Functional Behavior Assessment - James Siphaengphet - 2024 PDF

**Functional Behavior Assessment (Concise)** **Community Based Services** **Individual's Name:** James Siphaengphet **Date of Report:** **10/14/2024** ------------------------------------------- --------------------------------------------------------------------- **Date of Birth 5/16/1996...

**Functional Behavior Assessment (Concise)** **Community Based Services** **Individual's Name:** James Siphaengphet **Date of Report:** **10/14/2024** ------------------------------------------- --------------------------------------------------------------------- **Date of Birth 5/16/1996:** **Person Completing Report:** Mekala Gnau SDS, Amanda Napierala SDS **Medical Record \#:** 90092 **[Purpose of the Report:]** The FBA process and this report serve to help residential staff understand the functions of James\' challenging behaviors for the purposes of writing positive and supportive programming for intervention of challenging behavior. A Functional Behavior Assessment is a systematic method for observing and assessing the purposes a behavior serves for an individual. Recommendations serve to help develop programming that can use this information to increase quality of life and reduce the need for restrictive procedures and rights restrictions. **[Sources of information:]** \* Restraint & Seclusion Forms from FMHP St. Peter from 1/1/2020 to date of writing\* Behavior Timeline from FMHP St. Peter from 7/1/2021 to date of writing\* MN DHS DCT Inpatient History and Physical 5/20/2021\* MN DHS SOS Psychiatric Assessment 9/14/2017\* MN DHS SOS Psychological Assessment 10/12/2017\* MN DHS SOS/Forensic Services Social Services Assessment Initial 10/12/2017\* Psychiatric Progress Notes 5/10/2021, 6/10/2021, 7/7/2021\* Observations\* Interviews and informal conversation with James **[Current Diagnostic Information:]** +-----------------------+-----------------------+-----------------------+ | **Diagnoses** | **Source of | **Date** | | | Information** | | +=======================+=======================+=======================+ | Autism Disorder, | DHS 3509 Inpatient | 5/20/20217/23/2024 | | Intermittent | History and Physical | | | Explosive Disorder, | - MN DHS DCT - FMHP | | | Moderate Intellectual | St. PeterDr. Bryan | | | Disability, | Carleton | | | Developmental | | | | Disorder of | | | | speech/language, | | | | Dysthymic disorder, | | | | Vitamin D deficiency, | | | | constipation, and | | | | urinary incontinence, | | | | brief psychotic | | | | disorder. | | | +-----------------------+-----------------------+-----------------------+ **[Current Medications:]** **Review of Medication Information provided by** [     ] **(medical professional preferred).** For the complete Nursing Consultation Report, please see:. **Medication** **Reason Prescribed** **Relevant Potential Side-Effects** ---------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Lexapro Anxiety -Behaviorally expressed by pacing, rocking, increased voice volume, decreased ability to engage in extended conversations or activities Decrease interest is SexInsomniaIncrease energyDecrease in appetite Clozaril Psychosis -Causing misinterpretations of other\'s motives and intentions which result in verbal confrontations and physical aggressions toward those James perceives to be lying to him, disrespecting him, or threatening him. Also mispercieving social boundaries and relationships resulting in increased liklihood of sexulaized language toward and contact with females in his vicinity.osis Neuroleptic Malignant syndrome- Symptoms include high fever, confusion, rigid muscles, variable blood pressure, sweating, and fast heart rate.Weight GainConstipation is very commonPolyuriaIncrease Drooling/ Saliva productionDecrease in White Blood Cell production Extrapyramidal Symptoms include; movement dysfunction such as dystonia (continuous spasms and muscle contractions), akathisia (may manifest as motor restlessness), parkinsonism characteristic symptoms such as rigidity, bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements). Depakote Mood Instability - Behaviorally expressed by extreme variability in voice volume and rate, verbal combativness, and verbal and physical sexual expressions: e.g. statements towards others of direct sexual intent or desire, describing preffered sexual partners, masturbating in inappropriate settings Increase appetiteWeight GainChills or temperature regulationIncrease Nose BleedsBlurry VisionChanging in waking and balance Risperidol Anxiety -Behaviorally expressed by pacing, rocking, increased voice volume, decreased ability to engage in extended conversations or activitie Neuroleptic Malignant syndrome- Symptoms include high fever, confusion, rigid muscles, variable blood pressure, sweating, and fast heart rate.Weight GainConstipation is very commonPolyuriaIncrease Drooling/ Saliva productionDecrease in White Blood Cell production Extrapyramidal Symptoms include; movement dysfunction such as dystonia (continuous spasms and muscle contractions), akathisia (may manifest as motor restlessness), parkinsonism characteristic symptoms such as rigidity, bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements). Lithobid Mood Instability -Behaviorally expressed by extreme variability in voice volume and rate, verbal combativness, and verbal and physical sexual expressions: e.g. statements towards others of direct sexual intent or desire, describing preffered sexual partners, masturbating in inappropriate settings. (In combination with Depakote) PolyuiraIncrease thirstDecrease in sodium levels- Symptoms include;Nausea and/or vomiting. Headache. Muscle weakness, spasms (twitching), or cramps. Low blood pressure. Dizziness when standing up. Low energy or fatigue. Loss of appetite. Restlessness or bad temper.Lithium toxicity- life threatening symptoms include; Mental status changes that can range from mild confusion to delirium.Uncontrolled shaking (tremors). Coordination and balance issues. Muscle twitches. Slurred speech. Overactive reflex responses.Uncontrolled eye movements. Hyperthermia. Seizures. Coma (severe cases). Valium Agitation-Anxiety -Adjunct as needed to anti-psychotic and mood stabilizing medications noted above. ConfusionDifficulty to breath/ respiratory depressionMuscle weaknessLack of coordination **Note:** Not all side effects may be reported. You should always consult a doctor or healthcare professional for medical advice. Some of the side effects that can occur may not need medical attention. **[Preferences and Dislikes:]** James has some high-interest areas including Connect 4, Power Rangers, Pokémon, Yu-Gi-Oh, Dragon Ball Z, and wrestling. He likes to watch football and TV shows like The Simpsons, My Wife and Kids, and Fear Factor. James reports that he likes to swim and play football or basketball for exercise. He also likes to do body-weight exercises using his exercise dice. James really likes spicy foods and cheese. His favorite cheese is \"super sharp cheddar\" with pepperjack coming in second. He reports that he has three rules for staff: Ask permission, don\'t tease about food or games, and respect my privacy. James reports that he likes when staff \"save your life\" and \"protect me if someone else is trying to get me or punch me.\"James likes rules and structure and wants staff to be consistent with rules and routines. He appreciates communication that is straightforward and that explains the reasons for decisions, changes, and/or makes social rules explicit. He also appreciates active listening (ex. eye contact, not multi-tasking, and responsive nods), and he expects to offer this respectful listening in return. James likes predictable processes when he doesn\'t follow rules or expectations. He indicates that he liked that at Bar None they had to go in their room and complete a reflection sheet when they engaged in behaviors that were against the expectations. James feels that when he does something he perceives to be \"bad\" that he should be \"punished\". Often, he will make statements like \"I didn't earn that, or I don't deserve this.\" James also reports that his family is very important to him, though he has really only had the opportunity to maintain a relationship with his brother, Sunny, while at FMHP. Sunny encourages James to do the right thing and when visiting him at Center City, Sunny will remind James of boundaries. He talks about his desire to see more family again, especially his grandmother. He also sometimes talks about his mother and aunts or uncles. James is Laotian and indicates that staying connected to his culture is important. He wants to be able to eat Laotian food again and attend Lao cultural events. He has talked about attending spiritual services both at church and at a Buddhist temple. It seems that James has not had much access to cultural and spiritual practices since childhood when he lived with his uncle and grandmother. James has three long-standing triggers/dislikes that appear to show when in a peaked state of mind but does not appear to be a trigger when James is at baseline. 1. Gang activity - things he perceives as gang talk or gang signs. This is also used to extend to the color blue (associated with Crip gangs), but the color blue does not appear to be a recent trigger for him. On occasion, he will want to ensure that \"gang activity\" continues to be against the rules and state that it is something that he still doesn\'t like or approve of. At times James will pull down his pants to be a \"gangster\". 2. The name \"John\" This is believed to be connected to his history of childhood sexual abuse. Historically, he has assaulted people because their name or part of their name was John (i.e., last name Johnson). In recent years, James seems to still have a heightened awareness when the name \"John\" is spoken, but he seems able to process through what he is hearing without reacting when at baseline. James may also leave the area/go to his room to \"let it out\" and calm himself down. James went into crisis at was seen at Riverside Hospital, a male nurse named John entered his space and James assaulted the nurse. James let staff know that it was because of his name. 3. The perception that a male is gay. It has been hypothesized that James associates his childhood sexual abuse and abusers with gay men, so when he perceives a male to be homosexual, he believes they present a threat of sexual abuse or assault. In recent years clear opportunities to observe whether or not this is a current trigger have not occurred or been documented.James dislikes feeling disrespected or made fun of. He also dislikes when others break the rules or don\'t stay consistent with the rules or expectations that they are supposed to keep him accountable to. James dislikes when he feels like people are not trying when playing a game with him or if he perceives they are letting him win. James may have a shorter temper or be more on edge when he has recently woken up and seems to need about an hour to be fully awake, especially if he has been sleeping in during the day. During this wake-up period, staff may experience him as less talkative. James feels it necessary that whoever starts something has to be the one to finish it. (opening and closing van door) **[Brief Summary:]** James previously lived at the Forensic Mental Health Program in St. Peter where he had been since September 13th, 2017. He had previously been in the same program from February 26, 2014 - February 6, 2017. James lived in a unit without other patients. Staff would enter his unit to wake him up or for other personal needs like help with gathering laundry, changing bedding, playing games with him or to talk to him. He was able to go to canteen if he woke up and took a shower before 11:00 am, if he completed his shower after 11:00am FMHP staff would go and get him one item from canteen. When he went to canteen, he would have some access to more staff and sometimes peers, though his canteen time was supposed to be at a time when few others were present. James was staffed 2:1 at FMHP. James transitioned to a home operated by MSOCS in Center City. Prior to transition, Staff from Center City had been engaged with rapport visits with James for more than two years. During these visits James would like to play games and chat with staff. James did well with the structure and predictability of the environment at FMHP. He was familiar with the rules and expectations. He particularly seems to enjoy and appreciate his relationships with staff, especially those who are willing to chat with him and play games with him. When James is calm and relaxed, he will: \* Chat and joke around with staff - Common jokes might be pretending to misremember someone\'s name or not recognize them without his glasses. - Chatting may start with talking about something he knows he has in common with you or something he remembers about you.\* Play games.\* Watch TV.\* Be flexible when there are changes, especially if he understands the reasons behind the changes. Make sure to use clear and concise language with James. \* Complete his hygiene and chores and follow his routine. **[Previous Report(s) Summary:]** Functional Behavioral Assessment Summary & Support Recommendations, Stuart Hazard, 11/20/2014 This FBA focused on the occurrence of physically aggressive behaviors which typically included punching, followed by kicking or spitting once a restraint was implemented. At the time the frequency varied widely from multiple times a day to less than monthly. Intensity was serious to severe. The duration of these behaviors could vary from less than minutes to up to an hour of struggling against a restraint. At this time James had been civilly committed as MI-D. The underlying causes of his physically aggressive behavior was hypothesized to serve multiple functions including: \* Relieving internal anxiety or agitation through physical exertion.\* Relieving a fear of victimization or abuse by establishing himself as a physical threat. \* Gain attention and/or remove attention from others.Recommendations included more isolated living situations where James is the primary focus of staff, a consistent schedule of vigorous physical activity and engagement in productive/vocational activities. It was also recommended that James receive programming to increase James\' ability to relieve sensations of threat or anxiety through replacement behaviors. It was recommended that James have direct influence in housing and staffing planning to relieve anxiety and conflict.       **[Describe Interfering Behaviors:]** VERBALLY AGGRESSIVE BEHAVIORExamples: \*Intensity 1: anytime James is yelling or swearing, and it is directed at someone or not\*Intensity 2: anytime James is yelling or swearing, and it is directed at staff or anytime James is making threats towards staff.\*\*James has had 29 occurrences since April 24th, 2024SEXUALLY INNAPROPRIATE BEHAVIORExamples: \*Intensity 1-: James is making sexual comments. Trapping staff in area of the home (not letting staff around the table). Making comments such as \"I\'m thinking about Asian girls or commented to staff: your married\" when he knows the marital status. James is making gestures og grabbing breast or genitals. James asks staff for a hug or asks staff if they want a massage.\*Intensity 2: James's attempts/grabs chest/genitals or threatens assault, attempts to expose, or exposes his genitals or is masturbating in the common area. James is brushing up against staff, James is trying to kiss staff\'s hands or tries to touch staffs face or rubs his leg on staff. \*\*James has had 77 instances of sexually inappropriate behavior since April 24th, 2024. PHYSICAL AGGRESSIONExamples: \* James throws an object or a game piece at staff, but staff can evade\*James attempts to assault staff, but staff can either block or evade the assault or James hits staff with an object and staff is unable to block or evade the assault.\*James appears to have 2 separate types of physical aggression. Information has been gathered to support that if James is not in crisis, his aggression level appears to be redirectable with minimal force with his punches. While in a stage of crisis, James appears faster, stronger, and forceful. James also will fight for longer duration of time while in crisis. \*\*James has had 17 occurrences since April 24th 2024, Implementation of EUMR occurred on 5/8, 5/11, 9/17, 9/23, 10/3\*\*James Needs loud/clear demand (stop, back up) first and the reminder of safe 3's (safe space, safe language, safe touch).Non-examples: \* Throwing an object that appeared to be aimed at an inanimate target and hitting staff inadvertently. MOOD INSTABILITYExamples:\*James states \"I am excited\", or it appears that his excitement/mood level is rising. James's volume increases or he starts to interrupt staff when they are trying to explain something. James starts to enter staff\'s space but can be redirected, comes into staff's personal space. James gets up and goes to his room, then comes out and immediately or shortly after repeatedly making comments such as: \"I'm thinking about Asian girls\" or commented to staff \"your husband loves you\", \"you\'re married\" when he knows the marital status.\*James states, \"I\'m excited\" and throws an object or hits the wall or goes to his room and \"lets it out\" by screaming. James continuously invades staff's personal space and needs to be redirected multiple times. James attempts to touch staff out of the excitement.\*\*James has had 115 occurrences since April 24th, 2024PROPERTY DESTRUCTIONExample:Any instance of throwing or tipping objects not meant to be thrown/tipped, breaking objects, or taking apart things that do not belong to him without permission. Example: James tips over the kitchen table. Non-example: James throws a Nintendo remote control to staff after staff asked for one.\*\* James has had 5 occurrences since April 24th, 2024.PSYCHOSISExample: Statements or actions that demonstrate contact is lost with external reality. Inappropriate behavior for situation, "blank stare," "flat affect," repetitive motions or statements, impulsive behavior/statements, delusional behavior/statements Ex: James begins to stare at staff without acknowledgement, James will not acknowledge staff's communication/ stops exchanging dialog, James makes comments repetitively about "Burnt Sierra Orange" Harley Davidson, James makes statements about non reality based topics and becomes agitated/ elevated when redirected about the accuracy (believing transforming motorcycles are real), or believes that staff are his girlfriend. Non example: James takes a moment to answer a question and stares at you.\*\* James has had 48 occurrences since June 2024AGITATIONExample: \*Displaying or expressing feeling of annoyance, restlessness, clenching fists, rubbing hands together, getting up and down constantly or feeling restless. Ex: \-\-\-\-- Non-example: James gets up frequently to check the time for canteen.\*\*James has had 66 occurrences since June 2024ANXIETYExample:Rubbing hands together, getting up and sitting back down constantly or acting/ expressing feeling restless, compulsive acts he cannot seem to control, impulsive acts, repetitive acts or statements needing redirection/ assurance, pacing paired with limited eye contact and/or "side-eye", slapping his stomach and or face. Ex: James states he does not feel safe/reminds staff that he is safe, looking for confirmation. James states "you don't believe me", after staff ask him a question. James touching staff or attempting to touch staff. Non-example: James gets up frequently to check the time for canteen.\*\*James has had 64 occurrences since June 2024Attempted ElopementExample:Anytime James attempt to leave the property or leave the fenced in backyard area without staff. Example: James is in the backyard and attempts to scale/ jump over the fence. Non-Example: James is in the backyard and looks over the fence.\*\*James has had 2 occurrences since April 24th, 2024. Implementation of EUMR occurred on 5/8, 5/11.SELF-INFLICTED INJURYExample:Self-Inflicted Injury: Anytime James inflicts injury upon himself. Example: James hits head on the wall or slaps himself. Non-Example: James is in a living area and stubs his toe.\*\*James has had 25 occurrences since April 24th, 2024 **[Context:]** James has Autism Spectrum Disorder, which is characterized by language processing needs, difficulty with theory of mind (making a guess about how someone else feels or thinks), rigid thinking - including attachment to rules and routine, repetitive speech or behavior patterns, and social skill needs. James is also labeled with a moderate intellectual disability and developmental disorder of speech/language. These needs combined with his ASD create a need for ample processing time. James\' vocabulary is small, but he will often ask for a different explanation if he doesn\'t understand something. James also has needs in the area of executive function - being able to break large tasks down into steps, understanding cause and effect, etc. James has a very black and white way of thinking and will needs guidance through changes and complications that may occur.James also has an extensive trauma history related to childhood experiences. His mother was diagnosed with Schizophrenia. Her previous and present treatment status are unknown. His father was reported to have substance abuse issues. When James was almost 8, he and his siblings were removed from his mother\'s custody in the years following his parents\' divorce due to physical assault, emotional assault, and neglect. James was in foster care for over a year before ending up in his uncle\'s custody. James has reported sexual abuse, but it is unclear who the perpetrators were or the frequency or scope of the sexual abuse during his childhood. It is believed that there were multiple occasions and multiple perpetrators including possibly his brother, other neighborhood children, an unknown man and woman at a park, and that his disdain for the name \"John\" and aversion to things he perceives as \"homosexual\" are related to his childhood sexual abuse history. James demonstrates traits typical of people with extensive trauma history including some degree of hyper-vigilance, testing relationships, trouble trusting others or allowing relationship repair, and potentially hypo-arousal/shut down.James also expresses developmentally appropriate and typical interest in sexual activity and experiences, though due to his struggles with understanding social rules and difficulty with impulse control, these interests may surface in atypical ways.Since James has spent an extended period at FMHP - St. Peter, he is accustomed to a very restrictive and rigid environment with highly predictable responses to his behavior. This long period of institutionalization has likely amplified some of the traits that also accompany his Autism and trauma background. Prior to November of 2023, James was in a unit alone where staff would monitor him through a pod. Physical interactions were limited to brief security searches every 15 minutes. James would play games with Center City staff through a medications window or a half door. Since November of 2023 James has had consistent staffing through FMHP. Center City staff as well as FMHP staff had been visiting with James in his common areas playing games, going on walks outdoors, and utilizing the gym. James is accustomed to having his behavior identified through a color system. James has identified that it is important for him to have a visual representation of the color associated with the behaviors that he is displaying (green, yellow, red). James has referred to the good power ranger as the color green and the bad power ranger as the color red. James has also identified that if he is starting to get \"too excited\" (loud, jumping, pacing) that staff will use hand gestures to slowly bring him back to baseline. Since coming to Center City in April 2024, James has continued to play games and utilize his backyard as well as watch his favorite shows with staff. James has a schedule that he follows and can earn Canteen bucks throughout the day for completing his daily tasks. James does well with praise and can handle 2 prompts at most at a time. Since his time at Center City, staff have learned many things about James and what works and does not work. James feels most safe in institutionalized setting and too many changes/demands will overload his system. James needs small changes, and they should occur over long periods of time. James can be manipulated very easily through seed planting and mirroring of staff. Staff need to be careful on how we are speaking with him and how we are passing off information to each other in front of him. He needs constant reassurance that he is safe, and that staff are watching him. James Feels when he does something wrong, he needs to be punished. James is caring and compassionate and notices if staff are not acting in typical fashion (pulling at pants, sniffling) James is not an accurate reporter and will not talk about the negatives that occur in his surroundings to people he upholds as \"high authority\". James does not like to have visits and will ask what the time frame is to completion of appt or visit. He will also check the clocks in his surroundings constantly during wakeful hours. **[Antecedent:]** Our data source for antecedents come from Restraint and Seclusion documentation from FMHP St. Peter rather than direct observation, so there is a variable amount of detail and information (range of dates from 1/1/2020 - 3/3/2023). Known antecedents for physical aggression seem to include:\* Belief that staff did not follow the rules or do their job correctly - ex. nurse did a \"bad mouth check.\"\* Frustration with staff, often the specific reason was not stated - ex. \"staff wouldn\'t let me watch Power Rangers.\"\* A perceived slight from someone who does not have frequent and extended contact with him - ex. getting his birthdate wrong\* A perception that someone has used gang-related language or hand gestures. \* High population density coupled with hyper-vigilance \*Falling out with brother \*Visually seeing something that he did not earnKnown antecedents for sexual touch seem to include: \* Perseveration on sexual thoughts\* A known \"crush\" or attraction toward a specific female\* Reporting of sexual thoughts or lots of sexual feelings\*Reading staff members shirts\*Staff too close-James is an opportunist and will reach for chest/genitals out of nowhere **[Consequences:]** Known or hypothesized consequences of physical aggression include:\* Being perceived as able to protect himself or as threatening as a protective factor against abuse or harm\* Receiving physical contact.\* Deep pressure/squeezing and limitations on movement with mechanical restraints \* Relief of built-up energy or anxiety through physical exertion. \* A sense of justice by providing a negative consequence for other\'s violation of the rules. \* Proving that by having the physical capacity to restrain him, staff would have the physical capacity to protect him if needed. \* Testing of attachment relationships by seeing how people will treat him after he does something aggressive. \* Establishing a feeling of control in and over his environment. Known or hypothesized consequences of sexual touch seem to include: \* Sexual gratification of touching private areas on others. \* Satisfaction of curiosity about sexual touch that may be inaccessible to James in other contexts. +-----------------+-----------------+-----------------+-----------------+ | **Context/Setti | **Antecedents** | **Behavior** | **Consequences* | | ng | | | * | | Events** | | | | +=================+=================+=================+=================+ | James is | Staff make a | James engages | James feels | | frustrated at | request or | in physical | relief from | | someone.James | enter his | aggression. | feelings of | | feels like | physical | | anger, a | | someone broke | space.James | | physical | | the rules or | sees that | | release, and | | did not treat | person | | receives | | him the right | again.James | | physical touch | | way.James is in | feels | | and deep | | a high | threatened by | | pressure/squeez | | population | one or more | | ing.James | | density | people in his | | feels a sense | | situation and | environment. | | of justice or | | is | | | that a | | hypervigilant. | | | punishment has | | | | | been served for | | | | | a | | | | | wrongdoing.Jame | | | | | s | | | | | gets | | | | | restrained.Jame | | | | | s | | | | | obtains status | | | | | as someone who | | | | | can protect | | | | | himself or | | | | | someone who is | | | | | dangerous. | +-----------------+-----------------+-----------------+-----------------+ | James is having | James sees | James engages | James gets to | | sexual thoughts | staff and has | in | experience | | or \"has a | the opportunity | non-consensual | sexual touch. | | crush\" on an | to engage in | sexual touch - | James | | individual.Jame | physical | grabs breasts, | experiences | | s | contact.James | grabs or hits | sexual | | is thinking | sees something | buttocks, grabs | gratification. | | about a real or | on TV or is | at groin, or | | | imagined | thinking about | attempts to | | | female. | something that | kiss.James | | | | arouses him. | masturbates in | | | | | common areas. | | +-----------------+-----------------+-----------------+-----------------+ **[Summary of Context, Antecedent, Behavior, and Consequences:]** **[Summary of Data:]** Due to James\' previous placement at FMHP - St. Peter, data for his target behaviors is limited. Much of the data received is on Restraint and Seclusion - Intervention Data forms. This includes information about what happened right before a restraint occurred but often lacks more complete contextual information. They also often lack detail regarding staff responses, so it is difficult to draw conclusions from this data. There were 21 Restraint and Seclusion forms reviewed dated from 1/1/2020. Only two (3/3/2023, 8/28/23) was from the previous year and 1 on 3/11/24 at the time of this writing. FMHP identified few successful interventions outside of manual and mechanical restraint. Talking to James to process or deescalate were documented as both successful and unsuccessful interventions depending on the occasion. Since there was not much information about what was said by staff, it was unclear whether the difference was the methods used by staff or the level of escalation James was already experiencing at the point verbal de-escalation was attempted. Once escalated, it appeared that verbal redirection was not successful. FMHP suggestions for future interventions mostly involved reducing staff contact with James and introducing barriers. In a couple of instances, there were suggestions to steer conversations away from a topic that is upsetting to James by using distraction or small talk. Since coming to Center City in April of 2024, James has had 8 manual restraints. Staff track data hourly every day to gather as much information as possible. James has had 25 occurrences of self-injurious behavior, 29 verbal aggressions, 77 sexually inappropriate behavior, 17 physically aggressive behaviors, 115 occurrences of mood instability, 64 occurrences of anxiety, 48 psychosis, 5 property destruction, 66 occurrences of agitation, 2 attempts at elopement, 25 occurrences of self-injurious behavior. This data was collected daily, several of these occurrences happened several hours of the day. **[Changes in Identified Context, Antecedent, Behavior and Consequences:]** Since James\' previous FBA (2014), he had been housed in more isolated units at FMHP. He was first moved to a dual unit where the staff pod was between two units. He did not have contact with the patient on the other side, but he could see and hear the patient at times. Most recently he had been housed in a unit with staff who are scheduled only to him. In this unit, he may see other patients and staff walking by in a main hallway. James had the opportunity to go to canteen and would typically go 2-3 times a week. His canteen time was supposed to be when other units are not there, but he does typically see a few staff or patients as he travels to and from canteen. During his time being housed by himself in a unit, James\' assaultive and aggressive behavior had drastically reduced, and his long-time major triggers of the name \"John\" and the color blue seem to have reduced in intensity and become mostly a non-issue. His previous FBA notes that mechanical restraint was \"virtually gone from his experience now.\" However, mechanical restraints were used in every restraint since January 1, 2020. James is no longer on a level system related to behavior, but he is asked if he is \"feeling safe\" before going into the general population of the hospital or to "contract for safety\" which means to communicate that he is not having thoughts about doing unsafe things before being released from mechanical restraints. Since coming to Center City, James has staffing in his space constantly, he has access to van rides and a daily option to go to the park. James has had 8 EUMRs since April 2024. James continued to struggle with feelings of being safe. His big triggers have only recently become a problem (during crisis). James is on a color system, per his request and he does have option to have canteen twice daily. It has been observed while in crisis that James seeks out reassurance for his level of safety and level of trust that staff have in James and James has in staff. This can look like James bringing his hand to the floor and telling staff \"this is how much you trust me\", in a way to look for reassurance on trust. **[Current and Previous Interventions and their Effectiveness:]** +-----------------------+-----------------------+-----------------------+ | **Successful Support | | | | Strategies** | | | +=======================+=======================+=======================+ | **Strategy** | **When to Use** | **Why It Works** | +-----------------------+-----------------------+-----------------------+ | Process with James - | When James is still | James sometimes finds | | validating his | able to process | it helpful to talk to | | feelings connected to | verbally why he is | staff about what is | | his perception of the | upset.When James may | bothering | | situation.It may help | be upset at one staff | him.Processing while | | to process while | but still talking to | walking can help to | | walking at times. | others.When | cue the brain that it | | | processing seems to | is safely moving | | | be keeping James at | through a threatening | | | the same or a | situation. | | | decreasing level of | | | | agitation (not if it | | | | escalates him). | | +-----------------------+-----------------------+-----------------------+ | Use coping skills | When James is | Large muscle | | that engage large | agitated and moving | movements to help | | muscle groups like | around - maybe | release anxiety and | | commando crawls, wall | hitting or kicking | agitation for James. | | push-ups, jumping | inanimate | | | jacks, or use of | objects.When James is | | | TheraBand\'s. | pacing or becoming | | | | agitated. | | +-----------------------+-----------------------+-----------------------+ | Use coping skills | When James is excited | This strategy will | | that involve | or somewhat agitated. | help to meet James\' | | decreases in | When James is able to | sensory needs and | | movement, or breaks | say or positively | regulate his nervous | | from typical | receive cues to | system to avoid | | interactions - taking | \"take a break\" or | further escalation. | | time away from staff | \"let\'s take some | They also help James | | in his room, yoga, | deep breaths\" | make an environmental | | exercise, taking deep | without escalating | change that can help | | breaths, etc. | further. When James | support his | | | has expressed sexual | inhibition of | | | desires or thoughts | impulses and boost | | | towards someone in | his impulse control. | | | the environment. | | +-----------------------+-----------------------+-----------------------+ | Talking with James | When James has come | This strategy work | | about a behavior | back to baseline and | best to demonstrate | | immediately after the | is able to process | the importance of | | behavior was | feedback. | safe behavior. If you | | displayed as long as | | wait too long to talk | | he is back to | | with James, he is | | baseline. | | likely to forget | | | | details, and not | | | | acknowledge what had | | | | happened as an | | | | important event. | +-----------------------+-----------------------+-----------------------+ |       |       |       | +-----------------------+-----------------------+-----------------------+ **Unsuccessful Support Strategies** ---------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Strategy** **What it was for** **Why It Did Not/Does Not Work** Process with James - asking about what has made him upset or attempts to process poor choices while he is still escalated. Attempts to communicate what he has done wrong or offer opportunities to process to deescalate. Processing with James when he is requesting or demanding silence and space will not work because he is cognitively less able to process language well when highly escalated and is not yet ready to reflect on mistakes. Punitive consequences/loss of privilege, especially in the absence of addressing root causes. Providing a deterrent for unwanted behaviors. James often understands the connection between behavior and consequences but may feel it necessary to engage in unwanted behaviors to meet his basic need for feeling safe in his environment regardless of the consequences. Or he may feel like the payoff of an unwanted behavior like sexual touch is worth the consequence he knows will follow.                                     **[Hypothesis Statement:]** When James is frustrated or having a disagreement with someone and they enter his physical space, James engages in physical aggression resulting in relief from feelings of anger, experiences physical release and receives physical touch. When James feels like someone broke the rules or mistreated him and James sees that staff again, James engages in physical aggression resulting in a sense of justice or that a punishment has been served for a wrongdoing. When James is having sexual thoughts or \"has a crush\" on someone, James engages in non-consensual sexual touch resulting in James getting to experience sexual touch. **[Support Recommendations:]** Staff should maintain consistency with rules and protocols, so James\' environment is predictable.If staff are unable to be consistent or there must be an exception to the rule, staff will explain why things are different this time and seek James\' feedback and consensus with that change. Staff should communicate with James using non-judgmental language and a matter of fact, nonjudgmental tone.Use social stories to build flexible thinking skills and reduce feelings of personal responsibility for executing justice. Reference and use familiar language from social stories for redirection and support skill building. Staff should disengage from power struggles when it is safe to do so or use distraction to preferred topics and activities if possible. Staff should ask James if he needs to use any of his coping skills as early in the escalation cycle as possible, including an offer of a PRN following the PRN protocols when appropriate. Staff should give James physical space when agitated. If behavior is escalating with lots of verbal interaction from staff or if James is demonstrating a desire for quiet or less interaction, staff should reduce language to short directives and only what needs to be said to maintain safety. **[Limitations:] Absolute predictions about human behavior are not possible. Limitations of this report include:** This FBA was originally written while James was still being housed in a separate unit at FMHP - St. Peter. Information and data were taken from reports provided by FMHP. Some reports included more detailed context and antecedents than others. Center City staff were able to identify important facts from James. James is accustomed to having his behavior identified through a color system. James has identified that it is important for him to have a visual representation of the color associated with the behaviors that he is displaying (green, yellow, red). James has referred to the good power ranger as the color green and the bad power ranger as the color red. James has also identified that if he is starting to get \"too excited\" (loud, jumping, pacing) that staff will use hand gestures to slowly bring him back to baseline. Since James moved to Center City, information has been gathered and updated on FBA from the dates of April 24th, 2024 through 10/15/2024. **[Advisory Statement and Follow up Considerations]** *This report was written by Minnesota Department of Human Services (MN DHS) personnel and represents a work product of Direct Care and Treatment (DCT).* - This information is supplemental and is not a substitute for consultation and treatment by other health care providers. - Significant changes in the individual's physical or mental health require reassessment by the appropriate specialist. - Materials and recommendations must be examined frequently by the individual's supports to make sure it is current best practice. - Materials and r*ecommendations are intended to support positive practices and to have only positive effects.  Stop using the recommendations and re-contact the authors if things are getting worse.* - Using this material for the individual it was developed for is best. Using the information for others may not be appropriate or work as well. - Unless otherwise stated, it is acceptable to copy this material for use within an individual's support network. - The authors have no conflict of interest related to this report. Thank you for the opportunity to consult with       and       support team. *Please contact the authors if there are additional questions or concerns. T*he team is invited to remain in contact with the author in support of further planning, techniques for measuring and evaluating progress, and revision as       needs evolve. [ ] **[10/14/2024]** Author\'s Name, credentials Mekala Gnau, Amanda Napierala Title: SDS Agency: MSOCS Address: 35226 Park Trail Center City MN 55012Phone Number: 651-257-0103 Email: amanda.n.napierala\@state.mn.us, Mekala.gnau\@state.mn.us [**References**:]