October 2011 bjl

1. Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS HealthcareSouthwestern PA Health Care Quality Unit(APS HCQU) October 2011 bjl

2. Disclaimer Information or education provided by the HCQU is not intended to replace medical advice from the consumer’s personal care physician, existing facility policy or federal, state and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented. Certificates for training hours will only be awarded to those who attend a training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.

3. Note of Clarification While mental retardation (MR) is still recognized as a clinical diagnosis, in an effort to support the work of self-advocates, the APS SW PA HCQU will be using the terms intellectual and/or developmental disability (ID/DD) to replace mental retardation (MR) when feasible.

4. Objectives Recall strategies for understanding and responding to challenging behaviors Describe basic premises about mental illness in relation to challenging behaviors List the important assumptions about challenging behaviors Summarize ways to report challenging behaviors accurately Recite methods of de-escalation

5. Understanding Challenging Behaviors • Why might it be necessary to understand challenging behaviors?

6. Why is it Necessary to Understand Challenging Behaviors? • To understand needs and wants • To prevent crisis situations • To improve relationships between professionals and individuals • To reduce need for hospitalizations and/or restrictive behavior plans

7. Meeting Needs and Wants • Challenging behaviors and aggression are coping mechanisms • ‘Strategies’ to meet needs and wants • Challenging behaviors are NOT results of mental illness or ID/DD

8. EXERCISE Meeting Needs and Wants

9. Meeting Needs and Wants Sally likes to go for car rides on sunny days. She has a blue convertible and will often put the top down when she takes it out for a spin. One day, Sally decided to go for a ride around the city. When she pulled out of her garage she put the top of her convertible down and started off, not noticing the grey clouds gathering in the western sky behind her. As she drove, the sun disappeared behind the clouds and everything appeared grey. Sally drove on, listening to her radio at full blast. Suddenly, she felt her face getting wet. She looked at her hands and noticed that they were covered in beads of water… and so was the interior of her convertible!

10. Basic Premises About Mental Illness • Symptoms never occur alone. • Symptoms can be observed behaviorally. • The key in identifying possible symptoms is to notice, describe, and capture changes in a person over time. • The cluster of symptoms is a significant change in how the person acts and can have an impact on his or her ability to function. • To understand the significance of a change in someone, caregivers need to understand how the person is when functioning at a normal, healthy level.

11. Basic Premises About Mental Illness • Symptoms never occur alone • Cluster of symptoms must be present • Cluster of symptoms occur over time

12. Basic Premises About Mental Illness • Example of symptom cluster for depression • Depressed mood most of the day, nearly every day • Diminished pleasure or interest in previously enjoyed activities • Significant weight loss or gain • Insomnia or Hypersomnia (sleeping too much) • Psychomotor agitation (restlessness) or retardation (moving about slower than normal for the person) • Fatigue or loss of energy every day • Feelings of worthlessness or excessive / inappropriate guilt • Diminished ability to think or concentrate • 4 • Recurrent thoughts of death / suicide

13. Basic Premises About Mental Illness • Symptoms can be observed behaviorally • How could depressed mood be described behaviorally? • How could hallucinations be described behaviorally? • How could obsessive-compulsive disorder be described behaviorally? • How could manic mood be described behaviorally?

14. Basic Premises About Mental Illness • The key in identifying possible symptoms is to notice, describe and capture changes in a person over time. • Onset • Increase / Decrease • Intensity • Noticeable patterns, episodes, or cycles of behavior

15. Basic Premises About Mental Illness • The cluster of symptoms is a significant change in how the person acts and can have an impact on his or her ability to function. • Not just a ‘bad day’ • Goes on for extended periods of time • Makes day to day living difficult • Impacts relationships, work / school, self-care

16. Basic Premises About Mental Illness • To understand the significance of a change in someone, staff needs to understand how the person is when she is functioning at her normal, healthy level. • Know what a person is capable of / usually enjoys doing • Talk with other staff, family members, doctors, etc.

17. Describing What is Seen and Heard • How are a person’s behaviors typically described: • in a chart? • during a shift report? • after an incident / crisis situation? • during a typical and uneventful day?

18. Describing What is Seen and Heard • Don’t interpret • No “suitcase” words • Avoid terms like ‘aggressive’, ‘isolative’, or ‘defiant’ • Take one symptom at a time • Capture behaviors at the person’s best (healthiest) and worst (most ill) • Don’t argue or decide if something is a symptom or not

19. EXERCISE Describing What is Seen and Heard

20. Challenging Behavior – Basic Assumptions • There is an unmet need or want. • Challenging behavior is meaningful. • People have good reasons to do what they do. • People do the best they can with what they have at that time and in that context.

21. Challenging Behavior – Basic Assumptions • Challenging behaviors interfere with an individual’s daily life. • Challenging behaviors may result from differences in culture and limitations in abstract thinking • Challenging behaviors threaten the safety of the person or others • Challenging behaviors are likely to limit or deny the person access to the use of various facilities

22. Challenging Behavior – Basic Assumptions • “All behavior is meaningful and can be understood. It is purposeful, seeking feelings of satisfaction and security, and this is especially true of psychiatric patients” – Dr. HildegardPeplau(1952)

23. EXERCISE The Amy Scenario

24. Challenging Behavior – Basic Assumptions • Intellectual / developmental disabilities do not cause challenging behaviors. • The only behavior that can be attributed directly to intellectual and/or developmental disability is slow learning of new academic information (Ryan 1993).

25. Challenging Behavior – Triggers • People, places or things that remind someone of an event, feeling or experience • Are different for everyone • Triggers can evoke good and bad memories • Depends on individual • Depends on experiences

26. EXERCISE Triggers

27. Challenging Behavior – Triggers • Staff responses to challenging behaviors can be triggers • Pay attention to person’s voice tone, what he/she says, his/her actions and requests

28. EXERCISE Joe’s Story

29. Challenging Behavior – Things to Consider • Communication • Environment • Emotions • Unaddressed Medical / Physical Needs • Trauma

30. Challenging Behavior – Communication • “The 18 Second Rule” • Give direct attention to the person • “Communication Partners” • Communication Tools • Communication Board • Social Stories • Liberator

31. Challenging Behavior – Environment • A person’s immediate surroundings • Includes who is with the person

32. Challenging Behavior – Environment • Questions to ask: • Is the person feeling too hot / cold? • Is the person hungry / thirsty? • Is the person tired / fatigued? • Is the environment too stimulating / not stimulating enough for the person? • Does the person need to exercise / move around? • Does the person need to use the restroom (may be embarrassed or unable to ask) • Are the person’s privacy / boundaries respected? • Does the person like the people he/she is interacting with?

33. Challenging Behavior – Emotions • One’s feelings / experiences directly impact one’s perception of stress and coping skills • What is fun / difficult / boring / sad for one person is totally the opposite for another • Pay attention to person’s communication to gauge his/her feelings • This helps the person cope with stress • Strengthens relationship between person and staff

34. Challenging Behavior – Emotions • Safety • Key aspect of emotional wellness • Fear leads to: • Anxiety • Irritability • Defiance • Aggression • Depression

35. Challenging Behavior – Emotions • People must feel safe to feel well emotionally • Lack of safety may result in behaviors like: • Clinginess • Always wanting a preferred person present • Asking the same questions repeatedly • Refusing medications and/or treatments • Eloping from group home

36. Challenging Behavior – Emotions • Stability can be reassuring • Structure provides an expectation of what will happen from day to day

37. Challenging Behavior - Unaddressed Physical/Medical Needs • Illnesses affect people with ID/DD as they do anyone else • Many individuals have multiple illnesses / conditions • Symptoms may bring about challenging behaviors

38. Challenging Behavior – Unaddressed Physical/Medical Needs • Common conditions and physical symptoms • Migraines – chronic headaches • Constipation, diarrhea – GI conditions • Degenerative joint disease, pain, inflammation – arthritis • Premenstrual Syndrome • Immobility (being unable to move around as one likes) • Cardiovascular disease (heart conditions, circulation problems) • Neurological conditions (dementia, memory loss)

39. Common indicators of pain Guarded/altered body position Moaning Sighing Grimacing Withdrawal Crying Muscle twitching Restlessness Elevated/decreased blood pressure Quietness Diaphoresis (excessive sweating) Muscle tension Nausea/vomiting Weakness Dizziness Unconsciousness Lethargy Fever Hitting a painful area Staring Dilated (large) pupils Challenging Behavior – Unaddressed Physical/Medical Needs

40. Challenging Behavior – Trauma • Sobsey & Doe – “Individuals who have some level of intellectual impairment are at the highest risk of abuse” • ID/DD population most traumatized of all • 90% have experienced some kind of trauma • Trauma – an experience that the person didn’t ask for and can’t stop or escape; perceived as life threatening and involves intense fear and helplessness

41. Signs of trauma Mood swings/instability Unexplained outbursts of anger Depression Nightmares Flashbacks Hypervigilance Anxiety/panic attacks Avoidance Inability to experience pleasure Unexplained physical pain Sexual problems Unexplained grief reactions Hopelessness Poor concentration Eating too much or too little Self abusive behaviors Poor self-esteem, shame, guilt Headache, stomach ache, dizziness Challenging Behavior – Trauma

42. Challenging Behavior – Trauma • Basic needs of traumatized person • To feel relatively safe • To know others will respect his/her boundaries • To feel accepted, validated and listened to • To talk and be listened to • To have their feelings paid attention to

43. Mental Health First Aid Action Plan • ALGEE • A Assess for risk of suicide or harm • L Listen non-judgmentally • G Give reassurance and information • E Encourage appropriate professional help • E Encourage self-help and support strategies

44. Recognizing Signs of Escalating Behavior • What signs might indicate that someone is becoming: • frustrated? • anxious? • scared? • angry?

45. Signs of Escalating Behavior • Observable signs of escalating behavior: • Faster breathing • Talking louder • Stiff, rigid movements • Quick movements • No eye contact • Reddening in the face

46. De-escalation: What Is It? • Helps staff manage challenging behaviors before they become a crisis situation (escalate) • Helps person return to baseline / normal functioning

47. Techniques for De-escalation • Proximity • Be out of arm’s reach • Pace • Move and speak slowly / calmly • Purpose • Mean what you say • Do not make promises that cannot be kept • Process • Be flexible; adapt to individual and situation • Plan • Have a plan in place • Think about what worked in the past

48. Techniques for De-escalation (continued) • Practice • Use techniques that work for the person often, even when not in crisis • Presentation • Be aware of body language and voice tone • Pivot • Know escape routes and be ready to use them quickly • Persuasion • Let person talk • Remind person that you want to help • Pre-empt • Know person’s triggers • Try to avoid / limit exposure to them

49. Techniques for De-escalation - Restraints • Restraints may be necessary at times • Once restraint started, goal is to discontinue it as soon as possible • Restraint is not the end of a crisis • Does not solve problems that led to crisis • Can damage trust and relationship between person and staff

50. Techniques for De-escalation – What To Do and Say During a Restraint • Prevention of physical harm • Asking what the person needs • Assist in relaxation • Ending the restraint