Low arousal and self control

Transcription

1 Low arousal and self control - Concepts in the management of challenging behaviour Bo Hejlskov Elvén Clinical psychologist

2 Challenging behaviour? Who's challenged? - We define a behaviour as challenging when we are challenged - By our own lack of tools and skills This definition is about our own powerlessness

3 The principle of responsibility He who takes on responsibility can make a difference Bernhard Weiner

4 The principle of responsibility If our methods are bad we often try to get rid of our responsibility

5 The principle of responsibility We often try to place the responsibility on those who cannot take it - Next of kin - Politicians and leaders - Culture - The people we work with

6 Elven's car work shop We work in a car work shop - Who's responsible for service and repairs in the work shop? - The owner of the car? - The car? - Cars don't have to coorporate - Cars can't just stop being broken - The mechanic needs to use the proper tools and procedures

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13 Elven's car work shop We work in a car work shop - Who's responsible for service and repairs in the work shop? - The owner of the car? - The car? - Cars don't have to coorporate - Cars can't just stop being broken - The mechanic needs to use the proper tools and procedures

14 The meter maid If you get a parking ticket you have two possible thoughts - I put the car in the wrong spot. That was stupid - The meter maid is an idiot - The last thought doesn't make you choose another spot tomorrow - And you will get a new parking ticket - Which confirms your opinion: They are idiots - And you do not learn anything

15 Elven's car work shop We work in a car work shop - Who's responsible for service and repairs in the work shop? - The owner of the car? - The car? - Cars don't have to coorporate - Cars can't just stop being broken - The mechanic needs to use the proper tools and procedures

16 Elven's car work shop The car is supposed to be in better shape after you pick it up at the work shop

17 People Who Can Behave Will Behave (Ross W. Greene)

18 Or he or she cannot live up to our demands or expectations regarding - Understanding the consequences of one's own behaviour - Flexibility - Endurance - Impulse control - Social abilities - Stress threshold - Surplus - Acquiescence

19 People Who Can Behave Will Behave (Ross W. Greene)

20 Fostering This means that we have to rethink what we learned as kids - Special needs mean that ordinary methods are useless - We sometimes hit the method ceiling and start using fostering methods Methods that do not work should not be used!

21 Methods? Reprimands Limit setting Punishment Consequences

22 The principle of responsibility He who takes on responsibility can make a difference Bernhard Weiner

23 Problem solving Challenging behaviour and conflicts are often reciprocal problem solution - I have a problem that I solve - My solution becomes a problem for somebody else that he or she must solve - In a way he or she becomes a problem for me to solve... This kind of conflict can only be solved by one of us using solutions that do not become a problem for the other

24 Solutions We would like to teach others to use solutions that do not cause problems for us It would be more logical that we find solutions that do not create problems for the people we work with In order to avoid powerlessness and lack of control Both being key issues in both the Low Arousal Approach and in restraints

25 The Principle of Control You have to have self control in order to lend somebody else control of a situation

26 The Principle of Control Everybody wants to avoid lack of control in order to avoid - Severe anxiety - Hitting - Kicking - Biting - Throwing of furniture - Severe self harm

27 The Principle of Control That's why everybody has solutions and strategies in order to keep self control - Refusing

28 Affect regulation Affect intensity Affect trigger Chaos No control Self control Time

29 Affect Regulation No control Self control Affect intensity Affect trigger Time

30 Affect Regulation Affect intensity Affect trigger Chaos Strategies - Refusing - Lying - Running away - Spitting - Hitting - Self No control harm - Threats Self control - Bad names Time

31 Affect Regulation Affect intensity Affect trigger Kaos No control Self control Time

32 The Principle of Control That's why we must strive to - Make sure the service user keeps his or her self control - Help the service user regain his or her self control if he or she has lost it - Use methods that helps the service user lend control to us

33 Tools The basic rule: 1. Manage best you can without escalating the situation 2. Evaluate 3. Change what needs to be changed so that it doesn't happen again

34 Tools The basic rule: 1.Manage best you can without escalating the situation 2. Evaluate 3. Change what needs to be changed so that it doesn't happen again

35 Affect Contagion Affect is contagious - we feel other's affects Using mirror neurons Mirroring muscle tension

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42 Affect Contagion All children are born with the ability to mirror affect It is the basis of empathy development People with special needs do not have a standard empathy development They do not develop the ability to separate their own from somebody else's affect In dementia, psychosis and brain damage that ability is lost

43 Affect contagion Affect intensity Chaos No control Self control Time

44 Method: Low arousal approach Affect intensity Affect trigger Chaos No control Self control Time

45 Control and restraint I never saw a restraint that looked as controlled as this picture - In my experience restraints are characterised by chaos Still the most used argument in favour of physical restraint is taking control of the situation

46 Control and restraint I believe that most people restraining children actually believe that they are solving a problem in the best possible way

47 Control and restraint But it is very dangerous More than 150 documented restraint related deaths among children in the last 25 years

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50 Principles for physical interventions Effective No harm No pain Easy movements Social acceptable

51 Low Arousal Approach Keep calm Avoid prolonged eye contact

52 Low Arousal Approach Keep the distance - When the person steps backwards you step backwards as well - Step backwards in demand situations - Do not stand opposite the person

53 Low Arousal Approach

54 Low Arousal Approach

55 Low Arousal Approach Sit down when the person is agitated Avoid a marked body language Pretend to be walking home from the pub Avoid being infected by the other's tension Make sure your calm is contagious

56 Method: Chaos Affect intensity Affect trigger Chaos No control Self control Time

57 Low Arousal Approach - When In Chaos Wait- it is often enough Make other people leave Avoid touching with tense muscles Relax when somebody grabs you

58 Low Arousal Approach - When In Chaos And in emergency situations when you need to grab someone - Use the person's own movement instead of restraint - Let go after a few seconds - Avoid pain! - Use reflexes

59 Metod: Deescalation Affect intensity Affect trigger Chaos No control Self control Tid

60 Low Arousal Approach Stay calm Wait Clean up the mess Divert onwards

61 Metod: Calm again Affect intensity Affect trigger Chaos No control Self control Tid

62 Calm again Evaluate

63 Tools The basic rule: 1. Manage best you can without escalating the situation 2.Evaluate 3. Change what needs to be changed so that it doesn't happen again

64 Calm phase Affect intensity Affect trigger - What were happening just before the crises? - What did we expect the child to be able to? - Did the child fail to live up to our expectations Chaos because of a lack of supporting structures? No control - Did our behaviour trigger Self the control crises? - How can we make sure it won't happen again?

65 Escalation phase Affect intensity - What strategies did the child use? - Were they OK? - Did the child have any chances of calming down on his own? - Did we cause the escalation by using strategies that were counter Chaos productive? - Did we raise the demand level? - Did Affect we trigger use deescalation strategies? - How was our body language and use of voice? - Did we use diversions in order to deescalate? No control Self control

66 Chaos phase Affect intensity - Was there immediate danger? - If there was: - If there Affect trigger wasn't: Chaos - Did we manage the situation without escalating it further? - Were we able to resist intervening? - Was our behaviour shortening or prolonging the crises? No control Self control

67 Deescalation phase Affect intensity - Did we manage to secure calm and space enough for the child to calm Chaos down? Affect trigger - Or did we make the situation escalate once again? No control Self control

68 Calm again Affect intensity - Evaluating which structures and routines that need changing in order Chaos to avoid a next time Affect trigger - Do we have an action plan for the next time it happens anyway? No control Self control

69 Register behaviour Use colours - Red = severe challenging behaviour - Yellow = challenging behaviour - Green = ok A little red, som yellow and a lot of green is most efficient When there is no more red the yellow becomes red and we continue 7

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72 Stress assessment Uhrskov & Hejlskov Elvén 2007 Chaos Injustice The wrong food Not knowing what's going to happen Warning signs Stress level Sensory overload Poor sleep

73 Stress assessment Uhrskov & Hejlskov Elvén 2007 Assess - Basic stress factors - Warning signs and coping strategies - Chaos signs Qualify the stress factors - Which ones can we take away? - Which ones do we want to take away? Use warning signs for navigation

74 The ALSUP Identify -Lacking skills -Unsolved problems Ross told you how to do that

75 Tools The basic rule: 1. Manage best you can without escalating the situation 2. Evaluate 3.Change what needs to be changed so that it doesn't happen again

76 Method: Calm Affect intensity Affect trigger Chaos No control Self control Time

77 Tools Demands - We compensate for the lack of ability to know what's good for oneself - We use demands in order to - Avoid danger - Secure care - Enhance autonomy But we have to accept responsibility for the demands

78 Adjustment of Demands Refusing is a solution Everybody is entitled to say no! Our responsibility is to make sure the person says yes! - Comprehensible structures - Physical

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81 Adjustment of Demands Refusing is a solution Everybody is entitled to say no! Our responsibility is to make sure the person says yes! - Structures that makes sense - Physical - Rules - In time - Compensates for low ability to predict

82 Adjustment of Demands On top of that we can facilitate short term sense - Sense of participation - Choices - Experience of an us - Validating - Future - Preparation time - Getting ready - Snoozing

83 Adjustment of Demands Further short term comprehension tricks - Prompts and cues - Creating general view - Creating reasons - A sense of having finished - Bribes - Motivating acts

84 Method: Escalation Affect intensity Affect trigger Chaos No control Self control Time

85 Diversion Straight diversions - Talking about the service user's interests - Questions - Look! Affective diversions - Humor - Change of staff - Safe and well known activity Perceptual diversions

86 Action plans A good plan has five levels 1. Create space and time for the child's own strategies 2. Use a documented effective diversion - concrete 3. Use a documented effective diversion - affective 4. Use a documented effective diversion - affective or perceptual 5. Abort - everybody leave or a low arousal physical intervention

87 Never force Never abandon Petra Björne

88 Low arousal and self control - Concepts in the management of challenging behaviour Bo Hejlskov Elvén Clinical psychologist