BEHAVIOUR TRANSITION PLAN

Name: D.O.B.: Transition Date: Date of Report: Start Date: Review Date: John DOE February 15, 1955 April 29, 2008 March 2008 April 29, 2008 June 11, 2008 (approximate)

A thorough assessment of John was conducted to provide sufficient information regarding his needs and abilities. The collected information is to assist in the process of facilitating his successful transition from XXX Regional Centre to a supported community group home environment under the auspices of XXXX Community Living. Enclosed is a behavioural summary of John based on a file review of past reports, staff documentation, staff interviews and direct observation. BACKGROUND INFORMATION John Doe was born on February 15, 1955 in Toronto, Ontario. Developmental milestones were met relatively late, and he was eventually diagnosed with mental retardation. In 1961, John had a psychological assessment completed which indicated an IQ of 54. A second psychological assessment was completed in 1964, and his IQ was reported at 48. At the age of nine, John was admitted to XXX Regional Centre. At this time, he was able to independently dress and undress, self-feed, and was successfully toilet trained. He was noted to have behaviour problems at this time, and was reported to be very bossy and suggestible, according to his Personal Plan. Moreover, it was reported in his Personal Plan that John wept for three (3) days after his admission to XXX before finally settling. A more recent psychological assessment was completed in 1977, when John was twenty-two years old. According to file reports, results of this assessment suggested a slight deterioration in his functioning level, which dropped from the high moderate range to low moderate range, and noted some emotional disturbance. John has been intermittently involved in workshop placements throughout his time at XXX (from 1972 to 1991), however; due to ongoing behavioural problems and reduced interest, this was eventually terminated. Currently, John is a fifty-three year-old gentleman living in an apartment style living unit at XXX with several peers. He has a history of engaging in a number of outburst behaviours including verbal and physical aggression, anxiety issues, and obsessive-compulsive behaviours.

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According to XXX staff accounts and file reports, John spends the majority of his day alternating between the bathroom and his bedroom. He has been known to spend extended periods of time in the bathroom washing his hands, standing over the toilet or flushing the toilet, and drinking water from the taps in the bathroom. He is a highly anxious individual who prefers to spend time alone rather than with peers. By all accounts, John responds well to familiar staff who he knows well. When familiar staff are not present, this may serve to trigger him to engage in anxiety-related behaviours such as loud vocalizing, pacing, swearing, slamming doors and/or property destruction. He struggles with any kind of demands or daily schedule, preferring instead to pursue his own interests at his chosen pace. He is on a number of medications. Johns family, including his brother (H.D), sister (M.D), and mother are very much involved in his life. HEALTH AND MEDICAL John is diagnosed with a number of health concerns, including: Developmental encephalopathy Bipolar disorder with OCD features Respiratory failure in 2004 Nephrogenic diabetes insipidus 2004 Hypertension Epilepsy Hatus hernia and mild GE reflux Clonus lower limbs Prolapsed rectum 1993 Degenerative disc disease (DDD) cervical spine Lubar facet joint sclerosis Anterolateral ST depression on an ECG in 1998; ECG normal in 2000 and 2004; Repeated in January 2007 There is a noted history of adverse reactions to antipsychotic medications, which cause lethargy and tremors, etc. There are no known allergies; however Lithium should be avoided in the future. As well, John suffers from nephrogenic diabetes insipidus. This is an acquired disorder, which results in the kidneys excreting an excessive amount of water into the urine, producing a large quantity of very dilute urine. As a result, there is therefore a risk for dehydration, which should be monitored closely. He is currently on a number of medications (current as of July 2007): Tylenol Extra Strength analgesic/antipyretic - used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and

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reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Valium - used to relieve anxiety, muscle spasms, and seizures and to control agitation caused by alcohol withdrawal. Epival (Valproic Acid) anticonvulsant - used to treat mania (episodes of frenzied, abnormally excited mood) in people with bipolar disorder (manic-depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). It is also used to prevent migraine headaches, but not to relieve headaches that have already begun. Prozac SSRI - used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), some eating disorders, and panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks). Multivitamins - multivitamins Seroquel antipsychotic - used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). It is also used to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Altace angiotensin-converting enzyme - used alone or in combination with other medications to treat high blood pressure. It is also used to reduce the risk of heart attack and stroke in patients at risk for these problems and to improve survival in patients with heart failure after a heart attack. Ranitidine H2 blocker - used to treat ulcers; gastroesophageal reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and injury of the food pipe (esophagus); and conditions where the stomach produces too much acid Zantac (same as ranitidine) Lactulose (PRN) - a synthetic sugar used to treat constipation. Valium (PRN) Pumice Stone Sulfur Soap Uremol

*Source: www. SafeMedications.com

Johns pills are administered with water. They are not crushed. He is receptive to this, and in fact, anticipates receiving his medications at the appropriate times. If his medications are not dispensed at the time that he expects, John will request his medications from staff. John requires sedation in order to have an opportunity for successful follow through with medical appointments and/or treatments. His vision was last tested in March 2007. At this time, no abnormalities were noted, though it was suggested that he be seen again in two years for a follow-up appointment. According to his file reports, in a hearing assessment in 2004, John presented with bilateral mild to moderate, sloping, symmetrical sensorineural high frequency loss above 2 KHz. As a result, it should be expected that he may some difficulties understanding information presented in a verbal format, especially when the environment is excessively loud. As well, Johns ears

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need to be monitored regularly by staff to manage his earwax accumulation an issue that John does not seek assistance for. With respect to dietary issues, John is required to eat a double-portioned, minced texture diet due to his choking risk. Bran is typically added to his breakfast to promote bowel regularity. He is on a 2600 calorie per day diet, with 2500 ml of fluid per day. COGNITIVE/LEARNING PROFILE John has very good expressive language skills, and has a unique manner of interacting with others. Often this will include teasing others or referring to those within his environment by colourful nicknames, which he attributes to them. He does not like demands of any kind being placed on him, and will often become verbally aggressive and engage in problematic behaviours in response to this. As well, John may retreat to his room in response to environmental conditions, i.e., if the environment is too loud, busy, or if a non-preferred or novel individual is in the area. John, in particular, benefits from regular, consistent staffing with preferred individuals that he is familiar with. Given his high levels of anxiety, he also requires advanced notice of any changes or special activities/requests in order to facilitate the chances of successful completion. In a review of his XXX file, it was noted that his level of intellectual functioning has been gradually diminishing since being initially tested in 1961. Whereas his I.Q. was first reported at 54 in 1961, a psychological assessment conducted in 1975 rated his I.Q. at 38. It is hypothesized in several file reports that this may be a function of emotional disturbance and other environmental factors. The latest record of psychological assessment, completed in 1977, noted his I.Q. in the 50-60 range. According to file reports and XXX staff interviews, John tends to function best in an environment with limited structure and decreased demands. This means that he does well with loosely programmed routines such as meal times, hygiene responsibilities, and limited recreational programming, etc.; however staff should be careful not to overprogram or place high demands on him. The behaviour therapist will further explore this at a later date to determine the appropriateness of behavioural programming. LIFE SKILLS John has good gross motor skills. He can independently ambulate and has little difficulty with stairs. He is also able to shave with an electric shaver, though it is advisable that staff are present when he does so. He requires assistance with his bathing routine, and is dependent upon staff to monitor his diet, weight, food/fluid intake, and medication administration. John is able to dress and undress independently, and is able to initiate successful toileting routines. John also is able to dry himself after showering, and place his clothes in his hamper. He will appropriately set the table if dishes are left out for him.

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John will independently and routinely initiate afternoon naps in his room. He enjoys doing this often. John does well in settings where there are minimal expectations. Routines are loosely structured so that essential activities are completed, such as hygiene activities, meal times, medication administration times, etc., however he also is allowed unstructured free time throughout the day to pursue his own interests. He will wake several times during the night and will often check in on staff or use the bathroom. John does not recognize danger, and may wander out of his area if not adequately supervised. As a result, it is appropriate to consider locking exterior doors and/or strategically installing chimes on doors, which allow access to unsafe/exterior areas. BEHAVIOUR John is noted to engage in the following target behaviours: Aggression John may attempt to push, strike or otherwise attempt to physically control another individual in a forceful manner when upset or anxious. Procedural Response: 1. If John begins to escalate, staff should immediately attempt to redirect his attention to a different activity. This may include redirecting him to a quiet area such as his bedroom. 2. Using a team approach, at least two staff will be directly responsible for any interventions used in the process of monitoring, de-escalating and/or managing Johns behaviours at this point. 3. If John continues to escalate or engage in outburst behaviours of any sort, including but not limited to aggression, for five (5) consecutive minutes or more, staff will administer his PRN medication, as outlined in his PRN Protocol. Consult Johns PRN Protocol for further details. 4. If John begins to engage in aggressive behaviours, i.e. which places his safety or the safety of others at risk, staff will immediately intervene using approved Safe Management Group (SMG) techniques to block the behaviours. 5. Staff will then verbally prompt John to calm down using a firm tone of voice by saying, John stop. You need to calm down. Consideration should be given to directing him to his room or other quiet area, away from others, to facilitate this. 6. Specific verbal praise should be given to John if he goes to his room to de-escalate by saying, i.e., Good choice, John. Take some time to calm down in your room. 7. Strong consideration should be given to quickly removing others from the immediate vicinity, if possible. Ideally alternate staff, i.e., those not already directly involved in managing Johns escalating behaviours, should do this. 8. Staff observing John throughout this process will not engage him in non-essential conversation and will avoid engaging him in any manner whatsoever other than to ensure his safety.

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9. Remember that safety precedes behavioural programming. Consideration must be given to contacting 9-1-1 should Johns behaviours become unmanageable and his safety or the safety of anyone else within the vicinity become compromised. Property Destruction (Environmental Aggression) John will slam doors and/or hit inanimate objects in a forceful manner when upset or anxious. Procedural Response: 1. If John begins to escalate, staff should immediately attempt to redirect his attention to a different activity. This may include redirecting him to a quiet area such as his bedroom. 2. Using a team approach, at least two staff will be directly responsible for any interventions used in the process of monitoring, de-escalating and/or managing Johns behaviours at this point. 3. If John continues to escalate or engage in outburst behaviours of any sort, including but not limited to mild property destruction, for five (5) consecutive minutes or more, staff will administer his PRN medication, as outlined in his PRN Protocol. 4. If John begins to engage in serious property destruction, i.e. which places his safety or the safety of others at risk, staff will immediately intervene using approved Safe Management Group (SMG) techniques to block the behaviours. 5. Staff will then verbally prompt John to calm down using a firm tone of voice by saying, John stop. You need to calm down. At this point, staff should attempt to redirect him to his room or other quiet, low-stimulus area (away from others). 6. Provide specific verbal praise if John goes to his room by saying, Good choice, John. Take some time to calm down in your room. 7. Strong consideration should be given to quickly removing others from the immediate vicinity, if possible/necessary. Ideally alternate staff, i.e., those not already directly involved in managing Johns escalating behaviours, should do this. 8. As well, if possible, all projectiles within the immediate vicinity will be removed and placed out of Johns reach. This should be done by alternate staff that are not directly involved in managing his outburst behaviours at the time. 9. Staff observing John throughout this process will not engage him in non-essential conversation and will avoid engaging him in any manner whatsoever other than to ensure his safety. In other words, only demands/direction will be provided to John in response to his behavioural presentation. Staff will remain neutral and will not show any outward signs of distress or disapproval. 10. Remember that safety precedes behavioural programming. Consideration must be given to contacting 9-1-1 should Johns behaviours become unmanageable and his safety or the safety of anyone else within the vicinity become compromised. Verbal Aggression John will engage in loud, forceful vocalizations, including swearing, threats of physical harm toward others, screaming, or attempting to intimidate others within his environment when agitated or upset. Procedural Response:

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1. 2. 3. 4. 5. 6. 7. 8. 9.

If John begins to engage in persistent and/or escalating verbal aggression, staff working with John should attempt to redirect him to a different activity that he finds interesting or engaging, or by engaging him in conversation. Consideration should be also given to providing John with reassurances that he is safe, given that he may be experiencing heightened anxiety in response to environmental triggers. If redirection/reassurance is unsuccessful, staff should use a firm voice to enforce behavioural limits by saying, for example, John, you need to stop. Provide specific verbal praise to John if he stops vocalizing once directed, i.e., by saying, Good listening, John. I like it when you are calm, quiet and in control. If John continues to engage in verbal aggression at this point, he is to be directed to a different (low stimulus) area of the house, i.e., his bedroom, to calm down. This should be done using a firm, confident tone of voice. Staff should make efforts to monitor John by checking in on him intermittently, i.e., every 15 minutes, to determine if he has calmed. Do not verbally engage him at this point however. If John continues to escalate or engage in outburst behaviours of any sort, including but not limited to aggression, for fifteen (15) consecutive minutes or more, staff will administer his PRN medication, as outlined in his PRN Protocol. Once calm, staff can verbally re-engage John by saying, Youre calm now, John. Good stuff. Do you want to come out of your room now? Allow John the choice to remain in his room, if preferred.

Obsessive-Compulsive Behaviour John may engage in consistent, repetitive, and ritualistic behaviours, such as persistent hand-washing, drinking water or flushing toilets, etc. when anxious or upset. These behaviours are typically internally driven and resistant to staff redirection. Procedural Response: 1. Given that Johns OCD-like behaviours are organically driven, i.e., beyond his control, it is important for staff working with him to allow him the opportunity to follow through with ritualistic, repetitive behaviours that do not place him or others at risk. 2. Do not confront John or otherwise engage in power struggles with him over his compulsive need to follow through with ritualistic, repetitive behaviours that pose no harm or risk to him or others. 3. As a preventative measure, it may be worth exploring ways in which to keep John engaged in alternate activities that he finds interesting. This may be done by gradually introducing programming activities/demands that he has responded to favorably in the past. 4. As a secondary means of prevention, it may be wise to consider implementing close supervision of John so as to monitor his water intake and/or other behaviours that may pose increased risk with persistent repetition. 5. In the past, staff at XXX have limited his access to water by shutting off water valves in his bathroom. Consideration can be given to doing this if/when it is determined that his thirst levels are as a result of OCD-like symptoms and not because of other medical or health-related issues. Limiting his access via environmental

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6. 7.

8.

9.

manipulation, i.e., locking doors, shutting off water valves, etc. can be an effective way to reduce the frequency of his inappropriate OCD behaviours. Ongoing consultation with a qualified medical professional should be sought with regard to this matter. Given Johns past history of aggressive or threatening behaviours resulting from his insistence that others leave the bathroom (related to his compulsive behaviours), consideration should be given to giving John lone access to a predetermined bathroom that peers do not use, if possible. Remember to give lots of reassurance to John whenever he is noted to engage in escalating behaviours by reminding him that he is safe and/or cuing him to engage in appropriate means of de-escalation, including deep breathing techniques, positive self-talk, i.e., I can handle this or I am o.k. and taking space away from others if necessary. If John engages in ritualistic behaviours that place himself or others within the vicinity in any kind of danger, staff must immediately intervene using approved Safe Management Group techniques to block the behaviour, redirect him, and engage in de-escalation techniques, as necessary.

GENERAL RECOMMENDATIONS 1. Given his nature, it is important for staff supporting John to develop a relationship with John so as to facilitate his comfort levels and successful transition to the group home environment. Based on file reports and XXX staff interviews, it appears as though he typically responds more favorably to individuals who are soft spoken and respect his space. Generally, he responds well to staff who take a gradual approach to developing a bond with him being present within the environment, giving him space, allowing him to initiate contact, offering help to him in situations where it appears help is necessary/accepting his feedback, etc. If possible, it would be advantageous to assign John his own bathroom to use, which other residents to not have access to. This will help prevent potential outburst behaviours in the future, as it relates to his OCD-like behaviours. John responds well to consistency and predictability. This is especially important as it relates to staff. It is therefore recommended that efforts be made to assign consistent (and preferred) staff on each shift whenever possible. Few demands. Up to this point, John has thrived in a setting where very few demands have been made of him, other than those which are absolutely necessary, i.e., hygiene, meal times, etc. It is important to mimic this situation initially within the group home environment so as to facilitate early success. As he becomes more comfortable and familiar in his new surroundings, consideration will be given to introducing increased daily demands on a gradual basis, with the consultation of the behaviour therapist. Given his reduced ability to recognize danger, his limited attention span, and marked developmental disability, it is necessary to maintain close, i.e. eyes-on, supervision of John at all times in order to ensure his safety. In order to ensure this, staff will be required to sign/initial a 15-minute observation checklist. When the assigned supervising staff person is required to leave the area, a recorded/documented handover should occur with another staff person, who will assume supervision responsibilities.

2. 3. 4.

5.

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6.

7.

8. 9. 10.

11. 12.

13. 14.

15.

16. 17. 18.

All exterior doors at his group home should remain locked at times, with access to be made available by direct care staff as necessary and when appropriate, i.e. when proper supervision and environmental checks can be provided. Consideration should be given to installing alarms on exterior doors as a secondary means of prevention. Access to the kitchen area should be limited for John, and he should enter only if accompanied by a supporting staff person. The kitchen area should remain locked and inaccessible to him unless accompanied by a staff person so as to accommodate his safety needs. John tends to prefer quiet, low demand environments, where he has the opportunity for lots of staff interaction, at his discretion or initiation. He is less likely to seek out interaction with peers. John enjoys taking regular afternoon naps, and seeks opportunities to nap frequently throughout the day. Staff should not discourage him from participating in his regular afternoon naps, since this will trigger outburst behaviours. It is important for staff to give ample cues to John whenever introducing a new activity or change in routine for him. This should be done by giving him advanced verbal warning of impending events. Moreover, it should be noted that John requires approximately one full day advanced notice of upcoming community events, such as going to a medical appointment, going on a van ride to a leisure event, etc. John may require less notice for activities that he deems potentially less stressful, such as daily transitions from activities. John requires medical sedation when going to medical appointments of any kind. After a review of his XXX file, it appears that John would benefit from limited access to his beverages during mealtimes until the he has finished eating. He should not be given access to his dessert until after he has finished eating as well. At times, staff have encouraged him to finish eating by presenting half portions of his meal to complete before giving him the remaining portions to eat. John will sometimes engage in sudden and unpredictable behavioural outbursts. As such, staff must always be aware of this possibility and take appropriate precautions when working with him. John has a tendency to assign unique and at times unusual nicknames to people within his life, including staff and peers. These nicknames are not to be intended as verbal aggression and staff are encouraged to refrain from reacting in a negative manner to this. Staff are not to leave official documents with his name out in the open that John can access. Given his limited ability to read, coupled with his high levels of anxiety, John may react inappropriately, i.e., by ripping documents, screaming, etc. when he notices this. As well, staff are not to speak about him in his presence since this will trigger outburst behaviours. All staff working with John must be familiar with his Personal Plan and Behaviour Transition Plan. All staff working with John must be trained in Safe Management Group Crisis Intervention Training. John will require ongoing consultation from a range of medical professionals on a regularized basis in order to ensure adequate attention is given to his medical/health needs. He will require attention from a team consisting of: general practitioner,

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19.

20.

psychiatrist, behaviour therapist/psychologist, dentist, optometrist, audiologist, and dietician. Once John has settled in his new group home environment, the behaviour therapist will meet with group home staff to review initial progress and address behavioural concerns. This should take place approximately 4-6 weeks post transition. Approximately three months after his transition, a team meeting with the behaviour therapist should be scheduled in order to revise the transition plan, as required, in order to incorporate constructive strategies geared toward teaching coping and habilitative skills.

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APPROVALS

_________________________ Supervisor XXXX Community Living Services

___________________________ Manager XXXX Community Living Services

_________________________ Pat Veleno, B.Sc. (Specialist) Behaviour Consultant

___________________________ Dr. C.P, Ph. D., C. Psych. Consulting Psychologist

_________________________ Manager of Clinical Services XXXX Community Living Services

___________________________ Executive Director XXXX Community Living Services

_________________________ H. Doe Brother Substitute Decision Maker

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Reviewed and Understood by:

______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________ ______________________________ _______________________________