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Managing Challenging Behaviors in Adults with Developmental Disabilities in a Day Program EnvironmentAAA

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Managing Challenging Behaviors in Adults with Developmental Disabilities in a Day Program EnvironmentAAA

  1. 1. 419 Mason Street, Suite 118 Vacaville, CA 95688 (707) 448-2283 MANAGING CHALLENGING BEHAVIORS IN ADULTS WITH DEVELOPMENTAL DISABILITIES IN A DAY PROGRAM ENVIRONMENT .
  2. 2. 2 MANAGING CHALLENGING BEHAVIORS IN ADULTS WITH DEVELOPMENTAL DISABILITIES IN A DAY PROGRAM ENVIRONMENT All parts of this material may be reproduced or transmitted in the full format without written permission from the author. All rights to this material are maintained by McGrew Behavior Intervention Services, Inc. David Mauger, MA McGrew Behavior Intervention Services Program Specialist, Pace Solano djmauger@comcast.net
  3. 3. 3 Contents Preface …………………………………………………………………… 4 Chapter 1 “Catch me if you can” ………………………………………. 5 Chapter 2 “Take my anxiety, please!” ...................................................... 8 Chapter 3 “I do not want to be in that group”.........................................10 Chapter 4 “No, you did not earn your sticker.” .......................................12 Chapter 5 “Out of sight, out of mind”..................................................... 14 Chapter 6 “The less you find for me to do”............................................. 15 Chapter 7 “Please go to the kitchen and get me some paper towels.” ... 16 Chapter 8 “Keep your finger in the dam”............................................... 18 Chapter 9 “Pick your Battles”................................................................. 20 Chapter 10 “If you do not give it to me, I will take it”.............................. 21 Chapter 11 “Take me to the restroom, RIGHT NOW!” ............................ 22 Chapter 12 “I see nothing!”...................................................................... 24 Chapter 13 “I love race cars” ................................................................... 25 Chapter 14 “Break the chain”................................................................... 26 Points to Consider ..................................................................................... 27
  4. 4. 4 Preface The intended use of this material is to assist direct support professionals working with adults who have developmental disabilities. The focus of this material is on understanding the communicative nature of unexpected behaviors, and on respecting that these challenging behaviors often have a meaningful purpose and are functional in what they are trying to communicate. At times, direct support professionals may feel undertrained and unprepared to manage these types of behaviors, which may include verbal abuse, physical aggression, property damage, severe unwillingness to cooperate, and self-abuse and injury. The concepts presented in this material are based on person-centered principles. This training material is the product of four years of staff interviews with instructors serving adults with developmental disabilities. In each of these interviews, our objective was to understand the communicative nature of a behavior. Each interview resulted in a written support plan. These plans were designed to enable the consumer to be understood without resorting to unexpected behaviors. It became apparent that there were recurrent themes in these interviews. This training material attempts to identify these themes and, hopefully, to provide a tool for those working with challenging behaviors in a day program or residential environment. All material in this handout has been reviewed and edited by my beautiful wife of thirty years: Deborah M. McGrew, Psy.D, BCBA-D, LMFT, LPCC McGrew Behavior Intervention Services, Inc.
  5. 5. 5 Chapter One “Catch me if you can” The intensity of effort required to implement a behavior support plan can be measured against the intensity of effort required to manage the challenging behavior after it has occurred. Case Study: Morton has been exhibiting some extremely challenging behaviors. These behaviors include screaming, out-of-control physical aggression, leaving the program, verbal abuse, and property destruction. Analysis: Morton’s treatment plan is comprehensive. It requires a significant effort from the instructor. The first part of this plan involves preventing these challenging behaviors through proper management of his environment. The second part of this plan, occurring concurrently, involves the development of a positive relationship with Morton. Morton is a person who, on a minute-by-minute basis, experiences a great deal of insecurity and mistrust of what is occurring around him. Morton is constantly evaluating his environment and looking for reassurance and acceptance. Our job is to have empathy for how difficult this state of mind is for Morton, and in return, to do everything we can to reassure him and to help him feel accepted and safe. Following this, it must be appreciated that Morton has no available resources for dealing with feeling rejected or reprimanded; which is the true challenge of working with Morton. Working with Morton is analogous to trying to keep a top spinning. Unless you keep it spinning, it will drop to the ground. Treatment: In practice, Morton’s treatment begins by crafting each interaction with him to be reassuring and to make him feel safe and secure. The first time Morton sees a person, he tries to calculate that person’s disposition, especially if there is the potential for Morton to be (in his perception) “in
  6. 6. 6 trouble.” To counter this, the instructor smiles at Morton and maintains good eye contact when greeting him in the morning. In effect, the instructor is putting a spin on the top. Next, the instructor says something nice and supportive to Morton. The instructor might touch his arm or pat his back, all designed to spin the top faster. It is important, and challenging, for the instructor to start fresh following the resolution of an explosive behavior. Morton’s explosive behaviors cause him to feel badly toward himself. Morton feels shame after one of his challenging behaviors, and is quick to apologize. He does not use these behaviors to bully others or because he is trying to get his way. Morton does not have the ability to control these outbursts when he feels rejected, disliked, or mistreated. If the instructor continues to focus on the past problem, it is preventing Morton from moving on, and increases the possibility of a new undesired behavior. This point encourages the instructor to have empathy for Morton’s predicament. It is hard to feel sorry for someone who uses aggressive behavior to control other people, or for self-serving purposes. However, when we realize that this is not the case, we feel more of a desire to help Morton avoid explosive behaviors. This is an awkward comparison, but if we understood that behaving in a certain manner prevented a person from having a seizure, we would do everything within our power to help that person circumvent a seizure. Let’s create some scenarios for Morton and look at alternative responses. How do we avoid any type of negative interaction with Morton? The answer is to use a redirection to an equally positive activity. By engaging in that activity, the positive behavior is incompatible with the challenging behavior. Morton must exchange one behavior for the other. One tool we have available to us is that Morton enjoys being helpful. So let’s say that in a classroom setting, Morton is teasing another student and is enjoying watching that student become upset. If we approach the behavior head on by saying, “Morton, stop teasing Susan,” we are at risk for spending the next hour trying to calm Morton down, which might include chasing him across a field. Morton is fast. Some instructors may struggle with the ideas presented in this paper because they might come across as “giving in,” or “losing control over the classroom.” However, when the instructor has
  7. 7. 7 had to resort to physical restraint, or had to chase Morton across two fields to catch him; Morton has already taken the control away from the instructor. So how is the instructor going to resolve this situation? The first step is to hold back for one moment and strategize. Start with the foundation that even though the behavior is negative, you are going to be positive. “Morton, I need to talk to you about how well you have been doing in my classroom. Can I see you at my desk?” “Morton, will you please get me some paper towels from the kitchen? You are my best helper!” “Morton, can you tell the class about your plans for the weekend?” Notice that for Morton to do any of the above, he must stop bothering the other student. You are avoiding conflict with Morton while at the same time spinning the top faster. Scolding Morton or reprimanding him is the equivalent of stopping the top entirely. Other techniques that are equivalent to keeping the top spinning might include the following:  Giving Morton job assignments  Frequent verbal praise  Positive acknowledgements  Telling him he looks nice  Telling him that he has good hygiene  Telling him how smart he is, etc. As time goes on, you are working with Morton using a relationship-based technique, meaning that Morton feels so positively toward you, and that he likes and trusts you so much, that all future work becomes easier. Morton starts to have a good day based on your presence. As noted in the beginning, this is an intensive effort on the part of the instructor. However, it does not come close to the intensity of managing one of Morton’s outbursts. Furthermore, these techniques let us maintain control of the classroom, rather than giving that control to Morton.
  8. 8. 8 Chapter Two “Take my anxiety, please!” In some cases, there may be unresolved anxiety underneath an undesired behavior; if we resolve the anxiety, we prevent the undesired behavior (e.g., attacking an instructor). Case Study: An instructor needed a cart to be removed from Bobby’s room. Removing the cart from Bobby’s room had previously caused Bobby anxiety because he noticed the change immediately, and he experienced anxiety until the cart was replaced. The degree of anxiety he experienced was related to the length of time the cart was gone. To address this, the instructor made a note that was posted on the wall each time the cart was removed, telling Bobby where the cart was located. This intervention was successful. In a second incident, and instructor had to clean Bobby’s room at a later time than usual. Bobby insisted that the lights were supposed to be off at that time of day. The instructor immediately turned the lights off and continued to clean Bobby’s room without interruption. This intervention was successful. In a third situation, the dividing curtain in Bobby’s classroom was open for cleaning to be performed, and Bobby expressed that the curtain should be closed. Bobby was not trying to be the boss and tell people what to do, but the open curtain was causing him high levels of anxiety because “they were not supposed to be open.” The instructor politely explained to Bobby why the curtain was open. Bobby charged at the instructor with great force that had the potential to do significant physical harm. Explaining why the curtain had to be open did not resolve Bobby’s anxiety, and instead, only made it worse. Eventually, given a lack of resolution, Bobby charged the instructor. Analysis: We learned the appropriate intervention for Bobby from the school of hard knocks. Typically, we would try to explain to Bobby why we were doing something: “I have the lights on because I need to clean the room.” But Bobby does not care about why. Bobby wants order restored, and
  9. 9. 9 for his anxiety to go down. Given this understanding, the instructor can almost always rescue Bobby with the most direct action. This level of action shows a great deal of empathy for who Bobby is as a person. Bobby’s aggressive behaviors often resulted in significant harm, including injuring instructors, destroying property, and scaring other students. Taking direct action was an easy procedure to follow in exchange for Bobby suppressing these explosive behaviors. When Bobby gets anxious and aggresses outward, it is a functional behavior. It is Bobby’s way to handle high levels of anxiety caused by something in his environment. In this light, it is a logical behavior. Treatment: The interested instructor can begin to use desensitization techniques by playing a game with Bobby. For example, have him close his eyes, and move something in the room and tell him it is his job to discover what is different. This way, we might be able to make it fun for Bobby to discover change in his environment. Provide positive praise for all successes.
  10. 10. 10 Chapter Three “I do not want to be in that group” In a day program environment, participants have a wide range of skill levels. Our ability to offer programs in a multilevel format can result in fewer challenging behaviors. Case Study: Aaron likes to walk away from his group in the community, is often verbally aggressive, and generally seems angrier and more resistive than he had in the past. Once Aaron is angry, he can be difficult to calm down. Additionally, Aaron frequently puts his head down and pretends to be asleep, ignoring any request made of him. Aaron is a handsome young man who enjoys coming to the program each day, and he will get involved if an activity is of interest to him. However, Aaron will shut down if he has no interest in what is occurring. Aaron does not see himself as the typical participant, but instead as more advanced, and entitled to more privileges and responsibilities. Aaron will typically respond poorly when he is told what to do or feels that he does not have a choice in a situation. This is important to understand for any instructor working with Aaron. It also has implications for how we talk to him, and for which activities he is offered. Analysis: Aaron is fiercely independent, and is hypersensitive to how he is treated. Respecting how Aaron sees himself and treating him accordingly may help to decrease challenging behaviors. Aaron uses his anger to reestablish how he expects to be treated within the program. Our goal is to give him a feeling of being special before he asks for special treatment. If we are successful, we may circumvent his need to demand it through aggressive behaviors.
  11. 11. 11 Treatment: There are two components to our plan for Aaron. The first is to restructure how we interact with him, and the second is to assess the type of activities offered to Aaron throughout the day. As an example, you have a group of participants at the county fair, and Aaron is walking away from the group. As the instructor, you need to say something to Aaron that will result in him returning. While the goal remains the same—for Aaron to return to the group—the technique can be varied. Let’s start with, “Aaron, you know you have to stay with the group. Please come back.” This has a high potential for failure, and may result in increased resistance. As a rule, avoid anything that sounds parental in tone. Compare the first technique to the following ones: “Aaron, do you have any new games at home?” “Will you be my helper today and help me keep everyone together? The helper gets a…” “Can you show us where the rides are?” “Aaron, are you going to camp this year?” It is assumed that in each of these situations, the goal of Aaron remaining with the group will be met. Creative instructors may be able to develop better examples. In this example, we are trying to get Aaron to stay with the group, but this technique may be applied to other situations. As a basic rule, avoid telling Aaron what to do. Always allow Aaron to feel that he is in control of what is going to happen. This may be challenging to instructors who feel it is their job to be in control. Aaron is allowed to have control, and he is maintaining his control by being offered a better choice than what he was doing. The instructor offers the choices, and Aaron maintains control.
  12. 12. 12 Chapter Four “No, you did not earn your sticker” Contingency management may be more of a punishment than a reward. Case Study: A plan was developed that provided Barbara with stickers when she was cooperative, and withheld them when she was not cooperative. Barbara loved these stickers and earned them seventy percent of the time. When Barbara did not earn her stickers, she became upset with herself and with others. During these times, Barbara had the potential to slap herself in the face, knock over property, and verbally abuse her instructor. This would sometimes snowball into Barbara losing additional stickers. Analysis: This plan had as much potential to do harm as it did to improve behavior. Withholding the stickers represented a punishment. When you have a student displaying challenging behaviors, and discover something the student loves, it may be tempting to use that item as a tool to manage challenging behaviors. An extreme form of this is the student who smokes cigarettes and must earn the cigarettes in some way, either through an appropriate behavior or by performing a task. It is easy to see the problem with that plan, but it becomes less obvious when the reward is a sticker. One way to proceed is to avoid plans that involve something being earned. It takes discipline and consistency to implement contingency plans. They quickly become distorted from one instructor to another, leaving the student confused about the criteria. Contingency management is a respected technique. I am not disparaging it across the board; I am saying that a day program is not a controlled environment, and that the procedure often cannot be implemented effectively.
  13. 13. 13 Treatment: When we learn of something that a student loves, we should make it readily available within their environment. In Barbara’s case, give her stickers throughout the day on a non-contingent basis. If each sticker makes Barbara happy, and she is getting them throughout the day, this strategy will result in Barbara spending more time in a good mood. Being happy is not compatible with being upset, so her challenging behavior will naturally decrease. Other examples would include the use of positive comments throughout the day, compliments, and positive attention—not because she is being “good”, but because she enjoys this type of attention.
  14. 14. 14 Chapter Five “Out of sight, out of mind” In some cases, we can manage challenging behaviors by altering the environment. Case Study: During the last three months, Cathy has eaten three cigarette butts. Analysis: As Cathy is being dropped off to attend the day program, while still in the van, she is looking out of her window, scanning the parking lot for cigarette butts. When Cathy has spotted a cigarette butt, it becomes her first target of the day. When Cathy goes for a walk, she will eat this cigarette butt. Treatment: Proactively search the grounds each day and remove all cigarette butts. This intervention resulted in zero cigarettes butts being eaten within a three-month period. This is a pretty straight-forward example. If there is no cigarette butt within the environment, there is no opportunity for the undesired behavior to occur. A similar situation involves managing a participant who is constantly taking other participants’ food. We cannot underestimate the seriousness of this type of problem. We only need to imagine that we are at a restaurant, and just as our food arrives, the person at the next table grabs something off of our plate and eats it. Managing the environment may be the key to working with this problem. Ensure the crafty participant is not in a position where he or she can take another person’s food. The more this person is successful, the more ingrained the behavior will become. Immediate and direct intervention is called for in these circumstances.
  15. 15. 15 Chapter Six “The less you find for me to do, the more I will find for you to do” People are less likely to exhibit unexpected behaviors if they are engaged in an activity they enjoy. Case Study: Connie spends her day sitting at a table, drooling saliva out of her mouth, and flinging it with her finger at anyone who gets close enough for her to hit with it. If you look at the physical structure of this class, it appears as if Connie is leading an orchestra with her arm flinging, and everyone staying out of range. Analysis: It is common to see an instructor working hard, trying to engage a participant, only for that participant to reject them. This was the case with Connie. There was no lack of effort to engage Connie in more meaningful activities, but Connie really liked flinging her spit. She would laugh and laugh if she successfully hit a person. Treatment: A simple plan might involve identifying a single activity per month that the person will enjoy. Using a timer, have the instructor introduce a different activity every thirty minutes. As interesting activities are discovered, they can be posted on the wall using Velcro, so that activities that have grown out of favor may be replaced with new activities. In Connie’s case, we introduced a variety of different textured materials, such as silk, for her to hold. Holding on to an item is not consistent with flinging saliva, so it trumps that behavior. The item Connie is holding, or the activity in which she is engaged, must be more pleasurable than the behavior being discouraged.
  16. 16. 16 Chapter Seven “Please go to the kitchen and get me some paper towels” As we discussed in chapter one with Morton, in some cases, it may be more helpful to introduce a preferred redirection away from a challenging behavior, rather than to address the challenging behavior directly. Case Study: Robbie was provoking another student. Robbie’s instructor asked her to please stop picking on the other student. The instructor was polite, but Robbie perceived this as confrontational. Robbie began to call her instructor names, saying she was not her boss, and she could do what she wanted. When the instructor asked her to stop the name-calling, Robbie picked up a lunch box and threw it at her instructor. Analysis: In the situation above, Robbie was confronted twice: when she was told to leave the other student alone, and when she was asked to stop calling the teacher names. Asking Robbie to stop picking on the other student was talking to the negative behavior. Talking to a preferred redirection would be, “Robbie, you are so helpful. Would you please go to the kitchen and get me some paper towels?” The desired behavior is for Robbie to stop bothering the other student. We are hoping that the preferred redirection will be incompatible with the challenging behavior; when Robbie goes to get the paper towels, she is equally no longer provoking the other student, because one behavior is not compatible with the other. In cases where this approach might be helpful, there is usually a pattern in which directly confronting the behavior has been ineffective. We know from experience that once Robbie perceives that something is going against her will, there is the possibility of a challenging behavior. Sometimes, we can achieve the same goals without using language that Robbie will interpret as confrontational.
  17. 17. 17 Our ability to manage a challenging behavior is often tied to the words we use when working with a participant. Instructors can benefit from waiting before reacting, and from thinking about which words have the potential to escalate the problem or to deescalate the problem. Instructors who maintain an insistence that they are the one “in control” and that they are the one who needs to be listened to, often have the most problems when dealing with challenging behaviors. Treatment: Intervention begins with understanding what activities an individual would prefer. Robbie enjoys seeing herself as a teacher’s aide; asking her to do something she does not like to do would not be as successful.
  18. 18. 18 Chapter Eight “Keep your finger in the dam” In some cases, challenging behaviors are not changed as much as they are prevented through the instructor’s actions. There may be fewer occurrences of the challenging behavior, but as soon as the instructor stops doing what they are doing—removing his or her finger from the dam—the challenging behaviors may resurface. Case Study: Barbara is a charming young lady who may also present some challenging behaviors, including verbal abuse and physical aggression. The success of preventing these more undesired behaviors is based on the ability of the instructor to remove potential behavior triggers within her environment. When Barbara comes into her classroom, she has the same potential to exhibit a wide range of challenging behaviors, as she does to be charming. The direction this will go is less related to Barbara, than to the efforts made by her instructor. For Barbara, a low occurrence of challenging behaviors does not mean she is doing better; it means the instructor’s efforts have been significant. In Barbara’s case, her instructor protects her environment by having her sit in a place where she is the least likely to cause a fight with another student; by allowing her to be a teacher’s helper; by limiting unexpected changes in the classroom; by keeping Barbara in small groups; by providing opportunities for control; by avoiding delays; by quickly responding to and resolving problems; by maintaining a low-noise environment; and by ensuring that other students do not touch Barbara or her belongings. All of these are important to managing Barbara’s more difficult behaviors throughout the day. Analysis:
  19. 19. 19 The instructor’s efforts act as a type of glue that holds Barbara together throughout the day. As each of these efforts is removed, the likelihood of Barbara exhibiting challenging behaviors increases. If there is a lack of understanding of what needs to occur for Barbara to do well, a resurgence of these behaviors will catch a new instructor by surprise. If a supervisor switches Barbara’s instructor without an appreciation of why Barbara is doing well, problems may result. In some cases, the new instructor may be considered “not as good” as the old instructor, but the truth would be that they were not properly trained. In addition, the behavior data may be misleading, suggesting there are no behavior concerns because there are no documented incidents. When undesirable behaviors occur less frequently, they may become less likely to occur as an immediate response to a problem situation. Treatment: Train all staff working with Barbara to understand and implement the above. Continue to add to the list of activities that help Barbara to maintain appropriate behavior throughout the day.
  20. 20. 20 Chapter Nine “Pick your Battles” Not every challenging behavior requires a reaction. Instructors should assess each situation to determine the need and the reason for an intervention. In some cases, the behavior is harmless and can be ignored. Realize that once that decision is made, no intervention is needed—you are done. When that happens, there is also less risk of rewarding the behavior with attention. Case Study: Tim is listening to music using headphones when he should be paying attention to the instructor. If Tim is asked to remove his headphones, he will become upset. Analysis: First, assess whether Tim really does need to listen. There is currently no disruption to the class. If there is an intervention, there may be a major disruption to the class. So, ignore the behavior; it is harmless. Let it go. Pick your battles and avoid all unnecessary conflicts. Tim has the right to refuse an activity. Who has the control? If the behavior is ignored, the instructor maintains control—or perhaps it is better to consider it a shared control. If the behavior is confronted, the student will take control through unwanted behaviors. (Note): From the perspective of shared control between two adults, when one tries to take more than his or her share, it forces a response from the other to balance the control. When either the participant or the instructor tries to take more than his or her share, the other person must respond by taking back the control, and then some. Now you have a battle for control (power struggle) because the first person tried to take something to which he or she was not entitled by the rules of shared control in adult relationships. Treatment: Analyze the event. Often, we come to this type of understanding after the event has occurred. In retrospect, instructors have realized that the problem they were trying to resolve was nothing compared to the problem that developed.
  21. 21. 21 Chapter Ten “If you do not give it to me, I will take it” People are going to use behaviors that get the results they want. Undesired behaviors are often rational and purposeful. We want to decrease these behaviors. That is the purpose of each chapter. However, we equally want to understand what the behavior is designed to communicate. Case Study: Katlin exhibits loud outbursts throughout the day. Her favorite activity is to talk about her problems. She uses false accusations, aggression, and frequent medical complaints to acquire attention. These behaviors are effective. Analysis: Wanting control and attention is not a bad thing. We start by respecting that. The behaviors Katlin uses to gain attention and control have a harmful effect on an instructor’s desire to spend time with her. Katlin has alienated the people with whom she most wants to spend time. Unfortunately, avoiding her perpetuates the cycle. Treatment: Build large amounts of one-to-one time into Katlin’s schedule. It is important to note that Katlin is already taking this time on her own terms. Have Katlin begin each day with a meeting to review her concerns. Build in frequent opportunities for Katlin to discuss her problems throughout the day. Conduct staff trainings and acknowledge how this will be hard for some staff who have been negatively affected by Katlin’s past behavior. Help them understand the intent of the plan.
  22. 22. 22 Chapter Eleven “Take me to the restroom, RIGHT NOW!” Although not common, there can be cases of a participant damaging an instructor’s desire to provide services. These challenging behaviors appear to be designed for the sole purpose of upsetting the instructor. Case Study: Martha requires one-to-one assistance to use the restroom. These situations require a significant effort. Frequently, once there, Martha does not actually use the restroom. Analysis: Instructors were challenged by this behavior. Our attention is first on the instructors and then on Martha. The instructors needed to be rescued before anything else. There is some risk when instructors become frustrated and upset with a participant, and the supervisor needs to recognize the situation and provide support. Otherwise, instructors are being told, indirectly, to fix it themselves. In our court system, we do not allow victims of crimes to determine the sentence the criminal receives. In the same way, we do not want an instructor who is upset with a participant to develop the participant’s behavior plan. It is not uncommon for participants who have minimal ability to control their environment to develop unconventional ways to control their environment. Respecting their need to have more control over their environment, and responding to that need rather than to the behavior, may have value. Treatment: The treatment is specific to the case. With Martha, the reason she makes these frequent trips to the restroom is not well understood. It may be that she has a physical sensation of needing to use the restroom, but no longer feels it once she is there. Alternatively, she may enjoy the attention. Because we do not know, it is best to assume that each time Martha requests to use the restroom, she needs to use it, and we should continue to assist her. I recommend that during these times,
  23. 23. 23 there should be as little engagement with Martha as possible. This does not mean ignoring her, but rather, just minimizing attention. There is a strategy we can use to understand Martha’s motivation to use the restroom so frequently. In these situations, present Martha with an alternative activity that she may find more enjoyable than going into the restroom. Both activities are going to be staff intensive, but the alternative activity may be preferable. If Martha decides not to use the restroom in place of this activity, we may begin to infer that the frequent requests to use the restroom, are more related to a desire for attention, an expression of boredom, or maybe even a form of control over the instructor. Currently, Martha obtains a high level of personal attention based on (potentially) maladaptive behavior. The second part of this plan begins with an assessment of the amount of attention that Martha achieves each day through the use of her “unconventional” techniques. Using this information, we can redesign her program to give her that same level of attention in a healthier and more positive manner. From there, we can build a significant amount of favorable one-to- one time into Martha’s schedule so that she has attention before she needs to ask for it. In a sense, we will be lavishing Martha with positive attention as a way to reset the playing field. Our hope is that this approach will decrease Martha’s motivation to use more (potentially) maladaptive techniques to acquire the same result. In time, this approach may result in her requiring less staff intensity.
  24. 24. 24 Chapter Twelve “I see nothing!” The attention we give to a challenging behavior may have the unintended outcome of increasing the frequency of the behavior. Case Study: Gwen frequently takes off her shoes. Analysis: Given that medical reasons and the possibility that her shoes are uncomfortable have been ruled out, we should consider how this behavior is responded to in the classroom. If this behavior results in Gwen getting attention, such as helping her put her shoes back on, we can assume that this attention might be the motivation for Gwen taking off her shoes. Treatment: Ignoring the behavior, does not mean to ignore the person. If Gwen takes off her shoes for attention, our treatment plan is to increase Gwen’s level of attention to a point that she does not need to ask for it by taking off her shoes. From this perspective, we look at Gwen taking off her shoes as a communication of, “I would like some attention, please.” Wanting attention is an appropriate request, and so we want to respect that, and accommodate her. When Gwen takes off her shoes, we will not “see” that behavior, but we will continue to work with her as if nothing has happened.
  25. 25. 25 Chapter Thirteen “I love race cars” Sometimes, we miss the obvious. Successfully managing challenging behaviors may require bringing an item into the classroom that you have learned is important to the participant, based on an interview with the participant and his or her family. Case Study: Rather than participating in the normal day program structure, Larry preferred to wander around the outside of the building. Larry did not cause any problems, but instructors were disappointed that they did not have a connection with him. They felt like they should be doing more. At one point, Larry began to urinate outdoors, rather than coming inside to use the restroom. Analysis: Larry was uninterested in the day program activities. Treatment: We made a formal effort to learn about Larry. Our goal was to develop a program for Larry that was more reflective of his interests. From this effort, we learned that Larry was fascinated with race cars. Larry was absorbed with anything related to race cars, and he had an advanced understanding of them. Our new program for Larry included watching race car videos, providing the opportunity for him to talk about race cars, providing a subscription to a race car magazine, and posting pictures of race cars in his classroom.
  26. 26. 26 Chapter Fourteen “Break the chain” The sooner you respond, the less challenging the undesired behavior may be. Case Study: Tommy’s aggression follows a type of chain reaction, with each link in the chain leading to a more disruptive behavior. As an example, Tommy wants, and takes, an instructor’s pen. The instructor takes it back, creating the first link in the chain (i.e., Tommy being denied something he wants). Tommy may proceed to throw something on the floor. If this does not work, he may go hit the window. If this does not work, he may begin to bite his hand, or he may hit the instructor or another student who is in close proximity to him. Instructors have previously had to clear the room and allow Tommy a sufficient amount of quiet time to calm down. Analysis: Historically, once Tommy’s behaviors are intense enough, they usually result in Tommy getting what he wants. This behavior is functional. It works. Treatment: Our intervention begins at the first link of the chain. As soon as there is a conflict, Tommy must be redirected toward something that has equal or greater value to him. In the first example, Tommy has the control. Tommy will increase his behavior until the desired item is obtained. Using a well-planned redirection, the instructor and Tommy may have the opportunity to share the control, and the behavior may be averted. The key is that there is no appearance of a conflict (i.e., taking the pen away), and that the redirection is equal to, or more preferable than, having the pen. You may consider allowing Tommy to hold the pen until a more preferable item is discovered (e.g., a pen that has his name on it).
  27. 27. 27 Points to Consider Working with challenging behaviors often involves altering our behavior rather than that of the participant. The personal hygiene of each participant attending a day program is an important concern for program instructors and supervisors. Each participant should pass basic criteria in order to attend the day program. Allowing participants to attend while having severe halitosis, significant body odor, inadequate lunches, soiled clothing, or similar type of concerns is disrespectful to both the participant and the instructor. To ignore these issues allows them to continue. Behavior is communication. Respect the communication. We do not want to disregard what is being communicated when we are trying to alter the challenging behavior. Only after we understand the communication should we consider altering the behavior. Consider the implication of trying to change the behavior of a person communicating that he or she is choking. It is tempting, when we discover what is important to participants, to use those things as bargaining chips to get the participants to do what we want (e.g., “If you give me good behavior, I will give you XYZ.”). These approaches exceed our authority, often represent a client rights violation, and should not occur within a day program environment. In addition, now the instructor is implementing his or her own, made-up behavior plans. What we sometimes do not understand is that saturating participants with what they want may be more effective at eliminating challenging behaviors. Once the behavior plan is written, the next step is to determine who will be responsible for overseeing implementation of the plan. It is important, and sometimes overlooked, that the plan is written for the person who will be providing the services; just as this document is designed for the person who will be providing the services. The direct support professional is the most important person in all of our efforts to understand and work with challenging behaviors.
  28. 28. 28 Once the instructor develops a positive relationship with the participant with whom they are working, half of the work is done. The participant will improve by being with that instructor. Reinterpreting a challenging behavior may help the instructor to have more empathy and to be more forgiving when the behavior occurs. In Chapter Two the behavior was reinterpreted as anxiety rather than something the consumer was doing “against” the instructor. Consider this exercise when a participant is starting your program. In this scenario, imagin that that you are starting a new day program, and the administrator of the program has given you thirty minutes to write down everything you consider important about the services you will receive. Let’s say your list includes morning coffee with cream, Michael Jackson music, arts and crafts, a preferred nickname, and puppies. The program can use this information to get things off to a good start. Imagine that on your first day, they have a cup of coffee with cream for you, posters of Michael Jackson and pictures of puppies posted in the classroom, they call you by your preferred nickname, and the morning activity is arts and crafts. (This is also relevant to residential services.) Learn to avoid power struggles. Be as clever as you need to be to avoid them. The End
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