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"THEY KICKED ME & RAN OUT! WHAT DO I DO NOW?"

An Examination of Crisis Prevention & Intervention Alternatives

LISTEN TO DR. CRYSTAL LAURA

WONDER, WORRY, QUESTION

A CASE STUDY

A CASE STUDY

  • 10 yr old 4th grade student
  • Transferred into a therapeutic school from an ICT classroom
  • Diagnosed with ADHD, MMDD, ODD at the time of enrollment
  • Elopes when frustrated
  • When unable to elope or when prevented from leaving a space, will yell, throw objects, knock over furniture and sometimes lash out physically at adults and other students

SO...

... WHAT NOW?

How do we support this student through a challenging moment?

SO, WHAT ARE MY OPTIONS?

RETURNING TO DR. LAURA

WHAT ARE MY OPTIONS?

Common Systems

TCI & NCI

  • include a system of physical restraint to be used as a last resort “If a child cannot control their rage, frustration and anger, and they are in danger of injuring themselves or others, safe and therapeutic physical management techniques are taught to ensure that child’s acting out is contained and later used as an opportunity for learning, growth and discovery.” (Nunno, Holden & Leidy, 2003, p. 296)
  • designed to reduced the need for restraint
  • components: general information, crisis antecedents and descalation, restraint procedures, restraint monitoring, debriefing and follow up (Couvillon et al, 2010, p. 10)

TCI & NCI

TCI

NCI

  • created by the Crisis Prevention Institute
  • used by healthcare, education, human services, security, behavioral health and dementia care professionals
  • basic training takes 12 hours
  • school program marketed as "designed to develop resilient educators"
  • "a highly structured training program to increase child and youth care staff skills to respond to the both feeling and behavior of children when they are upset, in criris or at their most destructive" (Nunno, Holden & Leidy, 2003, p. 296)
  • created by a team at Cornell in the 80s for use in residential childcare facilities (Nunno, Holden & Leidy, 2003, p. 296)
  • uses the Life-Space Interview format in de-escalation
  • basic training takes 28 hours (Couvillon et al, 2010, p. 10)

What it's like

Standing

(sometimes called a "basket hold")

Seated

Prone

RE-IMAGINING INTERVENTION

RE-IMAGINING INTERVENTION:

CPS, PROJECT LETS, SOLHOT

THE COLLABORATIVE PROBLEM SOLVING METHOD

PLAN A

"when adults pursue their original expectation by imposing their will upon the child, despite understanding that doing so may trigger externalizing behavior." (Pollastri et al, 2013, p. 190)

PLAN C

CPS

  • alternate method for managing externalizing behaviors such as physical aggression INSTEAD OF restrictive interventions like restraints
  • meant to prevent dangerous behaviors
  • focused on identifying and teaching behavioral and self-regulation skills
  • philosophically "contrary to the belief that 'children do well if they want to'—which underlies most behavioral approaches and also corresponding interventions that focus on increasing motivation—the philosophy of CPS is that 'children do well if they can.'" (Pollastri et al, 2013, p. 190)
  • preliminary research shows signigiant positive impact in schools

"when the adult chooses to withdraw the

expectation, at least for a short time, in order to decrease externalizing behavior... useful in stabalizing the situation... a preemptive strategy, communicated ahead of time to the child and should not be confused with “giving in...” (Pollastri et al, 2013, p. 190)

PLAN B

"...used when the adult attempts to solve the problem collaboratively with the child...successfully completed when both adult and child have agreed on a mutually satisfactory and realistic solution. ” (Pollastri et al, 2013, p. 190-191)

STEP 1

STEP 2

"...the adult gathers information in order to gain a clear under-

standing of the child’s concerns about a particular recurring problem or issue (e.g., “I don’t like stopping free time when I’m in the middle of reading, because it’s hard for me to find my place again later.”)” (Pollastri et al, 2013, p. 190)

STEP 3

"the adult states his or her concern or perspective (“My concern is that we need to move on to math at that time. I don’t want you to miss out on the beginning of math, because it will be hard to catch up later.")” (Pollastri et al, 2013, p. 190)

PLAN B PROCESS

"adult and child brainstorm solutions that will address both their concerns. The child is given the first opportunity to generate a solution (e.g., “What if you warn me when we have a few minutes left, so I can find a good stopping point?”). No solutions are dismissed outright, and the adult helps the child to think through whether each solution addresses the concerns of both parties and whether it is realistic and feasible." (Pollastri et al, 2013, p. 191)

SAVING OUR LIVES HEAR OUR TRUTHS

SOLHOT is...

"the force that says Black girlhood is to be celebrated in all of its complexities and while the center of this work is face to face time organizing with Black girls" (Brown, n.d.-b, para. 1)

SOLHOT

"you can do SOLHOT when you, smack your lips, give freely, take whats yours , rap and write , make a friend and go together ; when you dream , set goals , take control , think critically , put yourself out there , and speak up for yourself ; when you’re loud , quiet , taking care ; and DEFINITELY when you tell your own truth." (Brown, n.d.-b, para. 3)

"where we meet physically face to face, heart to heart, and hand to hand, to discuss issues that are important to us and strategize together on ways we can make this world better for everyone" (Brown, n.d.-b, para. 2)

"You do SOLHOT when you love Black girls and care so much about us, you are transformed." (Brown, n.d.-b, para. 6)

THE PROJECT LETS PHMA MODEL

PROJECT LETS

  • 6-week training program the covers relationship building, trauma-informed care and crisis response amongst other topics
  • not therapists or replacements for professionals advocates to support people navigating the system
  • based in the social model of disability
  • a system for providing a peer support network
  • collaborative advocacy rather than survaillance and management

DOES THAT WORK?

DOES THAT WORK?

Evidence Documenting Impact

WHAT WE KNOW

WHAT WE KNOW

"TCI-S currently being applied internationally in schools and is gathering an evidence base for demonstrating improvements across student mental health, academic engagement and the prevalence of critical incidents." (Rodgers & Hassan, 2021, p. 3)

"Initial evaluation of the program reported that in the midst of a public campaign to reporting child abuse in residential care, signigfigant decreases in child abuse reports occured in those facilities that implemented TCI. On the other hand, signigiant increases occured in those comparision facilities that did not implement TCI." (Nunno, Holden & Leidy, 2003, p. 312)

"After the implementation of TCI-S, school staff at WCS noted that they experienced more job satisfaction and that more students remained in the school program rather than being suspended for challenging behaviour. 'When teachers could repair relationships with students before the end of the day, they reported a significant positive impact on the following day’s events' as quoted by a residential teacher as noted in the WCS interview notes of the visit." (Rodgers & Hassan, 2021, p. 5)

THE GOOD

THE GOOD

“If a child cannot control their rage, frustration and anger, and they are in danger of injuring themselves or others, safe and therapeutic physical management techniques are taught to ensure that child’s acting out is contained and later used as an opportunity for learning, growth and discovery.” (Nunno, Holden & Leidy, 2003, p. 296)

"Direct care staff increased and retainted their crisis intervention knowledge and techniques. Staff reported that their confidence working with colleagues increased and overall there was a more consistent approach to children in crisis across units and among staff shifts within units" (Nunno, Holden & Leidy, 2003, p. 312)

“Black children constitute about 17% of all students enrolled in school, but they account for 33% of those identified as cognitively disabled. Black children are nearly twice as likely to be labelled ‘learning disabled’ as White students, almost twice as likely to be labeled ‘emotionally disturbed’... Students labelled ED or MR have the lowest graduation rates and the highest drop out rates. More than half of all Black students with emotional and behavioral problems who do not finish high school are arrested within 3 to 5 years of dropping out” (Laura, 2014, p. 20)

"Across critical incident studies, quality surveys, and meta-analyses, seclusion and restraint are widely documented as inequitably administered to men or to people who are Black, unemployed, or homeless or who have been previously hospitalized and had longer hospital stays. Among women, Black women and those with prior interactions with police are more likely to experience involuntary interventions. These patterns persist in children’s inpatient psychiatry settings, where younger age and Black race are associated with seclusion, and in emergency departments, where Black patients are more likely than White patients to be restrained.” (Bhattacharyya et al, 2021, p. 341)

"Authors... advocate for the implementation of strict guidelines about its use, the possible indications and close monitoring during SRU. Most of these authors agree that in daily clinical practice, such guidelines are not in place” (de Hert et al, 2011, p. 229)

THE BAD, THE UGLY

THE BAD, THE UGLY

"Between 1993 and 2003, there were 45 seclusion and estraint related fatalities in child and adolescent residential units in the United States, 7 of which were related to seclusions [9]. Additionally, their use can be re-traumatizing for children who have been victims of violence in the past." (Vidal et al, 2020, p. 648)

“Participants reported that physical restraint evoked an experience of loneliness (77.5%), humiliation (78.5%), and loss of autonomy (82.5%).” (Spinzy et al, 2018, p. 694)

“Most of the participants regarded physical restraint as the most aversive experience of their hospitalization and strongly objected to its overuse (a mean of 3.3 out of 5). Participants complained about the over-use of physical restraints (a mean of 2.87 out of 5) more than about their under-use (a mean of 1.97 out of 5).” (Spinzy et al, 2018, p. 694)

“…reports indicate that students with disabilities are the most likely to be restrained (75%) or placed in seclusion (58%)” (Trader et al, 2017, p. 77)

"...there is growing evidence that restraint and seclusion procedures may actually heighten aggressive behavior in children." (Pollastri et al, 2013, p. 188)

ANOTHER WORD FROM DR. LAURA

ANOTHER WORD FROM DR. LAURA

What's the long term psychological impact of restraint on kids?

How does experiencing physical restraint in school impact a student's ability to learn?

Is there any coorelation between being restrained in school & later dropping out? being incarcerated?

WHAT WE DON'T KNOW

WHAT WE DON'T

Are restraints always being applied correctly & as a true last resort?

How often are students of color unnecessarily restrained?

How often restraints actually being used in schools?

AN ALTERNATE CASE STUDY

CHOICES, CHOICES

RETURNING TO OUR CASE STUDY WITH NEW EYES

CHOICES, CHOICES

  • 10 yr old 4th grade student
  • Transferred into a therapeutic school from an ICT classroom
  • History of traumatic educational experiences including detainment and restraint by armed police officers
  • Challenging relationships with both parents especially father
  • Interested in fashion, avid reader, loves music (especially Cardi B)
  • Close relationship with younger sister
  • Struggles with low self-esteem and negative body image
  • Triggered by feelings of “failure” including answering questions incorrectly and art projects that don’t align with original vision
  • Responds well to deep pressure, visual schedules, reduction of sensory input and clear expectations
  • Struggles with peer social communication and frustration tolerance

REFERENCES

REFERENCES

Bhattacharyya, S. Breslow, A. S., Carrasco, J. & Cook, B. (2021) When Structural Inequity Is Ubiquitous, Can Force Ever Be Compassionate? AMA J Ethics. 2021;23(4):E340-348. doi: 10.1001/amajethics.2021.340.

Brown, R. N. (n.d.-a). SOLHOT. Ruthnicolebrown. Retrieved May 7, 2022, from https://www.ruthnicolebrown.com/solhot

Brown, R. N. (n.d.-b). What is solhot? SOLHOT. Retrieved May 7, 2022, from https://www.solhot.com/what-is-solhot

Couvillon, M., Peterson, R. L., Ryan, J. B., Scheuermann, B., & Stegall, J. (2010). A review of crisis intervention training programs for schools. TEACHING Exceptional Children, 42(5), 6–17. https://doi.org/10.1177/004005991004200501

Crisis Prevention Institute Inc. (n.d.). About Us. Crisis Prevention Institute. Retrieved May 4, 2022, from https://www.crisisprevention.com/About-Us

de Hert, M., Dirix, N., Demunter, H., & Correll, C. U. (2011). Prevalence and correlates of seclusion and restraint use in children and adolescents: A systematic review. European Child & Adolescent Psychiatry, 20(5), 221–230. https://doi.org/10.1007/s00787-011-0160-x

Doughty, J., & Houglet, R. (2021, April 2). DISABILITY JUSTICE AND THE PROJECT OF ABOLITION How crisis responses can and must center community. The indy. Retrieved March 3, 2022, from https://www.theindy.org/article/2340

Greene, R. W. (2014). Lost at school: Why our kids with behavioral challenges are falling through the cracks and how we can help them (1st ed.). Scribner Book Company.

Kaufman, S. [TEDx Talks]. (2017, December 15). Hearing our voices: Peer support and mental illness | Stefanie Kaufman | TEDxBrownU [Video]. YouTube. https://www.youtube.com/watch?v=bd797eF62k8

Kluth, P. (2003). You’re Going to Love This Kid!: Teaching Students With Autism in the Inclusive Classroom (1st ed.). Paul H Brookes Pub Co.

Laura, C. [EHE Distance Education and Learning Design]. (2016, February 22). Dr. Crystal Laura presentation [Video]. YouTube. https://www.youtube.com/watch?v=kc8BnKoxvL8

Laura, C. T., Ayers, W., Quinn, T., & Meiners, E. R. (2014). Being Bad: My Baby Brother and the School-to-Prison Pipeline (The Teaching for Social Justice Series). Teachers College Press.

Left of Black [John Hope Franklin Center at Duke University]. (2014, April 28). Left of Black with Ruth Nicole Brown [Video]. YouTube. https://www.youtube.com/watch?v=wzCJWEIDyzY&t=661s

Nunno, M. A., Holden, M. J., & Leidy, B. (2003). Evaluating and monitoring the impact of a crisis intervention system on a residential child care facility. Children and Youth Services Review, 25(4), 295–315. https://doi.org/10.1016/s0190-7409(03)00013-6

Pollastri, A. R., Epstein, L. D., Heath, G. H., & Ablon, J. S. (2013). The collaborative problem solving approach: Outcomes across settings. Harvard Review of Psychiatry, 21(4), 188–199. https://doi.org/10.1097/HRP.0b013e3182961017

Rodgers, S., & Hassan, S. (2021). Therapeutic crisis intervention in schools (TCI-S): An international exploration of a therapeutic framework to reduce critical incidents and improve teacher and student emotional competence in schools. Journal of Psychologists and Counsellors in Schools, 31(2), 238–245. https://doi.org/10.1017/jgc.2021.2

Spinzy, Y., Maree, S., Segev, A., & Cohen-Rappaport, G. (2018). Listening to the patient perspective: Psychiatric inpatients’ attitudes towards physical restraint. Psychiatric Quarterly, 89(3), 691–696. https://doi.org/10.1007/s11126-018-9565-8

The Residential Child Care Project at the Bronfenbrenner Center Transitional Research. (n.d.). Therapeutic Crisis Intervention Overview. Cornell University. Retrieved May 4, 2022, from https://rccp.cornell.edu/TCI_LevelOne.html

Trader, B., Stonemeier, J., Berg, T., Knowles, C., Massar, M., Monzalve, M., Pinkelman, S., Nese, R., Ruppert, T., & Horner, R. (2017). Promoting Inclusion Through Evidence-Based Alternatives to Restraint and Seclusion. Research and Practice for Persons with Severe Disabilities, 42(2), 75–88. https://doi.org/10.1177/1540796917698830

Westling, D. L., Trader, B. R., Smith, C. A., & Marshall, D. S. (2010). Use of Restraints, Seclusion, and Aversive Procedures on Students with Disabilities. Research and Practice for Persons with Severe Disabilities, 35(3–4), 116–127. https://doi.org/10.2511/rpsd.35.3-4.116

Zaccaro, D. E. (2014, May). Unregulated, untrained, and unaware: Restraint and seclusion practices in educational settings (Thesis). University of Northern Iowa.

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