Implementation of TSS: Practical Approaches

Source: DPW Best Practice Guidelines for TSS

TSS is a mental health support service that, when medically necessary, is guided by the individualized behavioral health treatment plan for the child or adolescent, the primary clinician as designated by the interagency team and the TSS supervisor. The behavioral health treatment plan itself is a reflection of the interagency team process, and has been developed with the active participation of the child and parents or other caregivers. The TSS worker acts to support the implementation of the behavioral health treatment plan in support of the identified child and family goals.

Implementation of TSS may involve a variety of practical approaches, in support of commonly identified goals. In what follows, practical interventions are identified that enable the TSS worker to work toward the achievement of certain commonly identified treatment goals. While, for purposes of training, a list of interventions is offered below, it must be understood that these interventions are to be used only in accordance with the child’s specific treatment plan, as directed by the primary clinician and the TSS supervisor.

Common Treatment Goals and Potential TSS Interventions:

1. Obtaining information about the child’s problematic behaviors, in order to determine the child’s behavioral patterns.
The TSS worker records this information systematically, and conveys it to the primary clinician so that it can be incorporated into the treatment plan. The TSS worker may also share information with the parents and child, as determined by the primary clinician. Following are some examples of information to be obtained and documented: (Guidelines for Best Practice in Child and Adolescent Mental Health Services Page 100)

  1. Where problematic behaviors occur (e.g., at school, during recess, at home, during dinner, in the community, when with older peers);
  2. Frequency of behavior;
  3. Apparent precipitants;
  4. Specific behavioral responses by child;
  5. Duration of episodes;
  6. Typical reactions and responses by others, and effect of these on the child;
  7. Most effective interventions to interrupt cycle;
  8. The child’s own ways of maintaining control, problem-solving, and settling self;
  9. The child’s response to TSS worker during times of emotional upset, as compared to other times.

2. Reinforcing parental roles and responsibilities with the child:

  1. TSS worker discusses, with parent, the plan for scheduled contact with the child that day.
  2. TSS worker obtains updated information from parent, about the child’s functioning, since the last contact.
  3. TSS worker highlights and verbally reinforces cooperative, respectful, age-appropriate responses by the child toward the parents (e.g., “I was impressed with the way responded to your mother’s request right away, and how you looked right at her when you spoke to her”).
  4. TSS worker supports parental adherence to specific protocols developed by primary clinician, for use with the child (e.g., Stop and Think approaches, sticker calendars with specific tasks for the child, consistency in limit-setting).
  5. TSS worker offers positive statements to the child individually, at appropriate times, about his or her parents (e.g., “Did you notice how proud your dad looked when you showed him the terrific point sheet from school today?”).
  6. TSS worker helps the child practice expressing him or herself to parents, using techniques as directed by the primary clinician in the treatment plan (e.g., “Do you really think your mother is going to listen to you if you yell at her like that? Why don’t you try it again, more slowly and calmly?”).

3. Helping the child integrate into an identified community activity:

  1. TSS worker reviews with the child, prior to the specific activity, the nature of the activity to follow and likely expectations for that activity (e.g., “As you know, part of the reason that you’re joining this team is to make friends and get along better with other kids. During the game, it may get intense, but that’s no reason to lose your cool”).
  2. TSS worker observes the child’s interactions with agency staff and peers, in terms of:
    1. Degree of attentiveness and responsiveness to the coach or other adult authorities;
    2. Ability to follow specific rules;
    3. Positive individual and team efforts by the child (e.g., the child approaches a peer and starts a conversation; the child hustles during tem play; the child offer encouragement to a teammate; the child passes the ball, rather than hogging it);
    4. Responses to aggressive and/or inappropriate behavior by peers;
    5. Degree of self-control.
  3. Based on systematic observation of the child’s functioning, TSS actively supports the child’s participation in the community and other setting. Specific individualized TSS responses may include the following: (Guidelines for Best Practice in Child and Adolescent Mental Health Services Page 101)
    1. Nonverbal cues of support for child’s positive responses (e.g., “thumbs up” or a clap of hand, when the child scores a basket, catches the football, or ignores an elbow by another peer during the game);
    2. Nonverbal cues for the child to change an immediate behavioral response (TSS worker points at forehead, to signify “stop and think,” or points at wristwatch, to tell the child to “slow down and calm down”);
    3. Taking the child aside momentarily, if necessary, to discuss the situation and to consider positive choices to be made;
    4. Discussion about the experience afterwards with the child and parents (e.g., To the child: “I was impressed with how focused you stayed during the game, and how you didn’t let yourself get angry when that other guy started trash talking you.” To parents: “Your son made good progress with his treatment plan today. Bill, do you want to tell them first, or should I start?”).

4. Helping the child improve interactional skills with peers:

  1. TSS worker encourages the child to identify areas of interest, competence, and familiarity, which he/she can use in social conversations (e.g., “OK, Sue, we both know you have many interests and are an interesting person. What are some of the things you can talk about with your classmates at the party tomorrow?”).
  2. TSS worker encourages the child to learn to ask question with peers, and to listen actively to responses;
  3. TSS worker encourages the child to practice use of social skills (e.g., “Can you remember that one of the best ways to start a conversation is to ask the other person a question? What kind of questions could you ask Tyrone?”).
  4. TSS worker helps the child build confidence in preparing for social interactions through practice of conversations with TSS worker (e.g., TSS worker engages a quiet or shy child in a conversation about an area of interest to the child, then points out how well the child did; TSS worker discusses a child’s recent interaction with a peer afterwards, and offers supportive feedback).

5. Helping the child to de-escalate when angry.

  1. TSS worker helps the child identify, even write down, specific trigger points for anger, as directed by primary clinician (e.g., “What was it that got you so angry? Do you think it had to do with his tone of voice, or what he said?”).
  2. TSS worker helps the child identify the benefits of non-aggressive responses, and possible consequences of aggressive responses (e.g., “Do you realize that when you let Justin get you to lose your cool, you’re giving him the power to control you? What can you do instead of punching him out?”). (Guidelines for Best Practice in Child and Adolescent Mental Health Services Page 102)
  3. TSS worker helps the child implement a specific protocol for decision-making/de-escalation (e.g., stop and think or others), if identified within treatment plan (e.g., “OK, Bill, this is what we’ve talked about. You’re starting to get ticked off. Remember what you’re supposed to do when this happens?”).
  4. TSS worker cues child nonverbally and indirectly, at sign of de-escalation, or uses simple verbal cue, as previously agreed upon (e.g., TSS worker points to forehead, to encourage the child to “stop and think,” or to wristwatch to encourage the child to calm down; TSS worker calls out to the child, “Remember RJ,” because RJ is a positive role model whom the child has identified as a verbal cue for when he is about to lose his temper).
  5. TSS worker reviews the de-escalation plan with adults in the setting where services are being provided (e.g. with parents in home, teacher in school, or coach in community activity) and with child, so that implementation is predictable and consistent for child and others.
  6. TSS worker uses time-out interventions, as needed and as previously determined by primary clinician and parents (e.g., “OK, Mrs. Williams. Charles is disrespecting you, and you’ve given him three chances, just like the treatment plan says. Do you think Charles needs time-out now?”).
  7. TSS uses verbal praise for the child when the child is showing self-control.
  8. TSS worker discusses the situation with the child, after a specific incident or near-incident; • TSS worker encourages the child’s keeping of a journal or diary, as directed by the therapist, for the child to record feelings or instances of positive coping.

6. Promoting appropriate attitude and decision-making by the child:

  1. TSS worker, building on earlier efforts by the primary clinician, helps the child identify positive role models within the family, neighborhood, or larger culture (e.g., “I really respect how hard your father and mother work to support you and your sister.” “You told your mobile therapist that you respect your family’s minister. What is it you like most about him?”).
  2. TSS worker offers ongoing positive feedback for positive choices by the child.
  3. TSS worker reminds the child of his or her previously identified personal goals, and of the importance of making good choices in order to achieve them (e.g., “You said that you want to get off probation. What do you think will happen if you hang out with those guys who are breaking into cars?” “What’s more important, getting money fast, no matter how you get it, or taking the time to earn it?”).