Initial Management of Behavioral Crises
Consider the crisis behavior as a symptom and not a disorder. Behavioral change is often the only way people with intellectual and developmental disabilities (IDD) can express that something is wrong and communicate a need. Very frequently, the “something wrong” is not a psychiatric problem. It may be a signal that the person has a physical health problem causing pain or discomfort or that his/her environment is not meeting his/her needs.
Assess and manage the behavioral crisis by working with the patient, caregivers and available supports.
- Use Diagnostic Formulation of Behavioral Concerns to clarify the cause of the crisis, and assess and manage sequentially any discernible contributing factors, such as medical issues, supports and expectations, emotional issues and psychiatric disorders (see Diagram 1 below).
- Risk Assessment: Assess risk to the patient and others. (Risk Assessment Tool)
Diagram 1: Diagnostic Formulation of Behavioral Concerns
(Keep in mind: Behavior is a symptom, not a diagnosis)
Note: Individuals with IDD are often in a delicate balance between their health challenges (physical, emotional and psychiatric) and the available supports and expectations in their environment.
Changes in any of these considerations can upset the balance and precipitate behavioral crises, which signify that help is needed to re-establish or find a better balance. The person may go in and out of crises, until a comprehensive assessment is done, precipitating factors are identified, and a treatment plan is initiated.
BEHAVIORAL CRISIS MANAGEMENT PLAN: FIRST 24 – 72 HOURS
Immediate options to manage risk and escalating or concerning behaviors:
1. Re-stabilize the situation in the short term
Plan, with the patient and caregivers, how to re-stabilize the situation and manage the behavior. These strategies need to reflect the uniqueness of the patient, his/her triggers and coping strategies, helpful environmental changes and modifications, and caregiver resources.
- What has been helpful or not for this patient in the past.
- De-escalation strategies (e.g., have the patient go to a quiet, safe place; use existing safety response plans).
- Increasing environmental supports and/or decreasing environmental stressors (e.g., additional family/agency/staff supports, change in expectations).
- What to do if symptoms worsen or caregivers are unable to manage, including the option of going to an Emergency Department.
2. Send to Emergency Department, if indicated.
3. Use medications, if indicated, e.g., PRNs.
- Consider short-term medication options to stabilize the immediate situation and ensure safety, with a plan for review when the situation stabilizes.
BEHAVIORAL MANAGEMENT PLAN: POST CRISIS
Manage the underlying problem(s) that caused or contributed to the behavior concerns, in order to meet the needs and enhance the quality of life of the patient and to prevent recurrences of behavioral crises.
- Behavioral Problems and Emotional Concerns–Providers Checklist
- Or Behavioral Problems and Emotional Concerns–Caregiver Checklist
- Or Psychiatric Symptoms and Behavior Checklist
- Schedule an appointment to debrief. Involve the patient, as appropriate, key caregivers, and interdisciplinary team professionals.
– If a case manager or other needed resources (e.g.,a behavior analyst) are not in place, work to access local/regional resources. (Check State and Local Resources.)
- Use/review Antecedents-Behavior-Consequences (ABC) Chart to better understand triggers for behaviors of concern.
- Review crisis strategies, actions taken, and what was effective or ineffective.
- Make recommendations for management and prevention of future behavioral crises. With caregivers and available resources, begin to develop a comprehensive and proactive Crisis Prevention and Management Plan to meet the patient’s needs and enhance his/her quality of life.
- For patients who visit the Emergency Department frequently for behavioral causes, it may be helpful to develop a dialogue with local Emergency Department staff.
Review medications: Include regular, PRN, over-the-counter medications, and any possible recreational drugs used. In particular, review any new medications prescribed during behavioral crises.
Original Tool: ©2011 Surrey Place Centre.
Developed by Bradley, E & 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.