Severe Behavior and Crisis Planning

Some individuals with intellectual and developmental disabilities may engage in severe behavior, such as aggression, self-injurious behavior, or property destruction. Severe behaviors may sometimes present occasionally and at a mild intensity that is safe to manage. In other cases, severe behaviors may present frequently and at a high intensity, resulting in immediate risk of injury to the individual and others (e.g., closed-fist hits to self or others, severe headbanging). When individuals engage in severe behaviors at a high intensity and frequency for an extended period of time, it may sometimes lead to a crisis. Behavioral crises, whether they occur daily, weekly, or less frequently, are challenging for everyone involved.

What is considered a behavioral crisis?

A behavioral crisis may look different across individuals and environments. In general, a behavioral crisis is when an episode of severe behavior cannot be quickly de-escalated and places an individual themself or others at immediate risk of severe harm.

Behavioral crises can sometimes be predictable but may also occur spontaneously. For example, they may occur during unplanned or unexpected changes in the environment or uncommon emergencies (e.g., fire, severe weather). It is important to plan for both predictable and unpredictable behavioral crises.

What is behavioral crisis planning?

Behavioral crisis planning involves proactively preparing a plan and resources for the possibility of future behavioral crises. Developing a behavioral crisis plan can allow caregivers to prevent and respond to behavioral crises in the most appropriate and effective way possible.

Why should one have a behavioral crisis plan in place?

Similar to how we regularly check our smoke detectors and review fire safety with children, it is important to prepare for and attempt to prevent behavioral crises. Having a behavioral crisis plan in place can help to ensure that everyone involved in a potential crisis responds in the most appropriate and effective way possible.

How is a behavioral crisis plan made?

We suggest that caregivers collaborate as much as possible when developing a behavioral crisis plan. For example, it is best to involve as many family members as possible in the planning. It is also often beneficial to incorporate the child’s providers as well (e.g., BCBA). Collaboration helps to make sure that you do not forget any important components of the plan and allows everyone who may be impacted by the crisis to have a voice in the development of the steps to a plan.

What does a behavioral crisis plan look like?

It can look different for each family! You want to make the plan in a way that you will find it accessible and easy to use. It may be in the form of a checklist or a list of steps. It could be an electronic, printed or handwritten document.

What are some important components of a behavioral crisis plan?

There are a few categories of information that you should consider incorporating into a behavioral crisis plan. The exact components and content of the plan will depend on you and your child’s unique situation and preferences. In general, here are a few recommended components:

General Information: You will want to provide some important general information that someone (e.g., family member, first responder) might need during a behavioral crisis. For example, you might consider including some of the following:

Name
Date of birth
Emergency contact information
Diagnoses
Description of severe behaviors
Description of how your child communicates (e.g., one-word phrases, AAC device)
Primary medical doctor
Preferred hospital
Allergies

Prevention Techniques: It is critical to focus on prevention techniques that can decrease the likelihood of a behavioral crisis occurring. This section will be more useful for your family in preparing for and avoiding behavioral crises than during an active behavioral crisis. Your child’s providers (e.g., BCBA) may be able to help collaborate with items in this section. A few items to consider include:

A list of some of your child’s favorite items and when someone should give them those items.
- For example, you might want to make sure they have access to something they really enjoy during difficult transitions or scenarios.
A list of any items that help your child in difficult transitions or scenarios and when caregivers should make sure they have those with them.
- For example, noise-canceling headphones when going into a loud store.
A list of ways to modify difficult transitions or scenarios to make them less challenging for your child.
- For example, they may prefer seeing a caregiver getting their ears and throat checked during a well-child visit before they let a doctor approach them.
A list of skills to teach that can replace severe behavior.
- For example, working on coping skills or waiting and finding something else to do when a favorite item is not working or unavailable.
A list of scenarios to break down into small steps, practice, and slowly build tolerance during. If there are situations in which you frequently anticipate a behavioral crisis, you can work on slowly teaching them skills to use in those situations.
- For example, you might ask your BCBA to work on teaching your child to stay next to an adult when walking outside, crossing the street, or in a crowd.
Safety equipment to decrease the risk of harm during behavioral crises
- For example, child-proof locks on exit doors or cabinets with dangerous fluids, corner guards on sharp surfaces around the home, and protective padding.
Checklists to ensure emergency preparedness in the home.
- For example, a fire safety checklist, wandering prevention checklist, and natural disaster checklist (checklists from The September 26th Project: https://www.september26.org/)

De-Escalation Strategies: You may briefly describe techniques that you have found to be successful for de-escalating severe behavior once it has started. Each individual is unique in what they might prefer, so this section will be very individualized to your family. Items you might consider include:

Behaviors a caregiver should engage in to help your child reach a calm state.
Behaviors a caregiver should not engage in that may potentially increase the likelihood of severe behaviors continuing or escalating.
A list of activities someone could offer your child to redirect them.

Crisis Responses: It is important to include any steps you would want someone to follow if your child’s severe behaviors escalated to the point of a behavioral crisis. Again, this will all be individualized based on you and your child’s preferences. A few pieces of information to consider include:

Who should they call (e.g., emergency contact)?
What situations would warrant a 911 call?
Are there specific behaviors you would want someone to redirect or block to ensure safety (e.g., headbanging directed at hard surfaces)?
What behaviors should a caregiver engage in to keep the individual safe and help them reach a calm state?

Post-Crisis Responses: It is always important to debrief after behavioral crises and identify ways to increase safety and prevent it from happening again. The post-crisis responses may differ across families and should be modified based on individual preferences. At some point after a behavioral crisis has ended, you might consider discussing some of the following with as many people that were a part of the crisis as possible:

Who should be informed that the crisis occurred?
Was anyone injured during the crisis? If so, what kind of care do they need, and who needs to be notified?
Does anyone need additional resources as a follow-up to the crisis (e.g., counseling, training)?
What led to the crisis, and what steps should be taken to avoid a similar crisis in the future?
What resources do we need to increase safety or prevent the crisis from occurring again and how will we go about getting access to them?
What went well and what did not go well? How can we improve next time?

Who should I share our behavioral crisis plan with?

You should share your plan with anyone who may be impacted by, respond to, or be a part of a potential crisis. This will likely include immediate and extended family members and any other regular care providers. Sharing your plan with anyone who has the potential to be involved allows you to be confident that everyone is proactively aware of how they can respond in the best way.

What behavioral crisis resources exist?

Behavioral crisis resources may vary across regions. Your state may provide specific resources to help you plan for and respond to a behavioral crisis. Here are a few other resources that you may find beneficial when developing a behavioral crisis plan:

The September 26th Project annual emergency preparedness checkup: https://www.september26.org/
Autism of NJ has many helpful articles surrounding behavioral crises:
The National Council on Severe Autism provides several crowd-sourced lists of resources:
- - Severe autism nonprofit organizations that may provide state-specific resources: https://www.ncsautism.org/state-nonprofit-list
  - Outpatient treatment resources for severe autism: https://www.ncsautism.org/outpatient-treatment-resources
  - Inpatient and psychiatric treatment resources for severe autism: https://www.ncsautism.org/outpatient-treatment-resources, https://www.ncsautism.org/psychiatric-treatment-resources