Fill - Free fillable Trauma-Responsive Student Support Planning Packet (City of Oakland) PDF form

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Trauma-Responsive Student Support Planning Packet

The following resources are intended for educational purposes only. The information contained herein is not intended to take the place of

informed professional diagnosis, advice, or recommendations. The KSDE TASN SMHI assumes no liability for errors or for the way in which

this information is used.

The TASN School Mental Health Initiative (SMHI) is funded through a grant from the U.S. Department of Education (#H323A17006) and is

administered by the Kansas Department of Education. The contents do not necessarily represent the policy of the U.S. Department of

Education and endorsement by the Office of Special Education Programs should not be assumed. The SMHI does not discriminate on the basis

of race, color, national origin, sex, disability, or age in its programs and activities. Inquiries regarding non-discrimination policies should be

sent to: Deputy Director, Keystone Learning Services, 500 E. Sunflower Blvd., Ozawkie, KS 66070; 785-876-2214.

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Table of Contents 
How To Use This Packet  3 
Resource Roadmap  3 
Functional Behavioral Assessment (FBA) & Student Support Plan (SSP) Form  4 
Student Support Plan Meet Back Form  9 
Factors Related to Functions of Behavior  11 
Biological Regulation  11 
Social Connectedness  11 
Emotional Regulation  12 
Access to Curriculum and/or Instruction  12 
Communication Skills  13 
Cultural Environmental Skills  13 
User’s Guide to Functional Behavioral Assessments (FBAs) & Student Support Plans (SSPs)14 
Element 1: Identify resilience characteristics and strengths.  14 
Element 2: Define problematic behavior.  14 
Element 3: Review setting conditions.  15 
Element 4: Identify factor(s) related to function of behavior.  16 
Element 5: Match support strategies to factors and/or setting conditions.  16 
Element 6: Identify replacement behavior.  16 
Element 7: List resources needed to implement the plan.  17 
Element 8: Adult accountability.  17 
Element 9: Specify data points and responsible adults.  17 
Element 10: Set meet back date(s)/time.  17 
Element 11: Behavior Threshold Analysis  17 
Functional Behavioral Assessment (FBA) & 
Student Support Plan (SSP) Setting Conditions  20 
School Setting Conditions  20 
Community Setting Conditions  23 
Home Setting Conditions  25 
Sample FBA/SSP Form  27 
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How To Use This Packet

The resources found within this packet are intended to help teams create, implement, and review

trauma-responsive Functional Behavioral Assessments (FBAs) and Student Support Plans (SSPs).

Use the roadmap below for learning more about each resource and how they can be used to

facilitate this process.

Resource Roadmap

1. FBA/SSP Form. This blank form can be printed or downloaded and utilized to create a

trauma-responsive FBA/SSP.

2. Meet Back Form. This blank form should be used when teams meet to review data related

to existing trauma-responsive FBA/SSPs.

3. Factors Related to Functions of Behavior. In this section, find descriptions of factors that

should be considered when utilizing the trauma-responsive FBA/SSP Form. These factors

include biological regulation, social connectedness, emotional regulation, access to

curriculum/instruction, communication skills, and cultural environmental skills.

4. User’s Guide to FBAs & SSPs. The User’s Guide provides a description of each element

within the trauma-responsive FBA/SSP form. Additional information on trauma is also

included.

5. FBA & SSP Setting Conditions. This section can be used to review both positive and

negative/harmful indicators for potential setting conditions within the school, home, and

community.

6. Sample FBA/SSP Form. This sample form provides an example of what a

trauma-responsive FBA/SSP Form can look like once completed.

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Functional Behavioral Assessment (FBA) & Student Support

Plan (SSP) Form

Date

Student Name

Present

Absent

Note Taker

Element 1: Identify resilience characteristics and strengths.

Element 2: Define problematic behavior.

Location

Where does the behavior occur? Ex: locker room, first grade classroom, math class, before/after school areas

Rate of Behavior

How often does the behavior occur? Ex: X number of times per minute, hour, day, week, or month, as appropriate

Percent of Time

What percent of a particular hour or day is the child engaged in the behavior?

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Intensity

When the behavior occurs, how disruptive is the behavior to the school environment and/or student learning? Consider

using a 1-10 scale to describe intensity; 1 being low intensity and 10 high intensity.

Element 3: Review setting conditions.

Describe conditions in school, community, and home that could explain problematic behavior.

School

Community

Home

Element 4: Identify factor(s) related to function of behavior.

Develop a working hypothesis regarding why the student behaves as he/she does. Check the factor that best explains the

behavior.

Biological Regulation

Social Connectedness

Emotional Regulation

Access to Curriculum/Instruction

Communication Skills

Cultural Environmental Skills

Working Hypothesis

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Element 5: Match support strategies to factors.

Identify support strategies that match hypothesized factors. Consider student/home strengths and resilience characteristics.

Factor/Setting Condition

Supports

Element 6: Identify replacement behavior.

What do you want the child to do? Clarify family involvement.

Replacement Behavior

Element 7: List resources needed to implement the plan.

Be realistic.

Element 8: Establish adult accountability for plan implementation.

Specify person(s) responsible for plan implementation.

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Element 9: Specify data points.

Specify data points and who will be responsible for data collection.

Person Responsible

Data Point

Element 10: Set meet back date(s)/time(s).

Element 11: Behavior Threshold Analysis.

To be completed if the team needs a plan of action to support the student while her behavior is escalating, peaking, or

deescalating.

Describe indications that the student

is escalating.

What are adults expected to do

when escalation behaviors are

noted?

Describe observable indications that

the student has resumed gross

control, self-control necessary to be

safe with respect to both self and

others.

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Describe observable indications that

the student has resumed

instructional control, self-control

necessary to de-brief and to learn

from experiences.

Describe which adult(s) will engage

in teaching interventions based

upon the recent situation.

Time/date for adult debriefing of

the incident.

Adapted with permission from Aldridge, L. & Harrison, R. (2019). Functional behavioral assessment (FBA) & student support plan (SSP)

form. Unpublished document in preparation.

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Student Support Plan Meet Back Form

Date

Student Name

Present

Absent

Note Taker

Data Review/New Information

Plan Changes/To Be Continued

Factor/Setting Condition

Supports

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New/Continued Data Points

Person Responsible

Data Point

Additional Information

Person responsible for plan

implementation/data.

Next meet back date/time.

Adapted with permission from Aldridge, L. & Harrison, R. (2019). Functional behavioral assessment (FBA) & student support plan (SSP)

form. Unpublished document in preparation.

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Factors Related to Functions of Behavior

Following are descriptions of factors often related to troubling behaviors. These factors help

explain why a student is doing what she does. Put another way, factors assist in understanding

the function of behavior. Often, there is no single factor that fully explains the behavior in

question. Instead, there is a complex interaction of circumstances across settings and time. This

is especially true when complex trauma is involved. In traumatic situations brain architecture

has been altered leaving the child neurodevelopmentally unable to do required academic or

social tasks. Understanding that some behaviors or academic tasks may be beyond the child’s

current capability is the first step in designing supports that are sequenced developmentally.

Academic and social expectations and supports must be scaffolded to facilitate skill attainment.

1. Biological Regulation

The human brain predicts and responds to environmental conditions. While doing so, the

brain triggers the release of chemicals, in appropriate amounts, to keep bodily systems

running. Traumatic and surprise events influence this prediction/response process. Lack of

biological regulation may result in behaviors considered to be inappropriate, even

aggressive. Biological regulation issues result from a variety of conditions to include sleep

deprivation, nutrition problems, and numerous mental health conditions (anxiety,

depression, stress & fear responses, etc.).

Depending upon underlying reasons for biological regulation issues, supports might include

rest, food or medication. Movement is often important in helping a person maintain or regain

balance. Likewise, a person may need access to a safe, quiet space. Regulatory supports may

be needed over a very long period of time when the problem is one of overly active traumatic

neuropathways.

2. Social Connectedness

Relationships are key to understanding social connectedness. Students lacking social

connections usually experience few or no friendships. Development of trust relationships

with adults is extremely difficult. In addition, students have few positive social encounters

within an hour or day. Humans require social connectedness to feel safe, valued, and

supported. Relationships with trusted adults enhance feelings of safety and calm when

threats are perceived. Absence of positive relationships results in awkward, aggressive and

inappropriate interactions and can impede student capacity to handle perceived threats.

It is critical to assist the student in resolving social connectedness challenges. Going beyond

typical attention-seeking remedies, necessary supports address the child’s need to feel safe

and accepted in a social community. Help the student to establish meaningful relationships

with adults and peers. Create roles where that student is a valued and important member of

the class and school.

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3. Emotional Regulation

To understand this highly complex factor, consider the following: The student needs

assistance in recognizing emotions - first in himself and later in others; guidance is required

to develop appropriate responses to emotions; and finally, emotions are directly tied to

biology. Capacity to recognize and respond to emotions is usually learned through infant and

childhood experiences. This learning occurs within the context of a lived relationship with

another person who genuinely cares for you; it cannot be faked. All emotions are learned first

in a primal relationship and then used in relationships with others. Teachers will encounter

children who do not have implicit memory regarding emotional regulation; such children will

need help with this type of learning.

Emotions include the full range of feelings: happiness, anger, sadness, and fear. The

emotional impact of daily schooling requires constant scrutiny and engineering. Classroom

and school-wide practices can be structured to ease emotional burden, especially within the

context of a preferred relationship with an adult. Common practices can also escalate

inappropriate emotional responses. Such practices include some disciplinary procedures

(punishment, for example), instructional techniques such as ability grouping, and a high

tolerance for insensitive social interactions. When school setting conditions contribute to

emotional overload, adults in charge need to rethink and restructure.

Emotional regulation issues can be addressed through a variety of curricula. “Teachable

moments” also present opportunities to reflect upon emotional responses and to plan

alternative behaviors for the next time. Such conceptually based approaches to teaching

emotional regulation are effective when the student has sufficient developmental capacity for

engagement. Children at an earlier developmental stage will need lived experiences with a

caring adult, sensory opportunities to understand becoming calm, to feel secure, to deal with

anger.

4. Access to Curriculum and/or Instruction

This factor is isolated for scrutiny due to extreme prevalence, especially when associated

with academic success or failure. Avoidance may be related to fear of failure or lack of

pleasure associated with school work. Thus emotional regulation issues often occur in

conjunction with avoidance challenges.

Every student needs academic work that is rigorous, enjoyable, and provides the opportunity

for personal growth. Extensive research surrounding curriculum and instructional

differentiation provides guidance regarding methods for engaging every learner. When work

avoidance is considered to be the primary factor behind inappropriate conduct, educators

have a wonderful opportunity to utilize the best instructional practices. Rethink what is

being taught and/or how it is being taught.

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5. Communication Skills

Communications skills allow people to interact verbally and nonverbally, to learn, to

understand others, to be understood and to be valued. Put another way, communication

skills are central to the human experience. When a person experiences communication

challenges, even relatively minor ones, social consequences can be catastrophic. Unmet need

for communication results in a variety of aberrant behavior such as aggression, and

self-injurious behaviors to include substance abuse, stealing, lying, cheating, and property

destruction. Individuals with communication issues often have difficulties initiating or

sustaining healthy relationships. Communication issues can be interpreted as evidence of

emotional disturbance, intellectual disability, or conduct disorder. Students dealing with

communication challenges are often misunderstood, blamed for bad behavior, and punished

accordingly.

An alternative communication system, combined with a predictable, visual schedule are

useful supports when helping a student to express his needs and wants. Speech and language

pathologists can provide targeted, highly effective therapy. Speech/language therapy,

especially when delivered in an emotionally safe environment with a trusted adult, can be

foundational in assisting a student with behavioral changes.

6. Cultural Environmental Skills

This factor encompasses social and character development skills, as part of clearly

articulated school expectations that are taught and modeled. Positive Behavioral

Intervention Systems (PBIS) and Multi-Tiered System of Supports (MTSS) are methods by

which educators design and implement strategies to maximize positive skill acquisition.

When it is hypothesized that cultural environmental issues are the root cause of poor

behavior, it makes sense to first examine school and classroom environment. Look for

misalignment with the child’s culture or traditions. Consider problems associated with

inconsistent expectations or situations where adults fail to model expectations. Adults then

bring about environmental accommodations or changes, as needed. Once school

environmental issues are eliminated as a possible factor in student misconduct, progress to

an individual, small group, or universal teaching of social skills and character development.

As with emotional regulation, curricula abound for teaching social skills and character

development.

Adapted with permission from Aldridge, L. & Harrison, R. (2019). Six factors related to functions of behavior. Unpublished document in

preparation.

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User’s Guide to Functional Behavioral Assessments (FBAs) &

Student Support Plans (SSPs)

Element 1: Identify resilience characteristics and strengths.

Consider strengths stemming from family, cultural, community circumstances. Include

attributes associated with resiliency - character traits, social skills, and resources that help

a person to deal with tough times and challenging issues. Resiliency characteristics might

include:

● Trust relationship with one or more people in the family or community.

● Trust relationship with one or more adults in the school.

● Social skills that enable the student to cooperate with others.

● Food security. (The student knows he will always have enough to eat.)

● Friendship with at least one student.

● The student feels safe at school.

● The student feels safe at home.

● The student feels safe in her community.

● Capacity to adapt social skills to immediate circumstances, switching between

home, school, and community as needed.

● Optimistic, hopeful view of circumstances and future; believes things will get

better.

Element 2: Define problematic behavior.

Specific descriptions include location, rate of behavior, percent of time, and intensity. In

most situations where an FBA is initiated, data have already been gathered through referral

to a school support team and/or implementation of general education interventions. To

clearly define problematic behavior, educators access these data and, within a matter of a

few minutes, come to an agreement regarding a clear, concise description of behavior. In

situations where referral for special education evaluation is considered and such data are

not available, it could be that team members need to make sure general education

interventions have been authentically identified and implemented. When support teams

routinely run into problems with this beginning step, it could be that general education

intervention protocols need to be reviewed and revised.

Note: This FBA/SPP process is fully adaptable to general education intervention (GEI) processes. When

used at the GEI level, teams sometimes need to develop a data-drivenulture as they work together to

help students. It is critical to support educators as data management skills are developed, just as

supports are provided to students who are learning new and (for them) difficult skills.

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Element 3: Review setting conditions.

Consider setting conditions related to school, community, and home that could reasonably

explain problematic behavior. Review school setting conditions first. If school setting

conditions are initiating or sustaining inappropriate conduct, change these conditions prior

to the development of a student support plan. Do not blame the student for conditions

controlled by school personnel.

The student may have experienced traumatic situations in school, community or home

settings. If trauma is suspected, the following resources may be helpful in gathering

additional information.

● Adverse Childhood Experience Checklist

(https://acestoohigh.com/got-your-ace-score/)

● Child Report of Post-traumatic Symptoms (CROPS) - child symptom self-report

(http://www.childtrauma.com/publications/assessment-instruments/)

● Trauma Symptom Checklist for Children

(https://www.parinc.com/Products/Pkey/461)

Be sensitive regarding the use of trauma assessments and screeners. For further learning,

see Guidance for Trauma Screening in Schools and the accompanying webinar. Best practice

involves a trust relationship between the family member(s) and school staff when

completing this checklist and when sharing resulting information.

Relevant community and home setting conditions require sensitive interaction with family

members. Often, these conditions are beyond the control of school personnel. Related

behavioral supports are more effective when it is remembered that the child is also unable

to control key setting conditions. Action plans may include these components:

● Collaboration with mental health providers might be necessary, especially if

complex trauma is documented or suspected.

● Develop a long-term plan involving family and community to address underlying

conditions.

● Affirm to the child that behaviors considered to be problematic at school might be

very useful and appropriate in other situations.

● Teach social skills appropriate for school. Where it makes sense, emphasize that

“code switching” is not only OK, but often a strong coping mechanism as the student

travels through her daily circumstances in school, community, and at home.

● Students who experienced (or are experiencing) complex trauma may not yet have

neural development necessary to process social/emotional supports in an

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age-appropriate way. Communication with family and mental health staff might

provide insight regarding developmentally appropriate supports for a particular

child.

● Recognize that students dealing with community or home setting conditions often

take on adult level worries. (Ex: concerns about unsafe situations, lack of food,

inadequate care for younger siblings, need for heat, water, and electricity.) Effective

supports provide a way to productively address such issues while honoring the

child’s maturity and the realistic nature of these worries.

Element 4: Identify factor(s) related to function of behavior.

There is no magical list of factors that will account for all possible issues associated with

student conduct. Start with what is known about the particular child, his/her

circumstances, needs, personality characteristics, home situation, etc. Consider the

following factors as research shows that one or more are often lurking behind problematic

behaviors.

● Biological Regulation

● Social Connectedness

● Emotional Regulation

● Access to Curriculum/Instruction

● Communication Skills

● Cultural Environmental Skills

See Factors Related to Functions of Behavior for an expanded explanation of each factor.

Element 5: Match support strategies to factors and/or setting conditions.

Support strategies must match hypothesized factors influencing behavior. For example, if it

is hypothesized that a student is irritable and angry because of inadequate sleep, try

scheduling a nap time. Students are not required to earn supports identified as needs. If a

school setting condition is suspected to initiate or sustain the behavior, there must be some

remedy. For example, if the lunchroom is chaotic, the student might be given the option to

eat elsewhere.

Element 6: Identify replacement behavior.

Clearly defined replacement behaviors are essential in establishing goals and determining

support plan success. It is not enough to eliminate or reduce undesirable behaviors. There

must be clear agreement across adult team members regarding behavior considered to be

acceptable.

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Element 7: List resources needed to implement the plan.

Be proactive; make sure the student and school personnel have what is needed for success.

Don’t make promises you can’t keep. When non-school agencies are involved, make sure to

specify accurate timelines and resources, in accordance with that agency’s capacity.

Element 8: Adult accountability.

Identify, by name, those adults responsible for plan implementation. It is critical that

colleagues both expect each other to meet their responsibilities AND stand ready to

provide assistance if something isn’t getting done. Bottom line, healthy school culture is

centered around student needs; adults are expected to get their work done and to

communicate results with their teammates.

Element 9: Specify data points and responsible adults.

Specify a specific person responsible for ensuring that data are gathered and shared. Again,

adult accountability is the key to support plan success. Consider a universal data system,

one that can be applied across many students and school settings, to build consistency and

reliability across school personnel. In most cases, establish a data system that directly

involves the student. Each data point must be clearly identified and related to a support or

skill area included in the plan. A clear, relevant feedback loop can be a powerful support.

Element 10: Set meet back date(s)/time.

Do this! Data analysis is critical; assume that the team will not be successful the first time. It

is necessary to consider whether or not student conduct improves, modifying the plan as

needed until success is achieved. Highly complex situations take time for resolution, one

way or another. Be proactive in scheduling meet backs; it is much easier to cancel meetings

as they become unnecessary. In situations where aggressive behavior is involved, the team

may need to meet weekly, at first. If one or more team members can’t attend every meeting,

document the method by which that person will be kept apprised. Meet backs should be

short; try to keep meeting length to less than thirty minutes. Utilize the meet back form to

document decisions.

Element 11: Behavior Threshold Analysis

To be completed if the team needs a plan of action to support the student during the

escalation/de-escalation process. It is essential that this analysis be completed if violent, or

aggressive behavior is predicted.

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Possible indicators that a student is escalating:

● Change in voice tone

● Student is vocalizing distress

● Student attempts self-protection through withdrawal or aggression

Possible adult actions to be taken when escalation is noted:

● Reduce lighting

● Calm music

● Reduce number of classmates present

● Reduce/eliminate adult verbalizations

● Back off, give student room

● Limit number of adults present; request presence of most trusted adult

● Notify parent (NOT as punishment, but to alert the parent that home support

may be needed)

● Use non-verbal signals (pre-taught and practiced) to remind student of safe

spot options

Indications that student has regained gross control, self-control necessary to

be safe:

● Normalized rate of breathing

● Relaxed body posture

● Requests for assistance (verbal and nonverbal)

● Facial expression indicates student is calm and/or tired

● Student refrains from dangerous or disruptive behaviors

● Calm tone of voice

● Indicates willingness, when prompted, to follow a simple instruction (Ex: I

will stay in this seat/area.)

Indications that student has regained instructional control, self-control

necessary to engage in learning:

● Is able to follow instructions

● Is able to return to an instructional setting

● Is able to complete school work

● Is able to accept comfort/sensory experiences necessary to regain a sense of

safety and trust

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● Engages in discussion about her feelings and actions

● Reflects upon the situation

● “Owns” his behaviors

● Wants to make things right

● Accepts consequences

Student follow-up might include discussion about what happened, how the student and

adults might do things differently in the future, and consequences (NOT punishment)

regarding the situation. Often times, consequences have naturally occurred (recess went on

without him; school work still needs to be accomplished; other students were afraid, et.). IT

IS NOT NECESSARY TO INVENT CONSEQUENCES, especially if the student has already

experienced trauma. Often, the student WILL benefit from opportunities to “make things

right.” Such opportunities could include: apology, picking up the mess; thinking of ways to

modify his plan to prevent future occurrences or helping other students or staff affected by

the incident.

Students dealing with complex trauma may not yet have sufficient neural development

necessary for cognitive processing of the incident. Follow-up may involve sensory

experiences where the child feels comforted, supported, and safe. Student follow-up needs

to be developmentally appropriate; supports may be more typical of interactions with

much younger children.

Adult debriefing is essential, especially in situations involving aggressive behavior,

seclusion, or restraint. Establish a time and date, closely following the incident, where

support team members discuss the situation, analyze data associated with the support

plan, and agree upon plan changes, as necessary. In situations where escalations occur with

high frequency, it makes sense to proactively schedule debriefings daily or weekly, as

necessary. It is much easier to cancel a previously scheduled meeting than it is to call

people together without prior notice.

A final word about adult debriefing: Adults need positive, collegial support. Debriefings

might include adult processing of emotions they’ve experienced, along with sharing of

self-care techniques and ideas about how to provide mutual support. Donuts might be a

good idea, or, OK, healthy snacks. The key is to plan for adult needs when situations might

involve extreme stress.

Adapted with permission from Aldridge, L. & Harrison, R. (2019). Functional behavioral assessment (FBA) & student support plan (SSP).

Unpublished document in preparation.

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Functional Behavioral Assessment (FBA) &

Student Support Plan (SSP) Setting Conditions

School Setting Conditions

School Setting

Conditions

Positive Indicators

Negative/Harmful Indicators

Competent staff

Personnel demonstrate necessary

skills, values, and attitudes

necessary to help the child. They

understand that they may be

inadvertently triggering the child.

Staff evidence knowledge and skills

necessary to recognize and

appropriately respond to

trauma-related behaviors.

Some children experience teaching

practices that are ineffective

and/or harmful.

A widely held belief is that bad

behavior must be punished; trauma

is just an excuse.

Effective

relationships

amongst staff and

between students

and staff

Staff possesses those skills

necessary to establish and maintain

academically friendly relationships;

these skills are modeled in adult

relationships and explicit

development of positive

student/adult rapport.

Students observe adults behaving

poorly. Some adults lack necessary

skills and/or inclination to develop

healthy relationships with all staff

and students.

Effective

relationships among

students

School culture fosters acceptance of

every child; each student is valued

and welcome in the school. Students

are explicitly taught relationship

building skills.

Bully behavior is tolerated and

even encouraged. Some students

do not feel emotionally or

physically safe.

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Effective

relationships with

Community Mental

Health providers

A strong partnership exists between

school and community mental

health agencies. Individuals within

each organization respect and trust

one another.

Little or no communication occurs

between school and mental health

organizations. Turf wars,

inconsistency in

interventions/supports, and lack of

trust are the norm.

Emotional and

physical well-being of

staff

Staff possesses the emotional and

physical well-being necessary to

help others to learn.

Some key staff members lack the

emotional and/or physical

well-being necessary to be effective

instructors.

Supportive classroom

climate

Classroom climate is supportive of

positive changes in student

behavior and learning; student

capacity to engage in learning

activities is expanded.

One or more classrooms in the

school foster a climate that

excludes some students and fails to

produce expected learning

outcomes in all students.

Staff attendance

Staff is regularly in attendance; the

student experiences continuity with

respect to teachers who are

assigned to help him/her to learn.

The student experiences a lack of

consistency with respect to teacher

availability. Unpredictable

expectations and teaching styles

are a deterrent to effective

learning.

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Effective curriculum/

instruction

Differentiation of curriculum and

instructional methods is effective in

meeting the needs of all learners.

Some students experience

academic expectations that are

lacking in rigor and/or situations

where they cannot be successful.

Effective behavioral

supports,

school-wide and

individualized

Staff utilizes effective supports

when attempting to bring about

improvement in student

conduct/learning. Positive

behavioral supports are both

universal and explicitly tailored to

the needs of some students.

Some students experience harmful

and/or ineffective practices (Ex:

punishment, lack of positive

supports, and harsh treatment.)

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Community Setting Conditions

Community Setting

Conditions

Positive Indicators

Negative/Harmful Indicators

Availability of

medical resources

Physical and mental health services

are available to all students and

their families.

Some students lack access to basic

preventative care and/or

treatments necessary to remedy

specific conditions.

Availability of

nutritional

resources

Nutritious, healthy food sources are

available to families.

Some students arrive at school

hungry and lack nutrition necessary

to sustain healthy growth patterns

and cognitive development.

Positive culturally

embedded practices

and beliefs

Community programs are in place to

combat effects of racism, sexism,

and other cultural factors known to

impede student academic success.

Cultural practices promote the well

being of families.

Some students are “thrown away”

via foster care, adjudication,

violence, and other conditions often

associated with racism and poverty.

Employment

opportunities

Employment featuring family

friendly hours, access to health

insurance and childcare, and

competitive wages are available in

the community.

To maintain employment, parents

work irregular hours, nights, and

weekends. Health insurance and day

care are not available through

employers. Wages are low, often

necessitating two or three jobs in

order to meet basic expenses.

Safety

The student and his/her family feel

safe when at home and in their

community.

Students expend considerable

energy in survival mode,

realistically concerned about their

safety and the safety of those they

love.

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Transportation

availability

Families are able to travel to

locations where they can procure

necessary resources such as healthy

food, medical care, employment and

educational services. Cultural and

social events are accessible to

families.

Due to lack of transportation, some

families are unable to access basic

resources. In addition, they are

excluded from cultural/social

events that positively impact

academic growth.

Availability of after-

school programs

with adult

supervision

Students and families have options

for after-school programs and

appropriate adult supervision to

ensure safety.

Students are unsupervised during

after-school hours, increasing lack

of safety and likelihood of

unsafe/unhealthy choices.

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Home Setting Conditions

Home Setting

Conditions

Positive Indicators

Negative/Harmful Indicators

Competent

caregivers/parents

The child has at least one adult in

her life who both loves her and is

able to provide adequate care.

One or more parental figure is

engaged in substance abuse; there

is no adult able to provide basic

parenting.

Appropriate medical

treatment/

mental health

services/medication

The child receives necessary

treatment for underlying mental or

physical health conditions.

Caregivers fail to procure basic

preventive medical care and/or

treatment for specific mental or

physical conditions.

Adequate nutrition

Cognitive functioning, physical

development, impulse control, and

behavioral choices are positively

impacted by adequate nutrition.

Family resources are directed to

non-essential items at the expense

of provision of adequate nutrition.

Adequate sleep

The student engages in sleep

patterns necessary to support

normal growth and development.

The student is often tired, irritable,

and unable to focus on learning

activities.

Home routines for

conflict resolution

Caregivers engage in and model

positive conflict resolution skills.

The student witnesses and/or

emulates violent, confrontational

methods of conflict resolution.

Home stability

The student experiences a high

degree of predictability with

respect to before/after school

routines, sleeping arrangements,

and housing stability.

The student is unable to predict

what will happen before and after

school. Address changes are

frequent; sleeping arrangements

fluctuate; primary caregivers are

not consistent.

25

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On-going availability

of necessary

equipment (ex:

glasses, hearing aids,

mobility devices)

The student has consistent access

to devices necessary to experience

normal sensory input or mobility.

Ability to learn is negatively

influenced by lack of glasses,

hearing aids, mobility devices –

basic devices necessary for

productive learning experiences.

Strong school

attendance patterns

The student is in school often

enough to make expected academic

progress

Attendance patterns are not

consistent; absences negatively

impact student achievement.

Appropriate hygiene

Body odor, and/or personal

appearance issues are consistent

with those necessary to build and

maintain positive peer

relationships.

Body odor, clothing, and general

hygiene issues interfere with social

acceptance and learning.

Adapted with permission from Aldridge, L., Harrison, R., Harrison, K., & Blanchat, C. (2014). Exploring and utilizing the concept of setting

conditions in the functional assessment process. Journal of Adolescent and Family Health, 6(2). Retrieved from

https://scholar.utc.edu/jafh/vol6/iss2/5

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Sample FBA/SSP Form

Date October 2, 2019

Student Name James

Present

Absent

Write first and last names of

If a key person is absent, document that person’s name.

everyone present. Including those

participating remotely.

Note Taker

Write the first and last name of the person responsible for recording key data. This person needs

to understand the process and is responsible for documenting critical decisions. The note taker

utilizes complete sentences and identifies responsible staff by name, throughout the document.

Element 1: Identify resilience characteristics and strengths.

James has a strong, positive relationship with his second grade teacher, Kelcie. When becoming

anxious in his classroom, he tends to run to the counselor’s office (Wanda), where he feels safe.

James often expresses love and caring for his baby brother and has verbalized a commitment to

caring for his brother when at home. Academic progress (reading, writing, and math) is

comparable to that of his fellow second grade students.

Element 2: Define problematic behavior.

Location

Where does the behavior occur? Ex: locker room, first grade classroom, math class, before/after school areas

James has greatest difficulty before/after school, in the lunchroom, PE, music, recess, and when in

the other second grade room for social studies.

Rate of Behavior

How often does the behavior occur? Ex: X number of times per minute, hour, day, week, or month, as appropriate

During the past five school days, James ran from his assigned environment 14 times: 8 times from

lunch; twice (2) from recess; three (3) from social studies; and once (1) from PE. Each time, he

ran to the counselor’s office. Prior to running, James screamed, threw objects at peers and

teachers, and made threatening statements (ex: I am going to kill you.). Teachers report that this

five day period is typical of James’ behavior so far this school year. This behavior was not evident

when James was in K or first grade when he attended a different school and prior to the birth of

his brother.

Percent of Time

What percent of a particular hour or day is the child engaged in the behavior?

Length of each episode (from when behavior is first evident to arrival at counselor’s office) varies

between one and ten minutes with an average length of engagement in this behavior of about 15

minutes/day or less than 4% of each school day.

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Intensity

When the behavior occurs, how disruptive is the behavior to the school environment and/or student learning? Consider

using a 1-10 scale to describe intensity; 1 being low intensity and 10 high intensity.

When fully escalated, peers and staff express fear. Rating of behavior, at its peak, is reported to be

in the 7-9 range and is extremely disruptive to the environment where the behavior begins.

Element 3: Review setting conditions.

Describe conditions in school, community, and home that could explain problematic behavior.

School

Team members report that the lunchroom situation is chaotic, with the highest number of office

referrals (school-wide) coming from lunch. The second grade teacher (Amanda) - where James

goes for social studies - does not yet have a trust relationship with James. James expresses

reluctance to go to social studies.

Community

The local mental health agency is working with James’ mother.

Home

James’ mother reports that father is an alcoholic who occasionally drops by when intoxicated.

James is afraid of his father. Mother is receiving support from the (Local Mental Health Agency)

where she is learning that both she and James may have issues with anxiety. At this point, neither

she nor James take medication for anxiety disorder.

Element 4: Identify factor(s) related to function of behavior.

Develop a working hypothesis regarding why the student behaves as he/she does. Check the factor that best explains the

behavior.

_X_ Biological Regulation

_X_ Social Connectedness

____ Emotional Regulation

____ Access to Curriculum/Instruction

____ Communication Skills

____ Cultural Environmental Skills

Working Hypothesis

Two factors are under consideration. The first is biological regulation; James may have anxiety

issues. Social Connectedness is also considered; anxiety issues are especially evident when in

environments where he does not have a trust relationship with the adult(s) in charge and where

he perceives the situation to be chaotic.

28

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Element 5: Match support strategies to factors.

Identify support strategies that match hypothesized factors. Consider student/home strengths and resilience characteristics.

Factor/Setting Condition

Supports

School setting condition:

Lunchroom

School-wide efforts are under way to address chaotic

conditions in the school lunchroom. Until this situation

improves, James will have the option of eating lunch in the

Counselor’s Office. He will also have the option of inviting a

peer or adult to dine with him.

Social Connectedness

The counselor (Wanda) and primary second grade teacher

(Kelcie) will work with the social studies second grade

teacher (Amanda), first observing and then making

recommendations to build a trust relationship between

James and Amanda.

Biological Regulation

Linda (principal) will obtain permission to consult with the

mental health therapist; subsequent meetings will be

scheduled at a time when the therapist can attend or

participate via Zoom.

Wanda will check in with James each day, reminding him

that he can come to her office any time and that he can eat

lunch in her office. They will also practice leaving target

areas and going to her office. Kelcie (primary second grade

teacher) will utilize preventive prompts, each time James is

preparing to leave her classroom.

In every school environment, the adult in charge will know

that James can leave at any time, will be taught indicators

that James is becoming fearful, and will rehearse methods

by which James can gently and privately be reminded of his

option to leave. Wanda (counselor) will connect with the

adult in charge before and after school, in the lunchroom,

PD, music, and recess.

When James exhibits behaviors indicative of anxiety or

fear, he will experience emotional support/comfort from a

trusted adult. This support may be a hug, gentle

conversation, music, connection with art materials, or

anything else James chooses to regain a feeling of safety.

While trusted adults are limited, at this time, to Wanda and

Kelcie, other staff (Amanda, Linda, adults in charge of other

areas will focus on building a trust relationship, thus

expanding the circle of adults James can rely upon for

comfort and support.

29

Element 6: Identify replacement behavior.

What do you want the child to do? Clarify family involvement.

Replacement Behavior

When James self-identifies that he is feeling scared or anxious, or when gently and privately

prompted by an adult, he will go to the counselor’s office.

Element 7: List resources needed to implement the plan.

Be realistic.

Time, especially in Wanda and Kelcie’s schedule, is the biggest challenge. Throughout the school

day, both are scheduled to provide services for other children, and may not be immediately

available. Thus, the circle of trusted adults must be expanded as quickly as possible, through

relationship building activities between each adult and James. Until then, either Kelcie or Wanda

will available each time James is outside of Kelcie’s classroom. Schedule changes will occur to

ensure that both Kelcie and Wanda have daily lunch and plan time. Linda (principal), Derek

(social worker) and Alison (school para-professional) will be available to cover for Wanda and

Kelcie, as needed. This arrangement is short-term in nature. James’ behavior will be re-evaluated

after ten school days.

Element 8: Establish adult accountability for plan implementation.

Specify person(s) responsible for plan implementation.

Wanda and Linda are responsible for ensuring that this plan is fully implemented.

Element 9: Specify data points.

Specify data points and who will be responsible for data collection.

Person Responsible

Data Point

Wanda

● Number of elopements/day

● Number of minutes/elopement

● Anecdotal report on each elopement, specifying

behaviors preceding elopement and James’

response to comforting adults

30

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Element 10: Set meet back date(s)/time(s).

The team will meet every two weeks, every other Wednesday with the next meeting scheduled

for Oct. 16, 3:45 PM, conference room. Meetings will continue until all team members are satisfied

that extreme disruptions no longer occur.

Element 11: Behavior Threshold Analysis.

To be completed if the team needs a plan of action to support the student while her behavior is escalating, peaking, or

deescalating.

Describe indications that the student

is escalating.

James starts to use a louder voice tone. He appears to be

frightened and may move to an unusual space (ex: under

table, corner of room)

What are adults expected to do

when escalation behaviors are

noted?

The adult in charge quietly and privately reminds James

that he can go to the counselor’s office. Utilize nonverbal

signals such as pre-taught hand gestures or note card. She

then moves away from James and uses the school

connection system to request that Wanda or Kelcie come to

assist. If other children show signs of fear and/or James

engages in behavior that could result in harm to others, all

staff and students will go to an alternative location. Either

Kelcie or Wanda will remain with James.

Describe observable indications that

the student has resumed gross

control, self-control necessary to be

safe with respect to both self and

others.

James goes to the counselor’s office. He uses a normal voice

and is no longer afraid.

Describe observable indications that

James accepts physical comfort, engages in a calming

the student has resumed

sensory experience involving art or music, and when asked,

instructional control, self-control

indicates that he is ready to go back with his classmates.

necessary to de-brief and to learn

James appears to be calm, utilizes an appropriate voice

from experiences.

tone, and can follow simple instructions.

Describe which adult(s) will engage

in teaching interventions based

upon the recent situation.

Kelcie or Wanda will have a brief interaction with James

(maybe 5 minutes, at most), involving comfort behavior

and verbal affirmation that James was able to regain a

sense of calm and safety.

Time/date for adult debriefing of

the incident.

Each time a significant escalation occurs, the team will

debrief at the end of that day, 3:45 PM to 4:00 PM in the

conference room.

Adapted with permission from Aldridge, L. & Harrison, R. (2019). Functional behavioral assessment (FBA) & student support plan (SSP)

form. Unpublished document in preparation.

31

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