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Challenging Behaviors: Assessment and Intervention Strategies. Laura A. Flashman, Ph.D., ABPP Associate Professor of Psychiatry Neuropsychiatry Section, Neuropsychology Program and Brain Imaging Laboratory, Department of Psychiatry,Dartmouth-Hitchcock Medical Center, Lebanon, NH - PowerPoint PPT Presentation

Text of Challenging Behaviors: Assessment and Intervention Strategies

  • Challenging Behaviors: Assessment and Intervention StrategiesLaura A. Flashman, Ph.D., ABPPAssociate Professor of Psychiatry

    Neuropsychiatry Section, Neuropsychology Program and Brain Imaging Laboratory, Department of Psychiatry,Dartmouth-Hitchcock Medical Center, Lebanon, NH & New Hampshire Hospital, Concord, NH

  • What are Challenging Behaviors?Related to Personality ChangesImpulsivity, Intrusiveness, Poor Boundaries, Irritability, Emotional Lability, Low Frustration Tolerance

    AggressionSelf injurious behavior, hurting others

  • What are Challenging Behaviors?Related to Deficit SyndromesIsolation, withdrawal, apathy, low motivation

    Related to Cognitive ChangesPoor judgment, inability to comprehend consequences, poor decision making, perseveration, impaired memory and concentration, difficulty adjusting to the unexpected

  • Ways to Deal with Challenging BehaviorsMedications

    Behavioral Programs

    Cognitive Remediation Strategies

  • Applied Behavioral Analysis (ABA)Goal: To increase or decrease a particular behavior, to improve the quality of a behavior, to stop an old behavior or teach a new behavior

    General Uses: Can address a broad spectrum of human behaviorIncreasing productivity in the workplaceTeaching childrenPrecise training of military personnelIn our case, handle the challenging behaviors associated with TBI

  • Seven Essential Elements of anABA-based Program (Baer, Wolf & Risely (1967)Must be applied (i.e., behaviors focusing on should have some social significance).Must be behavioral (i.e., environment and physical events should be recorded with precision).Must be analytic (i.e., convincing evidence that the intervention is responsible for the change in behavior).Must be technological (i.e., techniques could be duplicated by another).

  • Seven Essential Elements of anABA-based Program5. Must be conceptually systematic (i.e., there should be relevance to established and accepted principles).Must be effective (i.e., should seek to change the targeted behavior to a meaningful degree).Should display some generalizability (i.e., seen in a variety of settings or to related behaviors).

  • Six Steps for a Solid Applied Behavioral AnalysisIdentify Target BehaviorsMeasure the BehaviorAnalyze the Behavior A B CsDevelop an InterventionProgram Generalization of the BehaviorEmpirically Evaluate the Results

  • Behavioral TerminologyBehavior any observable and measurable act

    Target Behavior the particular behavior you have identified for change

    Behavioral assessment a description of the frequency, duration, and conditions related to a target behavior

  • Identification of Target Behavior(s)Choose your battles

    Start with reasonable goals (3 shall be the number)

    Track appropriately

  • Once the Target Behavior is Identified.We need to learn all we can about this behaviorIs it a behavior we want to increase?Is it a behavior we want to replace?Inadequate in meeting an individuals needs?Inappropriate in the current environment?

  • Behavior ModificationModification of behavior is most effective if the motivation behind the behavior can be determined

    Once motivation is known, once we understand the need that the individual is trying to meet, we can develop and teach a more appropriate replacement behavior

  • Available Tools of ABAFunctional Behavioral Assessment: a precise description of a behavior, its content and its consequencesGoal: Better understand the behavior and the factors that influence itStarts with a Baseline Period a specified time period when the frequency, duration, or intensity of the target behavior is tracked prior to the implementation of an intervention

  • Behavioral Terminology: The ABCs of ABAAntecedent: the stimulus or situation to which the individual responds Behavior: the behavior (target behavior) we see exhibited by the individualConsequence: the stimulus or stimuli that the individual receives, or that s/he is stopped being subjected to, as a result of the behavior

  • Functional Behavioral AnalysisBegins as an assessment, but includes the step of systematically altering the antecedents to and consequences of the behavior to determine which are the driving forces behind the behavior

  • Functional Behavioral AnalysisThe first step: Carefully observe and precisely describe the behavior the individual is exhibiting, and the events and stimuli in the environment both BEFORE and AFTER that behavior (i.e., Identify the ABCs)

    Observe and describe the behavior across a wide sample of environments and occasions

  • Functional Behavioral AnalysisThe second step: Look for trends in the occurrences of the behavior, for stimuli that may be evoking it, or the needs the individual is attempting to fill by exhibiting this behavior

    Form hypotheses about the behavior and the function it is fulfilling

    Challenge these hypotheses by systematically altering the environment to determine which are influencing the behavior

  • Motivations/Purposes of Challenging BehaviorsTo gain attention from someoneTo gain a tangible consequence (a treat, token, money, favorite video, etc).To gain a secondary consequence (to get warmer if one is cold, colder if one is hot, to gain some sensory consequence)To self-regulate ones emotions (way to calm down if upset, to raise ones arousal level if depressed)

  • Motivations/Purposes of Challenging BehaviorsTo escape from or avoid an undesirable situationOften in anticipation of a request to work, go to an activity, communicate, be in an environment they find uncomfortable, loud, overstimulating, etc.To make a comment or declaration (about ones environment, perceptions or emotions)To fill a habitual need, in a way that no longer works

  • Most Important Factor in Success of an ABA ProgramCONSISTENCY

  • Behavioral TerminologyDiscriminative Stimulus the instruction or environmental cue to which we would like the individual to respondResponse the skill or behavior that is the target of the instruction/cueReinforcing Stimulus a reward designed to motivate the individual to respond and respond correctly

    Example: I ask Cathy to get up and get ready for work in 5 minutes (DS), she does (R), and she gets to watch TV while eating breakfast (SR).

  • The Discriminative StimulusA specific environmental event or condition in response to which we would like an individual to exhibit a particular behavior (teach a person what to do when a particular thing occurs)Goal: Help individual begin to discriminate certain stimuli from the background noise of every day life as something important

  • The Discriminative Stimulus: GuidelinesMake sure you have the individuals attentionInstructions should be simple and clear; concisely communicate only the most salient informationBe consistent in beginning stages; can be varied in many settings to encourage flexibility and generalizability as response occurs more regularlyRepetition of the instruction should be avoided (preset limits e.g., 2 cues, 3 prompts)

  • The ResponseThe response is the behavior the individual exhibits after AND AS A RESULT OF the discriminative stimulus. If person is reacting to other stimuli, need to look at other factors (environment too distracting, person not attending?)

    Be very clear about what the correct response is (Sarah will pick up all the clothes on the floor in her room and place them in the laundry basket within 1 minute of the request.)

    3 possible responses: Correct, Incorrect, No Response

  • Correct Responses are ReinforcedReinforcing Stimuli are environmental events that occur after a behavior that increase the likelihood of that behavior occurring in the future

    Treats, praise, special privileges, music, trips, almost anything can be used as reinforcement if it serves to increase the occurrences of a particular behavior (positive reinforcement)

  • Types of ReinforcersPrimary Reinforcing Stimuli are unconditionedEvents or rewards whose value are intrinsically realized (food, water, warmth, etc)Advantages: Value does not need to be taught, will not extinguishDisadvantages: Subject to satiation after relatively short periods of time, not representative of the natural environment

  • Types of ReinforcersSecondary Reinforcing Stimuli are conditionedIntrinsically neutral but become reinforcing through associationCan be social in origin (praise, smiles, sense of accomplishment) or a token economy (earning tokens (e.g., money) for desirable behaviors; each one is a step towards acquisition of a primary reinforcer)Advantages: more convenient to use, lessens the need for proximity, more reflective of natural environments, can broaden a persons interests, can increase length of time between presentation of reinforcers (token economy)Disadvantage: Need to be taught, must be maintained by repairing to primary reinforcer to reestablish interest sometimes

  • Types of ReinforcersPositive Reinforcement: presentation of positive events after a particular behavior to increase the likelihood that the behavior will occur in the future

    Negative Reinforcement: removal of aversive events after a particular behavior to increase the likelihood that the behavior will occur in the future (e.g., alarm goes off, you get up and shut if off, get ready for work)

  • Differential Reinforcement: involves reinforcing almost any positive response (successively closer approximations of the correct behavior) to some degree, but providing very strong reinforcement when the person completely exhibits the target behavior or skill

    Types of Reinforcers

  • 4 Types of Punishme

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