Police Response to Juveniles in Crisis

A *collaborative Approach and Training

August 2009*Police/Corrections/Mental health/District

attorney/Parents

GoalThis training is designed to give officer’s

information that will help guide them when responding to calls for Emotionally Disturbed Persons, both Juveniles and Adults. Developing a protocol for response, as well as, working with agencies to provide information sharing, will help provide the proper treatment and/or detention for the adult/juvenile. Working with local agencies to develop a “Crisis Plan” will help reduce the amount of repetitive calls an officer receives.

Performance Objectives

The student will be able to do the following as outlined1.1 Provide a better response by early identification of at

risk juveniles in crisis by early identification of at risk juveniles

1.2 Define a behavioral Crisis1.3 Identify the effects of mental health & disability

diagnoses in youth behavior1.4 Define a “melt down” and possible triggers1.5 Define the cycle of a “Melt down”1.6 Define power struggle1.7 Recognize juvenile mental health and behavioral

issues

Performance Objectives

1.8 Recognize common psychotropic medications

1.9 List 3 interventions for behavioral crisis to help reduce the amount of repetitive calls an officer receives

1.10 Recognize the importance of collecting information and collaboration with agencies

1.11 Provide officers with resources for youth committing crimes that also exhibit a Behavioral Crisis

1.12 Identify and divert youth better served in behavioral health out of the Juvenile Justice System

1.13 Recognize the nature of a call when dealing with an EDA

1.14 Recognize the options available when dealing with an EDA

A Juvenile in Crisis is A Juvenile Displaying One or More of the

following Behaviors:

Disruptive Destructive

Violent Criminal

Self-harming Threatening

Assaultive

Difficult Behaviors and Emotional Disorders

It is important to note that all children that have difficult behaviors do not have a mental illness.

Likewise, children that have mental illnesses do not always have challenging behaviors.

Children and Mental Illness

Brain disorders and mental illnesses are equal opportunity conditions and effect children and adolescents from a broad

spectrum of families

Brain researchers encourage teachers, doctors and mental health providers to resist blaming mental illnesses on “poor

parenting”

Melt Down

For children with special needs, physical or emotional, a melt down is not about using a tactic or a voluntary behavior; it is a symptom signaling that something deeper is happening. *“The child has moved beyond coherent and rational thought”

*Dr. Ross Greene

Melt down triggers Lack of, or changes in medications Trauma (current or past) Change in normal routine (divorce/loss,

moving, changing schools, home disruption)

Lack of child/parent coping skills Power struggles Inability to deal with conflict

Cycle of a Melt DownAgitation Stage- lack of coping skills, Many possible triggers

MELT DOWN- may be quiet or very violent, not in a normal state of mind

Recovery Stage- exhaustion, may not remember events

Brenda Smith Myles & Anastasia Hubbard 2005

Everyone deals with lacking skills differently police usually called on the extreme end

Primary concerns for officers responding to Juveniles in Crisis

1. Public safety (threat to self or others)              Emergency evaluation

2. Jeopardy (unsafe environment) = DHHS Parent is unable to control the child

3.  Crime(s) committed = D.A.s’ Office/JCCO

4. Mental health/behavioral condition =  Refer to crisis

Why Collaboration is Needed A juvenile in crisis call involves many

domains/agencies; Mental health/hospital/crisis DHHS Corrections District Attorney's Office Community Support Agencies Schools Police

Why Collaboration is Needed cont. Police officers acting in isolation and

failing to communicate with the appropriate support agency may be increasing the chance for a repetitive occurrence

Many of these calls are more appropriately handled by support agencies but they can only help if they know about the event.

Appropriate intervention and services often leads to better long term out comes in the juveniles behavior.

Primary Collaborative Partners District Attorney's Office Juvenile Corrections DHHS Crisis/Hospital Schools Community Support Groups Parent and Parent Support Groups Police Services

Collaboration with partners The officer should make every effort to

know and develop a positive working relationship with professionals from the various support agencies.

Absence any other tactic, personal professional ongoing dialog with support agency personnel helps to foster the best interagency working relationship leading to better coordinated service delivery for the juvenile in crisis.

To effectively respond to a juvenile in crisis call the officer should Recognize a juvenile in crisis Understand the surrounding/causal factors Document critical information Be familiar with local and state support

agencies Be prepared to communicate with support

agencies (in accordance with state privacy laws)

Possess a working knowledge of each agencies responsibilities and resources

Provide appropriate referral information to the parent

When responding to a juvenile in crisis call officers should do the following

Determine the nature of the call

Public safety Jeopardy Mental health Criminal Combination of the above

When responding to a juvenile in crisis call officers should do the following (Cont.)

Gather critical and appropriate information Make the scene safe Make a decision which action is most appropriate:

Transport for an emergency mental health evaluation Refer to crisis Refer to DHHS Provide support agency information to

parent/guardian Charge the juvenile Call the JCCO Combination of the above

Criminality/Behavioral Flow chart

Officer responds

to call

Criminal

And/or

Behavioralactivity

SummonsRefer to

JCCO

Need forDetention

JCCO releases or Detains

Call ADA if youDisagree

Contact JCCO

History of

Mental Illness

Or

Developmental

Disability

DATA

COLLECTION

CrisisEval

FamilyCrisis Plan

FamilySupports

PossibleOutcomes

HomeFamilyFriendsCrisis

Hospital

Detention(if charged)

Make the scene safe

Criminal Behavior VS.Behavioral Crisis

Any criminal behavior should be investigated along with any behavioral health concerns

Recognizing and addressing mental health and disabilities should result in less officer responses and a better future for the juvenile

Why capture information Police observation and information

gathering is essential because it gives a realistic unbiased picture of what is happening in the home at the time of the melt down/behavioral crisis

This is critical information for support agencies to be able to successfully intervene

Why to capture information (cont.) Police officers are in the unique position to

identify children at risk at an early stage Police intervention through

collaboration/communication with appropriate support agencies can expedite the delivery of critical services to the juvenile and family

Early intervention reduces the occurrence of increased disruptive/criminal behavior

Responding officers should avoid engaging in power struggles Power struggles may damage your rapport with the

youth or other youth who observe the interaction.

There are 4 common types of power struggles: The individual challenges your authority The individual pushes your buttons to shift

the attention from their behavior to you. Making threats or giving ultimatums. Bringing up non-pertinent and non-related

past history.

De-escalation Strategies With Children & Adolescents

Don’t get into a power struggle, focus on the 3 S’s1. Safety2. Support3. Stabilization of the biological,

cognitive and emotional status of the child

Approach slowly, create a calm and a sense of safe adult control

De-escalation Strategies With Children & Adolescents Scan for possible dangerous escape

routes or objects Physically position self in the least

threatening posture possible, but be prepared to move quickly

Simply introduce yourself and let the child know that you are there to help

Go slowly and try not to introduce any unnecessary strangers into the situation

De-escalation Strategies With Children & Adolescents (cont’d)

• Keep the child informed of what you are doing so as to reduce any startle response

• Use redirection if at all possible• Use ignoring and work not to be baited or

triggered by language, name calling and oppositional behaviors

• Assess the developmental age of the child. Don’t let chronological age fool you

De-escalation Strategies With Children & Adolescents Assess for any comforting individuals

or objects to build a relationship As the child stabilizes, check on the

basic needs as appropriate such food, liquids, blanket, comfort from a loved one…….

Know your own triggers when dealing with parents, teens and children

Officers should possess a thorough understanding Maine’s juvenile code Recognize the underlying premise of the

code is different than the adult code The district attorney's office and JCCO

approach juvenile cases with the goal of diverting out of the criminal justice system at the earliest opportunity (in all but the most serious offences)

Officers working with a misunderstanding of this process may become frustrated and disillusioned with the system

Dangers of Detention Can increase recidivism Increases risk of getting to know

other at risk youth (peer deviance) Makes mentally ill youth worse Increases risk of self harm Youth with special needs fail to

return to school Justice Policy Institute         Barry Holman and Jason Ziedenberg

Title 15

1. Purposes.  The purposes of this Part are:

A. To secure for each juvenile subject to these provisions such care and guidance, preferably in the juvenile's own home, as will best serve the juvenile's welfare and the interests of society; [1997, c. 645, §1 (AMD).]

B. To preserve and strengthen family ties whenever possible, including improvement of home environment; [1977, c. 520, §1 (NEW).]

Title 15 cont. C. To remove a juvenile from the custody of the

juvenile's parents only when the juvenile's welfare and safety or the protection of the public would otherwise be endangered or, when necessary, to punish a child adjudicated, pursuant to chapter 507, as having committed a juvenile crime; [1997, c. 645, §1 (AMD).]

D. To secure for any juvenile removed from the custody of the juvenile's parents the necessary treatment, care, guidance and discipline to assist that juvenile in becoming a responsible and productive member of society; [1997, c. 645, §1 (AMD).]

Title 15 cont.

E. To provide procedures through which the provisions of the law are executed and enforced and that ensure that the parties receive fair hearings at which their rights as citizens are recognized and protected; and [1997, c. 645, §1 (AMD).]

F. To provide consequences, which may include those of a punitive nature, for repeated serious criminal behavior or repeated violations of probation conditions. [1997, c. 645, §1 (NEW).]

Differences between Juvenile and Adult criminal code Adult code is punitive

Fine Imprisonment

Juvenile code is rehabilitative Assessments Referrals Treatment Punishment is last consideration

How Police Intervention can Help Improve Outcomes through diversion from Juvenile Justice

Police can help by: Recognizing difference between

criminality and behavioral crisis Identify possible need for

services

How Police Intervention can Help Improve Outcomes through diversion from Juvenile Justice Supporting/Empowering parents

in engaging services Gather appropriate information

for purposes of documentation and referral

Mental health

Information

Nationally 1 in 5 children and adolescents have a mental health disorder. (SAMHSA 2009)

1 in 10 have a serious emotional disturbance * (SAMHSA 2009) * Serious Emotional Disorder means that the disorder disrupts daily functioning in home, school or community.

Did you know ……

Did you know…. Mental Illness strikes individuals often during adolescence

and young adulthood. Metal illnesses are treatable. 50%-70% of youth in the juvenile justice system have at

least one diagnosable Mental/Behavioral Health issue 25% to 33% of these youth had Anxiety and Mood Disorders Nearly half of incarcerated girls meet criteria for PTSD 13.7% of youths aged 14-17 considered suicide in the past

year Only 36% of those at-risk children received mental health

treatment or counseling Youth who used alcohol or illicit drugs in the past year were

more likely to consider taking their own lives MHA 2002; SAMHSA 2002

High Risk Populations for Violence Previous history of violence Under influence or withdrawing from a

substance that has the potential to impair the brain.

Has impaired executive functions Is exhibiting symptoms of psychosis,

increases if command hallucinations present Male gender Has a neurological impairment Is exhibiting symptoms of dementia

High Risk Populations for Violence(continued) Has symptoms of antisocial or borderline

personality disorder Weapon availability and preoccupation with

violent thoughts Adolescent and early twenties (high risk for

suicide) Previous history of an attempted suicide that

had potential to be lethal More planning than impulsive Not allow chance of discovery No prefaced signal for help

Self Injurious Behavior Direct – deliberate, immediate self

harm Cutting, burning, hitting

Indirect/passive Refusing medical treatment Not taking medication Smoking/alcohol Putting self in harms way

Not suicidal or sexual in nature

Self Injurious Behavior (cont.) “Para-suicidal” behavior Wanting to feel better versus

wanting to feel nothing Self define between self injurious

behavior and suicidal behavior SIB is alternative to suicidal

behavior

Mental Illness Requires Treatment Due to the many influences on

children, the neurochemistry of the brain can change and their best efforts at sustaining balance are not enough. Medication or other therapeutic processes

may be required to restore balance. Punishments alone do not restore the brain

chemistry or improve behaviors in a child needing therapeutic interventions

Overview of Child Diagnoses

Disruptive Disorders

Mood Disorders

Anxiety Disorders

Disruptive Disorders

Attention Deficit Hyperactivity Disorder (ADHD) Inattention

Careless mistakes Difficulty paying

attention Not listening Failure to

complete tasks Easily distracted Forgetting Losing things

Hyperactivity Fidgeting Excessive movement Talkative Blurts out answers Impulsivity Interrupting others Intrudes upon others Cannot stay seated

Oppositional Defiant Disorder (ODD)

Pattern of negative, hostile and defiant behavior Symptoms include: Deliberately annoying Often angry Resentful Defies rules Argumentative

Conduct Disorder

Pattern of behavior in which the basic rights of others and societal norms or rules are violated (according to age)

Symptoms include:

Aggression to people and animalsDestruction of propertyTheftTruancy, run away, violate curfew

Interventions for Disruptive Disorders

Interventions should address immediacy; instant gratification; distraction as an intervention

Mood Disorders

Mood Disorders in Children

Depression

Bipolar Disorder

Substance Induced Mood Disorder

Depression in Children

Separation Anxiety Behavior problems Family history of mood disorder or

substance abuse Unrealistic fears/anxieties/phobias Drug and/or alcohol use Negativity/irritability Aggressiveness or overactive behavior

Bipolar Disorder in Children

Sleep disturbance and irritability dating from infancy

Separation anxiety Night terrors Phobias and/or school phobia Raging and tantrums

Bipolar Disorder in Children (Cont’d)

Oppositional behavior Rapid cycling of mood Sensitivity to stimuli Distractibility and hyperactivity Impulsivity and risk taking Grandiosity and aggressiveness

Interventions for Mood Disorders

Interventions support self regulation; de-escalation; identify triggers; using language to convey feelings

Anxiety Disorders

Anxiety Disorders

Generalized Anxiety Disorder Panic Disorder Phobic Disorder Post Traumatic Stress Disorder Obsessive-compulsive Disorder

Generalized Anxiety Disorder

Overwhelming feelings of anxiety that impair functioning

Panic Disorder

Panic attacks - significant physical symptoms to include pulse racing, hyperventilating, chest pain, dizzy, etc... Develop abruptly and reach peak within 10 minutes.

Phobic Disorder

Intense anxiety when faced with specific stressor (i.e. closed spaces, heights, insects, social situations).

In children, anxiety may be expressed by crying, tantrums, freezing, clinging.

Post Traumatic Stress Disorder

Nightmares, hyper vigilance, feeling and reacting as if in the traumatic event, psychological distress at exposure to cues that resemble an aspect of the traumatic event.

Obsessive Compulsive Disorder

Obsessions are thoughts, impulses or images that are experienced as intrusive and inappropriate and cause marked anxiety/distress.

Compulsions are repetitive behaviors/mental acts the person feels driven to perform (i.e. hand washing, ordering, checking, counting, repeating phrases silently).

Interventions for Anxiety Disorders

Interventions address fears and increase comfort level; increase mastery over fear.

Types of Interventions for Mental Illness To improve behavior, thinking, and

brain biology problems, children and adults need several kinds of interventions: Biological (medications) Social (behavior plans) and educational (accommodations

and support) Substance abuse counseling

Barriers to Treatment Suicide is the 2nd leading cause of death among

15 to 24 year olds. Over 90% of children who die from suicide have a mental disorder

Among youth in juvenile justice facilities, 50% to 75% have mental illness

25% to 33% of these youth had Anxiety Disorders

or Mood Disorders

Barriers to Treatment (Cont’d)

• Frequently have more than one Co-occurring mental and substance use disorder

• Up to 80% of children suffering from mental illness fail to receive critically needed treatment

• Children receiving special education and designated with “emotional disturbance” fail more courses, earn lower grade point averages, miss more days of school and are retained at grade more than students in any other disability category.

Additional considerations for law enforcement

Suicide prevention Access to treatment Homelessness in Youth Substance Abuse Issues of Independence/development

and needing to feel accepted by peers Connection with community vs.

alienation

The Developmental & Physical Disability Spectrum

What are Developmental Disabilities?

Developmental disabilities are a diverse group of severe chronic conditions that are due to mental and/or physical impairments. People with developmental disabilities have problems with major life activities such as language, mobility, learning, self-help, and independent living. Developmental disabilities begin anytime during development up to 22 years of age and usually last throughout a person’s lifetime.

The Developmental & Physical Disability Spectrum

Autism Spectrum Disorder Mental Retardation Hearing Loss Cerebral Palsy Vision Impairment Brain Injury

What Is Autism?

A Pervasive Developmental Disorder (PDD)

On set by 36 months with serious to profound disturbances in language, social interactions, interest, and motor behaviors. Disturbance are highly repetitive, stereotypical and resistant to change.

What Is Asperger’s ?

Also a Pervasive Developmental Disorder

Intact language and intellectual development, but highly restricted capacity social and emotional interactions.

Mental Retardation

Limitation in functioning related to limited intelligence

IQ below 70 (90% mild MR) Issues relating to: communicating,

social skills and self care Affects 3 out of every 100 persons Important to consider developmental

age vs. chronological age when dealing with a youth with mental retardation.

Cerebral Palsy

Cerebral palsy refers to a group of disorders that affect a person's ability to move and to maintain balance and posture. It is due to a nonprogressive brain abnormality, which means that it does not get worse over time, though the exact symptoms can change over a person's lifetime. 

People with cerebral palsy have damage to the part of the brain that controls muscle tone. Muscle tone is the amount of resistance to movement in a muscle. It is what lets you keep your body in a certain posture or position.

Hearing Loss

Impairments in hearing can happen in either frequency or intensity, or both. Hearing loss severity is based on how well a person can hear the frequencies or intensities most often associated with speech. Severity can be described as mild, moderate, severe, or profound. The term “deaf” is sometimes used to describe someone who has an approximately 90 dB or greater hearing loss or who cannot use hearing to process speech and language information, even with the use of hearing aids. The term “hard of hearing” is sometimes used to describe people who have a less severe hearing loss than deafness.

Vision Impairment

Vision impairment means that a person's eyesight cannot be corrected to a "normal" level.  Vision impairment may be caused by a loss of visual acuity, where the eye does not see objects as clearly as usual.  It may also be caused by a loss of visual field, where the eye cannot see as wide an area as usual without moving the eyes or turning the head.

Brain Injury

There are two types of brain injury: Traumatic brain injury and Acquired brain injury.

• Traumatic Brain Injury is a result of a direct blow to the head.

• About 50-70 % of all TBI are the result of car accidents. Other causes include:• Slips and falls• Violence• Sports related injuries

Brain Injury (Cont’d) An acquired brain injury is one that has occurred after

birth, and is not hereditary, congenital, or degenerative. Common causes of acquired brain injury include;

• Airway obstruction• Near drowning• Electrical shock• Lightening strike• Blood loss• Heart attack• Stroke• Aneurysm

Common Medications Used for Youth

If you hear a youth is on medications it should be treated as a

major indicator that there may be something else going on for this youth

Commonly Used Psychotropic Medications

Antidepressants- Prozac, Zoloft, Lexapro, Celexa, Luvox Wellbutrin, Cymbalta, Effexor

Mood Stabilizers/Antipsychotics- Abilify, Seroquel, Geodon, Zyprexa, Risperdal, Depakote, Lithium, Lamictal, Thorazine

Stimulants- Ritalin, Concerta, Ritalin LA, Focalin, Daytrana, Adderall, Vyvanse, Strattera

Commonly Used Psychotropic Medications Antianxiety- Buspar, Vistaril,

Ativan, klonopin, Valium, Xanax, Doxepin

Other- Clonidine, Tenex, Propranolol, Trazodone, Remeron, Melatonin, Benadryl.

This list is a simple compilation of the most common medications used at LCYDC (Kim Foster, NP, psychiatric provider at Long Creek

Gathering Information

It is important to start identifying and collecting

information for those youth in the realm of

behavioral Crisis

Information Sharing

Share information between (no consent needed unless indicated) Law enforcement DHHS *Hospital Crisis Services Non-emergency crisis (with consent*) Community Providers (with Consent) Schools (only with imminent threat)

*contact your regional crisis provider and discuss parameters of receiving

information re. with or without consent..

*Hospital When an officer transports a juvenile to the

hospital for an emergency mental health evaluation information sharing is critical Either a *written or verbal report of incident

should be provided for the hospitals review to assure evaluators fully understand the crisis

Self harming/threatening and violent behavior/statements should be noted

The child may be released prematurely if accurate information is not provided to the hospital

*written report with critical information is preferred

Red Flag Behaviors

Bullies Threatens Intimidates Used a weapon Physically cruel to

people Physically cruel to

animals Stolen property Destroyed property

Broken into someone home/car

Lies (cons) Stays out past

curfew Runs away Truant from school Plays with fire Acts out sexually

Demographics Date, time, location, case number of incident. Juvenile biographical information. Name, DOB,

height, address, weight, eyes color, hair color Juveniles general health/injuries. Parent/guardian-(denote relationship)

biographical information. Contacted yes/no. Describe behavior that generated the police

response. List possible criminal behavior committed.

(Felonies to be highlighted)* *JCCO/DA take special note of JV felony charges

Basic information to capture

What specific behavior generated the call

Parents concerns (juveniles behavior)

Include 911 call information and excited utterances about behavior and juvenile history

911 call information (cont.) The exited utterance on the

911 tape are critical because the information gained is important to the support agencies to intervene appropriately and gain an accurate understanding of the event.

911 call information cont. Statements made about behavior Statements made about medication Statements made about mental health

conditions Statements made about fear of the child Statements made about

assaults/threatening Statements made about parents inability

to control the child (out of control Juvenile)

Juvenile History

Number of times the police were called because of the child’s behavior? The last time/date? Very important to demonstrate the need for

additional services Would you consider the juvenile a threat

to self or others? Is the juvenile on probation/who is

his/her P.O.? Contacted yes/no.

Medications Diagnoses Current community services Case manager Educational information Other concerns in the family

Voluntary Information

Voluntary Information

Is the child receiving services (counseling) currently?

From what agencies? Who is the case manager(s)*? What medications is the child taking? What diagnosis does the child have?

* Often a child with have several case managers.

Voluntary Information cont What medications is the child taking? Last time medication was taken What diagnosis does the child have? How many times has your child had a

crisis evaluation? Does the child use drugs/alcohol? Where does the child attend

school/grade? Are juveniles associates/friends in

trouble with the law/school?

Voluntary Parent Questions

Do you have concerns for your child?

Please explain What additional services do you feel would help you/ juvenile/family?

Crisis Plan Many families who are receiving

support services may have a crisis plan The officer should ask to review the plan The officer should determine if the plan

appropriately identifies a crisis and the appropriate time to call the police (911)

The officer should work with the parent/agency to improve the plan if necessary

Crisis Plan (cont.) Many parents and social service agencies

have a fundamental misunderstanding of the role and abilities of the police

Crisis plans developed without input from police or an understanding of the police’s role often call for police intervention for misguided reasons

Parents may incorrectly call the police to discipline their child, take their child out of the home or frighten their child

Police officers should educate the parents about what the police can and cannot do

Officer Action

Officer action Explain why action taken or not taken Charged Yes/No Referred_________________________________

______ Emergency

evaluation_____________________________________

Mediated______________________________________

I have it, Now what do I do?

Agencies you can release to: JCCO D.A.’s office DHHS Crisis Hospital

Family Support and Family Support and EngagementEngagement When parents feel like they When parents feel like they

are part of the problem-solving are part of the problem-solving team rather than “the team rather than “the problem” they are more likely problem” they are more likely to seek out treatment and skill to seek out treatment and skill building building

(results in less 911 calls)(results in less 911 calls)

How?How? Support Support CommunicateCommunicate EmpowerEmpower Knowledge and EducationKnowledge and Education

Criticism and Blame = RecidivismCriticism and Blame = RecidivismEncouragement and Education = Reduced Encouragement and Education = Reduced

Recidivism and Family InvestmentRecidivism and Family Investment

Response to Emotionally Disturbed Adult Is the subject a threat to self or

others Has the subject committed a crime Is the subject in a jeopardy situation Is the call a combination of the

above None of the above conditions apply

Protective Custody T 34-B 3862 Protective Custody If a subject is a threat to self or

others, they may be taken into protective custody and transported for an emergency mental health evaluation based upon this Maine Statute.

REFER to your handout

Officer can Voluntary transport

A voluntary transport precludes the Protective Custody Statute

Often assistance from family or friends is useful under this action

If a Crime is Committed Arrest and/or Summons the

Subject Transport to Correctional Facility Transport to a hospital for an

evaluation Once under arrest the officer must either maintain

custody until cleared by the mental health facility or bail the subject through either a bail bondsman or personal recognizance

Jeopardy Situation = unable to care of themselves Call your local Crisis Service for

evaluation Crisis will coordinate with other

agencies to provide needed care Crisis services state wide number 1-888-568-1112

Combination of Conditions

Which condition require immediate action and act accordingly. Life safety and/or the magnitude of the criminal act.

Multiple actions can be taken Arrest or Summons and

Protective Custody Summons and call Crisis Call crisis and disengage from

the subject if not imminent threat

No Threat, No Jeopardy, No Crime Disengage Call Crisis Services for Support if

appropriate Collaborate with family or friends

to assist Collaborate with community

Conclusion Review Goal Review Objectives Answer Questions