CLTS FS Instructions Module 5 - Behaviors

Contents

5.1 Overview of Behaviors
5.2 Definition of Behaviors
-- High-Risk Behaviors
-- Self-Injurious Behaviors
-- Aggressive or Offensive Behavior Toward Others
-- Lack of Behavioral Controls
5.3 Frequency of Behavior
5.4 Current Intervention Category
5.5 Duration of Behavior
5.6 Describe Behavior in Detail
5.7 Unable to Describe Child
5.8 Evaluating the Child not the Child in Services

5.1 Overview of Behaviors

This section allows screeners to describe behavioral symptoms that fall into “High Risk, Self-Injurious, Aggressive or Offensive, and Lack of Behavioral Controls.” If a screener checks a behavior, they will be asked about its “Frequency” and the “Interventions” in place to prevent or control it. “Frequency” ranges from “Never” to “4 or more days each week” and represents the average occurrence of the behavior over the last six months. “Interventions” are divided into three categories: Timeouts/Supervision, Medical/Professional, and Emergency. Finally, each behavior that is checked will have a “Notes” section. The screener should use these sections to describe the behavior in detail.

5.2 Definition of Behaviors

Please follow the definitions and contact designated state or Wisconsin Department of Health Services (DHS) staff with questions.

Determining needs of the Child, not the Child in Services: In understanding behaviors in children for the purposes of the screen, you are considering the child without services, excluding medication. Parents, schools, providers and other caregivers may have plans (formal or informal) in place to address the child’s behaviors.

As an example, a child who acts out aggressively when overstimulated in the classroom may spend gym time in an alternate environment to prevent the physical aggression that would otherwise occur. In this situation, the trigger or stimulus is removed, and the child is not engaging in the aggressive behavior. However, the child has also not internalized the self-regulation skills needed to interact successfully in gym class, so the occurrence and frequency of this behavior, if this accommodation was not in place, should be considered.

Another example of this concept is a child who runs away frequently but is no longer engaging in this behavior because their caregivers have installed safety measures to prevent this behavior from occurring (locks on doors/windows). However, in understanding this child, it would be appropriate to ask their caregiver what would happen if these measures were removed. If the child would resume the behavior, this item would be checked. This would not be checked when a child has internalized the skills needed to prevent the behavior and does not need outside controls.

Take note of this concept when interviewing: A caregiver will often know what triggers will lead a child to a particular behavior and will instinctively take action to ensure the child is successful when that trigger occurs. Interview caregivers to understand the extra measures they instinctively take to care for children.

High-Risk Behaviors

• Running Away—Impulsive flight without regard to safety.

This behavior is checked for children who:

• Run off in a store.
• Leave a building without notice.
• Run away without regard for safety or where they are going (for example, darting out in traffic, unaware of surroundings).
• Run as an emotional response or due to a lack of awareness of rules or structure.

This behavior is not checked for children who:

• Run away from their parent or caregiver but never go out of the caregiver’s eyesight.
• Wander off without supervision but are aware of their surroundings and are able to return to home or school independently.
• Substance Abuse—Use of illegal drugs including alcohol or misuse of prescription medications. This does not include use of tobacco products.
• Dangerous Sexual Contact—A child who is a victim of a sexual act/assault (including, but not limited to, sexual abuse, human trafficking, intercourse, oral sex, genital contact, exposure). This includes virtual/visual sexual “contact” via the internet (e.g., face-to-face, text, video, or social media), having substantially older sexual partners or having sex with strangers. This does not include peer-to-peer, consensual sexual contact.
• Use of Inhalants—Inhalants are substances that can be inhaled (huffing) from an aerosol can; a cloth, or a cotton ball that is soaked with an inhalant; a plastic bag; a gas tank of a car; or a balloon. This will cause an immediate, mind-altering effect after inhaling.
  • Examples (not an exhaustive list): Correcting fluid (“White-out”), degreasers, paint remover, paint thinner, containers that contain nitrous (aerosol cans, balloons, etc.), spray paint, nail polish remover.

Self-Injurious Behaviors

In evaluating self-injurious behaviors, think about how often the behaviors occur and to what extent. It does not matter why a behavior occurs or under what circumstances (self-stimulation, regulation, frustration, etc.) but to the degree of injury/potential injury of that behavior.

• Head-banging—Repeatedly banging one’s head which can lead to injury. Banging one’s head without regard for the surface that they are hitting.

• Cutting or Burning or Strangulating Oneself—Repetitive cutting of the skin with a sharp object, burning of one’s skin including friction burns, or strangulation resulting in unconsciousness or near unconsciousness. This includes any abuse of current fad or social media challenges that pose a threat to the child’s safety and health (e.g., ice cube challenge or choke out challenge). If these behaviors are occurring with suicidal intent, they need to be captured as suicidality under Mental Health.

  Injury that leaves a mark that disappears in a few hours would not meet these criteria. However, injury that requires time for the skin to heal does meet the criteria for self-injurious behavior.

• Biting Oneself Severely—Biting is a severe form of self-mutilation that can lead to damage of the body. A child who engages in this behavior will rupture the skin, which may bleed and scar. A child who bites their nails or cuticles because of a nervous habit would not be considered self-injurious. An injury that leaves a mark that disappears in a few hours would not meet these criteria. However, injury that breaks the skin and requires time for the skin to heal does meet the criteria for self-injurious behavior.
• Tearing At or Out Body Parts—Severe self-mutilation from rubbing the eyes, tearing their nose and ears, and any number of other severe injuries. A child who picks at a scab or scratches until a body part bleeds would not be considered self-injurious unless the injury requires intensive treatment.
• Inserting Harmful Objects into Body Orifices—Harmful objects include anything that can puncture the skin, such as scissors, knives, pens, and pencils. It also includes items that can cause physical harm or illness such as coins, batteries, and inedible objects.

Aggressive or Offensive Behavior Toward Others

• Hitting, Biting, or Kicking—The aggressive behavior involves multiple victims on an ongoing basis (meaning the behavior does not just occur once or twice). Aggression is beyond an age-appropriate level when two of the following are present:
  • Child cannot regulate their body to cease the behavior.
  • Child approaches the incident with the intent to cause harm to others.
  • Others cannot stop the aggression with typical caregiving strategies.
  • The situation requires one or more of the following interventions:
    • An intervention plan (formal or informal) which includes adult intervention to cease the behavior, or avoidance of the stimuli triggering the behavior.
    • Use of physical protective measures, including the removal of other children from the vicinity or the removal of the child from others.
    • Physical intervention.
    • Police or police liaison intervention.
  • Child’s repeated acts of aggression have created an atmosphere of fear.
  • Victim sustains injuries severe enough to require medical attention.
• Masturbating in Public—Masturbation is not abnormal or excessive unless it occurs to the point of injury or is done in public places after age five or six, when most children learn discretion and masturbate only in private.
• Inappropriate elimination—Urine, feces, or other bodily fluids (including spit or menstruation)—This includes intentional urinating or defecating in inappropriate places, such as public parks and living spaces, containers, etc. Smearing feces involves spreading of feces on the floor, walls or furniture. This does not include accidental elimination.
• 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 overt, serious, hostile behaviors or threats directed at one or more people. The threats must be perceived as true threats of violence.
• Sexually Inappropriate Behavior Toward Children or Adults—This behavior includes when the child’s sexual play or behaviors are not welcomed by others. This can include inappropriate sexual comments or gestures, or sexual molestation and abuse of other children or adults. Examples are aggressive attempts to undress, sexually touch or grab, or attempt intercourse.
• Abuse or Torture of Animals—Abusing animals to find power, joy, or fulfillment through the torture of victims they know cannot defend themselves. Most children, with guidance from parents and teachers, develop empathy for the pain animals can suffer.

Lack of Behavioral Controls

• Destruction of Property/Vandalism—Destroying or vandalizing the property of self or others by means other than fire-setting (arson is covered in “Rare/Extreme” questions). Destruction of property can occur if a child is unable to regulate their emotional response to what is happening in their environment. If the behavior is significant (occurs repeatedly, produces damage), this behavior must be considered. Some examples include destroying objects in a child’s home or community.
  
  It includes behavior such as breaking windows, slashing tires, spray painting a wall with graffiti, and destroying a computer system with a virus.
• 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, apart from money, credit cards, or valuables that are taken for the purposes of making money.
  • Burglary is the unlawful entry into a building or other structure with the intent to commit any theft or felony inside.
  • 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 sometime later.
• Other (list)—Extreme, atypical behavior that affects the child’s ability to be in a variety of settings because it causes serious problems for others around them. This option is reserved for a behavior that meets both of the following characteristics:
  • Cannot be captured in any of the other behavior options. The screener should ensure the behavior does not fit under any other category, as behaviors listed under this category are not included in the eligibility calculation.
  • Causes extreme distress or disruption to others.

The screener should explain these behaviors in detail within the notes section.

5.3 Frequency of Behavior

When answering this question, consider the behavior each month over the past six months. Frequency is measured in days rather than episodes. The frequency is captured as it would occur without current interventions in place.

• 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 six months but no longer occurs and there are no current interventions in place, indicate frequency as “Never.”

When answering questions regarding the frequency of behaviors on the functional screen, the screener must remember to consider the impact of current interventions on the child’s behaviors. If the professionals involved agree that the child’s behaviors would resurface if they discontinued current interventions (except for medications), the screener must record the frequency of the child’s behaviors prior to receiving the interventions. See section 5.8 of instructions for further guidance.

Example A: The screener meets a child who was engaging in self-injurious behaviors as recently as six months ago but was put on a behavioral action plan and has not engaged in that behavior since. The screener would select a frequency of “Never” for this behavior because the behavior occurred outside the six-month window.

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

Example B: The screener meets a child who ran away from home for the first time two weeks ago, but the behavior will likely occur again. The screener would check “Less than once a month” for this behavior.

Example C: The screener meets a child who starting cutting their arm three weeks ago. The child is now engaging in this behavior at least two or three 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 D: 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 on a daily basis. The behavior then stops but always returns the next month. The screener would check “4 or more days each week.”

If the behavior fluctuates and is not predictable, consider it more “episodic” and select the average frequency of the behavior over the past six months.

Example E: The screener meets a child who will bang their head severely but there is no pattern to this behavior. In the past six months the child engaged in this behavior two days the first month, not at all the second or third month, eight days the fourth month, not at all the fifth month and twice in the last week. The screener would select the average frequency of the behavior over the past six months, or “1-3 days each month.”

5.4 Current Intervention Category

If only one type of intervention has been used in the last six months to counteract a behavior, select the category that best matches that intervention (e.g., if a child that becomes aggressive is always calmed by a time-out, the screener should select “Timeout/Supervision”).

If multiple interventions have been used that represent different intervention categories, select the most extreme intervention that has been used in the past six months and may be used in the future (e.g., if a child that normally calms with timeouts was aggressive to the point police were called to intervene, the screener must select “Emergency”). Remember to consider the child vs. the child with interventions in place when choosing an “Intervention Category” and frequency.

Timeout/Supervision

• Regular timeouts
• Restricted community access
• Constant supervision (“in-line of sight”)
  • Regular time-outs: Child requires frequent breaks from activities to regain a state of calm behavior; this includes in-school suspension. This can include grounding or removing privileges as punishment for a behavior.
  • Restricted community access: Restricting the child’s access to the community to prevent harm to themselves or others.
  • Constant supervision (“in-line of sight”): Child needs constant supervision by one or more adults throughout the day. The adult(s) do not need to be within arm’s distance but must be in the same room for the safety of the child and others.

Medical/Professional Intervention

• Professional medical treatment
• Regular professional therapeutic treatment/intervention (school professionals, CCS, Mental Health Wraparound)
• Regular use of protective gear
• Environmental limitations
• Constant supervision (“within arm’s reach”)
• Interventions taught/recommended to parents/caretakers and used
• Evidence-based Interventions parents/caretakers have sought out and used
  • Does not include having a medication prescribed to address behavioral issues
• Professional medical treatment: Child’s behavior results in injury to themselves or others that required medical attention from a health professional. Do not check this box for injuries that were mended using first aid (Band-Aids for cuts, ice for bruises).
• Regular professional therapeutic treatment: Child’s behavior addressed through consistent behavioral or psychotherapeutic intervention as part of a plan developed with professional oversight. Such professionals could be a psychiatrist, licensed psychologist, clinical social worker, marriage and family therapist, or a school psychologist/therapist. This does not include monitoring or administration of a medication regimen.
• Regular use of protective gear: Child must wear protective gear to avoid injury to themselves or others.
• Environmental Limitations: Child’s behavior is such that they need to have certain safety measures in place, such as an exterior door locks, fencing, a GPS device attached to the child, or alarms in place to ensure their safety or the safety of others.
• Constant supervision (“within arm’s reach”): Child’s behavior requires that adult(s) are able to intervene quickly to ensure physical safety of everyone present.

Emergency

• Urgent or emergency medical treatment
• Police involvement/Youth Justice involvement/Child Welfare
• Intervention resulting in a temporary placement out of the home for intensive monitoring/treatment within the last six months
• Urgent or emergency medical treatment: Child’s behavior resulted in emergency medical services intervening for immediate treatment of themselves or others. Violent acts that result in inpatient care for the victim are covered in the Mental Health section.
• Police/Youth Justice/Child Welfare involvement: Child’s behavior that has been caused by their diagnosis has resulted in the police/criminal justice or child welfare system to investigate. It does not matter if charges were filed. This is also captured as a Mental Health Service under Criminal Justice System.

5.5 Duration of Behavior

Expected to last six months or longer?

If the behavior is chronic, check “yes” for this question. If the screener is uncertain, check “yes” to give the child the benefit of the doubt, but be certain to review the behavior at time of a rescreen. If a behavior is marked “no” as in not expected to last for longer than six months, additional notes indicating specific reasoning are needed.

5.6 Describe Behavior in Detail

Once a behavior has been selected, it must be described in detail in the notes section. Some questions to consider are:

• Is there a precursor to this behavior?
• Where has or does the behavior usually happen?
• When has or does the behavior usually happen?
• What does the behavior typically look like?
• How severe is the behavior?
• What do others do when the behavior occurs?
• If the behavior occurs in multiple environments, in which environments is it most frequently occurring?
• What sources of information were utilized?

These behavior-specific notes will not be saved with the history screens but will serve to guarantee that the behavior was selected appropriately on the functional screen. Any time one of the three dropdowns associated with a previously selected behavior is changed (frequency, intervention, or duration), the Note section will need to be completed. This is a required textbox on the screen.

5.7 Unable to Describe Child

There may be behaviors children demonstrate that are not reflected in the questions asked on the CLTS FS. As with ADL/IADL questions, the CLTS FS captures items that will affect functional eligibility, which is why behaviors need to be more extreme. If the screener wishes to document behaviors not reflected in the specific CLTS FS questions, those behaviors can be described in the Notes section. The Notes section should not be seen as a field to input information in place of selecting a behavior.

5.8 Evaluating the Child not the Child in Services

Children’s behavior will frequently improve with the addition of needed interventions. It is important to evaluate a child’s baseline of behaviors without the services and supports. This evaluation provides a more accurate picture of the child; therefore, screeners should evaluate frequency of behaviors as if the services or supports were removed. If the behavior would increase without the services/supports in place, that frequency must be listed on the CLTS FS.

In addition, the screener must select that the behavior is expected to last six months or longer. Do not try to predict what the behavior would be in the future; rely on the information available prior to treatment.

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

This option does not apply in situations where the child has been removed from their family home due to issues or behaviors that are specific to their family of origin and not repeated in other homes. This is an example of a circumstance that requires the support of the foster care system rather than children’s long-term support programs.