Safety Hug Curriculum - centralpt.comcentralpt.com/upload/477/OrientationDocuments/14182_SafetyHugCurriculum.pdfrespond to rationale and has trouble thinking of long and short‐term

1/16/2011

Safety Hug Curriculum

Page 2 Safety Hug Curriculum

TABLE OF CONTENTS

SECTION PAGES

1. Preventing the Use of the Safety Hug

Conflict De‐escalation Techniques

The Cycle of Self‐Control and Interventions at Each Stage

DISCUSSION: Proactive Approaches

SCENARIOS: De‐escalation

3‐10

2. Approved Technique: The Safety Hug

Approved Circumstances in which to Use the Safety Hug

Safety Hug Technique

DEMONSTRATION & PRACTICE: Safety Hug

11‐13

3. Why Doing the Safety Hug Right is So Important

Keeping Yourself & the Child Safe

Dangers Associated with Restraint

DISCUSSION: Dangers of Restraint

14‐15

4. Post Safety Hug Procedure

Safety Hug Order From

Safety Hug Documentation Form

16‐17

5. References 18


PREVENTING THE USE OF THE SAFETY HUG

CONFLICT DE‐ESCALATION TECHNIQUES

One‐on‐One Active Listening:

Stay calm: Speak softer, speak more slowly, look the child in the eyes.

Tune into your body language: Relax, take a deep slow breath, uncross legs and arms, take another deep breath, sit or stand at eye level ‐‐ neither one of you is up or down. Make sure your non‐verbal communication shows interest and support (e.g., maintain eye contact, nod at appropriate times, relaxed body posturing).

Posturing: Stay at eye level with the child and at least three feet away.

Suspend Judgment: Do your very best to remove your bias and judgment.

Empathize and listen: Perhaps that is all that they need. Sometimes staff talking and not listening discourages the child from wanting to share.

Notice Incongruence: Look for differences in what they are stating versus their facial expressions, body posturing, and tone. Sometimes the child is confused about their feelings or is guarded with their emotions initially.

Give "I" messages: I feel, I think, I wonder

Reflect what they are saying or presenting (“you look sad”; “I heard you say you were ready to come for your snack but your loud voice says to me that you’re still upset”).

Use de‐escalating words: maybe, what if, I feel, it seems like, I think, sometimes, perhaps, I wonder.

Remember to breathe: It’s important to keep yourself in check. Pay attention to what is happening to you during the escalation. Continue to keep yourself at a de‐escalated level.

Affirm and acknowledge the position and needs of the other(s). "I can understand why that would you would be upset by that... It sounds like your feelings were hurt... Thank you for your..." With practice, we can all understand and/or appreciate another's point of view or needs.

Ask open‐ended questions: These are questions that do not require yes or no answers. For example, "What are your thoughts on this?" Instead of, "Do you think we should do this activity?" Yes or No?

Take another deep breath. Listen to your voice. Is it calm? Relaxed? In control? Look at your body. Are your fists clenched? Are your lips pursed? Listen to your thoughts. Are you really listening to the child? Are you brainstorming alternative ideas or stuck in your mind with your original point of view? Can you find something that you appreciate about the other(s) positions, needs and/or feelings?

Encourage Solution Finding if Appropriate: Ask them what they would like to see happen and present choices


o Ask older kids to commit to a solution to their dilemma if the situation applies (“Give me two things you can do to take care of yourself tonight”)

Summarize: At the end of the one‐on‐one active listening session summarize what was said and anything decided.

Follow‐up: With the older kids, plan a time where you will follow‐up with what they committed (“How about I check with you tomorrow to see if those solutions worked”).

When actively listening AVOID:

Going into details

Probing questions

Interpretations

Harsh confrontation

Having conversations lasting longer than 10 minutes

Casting judgment

Doing all the work and talking

Interrupting

Raising your voice and aggressive mannerisms

Dealing with an Escalated Child: Children generally do not stay escalated for long periods. With proper intervention, they will eventually calm.

Remember to stay calm. Speak softer, speak more slowly, look the child in the eyes.

Decide if the child needs to take space. “Let’s go outside and chat or go to another room so I can hear what you have to say”).

To help avoid confrontation it may be appropriate to not "frontally" face your child. Stand facing them with your side. This body language is less threatening and puts you in a better self‐defense position should the child get out of control.

Get down on the child’s level

Quickly assess whether you can handle the situation on your own or need staff assistance. Involve other staff member

whenever necessary.

Keep safety a priority. Remember that the priority is to maintain safety of all clients.

Understand the cycle of escalation. Escalation can happen when feeding off someone’s emotions. If a child is upset with you and wants to get angrier they need to "hook" you into their game. If the child can get you as angry as the child is then it gives the child permission to become angrier. The more upset and angry you become the more the child can justify his or her continued escalation. Pacing is the same as they old saying, "It takes two to tango."

Remember children will try new ways to remain in control. When you no longer participate in the escalation game, the child will try something new to get you back on the Hook.

Stay in control. When is child has the least control of themselves it is the time for you to have the most control of yourself.


Speak in statements of fact. Avoid saying "if you don't... you can't..." or "If you'll... I'll let you..." Bargaining, bribery and threatening are ineffective with an emotional fragile child. It is far more effective to say in a matter of fact way, "When... Then..."

Redirect to calm down: “I know you said you don’t want to take a nap but I would like you to have a seat and take a few deep breaths first – you will probably feel better”. Always remember to give choices.

Help the child stay focused on the issue or task. Communicate one thought or idea at a time. Try to break down complex concepts into smaller ones or smaller steps.

Do not try to discipline or change the mind of a child while they are in crisis. Pointing out reality will only increase your child's frustration. Wait for the child to have a calm body and voice to talk with a child in order to get your point across. A child who is escalated generally does not respond to rationale and has trouble thinking of long and short‐term consequences. They are not ready to engage in solutions and problem solving.

A child is generally de‐escalated and ready for solution‐focused conversation when:

o They are have a calm body and voice (e.g., seated, voice lower, breathing more calmly)

o Are more focused on themselves and managing themselves versus worried about others or circumstances

o Have verbalized they are ready to find some solutions

Use Active Listening Technique: Once a child is at this point then use the active listening techniques outlined above.

Ask for help if you are unable to de‐escalate the child.

Specific Pre‐therapeutic hold Interventions:

Give the child choices and redirect.

Prompt the child to express his/her feelings with their words (such as yelling "I'm mad” and then having them ask to get in the angry box).

Let the child use an "angry box" or a "feelings box" that has squishy balls, bubble wrap, stomping feet, paper and crayons, and rabbit fur in it to help the child get their feelings out

Having the child "take space" (time out) on their own in a chair, sitting by the wall, or on a couch depending on the room. The place that a child takes space is consistent in the classrooms.

Have the child sit in a caregiver's lap (without a safety hug).

If the child calms down with these techniques, have the child problem solve and talk about their feelings.


CYCLE OF SELF‐CONTROL

Positive Behavior Support (PBS) is a general approach to help a child remain in control. The primary focus is to develop important learning outcomes and enhanced quality of life. There are times, however, when stress and crisis will occur. PBS includes taking appropriate action when necessary. PBS should also focus on taking an individualized approach to supporting a person when they are losing control. A child’s response to stress generally follows a pattern that includes: in control, stressed, losing control, out of control, stress easing, and regaining control. The cycle may vary to some degree depending upon the child’s ability to cope. The child may skip across the circle to a different level in response to the stress and type of support provided. Observers who recognize that a change is occurring in the child may improve the situation before the child loses control.


In Control

Staff’s Responsibility: Support the child to maintain “the calm.”

Suggested Actions:

Focus on the positives

Reinforce the child when they are calm

Be observant; know what “being calm” means to the child

Maintain the reinforcing environment

Have a sense of humor, be fun to be with

Include the child in all activities and choices when at all possible

Explain changes in advance

Help with transitions

Reinforce compliance and following directions and routines

Maintain at least a 4:1 praise/correct ratio of interactions

Build rapport

Develop a plan to minimize stress and/or what to do if the child is losing control before it happens

Practice coping with stress in a fun, non‐threatening way before it happens

Stress

Staff’s Responsibility: Support the child to help manage the stress or to minimize the stress

Suggested Action:

Ignore what can be ignored

Be prepared to apologize if you were the source of the stress

Reinforce positive behavior by praising, giving support, and interacting with the child when they are not upset

Provide extra assistance for difficult tasks

Do not expect the child to be perfect. Have developmentally appropriate expectations.

Explain changes in advance

Monitor the child’s body language

Provide tools to help the child cope with stress

Use active listening

Consider physical activities to release tension

Monitor own body language

Listen, be non‐judgmental, offer empathetic talk

Respect the child’s feelings; acknowledge their right to have them

Avoid power struggles. Change staff if need be.

Provide choices

Be prepared to change the “schedule” to accommodate stress

Respect personal space

Monitor own stress level

Look for the need behind the behavior and meet it

Sometimes a child just needs a boundary


Losing Control

Staff’s Responsibility: Provide support as the child is losing control.

Suggested Action:

Make eye contact; get down to the child’s level

Monitor potential safety concerns for child, self, and others

Lower your voice and speak more slowly

Use clear, concise language telling the child what they can do

Use reflective listening and show empathy

Give the child a chance to cooperate. Remember that some children need more time to process information when they are under stress.

Avoid showing tension and remain calm

Provide structure. Give two choices only. Do not nag!

Arrange the environment to minimize risks. Consider others in environment.

Remind the child of consequences in a neutral, matter‐of‐fact way

Notify other staff, if appropriate

Use behavior momentum or make request for known preferred action, i.e., “Hey, would you do ___________________ for me?”

Ignore what can be ignored

Offer relaxation techniques and be willing to do them together

Avoid power struggles; this is not a time to make demands

Use humor to distract or redirect when appropriate

Engage the child in problem‐solving or remind them what they practiced in the past that was helpful

Give the child some space, if appropriate

Say, “I’m going to count to three, and then I will help you do it.”

Out of Control Staff’s Responsibility: Control self and keep everyone safe Suggested Actions:

Respond to each child’s pattern of escalation

Use behavior specific talk, i.e., tell the person what they can do vs. what they can’t do

Use short messages. Reduce dialogue and interactions.

Be aware of other people in the environment and potential hazards; arrange the environment for safety in a subtle way

Remove demands

Remove the “audience,” if possible; sometimes taking away the attention stops the acting out

Identify a calm, safe environment the child may need to access and if needed, direct the child verbally to a safe, calm environment as you monitor from a safe distance

Do not take interaction personally

Be accepting of the child but not their behavior

Do not use a stressful situation as the time to teach or to lecture

Do not take away food or affection as a punishment.

Carefully assess the benefit of approaching or touching a child who is highly agitated. Allow them their personal space when at all possible.

Monitor own stress level and make appropriate adjustments or accommodations.

Do not overwhelm the child with too many people in the environment, too many demands, too much stimulations, etc.

Use safety hug as a last resort


Stress Easing

Staff’s Responsibility: Stabilize the situation

Suggested Actions:

Allow the child time to cry, and to calm down, and vent in a safe, quiet area

Remove stressors

Monitor from a safe and unobtrusive distance

Make sure the child has known relaxation items to access while they calm themselves

Be available

Approach calmly and tell them where you are and what you are doing. Give the child space to calm down (not talking to them and giving them physical space), but do not leave the room. Ask them to tell you when they are ready, or give them a time limit for being ready to talk when necessary.

Do not take interactions personally

Be prepared to restore the environment if it might cause the child to re‐escalate

Wait for the child to approach and show willingness to talk.

Monitor own feelings and level of stress. Seek assistance if necessary.

Regaining Control: After the Event

Staff’s Responsibility: Re‐establish the relationship and provide supports to enable the child to resume typical activity and to regain the “calm.”

Suggested Actions:

Let the child know you still care about them

Ask permission to approach

Be prepared to apologize if you unintentionally created or contributed to the stressful interaction

Follow routine as appropriate (at a minimum, keep structure of meals, circle, art, play time, meds, nap/bedtime, daily activities).

When the child is de‐escalated and ready, initiate problem solving about what just happened (in a neutral, non‐punitive manner). Explore the child’s feelings, give them suggestions about how to express those feelings in a healthy way, and have them repair the relationship with their peer or caregiver or property that initiated the situation (e.g. apologize for hitting or clean up spit from the floor)

Ask the child to apologize and make it right

If appropriate, help restore the environment together

Monitor your emotional level and seek assistance. Make changes as needed.

Notify appropriate professional(s) and write an incident report as required

Process interaction with supervisor and team members

Congratulate yourself for positive approaches and positive attempts to manage the situation

Develop additional personal strategies to help manage stress if self and/or child in the future


DISCUSSION

Instructions: Break into small groups (2‐4 people). Discuss the following questions. (Instructor: May divide questions among groups)

1. What are 5 key skills to use when active listening? 2. What are 5 key skills to use when de‐escalating an escalated child? 3. What are the stages of the Cycle of Self Control? What are 2 suggested interventions to use in

the Out of Control stage? 4. What is an advantage of using a proactive approach?

SCENARIOS Instructions: Break into small groups. Each group will take a scenario. Discuss what stage of the Cycle of Self‐Control the child is in and determine how to de‐escalate the situation (using the techniques outlined above). SCENARIO #1: Bridgette’s Scenario Bridgette, a six‐year‐old girl, is having a very, very bad day. So far, she is crabby, has cried a lot, hit John, and had two temper tantrums, and she has only been at child care for one hour! Now Bridgette and Sally both want to play with the ball. They are both screaming “It’s my turn.” SCENARIO #2: Jamie’s Scenario Jamie is nine years old. Her mother yelled at her and her brother last night for leaving toys on the floor. Jamie was frightened because abuse has been present in their relationship. They went to bed without resolving the issues. When Jamie arrives, she is visible upset and withdrawn. SCENARIO #3: Luke’s Scenario Luke (age 4) has a history of kicking and hitting when he does not get his way. On this day, Luke did not eat a very good breakfast nor take an adequate nap. By the afternoon he is very grumpy. He has been asked to clean up his toys in order to get ready for story time. Luke starts to cry, yell, and flail uncontrollably.


APPROVED TECHNIQUE: SAFETY HUG

Approved Circumstances Under Which One Can Use the Safety Hug: This is a form of passive restraint and is the ONLY form of restraint allowed at Odyssey House and only with clients that are children (ages 3‐10). Only trained staff members who have been “safety hug certified” by demonstrating competence in this technique are allowed to employ it. Parents are also allowed to restrain their own child. The initial assessment of a child determines whether a child may be adversely affected by a physical hold (health, physical abuse, etc.)

Safety hug to manage behavior must only be used under the following emergency circumstances and only if these elements exist:

The child’s actions pose an imminent risk of harm to him/herself or others.

Less restrictive measures appropriate to the behavior exhibited by the child have not effectively de‐escalated the risk of injury.

The safety hug lasts only as long as necessary to resolve the risk of danger or harm.

The degree of limitation or restriction of another person’s freedom of movement that is applied may not exceed what is necessary to protect the child’s or other persons from imminent bodily injury.

Safety Hug Technique:

For children who are unable to maintain safety of self or others despite use of non‐physical de‐escalation techniques, staff may use the safety hug. A witness (staff member not physically holding the child) must be present.

Step 1: The child is placed on the staff member’s lap with the child’s back against the staff member’s chest. This can be done in a sturdy chair or on the floor with the caregiver’s back agains a wall for support.

Step 2: The child’s arms are loosely crossed in front of the chest while the staff member gently holds the child’s hand or wrists. Make sure the child’s hand are on top of the caregiver’s (see detail picture on page 12).

Step 3: If child is kicking, staff member gently wraps the child’s legs under his/her own leg. Keep your head to the side of the child’s head (not directly behind theirs) for safety.

Step 4: Once the child in securely in the safety hug, engage in deep breathing, do not speak to the childmore than once per minute (and only to reassure them that you are keeping them safe and you will let go when they calm down).


Alert: The child is released from the hold as soon as the child regains control of his/her behavior. Therapeutic holds are limited to NO MORE THAN ONE HOUR and NO MORE THAN 8 TIMES IN ONE DAY. And the child must be assessed every 15 minutes by a trained competent staff member for signs of harm.

Step 9: Complete post‐safety hug procedure (see next page).

Detail pictures and modifications for smaller or larger children:

Step 8: When the child is ready to talk, problem solve. Ask the child why they were put in the safety hug. If they don’t know, explain it. Then discuss their feelings, how they can express those feelings in a healthy manner, and then have the child do repair work (apologize if they hurt someone, clean up, etc).

Step 5: Tell the child that when their legs are calm, you can remove your leg. When the child stops kicking, wait a few minutes for them to maintain their “calm legs” and then take your leg off. If the child begins to kick again, put your leg back on.

Step 6: After the child has kept the legs calm for a few minutes by themselves, tell them if they can keep their arms calm you will remove your arms. If the child cannot sit calmly on your lap after you remove your arms, put your arms back. If they can sit calmly on your lap for several minutes, move to step 7.

Step 7: See if the child can sit next to you or in their own chair, so the child can have the opportunity to regulate their emotions themselves. If they can maintain a calm body in their own space for several minutes, move to step 8. If not, go back to step 6.

Detail of hand position: hold your hand over the child’s hand and wrist, in order to support their wrist when they are

wiggling.

If the child is larger or stronger than the staff member, a second staff

member can hold the child’s legs.

For toddler aged children, a full safety is usually not needed. The child can just be in your

lap, and hold their hands and legs softly if

needed.


DEMONSTRATION & PRACTICE Instructions: The Instructor will:

1. Review the steps involved in the Safety Hug. 2. Demonstrate the technique. 3. Each individual will practice the technique.


WHY DOING THE SAFETY HUG RIGHT IS SO IMPORTANT

Since the safety hug technique is more intrusive, staff must:

Review techniques frequently for the safety of each person involved.

Provide documentation of the interaction including a safety hug documentation form as required.

Re‐establish rapport with the person after the interaction.

Be aware of danger for positional and restraint asphyxia and agitated delirium.

Remain aware of the age and medical condition of the person being restrained.

Keeping Yourself Safe:

Make sure your arms are underneath the child’s arms so he/she can’t bite you

Make sure your head is off to the side, so the child cannot head butt you

Make sure you are in a chair or against a wall, so avoid unnecessary jostling Keeping the Child Safe: Odyssey House only approves the use of the Safety Hug because more restrictive, prone restraints are very dangerous. Even though, at Odyssey House, we only use the Safety Hug, it is important to know what could potentially happen if the Safety Hug was done incorrectly. Literature show that injury and death during restraint, particularly for those in a state of agitated delirium (a clinical syndrome described below), is not an uncommon phenomenon but one infrequently reported in medical literature. The mechanism of death is a sudden fatal cardiac arrhythmia or respiratory arrest due to a combination of factors causing decreased oxygen delivery at a time of increased oxygen demand.

Positional Asphyxia is most likely to occur when a person is placed in a prone position; however, it is a danger whenever a hold, lift, or restraint is used.

Positional Asphyxia is insufficient intake of oxygen as a result of body position that interferes with one’s ability to breathe

Restraint Asphyxia is a form of positional asphyxia that occurs during the process of subduing and restraining an individual in a manner causing ventilation compromise

o As a consequence of the restraint application, respiration is compromised causing insufficient oxygen in the blood to meet the body’s oxygen needs or demands (hypoxia) which then results in a disturbed heart rhythm (cardiac arrhythmia)

Research studies and the literature have suggested a combination of factors that place a person at risk of positional asphyxia. They include:

o Position during restraint (particularly the prone position) o Agitated delirium syndrome

Risk factors for positional asphyxiation include:

Excessive body weight: If a subject is obese, the excess fat tissue is forced upwards into the abdominal cavity, pressing on and immobilizing the diaphragm.

Prolonged struggle or physical exertion

Respiratory syndromes including asthma and bronchitis

Pre‐existing heart disease including enlarged hear and other cardiovascular disorders

Epilepsy


Agitated Delirium:

Agitated delirium (or excited delirium or acute exited states) is a condition of extreme mental and motor excitement characterized by aggressive activity with confused and unconnected thoughts, hallucinations, paranoid delusions and incoherent and meaningless speech.

Victims display extraordinary strength and endurance when struggling, apparently without fatigue. Hyperthermia, or extremely high body temperature, is often part of this syndrome.

Visual Signs of Distress:

Change in facial color (purple, red, pale, etc.)

Bulging eyes/veins

Rapid and shallow breathing patterns

Blue coloring to the nail beds

Similar to signs of shock as described in First Aid/CPR training

Vomiting

Confusion/disorientation

Additional Risks: There are additional physical, emotional, and relationship risks present when one decides to physically intervene with a person, e.g. injury to muscles; bones, joints; abrasions, contusions, bruising; emotional damage; and adverse impact on the relationships and therapeutic goals if done inappropriately for the purposes of punishment or if pain is caused).

DISCUSSION Instructions: Break into small groups (2‐4 people). Discuss the following questions. (Instructor: May divide questions among groups)

1. How do you and your team recognize signs of distress and how should you respond? 2. Discuss how the history of sexual or physical abuse may affect the way in which an

individual served reacts to physical contact. 3. Discuss the dangers of any restraint.


POST SAFETY HUG PROCEDURE

Step 1: Complete the Safety Hug Authorization Form (see form on following page; also available on L Drive)

Step 2: As soon as possible, but no longer than one hour after the initiation of the safety hug qualified staff do the following:

a) Notifies and obtains an authorization (verbal or written) from a licensed mental health professional (see form below; also available on the L Drive) b) Consults with the licensed mental health professional about the physical and psychological condition of the individual served

Step 3: The licensed mental health professional does the following:

a) Reviews with staff the physical and psychological status of the individual served (When necessary, modify the child’s plan for care, treatment, or services) b) Supplies staff with guidance in identifying ways to help the individual regain control so that future safety hugs can be prevented c) Supplies an authorization for the safety hug (verbally or written) and documents in client file

Step 4: Staff contacts the family/guardian as soon as possible to notify them of the use of the safety hug. Step 5: A licensed mental health professional evaluates the individual who received a safety hug in person within two hours of initiation.

SAFETY HUG AUTHORIZATION

CHILD: RESTRAINING STAFF:

DATE/TIME OF SAFETY HUG: TIME ORDER GIVEN:

LMHP GIVING ORDER (WITHIN 1 HOUR):

I, ____________________________, have evaluated the physical and psychological condition of the above child post‐safety hug (within 2 hours of initiation of the safety hug):

LMHP Signature: _____________________________________________Time: ______________Date: ___________


SAFETY HUG DOCUMENTATION

CHILD: RESTRAINING STAFF:

DATE: TIME INITIATED: TIME ENDED:

DOB: AGE: LOCATION:

PARENT(S): CASEWORKER: Personnel involved in incident (additional documentation may be attached if determined necessary): _____________________________________________________________________________________________

Why was the child put in a safety hug? _____________________________________________________________________________________________

Describe the child’s activity and behavior directly before the behavior that prompted the safety hug: _____________________________________________________________________________________________

Describe efforts to de‐escalate and alternatives to the safety hug that were attempted: Actively listened Asked child to take space Gave boundaries Gave choices Counted to three Asked child to express feelings with words Used angry/feelings box Child sat in lap (w/o Safety Hug) Offered relaxation techniques Other: _____________________________

Describe the actions of the child and employee during the safety hug: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Describe observed child and employee behaviors following the safety hug: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Describe de‐escalation techniques and interventions utilized following the safety hug: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Describe any injuries to the child, other children, or employee(s): _____________________________________________________________________________________________

_____________________________________________________________________________________________

Safety Hug was used as a last resort: Yes No If not, what future interventions or alternatives to the safety hug could be utilized for this child: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Findings of debriefing meeting: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Signatures: Employee Completing Form: _________________________________________ Date: _______________________

Program Coordinator: ______________________________________________ Date: _______________________

Witness of Incident: ________________________________________________ Date: _______________________

LMHP: ___________________________________________________________ Date: _______________________

Notification to Parent& or Caseworker/Guardian: Parent(s) Caseworker Guardian

Type: ______________ Date & Time: _______________________ By whom: _______________________________


REFERENCES

1. Odyssey House Restraint & Seclusion Policy & Procedure 2. Creating Strategies, De‐escalate a Conflict

http://www.creatingstrategies.com/articles/communication_tips/deescalate_a_conflict 3. Families.com, Learning to De‐Escalate Emotional Situations With Children

http://adoption.families.com/blog/learning‐to‐de‐escalate‐emotional‐situations‐with‐children 4. Starstab.com, Child Guidance: Communication

http://www.starstab.com/20%20hr%20Basic%20School‐age%20wkbk%20part%202.pdf 5. Least to most restrictive intervention: A continuum for mental health care facilities. Mary L.

Kozub; Rick Skidmore. Journal of Psychosocial Nursing & Mental Health Services; Mar 2001; 39, 3; ProQuest Psychology Journals

6. Support, Options, Actions for Respect (SOAR): An Approach for Positive Interactions. Utah Association of Community Services. 2006