This blog is my place to vent and share resources with other parents of children of trauma. I try to be open and honest about my feelings in order to help others know they are not alone. Therapeutic parenting of adopted teenagers with RAD and other severe mental illnesses and issues (plus "neurotypical" teens) , is not easy, and there are time when I say what I feel... at the moment. We're all human!

Thursday, December 1, 2011

Crisis Plan and Alternative Placement

Here's the letter I just sent the school:

1. I am officially requesting that calling parents for emotional support when Kitty is displaying "Acting In" behaviors needs be added to Kitty’s Crisis Plan. Until she’s able to consistently demonstrate that she can meet her Behavioral IEP goals of being able to express her feelings to school staff, she needs to have easy access to a person she knows and considers safe (myself or one of her therapists) during this time of emotional instability. I will continue to encourage her to share her feelings with school staff, and to return to class as appropriate. Until Kitty is more stable it is detrimental to her emotional health and feelings about school, to not allow her access to these trusted adults.
Behavioral IEP Goals:
Using a scale, Kitty will verbalize or express her feelings to a trusted adult in the school setting a minimum of 1 time a day
When Kitty is expressing anxious feelings or exhibiting "acting in" behaviors, she will request the assistance of a trusted adult 5 of 5 times

2. Kitty is still working on trusting staff enough to express her feelings, but she’s expressing that when she tries it feels like she’s not being heard, which of course defeats the purpose.

  • Establish concrete definitions. When Kitty says she doesn’t feel “safe.” It needs to be figured out what this means to her. Generally it means she is struggling not to hurt herself.

  • Establish concrete scales for Kitty. On a scale of 1 to 10, a 5 is NOT mild. Kitty at a 5 is beyond coping skills and cannot function in class. She told Ms. M, a school psychologist she just met, that her level of anxiety on a scale of 1 to 10 was a 6. {I came up with an Anxiety Scale for Kitty to use at school  - posted here - so she can get help while her anxiety level is still low enough for her to "access" and comply with calming techniques}

  • Trust issues preventing compliance. When asked to try different methods for calming herself on Monday, she was unable to comply. We all know that Kitty would comply if she possibly could, as she gets her self-esteem from the positive regard of others and would rather die (literally) then trust others to see that she is not perfect or struggling.
  • Actions speak louder than words. Until Kitty can express what’s going on inside, the "Acting In" behaviors need to be closely observed. For example, Kitty’s leg was vibrating like a jackhammer on Monday, and while she was able to control the self-harming behaviors (wanting to use a pencil and eraser on her skin), the fact that she even mentioned them to staff is huge for her. Her actions speak louder than her words, especially when she is too scared to express what’s going on, or sometimes is just unaware of her own body and feelings.
  • Calming Techniques. A staff member (preferably more than one in case someone is not available) needs to be trained in the use of calming techniques with Kitty so she can try to get calm without having to leave school.
3. Rating scales need to be more concretely defined for Kitty. Kitty needs to understand exactly what the scores on the rating scales mean. When asked, “on a scale of one to ten, how suicidal do you feel?” she told the crisis assessment counselor she was a 6. When asked to elaborate, she said she felt suicidal, had a plan, but unlike a 10 she didn’t have the means (no rope or belt). To me, this would be more like an 8 or 9! Obviously the crisis counselor agreed, because she sent Kitty to the hospital.

4. We have still only received two Behavior Reports to date.

5. We are officially requesting alternative placement for Kitty again. for the following reasons:

  • Obviously things are escalating. Kitty has been hospitalized 3 times this month alone!

  • Safe place so can focus on trauma work. Kitty MUST continue doing intense trauma work in therapy, and only has so much energy/strength to cope with the other areas of her life (personal/trauma history, home/family, school/community). School is one of the few areas that still has the ability to reduce some of the stress. Right now Kitty is spending all of her energy trying to maintain a positive image with her peers and teachers. When she comes home and in therapy, she has nothing left. We’ve done all we can to structure Kitty’s home life to give her as little stress as possible so she can focus on healing. She needs to be able to reduce that stress in school to give her more energy/strength for doing this key trauma work.

  • Lessen the shame and stigma of her disabilities. While Kitty definitely needs the shadowing and support by the behavior program staff and other school staff, being singled out and feeling different is feeding into her shame, and feelings of being excluded/ singled out and criticized. At the special school, ALL the children receive this type of support so Kitty wouldn’t feel the stigma.

  • Not receiving an education. Under the current schedule, Kitty is still missing significant amounts of school (see attached) over 50%. This includes hospitalizations and doctor and therapy appointments, but also the significant amount of time she is out of class due to her emotional issues (walking the halls, sitting in the nurse’s office, talking to behavior program staff and school staff…). This report does NOT include testing, time spent with school staff who are not behavior program staff (like counselors, school psychologists, the AP, case manager, time in Learning Lab…), and does not include ALL of the time spent with the behavior program staff out of the classroom (there is at least one undocumented event that I am aware of involving Kitty having symptoms of a panic attack at the thought of giving a speech and being out of the classroom during the time the speeches were given. Her current placement cannot be correct if she can’t stay in class long enough to learn!

  • Classroom environment. According to Kitty’s recent neuropsych report (filed with her school psychologist), when Kitty is in a loud and/or chaotic environment, her ability to process and learn drops significantly. Calm and quiet, does not describe the environment of some of her classes.

  • Classroom environment. The recent neuropsych eval recommends that because Kitty is an auditory learner, that having her doing worksheets or studying independently is not effective for her. Sending her to the Learning Lab to do makeup work without an experienced teacher to work with her is not likely to work well.

  • Kitty requires extensive emotional support to get through the day. School staff are obviously spending an extensive amount of time trying to provide this for her, but of course their actions are focused on providing academics and keeping her in class, not skills training – such as training her on HOW to achieve her behavior goals.

  • Kitty needs consistent, qualified support. There have been a LOT of different people involved in working with her. Her Behavior IEP states she needs to express her feelings, but to do that she needs to establish trust with one or two staff.
6. I’ve heard a lot of concern that if Kitty is allowed to continuously leave the classroom then she’ll develop issues with not wanting to return. My response to this is that Kitty is in crisis mode. Like a person undergoing major surgery needs morphine, despite the fact that it is a highly addictive drug, we need to focus on what is best for Kitty right now and deal with the fall out later when she’s stable. I also want to point out that although Kitty normally LOVES school, forcing her into the classroom when she’s overwhelmed is a big part of what is making her not want to return.

7. Final Exams. Kitty will most likely be released from the hospital just before finals, and the stress of being behind is already causing her anxiety. I doubt she has mastered the material enough to exempt exams. Possibly she should be given Incompletes?

Edited to Add the Concrete Anxiety Scale (Thank you commenters!)

0 – Cool as a cucumber.  INTERVENTION:  No intervention  needed
EX:  On the third day of a long vacation, soaking alone at a spa.

1 – Everyday minor stress needed to function.  Occasional twinges of minor discomfort.  
INTERVENTION:  No intervention needed.
EX:  Alarm clock goes off.  First bell rings.

2 - Minor bother.   
INTERVENTION:  Self-initiated calming skills.  No outside intervention needed.
EX:  Need to move quickly to get to class.  Momentarily can’t find homework.  See a cute boy.

3 – Anxiety annoying enough to be distracting. 
INTERVENTION:  Coping/calming skills still work, but might need outside reminders to use them.
EX:  Loud, chaotic environment.  Quiz you’re prepared for.  Ex-boyfriend standing 15ft away.

4 - Can be ignored if you are really involved; still distracting.  Somatic symptoms (upset stomach, headache...).  
INTERVENTION:  Brief breaks with adult support and assistance using coping/calming skills.  Can be redirected back to class.
EX:  People arguing.  Test you're prepared for.  Presenting a well-prepared presentation with a group.

5 - Can't be ignored for more than 30 minutes.  Thoughts of hurting self intruding, but controllable.  
INTERVENTION:  Brief breaks with adult emotional support.  Might be able to access coping skills with assistance.  Can probably be redirected back to class or work independently in less stressful environment.
EX:  Giving a speech to a group.  Getting feedback or gentle teasing.  Feeling behind in schoolwork

6 - Can't be ignored but still can work.  Wants others to keep her safe from acting on feelings of self-harm.
INTERVENTION:  Leave stressful environment and continue work.  Learning Lab?  Talk with behavior specialist.  Coping skills might work after calm down a little.
EX:  Picked on/teased by peers.  Test in class struggling in.

7 - Hard to concentrate, bothers sleep.  Can still function.   Feel need to escape.  Suicidal thoughts.  Needs stressors limited by others or will escalate.
INTERVENTION:  Leave stressful environment and not able to access cognitive part of brain for school work.  Can’t access coping skills.
EX:  Feels personally attacked by someone close to her.  Overwhelmed because behind in classes. 

8 - Activity limited a lot. Can read non-school books and talk with effort.  Suicidal thoughts with a plan, but not seeking out means.  Paranoid others hate her and are out to get her.  Acting out behaviors if can’t escape/ act in.
INTERVENTION:  Reduce stressors as much as possible.  Consider hospitalization, but can wait for an open bed.

9 - Unable to function. Crying out or moaning.   Acting out.  Fight/ Flight or Freeze Reactions.  Suicidal thoughts with plan and means, threatening, but not actively attempting to commit suicide.  
INTERVENTION:  Immediate removal from all stressors.  Hospitalization.

10 – Totally Stressed Out. Eyeballs explode.

Additional Post:
Handling Child Stress


schnitzelbank said...

Quick comment, while I'm processing a lot of what you said. You know how in a doctor's office or hospital, they have an infographic on the wall for the pain level a person is in? It is something like this, It has a face in varying degrees of being happy to unhappy. There are descriptive adjectives to accompany each level:

0 - No pain.
1 - Slightly uncomfortable. Occasional minor twinges. Ne medicine needed.
2 - Minor bother. Ne medicine needed.
3 - Annoying enough to be distracting. Mild medication like Aspirin or Tylenol help.
4 - Can be ignored if you are really involved; still distracting. Mild medication helps for 3-4 hours.
5 - Can't be ignored for more than 30 minutes. Mild medication helps for 3-4 hours.
6 - Can't be ignored but still can work. Stronger pain medication helps for 3-4 hours.
7 - Hard to concentrate, bothers sleep. You can still function. Strong pain medication only helps some.
8 - Activity limited a lot. You can read and talk with effort. Nausea and dizziness are part of the pain.
9 - Unable to speak. Crying out or moaning.
10 - Unconscious. Pain makes you pass out.

I am wondering if you could create one for Kitty's emotional states, and what the plan of action should be at each level.

beemommy said...

I think Schnitzelbank's comment is spot-on! All schools should have something like this in place. Not the "How do you feel" poster with fifty emotions on it but a continuum of stress levels. Great idea! Great parenting Mary, I know in the trenches, we don't hear that a lot especially from some educators/administrators.

Anonymous said...

Real-name alert.

And I agree w/ the concrete scale, as that is what Kitty is -- a concrete thinker. I personally hate rating scales. ... You are great with finding pictures. Perhaps you can find pictures that represent at least 5 points on the scale?
If you create a scale, help her to understand where she is on it. Is she having a good time, laughing? Show her that she is probably a 1 or 2 at that moment. ... if you've trained her and she answers staff with an "I don't know", then they need to understand that she's just said "I cannot access the rational logical part of my brain so I must be at a 7 or above" (or whatever) ... She must be allowed to say "I don't know" rather than feeling she has to (randomly) pick a number.

marythemom said...

schnitzelbank - Great minds think alike! Started working on this today.