Module #5: Behaviors

Contents

5.1 Overview of Behaviors
5.2 Definition of Behaviors 
      -- High-Risk Behaviors
      -- Self-Injurious Behaviors
      -- Aggressive or Offensive Behaviors
      -- Lack of Behavioral Controls
5.3 Frequency of Behavior
5.4 Current Intervention Category 
5.5 Duration of Behavior
5.6 Unable to Describe Child
5.7 Current Interventions have Extinguished the Child's Behavior

This section serves two purposes:

1. To allow screener to describe behavioral symptoms in any child, and
2. To present existing criteria for functional eligibility for Psychiatric and Developmental Disability target groups.

"Behaviors" is a separate section from "Mental Health" on the CLTS FS. Screeners may check behavior boxes for children who do not have emotional disability or mental health symptoms. The Behavior section allows the screener to describe behavior problems that result from cognitive, emotional or social impairments.

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5.2 Definition of Behaviors

The behaviors listed are precisely defined to increase inter-rater reliability. Please follow the definitions precisely and contact designated State Clinical Staff with questions.

HIGH-RISK BEHAVIORS

1. Running Away
Impulsive flight to unsafe locations with the intention of not returning. These are children who will be living on the street if intervention is not provided.

Examples for children under 6 years old:

This behavior is checked for children who:

• Run off in a store and leave the building without notice.
• Run away in their home neighborhood and cannot be found with reasonable effort.

This behavior is NOT checked for children who:

• Run off to a known location, such as their favorite play structure in a neighborhood park or a friends' house.
• Bolt away from their parent/caregiver but stay within a reasonable distance (e.g., runs from the back yard to the front yard).
• Wander off without supervision.

2. Substance Abuse
Use of illegal drugs including alcohol or misuse of prescription medications. This does not include use of tobacco products.

3. Dangerous Sexual Contact
A child who is a victim of sexual behavior (intercourse, oral sex, or other genital contact) even if the child willingly engages in the activity. This includes contact with sexual partners from the internet (i.e., face to face or by webcam), having substantially older sexual partners or having sex with strangers.

4. Use of Inhalants
Inhalants are substances that can be inhaled from an aerosol can, a cloth or cotton ball that is soaked with an inhalant, a plastic bag, or balloon, and will cause a mind-altering effect within 2-5 minutes after inhaling.

Commonly used inhalants: Correcting fluid, degreasers, paint remover, paint thinner, aerosol deodorant, aerosol fabric spray, aerosol hair spray, aerosol cooking spray, aerosol cleaning products, whipping cream containers that contain nitrous, spray paint, nail polish remover. Less commonly used inhalants: felt tip markers, gasoline, dry cleaning fluid, and glue

Important note: Inhalants can cause damage to all organs, including the brain, but the damage can be reversible if the use of inhalants stops after a short period of time (within a few months). If the inhalant use is not stopped within that time period, then the damage to the organs is irreversible and the child will face significant medical and psychological impairment that will last a lifetime.

SELF-INJURIOUS BEHAVIORS

1. Head-banging
Repeatedly banging one's head against hard surfaces. This does not include children who bang their heads due to sensory integration or visual/hearing impairments.

2. Cutting or Burning or Strangulating Oneself
Repetitive cutting open the skin with a sharp object like a knife or razor, or repetitive burning one's skin with a lighter, candle, or stove. Excessive piercing or tattooing is not self-injury if the primary purpose is body decoration or to fit in with peers. Non-lethal strangulation involves the production of unconsciousness or near unconsciousness by restriction of the supply of oxygenated blood to the brain: the act of suffocating by constricting the windpipe.

3. Biting Oneself Severely
A severe form of self-mutilation that can lead to: the loss of lips and fingers from biting. A child that engages in this behavior will attempt to rupture the skin, may bleed, and will most likely scar. A child that bites their nails or cuticles because of a nervous habit would not be considered a child that self-mutilates.

4. Tearing At or Out Body Parts
A severe form of self-mutilation which can lead to vision loss from rubbing the eyes, picking and tearing at the nose and ears, and any number of other severe injuries. A child that picks at a scab or scratches until a body part bleeds would not be considered a child that self-mutilates. It also does not include hair pulling. Severe hair pulling, for which the child is diagnosed with Trichotillomania is captured on the diagnosis page.

Reasons for Self-Injurious behaviors:

• Rapidly reduce the tension in their body and mind.
• Relieve their emotional pain caused by feeling worthless, angry, fearful, abandoned, depressed, anxious, or trapped.
• Feel pain that tells them they are "alive" thus warding off emotional detachment.
• Regain control since turning mental and emotional pain into physical pain is easier for them to handle.
• Punish themselves for real or perceived offenses like being bad, fat, ugly, stupid, or guilty.
• Express anger/rage when words or outward actions are unacceptable or when the pain is too severe to put into words.

5. Inserting Harmful Objects into Body Orifices
Harmful objects include anything that can puncture the skin such as scissors, knives, pens and pencils. Other objects that cannot cut, tear or puncture the skin such as food, paper products, cotton balls coins and fingers should not be considered when answering this question.

AGGRESSIVE or OFFENSIVE BEHAVIOR TOWARD OTHERS

1. Verbal Abuse
To be considered abusive, words must:

1. Be presented in a threatening, harassing, or violent manner, AND
2. Be reasonably expected to cause physical, sexual, or mental harm.

This is not to be checked for children who yell, scream, shout or use profanity or other bad language unless the above requirements are met. It is a rare child who rises to this level of verbal attack. A measurement of harm is whether the abuse is of such severity that the target of the verbal assault requires professional intervention to address the physical, sexual or mental harm.

Do not duplicate with Serious Threats of Violence. If violence is expected, check Serious Threats of Violence rather than Verbal Abuse. "Bullying" is considered only if it meets criteria "a" and "b" above.

2. Hitting, Biting, or Kicking
Expression of anger through these behaviors beyond an age appropriate level. Must involve a pattern of aggressive behaviors rather than a single incident. May be a result of a rage reaction in older children but should not be counted when included in a temper tantrum in young children. Note: rage is characterized by an unpredictable and primitive display of violence that is out of proportion to the provoking event and often threatens serious self-injury or harm to others. Hitting, biting, and kicking are not considered aggressive behaviors if a child is reacting due to frustration from a communication/language disorder.

3. Masturbating In Public
Masturbation is not abnormal or excessive unless it is deliberately done in public places after age five or six, when most children learn discretion and masturbate only in private.

4. Urinating on Another or Smearing Feces
Urinating on another is understood as literally urinating on another person. This does not include accidental urination during normal elimination in a bathroom or on a changing table. This does not include urinating in inappropriate places such as public parks, etc. It only applies to children who urinate directly on another person. Smearing feces involves intentional spreading of feces onto inappropriate places such as on the floor/walls/furniture.

5. Serious Threats of Violence
Threats about hurting or killing someone or a group of people. This doesn't include suicidal threats as that is covered on the Mental Health page. This involves a sequence of overt, serious, hostile behaviors or threats directed at peers, teachers, parents or other individuals. This is not to be mistaken with the child who expresses their anger at having too much homework by saying in the cafeteria over lunch, "I hate school, I want to kill my teacher." The threat must be perceived by anyone who witnesses it as a true threat of violence.

6. Sexually Inappropriate Behavior Toward Children or Adults
This behavior is a prominent motivation in a child's life when interacting with others. It includes when sexual play or behaviors are not welcomed by others, including inappropriate sexual comments or gestures, mutual sexual activity with other children, or sexual molestation and abuse of other children or adults. Examples are: aggressive attempts to undress, sexually touch, or attempt intercourse.

7. Abuse or Torture of Animals
Abusing an animal to find power/joy/fulfillment through the torture of a victim they know cannot defend itself. Includes abusing animals for no obvious reason. Note: nearly all children go through a stage of "innocent" cruelty during which they may harm insects or other small animals in the process of exploring their world. Most children, however, with guidance from parents and teachers, develop empathy for the pain animals can suffer.

LACK OF BEHAVIORAL CONTROLS

1. Destruction of Property / Vandalism
Destruction of Property involves destroying the property of others by means other than fire setting. The intentional destruction of property is popularly referred to as vandalism. It includes behavior such as breaking windows, slashing tires, spray painting a wall with graffiti, and destroying a computer system through the use of a computer virus. Vandalism is a malicious act and may reflect personal ill will, although the perpetrators need not know their victim to commit vandalism.

2. Stealing, Burglary or Kleptomania within the Community

• Stealing means taking the property of another without right or permission. For the purposes of the CLTS FS, it does not include taking property from the child's own home as it must occur within the community.
• Burglary is the unlawful entry into a building or other structure with the intent to commit an illegal act.
• Kleptomania is a condition in which a person is compelled to steal things, generally things of little or no value, such as pens, decorative pins, or wall decorations. They are often unaware of performing the theft until some time later.

3. Obsessions Interfering with Daily Life
An obsession is a thought, a fear, an idea, an image, or words that a child cannot get out of his/her mind. The child experiencing the obsession is aware of but is unable to control the influence of their own though patterns. Only select obsession, or the related compulsive abnormal actions or immobilization, as a behavior if:

1. It prevents the child from participating in activities of daily life such as hygiene tasks, sleeping, leaving the house, walking on certain pavements, or sharing community equipment with others, AND
2. It affects the child's functioning throughout the day.

4. Other (list)
Not only does the child for whom this answer would be filled in and selected have to demonstrate this listed very atypical behavior, but that behavior also must be so extreme that it affects the child's ability to be in a variety of settings because it causes serious problems for others around them. In summary, this option is reserved for a behavior that meets ALL of the following characteristics:

1. Cannot be captured in any of the other behavior options,
2. Occurs in a variety of settings (home, school and community), AND
3. Causes extreme distress/disruption to others.
   
   

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5.3 Frequency of  Behavior

When answering this question, consider the behavior each month over the past 6 months. Frequency is measured in days rather than episodes.

• Never
• Less than once a month
• 1-3 days each month
• 1-3 days each week
• 4 or more days each week

If the behavior was present within the past 6 months but no longer occurs, indicate frequency as "Never."

• Example: The screener meets a child who was engaging in self injurious behaviors as recently as 5 months ago but was put on medications and has not engaged in that behavior since. The screener would not select a frequency (other than Never) for this behavior.

If the behavior is new, indicate the current frequency of the behavior.

• Example: The screener meets a child who ran away from home for the first time 2 weeks ago, and there was no indication that this behavior was a one time episode. The screener would check "Less than once a month" for this behavior.
• Example: The screener meets a child who starting cutting their arm three weeks ago. The child is engaging in this behavior at least 2-3 days a week. The screener would check "1-3 days each week."

If the behavior fluctuates on a predictable basis, indicate the predictable frequency of the behavior.

• Example: The screener meets a child who always has difficulty with aggression towards others on a cycle of one to two weeks every month. During these weeks, the child will be severely aggressive with hitting, kicking and biting others on a daily basis. Then the behavior stops but always returns the next month for a week or two. The screener would check "4 or more days each week."

If the behavior fluctuates and is not predictable, then consider it more "episodic" and select "Less than once a month."

• Example: The screener meets a child who will bang their head severely but there is no pattern to this behavior. In the past 6 months the child engaged in this behavior 2 days the first month, not at all the second or third month, 8 days the fourth month, not at all the fifth month and just banged their head twice in the last week. The screener would check "Less than once a month."

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5.4 Current Intervention Category

Select the category that is most often used to address the child's behavior. Consider any intervention listed under the category, the current intervention does not need to include all the listed interventions. Use the Intervention Category that is most often used with the specific behavior, even if the behavior is not under control at this time. If caregivers do not intervene, ignore the behavior, or only use occasional time outs, check "None" for intervention.

TIME OUT / SUPERVISION
 --  Regular time-outs
 --  Restricted community access
 -- Constant supervision ("in-line of sight")

• Regular time-outs:
  Child requires frequent breaks from activities in order to regain a state of calm behavior. This does not include use of grounding or removing privileges as punishment for a behavior. This does include a child on an in-school suspension.
  
  
• Restricted community access:
  A specific treatment or intervention decision has been made to restrict this child's access to the community to prevent harm to themselves or others. The restricted access must involve multiple community locations. It may include out of school suspensions as long as it is in conjunction with other community restrictions.
  
  
• Constant supervision ("in-line of sight"):
  Child needs constant supervision by one or more adults. This is regular supervision throughout the day. This child does not need someone within an arm's distance but does need someone within the same room to provide supervision for safety.

MEDICAL / PROFESSIONAL TREATMENT
 --  Professional medical treatment
 --  Regular professional therapeutic treatment
 --  Regular use of protective gear
 --  Environmental restraints
 --  Constant supervision ("within arm's reach")

• Professional medical treatment:
  Child's behavior results in injury to themselves or others such that the injured person needs medical attention at a clinic or hospital. This is not the child who causes injuries that can be mended using traditional first aide (for example, Band-Aids for cuts or ice for bruises).
  
  
• Regular professional therapeutic treatment:
  Child's behavior is addressed through consistent behavioral or psychotherapeutic intervention with a psychiatrist, licensed psychologist, clinical social worker or marriage and family therapist. Child benefits from an implemented therapeutic plan developed with professional oversight. This does not include monitoring or administration of a medication regime.
  
  
• Regular use of protective gear:
  Child must wear protective gear to avoid injury to themselves or others.
  
  
• Environmental restraints:
  Child needs to have exterior doors of their home double locked, have specialized locks on windows, and/or the use of door alarms to ensure their safety or the safety of others.
  
  
• Constant supervision ("within arm's reach"):
  Child's behaviors require that others be able to quickly physically intervene to assure physical safety.

EMERGENCY
 --  Urgent or emergency medical treatment
 --  Police involvement

• Urgent or emergency medical treatment:
  Child's behavior resulted in an individual requiring immediate medical intervention or necessitated calling an ambulance. This could be the result of self injurious behaviors. Remember that violent acts that result in inpatient care for the victim are covered on the Mental Health page under Violence.
  
  
• Police involvement:
  Child's individual behavior has resulted in a call to the police and they arrive on site. It does not matter if charges were filed; the fact that police were involved is enough.

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5.5 Duration of Behavior

Expected to last 6 months or longer?

If the behavior is chronic, then check "yes" to this question. If the screener is uncertain, check "yes" to give the child the benefit of the doubt for the next year but be certain to review again at time of re-screen.

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5.6 Unable to Describe Child

There may well be many behaviors that children demonstrate that will not be reflected in the questions asked on the CLTS FS. As with ADL/IADL questions, the CLTS FS is set up to capture items that will affect functional eligibility and that is why behaviors need to be of a more extreme nature. If the screener wishes to document behaviors not reflected in the very specific CLTS FS questions, those behaviors can be described in the Notes section.

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5.7 Current Interventions have Extinguished the Child's Behavior

If the child exhibited behaviors and then started some type of physical/therapeutic intervention to address those behaviors, the screener needs to consider whether those behaviors could resurface if the physical/therapeutic interventions are removed. Types of physical/therapeutic intervention may include:

• In Home Therapy for children with Autism
• Day Treatment
• Treatment foster homes

If the professionals involved agree that the child's behaviors would resurface if the interventions were discontinued, then the screener is directed to check the behavior/frequency/intervention of the specific behavior prior to receiving the intervention. DO NOT try to predict what the behavior would be in the future; simply rely on the information available prior to treatment.

In this context, physical/therapeutic interventions do not include medications. If a child is on a medication and is no longer exhibiting a specific behavior or the level of frequency has changed as a result of the medication, then only check what is currently (within the past 6 months) true for the child.

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