Understanding and Managing Challenging Behaviors

Nicole Baumer, M.D., M.Ed.

March 8, 2014

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Down Syndrome Program, Developmental Medicine Center

Department of Neurology

Objectives

• To Identify Behavior Challenges • Background, Risk Factors, Why Intervene

• To Understand the Purpose of Behaviors • To Develop Proactive, Positive Behavioral

Strategies

• To Discuss Evaluation and Intervention for Severe, Persistent Behavioral Challenges

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Setting the stage…

• Behavioral problems are common in all children, but especially in children with neurodevelopmental disabilities.

• Prioritize relationships.

• There are effective strategies and resources.

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Common Behavioral Challenges

• Defiance

• Aggression

• Non-compliance

• Agitation

• Restlessness

• Hyperactivity

• Disruptive

• Inattentive

• Destructive Behavior

• Tantrums

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Why Intervene?

•Unsafe, self-injurious behaviors

•Behaviors that interfere with socialization, learning, daily living

Act Now! Without intervention, behavioral problems in childhood persist, and predict the same in adulthood FCSN Baumer, 2014

How does the child regulate their behavior in the face of frustration, and social / emotional challenges?

Behaviors result from a complex interaction of child characteristics and

environment

Neurodevelopmental Profile

Skill level

Environmental Challenges

Social/Emotional Stress

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Child Characteristics: Temperament

• Unique characteristics of a child that contribute to their behaviors

• Difficult temperament traits predict degree of behavioral challenges

• Intense reactions, low sensory threshold, irregular cycles, negative mood, withdrawal

Thomas, Chess, Birch 1968

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Child Characteristics: Neurodevelopmental Profile

• Neurodevelopmental Disabilities / Biology

– Affect learning, memory, emotional regulation

• Intellectual Disability, Communication Disorder, Autism Spectrum Disorder, ADHD, Neuromotor Disorder, Specific Learning Disorder

-DSM 5

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Environmental Factors

• Family functioning / stress

• Parent-child relationships

• Educational setting

• Appropriateness of curriculum

• Fit with teacher

• Level of consistency / predictability

• Strength of social networks and support systems FCSN Baumer, 2014

The Brain Controls Behavior

Brainstem •Alertness •Sleep

Cerebellum •Balance •Motor memory / planning •Learning

Occipital •Vision / Visual Processing

Parietal •Visual attention •Integration of senses

Frontal •Motivation •Expressive language Executive Functioning: •Attention •Problem solving •Impulse Control •Organization / Planning •Judgement

Temporal •Hearing •Receptive Language •Memory •Emotion

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Overview of Behavioral Management: The Big Picture

• Understand Purpose / Motivation of Behavioral Problems

• Proactive, Positive Behavioral Strategies • Prevention:

• Set Expectations, Teach Skills and Adapt Environment

• Planned Responses: • Behavioral Principles: Operant conditioning • Reinforcement and Punishment

• Evaluation and Intervention Plan for Severe,

Persistent Behavioral Challenges FCSN Baumer, 2014

Caveat: This is NOT Easy! The Goal: Small Meaningful Changes Over

Time

• Expect variable results over time

• There are no quick fixes.

• Trial and error may be required

-Dave Stein

TIME

BEHAVIOR

Aim for Improvement, Not Perfection!

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http://www.sxc.hu/browse.phtml?f=download&id=1131299&redirect=photo

Prioritize!

• Dangerous behaviors, safety concerns

• Teaching fundamental skills to make improvements across several scenarios

• The relationship – Parent-child, teacher-child

Choose your battles!

Challenging tasks high energy demand frustration

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Understanding Behavioral Problems

“Kids do well if they can.”

Challenging behaviors result from

“lagging skills” and “unmet needs” -Dr. Ross Greene, The Explosive Child

When kids have persistent behaviors, it is often because the behaviors are working for them.

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All Behavior Has a Purpose: Understand the Motivation Driving

the Behavior

• Communication

– Get needs met!

– Express emotion

• Avoid / Escape

– Difficult task

– Anxiety/fear

– Limited motivation

• Attention seeking – Even negative attention can

be highly rewarding

• Sensory / Self-Stimulatory – Not socially-motivated

– Results in a feeling the person likes

– Rocking, twirling, flapping

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Communication

• Difficulty understanding instructions / tasks

• Difficulty expressing thoughts, needs, emotions

Frustration!

Functional Communication is Key! – Use simple, short sentences

– Language instruction, pictures/symbols, signs/gestures, communication devices

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Be a Detective. Gather the Facts.

• Assess medical, cognitive, emotional factors

• Observe details about potential triggers:

– Where? (Particular environment?)

– When? (Particular time?)

– How? (Sudden? Escalating?)

– Who? (Certain people?)

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Consider What is Getting in the Way of Success

• Lack of skills

– Functional communication

– Social / interpersonal

• Mood, fear, anxiety, physiological states (hungry, tired)

• Environmental factors

– Schedule, curriculum, no routine

– Distractions: audio, visual FCSN Baumer, 2014

Proactive, Positive Behavioral Strategies: Key Components

• Identify child’s strengths

• Identify the concerning behaviors

• Consider what the behaviors represent

• Decide what environmental changes can be made

• Identify new skills that should be taught

• Develop a reinforcement plan for positive behaviors and new skills.

• Develop an intervention plan / planned responses to challenging behaviors

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Identify the Child’s Strengths and Weaknesses

• Try: • Visual cues / reinforcers • Social reward – earn play time

with friends • Predictable, consistent routine • Teach self-regulation, calming,

de-escalation • Avoid:

• Complex language • Over-explanation • Curveballs Stein, 2013

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Proactive NOT Reactive

1) Prevention •Set expectations and stick to them

•Adapt the environment

•Teach important skills

2) Planned Responses

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Anticipate Difficult Situations Prepare for change

Make things predictable

• NEW situations

– Social Stories:

• Simple, shows sequence of events

• Shows desired behaviors

• Adds structure, visuals, and repetition Social Stories, Carol Gray “The New Social Stories Book: Illustrated Edition”

• Transitions

– Visual timers

– Visual Interactive Schedules

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Visual Schedules / Routines

• Help children: •Process verbally delivered information

•Shift focus between one activity and the next

•Complete every step within a task

•Initiate activities

•Stay focused Less Nagging!

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Visual Representations of Expectations

Story of what happens when actions are followed through correctly and when they are not…

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If a Child is Having Behavior Problems…Teach Skills!

• Social Skills

• Emotional processing / coping skills

• Self-regulation / de-escalation skills

• Problem solving – Asking for help, cooperation, negotiation

• Language / Communication skills – Emphasize functional communication

Show what you want with visual aides, photos, video models

Autism Speaks, 2012; NDSC; NDSS

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Reward Patience and Flexibility

• Jimmy wants the iPad RIGHT NOW. Instead of an automatic “No” which might lead to a tantrum… TEACH him to WAIT.

Ipad only: – After a task (start easy and build to longer/harder)

– After adult completes task (Yes, after I finish making lunch)

– After specific amount of time

• “I know you were disappointed because the store was closed. Since you stayed calm and were flexible, let’s go get ice cream instead.”

http://www.socialthinking.com

Social Thinking Curriculum:

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When Challenging Behaviors Do Arise…

Planned Response Different Responses for Different

Behaviors FCSN Baumer, 2014

Planned Response: Consider the nature of the behavior

• Basket 1: Safety issue cannot ignore

• Basket 2: Not a safety issue, but potentially problematic MAY ignore or respond

• Basket 3: Not a safety issue, not that big of a deal consider letting it go.

-The Explosive Child, By Ross Greene, PhD

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Planned Response: Consider the motivation behind the

behavior

– Attention Seeking

– Task Avoidance

– Sensory

– Means of Communication

– Impulsivity

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The Goal: INCREASE Desirable Behaviors and DECREASE

Undesirable Behaviors

Reinforce what you want to see more of Do NOT reinforce what you want to see less of

Behavioral Principles: Operant Conditioning

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http://syarafina-teach-science.blogspot.com/2011/03/behaviourism-classical-and-operant.html

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Punishment • Works Immediately

• Decreases likelihood of behavior

BUT not effective for long-term behavioral change

Limitations:

• Causes intense, emotional responses

• Model for aggressive behavior

• Teaches what NOT TO DO

• Does not build skills or

knowledge about what TO DO.

• Strains relationships

Reserve for rare, well-defined behaviors

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Natural

Token

Social

Tangible

Reinforcement • Stimuli that increase likelihood of behavior • Most effective in creating long-term behavioral change

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In General, Children Respond Better to POSITIVE Behavior Supports than

to Punishment

• Give positive feedback much more frequently than

corrections / negative feedback

• Fosters sense of competence, interest, motivation

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Planned Responses Reinforcement Strategies / Rewards

• Use simple, consistent reward systems

Its not a bribe… We are all motivated by rewards! FCSN Baumer, 2014

Example: Attention Seeking • Bobby turns off the lights in the doctor’s office

• Katie pinches Julie on the playground

• Joshua jumps on the bed…

Pay attention to GOOD behavior. IGNORE the PROBLEM behavior!

• Extinction Burst is normal Stay the Course!

• No strong reactions: eye contact, touch, yell, over-talk…

– FUN and INTERESTING: Reinforcement FCSN Baumer, 2014

Example: Escape / Avoidance – I don’t want to leave the party, so I’m going to flop

on to the floor and refuse to move.

– Math is hard, so I’m going to run out of the classroom to avoid it.

Strategies: – Choose “Just Right” Tasks – Provide choices / control (within parameters) – Take advantage of good mood and momentum – Break up tasks into small steps – Teach how to request breaks – Teach new skills / make modifications

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Example: Self-Stimulation / Sensory Seeking

• Rocking, flapping, twirling, teeth grinding • Problematic when interfering and consuming

Goal: Slowly Restrict in Time and Place

Strategies:

– Increase range of interests

– Occupy time

– Replacement, substitute behaviors

– Do not reinforce

– Sometimes, ignore and accept FCSN Baumer, 2014

Dangerous / Aggressive Behaviors

• May require our last resort method: Discipline.

• Consider whether planned or reactive / impulsive – Planned aggression:

• Cognitive Behavioral Strategies / Therapy

• Clear limits / consequences

– Reactive aggression:

• Address self-control, replacement behaviors

• Breaks, calming activities

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Time-outs • Try to use as a time away from reinforcing behaviors

or as a preventative strategy, instead of punishment

• Remove only from a desirable situation

– Or it may become escape/avoid tactic

• Boring or neutral setting

• No attention

• Use as a break!

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Professional Evaluation and Systematic Intervention For Severe, Persistent

Challenging Behaviors

• Medical assessment

• Close collaboration among parents, caregivers, educators, medical providers

• Consider potential psychiatric, neurodevelopmental, or behavioral disorders

• Consider medication trials

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Assessing New / Persistent Behavioral Concerns

• Medical / Behavioral History: – Family history of psychiatric / behavioral problems

– Assessment of stressors • student/teacher fit, major environmental change, loss,

transition

– Assessment of skills • cognitive, adaptive, expressive communication, receptive

language / comprehension

• Physical examination

• Behavior checklists

• Collaborate with child’s team FCSN Baumer, 2014

Potential Medical Causes of Challenging Behaviors

• Pain

• Infection

• Sleep Problems

• Nutrition

• Hearing or Vision concerns

• Celiac disease

• Thyroid disease

• Gastrointestinal problems: constipation, reflux, abdominal pain

• Depression, Anxiety, Psychosis

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Functional Behavioral Analysis Should tell you: A,B,Cs

• Antecedent: what happens BEFORE the behavior (trigger)

• Behavior: what the target behavior looks like – How often, how long does it occur

• Consequence: what happens AFTER the behavior (outcome)

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Behavioral Intervention Plan

• Goal:

– Reduce problem behavior

– Increase appropriate behavior

– Improve quality of life

• Systematic data collection

– Target behaviors, measure specific goals

• Evaluate and revise plan regularly

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Some Children Require Medication in Addition to Behavior Strategies

Medications can be used to target: – Impulsivity – Hyperactivity – Inattention – Mood – depression, mood swings – Anxiety – Obsessive-compulsive behavior – Aggression – Self-Injurious behavior FCSN Baumer, 2014

Closing Points

• The goal is improvement, not perfection

• Focusing on your relationship, the positives, and the child’s strengths will help you choose the best behavior strategies.

• The hope is that we can limit behavior problems over time, so that the individual can live a fulfilling adulthood

– The “endpoint” is not tomorrow or next month.

– Celebrate the small successes along the way.

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Resources / Further Reading

• Association for Behavior Support

– www.apbs.org

• National Dissemination Center for Children with Disabilities

– http://nichcy.org/schoolage/behavior/behavassess

• Center on Positive Behavioral Intervention and Supports

– http://www.pbis.org

• Federation for Children with Special Needs

– http://fcsn.org

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http://www.apbs.org/http://nichcy.org/schoolage/behavior/behavassesshttp://www.pbis.org/http://fcsn.org/

Many Resources Available

Positive Strategies for Supporting Behavior Improvement. Autism Speaks 2012

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Thank you! Thank you to my team:

• Partner in Crime: Dr. David Stein (Psychology, DMC)

• My team at Boston Children’s Hospital

• My family

• The children and families with whom I work

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