Treatment Plans That Worked

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     An appalling lack of standards exists as to what a child’s behavioral treatment plan should look like. As a result, parents are frequently at a loss to determine if the Plan proposed for their child is either adequate or appropriate. As an alternative to wishful thinking, misplaced trust in an unknown and untested service provider, and to raise the standards for treatment plans for children who are displaying challenging behavior, this internet resource has been created. Let’s define our terms, first of all.

A Treatment Plan should provide all of the information necessary for a conscientious person to deliver the correct treatment procedures, at the correct times, and with sufficient consistency to produce the changes in behavior that are described in the Plan — reducing or eliminating undesirable behavior and increasing or improving desired behavior, while providing a means to monitor progress on an ongoing basis that informs the process of treatment.

     With that in mind, the following “treatment plans that worked” are offered as examples to guide professionals in the creation of age-appropriate behavioral treatment interventions for children, and as examples of successful treatment planning documents that parents may provide to professionals as a means of setting basic standards for treatment design and monitoring. These plans were all successful in that they all produced reduction or stabilization in the target (undesirable) behavior of children. Although these plans were successful in these cases, it is clear that all children are different, and that the exact same plan may or may not be effective for any other child, and that professional guidance should always be sought before and during the implementation of any treatment plan or program.

     Subtle differences can change the outcome of any treatment plan. Because these plans are presented in the interest of helping to establish “standards” for the development of behavioral intervention plans for children, all of the treatment plans here are offered “as is” for informational and comparison purposes only, without any warranty whatsoever as to suitability for any particular purpose or child, or any claim of usefulness or value in the treatment of any disability. Results will vary in any treatment program; the fact that any one of these treatment plans “worked” in one case does not indicate that it will “work” in any other case.

     In this field, for every expert, there is an equal and opposite expert. Nevertheless, there are some basic standards on which everyone should agree. At a minimum for example, all behavioral treatment plans should provide the following information. The order of presentation isn’t as important as the level of understanding that it creates in the mind of the person who is to implement the plan, such as a mental health worker or a parent. A very simple plan, accompanied by a very high level of professional supervision, training and support, can achieve tremendous results. A highly complicated, lengthy, jargon-ridden treatment plan written by someone with impressive credentials obviously doesn’t guarantee success. The middle ground (where the treatment plan is complete in terms of its components, explicit in its directions to the person who will implement it, and which can be evaluated objectively as to its effectiveness) is ideal.

Any behavioral treatment plan should specify the exact behavior that is “targeted” for improvement. The plan must say exactly what is to be reduced or eliminated. By the same token, the plan must say exactly what is to be taught in replacement of the “targeted” behavior. It is rarely helpful to tell a child what not to do; you always have to specify what he/she should do as well.

A treatment plan should explain exactly what the treatment provider should be doing to accomplish the replacement of the “target” behavior. A treatment provider should be able to look at the treatment plan and know precisely which techniques are to be used, how often and in which circumstances. When terms like “contingency contracting” are used, a glossary of terms that is accessible to the treatment provider is essential. How else can the treatment provider know exactly what to do?

A treatment plan should always contain a simple and easy means of measuring progress from the perspective of the treatment recipient, not the treatment provider. Outcome progress measurement should include a “baseline” measure, which is a starting point in the measurement of treatment outcomes that precedes the start of the treatment period. How else will you know how far you’ve come (or how far you’ve gone astray) if you don’t know where you started?

Treatment plans must include a planned stop date, so that the treatment team can prepare to present information to funding authorities prior to that date in order for funding to be continued. Continued funding is necessary and therefore justifiable whenever the child is within the age served by the funding entity, the treatment plan is working, but the work has not yet been satisfactorily completed.

All of the “treatment plans that worked” in this collection meet these standards, to a greater or lesser extent. They are all actual real-life plans written by many different authors at the Institute for Behavior Change between 2002 and the present date, so some variation in quality and effectiveness will be apparent — but they were all successful, nonetheless. Some corrections in the use of punctuation, grammar and formatting were made to improve the consistency of the plans in order to facilitate rapid comparison between plans. It is a good idea to look at several plans and take “the best ideas from all” in the process of creating a plan for any given child.  You can view the current list of Treatment Plans that Worked in the database here. 

Suggestions for improvement or corrections to the plans are always appreciated.  

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TREATMENT PLANS THAT WORKED are available for five different behavioral domains:

1.  Safety Awareness
2.  Communication Deficits
3.  Socialization Deficits
4.  Physical Aggression
5.  Noncompliance with adult prompts

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Safety issues are more important than any other issues. When a child is placing himself in danger by ignoring automobile traffic, eating inedibles or harming himself through self-injurious behavior, immediate action is required. Self-injury is often a symptom of a painful condition. Tooth pain can produce head-banging or head-slapping as the child struggles to “make it go away.” Some children are drawn to dangerous behavior because it is physically exciting to jump from heights, or to go closer to the cars that are zooming by on the street. Each situation is different. It is important to try to understand what is motivating the child to engage in the dangerous behavior. If it is known what the child is seeking, it may be possible to provide it safely, and the child’s need for the dangerous behavior disappears. Several intervention principles are noteworthy in addressing safety issues:

Every child who is at-risk of a safety problem (nonverbal, cognitively impaired, communication disorder, etc) should be identified by their parent to law enforcement and other first-responder authorities. The child should be acquainted with these people and their uniforms so that the child is less likely to flee from such persons in emergencies. Special programs like the Premise Alert program in Pennsylvania are especially helpful in getting necessary safety information to 911 systems and should be a part of every child’s treatment plan, when safety issues are involved.

Environmental modification is necessary – never trust the conscientiousness of any adult caretaker as the sole means of preventing elopement (running away) or access to dangerous objects, chemicals or places. The placement of “childproof” locks is effective only until the child figures out how to open them, which is inevitable in most cases. Alarms are necessary to detect opened doors and windows, when elopement is a concern.

Repeated practice, with various adult caretakers in a variety of settings, is a prerequisite to acquiring strong safety habits. Children who learn safety skills in the home, at school, in the daycare setting, at Grandma’s house and in different stores are much safer than children who learn “safety skills” in a special education classroom, no matter how often those skills are taught.

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Ideas about the causes and treatments of Communication Deficits vary tremendously across professions and even from one professional to another within a given profession. Some authorities believe it is a good practice to teach a child to point to a picture, rather than use his voice, even when the child can speak. This practice teaches the child to communicate and can be a springboard to verbal communication; however, it could also create a reliance on the use of pictures instead of speech. Although it is advantageous to show a child that any means of communication is better than not communicating at all, it is important to relentlessly seek to reinforce speaking if the use of speech is a desired means of consistent communication. Although the approaches to the treatment of communication deficits vary tremendously, several intervention principles are common in addressing communication deficits from a behavioral perspective:

Identification of physical barriers to speech production is necessary. Children who have hearing deficits often display speech deficits – if they can’t hear speech, they really can’t figure out how to produce it or refine it for clarity.

The use of ancillary communication devices or methods (the Picture Exchange Communication System (PECS) methodology, devices to simulate speech) may be helpful and expedient. However, if the child is capable of making any speech sounds, it is probably possible to teach the child to make those sounds more consistently and intentionally, with a wider range of sounds, as a means of communicating. This is the foundation for most training in “verbal behavior” skills.

The training of communication skills can be approached just like any other behavioral training process. It starts at a basic level, takes small steps that build on success, and has a developmental plan to guide the process. Obtaining advice from a speech pathologist is invaluable in terms of creating the “developmental plan” for a given child’s communication behavioral training program.

Training in communication skills can be approached from the perspective of teaching the child to become more tolerant of age-appropriate performance expectations. Speech is a normal performance expectation for any child over the age of 1 year, so a mental health professional can assist any child over the age of 1 in acquiring speech skills by addressing the child’s behavior (escape, avoidance) in response to attempts to teach the child age-appropriate communication skills. The treatment provider is not teaching the child how to speak, which is a “life skill.” Rather, the treatment provider is behaviorally intervening to help the child tolerate the age-appropriate expectation of learning how to speak.

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Socialization deficits occur in enormous variety, running from extreme shyness and withdrawal to extreme intrusiveness. Children with socialization deficits may simply not care about the social implications of their behavior, may really not be aware of how their behavior affects others, or may be so self-focused that there are no “others” to affect as far as they are concerned. No matter where the social deficits lie, however, the treatment of every socialization deficit requires improvement in the child’s awareness of other people and their feelings. When a child does not have the ability to “put himself in another person’s shoes,” which affects many children with Autism spectrum disorders, the child is capable of learning “social skills” only by practicing them consistently so they become habits. Maintaining these habits will result in less self-stigmatizing social behavior and consequently greater access to socialization opportunities. Several intervention principles are noteworthy in addressing socialization deficits from a behavioral perspective:

Identification of cognitive or thought-process deficits that present a barrier to learning social skills is necessary. Children who have autism or significant cognitive (intelligence) deficits often have great difficulty “putting themselves in another person’s shoes” and will need to practice social skills conscientiously over relatively longer periods of time in order for these skills to become habits.

Abstract thinking (the ability to see a link between two objects or events) may be impaired in children who display socialization deficits. Accordingly, it may not be productive to use analogies, metaphors or other abstractions when teaching socialization skills.

Visual cues are often helpful to children who are learning social skills. Ongoing visual feed-back regarding behavior through the use of a device like the Behavior Barometer is more effective than verbal prompting alone for most children. Programs like “star charts” that provide just one feed-back point (usually at the end of the school day) are usually insufficient to teach new social skills.

For many children, the learning of social skills may create anxiety and requires practice in “safe” settings. Practicing a social interaction in a “dry run,” before the actual event is called “behavioral rehearsal” and is often very helpful. “Social Stories” give opportunities for the child to learn about a social behavior before it must be “demonstrated” it in a real-life situation.

A technique like “role playing” is inappropriate for children with deficits in the ability to “put themselves in another person’s shoes,” since role playing requires the child to switch roles with an adult (the adult “plays” the role of the child).

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The definition of Physical Aggression varies from professional to professional. Some do not distinguish between aggression directed against objects (more accurately characterized as “property destruction”), aggression directed against the self (more accurately characterized as “self-injurious” behavior) and aggression directed against others through verbal means (more accurately characterized as “verbal aggression”). Although the definition of physical aggression may be more or less inclusive of these various behavioral anomalies, several intervention principles are common in addressing aggressive behavior:

An immediate limit-setting response is necessary. It is inappropriate to “ignore” aggression, especially if someone is being injured.

The immediate limit-setting response must not be reinforcing – if the child wants to leave the room, and you take the child out of the room when he behaves aggressively, then you’ve effectively reinforced aggression.

It may not be possible, or legally permissible, for the treatment provider to implement “contingent exclusion” without the assistance of the adult caretaker. Regulations regarding the use of physical restraint vary from location to location. Physical restraint (holding the child to prevent movement) is not recommended by most professionals, may jeopardize the health and safety of the child, and may be illegal, depending upon its implementation.

The use of physical guidance, physical prompting or other means of redirecting (moving) the child to a less-stimulating or less-dangerous setting is usually permissible, but it is always preferable to redirect the child through the use of verbal means. This depends upon the existence of rapport between the child and the treatment provider.

The treatment provider is always “icing on somebody else’s cake.” In a school, the “cake” is the teacher or classroom aide. At home and in the community, the “cake” is the parent, adult babysitter, or other adult, who is responsible for the child (daycare staff, etc). When physical aggression occurs, it is almost always necessary to “get the cake involved” quickly.

Aggression is usually “the tactic of last resort,” when other modes of communication have failed. To reduce aggressive tendencies in children, it is almost always necessary to work on improving communication skills.

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Noncompliance issues are often a symptom for underlying feelings of worthlessness, frustration, or alienation. When children experience age-appropriate privacy and are allowed to preserve their dignity, they are much more likely to be compliant, cooperative, willing to engage, and tolerant of redirection and limit-setting. When privacy and dignity are deprived, children (all people, really) tend to become depressed, aggressive, withdrawn and/or noncompliant. The restoration of privacy and dignity by avoiding sarcasm, preserving confidentiality, responding reasonably and consistently to misbehavior and modeling cooperative, collaborative behavior are all prerequisites to treating children who display noncompliance issues. Several intervention principles are noteworthy in addressing noncompliance issues:

Don’t hit a tack with a sledgehammer. The consequence for a given misbehavior must be reasonable. When in doubt consult someone else who likes the child to get a fresh perspective on the problem behavior and possible responses. 

Plan responses ahead of time and stick to the plan when the time comes. It is possible to anticipate the child’s behavior pattern, so you should be able to “build a staircase” of increasingly intensive responses so that the treatment provider can “climb the staircase” if the child’s behavior does not respond to the first, or second, or third level of response. The top of the staircase is always “911” and the treatment provider should not be afraid to contact local law enforcement authorities if the child requires limit setting beyond a level at which the treatment provider is capable.

Always use an approach that encourages “forward” motion on the child’s part – toward a more optimistic future, a better day tomorrow, the restoration of privileges, and a better relationship with all involved. Avoid sarcasm and harsh, painful or punitive disciplinary practices that encourage the child to harbor resentment, experience embarrassment or humiliation. 

Work out responses to misbehavior with the child in advance. A behavior plan that includes consistent responses to the child’s misbehavior will be much more effective if the child participates in the creation of the plan. Include both rewards for good behavior and reasonable consequences for misbehavior. 

Never run to a fight. Emotions will be excited by the misbehavior, obstinacy or refusal (and perhaps embarrassing behavior) of the child. Delaying a response, in order to get emotions under control, will have a greater positive long-term effect than an immediate, intense over-reaction.

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