Transcript Managing Challenging Behaviors in People with TBI

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 Development
Lakeview Specialty Hospital & Rehab
What are “Challenging Behaviors”?
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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
ESCAPE:
Person, request,
activity
GET/
OBTAIN: food,
item, activity
Organic or
Sensory
Stimulation
Team Problem Solving & Analysis
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Analysis of a problem
Setting Events
Antecedent
Behavior
Consequences
Less than 6 hr of
sleep
Transitions,
Asked to speak to
class,
Asked to write
Complete
tasks/activities
Praise + high five
Desired Behavior
Maintaining
Consequences
Scream, hit others,
self-slap
Problem Behavior
Setting Event
Antecedent
Request a “break”
Alternative/Replacement
Behavior
* Example adapted from Horner, Albin, Sprague, and Todd (2000)
Escape aversive
tasks
Maintaining
Consequences
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 3
Crisis
Phase 2
Escalation
Phase 4
De-Escalation
Phase 1
Phase 5
Stimulation
Stabilization
Phase 0
Phase 6
Base line
Post-Crisis
* 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 Profile
o Identify:
o Relationships
o Places
o Background
o Personal Preferences
o Most Important Things
o Strong Preferences
o Hopes, Dreams, & Fears
o Support Needs
o Strengths and Skills
o Interview:
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The individual served
Parents / guardian
Family members
Core team members
Friends of the individual
Teachers
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-incare;
• 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  To Create a Schedule,
and consistency across days,
Determine:
staff, etc.
Activities
• Schedules increase
Sequence
predictability, control, and
Level of choice
independence for our
 Coordinate schedules
clients
Two forms
• Schedules create
Staff schedule
opportunities to use
Consumer schedule
strategies that teach life
skills
 Teach independent use
Relationship Development
• Nine elements of a good relationship
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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 4
De-Escalation
Phase 1
Phase 5
Stimulation
Stabilization
Phase 0
Phase 6
Base line
Post-Crisis
* 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
Situation: What is the problem?
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Options: What could you do that would solve the problem?
Option 1:
Option 2:
Option 3:
Option 4:
Disadvantages: What are the disadvantages (bad things about) of these options?
Option 1:
Option 2:
Option 3:
Option 4:
Advantages: What are the advantages (good things about) these options?
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Option 1:
Option 2:
Option 3:
Solutions: What is the best solution? Which option has the least disadvantages and the most advantages?
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Option 4:
Teach Problem Solving Skills:
SOS
Situation: What is the problem?
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Options: What could you do that would solve the problem?
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Option 1:
Option 2:
Solutions: What is the best solution?
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Option 3:
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 4
De-Escalation
Phase 1
Phase 5
Stimulation
Stabilization
Phase 0
Phase 6
Base line
Post-Crisis
* 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 53185
[email protected]
800-611-2063
262-995-7433 FAX