2015 fscn understanding and managing challenging behaviors...
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Understanding and Managing Challenging Behaviors
Nicole Baumer, M.D., M.Ed. March 7, 2015
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Baumer, 2015
Disclosures / Conflicts
• I have no disclosures or conflicts to disclose
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Brief Background • Pediatrician / Child Neurologist Neurodevelopmental DisabiliKes
• Boston Children’s Hospital – Neurology Department, Behavioral Neurology / AuKsm Spectrum Center
– Developmental Medicine Center, Down Syndrome Program
• Background in EducaKon
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ObjecKves • To IdenKfy Behavior Challenges
• Risk Factors, Why Intervene?
• To Understand the Purpose of Behaviors • To Develop ProacKve, PosiKve Behavioral Strategies
• To Discuss EvaluaKon and IntervenKon for Severe, Persistent Behavioral Challenges
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SeYng the stage… • Behavioral problems are common in all
children, but especially in children with neurodevelopmental disabiliKes.
• Behavioral challenges impact stress levels, relaKonships. It is important to prioriKze relaKonships.
• There are effecKve strategies and resources that can help.
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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 • Interferes with socializaKon, learning, independence , daily living
Act Now! Without intervenKon, behavioral problems in childhood persist, and predict the same in adulthood
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How does the child regulate their behavior in the face of frustraKon, and social / emoKonal challenges?
Behaviors result from a complex interacKon of child characterisKcs and
environment
Neurodevelopmental Profile
Skill level
Environmental Challenges
Social/EmoKonal Stress
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Child CharacterisKcs: Temperament
• Unique characterisKcs of a child that contribute to their behaviors
• Difficult temperament traits predict degree of behavioral challenges
• Intense reacKons, low sensory threshold, irregular cycles, negaKve mood, withdrawal Thomas, Chess, Birch 1968
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Child CharacterisKcs: Neurodevelopmental Profile
• Neurodevelopmental DisabiliKes / Biology – Affect learning, memory, emoKonal regulaKon
• Intellectual Disability, CommunicaKon Disorder, AuKsm Spectrum Disorder, ADHD, Neuromotor Disorder, Specific Learning Disorder
-‐DSM 5
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Environmental Factors • Family funcKoning / stress • Parent-‐child relaKonships • EducaKonal seYng • Appropriateness of curriculum • Fit with teacher, aide, peers • Level of consistency / predictability • Strength of social networks and support systems Baumer, 2015
Brief neurology detour Don’t be frightened…
How does the brain fit in?
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The Brain Controls Behavior
Brainstem • Alertness • Sleep
Cerebellum • Balance • Motor memory / planning • Learning
Occipital • Vision / Visual Processing
Parietal • Visual ahenKon • IntegraKon of senses
Frontal • MoKvaKon • Expressive language ExecuKve FuncKoning: • AhenKon • Problem solving • Impulse Control • OrganizaKon / Planning • Judgement
Temporal • Hearing • RecepKve Language • Memory • EmoKon
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Overview of Behavioral Management: The Big Picture
• Understand Purpose / MoKvaKon of Behavioral Problems
• ProacKve, PosiKve Behavioral Strategies • PrevenKon:
• Set ExpectaKons, Teach Skills and Adapt Environment • Planned Responses:
• Behavioral Principles: Operant condiKoning • Reinforcement and Punishment
• EvaluaKon and IntervenKon Plan for Severe, Persistent Behavioral Challenges Baumer, 2015
Caveat: This is NOT Easy! The Goal: Small Meaningful Changes Over
Time
• Expect variable results over Kme
• There are no quick fixes • Trial and error may be
required
-‐Dave Stein, PsyD
TIME
BEHAVIOR
Aim for Improvement, Not PerfecKon!
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PrioriKze! • Dangerous behaviors, safety concerns • Teaching fundamental skills to make improvements across several scenarios
• The relaKonship – Parent-‐child, teacher-‐child
Choose your bahles! – Challenging tasks à high energy demand à frustraKon
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“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 omen because the behaviors are working for them.
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All Behavior has a Purpose: Understand the MoKvaKon 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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CommunicaKon • Difficulty understanding instrucKons / tasks • Difficulty expressing thoughts, needs, emoKons FrustraKon!
Func:onal Communica:on is Key! – Use simple, short sentences – Language instrucKon, pictures/symbols, signs/gestures, communicaKon devices
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Be a DetecKve. Gather the Facts.
• Assess medical, cogniKve, emoKonal factors • Observe details about potenKal triggers:
– Where? (ParKcular environment?) – When? (ParKcular Kme?) – How? (Sudden? EscalaKng?) – Who? (Certain people?)
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Consider What is GeYng in the Way of Success
• Lack of skills – FuncKonal communicaKon – Social / interpersonal
• Mood, fear, anxiety, physiological states (hungry, Kred)
• Environmental factors – Schedule, curriculum, no rouKne – DistracKons: audio, visual
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ProacKve, PosiKve Behavioral Plan: Key Components
• IdenKfy child’s strengths • IdenKfy the concerning behaviors • Consider what the behaviors represent • Decide what environmental changes can be made • IdenKfy new skills that should be taught • Develop a reinforcement plan for posiKve behaviors and new skills.
• Develop an intervenKon plan / planned responses to challenging behaviors
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IdenKfy the Child’s Strengths and Weaknesses
• Try: • Visual cues / reinforcers • Social reward – earn play Kme
with friends • Predictable, consistent rouKne • Teach self-‐regulaKon, calming,
de-‐escalaKon • Avoid:
• Complex language • Over-‐explanaKon • Curveballs Baumer, 2015
ProacKve NOT ReacKve
1) PrevenKon • Set expectaKons and sKck to them • Adapt the environment • Teach important skills
2) Planned Responses
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AnKcipate Difficult SituaKons Prepare for change
Make things predictable
• NEW situations – Social Stories:
• Simple, shows sequence of events • Shows desired behaviors • Adds structure, visuals, and repeKKon
Social Stories, Carol Gray “The New Social Stories Book: Illustrated EdiKon” • Transitions
– Visual Kmers – Visual InteracKve Schedules
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Visual Schedules / RouKnes • Help children:
• Process verbally delivered informaKon • Shim focus between one acKvity and the next • Complete every step within a task • IniKate acKviKes • Stay focused
Less Nagging!
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Visual RepresentaKons of ExpectaKons
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Visual ConKngency Map Story of what happens when acKons are followed through
correctly and when they are not…
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If a Child is Having Behavior Problems…Teach Skills!
• Social Skills • EmoKonal processing / coping skills • Self-‐regulaKon / de-‐escalaKon skills • Problem solving
– Asking for help, cooperaKon, negoKaKon • Language / CommunicaKon skills
– Emphasize funcKonal communicaKon
Show what you want with visual aides, photos, video models AuKsm Speaks, 2012; NDSC; NDSS
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Reward PaKence and Flexibility • Jimmy wants the iPad RIGHT NOW. Instead of an automaKc “No” which might lead to a tantrum… TEACH him to WAIT. Ipad only: – Amer a task (start easy and build to longer/harder) – Amer adult completes task (“Yes, amer I finish making lunch.”) – Amer specific amount of Kme
• “I know you were disappointed because the store was closed. Since you stayed calm and were flexible, let’s go get ice cream instead.”
hhp://www.socialthinking.com
Increase frustraKon tolerance
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When Challenging Behaviors Do Arise…
Planned Response
Different Responses for Different Behaviors Baumer, 2015
Planned Response: Consider the nature of the behavior
• Basket 1: Safety issue → cannot ignore
• Basket 2: Not a safety issue, but potenKally problemaKc → MAY ignore or respond
• Basket 3: Not a safety issue, not that big of a deal → consider leYng it go.
-‐The Explosive Child, By Ross Greene, PhD
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Planned Response: Consider the moKvaKon behind the
behavior
– AhenKon Seeking – Task Avoidance – Sensory – Means of CommunicaKon – 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 CondiKoning
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Punishment • Works Immediately • Decreases likelihood of behavior
BUT not effecKve for long-‐term behavioral change LimitaKons: • Causes intense, emoKonal responses • May model aggressive behavior • Teaches what NOT to do • Does not build skills or knowledge about what TO DO. • Strains relaKonships Reserve for rare, well-‐defined behaviors Baumer, 2015
Natural
Token
Social
Tangible
Reinforcement • SKmuli that increase likelihood of behavior • Most effecKve in creaKng long-‐term behavioral change
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Is PosiKve Reinforcement Always Good?
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In General, Children Respond Beher to POSITIVE Behavior Supports than
to Punishment • Give posiKve feedback much more frequently than
correcKons / negaKve feedback • Fosters sense of competence, interest, moKvaKon
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Planned Responses Reinforcement Strategies / Rewards
• Use simple, consistent reward systems
Its not a bribe… We are all moKvated by rewards!
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PosiKve PracKce
• “Oops, let’s pracKce cleaning the right way.”
Then reinforce with praise: • “I love how you just put those toys away safely and quietly!”
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Baumer, 2015
Again… Reinforce what you want to see more of. Do NOT Reinforce what you want to see less of.
For problem behavior… RESPOND but do NOT REACT
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Example: AhenKon Seeking • Bobby turns off the lights in the doctor’s office
• KaKe pinches Julie on the playground • Joshua jumps on the bed…
Pay ahenKon to GOOD behavior. IGNORE the PROBLEM behavior!
• ExKncKon Burst is normal à Stay the Course! • No strong reacKons: eye contact, touch, yell, over-‐
talk… – FUN and INTERESTING: Reinforcement
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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 modificaKons
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Example: Self-‐SKmulaKon / Sensory Seeking
• Rocking, flapping, twirling, teeth grinding • ProblemaKc when interfering and consuming Goal: Slowly Restrict in Time and Place
Strategies: – Increase range of interests – Occupy Kme – Replacement, subsKtute behaviors – Do not reinforce – SomeKmes, ignore and accept
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Dangerous / Aggressive Behaviors
• May require our last resort method: Discipline
• Consider whether planned or reacKve / impulsive – Planned aggression:
• CogniKve Behavioral Strategies / Therapy • Clear limits / consequences
– ReacKve aggression: • Address self-‐control, replacement behaviors • Breaks, calming acKviKes
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Time-‐outs • Try to use as a Kme away from reinforcing behaviors or as a preventaKve strategy, instead of punishment
• Remove only from a desirable situaKon – Or it may become escape/avoid tacKc
• Boring or neutral seYng • No ahenKon • Use as a break!
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Baumer, 2015
Professional EvaluaKon and SystemaKc IntervenKon For Severe, Persistent
Challenging Behaviors
• Medical assessment • Close collaboraKon among parents, caregivers, educators, medical providers
• Consider potenKal psychiatric, neurodevelopmental, or behavioral disorders
• Consider medicaKon trials Baumer, 2015
Assessing New / Persistent Behavioral Concerns
• Medical / Behavioral History: – Family history of psychiatric / behavioral problems – Assessment of stressors
• student/teacher fit, major environmental change, loss, transiKon
– Assessment of skills • cogniKve, adapKve, expressive communicaKon, recepKve language / comprehension
• Physical examinaKon • Behavior checklists • Collaborate with child’s team
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PotenKal Medical Causes of Challenging Behaviors
• Pain • InfecKon • Sleep Problems • NutriKon • Hearing or Vision concerns • Celiac disease • Thyroid disease • GastrointesKnal problems: consKpaKon, reflux, abdominal pain
• Depression, Anxiety, Psychosis Baumer, 2015
FuncKonal Behavioral Analysis Should tell you: A,B,Cs
• Antecedent: what happens BEFORE the behavior (trigger)
• Behavior: what the target behavior looks like – How omen, how long does it occur
• Consequence: what happens AFTER the behavior (outcome)
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Behavioral IntervenKon Plan • Goal:
– Reduce problem behavior – Increase appropriate behavior – Improve quality of life
• SystemaKc data collecKon – Target behaviors, measure specific goals
• Evaluate and revise plan regularly
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Some Children Require MedicaKon in AddiKon to Behavior Strategies MedicaKons can be used to target: – Impulsivity – HyperacKvity – InahenKon – Mood – depression, mood swings – Anxiety – Obsessive-‐compulsive behavior – Aggression – Self-‐Injurious behavior Baumer, 2015
Closing Points
• The goal is improvement, not perfecKon
• Focusing on your relaKonship, the posiKves, and the child’s strengths will help you choose the best behavior strategies
• The hope is that we can limit behavior problems over Kme, 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 • AssociaKon for Behavior Support
– www.apbs.org • NaKonal DisseminaKon Center for Children with DisabiliKes
– hhp://nichcy.org/schoolage/behavior/behavassess • Center on PosiKve Behavioral IntervenKon and Supports
– hhp://www.pbis.org • FederaKon for Children with Special Needs
– hhp://fcsn.org
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Many Resources Available
PosiKve Strategies for SupporKng Behavior Improvement. AuKsm Speaks 2012
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Thank you! Thank you to my team:
• Partner in Crime: Dr. David Stein (Psychology in DMC)
• My team at Boston Children’s Hospital
• My family
• The children and families with whom I work
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Thank you!
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