Assessing off Baseline Behavior using T.E.M.P

Think about a person’s baseline as their usual experience on a typical day.

These questions will help us understand what a person’s baseline is.

What are their common eating and drinking and sleeping patterns?

What’s their general mood? How do they typically appear?

Some people, in fact, appear to be quite ill, but that is their usual experience.

On a typical day, a staff who is unaware of this baseline may assume the person needs medical attention, when in fact that’s normal for them.

Every person is unique, and whether they have cerebral palsy, down syndrome, or some other diagnosis, it doesn’t mean they fit in a one size fit all category.

Everyone deserves individualized support, and each person has their own ways of expressing their wants, needs and preferences.

This expression may be through the use of spoken language, but oftentimes it is not.

Their behavior may be all we have to gain valuable insight into the person’s experiences.

So if we see a person’s behavior vary from their baseline, it’s important to know there’s always a cause.

One way to find the root cause is to apply the acronym TEMP: trauma, environmental, social, medical, biological, and psychiatric psychological.

This acronym will help us understand what’s really going on and help us look beyond the behavior into what the person’s unmet need may be.

Other life experiences like the death of a loved one, getting bullied or teased, loneliness, isolation, and even segregated environments can be traumatizing.

So taking trauma into consideration may help you identify root causes when attempting to understand why the person is behaving outside their baseline.

So, is there new staff, maybe even a new roommate?

Did they recently move? I mean, think about that.

The last time you moved, how stressed were you?

These types of environmental and social stressors would throw anyone off their baseline.

Are there medical issues? Is the person experiencing pain?

Do they have a toothache? Are they ill?

Could it be a medication side effect?

Is this the cause of a biological issue, perhaps advancing dementia, neuropathy, increased seizure activity.

Here examples may include anxiety, depression, obsessive compulsive disorder, and bipolar disorder.

So TEMP can be a useful tool to help us identify the root cause of what may be causing the person to behave in a way that is different than their usual behavior on a typical day.

However, it’s important to recognize that a person’s needs and baseline may change over time.

In order to maintain appropriate levels of support, we must be willing to expand our understanding and adapt our behavior accordingly.

To further illustrate this concept, here are a couple of short stories where direct support professionals made false assumptions about why the person supported was exhibiting behaviors inconsistent with their baseline.

You’ll also hear about why it is important to avoid the common trap of thinking that a behavior is intentional and must simply need more and more positive reinforcement to fix them.

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Story from a DSP 1

I wanna tell you a story about a young man I used to support.

Um, this young man had cerebral palsy.

He had intellectual disability.

He had severe scoliosis due to the, uh, cerebral palsy, which caused him to lean to the left, caused his neck to slightly lean to the left and the arm to kind of hang on the side of his wheelchair.

Now, this young man’s baseline data on a typical day, uh, he was very, very, um, full of life, very verbal, uh, very vocal.

He loved activities, he loved talking to people.

Uh, he just loved life.

One day my husband and I noticed that he was leaning a little bit more to the left than typical.

Uh, his neck was more to the leaning, more to the left, and his arm was literally just hanging on the side of his wheelchair.

We also noticed that he was only using his right hand to wheel, his wheelchair, where typical baseline was, he would use both, but we attributed these behaviors to the neck.

Maybe he slept wrong.

The wheelchair, which was not a very supportive wheelchair to begin with, was causing him to lean over.

Uh, never did we think anything else.

So we would tell him things like, sit up straight, turn your neck over.

Uh, use both hands to wheel yourself.

And when he would try to straighten himself up, we also noticed that he would start reaching with his right hand to grab a table or whatever was closest to him to help support him and give him strength to lean over.

We noticed he was using his right hand to place his left hand on his lap and things like that.

When we would remind him to straighten up his neck, we noticed he would struggle, but he would do it.

Um, then we would start again reminding him verbally to sit up straight, because we didn’t want him to aspirate.

One evening we had to take him to the emergency due to aspiration.

After the doctors ran the multiple tests, they came back out and the first question out of the doctor’s mouth was, when did he have his stroke?

My husband and I both were shocked.

We looked at each other and at the same time said to the doctor, he’s never had a stroke.

The doctor gave us a half smile and he said, uh, according to the tests, he had a stroke.

We can’t tell you exactly when he had the stroke, but he had a stroke.

My husband and I then started thinking back as to when his baseline started to change, which was about four or five months ago.

All of these changes in his baseline had been caused by the stroke.

We had totally ignored that and attributed that to his current cerebral palsy and intellectual disability and never associated it with the medical issue.

It’s because of this that we have to really, really pay attention to the person’s baseline, uh, behavior.

And any little change should raise some concern.

Now that we realized it was a stroke, we were able to provide the proper support of physical therapy, uh, trying to get him occupational therapy, speech therapy to help him with the stroke.

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Story From a DSP 2

I wanna share a story with you about a young lady that I used to support.

Now, she was about 11 or 12 years old.

Her usual behavior, on a typical day, she was pretty happy.

Pretty content. Young lady, smile a lot, laugh once in a while, she’d get a little upset.

She may cry, but overall, pretty content young lady.

Now, one day I got a phone call saying that she had been screaming at the top of her lungs.

As a matter of fact, when they called me, I could hear her in, in the background.

And, you know, screaming just permeates.

It just, it gets everywhere. It goes through walls.

Anyhow, we start thinking of things to do and, you know, well, let’s give her some positive reinforcement.

Let’s give her some preferred items.

Let’s get her involved in some preferred activities.

Okay, wasn’t working. They call me the next day.

I can hear her again screaming.

So now I go over there and we’re thinking, okay, what do we do?

Well, she loved van rides.

Okay, well, let’s try to schedule maybe a van ride into her day, and let’s see how this goes today.

Um, it seemed to work, but she was still screaming.

We’re into the third day of this now. Someone brought up the fact that maybe there’s something medically going on with her.

Anyhow, word got back to her mom.

Mom immediately scheduled her an appointment.

She got in really fast.

Come to find out, the doctor recognized that she had an abscess tooth.

She was sent to the dentist. It was taken care of.

She was fine. She had a medical issue, an abscess tooth.

If any of you have ever had a toothache, man, those things hurt.

She couldn’t tell us that.

We assumed totally wrong, and it was a big lesson for us.

You see, not all behaviors are simply a calculated attempt to get something.

Some are, but not all of them.

Sometimes a behavior and oftentimes what we call an inappropriate behavior is a sign that the person has an unmet need, especially if their behavior is off their baseline.