Positive Approaches
to Challenging Behaviors
by
Stacie J. Lane-O’Brien, MSW
1
Stacie
• Stacie
– Over 20 years experience with individuals
with behavioral support needs
– Behavior Support Consultant
– Certified CPI instructor
– All different levels of provider agency for 16
years.
2
Overview
Day 1
• Overview of binder
• Positive Behavioral Supports
• Antecedent Strategies (Basic supports needed for
success)
• Behavioral Assessment
– A-B-Cs
– Classes of Reinforcement
• Hypothesized Function
• Matching supports with the function
• Managing Crisis
3
• Preparing for Day 2
Common Practice vs. PBS
Traditional
Discipline:
Positive Behavior
Support:
Focused on the
topography of
problem
behavior
Focused on cause
of problem
behavior
4
Common Practice vs. PBS
Traditional
Discipline:
Positive Behavior
Support:
Eliminate
inappropriate
behavior
Increase appropriate
and adaptive
response
5
Common Practice vs. PBS
Traditional
Discipline:
Positive Behavior
Support:
Goal was to stop
problem
behavior, through
the use of
random rewards
or punishment
PBS reduces
reinforcement for
problem behavior,
and provides
reinforcement for
appropriate behavior
6
7
Common Practice vs. PBS
Traditional
Discipline:
Positive Behavior
Support:
Sees problem
behavior as a
problem
Sees (destructive)
behavior as
communication and/or
a lack of skills
8
Common Practice vs. PBS
Traditional
Discipline:
Positive Behavior
Support:
Behavior
Modification
Applied Behavior
Analysis (ABA)
9
Common Practice vs. PBS
Traditional
Discipline:
Positive Behavior
Support:
Observer or
Object of
Offensive Acts
and police officer
of problem
behavior
Investigator of
Environmental
Influences and
provider of preferred
possibilities
10
Applied Behavior Analysis
• ABA asks “Why do behaviors occur?”
• Behavior that persists serves some
function.
• Persistent behavior is communicating
information about the function.
11
12
Antecedent Strategies
Basic Supports Needed for Success
History and Psychosocial Stressors:
• Medical concerns
• Diagnosis
• Past life events
13
Antecedent Strategies
Basic Supports Needed for Success
Environmental Considerations:
•
•
•
•
Home environment
Work/School environment
Roommates
Staff interactions
– The first question is not what to do when Joe hits, but,
what can I do to prevent Joe from wanting to hit in the
first place? The second question is what do we do
when he does hit his head.
– Changing staff responses vs. focusing on the
changing the other person’s behavior
• Current rights restrictions
• Routine and schedules
14
Antecedent Strategies
Basic Supports Needed for Success
Triggers/Antecedent
• Events or situations that routinely
precipitate challenges for the person
• Problems that have yet to be solved
• Identifying triggers can make problem
behaviors highly predictable
• Examples
15
Antecedent Strategies
Basic Supports Needed for Success
• Understand transitions are hard, and have
patience!
• Watch out for the honeymoon period!
• Remember: Behavior Change takes time!
• Watch out for certain “rules” being established
the first few days.
• Staff Training:
– Train staff prior to working with the person.
– Anticipate additional trainings that may be
needed.
16
Does the behavior need to
change?
• Is it destructive behavior?
- Is it dangerous to the person?
- Is it dangerous to others?
- Is there property destruction?
• Is it a problem behavior?
- Is it preventing the person from advancing to more
independent opportunities? (will a change in the
behavior help the person in reaching short and long
term goals?)
- Is the behavior a disruption to the program?
- Is the behavior jeopardizing the person’s placement?
17
18
Define the Behavior
In order to address a challenging
behavior, we need to define what a
behavior is:
• Observable
• Measurable
• Inter-observer Agreement
19
Non-behavioral term
Behavioral definition
(Emotional)
(Descriptive)
–Speaks when others are talking
Rude
–Calls people names (e.g., idiot)
Controlling
Bi-polar
Rigid
Lazy
20
• Behavior occurs in settings.
• It is important to know what happens
before and after a behavior so we
might know how the environment may
be related to the behavior.
21
Specific things in the environment
(Stimuli)
A-B-Cs:
• What happens before the behavior
occurs (A or antecedent)?
• What is the behavior (B)?
• What happens after the behavior occurs
(C or consequence)?
22
A-B-C
Antecedent
A. Late for important meeting at work
Behavior
B. Drive fast to get to work
Consequence
C. Get speeding ticket
23
A-B-C
Antecedent
A. Teacher gives math seat work.
Behavior
B. Sally draws pictures instead of
completing math work.
Consequence
C. Sally spends recess completing
math work.
24
A-B-C
Antecedent
A. Dinner is announced by staff.
Behavior
B. Jeremy bangs his head on the arm
chair.
Consequence
C. Jeremy is instructed that he has 5
minutes to “get it together” and get
to the table.
25
A-B-C Worksheet
(Training Binder: section 5, page 11)
26
Name
Date
Time of Day
Morning
6:00-6:30 am
6:30-7:00 am
7:00-7:30 am
7:30-8:00 am
8:00-8:30 am
≈≈≈≈≈≈≈≈≈
5:30-6:00 pm
Evening
6:00-6:30 pm
6:30-7:00 pm
7:00-7:30 pm
7:30-8:00 pm
8:00-8:30 pm
8:30-9:00 pm
9:00-9:30 pm
9:30-10:00 pm
Daily Behavior Record
(Training binder: section 5, page 7)
How often?
What behavior
occurred?
What did you do
about the behavior?
≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈≈
≈≈≈≈≈≈≈≈≈≈≈≈≈
≈≈≈≈≈≈≈≈≈≈≈≈≈
A
B
What activity was involved?
____________
__________
__________
__________
__________
__________
≈≈≈≈≈≈≈≈≈
Data is collected
throughout the day
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
C
This record will help us understand the times and situations in which problems occur.
Here is a sample entry:
Time of Day
3:30-4:00 pm
How often?
What activity was involved
__________
Picking up toys
What behavior occurred? What did you do about the
behavior?
Refused to pick up,
Gave up, picked up 27
toys
screamed, bit hand
myself
Antecedents & Consequences
Caveats to A-B-Cs:
• C maintains, but A is predictive
• C is often misunderstood (the
consequence could have happened years
ago)
• Pulling A-B-Cs from records
28
Behaviors continue to occur for one of
two reasons:
• To gain something that is desired
–Positive reinforcement
• To avoid something that is aversive
–Negative reinforcement
29
Positive Reinforcement
Major gain categories – Positive
Reinforcement:
• To gain attention
• To gain access to preferred items and
activities
• To increase stimulation
Make coffee in the morning.
30
Negative Reinforcement
Major avoidance categories – Negative
Reinforcement:
• To avoid attention
• To avoid/escape aversive items and
activities (e.g. work)
• To decrease stimulation
Take an aspirin to get rid of a headache.
31
Sensory Integration
Definition of Sensory Integration:
• The ability of the central nervous system to organize and
process input from different sensory channels to make
an adaptive response.
• We are bombarded with a variety of sensations
throughout or day. Some catch our attention and some
we disregard. This is because we have a working
sensory integration system.
• People with developmental disabilities, and especially
those with brain damage, tend to have major problems
handling the many sensations that other people without
processing problems take for granted. They may
become Sensory Defensive.
32
Sensory Defensiveness
Sensory inventory examples – does the person:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Layer clothing?
Resist grooming?
Try to handle or touch everyone or everything?
Persistently put hand in pants or pant pockets?
Display self-injurious behavior?
Lose balance easily?
Become upset with changes in room arrangements?
Display self-stimulatory behaviors?
Bite, hit, kick, pinch, etc.?
33
Sensory Defensiveness
Example activities to address Sensory Defensiveness:
1. Wilbarger Protocol
2. Lotions and rubs
3. Ball pits
4. Swinging
5. Hugs
6. Therapy balls
7. Jumping
8. Others?
34
Calvin & Hobbs
35
Positive
Negative
Something is
Something is
Added
Removed
Reinforcement
Behavior
Punishment
Behavior
36
Positive
Negative
Something is
Something is
Added
Removed
Reinforcement
Behavior
Punishment
Behavior
37
Positive/Negative
• This is the next step in evaluating the
influences of the behavior
Running your A-B-C through this process
• Why is this important?
It tells you what not to do, as well as what
you should do.
38
Positive/Negative
A. Math seat work given by teacher.
B. Sally draws pictures instead of
completing math work.
C. Sally spends recess completing
math work and chatting with the
teacher.
39
Positive/Negative
A. Math seat work given by teacher.
B. Sally draws pictures instead of
completing math work.
C. Sally spends recess completing
math work and does not have to go
to the playground where Jimmy the
bully often targets her.
40
Positive/Negative
A. Dinner is announced by staff.
B. Jeremy bangs his head on the arm
chair.
C. Jeremy is instructed that he has 5
minutes to get it together and get to
the table, and gets to finish the level
on his video game.
41
Positive/Negative
A. Dinner is announced by staff.
B. Jeremy bangs his head on the arm
chair.
C. Susan, the staff member Jeremy
really likes, persuades Jeremy to
come out and sit by her.
42
Positive/Negative
A. Dinner is announced by staff.
B. Jeremy bangs his head on the arm
chair.
C. Jeremy is assured that he will not
have to “try” any veggies.
43
44
Why the Function is so Important
• “Time-out” is a common consequence.
• What if negative reinforcement is desired
and we use time-out?
• What if positive reinforcement (Attention) is
desired and we provide a lecture about how
wrong the behavior is, and then we have to
apologize, etc.
45
Behavior Modification?
• Kid throws a tantrum at school.
• Time-out was not effective.
• Consequences now include loss of
recess and no computer time at home
after school, because time-out was not
an effective consequence.
46
A-B-C Worksheet
(Training binder: section 5, page 11)
47
Function
• Doing a functional assessment of the
problem behavior will help you identify
the function. (section 5, page 1)
• The environmental event maintaining
behavior (Function) must be identified.
• You can then create a support that
addresses the identified function.
48
49
Functional Communication Training (FCT)
Carr and Durand (1985)
• Identify the function of problem behavior.
• Teach recognizable communicative response
to produce a specific outcome.
• Reinforcement for problem behavior is placed
on extinction.
• Communication replaces problem behavior
because they serve the same function.
50
Replacement Behavior
Let’s teach Jim another way that he can
get the attention he needs:
• Jim currently uses head-banging.
• What other behavior might work?
51
Selecting Communication
Topographies to consider:
•
•
•
•
•
Verbal: I need your help.
Visual cue: picture card of staff
Sign: Anyone have a sign for a attention?
Assistive technology (microswitch)
Gesture
52
Replacement Behavior
The communication must:
•
•
•
•
Match function
Be efficient (easy to do)
Be effective (result in reinforcement)
Problem behavior on extinction
53
Replacement Behavior
Must be efficient:
•
•
•
•
•
Do they know how?
Can they easily do it?
Is it dependable?
Is it understandable?
Is it easier to bang head?
54
Replacement Behavior
Must be effective:
• Result in desired reinforcement
• Provide immediate result
• During teaching, many opportunities
may be needed!
• Shaping
55
Replacement Behavior
56
57
A-B-C Worksheet plus Behavior Support (Training binder: section 5, page ??)
58
A-B-C Worksheet plus Behavior Support (Training binder: section 5, page ??)
59
60
Managing Crisis Situations
+
Bell Curve
+
+
0
0
Mild
Moderate
Integrated
experience
-
Severe
61
Managing Crisis Situations
Staff Responses:
• Don’t take it personally!
• Be supportive and collaborative vs.
authoritative.
• “Acceptance is different than approval.”
• Introduce video clip.
62
Managing Crisis Situations
• Knowing what to do in a crisis situation
decreases staff fear and anxiety, injuries,
and ultimately decreases staff turnover.
63
Managing Crisis Situations
• Crisis Prevention Institute (CPI)
• Non-Violent Crisis Intervention
– Learn to set limits with challenging consumers.
– Learn to address challenging/confrontational
questions from a consumer.
– Learn to avoid or reduce power struggles.
• Care, Welfare, Safety and Security
64
Overview
Day 2
• Preventing Challenging Behaviors by Enhancing Quality of
Life
• The training process
• Managing participants and questions
• Transitioning between topics
• Groups teaching a portion of the class together
• Your Organizational Plan
• List Serve, PBS website and how to access
• Monthly/quarterly instructor conference calls.
• Post test
• Certificates for passing course and becoming a certified
trainer
65
Prepare for Day 2
• Teaching a portion of the class in groups (15 min
each)
– Traditional Discipline vs. Positive Behavioral Supports
– Teaching the A-B-Cs of Behavior
– Teaching classes of Reinforcement, including an
explanation about punishment.
– Teaching how to decide on a replacement behavior
and what your new response to a challenging behavior
will be.
66
Agenda
Day 2
• Preventing Challenging Behaviors by Enhancing Quality of
Life
• The training process
• Managing participants and questions
• Transitioning between topics
• Groups teaching a portion of the class together
• Your Organizational Plan
• List Serve and how to access
• Monthly/quarterly instructor conference calls.
• Post test
• Certificates for passing course and becoming a certified
trainer
67
Encouraging
Desirable
Behavior by
Improving
Quality of Life
68
69
The Focus on Function
• We tend to focus on problem behavior!
• What if we focus on supporting a person in
a way that helps them enjoy a quality of life
that makes problem behavior unnecessary
and irrelevant.
70
Preference/Choice/Communication
Assessments
-Preference assessment sec.5, pg. 19
• Assess a person’s ability to access their
preferences, rather than to look at which
conditions evoke problem behavior.
• By making this a focus, you can avoid
most problem behaviors before there is a
reason for them to occur.
• Be a provider of preferred possibilities!
71
Preventing Challenging Behaviors
by Enhancing Quality of Life
• Realizing Hopes, Dreams and Wishes
• Does the person believe or feel he or she
is living a meaningful life?
72
Preventing Challenging Behaviors
by Enhancing Quality of Life
Sometimes We Have Silly Rules:
• I have seen many silly rules.
• Silly rules take away from a person’s
Quality of Life.
• They interfere with:
– Self-determination
– Choice
– Self-direction
73
Preventing Challenging Behaviors
by Enhancing Quality of Life
In Work and Day Programs:
• I can’t use the telephone at the workshop
without written permission from my staff,
even if I want to call for a pizza.
• I work at a sheltered workshop and I can’t go
anywhere for lunch.
• If I have something in my lunch that I don’t
like, I can’t give it away.
74
Preventing Challenging Behaviors by
Enhancing Quality of Life
In My Own Home:
• I can’t eat or sleep in the living room.
• I can’t sleep in the TV room.
• I have to eat meals at a certain time.
• We have to be in bed by 9 pm.
• I can’t sleep in on weekends.
75
Preventing Challenging Behaviors
by Enhancing Quality of Life
In My Service Delivery:
• You have to work your way out of the
group home by proving that you can live
like they want you to live.
• I can’t go out to eat with my case manager.
• I can’t buy pop or anything for my direct
care staff.
76
Preventing Challenging Behaviors by
Enhancing Quality of Life
In My Relationships:
• I have to get permission from staff to date.
• I can’t have time with friends or family when
I want because staff have to go with me.
• I want to date this girl but wherever the girl
goes, staff goes. I want to take her to a ball
game, but the staff doesn’t want to go to
the game so I can’t take her.
77
Preventing Challenging Behaviors
by Enhancing Quality of Life
In My Personal Time & Preferences:
• If I want to go somewhere, everyone in the
house has to want to go there too.
• You can only smoke when staff will go
outside with you even if it is your lunch time.
• “We don’t have a say in making the rules!”
78
Preventing Challenging Behaviors
by Enhancing Quality of Life
No Silly Rules!
• Just say no to “Silly Rules!”
• Many “good intentions” behind “Silly Rules.”
• We see people do things that are NOT in
their best interests all the time.
• Push common sense, respect, and dignity!
79
The Training Process
Training
Practice
Situational
Applications
Training
Process
Reviews
Formal
refreshers
Policy discussions
Training
Training
Practice
Training
Process
Situational
Applications
Reviews
Formal
refreshers
• Explain (Lecture)
- keep it short
- vary the format to keep people engaged
- use examples – your own experiences and real
life examples
- use visual aids – videos, cartoons, etc.
• Demonstrate (Activity) -always show the participants
first/give them an example.
• Participate (Practice)-have them do the exercise or give
their own examples.
• Revisit Explanation-check in and make sure everyone
understands. Answer any questions they may have.
Policy discussions
Training
Situational Applications
Practice
Training
Process
Situational
Applications
Reviews
Formal
refreshers
Policy discussions
Address unique situations that occur by
tailoring your approach within the
framework of PBS
Refreshers
Training
Practice
Training
Process
Situational
Applications
Reviews
Formal
refreshers
Policy discussions
Schedule formal PBS refresher training
sessions every 6-12 months.
Policy Discussions
Training
Practice
Training
Process
Situational
Applications
Reviews
Formal
refreshers
Policy discussions
• Review of agency policy in relation to the
concepts being taught today using PBS.
• Change policies (any silly rules?)
- if not in alignment with PBS
- to use consistent language with PBS
• Review of policies with staff
Training
Reviews
Practice
Training
Process
Situational
Applications
Reviews
Formal
refreshers
Policy discussions
• Review of PBS concepts at staff meetings
• Review and analysis of incident reports
with staff
• Review of interventions being used and if
they are affective.
Training
Practice
Practice
Training
Process
Situational
Applications
Reviews
Formal
refreshers
Policy discussions
• Role play how staff are using each specific
intervention
• Demonstrate the use of schedules,
sensory interventions, de-escalation
techniques, and others.
• Role play presence, tone of voice,
cadence, volume
…and back to Training
Training
Practice
Situational
Applications
Training
Process
Reviews
Formal
refreshers
Policy discussions
Managing Questions
• Information seeking questions – open up to the group.
Don’t be afraid to say “I don’t know. I can find out and get
back to you.”
• Validation questions – not really questions. Careful
about passing judgement. You don’t have all the
information. Let participant reach his/her own conclusion.
• Choice Questions – 2-3 answers the participant is
unsure of. Deflect the question back to the participant.
Will usually come up with own answer.
• Challenging Questions – nonproductive. Power
struggle. Put back into that person’s lap. “how would you
handle that?”
88
The Inattentive Participant
• Make friendly eye contact with the person.
• Use proximity control – move closer to the person
while continuing to talk to the group.
• Involve the person in an active way – ask them to
help you out with something.
• Confront the person in private if the above hasn’t
worked.
• As a last resort, give the person the choice of
staying or leaving if they cannot refrain from
disrupting the group.
89
Transitioning Between Topics
• Ensure that the material flows together
• Bridge between one topic and another.
Explain how and why.
• For example: “Now that we are sure we
have addressed all of the person’s basic
support needs, we now need to determine
if the behavior is something that we really
need to change.”
90
Group Presentations
• Teaching a portion of the class in groups (15 min
each)
– Traditional Discipline vs. Positive Behavioral Supports
– Teaching the A-B-Cs of Behavior
– Teaching classes of Reinforcement, including an
explanation about punishment.
– Teaching how to decide on a replacement behavior
and what your new response to a challenging behavior
will be.
91
Organizational Plan
(Section 4,Page 1)
• Organizations get together in a group
• Fill out the Organizational Action Planning
Form.
• Share with the group when finished.
• Ask if you have questions.
92
Supports
• List Serve behavioral-support@uiowa.edu
• PBS web site:
http://www.uihealthcare.org/ucedd/selfadvocacy/money-follows-the-person/
• Quarterly Instructor Conference Calls if
requested.
93