Embed Size (px)
Citation preview
3/18/15
1
Understanding and Managing Challenging Behaviors
Nicole Baumer, M.D., M.Ed. March 7, 2015
QuickTime™ and a decompressor
are needed to see this picture.
Baumer, 2015
Disclosures / Conflicts
• I have no disclosures or conflicts to disclose
Baumer, 2015
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
QuickTime™ and a decompressor
are needed to see this picture.
Baumer, 2015
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
Baumer, 2015
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.
Baumer, 2015
Common Behavioral Challenges
• Defiance • Aggression • Non-compliance • Agitation • Restlessness
• Hyperactivity • Disruptive • Inattentive • Destructive Behavior • Tantrums
Baumer, 2015
3/18/15
2
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
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
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?
Baumer, 2015
3/18/15
3
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
Baumer, 2015
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!
Baumer, 2015
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
Baumer, 2015
“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.
Baumer, 2015
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
Baumer, 2015
3/18/15
4
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
Baumer, 2015
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?)
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
3/18/15
5
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
Baumer, 2015
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!
Baumer, 2015
Visual RepresentaKons of ExpectaKons
Baumer, 2015
Visual ConKngency Map Story of what happens when acKons are followed through
correctly and when they are not…
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
3/18/15
6
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
Baumer, 2015
Planned Response: Consider the moKvaKon behind the
behavior
– AhenKon Seeking – Task Avoidance – Sensory – Means of CommunicaKon – Impulsivity
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
3/18/15
7
Is PosiKve Reinforcement Always Good?
Baumer, 2015
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
Baumer, 2015
Planned Responses Reinforcement Strategies / Rewards
• Use simple, consistent reward systems
Its not a bribe… We are all moKvated by rewards!
Baumer, 2015
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!”
QuickTime™ and a decompressor
are needed to see this picture.
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
Baumer, 2015
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
Baumer, 2015
3/18/15
8
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
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
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!
QuickTime™ and a decompressor
are needed to see this picture.
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
Baumer, 2015
3/18/15
9
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)
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
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
Baumer, 2015
3/18/15
10
Many Resources Available
PosiKve Strategies for SupporKng Behavior Improvement. AuKsm Speaks 2012
Baumer, 2015
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
Baumer, 2015
Thank you!
Baumer, 2015
