Unlocking the Secrets of Self Esteem: A Guide ... - The NADD



Staff Training: The S.S.MMMEFSAP CurriculumA Holistic Assessment and Treatment ModelPresentation prepared for NADD 32nd Annual ConferenceSan Francisco, CANovember 18 – 20, 2015Presented by: Marie Hartwell-Walker, Ed.D.mariehartwellwalker@About Marie Hartwell-Walker, Ed.D.Marie Hartwell-Walker, Ed. D, is licensed as both a psychologist and a marriage and family therapist in Massachusetts. She received a master’s degree from the Alfred Adler Institute in Chicago and a master’s and doctoral degree from the School of Education at the University of Massachusetts at Amherst. She has recently retired from her position as an Area Psychologist for the Massachusetts Department of Developmental Services (DDS). For many years, she has taught undergraduate classes on Intellectual Disabilities and Mental Health at the University of Massachusetts in Amherst and graduate classes in Family Therapy at Westfield State University. Throughout her career, she has also conducted workshops in conflict resolution, parent and teacher education, case analysis, and working effectively with families.Dr. Marie is a feature writer with over 400 published articles in journals, newspapers and newsletters and on various websites, including and . She is also one of the advice columnists on PsychCentral’s “Ask the Therapist” page. You can follow Dr. Marie on Twitter (@MHartwellWalker) or Facebook (Marie Hartwell-Walker) or visit her website at MarieHartwell- where she writes a blog about life in small town New England.Book Titles What’s Wrong: How to Tell When They Can’t Tell You: A Manual for Caregivers of People with Intellectual Disability -- soon to be released by NADD PressUnlocking the Secrets of Self Esteem: A Guide to Building Confidence and Connection One Step at a Time – New Harbinger PressTending the Family Heart: Connecting your Family in Disconnecting Times – PsychCentral PressTending the Family Heart through the Holidays – PsychCentral PressSongs for Elementary Emotional Development (with W. S. Frieden) –ERA PressStaff Training: The Key to Staff RetentionStaff turn-over is a major problem for many agencies. Studies have shown that although 70% of managers think employees leave due to low wages, 88% of employees leave for reasons other than pay. Even agencies that are limited in their ability to increase the rate of pay can and should pay attention to other factors identified by studies as key to retaining valued staff: The work gives them meaningThey trust senior managementThey have positive relationships with supervisors There are opportunities for career development. This presentation focuses on the last item on the list. Staff who care want to learn new skills to expand their knowledge in the field and increase their ability to meet new challenges.It’s essential for agencies to go beyond the basic trainings in first aid, CPR, medication administration and behavior management that are usually included in new employee orientation. Professionalizing staff by providing additional trainings and workshops results in staff pride and investment in their workplace. ?Mastering more advanced skills increases staff competence and confidence.NADD’s booklist already includes many books that can be used for internal staff training study groups or workshops. Consider one or more of the following:The Dual Diagnosis Primer by Edward E. Hughes provides an overview of mental illness and intellectual disability. Review questions are provided at the end of each chapter.Intellectual Disability and Mental Health: A Training Manual in Dual Diagnosis by Sharon McGilvery and Darlene Sweetland provides an excellent overview of the factors that complicate diagnosis and offers innovative intervention strategies. Appendices provide useful tips for staff fort Training: A Manual for the Treatment of Specific Fears in People with Developmental Disabilities by Kelly Woolaway-Bickel and Norman B. Schmidt outlines a protocol for helping people with intellectual disability overcome their fears.Working with People Who Have Intellectual Disability and Behavioral Problems: A Self-Study Guide for Interdisciplinary Team Members by Ann R. Poindexter, MD and Paul D. Kolstoe, PhD uses a holistic approach to help interdisciplinary teams develop more successful treatment programs. This book has the advantage of being designed for self-study.Quandaries: Understanding Mental Illnesses in Persons with Developmental Disabilities by Sue Gabriel is a guide to understanding the differences between mental health and mental illness. Staff will undoubtedly recognize people they know in the funny but poignant stories Gabriel shares as illustrations.The Habilitative Mental Health Network in Canada has also published a thorough and useful staff training manual: Dual Diagnosis An Introduction to the Mental Health Needs of Persons with Developmental Disabilities Edited by Dorothy M. Griffiths, PhD, Chrissoula Stavrakaki, PhD, MD, and Jane Summers is a comprehensive curriculum that was designed to help staff understand the mental health issues confronted by people with developmental disabilities. Case study examples, provided throughout the book, can be used to start discussions.I’m adding to this library with a soon to be released workbook (published by NADD) called What’s Wrong? How to Tell When They Can’t Tell You. This comprehensive manual can be used alone or in group training. It provides a structured step-by-step process for analyzing what is wrong when someone with intellectual disability and limited verbal skills shows a change in mood or behavior – and what to do about it. Case studies and activities for testing one’s understanding provide practice in using the tools. _______________________________From the WorkbookThe S.S.MMMEFSAP Model forUnderstanding Challenging BehaviorEnvision yourself on a big ship navigating through a sea of data.This workbook is intended to teach or review skills for navigating through the data and for making a helpful plan when a person with Intellectual Disability is in distress. The journey of the ship called the S.S.MMMEFSAP is an extended (some would say tortured) metaphor to help you remember the steps for gathering the information you need to determine what is going on. This model provides a structure for a careful, systematic examination of the data available. By taking a step back to carefully consider what we know, what we think we know, and what we need to do to check things out, we avoid the very human fault of jumping to conclusions. Think of it this way: You are the captain of an icebreaker ship that is headed out into the North Sea. The ship has to navigate around icebergs, not an easy feat since more than three-quarters of those icebergs is under the surface. Then there are ice flows that distract us, looking more dangerous than they are. Avoiding them can put us off course. Beneath the surface are creatures, both benign and dangerous. There are moments of beauty when the sun shines bright and warm. Sometimes the surface appears calm but you need to stay on alert. You never know when a storm might hit. Hopefully, you have the skills necessary to keep yourself calm when the seas are tumultuous and people are scared. Hopefully, you remember to stop and admire the complex beauty of the sea and to appreciate the fellowship of the crew that makes the journey possible.Working with people in distress whose verbal skills are limited is not unlike being captain of that ship. Sometimes what is most visible and above the surface only hints at the depth of the problems beneath. Smaller problems come up that look more significant than they are. They can distract us or put us off course. Beneath the surface of any person’s exterior are beliefs, attitudes, and behavioral sets – some benign and even helpful, others that are dysfunctional or dangerous. There are moments of beauty when the person is feeling good and you are rewarded with smiles and warmth. Sometimes a person appears calm. But you need to stay alert. You never know when he or she might be triggered into a rage, a panic attack, a manic episode or a depression. Hopefully, you have the skills necessary to keep calm while feelings are tumultuous and people (the individual and the staff and/or family members) are scared. Hopefully you remember to stop and admire the complex beauty of the individuals you serve and to appreciate the fellowship of the family, friends, and colleagues who make that person’s life journey easier.I’ve named our ship the S.S.MMMEFSAP, using the initial letter of each step for analyzing a case. Yes, it’s a little silly. But yes, my students tell me that they don’t forget it.______________________________From the WorkbookINTRODUCTIONJune is new to her residential program. In the three days since she arrived, she has sat on her bed in her room and rocked and hummed to herself most of every day. She will interact momentarily with staff but can’t be persuaded to come out to the kitchen or living room. Is she having a hard adjustment? Is there something going on that wasn’t talked about during the transition? Staff feel bad for her and want to help but don’t know what to do. The psychologist at the program suggests that staff just ignore her, believing that she will eventually come out of her room. Is she right? Will this help or will it just make June feel worse? What if the problem has nothing at all to do with her move?The residential staff are very concerned about Harold. He’s been biting his hand and moaning far more than usual. Non-verbal, with severe Intellectual Disability (ID), he can’t tell them what is wrong. They’ve run through the usual questions. Is he sick or is he just trying to get their attention? How are they to figure it out?Josslyn is drinking dangerous amounts of water. Her doctor has put her on limited access to fluids. She says she understands she shouldn’t drink so much. She says she won’t. As soon as her provider’s back is turned, she makes a dash for the sink. At the day program, she grabs other people’s water bottles and puts her mouth under the open faucet when she uses the bathroom. Her doctor diagnosed her with psychogenic polydipsia. Her day staff think she’s being oppositional. (She has been involved in power struggles with staff around other issues many times before.) Her mother thinks she likes the attention and drama that is going on around keeping her away from drinking. Who is right? All of them? None of them?When someone is in distress and is minimally to totally non-verbal or simply can’t find the words to explain, it is very difficult to determine what is causing the problem. Often family members or staff who know the person well can provide important information. They’ve known the individual long enough to be able to read the signs of illness or pain or attention getting. But sometimes even they are mystified. Sometimes the person is reacting to a change inside his body or in the environment that isn’t immediately apparent. Sometimes caregivers have become so used to an individual, they assume they understand more than they do or they’ve become blind to it. And sometimes the individual has come up with something entirely new.It is only human to jump to conclusions based on past behaviors and to re-implement whatever “worked” before. If, for example, someone is known to be very creative in finding ways to get extra staff attention, it is easy to conclude that the new behavior problem is no different; that it is just another way to keep staff busy. Staff or the family then ignore the behavior or reward a competing behavior or just hope it goes away. At best, this is simply a waste of time. Eventually someone figures it out or whatever was bothering the person goes away. But at worst, it can be the loss of valuable time. If the person is hurt or ill, has been recently abused, or has an emerging mental illness, to name only a few examples, delay in getting appropriate help can result in a problem becoming much worse than it had to.The question, then, is how to make sure we really understand the problem before deciding whether and/or how to intervene. This workbook provides a holistic approach for analyzing why an individual with intellectual disability is in distress. The cause of troublesome behaviors may lie within (syndromes, seizures, medical issues, mental illness) or outside themselves (attitudes of others, environmental issues, and life challenges). In order to be helpful, we need to understand it. Analysis should then lead to a plan that directly addresses the problem. The workbook also provides an overview of the tools of the field. It then connects those tools with the analysis through a holistic approach to change. The unpronounceable acronym S.S.MMMEFSAP codifies what experienced helpers do almost automatically, checking off every possibility before deciding what to do. But even experienced caregivers get stuck at times. When that happens, it is helpful to slow down and take it a step at a time to make sure nothing has been overlooked. The model provides a structure for doing just that. For those who are brand new to the field, the model will help you understand what may be happening when someone’s mood or behavior changes. For experienced caregivers and clinicians, it is intended to be a review of the variables to consider when a case gets stuck.Behavior always makes sense. It is up to caregivers to understand what kind of sense it is making.The S.S.MMMEFSAP Model forUnderstanding Challenging Behavior – And What To Do About ItThe CurriculumEach section of the workbook includes descriptions of the issues with case study examples, opportunities to practice using the material with additional case studies, and an explanation of possible responses to those case studies. Case studies not only provide practice but also introduce the learner to the wide variety of issues and people they may encounter in their work. Further, the workbook becomes a helpful resource for those who complete it.S - SymptomsObservation of Behavior`Syndromes: Physical Characteristics; Behavioral and Medical IssuesChallenging Behaviors: Aggression, Property Destruction and Self Injurious BehaviorFactitious Disorders and Somatic Symptom DisordersS - StrengthsResiliency: Vulnerabilities and Resiliency FactorsThinking in Terms of StrengthsM - Map the SystemThe individual’s social context and its effectsGetting everyone on the same teamM - Medical IssuesCommon behavioral cues to medical issuesWhen what looks like mental illness might be medicalSeizure Disorders:: Types; What looks like a seizure isn’t always a seizure; Seizures and mental health; TreatmentsSleep Disorders: Value of sleep; Common sleep disorders; Why they often aren’t recognizedEating Disorders: Pica, Anorexia, Bulimia, Binge Eating Disorder, Prader-Willi, Avoidant/Restrictive Intake Disorder, Rumination, PolydipsiaElimination Disorders: Constipation, Bowel Obstruction, Encopresis, Eneuresis, Rectal digging, CoprophagiaM - Medication IssuesMedication issues: side effects; loss of effectiveness; drug-drug interactions; drug-food interactions; medication errors; medication refusalsCommon types of medications and usesDangerous side-effects: What to look forE - Environmental CauseStressors in the environment that can precipitate change in behavior or moodNegative impact of changes in environment, sensory stimuli, treatment by others, life events, social milieuF - Functional CauseAttention, Avoidance, Communication, ControlManaging feelings and/or physical distressSelf-stimulationNot all behaviors have a functionS - Substance AbuseAlcohol and Drug AbuseCaffeineNicotineA - Abuse and NeglectSex and Sexuality: What’s just normal?Sexual AbuseExploitation and violenceNeglect: The Quieter AbuseFact vs. HypothesisHunches – The “art part” of being an effective supportChecking out your guessesP – Psychiatry: Diagnosing Mental IllnessWhy there is a greater incidence of mental illness in People with IDProblems in diagnosingDiagnostic OvershadowingClues to the Possibility of Mental Illness`Assessment Tools Standardized Testing Data sheets and Graphing Mental Status Exam Using the DSM-IV, the DSM-5 and the DM-IDUses and abuses of DSM diagnosesWhy DM-ID was developedCommon Clinical Diagnoses (basic criteria)Adjustment Disorders BereavementUnderstanding Anxiety DisordersParaphilias Dissociative Disorders Obsessive Compulsive DisorderAffective DisordersMajor DepressionBi-polar DisorderAttention Deficit Hyperactivity DisorderImpulse Control DisordersIntermittent Explosive DisorderOppositional Defiant DisorderConduct DisorderSchizophrenia and Psychotic DisorderDementiaAutism Spectrum DisordersPersonality DisordersPractice with AnalysisLots of case studies accompanied by “answer sheets” so learner can check his or her answers.Tool Box of InterventionsBuild on Strengths – Always start with the positiveKeep it SimpleHow well meaning people may be creating the problem and what to do4 basic ways to help: Solve it; Avoid it; Reduce it; Teach coping skillsBehavior Treatment PlansApplied Behavior AnalysisPositive Behavior SupportsCommon Problems in Implementation Medication Treatment Plans: Responsible use of medicationsPsychotherapy Important considerations for referralDifference between therapy and a purchased “friend”Adaptations for use of talk therapy with people with IDTypes of therapiesModels for psycho-education Systems Consultationand Conflict ResolutionThe continuous analysis-plan loop: 51943001257300042291001257300041021005080 Analysis Plan00 Analysis PlanEvaluate the success of the Plan.Continue or change the plan based on data.Evaluate the success.Continue or change the plan based on dataEvaluate the success. And so on and so on and so on. It’s a continuous recursive loop. From the Workbook: Connecting the Dots: How a Plan is developed from the AnalysisS.S.MMMEFSAPTOOLSS – Symptoms: behaviors, mood, and/or attitudes that are currently or chronically causing difficulties Every element of the plan should be focused on one or more of the symptomsS - Strengths: The resiliency factors that already exist in the systemBuild on Strengths: Reinforce sources of self-esteem and self-efficacy and enhance their support system.Positive Behavior Supports are Person-Centered and emphasize strengths.M - Map the System: Make sure you know all the people involved, how they do and don’t influence the situation, where there are alliances and conflicts. Make sure you aren’t leaving someone out who is important in the system.Systems Analysis and Consultation: Reinforce alliances. Identify and resolve conflicts when you can. When you can’t resolve conflicts completely, see if you can find a way for people to agree to disagree for the benefit of the client.Social Skills Group to learn how to get along better with others.M – Medical: Make sure there isn’t an undiagnosed or under-treated medical condition.Keep it Simple: Take the person to the doctor or dentist. Check for UTIs and constipation. Rule out sleep disorders. Check on nutrition, exercise and caffeine intake.M- Medication: Consider the possibility of side-effects, inaccurate medication administration, medication failure, and/or non-compliance.Keep it Simple: Keep good data & review medications with doctor.Medication Treatment Plan Review: Make sure staff or individual is following plan. Adjust plan if doctor makes an adjustment.E – Environmental Stressors: Check outenvironmental changes, situations, or relationships that may be troubling the person.Keep it Simple: Solve it. Reduce it. Avoid it. Teach the person to cope. Positive Behavior Supports: Remove or reduce triggers.Family or Couple Therapy: if the problem is conflict with partner or family. Social Skills Group to learn how to get along better with others.Systems Consultation: If problem is conflict among caregivers and/or individual.F - Functional Cause: What does the person get out of doing the behaviors: Attention? Gets out of doing things? Communicates something?Remember there isn’t always a functional cause. Sometimes behavior is a consequence of brain damage, syndrome, etc. In that case, the behavior plan manages the behavior.Behavior Plan: and/or Positive Behavior Supports: Design a behavior plan that replaces negative behavior with new positive skills for accomplishing the same thing. – Or -- Design a plan to help staff manage a behavior that can’t be changed.Group Therapy may help person learn to relate differently to others. Individual Therapy may help person learn new skills and manage feelings better. Social Skills Groups can teach skills for communicating and interacting better with others.S – Substance Abuse: Check for use/misuse of alcohol, illegal drugs, nicotine, caffeine.Keep it Simple: Solve, reduce, avoid, cope. Help the person manage stress or boredom in a different way.Therapy: Refer to relapse prevention group. Refer to individual counseling to help with addictive behaviorA - Abuse/Neglect: Rule out possibility of abuse and neglect.Involve legal system to protect the person if necessary.Therapy: to help the person recover from effects of abuse or neglect.Sex Education may be necessary.P - Psychiatric Issues: If the person carries a psychiatric diagnosis:Refer to mental health clinic for evaluation.Medication Treatment Plan for psychiatric meds may be necessary.Therapy of some kind may be helpful: DBT for Borderline Personality Disorder; IBT for group dynamics; Individual for individual issues or to learn more coping skills. Etc.____________________________From the WorkbookUsing the S.S.MMMEFSAPCase ExampleSam: This case study is a detailed illustration of how someone might use the structure presented in this book. The chart is an example of how to systematically consider all the possibilities for a change or worsening of behavior. Doing so helps prevent the possibility of coming to a premature conclusion by teasing out what we actually know to be the truth and what is only a guess (hypothesis). It then pushes us to test our guesses before we develop a plan. This is critical. Analysis should always drive our planning.This case study is not complete or perfect. You’d have to know Sam to determine if the chart is filled out correctly. The case is presented here in order to give you an idea of how it all goes together. Don’t get anxious if you don’t understand all the pieces. You’re not expected to. By the time you get to the end of this workbook, you’ll be able to take a case apart just like it is done here. Sam is a 58 year old, visually impaired and physically handicapped man with moderate to severe ID. Due to problems with his joints, he uses a walker and requires some assistance when on uneven ground. He has a wheelchair for longer trips. At age 3, he was admitted to the local State School for the Retarded where he stayed for 15 years. When the State School closed, he was moved to his present residential program. While at the State School, he spent part of his days in physical and occupational therapy and some recreational activities; the rest of the time watching TV or wandering about the day rooms.Sam has lost the vision in one eye from severe eye-poking and head hitting. He has had successful surgery to reattach one retina so can now see fairly well with that eye. He now wears protective corrective goggles so that he can’t poke the eye and re-injure it. This self injurious behavior (SIB) responsible for most of the damage to his face apparently happened between the ages 3 and 6 but he continues to intermittently attempt to poke his eyes. Staff vigilance and protective devices since then have kept further injury to a minimum. Due to the severity of his head-hitting, he wears soft splints on both arms during the day and lockable splints at night. He can independently lock and unlock the daytime splints. He has chronic ear infections that can precipitate head-hitting. He has a history of stomach ulcers.There are structural abnormalities in his ears that impede hearing.Sam is an engaging guy. He is curious and interested in his surroundings. He will only sit with his back to a wall so that he can watch what is going on around him. He enjoys being active. Favorite activities include watching movies, going for rides, playing with some basic computer games, and arranging colored blocks into patterns. He likes to hold hands with people he trusts. He does not like to be touched by strangers and seems to have strong negative reactions to men who are bald – like the new staffer on second shift. He has good receptive language and, although he doesn’t speak, he knows 30 signs that he uses effectively to get what he wants and needs.Staff are concerned because his SIB (self-injurious behavior) has increased in the past few weeks. He throws items he is working with on the floor. He pushes staff away. He seems generally very angry. This is not the Sam the staff know. Incidents of attempts at eye poking have escalated and he is attempting more head-hitting. Staff at both the residence and the day program are reporting similar escalations of challenging behaviors. Asking him what is wrong just makes him more upset.Sam’s primary care physician and psychiatrist are helpful providers. Both have expertise in the ID population. The local pharmacy is responsive when there is a need for a rapid change in prescriptions. The Case of Sam -Sample Analysis and Plan 34328104953000Symptoms: What are people concerned about? Strengths (Resiliency factors): -SIBs have increased in the past few weeks, -Engaging personality -More eye poking - -Curious and interested-Throws things -Enjoys being active-Pushes staff away -Does variety of activities-Appears angry - Affectionate with known people-Similar escalations of challenging behaviors -Good receptive languageat both the day and res programs -30 signs for communication-Asking him what’s wrong makes him upset -Manages locking and unlocking splints5334012065M – Map the System: Solid line show alliances between people Dotted lines show where there is conflict. Day program staffResidential staffNew bald residential staff SAM Primary Care Physician Pharmacist Psychiatrist In this case, it is difficult to show the whole story on the map. He generally likes and trusts his regular staff. Currently he is pushing people away but still shows that he likes them. If I could draw a squiggly line, it might show the ambivalence. Although we don’t really know if the program and residential staffs are in alliance, we do know that they are observing the same thing. The medical people are doing their best to collaborate but time constraints make it difficult. They all like Sam and have worked with him for years.00M – Map the System: Solid line show alliances between people Dotted lines show where there is conflict. Day program staffResidential staffNew bald residential staff SAM Primary Care Physician Pharmacist Psychiatrist In this case, it is difficult to show the whole story on the map. He generally likes and trusts his regular staff. Currently he is pushing people away but still shows that he likes them. If I could draw a squiggly line, it might show the ambivalence. Although we don’t really know if the program and residential staffs are in alliance, we do know that they are observing the same thing. The medical people are doing their best to collaborate but time constraints make it difficult. They all like Sam and have worked with him for years.45567601249680002712720103187500520128500018173701123950051441352222500316611010477500449580086360002358390577850036233101117600044386505778500395859015811500187452015684500449580015684500What we knowHypotheses Guesses about what is going on. How to test:Tests and assessments we could do; consultations that are needed; questions we need to ask. Outcome of Testing For the sake of this illustration, I’ve included a “result” from the testing.M –Medical:Sam is prone to ear infections. Record states he has had ulcers in the past.He is head-hitting. Perhaps that is why he is head-hitting and irritable. Maybe he has ulcers again.Is there any possibility of dental pain? Constipation? (Just because it is always a possibility.)Medical check-up for ear infections. Medical check-up.Consultation with dentist.Keep data on elimination. While at doctor, check it out. No ear infection.Yes. He has again developed an ulcer.Teeth are okay.Pooping is fine.M - Medication: UnknownWrong Med? Dosage? Time? Side effects?Review medications he is taking and make sure protocols are being followed.No recent changes. Couldn’t get in touch with his PCP so should follow up.E - Environmental Issues:He looks uncomfortable.Perhaps his equipment is giving him trouble. Maybe the splints are irritating him in some way? Is it possible that he is frustrated because he can’t communicate as well or as much as he would like? Are staff responsive to his signed communication?Check equipment for fit. Check skin for irritation.Observation of how he makes his needs known and how responsive others are to him when he tries to communicate.Check for how many staff are fluent in Sam’s idiosyncratic signs.Splints are irritating his arms. He has gained a little weight and the splints are chafing him.Staff know him well and respond to him appropriately. There is at least one person on each shift who knows his signs.F - Functional cause? His behavior seems to function to keep people away from him.But why would he want to do that? We need to figure this out.Collect data on frequency and intensity of SIB. Look for setting events. Does data suggest any clear antecedent to his SIB?Ask familiar staff for hypotheses (educated guesses).Data shows that he acts up when staff go to put on his splints.He also acts up when the new res staff member is assigned to pick him up from the day program.S - Substance abuse? UnlikelyUnlikelyBut always ask those who know his routines and habits.Sam is always supervised so substance use and abuse are impossible.A - any evidence of Abuse/neglect: We don’t know anything definite. Given his history of institutionalization, his current behavior could be an anniversary trauma reaction, an indication of current abuse, or an indication that something is making him fearful of abuse.. Review his record for history.Inquire about current situation. - Have there been any staff changes? Activity changes?- Has anyone entered his life who is bald?-Has he been in any situations prior to escalation of behavior where someone could have abused him?-Record indicates frequent abuse by more capable males in institution when he was young.-A new middle aged and balding staff member has started at residential program. Sam has acted fearful ever since this man started work, even though by all reports the staff person has been absolutely appropriate.-No indication of current abuse.P - Psychiatric issuesHe is being treated for PTSD and depression.Sits with back to wall. Doesn’t like to be touched by strangers.He is irritable and he is isolating himselfThe recent hiring of a bald man has triggered his PTSD.Feeling powerless to change the situation, he has become depressed in spite of medication.Do a careful record review for prior psychiatric history.History and reaction to bald men suggest some bald male hurt him. He lived in an institution for 15 years. Records show he was repeatedly abused by more capable males. He has the exaggerated startle reflex often shown by people with PTSD.History also indicates that irritability and isolation are his characteristic symptoms of depression.VII: Make a plan. Our plan depends on the answers we get to questions and to outcomes from evaluations and assessments. Suggestions in the plan must be connected to our “outcomes”.(Please note: This plan isn’t complete. It’s meant to give you an idea of how to outline a plan. We want to be sure to address each of the issues we listed in the “SYMPTOMS” section of the analysis.) Do This To Address ThisBuild on StrengthsHe has good receptive language skills and he does have staff he trusts. Have a trusted staff reassure him and explain that no one will hurt him now.Also – explain that the splints are too tight and show him they can be loosened up.He enjoys lots of activities. Distract him with something he likes to do.Teach him some calming techniques.Fear response.Painful splints.When he gets upset. To give him some control when he is upset.Keep It SimpleReassign new staff to another program.If that’s impossible, figure out a way to desensitize Sam from his presence – perhaps with respectfully and gradually increasing friendly contact. Associations of bald new staff with former abuser.Positive Behavior SupportsProvide reassurance of safety by preferred staff.Give him maximum control of what he can control.Fears.Empower him as much as possible.Behavior PlanSet up a plan to reward increasing amounts of time when he does not SIB or act aggressively. He might respond, for example, to a plan where he gets to play his favorite game on the computer for 10 minutes for every ? hour where he doesn’t SIB. We probably would have to build up to that time. To help him manage frustration better and decrease the incidence of SIB.Medication PlanTreat the ulcers.Arrange a consultation with his PCP, the pharmacist, and a psychiatrist for evaluation – just in case we’re missing something in terms of med interactions or side effects.To manage stomach pain. We need to continue to check this out.TherapiesPsychotherapy isn’t likely to be helpful with someone like Sam. However, a clinician could teach staff how to teach him some self-soothing techniques.Increase the repertoire of soothing skills to offer him to help him deal with events that upset him.Systems ConsultNo changes seem to be indicated. Everyone who supports Sam seems to be on the same page about his care.__________________________________From the Workbook Here are a few pages from the strengths section to illustrate how information is presented, practiced, and then processed.The S.S. MMMEFSAP ModelS = StrengthsPsychologists often refer to someone’s strengths as “resiliency factors” (Comas-Diaz, et.al. ). These are the skills and natural abilities as well as external supports that help a person keep on keeping on when life is tough. It’s essential to recognize a person’s existing strengths (resiliency factors) if we are to be helpful. It is always easier to build on what already exists than to start from scratch. Everyone has some core of strength or they would not have gotten as far as they have. Our job as helpers is to find it and enhance it as best we can. Having strong resilience helps keep people with Intellectual Disabilities safe from harm and able to cope with the many, many challenges they face almost every day. Knowing a person's resiliency factors helps caregivers support someone when they are in emotional distress or physical pain.Although some people seem by nature to be more resilient than others, resiliency is a set of skills that can be taught (Masten, 1994). Most of the skills may seem obvious to you. Because they’re obvious doesn’t mean that they are easy or that someone is stuck with their current skill level. Like anything else, practice makes if not perfect, at least better. With a little thought and some effort, we can build and strengthen our own resilience repertoire so that it becomes increasingly reliable. With patience, support people can teach a client or family member with ID how to also bounce back more easily when life presents a challenge. The additional self-confidence that results is invaluable as any of us live that risky business called life.Here’s a list of the resiliency factors that researchers have identified as learnable skills. For your own development, check off the items on this list that you feel you already have. Any that are not checked are skills you might want to work on to increase your own ability to cope with the frustrations of life (Rutter, 1990). FORMCHECKBOX FORMCHECKBOX Resilient people are active problem-solvers. When they experience a set-back, they don’t give up. Instead, they get busy and try to find another way to solve the problem. FORMCHECKBOX FORMCHECKBOX Resilient people consistently find meaning in disappointments and failures. They find a kernel of usefulness in each experience and learn from it. FORMCHECKBOX FORMCHECKBOX Resilient people put things in perspective. They know the difference between a disappointment and a tragedy. They let mole hills be mole hills and save their energy for the mountains. FORMCHECKBOX FORMCHECKBOX Resilient people have a network of caring people they can reach for when they need support. Often they have an older, wiser person in their lives who acts as a role model. FORMCHECKBOX FORMCHECKBOX Resilient people stand up for what they believe in. They would rather not get the job, for example, than accept it on terms they can’t support. They have a strong sense of right and wrong and use this moral compass when life becomes confusing. FORMCHECKBOX FORMCHECKBOX Resilient people often have some kind of spiritual or religious practice. Faith in something bigger than self is a resource these people draw on in an emergency. FORMCHECKBOX FORMCHECKBOX Resilient people are optimists. They believe that life is essentially good. They are masters in finding the silver lining in even the darkest cloud. FORMCHECKBOX FORMCHECKBOX Resilient people know the qualities they like in themselves. They are able to hold onto the belief in their own self worth even when life looks bleak. FORMCHECKBOX FORMCHECKBOX Resilient people have a sense of humor. They can appreciate the absurd in difficult situations. FORMCHECKBOX FORMCHECKBOX Resilient people aren’t upset by change. In fact, they often thrive on it. To them change equals opportunity. They would far prefer handling the stress of change over getting bored with routine. As you can see, the emphasis is on being active. Resilience is not simply a personality characteristic. It’s an active, problem-solving approach to life. When resilient people experience a set-back, they don’t give up. Instead, they get busy and try to find another way to solve the problem, maybe several ways to solve the problem. Resilient people are involved – with other people; with the development of their own character and skills; with problems; in short, with life. In this sense, it is closely related to self-esteem. If positive self-esteem in more areas of life is the goal, resilience is one of the important means.Think about the obstacles to learning these skills that are present for a person with ID. Often no one thinks to help them learn these very important skills for managing the challenges and defeats of life. Sometimes families and staff don’t have the patience or the willingness to help a person with disabilities understand what happened in the wake of a problem or disaster. They may not take the time to help the individual figure out what power he or she does have to change a situation or to learn from it. Sometimes people with ID aren’t supported in developing a religious or spiritual practice. Sometimes they aren’t encouraged to develop a support network beyond the immediate family or agency staff.If you care for people with ID in any way, you can do a tremendous service by conscientiously providing opportunities for practicing these skills as often as possible. That means taking opportunities to help those in your care think of several ways to solve a problem and then make a choice. It means helping them develop natural supports. It means helping them process right from wrong. It means supporting spirituality. And it means appreciating and fostering a sense of humor.Knowing how to manage and learn from disappointment and mistakes is a building block for self- confidence and confidence. Resiliency skills sustain people for a lifetime.29146515240Think about it: Resiliency is a teachable skill. What are some ways that you can foster resiliency in someone you know who has ID?Person’s initials: _____Ideas: 00Think about it: Resiliency is a teachable skill. What are some ways that you can foster resiliency in someone you know who has ID?Person’s initials: _____Ideas: Practice in Identifying the Strengths in a CaseSaraAnn is 28 years old and has Down Syndrome. She was hit by a car when she was six. Although she didn’t sustain other significant bodily injuries, she did have a serious concussion and there is evidence there was damage to the frontal lobe. This is presumed to be the cause of even more impulsivity and poor judgment than is usually seen in someone with Down. When she sees something she wants, she doesn’t stop to think. She just goes for it. Sometimes she runs across the street without looking. Sometimes she takes things that don’t belong to her. Sometimes she gets into altercations with some of the local teenagers who like to get a rise out of her in the name of “joking”. She is cute and has a good natured, sunny disposition. She tends to be trusting of others and is very hurt when she is taunted.SaraAnn lives with her mother, father, and younger sister in a small town in rural Massachusetts. Her family owns a local “Mom and Pop” corner store where they sell gas, milk, bread, and other basics. They work long hours every day of the week. SaraAnn has been brought to the store since she was a little girl. She helps stock shelves, clean display cases, and sweep the floor. She is proud that she works there just like everyone else in the family. Many of the regulars know her and make a point to say hello to her. Because the town is so small, she is permitted to walk freely about town. Most of the time this works out okay. Sometimes, though, she goes into someone’s house or back yard when she hasn’t been invited. Most of the townspeople just bring her back to her parents’ store. When she is upset, she usually talks to her sister or her mom who comfort her and try to help her understand the situation. 1835155715What are SaraAnn’s vulnerabilities?What resiliency factors does she already have?What might you do to help her develop one or two more?00What are SaraAnn’s vulnerabilities?What resiliency factors does she already have?What might you do to help her develop one or two more?Ted is a bit more complicated. Some of his support people are well-intentioned but not supportive. Take some time to think about his vulnerabilities and resiliency factors.Ted is 22 years old and is diagnosed with mild intellectual disability, spina-bifida, and diabetes. He is also depressed and irritable. Sometimes he insists on doing things that are beyond his capabilities or simply dangerous. Several times this past year, he flipped over in his wheelchair because he was determined to go over a curb or through a field to get where he wanted to go. He rebels against the diabetic diet and often sneakssugary foods. One of his friends slips him a candy bar when he can. He has been picking on his youngest brother who obliges by yelling back. He is angry that he can’t do what other young adults his age are able to do. Last June he aged out of the school system and entered adult services. He worries about what kind of job he’ll be “stuck with”. Some days he just refuses to get out of bed.Ted has a winning smile and a good sense of humor. He lives with his parents and two younger brothers, ages 18 and 16. The 18 year old just graduated from High School with honors and is headed to a prestigious college. The 16 year old has ADHD and has difficulties in school. Both of the younger boys are on soccer teams and are popular with their classmates. Ted is on the Special Olympics soccer team. His older sister is a nurse and has recently married. She and her husband visit regularly and take over family responsibilities at least once a month so mom and dad can get a break and go off together for a weekend. The new husband is starting out as a High School physical education teacher and coaches Special Olympics soccer on the side. The family belongs to a local Baptist Church that is a central focus of their lives. In fact, the church sponsors the Special Olympics teams. The parents believe that the challenges they face are part of God’s plan and that they have been given only what they have the strength to manage.Ted has always been treated as one of the gang. He is included in all family events. He is encouraged to participate in whatever activity is going on. His parents state clearly that they believe that it is not what you are born with that counts, but what you do with it. They are generous to a fault and give in easily when the kids pester them. For example, Ted was supposed to earn a video game he wanted by folding laundry for the month. He only did half the job each week but at the end of the month they gave him the game anyway. They say that they want to reward any effort.109855142875What are Ted’s vulnerabilities?What resiliency factors does he already have?What could you do to help him develop one or two more?00What are Ted’s vulnerabilities?What resiliency factors does he already have?What could you do to help him develop one or two more?Possible answersSaraAnn’s impulsivity and innocence could get her in a lot of trouble. Her trusting nature makes her vulnerable to people who might try to exploit her. But she also has strong resiliency factors. She has an involved family and a supportive community. She’s attractive and good-natured so people are more likely to want to help her. She has meaningful work which is a source of positive self-esteem. Because her town is small and she is well-known, she has a degree of independence not shared by many people with ID. There are natural support people around her who help keep her safe. Probably most important, she is help-seeking when she is upset. A resiliency factor to develop: She does need some help understanding boundaries and right from wrong.Ted: Ted wants so much to be his idea of “like everyone else” that he often puts himself in jeopardy. He strongly resists accepting his limitations. This can be a strength. But it can also lead him to do things that are beyond his capabilities and get him into serious trouble (like flipping his wheelchair over in a field as he did late one night when there was no one nearby to help him get up). He also refuses treatment for his diabetes. He says he doesn’t like medicine. He doesn’t like being on a restricted diet. He also says he doesn’t really believe he has it. He therefore eats things he shouldn’t and periodically ends up in the hospital due to high sugar levels. His parents are generally terrific but giving in to him, however well intended, means that he isn’t learning important skills for an eventual increase in independence. Their generosity and sympathy may well back-fire and make him more vulnerable.On the other hand: Despite his irritability, he can be a charming guy. This wins him friends and support. He has a supportive extended family and natural supports from church members. Their inclusion from the get-go has given him strong social skills. The family’s spiritual belief also gives him an important source of comfort and solace. His insistence on doing things he wants to do can be seen as a strength. He strives for independence in many ways – both positive and negative.A resiliency factor to develop: Perhaps expand his friendship group so he has other people to rely on besides his family. Look into whether there are members of his church community who are natural supports for Ted as an individual as well as a member of his family. Work on his pessimism about being stuck.As with any cases in this workbook, we would have to know more about these two families to fully understand their strengths and the strengths of the adult children they have raised. You may have more guesses about positive resiliency factors than are listed here. If these were your cases, it would be important to develop respect and appreciation for all that is right if you are to be helpful when things go wrong._______________________________From the WorkbookHere are a few pages from the hypothesis section.Fact vs. Hypothesis: Check it OutNow that each element of the S.S.MMMEFSA (except the P – we’ll get to that in just a few more pages) has been explained, it’s time to turn our attention to the difference between a “hypothesis” and a fact.I’m sure you’ve run into the idea of a “hypothesis” before. In science, a hypothesis is essentially an educated guess. The researcher makes a carefully considered guess about what is causing a phenomenon, then tests it out. The same is true in assessing a case. Once we run through the usual variables that we are summarizing with the S.S.MMMEFSAP, we start to make some hypotheses/guesses. We then test them out by asking questions, gathering data, and perhaps by doing some psychological testing.Testing out is critical. It’s only human to jump to conclusions or to begin to think that a good guess is an accurate conclusion. But when a hypothesis gets raised to the level of “fact”, people start to act as if the hypothesis is true. At worst, this wastes everyone’s time. If we have a wonderful solution but it doesn’t match the real problem, the solution, however wonderful, won’t work. At worst, jumping to conclusions can mean that a medical or medication issue gets far worse than it had to get because people are focusing their energy on, say, an environmental issue or what they believe to be a functional cause.Don’t get me wrong. Hunches and guesses are a good thing. Using our intuition is the “art part” of being an effective support. But good practice means checking out each guess – and doing so carefully and systematically.Take a look at the example below: Bryan’s behavior has changed. He is giving the worker a very hard time every morning. It would be easy – too easy – to jump to the conclusion that the problem is that he doesn’t like an unfamiliar staff. But that may in fact be a coincidence. By running the information we have through only the MMMEFSA part of the model, we can see a number of possibilities. We then need to think about how we would confirm or deny each guess.A good analysis looks like this:Go through the S.S.MMMEFSAP model. Systematically consider each variable.Develop hypotheses based on your S.S.MMMEFSAP findings. Always stretch yourself and look for more than one or two. Creative brainstorming often surfaces an unexpected but valid reason for behavior change.Test out each hypothesis. Don’t skip any – even if you think the answer is obvious.Case Example:Bryan has moderate ID and cerebral palsy. He uses a wheelchair. Usually he is pretty good- natured. He lives with his elderly mom. A worker comes each morning to help get him up, showered, dressed, fed and out to the van that will take him to his day program. For the last few days, Bryan has been extremely uncooperative. He resists the shower. He doesn’t want breakfast. He doesn’t want to get on the van. He says his wheelchair stinks. The worker is getting frustrated. It’s the third day of hassling Bryan to get through the morning routine. But the worker who has been struggling with him is a relief worker. Bryan's preferred staff is out sick. Mom is sick with some sort of flu and hasn’t gotten out of bed much for the past four days. We know that when Bryan’s Dad died a year ago, he was sick in bed. Bryan was close to Dad and is also close to his Mom. What we know (Facts)HypothesesHow to check it out.Map of systemMake a map and look for conflictsRelief staff is unfamiliar and doesn't fit into the "system" of care that Bryan expects. Find out if this relief staff has ever worked with him before. Does the relief staff get along with everyone?Medical:Mom is sickHe's caught the flu from his mom or from his regular staff.Constipation (just because it often is.)Medical check up.Track bowel movementsMedication:None indicatedEnvironmental-He says wheelchair stinks-Mom is sick and Dad died 1 yr ago after being sick-Relief worker is taking care of himThe wheelchair really does "stink" (have a bad odor).There is something wrong with the wheelchair and it is hurting him.Routine is disrupted-Mom’s illness reminds him of Dad’s.He doesn't understand that his regular staff is out sick and will be coming back.Get close enough to check it out.Carefully examine the wheelchair.Check out what generally happens when routine is disrupted.Ask his mom if he always has a bad reaction when she is ill. See what happens if he is reassured that his regular staff will be back. Maybe arrange a phone call with the regular staff to reassure him. See what happens.Does the relief staff know Bryan's routines?Functional CauseHe just wants attention.He's communicating his fear that his mom will die just like his dad did.Talk to people who know him well. Is this his style for getting extra attention?Ask him. See what happens if he is reassured.Substance AbuseUnlikely since he’s in constant care – unless someone is giving him somethingAsk him.Abuse and NeglectUnlikely but it’s always important to consider it. Ask him. Observe how the relief staff is handling his care.Practice Case StudiesNow try it out. Systematically go through each of the following cases. Don’t move too quickly. Really sit with each case and develop good hypotheses. Think about ways to test out each of your guesses. Do you need additional information? Will you need to refer the person to a professional for testing or evaluation? Are there tests that could be done? This is important practice for becoming effective as a consultant or teacher, staff, case worker or family member. Your goal is to be able to think through the model as second nature. If you do, you are much less likely to miss something important.PRACTICE Cases: Take a careful look at these situations. What do you know is true? What are your hypotheses for what might be going on? How would you check out each of your guesses?Alice has mild to moderate ID. She works in an enclave where she pastes labels on jars of candles. Alice has been doing this job for several years. Last week, she told her supervisor she is sick of doing it. She wants a new job. Her supervisor told her that he will see if there is another job she can do but she needs to stick with this job for now. Today she is complaining about a stomach ache. Every fifteen to twenty minutes, she asks if she can go home. She is getting more and more agitated. She calls another worker a name. She accuses another co-worker of wanting to take her boyfriend. She says everyone is always picking on her – except Susie. Susie beams. A work coach takes her aside to talk to her for a few minutes and she calms down – for awhile. Then some version of this starts all over again. The work staff called the residential program for information. The residential staff say that one of Alice's housemates has the stomach flu and has been getting lots of attention for the last three days. They don't think Alice is sick. But it's also possible her meds are off. Alice refused to take her anti-anxiety medication this morning.Symptoms:Map of system(Conflicts/Alliances)What we knowHypothesesHow to check it out.MedicalMedicationEnvironmentalFunctional CauseSubstance AbuseAbuse or NeglectJerry is known as a grumpy old man. He’s in his 50’s and lives independently in the community. He goes to a local soup kitchen for lunch every Saturday and Sunday noon. The staff always say hello and ask how he’s doing. Sometimes he’ll manage a hello back. Often he just grunts and goes to get his food. He has a certain place he likes to sit – in a corner, away from others. He arranges his plate and his cup just so. He doesn’t like anyone to sit in the place next to him. Today he came in with a chip on his shoulder. It’s 80 degrees outside and he has a heavy sweater on. In an attempt to make things more cheerful, a new staff has brought in a CD player and country music is blaring. Jerry found that someone had already taken “his” place. He threw his tray to the floor and swore and yelled at the person to get out of his seat. When staff tried to calm him, he wouldn't listen. He dropped to the floor. The police were eventually called to escort him out of the agency.Symptoms:Map of system(Conflicts/Alliances)What we knowHypothesesHow to check it out.MedicalMedicationEnvironmentalFunctional CauseSubstance AbuseAbuse/NeglectPossible answers:Alice Symptoms:Complaining of stomach ache; wants to go home; Name calling; complaining about coworkersMap of system(Conflicts/Alliances)248412014668500Coworkers Supervisor 655320209550087757017335500 Alice215392033655001177925-190500 Work Staff 420370-190500 Residential staff SusieHypothesesHow to check it out.MedicalMaybe she is getting sick since housemates are sickTake her to nurse or doctorMedicationRefused her medications this morningConfer with prescriberEnvironmentalComplaints that coworkers are bothering herObservation: Sometimes people are right.Functional CauseAttention seekingEscape from work she doesn’t want to doCommunication: “Get me out of this boring job!!!”Give her more positive attention and see if negative attention seeking decreaseWhen all else fails – Talk to the client!Let her know she was heard in a way she can understand and see what happens.Substance AbuseInsufficient informationUnlikely because she lives in residential programAbuse or NeglectInsufficient informationDelaying gratification is something that is difficult for many people with ID. Alice is bored. She wants a change. It looks like the supervisor is sympathetic but can’t respond to the request right away. She can apparently be calmed by her job coach but it doesn’t last long. She’s sick of the job and she may be just plain sick as well. Her agitation is not surprising since she does have an anxiety disorder and she didn’t take her medication.Once we understand the many factors in a case, we are in a better position to be helpful. It would be a mistake to put someone like Alice in “time out” for not staying on task. It would be a disservice to her to not take her complaints about coworkers seriously. (Just because she is struggling doesn’t necessarily mean that she isn’t right about being picked on.)Jerry Symptoms: Irritable. When crossed, threw his tray and swore. Grounded when staff tried to interveneMap of system(Conflicts/Alliances)247459512065000 staff ? (Relationship to staff is unclear.)247459511811000129540011811000 Jerry ? Other diners police (We don’t know how he interacts with police.)What we knowHypothesesHow to check it out.MedicalHe has a sweater on in spite of the heat. Is he sick?Have the agency nurse take a look at him.MedicationHe may be depressed, have an anxiety disorder or OCD.Has he been evaluated? Is he being treated? Is he taking prescribed medications?Ask him. If you have access to support or outreach staff who work with him, ask them.EnvironmentalPredictability in his environment helps him feel safeObservation that changes in environment set him off.Music is blaring.Someone is in “his” seatFunctional CauseCommunication: “Get out of my seat!”Throwing his weight around. He may have had experience that if he has a tantrum, he gets his way.Pretty obvious, huh?Talk to those who know him bestSubstance AbuseNot enough informationAsk himAbuse/NeglectPossible. He protects himself by being in the cornerRecord review. When he is calm, have a person he trusts talk to himJerry seems to depend on structure and routine and keeping people at a distance to feel comfortable. We don’t know at this point what has happened in his life. That heavy sweater may mean that he is sick – in which case he is even less able to cope with the unexpected. Police intervention may have solved the immediate problem for the soup kitchen but may have traumatized him further. Hopefully some outreach can be put in place to help this lonely and probably depressed man._______________________________________From the WorkbookThere are 5 narratives of more complicated cases at the end of the workbook to give people an opportunity to stretch out and use all that they have learned. Here is one of the cases. Give it a try.TIM Tim is a 38 year old single male. He lived with his family until he was 22. He then went into a shared living situation in the country where he did quite well for many years. When he was 32, his shared living provider decided that she wanted to “retire” and asked that he be transferred to a group home. He then went to live in a 4 person house in town. Initial adjustment was rocky but he has settled in now. He enjoys time on the swing in the yard and spending time alone. He also likes to go to his brother’s house on weekends. He likes to play with his 5 year old nephew’s trucks and blocks but doesn’t seem to know how to be interactive in play. He does play side by side with the little boy and seems to like it. He can have conversations when he is feeling good although he communicates through 2 - 4 word phrases and has a limited vocabulary. He hoards crayons, pencils, and small objects. He loves trucks, especially fire trucks.Tim shows a variety of behaviors when distressed. He rocks and punches himself. He paces. He rubs his hands and his knees. He talks faster and faster and repeats himself. He makes little eye contact. He is difficult to calm down and often will need to be held/restrained before he can calm. During these episodes of distress, he likes to wear layers upon layers of clothes. Tim has a seizure disorder. During his seizures, he will head-bang or throw his body to the floor or into a wall. Then he goes limp and to the floor. Staff report that sometimes they think he is pretending to have an aura and will ground, especially when he doesn’t want to do something. Tim has moderate to severe ID. He has some autistic-like features but it is hard to tell whether he has autism. His sleep is poor. He goes to bed around 11:00 and gets up at 1:00 and paces for several hours before falling asleep again. He eats well but prefers bread over anything else. If staff aren’t vigilant, he will grab a whole loaf of bread and wolf it down.Recently, he has been increasingly agitated without seizures. He paces, “clears” surfaces by throwing everything on the floor, and takes things off the walls. These periods happen particularly during times when he is supposed to be transitioning from his residence to day program or back. Some staff think that his behavior correlates with the move of his day program. The program got the opportunity to have more space so moved to a building with much bigger rooms and in a safer location. At times, Tim is noted to go into the bathroom to hide and take a nap. He has become increasingly aggressive and there have been some staff injuries. Staff also report that at times they notice his eyelids fluttering and a glazed look.Trips to the psychiatrist have resulted in tweaking his medications. He takes a mood stabilizer. He has an under-active thyroid and high blood pressure which are also being controlled with medication. He has several small bowel movements a day instead of one regular dump. He is often bladder incontinent but it is unclear whether this is medical or a misbehavior. He can sit on a toilet for a time, then walk out of the bathroom and have an “accident” only a few minutes later.This week, things escalated. Tim has episodes where he kicks holes in the walls, throws things, and bangs his head. He seems more disinhibited with explosive speech and hugging people inappropriately. He sometimes swears. He puts all of his shirts on and then wants to go out. Although he engages in activities at the day program, he always wants to make things bigger. Drawing on paper moved to drawing on the whole table. He had to have all the Legos. He moved restlessly from place to place.When the clinician tried to engage him to do a Mental Status Exam, he was quiet but pleasant. He stared out the window but made periodic quick eye contact. He did not answer questions coherently. His mood was euthymic and affect was broad with large gestures. He was alert and oriented to his surroundings. He seemed to become upset over the course of the 10 minutes of the interview and began to rock and look distressed.Do an Analysis: The Case of ________________ - AnalysisSymptoms: What are people concerned about? Strengths (Resiliency factors):Map the SystemIf you are unfamiliar with “Mapping” you will find a complete explanation both in the workbook and here: Hartwell-Walker, M. &. Stein, A. (2006). A Case Manager's Guide to Moving a Stuck Case. NADD 23rd Annual Conference: Promoting Mental Health i Children and Adults with Intellectual Disabilites: Cross Systems Collaboration (pp. 75 - 84). San Diego: NADD.What we knowHypotheses (cite references)How to test outOutcomeM – Medical:M - Medication:E - Environmental Issues:.. F - Functional cause?S - Substance abuse?A - any evidence of Abuse/neglect:Psychiatric issues: Guess Evidence (cite references)Make a Plan Do This To Address This:(each element addresses a symptom)Build on StrengthsKeep It SimpleBehavior PlanPositive Behavior SupportsMedication PlanTherapiesSystems ConsultationBon Voyage ................
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