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Judy Reaven, Ph.D. Associate Professor of Psychiatry and Pediatrics JFK Partners/University of Colorado School of Medicine [email protected] October 2011
• Aggression • Temper tantrums • Self-injurious behavior • Non-compliance or defiance • Property destruction • Pica • Stereotyped movements and/or repetitive
behaviors • Feeding problems • Sleeping problems • Others?
• Problem behaviors are pervasive in youth with ASD • Challenging behaviors related to increased
parenting stress, especially for mothers • Marked impact on educational, social, and
community opportunities • Without intervention, problem behaviors likely
persist • In addition to skill building, focus on positive
behavioral approaches to challenging behaviors essential!!
Impaired social, communication and play behaviors are risk factors
Behavioral theories (i.e. classical conditioning, social learning, operant models)
Setting variables – biological/environmental events
Increased vulnerability No one single etiology Utilize biopsychosocial model (Griffiths, Gardner, & Nugent,
1999; Szymanski, 1994)
• Broad emphasis – Focus on lifestyle concerns – friends, social
outings, independence
– Primary focus is not just challenging behavior • Long term goals – Consider long-term goals/outcomes, rather than
just short-term behavioral outcomes • Functional assessment – Determine the function of the behavior and
develop behavioral plan
• Individuality and effectiveness • Teach functional skills
– Emphasis on useful, functionally equivalent skills to replace challenging behaviors
• Positive reinforcing • Antecedents
– Focus on antecedent procedures, rather than consequences
• Multi-component interventions – Antecedent interventions – Consequences – skill building
Critical Assumptions
Every problem serves a function
Most effective interventions are proactive
Measures of intervention effectiveness must be long-term as well as short-term – interventions should lead to more durable changes; enhance quality of life
(Bambara & Mitchell-Kvacky, 1994); O’Neill et al., 1990; Emerson, 1998)
Determine the most effective treatment approach
To understand the nature and function of the problem behavior
To determine the ongoing efficacy of treatment To identify the variables that elicit or predict
problem behavior
Setting Events & Primary Functions: S = Setting events E = Escape A = Attention T = Tangible S = Sensory
Biological Events Sleeping, eating/diet, medication, heat in the
room, toileting, physical and mental health Environmental Events Staffing changes, earlier fight, forgot favorite
toy, number of people in room, noise level, changes in schedule
Escape – work demands, chores, transitions to non-preferred activities
Attention – parent/teacher attention, peers, reprimands and praise
Tangible – preferred activities, toys, books and snacks
Sensory – deep pressure, visual stimulation, auditory stimulation, and rocking
Informant methods Direct observation
Functional analysis
Describe behaviors Define potential ecological events that affect
behavior Define events and situations that predict occurrence
of behavior Ask about perceived function Define the efficiency of the undesirable behavior Ask about primary method of communication
What events, action and objects are considered positive by the individual
What functional alternatives are known by the person
Previously tried strategies Assess for setting events Consider whether the challenging behavior
could be manifestation of a psychiatric condition
Observe across settings, time of day, etc. Obtain a minimum of 10-15 occurrences Charting can be simple or complex Keep charting user friendly Historical information helpful if behavior is
high impact, but low frequency
Time of
Day/Activity
Antecedent Behavior Consequences Intensity/Duration
(H, M, L)
Possible
Function
8-10AM
10-12PM
12-2PM
2-4PM
4-6PM
6-8PM
Interventions Need to be Data Driven Stimulus-based procedures (altering antecedent events) –
i.e. curriculum, schedules, physical setting Instruction-based procedures – direct instruction Extinction-based procedures – withhold presumed
reinforcers following problem behaviors Reinforcement based procedures – increasing desired
behavior through contingent delivery of positive rewards Punishment-based procedures – time out System change – change in staffing patterns Pharmacological based procedures – medications
Proactive interventions Skill based/functional alternatives
Environmental adaptations
Improve quality of interpersonal interactions
Provide opportunity for choice and control
Look at chain of behavior
Establish communication with families to identify setting events and treat when possible
Reduce expectations when setting event is present
Consider multiple antecedent modifications
Reactive plans
Extinction (ignore-redirect)
Mild punishment (verbal reprimands, loss of privileges, time out)
Crisis management/safety plans
4 year old boy with Autism Nonverbal Overall developmental functioning – (2 ½
yr old) Lives with parents and older brother, age 6 Attending preschool Presenting problem – SIB (head banging)
Increased head banging over the past 2 months, at times high intensity, varying frequency
Unpredictable – “out of the blue”; better or worse? Begins with agitation, crying, then head banging Previously tried - telling him to stop, protecting his
head, holding him No new family stressors, major environmental changes,
or health changes Perceived function – social attention?
Time of
Day/Activity
Antecedent Behavior Consequences Intensity/Duration
(H, M, L)
Possible
Function
8-10AM Breakfast –
making a
choice
Crying,
HB
Gave him both
foods
L
1x
??
10-12PM Watching TV,
asked to put
toys away
Crying,
HB
Time out H
8x
Avoidance
12-1PM
1-2PM
2-3PM Asked to hang
up coat and
put on shoes
Crying,
HB
Physical
prompts to
follow
directions
M
2x
Avoidance
3-4PM Brother comes
home from
school
Crying,
HB
Telling him no,
hugging
M-H
7x
Attention?
Clear bi-modal picture of SIB over the week Two levels of analysis – behavioral and
setting variables – Perceived function (s) – social attention from
brother, and avoidance (task demands) Setting variables - hunger
More frequent snacks, especially close to lunch time Directly teach him to follow simple directions such as “put
your toys away” or “hang up coat”, using task analysis, shaping behavior using physical prompts and then fading, combined with positive rewards
Directly teach him play skills for interaction with brother Directly teach appropriate attention-getting behaviors –
i.e. tap on the arm, offering a toy Use visual strategies to illustrate daily schedule,
especially when brother comes home
Safety plan Planned ignoring/extinction
Setting
Events
Antecedent
Triggers
Problem
Behavior
Maintaining
Consequences
Alternative
Replacement
Behavior
Always be on the look out to praise or reinforce good attention, effort, participation, waiting, tolerance, acceptance of change, coping, etc.
Link rewards to effort and participation but provide intermittently and not with a formalized contract ahead of time
Anticipate challenging situations Share written rules/guidelines with student
for specific situations Be explicit, rule-governed, clear, consistent Pick and choose battles
Avoid phrases like “behave yourself” – not specific enough
Tell the student exactly what is expected and for how long: “You need to be sitting quietly and reading your science book until 11:15.”
Emphasize words that indicate when – “now”, “later”, etc. and gently redirect if student acts before it is time
Autonomy is often very important for these students; use it to prevent problems and reinforce effort
Help the individual identify how choices are perceived by other people
Label the misbehavior in a calm, neutral manner
Whenever possible, allow natural consequences to arise
Do not process/discuss problem behavior in the moment
Wait for a calm time to discuss what the individual could have done differently
Help individuals to identify situations that are particularly challenging for them
Help individuals to create a list of options for responding to these situations in the future
Use self-reflection to strengthen self-esteem Demonstrate differences between individual’s
perspective and others’ perspective
Challenging behaviors (and mental health symptoms) are common in persons with ASD
Without intervention negative behaviors and mental health symptoms may persist
Positive behavior supports (and specific mental health interventions) can be effective in managing symptoms
Functional assessment is an essential component of positive behavior supports
Most effective approaches are proactive