-ordinate all the tasks and responsibilities and review the behaviour support plan.  For more information, see Good practice and guiding principles and Section 4 of the Toolkit.
Team Co-ordination

Replacement of behaviour:  CA responsible for card making, teaching TJ and other staff recording.

 

Counselling and ear infections:  Jan to arrange for referral to GP re: counsellor and ear infections.  All staff to follow Health Plan regarding observing TJ for signs of earaches.

 

Communication:  Jan responsible for providing notebooks and card making items

 

Daily Planner/Staff Roster:  to be kept up to date by staff on shift everyday

 

Daily support:  Shower after day placement continues as long as TJ wants it.  All staff responsible.  BA from Flinders Disability Services is his key worker for Day placement and is responsible for monitoring, recording and communicating with CA, TJ’s accommodation key worker.

 

CA responsible for co-ordinating the information flow between day placement, TJ’s home, his parents and any medical professional.

 

House staff and BA meet monthly to discuss any issue, incidents and plans.  TJ’s parents are invited to attend these meetings.

 

PCP goals are achieved as soon as possible especially those related to the behaviour:   All staff, parents, Nick and Bruce from day placement responsible.

 

Travel training to commence ASAP

 

Communication and review of goals
CA will make daily recordings of behaviour and card use
Card use reviewed by CA, JA and parents every three weeks, decisions on changes to strategies to be decided by all if progress towards quality of life goals (PCP), behavioural goals, or BSP implementation is not occurring or a critical incident occurs.
TJ’s health (ear infections), management of triggers or setting events, skills teaching, effectiveness of de-escalation strategies, behaviour, discussed at each team meeting.

 

SCIENCE
HEALTH SCIENCE
NURSING

 

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