effective behavior management strategies for the substance-exposed child erin telford, psy.d....

Effective Behavior Effective Behavior Management Management

Strategies for the Strategies for the Substance-exposed Substance-exposed

ChildChildErin Telford, Psy.D.Erin Telford, Psy.D.Children’s Research TriangleChildren’s Research Triangle

© Children’s Research Triangle 2006

AgendaAgenda

Prenatal substance exposure and Prenatal substance exposure and behavior managementbehavior management

What is behavior management?What is behavior management? Behavior management strategiesBehavior management strategies Behavior plansBehavior plans


Prenatal Substance Prenatal Substance Exposure and Behavior Exposure and Behavior

ManagementManagement

Children with a history of prenatal Children with a history of prenatal substance exposure have difficulties substance exposure have difficulties with:with: Abstract conceptsAbstract concepts Anticipating consequences Anticipating consequences Connecting their behavior Connecting their behavior


Prenatal Substance Prenatal Substance Exposure and Behavior Exposure and Behavior

ManagementManagement Impairments in information Impairments in information

processing are commonprocessing are common Sequencing is difficultSequencing is difficult

RESULT:RESULT: “traditional” discipline “traditional” discipline often ineffectiveoften ineffective


Research on Behavior Research on Behavior ManagementManagement

Little research on effective behavior Little research on effective behavior managementmanagement

Recommended treatment is often not Recommended treatment is often not based on research but child’s clinical based on research but child’s clinical picturepicture

Positive behavior programming, Positive behavior programming, consistency, and concrete consistency, and concrete interventions are effective interventions are effective (Miller, 2005)(Miller, 2005)


AgendaAgenda




What is the goal of behavior What is the goal of behavior management?management?

To understand the child’s behaviorTo understand the child’s behavior To understand contributing factors To understand contributing factors

to the child’s behaviorto the child’s behavior To increase child’s independence by To increase child’s independence by

teaching them skillsteaching them skills And, of course, to change negative And, of course, to change negative

or problematic behaviors! or problematic behaviors!


Reinforcement versus Reinforcement versus PunishmentPunishment

Behavior

Increases

Behavior Decreases

Stimulus

Applied

Positive

Reinforcement

Positive

Punishment

Stimulus

Removed

Negative

Reinforcement

Negative Punishment


Does Punishment Work?Does Punishment Work?

In one word…yes!In one word…yes! Punishment is Punishment is

extremely effective extremely effective in getting a quick in getting a quick response or response or behavioral changebehavioral change

Behaviors generally Behaviors generally end quicklyend quickly


Then what’s the Then what’s the problem?problem?

Punishment is Punishment is effective but effective but there are there are problems…problems…

GeneralizationGeneralization Does not generalize Does not generalize

wellwell Punishment across Punishment across

environmental environmental contextscontexts

Practical Practical problemsproblems Community useCommunity use Individual reactionsIndividual reactions


What What cancan we do? we do?

Proactive Proactive StrategiesStrategies

Decrease the Decrease the frequency of frequency of behaviorbehavior

Decrease intensity Decrease intensity of a behaviorof a behavior

Goal:Goal: to prevent to prevent negative behaviors negative behaviors before they occurbefore they occur

Reactive Reactive StrategiesStrategies

Immediately stop a Immediately stop a potentially potentially dangerous dangerous behaviorbehavior

Goal:Goal: get control get control over a behavior over a behavior quicklyquickly


AgendaAgenda




Proactive StrategiesProactive Strategies

ProactiveStrategies

Environmental Manipulation

DirectTreatment

Positive Programming

Planned Environmental

Changes

Any InterventionDirectly Affecting

Child

TeachingNew Skills


Environmental Environmental ManipulationManipulation

SettingsSettings InteractionsInteractions Instructional Instructional

methodsmethods Characteristics of Characteristics of

other peopleother people Instructional/Instructional/

personal goalspersonal goals Environmental Environmental

pollutantspollutants Number of peopleNumber of people


Suggested Suggested Environmental StrategiesEnvironmental Strategies

Plain wallsPlain walls Avoid Avoid

mobiles/hanging mobiles/hanging items with young items with young childrenchildren

Soft lightingSoft lighting Cover part of Cover part of

windows if windows if distraction is an issuedistraction is an issue

Limit open spaces by Limit open spaces by providing visual or providing visual or physical boundariesphysical boundaries

Label areas with Label areas with pictures and wordspictures and words

Keep areas clean – Keep areas clean – only have out only have out materials being materials being usedused


Suggested EnvironmentalSuggested EnvironmentalStrategiesStrategies

Help child organize personal spaceHelp child organize personal space Do not unexpectedly change the Do not unexpectedly change the

work/personal areawork/personal area Minimize extraneous noisesMinimize extraneous noises Picture cuesPicture cues


Direct TreatmentDirect Treatment

Reinforcement schedulesReinforcement schedules Stimulus controlStimulus control Medication adjustmentMedication adjustment Dietary changesDietary changes


Direct Treatment Direct Treatment SuggestionsSuggestions

Consistency across contextsConsistency across contexts Plan, structure, and organize Plan, structure, and organize PredictPredict Distinguish between willful Distinguish between willful

behavior and neurological behavior and neurological deficits deficits


Direct Treatment Direct Treatment SuggestionsSuggestions

Eliminate overwhelming stimulus Eliminate overwhelming stimulus before it occursbefore it occurs

Learn what child values for Learn what child values for reinforcement schedulesreinforcement schedules

Make “choice cards” for positive Make “choice cards” for positive rewardsrewards


Positive ProgrammingPositive Programming

ALL behavior has a purposeALL behavior has a purpose Need to teach news skills for Need to teach news skills for

behaviors you want to eliminatebehaviors you want to eliminate Teaches:Teaches:

1. General skills1. General skills

2. Functional skills2. Functional skills

3. Coping skills3. Coping skills


Suggested PositiveSuggested PositiveProgramming StrategiesProgramming Strategies

Gradual shift from external to Gradual shift from external to internal controlinternal control

Teach strategies for self-regulationTeach strategies for self-regulation Encourage self-monitoringEncourage self-monitoring Model calm, organized Model calm, organized

behavior behavior


Suggested PositiveSuggested PositiveProgramming StrategiesProgramming Strategies

Emphasize thinking skills (How did Emphasize thinking skills (How did you figure that out?)you figure that out?)

Teach “habits”Teach “habits” Teach relationship skillsTeach relationship skills Teach problem solving skillsTeach problem solving skills


Reactive StrategiesReactive Strategies

A reactive response can reinforce A reactive response can reinforce the negative behaviorthe negative behavior

Reactive strategies can include Reactive strategies can include punishmentpunishment

Reactive strategies are always Reactive strategies are always necessary when designing a good necessary when designing a good treatment plantreatment plan


Suggestions for Reactive Suggestions for Reactive StrategiesStrategies

Be firm, not punitiveBe firm, not punitive Consistently adhere to rulesConsistently adhere to rules Wait until child is calm and de-escalated Wait until child is calm and de-escalated

before interveningbefore intervening Avoid debates, just state the ruleAvoid debates, just state the rule Avoid punitive consequences such as Avoid punitive consequences such as

isolationisolation Use reactive strategies only to get Use reactive strategies only to get

immediate control over a potentially immediate control over a potentially dangerous situationdangerous situation


AgendaAgenda




Behavior Management Behavior Management PlansPlans

IIndividualizedndividualizedAAssessment-basedssessment-basedCConsistentonsistent

GGoal orientedoal oriented

AAcross contextscross contexts

CComprehensiveomprehensive


Step 1: Pick behaviorStep 1: Pick behavior

Pick specific behavior to work onPick specific behavior to work on Prioritize: what behavior needs to Prioritize: what behavior needs to

change?change? Once a behavior is chosen, define it:Once a behavior is chosen, define it:

What does the behavior specifically look What does the behavior specifically look like?like?

How long does the behavior last?How long does the behavior last?


Prioritize BehaviorsPrioritize Behaviors


Step 2: Track BehaviorStep 2: Track Behavior

Want to get a good understanding of Want to get a good understanding of what is contributing to the behaviorwhat is contributing to the behavior

Ask: Ask: What occurred IMMEDIATELY before What occurred IMMEDIATELY before

the behavior?the behavior? What occurred afterwards? What was What occurred afterwards? What was

the consequence of the behavior?the consequence of the behavior? When did it occur?When did it occur? How often does it occur?How often does it occur?


Sample Behavior Sample Behavior Tracking Tracking


Step 3: Analyze BehaviorStep 3: Analyze Behavior

Once the behavior is tracked, Once the behavior is tracked, analysis is easieranalysis is easier

Analysis should take place based on Analysis should take place based on the earlier dimensions:the earlier dimensions: Environmental factorsEnvironmental factors Direct interventionsDirect interventions Skill deficitsSkill deficits


Sample Behavior Sample Behavior AnalysisAnalysis


Step 4: Create PlanStep 4: Create Plan Identify interventions under each area:Identify interventions under each area:

1.1. What changes can be made in the What changes can be made in the environment to decrease the behavior?environment to decrease the behavior?

2.2. Can any behavior be reinforced to Can any behavior be reinforced to increase it?increase it?

3.3. Does there need to be any changes in Does there need to be any changes in medication? Diet?medication? Diet?

4.4. Are there skills that the child can be Are there skills that the child can be taught to replace problematic behaviors?taught to replace problematic behaviors?

5.5. What are the minimal reactive strategies? What are the minimal reactive strategies? When are they implemented? When are they implemented?


Case ExampleCase Example 7 year old girl 7 year old girl Frequent tantrums Frequent tantrums Triggers: transitions, Triggers: transitions,

frustration, frustration, communication communication problems, limits problems, limits

Impulsivity and Impulsivity and inattentioninattention

Home environment is Home environment is chaotic with limited chaotic with limited spacespace

Traditional behavior Traditional behavior management management ineffectiveineffective


Case ExampleCase ExampleEnvironmental StrategiesEnvironmental Strategies

Difficult to change the child, but can Difficult to change the child, but can change the environmentchange the environment

Create a personal spaceCreate a personal space Minimize extraneous people in the Minimize extraneous people in the

homehome Decrease noiseDecrease noise Sensory integration evaluation Sensory integration evaluation Transition warnings Transition warnings


Case ExampleCase ExampleDirect Treatment StrategiesDirect Treatment Strategies

Referral for Referral for psychiatric psychiatric evaluationevaluation

Reinforcement Reinforcement schedule for schedule for positive behaviorspositive behaviors

““External brain” External brain” strategies strategies


Case ExampleCase ExamplePositive Programming Positive Programming

StrategiesStrategies Relaxation techniques for when Relaxation techniques for when

feeling overwhelmedfeeling overwhelmed Supplemental communication Supplemental communication

strategies to use when feeling strategies to use when feeling overwhelmed or frustratedoverwhelmed or frustrated May include break or help cardsMay include break or help cards Simple cues that patient can give othersSimple cues that patient can give others


Case ExampleCase ExampleReactive StrategiesReactive Strategies

““Cool down” time Cool down” time if escalating (in if escalating (in personal area personal area already created)already created)

Removal from the Removal from the situation if situation if aggressiveaggressive

Holding patientHolding patient


Step 5: Review and Step 5: Review and ReviseRevise

Children are not static, so their Children are not static, so their behavior plan should not be static!behavior plan should not be static!

Have frequent reviews and revise as Have frequent reviews and revise as neededneeded

effective behavior management strategies for the substance-exposed child erin telford, psy.d....

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