Build on Strengths He 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 Simple Reassign 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 Supports Provide reassurance of safety by preferred staff. Give him maximum control of what he can control. Fears. Empower him as much as possible. Behavior Plan Set 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 ½ 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 Plan Treat 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. Therapies Psychotherapy 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 Consult No changes seem to be indicated. Everyone who supports Sam seems to be on the same page about his care.
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) Hypotheses How to check it out. Map of system Make a map and look for conflicts Relief 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 sick He's caught the flu from his mom or from his regular staff. Constipation (just because it often is.) Medical check up. Track bowel movements Medication: None indicated Environmental -He says wheelchair stinks -Mom is sick and Dad died 1 yr ago after being sick -Relief worker is taking care of him The 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 Cause He 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 Abuse Unlikely since he’s in constant care – unless someone is giving him something Ask him. Abuse and Neglect Unlikely but it’s always important to consider it. Ask him. Observe how the relief staff is handling his care.