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 Behavior in Multiple Locations
5.8 Unable to Describe Child
5.9 Current Interventions Have Extinguished the Child's Behavior


5.1 Overview of Behaviors

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 the Mental Health target group.

"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. This does not include children who hit their own head with their open hand or fist.

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, tearing their 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. Inserting harmful objects is only considered a form of self mutilation when done with such force that puncturing their skin is likely. Therefore, simply putting an item in an orifice is not considered self mutilation unless there is the intention to cause physical harm.


AGGRESSIVE or OFFENSIVE BEHAVIOR TOWARD OTHERS

1. Hitting, Biting, or Kicking
The aggression involves multiple victims including at least one non-family member. Aggression is beyond an age appropriate level. TWO of the following are present:

  1. Child approaches the incident with the intent of causing harm to others.
  2. Incident(s) involves multiple victims (more than one).
  3. Victim sustains injuries severe enough to require first aide or further medical attention.
  4. Others cannot easily stop the aggression. The situation requires:
    (i) Police;
    (ii) Police liaison;
    (iii) Use of physical protective measures;
    (iv) Parents report the use of physical restraint; or
    (v) Two or more adults must intervene.
  5. Child’s repeated acts of aggression have created an atmosphere of fear where the child is seen as a tyrant or abuser.

Hitting, biting, or kicking are not considered an aggressive behavior if a child is reacting in the moment to frustration from a communication/language disorder.

2. 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.

3. 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.

4. 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, and I want to kill my teacher." The threats must be perceived by anyone who witnesses them as true threats of violence.

5. 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.

6. Abuse or Torture of Animals
Abusing animals to find power/joy/fulfillment through the torture of victims they know cannot defend themselves. This includes abusing animals for no obvious reason. For purposes of the CLTS FS, the child must be demonstrating this behavior with multiple animals, not just the household pet. 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. 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 A: 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 B: 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 C: 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 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 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 E: 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 multiple interventions are used that represent different intervention categories, select the most extreme intervention that has been used in the past 6 months and may be used in the future. 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")
Don't check this box Does not include having a medication prescribed to address behavioral issues
Don't check this box Does not include proactive strategies to help prevent behavioral issues

  • 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 Describe Behavior in Detail

Once a behavior has been selected on the Behavior page it must be described in detail in the text box immediately following the selected behavior. Some questions to consider are:

  • Is there a precursor to this behavior?
  • Where does the behavior happen?
  • When does the behavior happen?
  • What does the behavior look like?
  • How severe is the behavior?
  • What do others do when the behavior occurs?
  • If it is a behavior that must occur in multiple environments, which environments is it occurring?
  • How do you know this information is accurate – what sources of information did you use?

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 drop downs associated with a previously selected behavior is changed (frequency, intervention or duration), the note section will need to be completed. This is a required text box on the screen.

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5.7 Behavior in Multiple Locations

Due to the nature of a number of defined behaviors, some behaviors must occur in multiple locations in order to be selected on the CLTS FS. The only exception to this requirement is made when a child lives in one environment at all times (e.g., a young child who is cared for entirely at home). This chart guides screeners to know when to consider whether or not a particular behavior occurs in more than one setting.

Behavior Multiple Locations?
High-Risk Behaviors
Running Away No
Substance Abuse No
Dangerous Sexual Contact No
Use of Inhalants No
Self-Injurious Behaviors
Head-Banging Yes
Cutting or Burning or Strangulating Oneself No
Biting Oneself Severely No
Tearing at or Out Body Parts No
Inserting Harmful Objects into Body Orifices No
Aggressive or Offensive Behavior Toward Others
Hitting, Biting, Kicking Yes
Masturbating in Public No
Urinating on Another or Smearing Feces No
Serious Threats of Violence No
Sexually Inappropriate Behavior Toward Children or Adults No
Abuse or Torture of Animals No
Lack of Behavioral Controls
Destruction of Property/Vandalism Yes
Stealing, Burglary or Kleptomania within the Community Yes

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5.8 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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5.9 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 specific 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. In addition, the screener must select that the behavior is expected to last 6 months or longer. 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.

This option does not apply in situations where the child has been removed from their family's home due to issues related to family dynamics. If the child's behaviors are specific to their family of origin but are not exhibited in other homes, this option does not apply. This is an example of a circumstance that requires the support of the foster care system rather than children's long term support programs.

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Last Revised: February 28, 2014
Wisconsin Department of Health Services
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