Coping withChallenging Behaviors
REALIZE …• It Takes TWO to Tango … or tangle…
Learn to Dance with Your         Partner
When Something Is Not   Working Well… What Do We Tend to        Do?
Being ‘right’ doesn’tnecessarily translate into agood outcome for both OR      either of you
Deciding to change yourapproach and behavior WILL REQUIRE you      to stay alert and make choices…       it is WORK
It’s the relationship that is        MOST critical NOT the outcome of one       encounter
Who Are       YOURChallenging People? Who Challenges YOU?
What are the Challenging    Behaviors that    GET TO YOU?
What Are the Most Common Issues            That Come Up???•   Not going to the MD         •   Eloping or Wandering•   ‘Los...
By managing your own  behavior, actions, words &reactions you can change the  outcome of an interaction.
REALLY Ask Yourself…Is this Behavior a Problem Behavior                  OR     is this a “So What” Behavior       An “Ann...
Is it REALLY a Problem?    Is it a RISKY BEHAVIOR?• Risk to that person (physical, emotional,  physiological risk)?• Risk ...
If it is a ‘SO WHAT’ Behavior…• Leave it ALONE!• Figure out how to let go of it …• Let it go!
If it is RISKY…• Describe the behavior – OBJECTIVELY  – WHO?  – WHAT?  – WHERE?  – WHEN?  – WHAT helps… WHAT makes it wors...
SIX Pieces to the Puzzle•   Personal history and preferences•   Type & current level of cognitive loss•   Other conditions...
Knowing the Person•   History•   Values and beliefs•   Habits and routines•   Personality and stress behaviors•   Work & f...
Level of Cognitive Function     What CAN the person do?  What can the person NOT do?What CUES are effective? Ineffective? ...
The person’s brain is dying
Normal Brain   Alzheimers Brain
Positron Emission Tomography (PET)       Alzheimer’s Disease Progression vs. Normal Brains                             Ear...
So… what is happening?• Memory damage                    • Language damage  –   Can’t learn new things         – Has very ...
So… what is happening?• Impulse Control Problems           • Performance Problems   – Say whatever they are             – ...
How do these losses relate     to some risky behaviors?•   Persistent ‘going’             •   Lost and ‘Looking’     – ina...
Diamonds - Routines & Repeats                            ACL 5•   Word finding problems       • Becomes anxious and•   Log...
Emeralds- Task Oriented                        ACL 4• Has trouble sequencing    • Uses visual information to  thru tasks &...
Ambers- Hunting & Gathering                         ACL 3• Uses hands to touch,       •   Imitates actions – copies you  f...
Rubies - Stuck on GO                         ACL 2• Gross motor only            • Can’t stop or sound• Poor finger use    ...
Pearls – Reflexes Rule                       ACL 1• Bed bound or chair bound   • Swallowing and eating• Unable to sit up f...
Health & Illness•   Mobility problems?•   Pain?•   Sensory problems?•   Mental health issues?•   Other diagnoses of import...
Comparison of Fat Pads
Environmental Factors &       Changes • Physical Environment • People • Programming
Environmental Aids• Setting  – familiar  – friendly  – functional  – forgiving (safe)
Environmental Aids• Props  – visible & invisible  – timely  – available  – matched to ability  – matched to interests
Care Partner   Approach  Knowledge     Skills
Three Reasons to Communicate • Get something DONE • Have a conversation • Help with distress
Communication –Getting the person to DO       Something  Form a relationship FIRST Then Work on Task Attempt
Connect• 1st – Visually• 2nd – Verbally• 3rd – Physically• 4th – Emotionally• 5th – Individually - Spiritually
How you help…• Sight or Visual cues• Verbal or Auditory cues• Touch or Tactile cues
To Connect Use the PositivePhysical Approach
Your Approach• Use a consistent positive physical  approach  – pause at edge of public space  – approach within visual ran...
Hand-Under-Hand Position
Your interaction…• Communicate with awareness  – look, listen, think!  – give your name  – make an empathetic observationa...
Give information• Keep it short and simple  – “ It’s lunch time”  – “Let’s go this way”  – “Here’s your socks”• Use famili...
Encourage Engagement• ask a person to try        •   use props or objects• ask a person to help       •   gesture  you    ...
Daily Routines &      Client-Centered Programming•   Old habits and routines•   Patterns during the 24 hrs•   A time to re...
To Cope with Challenging      Behaviors… • Where will you start???   – An idea –      • Care partner education      • Care...
Then…• Observe & document the risky behavior  thoroughly  – what is the pattern  – when does it happen  – where does it ha...
Is it really a problem?               … A RISK• If NO - leave it alone• If YES - its time to problem solve  – call the tea...
REMEMBER     Explore all of the following -•   Personal background information•   Type & Level of cognitive function•   He...
Re-look at the problematic    challenging behavior…• What does the person need?• What is the meaning of the the behavior?•...
Make a PLAN!•   Who will do what•   When will it be done•   How will it work•   What environmental change is needed•   Wha...
Implement your plan!• Keep track of progress• Document what is happening• Communicate among the team members• Rethink - if...
How can we help…     better?   It all starts with   your approach!
How you help…• Sight or Visual cues• Verbal or Auditory cues• Touch or Tactile cues
What Do They Do?•   Question•   Refuse•   Release – verbal•   Intimidate – physical•   Tension reduction
What Should You Do?•   Be supportive•   Offer choices & be directive•   Set realistic limits•   Act – Take control•   Re-c...
Believe -      People     Are doingThe BEST they can!
What shouldn’t we do???•   Argue•   Make up stuff that is NOT true•   Ignore problem behaviors•   Try a possible solution ...
So WHAT should we do???        Remember            who   has the healthy brain!
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Teepa coping with challenging behaviors

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Teepa coping with challenging behaviors

  1. 1. Coping withChallenging Behaviors
  2. 2. REALIZE …• It Takes TWO to Tango … or tangle…
  3. 3. Learn to Dance with Your Partner
  4. 4. When Something Is Not Working Well… What Do We Tend to Do?
  5. 5. Being ‘right’ doesn’tnecessarily translate into agood outcome for both OR either of you
  6. 6. Deciding to change yourapproach and behavior WILL REQUIRE you to stay alert and make choices… it is WORK
  7. 7. It’s the relationship that is MOST critical NOT the outcome of one encounter
  8. 8. Who Are YOURChallenging People? Who Challenges YOU?
  9. 9. What are the Challenging Behaviors that GET TO YOU?
  10. 10. What Are the Most Common Issues That Come Up???• Not going to the MD • Eloping or Wandering• ‘Losing’ Important Things • No solid sleep time• Getting Lost • Getting ‘into’ things• Unsafe task performance • Threatening caregivers• Repeated calls & • Undressing contacts • Being rude• Refusing • Feeling ‘sick’• ‘Bad mouthing’ you to • Striking out at others others • Falls & injuries• Making up stories • Infections & pneumonias• Resisting care • Seeing things & people• Swearing & cursing • Not eating or drinking• Making 911 calls • Contractures & immobility• Mixing day & night• Shadowing
  11. 11. By managing your own behavior, actions, words &reactions you can change the outcome of an interaction.
  12. 12. REALLY Ask Yourself…Is this Behavior a Problem Behavior OR is this a “So What” Behavior An “Annoying” Behavior
  13. 13. Is it REALLY a Problem? Is it a RISKY BEHAVIOR?• Risk to that person (physical, emotional, physiological risk)?• Risk to the caregiver?• Risk to Others?• Is the RISK REAL and IMMEDIATE?• If NOT, it is a ‘SO WHAT’ behavior
  14. 14. If it is a ‘SO WHAT’ Behavior…• Leave it ALONE!• Figure out how to let go of it …• Let it go!
  15. 15. If it is RISKY…• Describe the behavior – OBJECTIVELY – WHO? – WHAT? – WHERE? – WHEN? – WHAT helps… WHAT makes it worse? – Frequency & Intensity?
  16. 16. SIX Pieces to the Puzzle• Personal history and preferences• Type & current level of cognitive loss• Other conditions & sensory losses• Environmental conditions• Care partner approach and behaviors• What happened – full day & all players
  17. 17. Knowing the Person• History• Values and beliefs• Habits and routines• Personality and stress behaviors• Work & family history• Leisure and spiritual history• Hot buttons & comforts
  18. 18. Level of Cognitive Function What CAN the person do? What can the person NOT do?What CUES are effective? Ineffective? What are interests based on level? Consistency of Cognitive Level?
  19. 19. The person’s brain is dying
  20. 20. Normal Brain Alzheimers Brain
  21. 21. Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains Early Late Normal Alzheimer’s Alzheimer’s ChildG. Small, UCLA School of Medicine.
  22. 22. So… what is happening?• Memory damage • Language damage – Can’t learn new things – Has very concrete – Forgets immediate past understanding of words – Does time & space travel – Misses 1 our of 4 words – – Uses old memories like new may miss “Don’t…” – May not ID self or others – Word finding problems correctly – Word salad problems – CONFABULATES – COVERS – Follows visual cues – Follows your cues – Seeks out the familiar – Gets very vague & repeats – Can get stuck on an old – Uses automatic responses emotional memory track – Mis-speaks
  23. 23. So… what is happening?• Impulse Control Problems • Performance Problems – Say whatever they are – Thinks they can do better thinking than they can – Swear easily – Can sometimes DO – Use sex words or racial slurs BETTER under pressure – when stressed sometimes worse – Act impulsively – Uses old habits – Not think thru consequences – Attempts can be dangerous – Can’t hold back on thoughts or fatal or actions – They will tell you one thing – Responds quickly & strongly and then do another… to perceived threats – Families may over or under • Flight, fight, fright ‘limit’ activities
  24. 24. How do these losses relate to some risky behaviors?• Persistent ‘going’ • Lost and ‘Looking’ – inability to terminate – can’t find places – not able to anything else – looking for familiar – discomfort • Invading space• Eloping - escaping – automatic actions – following cues – following interests & habits – wanting to leave – no awareness of ‘personal space’ – going somewhere • Shadowing• Constant talking or – looking for help vocalizing – Comfort – Trying to communicate • Resisting care – Self-stimulating – Self-care• Lack of Initiation – Movement – Won’t move or cooperate
  25. 25. Diamonds - Routines & Repeats ACL 5• Word finding problems • Becomes anxious and• Logic problems frustrated easily• Place & time confusion • Has trouble with new• Very ‘independent’ or routines and locations seeking constant • Tries to maintain control & reassurance social behavior• Resents take-over • May try to escape/leave• Self-awareness varies • Can use signage & cues• Fearful about what is • Gets ‘turned around’ wrong • Momentarily ‘disoriented’• Typically resists outside • Does regular routines JUST helpers FINE!
  26. 26. Emeralds- Task Oriented ACL 4• Has trouble sequencing • Uses visual information to thru tasks & activities figure out what to do• Often skips steps • Follows samples & demos• Looking for what to do • Can’t do an activity if visual and where to be prompt is not there• Believes they can do it • Specifics and content in• ‘Don’t need your help’ speech can be limited• Has a mission in mind • Gets stuck on ‘stuff’• Goes back in time • Needs to be involved• Gets lost in place • Looks for ‘stuff’ to do
  27. 27. Ambers- Hunting & Gathering ACL 3• Uses hands to touch, • Imitates actions – copies you feel, handle, hold • Tool use is challenging• Explores what is visible • Follows others and hidden • Investigates the environment• Invade other’s space to • May taste or eat what they explore see • Difficulty terminating• Repeats actions over and over • Difficulty getting focused on care tasks• Sees in pieces not whole • Becomes easily distressed• Impulsive or indecisive with unpleasant tasks• Understands few words • Asks ?s mechanically
  28. 28. Rubies - Stuck on GO ACL 2• Gross motor only • Can’t stop or sound• Poor finger use asleep• Limited visual processing • Copies your mood –• Very limited facial expressions communication skills • Can’t grade strength• Unable to do more • Better with rhythm and complex motor actions repetitive movements• Imitates those around • Loses weight• Problems with chewing • On the move – wanders and swallowing forward – no safety awareness
  29. 29. Pearls – Reflexes Rule ACL 1• Bed bound or chair bound • Swallowing and eating• Unable to sit up for any problems length of time • Muscles shorten and• Unable to communicate contractures forms verbally • Pressure areas develop• Lots of reflexes because of no movement• Breathing changes & limited intake• Moments of being • Responds to touch, voice, present movement, smells• Can make eye contact & • Startles easily some automatic • Motor agitation indicates responses needs
  30. 30. Health & Illness• Mobility problems?• Pain?• Sensory problems?• Mental health issues?• Other diagnoses of importance?
  31. 31. Comparison of Fat Pads
  32. 32. Environmental Factors & Changes • Physical Environment • People • Programming
  33. 33. Environmental Aids• Setting – familiar – friendly – functional – forgiving (safe)
  34. 34. Environmental Aids• Props – visible & invisible – timely – available – matched to ability – matched to interests
  35. 35. Care Partner Approach Knowledge Skills
  36. 36. Three Reasons to Communicate • Get something DONE • Have a conversation • Help with distress
  37. 37. Communication –Getting the person to DO Something Form a relationship FIRST Then Work on Task Attempt
  38. 38. Connect• 1st – Visually• 2nd – Verbally• 3rd – Physically• 4th – Emotionally• 5th – Individually - Spiritually
  39. 39. How you help…• Sight or Visual cues• Verbal or Auditory cues• Touch or Tactile cues
  40. 40. To Connect Use the PositivePhysical Approach
  41. 41. Your Approach• Use a consistent positive physical approach – pause at edge of public space – approach within visual range – approach slowly – offer your hand & make eye contact – call the person by name – stand to the side to communicate – respect intimate space – wait for a response
  42. 42. Hand-Under-Hand Position
  43. 43. Your interaction…• Communicate with awareness – look, listen, think! – give your name – make an empathetic observational statement • “You look busy...” • “It looks like you are tired…” • “It sounds like you are upset…” – wait for a response
  44. 44. Give information• Keep it short and simple – “ It’s lunch time” – “Let’s go this way” – “Here’s your socks”• Use familiar words and phrases• Use gestures and props to help
  45. 45. Encourage Engagement• ask a person to try • use props or objects• ask a person to help • gesture you • demonstrate• give simple positive • guide directions - 1 step at a • distract time • redirect
  46. 46. Daily Routines & Client-Centered Programming• Old habits and routines• Patterns during the 24 hrs• A time to rest, work, play…socialize• Your needs… my time
  47. 47. To Cope with Challenging Behaviors… • Where will you start??? – An idea – • Care partner education • Care partner skill building
  48. 48. Then…• Observe & document the risky behavior thoroughly – what is the pattern – when does it happen – where does it happen – who is involved – what is said, done, attempted – what makes it better… worse
  49. 49. Is it really a problem? … A RISK• If NO - leave it alone• If YES - its time to problem solve – call the team together – put on the thinking caps
  50. 50. REMEMBER Explore all of the following -• Personal background information• Type & Level of cognitive function• Health information• Environmental issues• Caregiver approach & assistance• Habits, schedules & time of day
  51. 51. Re-look at the problematic challenging behavior…• What does the person need?• What is the meaning of the the behavior?• Do you understand the risky behavior better?
  52. 52. Make a PLAN!• Who will do what• When will it be done• How will it work• What environmental change is needed• What props are needed - where will they be
  53. 53. Implement your plan!• Keep track of progress• Document what is happening• Communicate among the team members• Rethink - if it isn’t working….• CELEBRATE - if it is!
  54. 54. How can we help… better? It all starts with your approach!
  55. 55. How you help…• Sight or Visual cues• Verbal or Auditory cues• Touch or Tactile cues
  56. 56. What Do They Do?• Question• Refuse• Release – verbal• Intimidate – physical• Tension reduction
  57. 57. What Should You Do?• Be supportive• Offer choices & be directive• Set realistic limits• Act – Take control• Re-connect
  58. 58. Believe - People Are doingThe BEST they can!
  59. 59. What shouldn’t we do???• Argue• Make up stuff that is NOT true• Ignore problem behaviors• Try a possible solution only once• Give up• Let them do whatever they want to• Force them to do it
  60. 60. So WHAT should we do??? Remember who has the healthy brain!

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