Proactive Interventions for Managing Challenging Behaviors in Community Based Settings

Best Practice Strategies for Improving Quality of Life

Mahin Para-Cremer, M.Ed.Associate Director of DevelopmentLakeview Specialty Hospital & Rehab

What are “Challenging Behaviors”?

• Aggressive Behaviors• Verbal Assaults• Refusals to participate• Isolating in room• Suicidal threats/behaviors• Elopement• Self-Injurious Behaviors• Alcohol / Drug abuse• Inappropriate relationships• Anxiety• “Learned Helplessness”• The three “D’s”

What if YOU could PREVENT the Challenging Behavior from occurring in the first place?

What do people get?

ATTENTION: good or bad GET/

OBTAIN: food, item, activity

ESCAPE:Person, request, activity Organic or

Sensory Stimulation

Team Problem Solving & Analysis

• Analysis of a problem• Setting Events• Antecedent• Behavior• Consequences

Complete tasks/activities

Praise + high five

Escape aversive tasks

Scream, hit others, self-slap

Transitions,Asked to speak to

class,Asked to write

Less than 6 hr of sleep

Request a “break”

Setting EventAntecedent

Problem Behavior

Desired Behavior

Alternative/Replacement Behavior

Maintaining Consequences

Maintaining Consequences

* Example adapted from Horner, Albin, Sprague, and Todd (2000)

Setting Event Strategies

Antecedent Strategies

Teaching Strategies

Consequence Strategies

• Parent contacts teacher to alert after “bad sleep” night and teacher adjusts schedule to reduce difficult tasks;

• Modify task from speaking in front of class to small group;

• Teach student to request a break;

• Increase reinforcers for appropriate task completion (use stickers and other tangibles);

• Implement soothing bedtime routine to increase quality sleep;

• Use picture sequence to prompt transitions;

• Teach student to ask for help;

• If problem behaviors occur, prompt use of appropriate communication alternatives (use pictures, request break)

• Provide opportunity for nap in nurse’s office after “bad sleep” night;

• Use interspersion strategy for difficult tasks;

• Teach use of picture sequence system for transitions;

• If problem behaviors occur, block and redirect as needed; do not allow escape (keep working through task).

• Classroom assistant increases one-to-one attention after “bad sleep” night.

• Classroom assistant increases one-to-one attention after “bad sleep” night.

• Implement sequenced curriculum to teach & improve writing skills;

• Pre-teach routine for transitions

• Teach student to speak in front of class using gradually increasing time periods and less familiar topics.

• Pre-teach or prompt use of “break” requests.

Understanding the Crisis Cycle

Phase 6

Post-Crisis

Phase 3 Crisis

Phase 2

Escalation

Phase 0

Base line

Phase 1

Stimulation

Phase 5

Stabilization

Phase 4

De-Escalation

* Diagram adapted from the Mandt System

Preventative Procedures

• Preventative Procedures are those actions that are within your control that can be applied whenever a client is not in crisis.• Increase in Quality of Life• Proactive• Best Practices for Quality Care• Reduces Challenging Behaviors

Create a Personal Profileo Identify:o Relationshipso Placeso Backgroundo Personal Preferences

o Most Important Thingso Strong Preferences

o Hopes, Dreams, & Fearso Support Needso Strengths and Skills

o Interview:o The individual servedo Parents / guardiano Family memberso Core team memberso Friends of the individualo Teacherso Residential Staff (across

different shifts, closest relationships)

o Natural community supports

Praise & Positive Reinforcement• Provide Behavior Specific Praise• “Catch them being good”

• Watch for positive things, actions, or behaviors & comment on them

• Be Genuine • Consider Public Praise• Reprimands and punishment are

very ineffective in making lasting changes to decrease challenging behavior• Most importantly does not

teach the desired appropriate behavior.

Body Posture & Facial Affect

• Be aware of your body posture

• Smile• Face the person• Enthusiastic voice tone• Eye Contact

Engagement & Per Opportunity Teaching

• Engagement: active participation in functional and normalizing activities that promote skills.

• Per-Opportunity Teaching: recognizing opportunities and engaging client in natural environment.

• “Errorless” Learning

Offer Choices• Teach people how to choose

• Making a simple choice• Problem-Solving / Decision Making

• Offer frequent opportunities for choice• Use choice opportunities as a means to decrease

challenging behavior• Make assessment of preferences part of the

interdisciplinary planning process• Increase person’s repertoire of skills and behavior so that

more opportunities for choice are available• Balancing Choice and Control with Identified Goals

Self-Government and Consumer Input

• Transfers day-to-day and life decisions from staff to individual-in-care;

• Teaches individual and group decision making skills;

• Allows choice of preferred lifestyle.

Person-Centered Rationales

• Provide the reason why the person should do what you are asking, given in the person’s perspective.• Why would it be important to them?• Language that is easily understood by them• Short & Sweet• Avoid Staff related rationales

Structure & Consistency• Schedules provide structure

and consistency across days, staff, etc.

• Schedules increase predictability, control, and independence for our clients

• Schedules create opportunities to use strategies that teach life skills

To Create a Schedule, Determine:ActivitiesSequenceLevel of choice

Coordinate schedules Two forms

Staff scheduleConsumer schedule

Teach independent use

Relationship Development

• Nine elements of a good relationship• Concern• Empathy• Affection• Respect• Flexibility• Encouragement• Humor• Focus on Positives• Allow Participation

Pre-Teaching

• Reviewing expectations prior to an event or activity gives the consumer the best chance of success.

• Tell the consumer the what, where, how, how long, with whom, why etc.

• Give opportunity to disagree, ask questions, negotiate, etc. so there are no surprises during activity.

• Helps staff to think ahead and plan for activity• Follow through and build trust

Healthy Living• Diet and Nutrition• Exercise• Regular monitoring & intervention of

on-going health concerns• Medication monitoring• Incorporate healthy lifestyle within

daily schedule• Skill development• Safety• Hygiene• Therapies

Effective Communication

• Defined as: Expression of desires and preferences in such a way that they can get or potentially get what they want without disrupting the environment.• Receptive vs. Expressive Communication• Modes of communication

• Non-symbolic, symbolic, verbalizations• Responsive communication partners• Teaching communication

• Planned vs. per-opportunity

Enriched Environments• Physical environment is homelike, attractive, and

comfortable• built-in opportunities for engagement• Taking pride in environment, welcoming

• A variety of age-appropriate engagement materials are continuously available• Functional activities• Age-Appropriate

• Adaptive and prosthetic devices are available to aid participation in self-care, domestic skill, and leisure activities.

• Environmental Cues posted to increase independence• Steps for tooth brushing• Client Schedules, etc.

Understanding the Crisis Cycle

Phase 3 Crisis

Phase 2

Escalation

Phase 0

Base line

Phase 6

Post-Crisis

Phase 1

Stimulation

Phase 5

Stabilization

Phase 4

De-Escalation

* Diagram adapted from the Mandt System

Positive or Non-Restrictive Procedures for Decreasing Challenging Behavior

Environmental Change

• The things in a person’s environment are altered which can result in a change in behavior

Redirection / Diversion

• A person is prompted to engage in a functional activity, rather than an inappropriate activity.

Teaching Alternative Appropriate Behavior

• Teach a person a functionally equivalent behavior that will replace the challenging behavior.

Teach Problem Solving Skills: SODAS

SSituation: What is the problem?

 

OOptions: What could you do that would solve the problem?

Option 1: Option 2: Option 3: Option 4:

DDisadvantages: What are the disadvantages (bad things about) of these options?

Option 1: Option 2: Option 3: Option 4:

AAdvantages: What are the advantages (good things about) these options?

Option 1: Option 2: Option 3: Option 4:

SSolutions: What is the best solution? Which option has the least disadvantages and the most advantages?

 

Teach Problem Solving Skills: SOS

SSituation: What is the problem?

        

OOptions: What could you do that would solve the problem?

Option 1:        

Option 2: Option 3:

SSolutions: What is the best solution?

        

Rewarding Alternative or Incompatible Appropriate Behavior

• A reinforcer is provided immediately after an appropriate behavior occurs.

• The incompatible appropriate behavior and the inappropriate behavior cannot occur at the same time

Rewarding Non-Occurrence of Inappropriate Behavior

• Person is reinforced when a challenging behavior does not occur during a given time.

Extinction & Planned Ignoring• A behavior is consistently not

reinforced over a long period of time, and the behavior gradually decreases.

Understanding the Extinction Burst

Word of Caution on Extinction

Restitution & Positive Practice-without resistance to physical prompts

• Restitution: A person is prompted to correct whatever in the environment that has been disturbed by an inappropriate behavior.

• Positive Practice: Person practices an appropriate behavior several times.

Cross-Dialogue

• Staff discuss amongst themselves, within hearing of the client, the appropriate behaviors and the positive consequences that would be received if the client were to engage in the appropriate behaviors.

Potentially Restrictive or Restrictive Procedures for Decreasing Challenging Behaviors

• Consult a Behavior Analyst for comprehensive Functional Behavior Assessment or Functional Analysis

• Use the Least Restrictive Interventions necessary

• Protect Client Rights • Obtain Ethics Committee

Approvals• Use an Interdisciplinary Team

approach

Understanding the Crisis Cycle

Phase 3 Crisis

Phase 2

Escalation

Phase 0

Base line

Phase 1

Stimulation

Phase 6

Post-Crisis

Phase 5

Stabilization

Phase 4

De-Escalation

* Diagram adapted from the Mandt System

Setting Event Strategies

Antecedent Strategies

Teaching Strategies

Consequence Strategies

Processing/De-briefing

• A preventative strategy to avoid future problems

• Perform after an incident

• Who to involve:• team members

involved• the client

Questions to ask when Processing/De-briefing• What was the antecedent?• What was the client’s behavior

prior to incident?• How did staff respond prior,

during, and after the incident?• Was staff response in keeping

with facility policy, state, and federal regulations?

• How could the team have responded differently to improve outcomes for the team and the client?

Please contact me with any questions

• Mahin Para-Cremer, M.Ed.,Associate Director of Development

Lakeview Specialty Hospital & Rehab 1701 Sharp Rd

Waterford, WI 53185mparacremer@lakeview.ws800-611-2063 262-995-7433 FAX