Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS

Behavior Is Communication: Strategies for Understanding Challenging Behaviors

Presented by: APS HealthcareSouthwestern PA Health Care Quality Unit(APS HCQU)

October 2011 bjl

© 2009 APS Healthcare, Inc. 2

Disclaimer

Information or education provided by the HCQU is not intended to replace medical advice from the consumer’s personal care physician, existing facility policy or federal, state and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.

Certificates for training hours will only be awarded to those who attend a training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.


Note of Clarification

While mental retardation (MR) is still recognized as a clinical diagnosis, in an effort to support the work of self-advocates, the APS SW PA HCQU will be using the terms intellectual and/or developmental disability (ID/DD) to replace mental retardation (MR) when feasible.


Objectives

Recall strategies for understanding and responding to challenging behaviors

Describe basic premises about mental illness in relation to challenging behaviors

List the important assumptions about challenging behaviors

Summarize ways to report challenging behaviors accurately

Recite methods of de-escalation


Understanding Challenging Behaviors

Why might it be necessary to understand challenging behaviors?


Why is it Necessary to Understand Challenging Behaviors?

To understand needs and wants

To prevent crisis situations

To improve relationships between professionals and individuals

To reduce need for hospitalizations and/or restrictive behavior plans


Meeting Needs and Wants

Challenging behaviors and aggression are coping mechanisms

– ‘Strategies’ to meet needs and wants

Challenging behaviors are NOT results of mental illness or ID/DD

EXERCISE




Sally likes to go for car rides on sunny days. She has a blue convertible and will often put the top down when she takes it out for a spin.

One day, Sally decided to go for a ride around the city. When she pulled out of her garage she put the top of her convertible down and started off, not noticing the grey clouds gathering in the western sky behind her. As she drove, the sun disappeared behind the clouds and everything appeared grey.

Sally drove on, listening to her radio at full blast. Suddenly, she felt her face getting wet. She looked at her hands and noticed that they were covered in beads of water… and so was the interior of her convertible!


Basic Premises About Mental Illness

Symptoms never occur alone.

Symptoms can be observed behaviorally.

The key in identifying possible symptoms is to notice, describe, and capture changes in a person over time.

The cluster of symptoms is a significant change in how the person acts and can have an impact on his or her ability to function.

To understand the significance of a change in someone, caregivers need to understand how the person is when functioning at a normal, healthy level.



Symptoms never occur alone

– Cluster of symptoms must be present

– Cluster of symptoms occur over time



Example of symptom cluster for depression

• Depressed mood most of the day, nearly every day

• Diminished pleasure or interest in previously enjoyed activities

• Significant weight loss or gain

• Insomnia or Hypersomnia (sleeping too much)

• Psychomotor agitation (restlessness) or retardation (moving about slower than normal for the person)

• Fatigue or loss of energy every day

• Feelings of worthlessness or excessive / inappropriate guilt

• Diminished ability to think or concentrate• 4

• Recurrent thoughts of death / suicide



Symptoms can be observed behaviorally

– How could depressed mood be described behaviorally?

– How could hallucinations be described behaviorally?

– How could obsessive-compulsive disorder be described behaviorally?

– How could manic mood be described behaviorally?



The key in identifying possible symptoms is to notice, describe and capture changes in a person over time.

– Onset

– Increase / Decrease

– Intensity

– Noticeable patterns, episodes, or cycles of behavior



The cluster of symptoms is a significant change in how the person acts and can have an impact on his or her ability to function.

• Not just a ‘bad day’

• Goes on for extended periods of time

• Makes day to day living difficult

• Impacts relationships, work / school, self-care



To understand the significance of a change in someone, staff needs to understand how the person is when she is functioning at her normal, healthy level.

Know what a person is capable of / usually enjoys doing

– Talk with other staff, family members, doctors, etc.


Describing What is Seen and Heard

How are a person’s behaviors typically described:

– in a chart?

– during a shift report?

– after an incident / crisis situation?

– during a typical and uneventful day?



Don’t interpret

No “suitcase” words

– Avoid terms like ‘aggressive’, ‘isolative’, or ‘defiant’

Take one symptom at a time

Capture behaviors at the person’s best (healthiest) and worst (most ill)

Don’t argue or decide if something is a symptom or not

EXERCISE



Challenging Behavior – Basic Assumptions

There is an unmet need or want.

Challenging behavior is meaningful.

People have good reasons to do what they do.

People do the best they can with what they have at that time and in that context.



Challenging behaviors interfere with an individual’s daily life.

Challenging behaviors may result from differences in culture and limitations in abstract thinking

Challenging behaviors threaten the safety of the person or others

Challenging behaviors are likely to limit or deny the person access to the use of various facilities



“All behavior is meaningful and can be understood. It is purposeful, seeking feelings of satisfaction and security, and this is especially true of psychiatric patients” – Dr. Hildegard Peplau (1952)

EXERCISE

The Amy Scenario



Intellectual / developmental disabilities do not cause challenging behaviors.

The only behavior that can be attributed directly to intellectual and/or developmental disability is slow learning of new academic information (Ryan 1993).


Challenging Behavior – Triggers

People, places or things that remind someone of an event, feeling or experience

– Are different for everyone

Triggers can evoke good and bad memories

– Depends on individual

– Depends on experiences

EXERCISE

Triggers


Challenging Behavior – Triggers

Staff responses to challenging behaviors can be triggers

Pay attention to person’s voice tone, what he/she says, his/her actions and requests

EXERCISE

Joe’s Story


Challenging Behavior – Things to Consider

Communication

Environment

Emotions

Unaddressed Medical / Physical Needs

Trauma


Challenging Behavior – Communication

“The 18 Second Rule”

Give direct attention to the person

“Communication Partners”

Communication Tools

– Communication Board

– Social Stories

– Liberator


Challenging Behavior – Environment

A person’s immediate surroundings

Includes who is with the person


Challenging Behavior – Environment

Questions to ask:

– Is the person feeling too hot / cold?

– Is the person hungry / thirsty?

– Is the person tired / fatigued?

– Is the environment too stimulating / not stimulating enough for the person?

– Does the person need to exercise / move around?

– Does the person need to use the restroom (may be embarrassed or unable to ask)

– Are the person’s privacy / boundaries respected?

– Does the person like the people he/she is interacting with?


Challenging Behavior – Emotions

One’s feelings / experiences directly impact one’s perception of stress and coping skills

What is fun / difficult / boring / sad for one person is totally the opposite for another

Pay attention to person’s communication to gauge his/her feelings

– This helps the person cope with stress

– Strengthens relationship between person and staff



Safety

– Key aspect of emotional wellness

Fear leads to:

– Anxiety

– Irritability

– Defiance

– Aggression

– Depression



People must feel safe to feel well emotionally

Lack of safety may result in behaviors like:

– Clinginess

– Always wanting a preferred person present

– Asking the same questions repeatedly

– Refusing medications and/or treatments

– Eloping from group home



Stability can be reassuring

Structure provides an expectation of what will happen from day to day


Challenging Behavior - Unaddressed Physical/Medical Needs

Illnesses affect people with ID/DD as they do anyone else

– Many individuals have multiple illnesses / conditions

Symptoms may bring about challenging behaviors


Challenging Behavior – Unaddressed Physical/Medical Needs

Common conditions and physical symptoms

– Migraines – chronic headaches

– Constipation, diarrhea – GI conditions

– Degenerative joint disease, pain, inflammation – arthritis

– Premenstrual Syndrome

– Immobility (being unable to move around as one likes)

– Cardiovascular disease (heart conditions, circulation problems)

– Neurological conditions (dementia, memory loss)


Challenging Behavior – Unaddressed Physical/Medical Needs

Common indicators of pain

– Guarded/altered body position– Moaning– Sighing– Grimacing– Withdrawal– Crying– Muscle twitching– Restlessness– Elevated/decreased blood pressure– Quietness– Diaphoresis (excessive sweating)

– Muscle tension– Nausea/vomiting– Weakness– Dizziness– Unconsciousness– Lethargy– Fever– Hitting a painful area– Staring– Dilated (large) pupils


Challenging Behavior – Trauma

Sobsey & Doe – “Individuals who have some level of intellectual impairment are at the highest risk of abuse”

ID/DD population most traumatized of all

– 90% have experienced some kind of trauma

Trauma – an experience that the person didn’t ask for and can’t stop or escape; perceived as life threatening and involves intense fear and helplessness



Signs of trauma

– Mood swings/instability– Unexplained outbursts of anger– Depression– Nightmares– Flashbacks– Hypervigilance– Anxiety/panic attacks– Avoidance– Inability to experience pleasure– Unexplained physical pain

– Sexual problems– Unexplained grief reactions– Hopelessness– Poor concentration– Eating too much or too

little– Self abusive behaviors– Poor self-esteem, shame,

guilt– Headache, stomach ache,

dizziness



Basic needs of traumatized person

– To feel relatively safe

– To know others will respect his/her boundaries

– To feel accepted, validated and listened to

– To talk and be listened to

– To have their feelings paid attention to


Mental Health First Aid Action Plan

ALGEE

– A Assess for risk of suicide or harm

– L Listen non-judgmentally

– G Give reassurance and information

– E Encourage appropriate professional help

– E Encourage self-help and support strategies


Recognizing Signs of Escalating Behavior

What signs might indicate that someone is becoming:

– frustrated?

– anxious?

– scared?

– angry?


Signs of Escalating Behavior

Observable signs of escalating behavior:

– Faster breathing

– Talking louder

– Stiff, rigid movements

– Quick movements

– No eye contact

– Reddening in the face


De-escalation: What Is It?

Helps staff manage challenging behaviors before they become a crisis situation (escalate)

Helps person return to baseline / normal functioning


Techniques for De-escalation

Proximity – Be out of arm’s reach

Pace – Move and speak slowly / calmly

Purpose– Mean what you say– Do not make promises that cannot be kept

Process – Be flexible; adapt to individual and situation

Plan– Have a plan in place– Think about what worked in the past


Techniques for De-escalation (continued)

Practice – Use techniques that work for the person often, even when not in

crisis

Presentation – Be aware of body language and voice tone

Pivot – Know escape routes and be ready to use them quickly

Persuasion– Let person talk– Remind person that you want to help

Pre-empt – Know person’s triggers – Try to avoid / limit exposure to them


Techniques for De-escalation - Restraints

Restraints may be necessary at times

Once restraint started, goal is to discontinue it as soon as possible

– Restraint is not the end of a crisis

– Does not solve problems that led to crisis

– Can damage trust and relationship between person and staff


Techniques for De-escalation – What To Do and Say During a Restraint

Prevention of physical harm

Asking what the person needs

Assist in relaxation

Ending the restraint


Techniques for De-escalation – A Note About Restraints

Restraints should be a last resort

– They can cause physical and psychological harm

– Can re-traumatize person

– Can induce fear and powerlessness

– Do not teach person how to control self

– Can damage trust between person and staff

EXERCISE

Bob’s Story


Debriefing

Process that helps one make use of personal experiences for learning and development

Explores why something happened, how it happened and what can be learned

Formalized way to evaluate one’s actions, interactions during and after an event


Debriefing

Who should debrief?

– Clinical staff

– Administrative staff

– Treatment team members

– Participants

– The individual


Debriefing - Steps

Reflect on the experience.

Analyze the experience.

Make sense of the experience.

Communicate about the experience.

Learn from the experience.


Debriefing with Individuals

I ESCAPE Formula

– I – Isolate

– E – Explore

– S – Share

– C – Connect

– A – Alternative

– P – Plan

– E – Enter


Caring for the Caregiver

Try not to take challenging behaviors personally

Acknowledge what causes your own anxiety.

It is okay to ask for help.


Caring for the Caregiver – Stress Reduction Tools

Breathing Exercises

Take a Break

Make time for yourself when possible

A ‘Stress Ball’

– Any small, portable item

– Can help reduce physical and mental tension


Caring for the Caregiver – Stress Reduction Tools

Share techniques with individuals

Can prevent build-ups of stress

– And potential crisis situations

– Remember: Everyone needs an outlet


Objectives Review

Recall strategies for understanding and responding to challenging behaviors

Describe basic premises about mental illness in relation to challenging behaviors

List the important assumptions about challenging behaviors

Summarize ways to report challenging behaviors accurately

Recite methods of de-escalation


Final Words

“The more creativity that staff and individuals are given in coming up with strategies, the greater the chance of those strategies being effective; remember that each person is an individual and will respond in unique ways to a variety of experiences, feelings, events, and situations.”


References

Author unknown. (n.d.) Liberator 2. Retrieved from http://www.pacmedhawaii.com/specialty/lib.htm (April 12, 2011)

Casey,T. (May 1, 2006). Elimination of restraints through positive practices. Mental Retardation Bulletin.

Charlot, L., and Shedlack, K. (2002). Masquerade: Uncovering and treating the many causes of aggression in individuals with developmental disabilities. The NADD Bulletin, Vol. V, No. 4.

Citrome, L. (2010). Aggression. Retrieved from http://emedicine.medscape.com/article/288689-overview (April 28, 2011)

The Gray Center for Social Learning and Understanding. (n.d.) What are social stories? Retrieved from http://www.thegraycenter.org/social-stories/what-are-social-stories (April 28, 2011)


References

Kitchener, B.A., Jorm, A.F., and Kelly, C.M. Maryland Department of Health and Mental Hygiene, Missouri Department of Mental Health, and National Council for Community Behavioral Healthcare (2009). Mental health first aid usa. Annapolis, MD. Anne Arundel County Mental Health Agency, Inc.

Lovett, H. (1996) Learning to listen: Positive approaches and people with difficult behavior. Baltimore, MD. Paul H. Brooks Publishing Co.

Legare, G. (2003) Positive approaches: Learning to listen and understand someone we find challenging to support. OMR Statewide Training and Technical Assistance Initiative. Pennsylvania.

Ogier,T. Restraints: a review of literature. Tasmanian School of Nursing, Nuritinga Issue 1, June 1998.


References

PMT Associates, Inc. (2009). Top ten list of de-escalation techniques: The p’s of de-escalation. Retrieved from http://www.pmtassociates.net/Top_10_Deescalation_Tips.html (April 29, 2011)

Sturmey, P. (n.d.). Treatment interventions for people with aggressive behaviour and intellectual disability. Retrieved from http://www.wpanet.org/uploads/Education/Educational_Resources/autism-part4.pdf (April 28, 2011)


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Documents

Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS