Challenging Behaviors: Assessment and Intervention Strategies

1. Challenging Behaviors: Assessment and Intervention Strategies Laura A. Flashman, Ph.D., ABPP Associate Professor of Psychiatry Neuropsychiatry Section, Neuropsychology Program and Brain Imaging Laboratory, Department of Psychiatry,Dartmouth-Hitchcock Medical Center, Lebanon, NH & New Hampshire Hospital, Concord, NH

2. What are “Challenging Behaviors”? • Related to Personality Changes • Impulsivity, Intrusiveness, Poor Boundaries, Irritability, Emotional Lability, Low Frustration Tolerance • Aggression • Self injurious behavior, hurting others

3. What are “Challenging Behaviors”? • Related to “Deficit Syndromes” • Isolation, withdrawal, apathy, low motivation • Related to Cognitive Changes • Poor judgment, inability to comprehend consequences, poor decision making, perseveration, impaired memory and concentration, difficulty adjusting to the unexpected

4. Ways to Deal with Challenging Behaviors • Medications • Behavioral Programs • Cognitive Remediation Strategies

5. Applied Behavioral Analysis (ABA) • Goal: To increase or decrease a particular behavior, to improve the quality of a behavior, to stop an old behavior or teach a new behavior • General Uses: Can address a broad spectrum of human behavior • Increasing productivity in the workplace • Teaching children • Precise training of military personnel • In our case, handle the challenging behaviors associated with TBI

6. Seven Essential Elements of anABA-based Program (Baer, Wolf & Risely (1967) • Must be applied (i.e., behaviors focusing on should have some social significance). • Must be behavioral (i.e., environment and physical events should be recorded with precision). • Must be analytic (i.e., convincing evidence that the intervention is responsible for the change in behavior). • Must be technological (i.e., techniques could be duplicated by another).

7. Seven Essential Elements of anABA-based Program 5.Must be conceptually systematic (i.e., there should be relevance to established and accepted principles). • Must be effective (i.e., should seek to change the targeted behavior to a meaningful degree). • Should display some generalizability (i.e., seen in a variety of settings or to related behaviors).

8. Six Steps for a Solid Applied Behavioral Analysis • Identify Target Behaviors • Measure the Behavior • Analyze the Behavior – A B C’s • Develop an Intervention • Program Generalization of the Behavior • Empirically Evaluate the Results

9. Behavioral Terminology • Behavior – any observable and measurable act • Target Behavior – the particular behavior you have identified for change • Behavioral assessment – a description of the frequency, duration, and conditions related to a target behavior

10. Identification of Target Behavior(s) • Choose your battles • Start with reasonable goals (“3 shall be the number”) • Track appropriately

11. Once the Target Behavior is Identified……. • We need to learn all we can about this behavior • Is it a behavior we want to increase? • Is it a behavior we want to replace? • Inadequate in meeting an individual’s needs? • Inappropriate in the current environment?

12. Behavior “Modification” • Modification of behavior is most effective if the motivation behind the behavior can be determined • Once motivation is known, once we understand the need that the individual is trying to meet, we can develop and teach a more appropriate replacement behavior

13. Available Tools of ABA • Functional Behavioral Assessment: a precise description of a behavior, its content and its consequences • Goal: Better understand the behavior and the factors that influence it • Starts with a Baseline Period – a specified time period when the frequency, duration, or intensity of the target behavior is tracked prior to the implementation of an intervention

14. Behavioral Terminology: The ABCs of ABA • Antecedent: the stimulus or situation to which the individual responds • Behavior: the behavior (target behavior) we see exhibited by the individual • Consequence: the stimulus or stimuli that the individual receives, or that s/he is stopped being subjected to, as a result of the behavior

15. Functional Behavioral Analysis • Begins as an assessment, but includes the step of systematically altering the antecedents to and consequences of the behavior to determine which are the driving forces behind the behavior

16. Functional Behavioral Analysis • The first step: Carefully observe and precisely describe the behavior the individual is exhibiting, and the events and stimuli in the environment both BEFORE and AFTER that behavior (i.e., Identify the ABCs) • Observe and describe the behavior across a wide sample of environments and occasions

17. Functional Behavioral Analysis • The second step: Look for trends in the occurrences of the behavior, for stimuli that may be evoking it, or the needs the individual is attempting to fill by exhibiting this behavior • Form hypotheses about the behavior and the function it is fulfilling • Challenge these hypotheses by systematically altering the environment to determine which are influencing the behavior

18. Motivations/Purposes of Challenging Behaviors • To gain attention from someone • To gain a tangible consequence (a treat, token, money, favorite video, etc). • To gain a secondary consequence (to get warmer if one is cold, colder if one is hot, to gain some sensory consequence) • To self-regulate one’s emotions (way to calm down if upset, to raise one’s arousal level if depressed)

19. Motivations/Purposes of Challenging Behaviors • To escape from or avoid an undesirable situation • Often in anticipation of a request to work, go to an activity, communicate, be in an environment they find uncomfortable, loud, overstimulating, etc. • To make a comment or declaration (about one’s environment, perceptions or emotions) • To fill a habitual need, in a way that no longer works

20. Most Important Factor in Success of an ABA Program • CONSISTENCY

21. Behavioral Terminology • Discriminative Stimulus – the instruction or environmental cue to which we would like the individual to respond • Response – the skill or behavior that is the target of the instruction/cue • Reinforcing Stimulus – a reward designed to motivate the individual to respond and respond correctly • Example: I ask Cathy to get up and get ready for work in 5 minutes (DS), she does (R), and she gets to watch TV while eating breakfast (SR).

22. The Discriminative Stimulus • A specific environmental event or condition in response to which we would like an individual to exhibit a particular behavior (teach a person what to do when a particular thing occurs) • Goal: Help individual begin to discriminate certain stimuli from the background noise of every day life – as something important

23. The Discriminative Stimulus: Guidelines • Make sure you have the individual’s attention • Instructions should be simple and clear; concisely communicate only the most salient information • Be consistent in beginning stages; can be varied in many settings to encourage flexibility and generalizability as response occurs more regularly • Repetition of the instruction should be avoided (preset limits – e.g., 2 cues, 3 prompts)

24. The Response • The response is the behavior the individual exhibits after AND AS A RESULT OF the discriminative stimulus. If person is reacting to other stimuli, need to look at other factors (environment too distracting, person not attending?) • Be very clear about what the correct response is (“Sarah will pick up all the clothes on the floor in her room and place them in the laundry basket within 1 minute of the request.”) 3 possible responses: Correct, Incorrect, No Response

25. Correct Responses are Reinforced • Reinforcing Stimuli are environmental events that occur after a behavior that increase the likelihood of that behavior occurring in the future • Treats, praise, special privileges, music, trips, almost anything can be used as reinforcement if it serves to increase the occurrences of a particular behavior (positive reinforcement)

26. Types of Reinforcers • Primary Reinforcing Stimuli are unconditioned • Events or rewards whose value are intrinsically realized (food, water, warmth, etc) • Advantages: Value does not need to be taught, will not extinguish • Disadvantages: Subject to satiation after relatively short periods of time, not representative of the natural environment

27. Types of Reinforcers • Secondary Reinforcing Stimuli are conditioned • Intrinsically neutral but become reinforcing through association • Can be social in origin (praise, smiles, sense of accomplishment) or a token economy (earning tokens (e.g., money) for desirable behaviors; each one is a step towards acquisition of a primary reinforcer) • Advantages: more convenient to use, lessens the need for proximity, more reflective of natural environments, can broaden a person’s interests, can increase length of time between presentation of reinforcers (token economy) • Disadvantage: Need to be taught, must be maintained by repairing to primary reinforcer to reestablish interest sometimes

28. Types of Reinforcers • Positive Reinforcement: presentation of positive events after a particular behavior to increase the likelihood that the behavior will occur in the future • Negative Reinforcement: removal of aversive events after a particular behavior to increase the likelihood that the behavior will occur in the future (e.g., alarm goes off, you get up and shut if off, get ready for work)

29. Types of Reinforcers • Differential Reinforcement: involves reinforcing almost any positive response (successively closer approximations of the correct behavior) to some degree, but providing very strong reinforcement when the person completely exhibits the target behavior or skill

30. 4 Types of Punishment Goal: introduction of negative or removal of positive stimuli to DECREASE a particular behavior • Time out: removal of the individual from any positive stimuli (need to know motivation behind behavior. If a person screams when asked to go to work, and he gets put in time out, behavior may be encouraged, not discouraged)

31. 4 Types of Punishment • Extinction: the withholding of a previously available consequence (reinforcer) for a response – essentially, ignoring the behavior, which results in a decrease or weakening of response rate, duration, or intensity. Behavior may increase before it decreases. • Response Cost (token economy): tokens are lost for occurrences of undesirable behavior. • Aversive Stimuli: strongly negative behavior introduced after an undesirable behavior (spanking, scolding). As a rule, to be avoided, as can do more harm than good.

32. Alternatives to Punishment Goal: Reducing difficult behaviors while encouraging more appropriate behaviors • Differential reinforcement of other behaviors (DRO): reinforcement for not engaging in the target for a specified interval of time (i.e., reading not hitting) • Differential reinforcement of alternative behaviors: reinforcement of behaviors which serve as alternative behaviors to the difficult behavior (i.e., count to 10) • Differential reinforcement of incompatible behaviors: reinforcement of behaviors which are incompatible with difficult behaviors (i.e., can’t be done simultaneously)

33. Guidelines for Reinforcement • If the reinforcement is to be consistent and effective, the criteria for the response need to be planned out in detail, understood and used consistently by all involved in the program • Consequences for correct and incorrect responses/ behaviors should be easily distinguishable • If reinforcement is being used after correct behavior, short-lived reinforcers should be used.

34. Reinforcement Schedules • Continuous Reinforcement Schedule: one that provides reinforcement after every correct response. Useful for teaching of new behaviors, when goal is to emphasize relationship between DS and associated R • Partial Reinforcement Schedule: one in which only some instances of the desired response are reinforced. Often produce more responses at a faster rate than continuous schedules. Useful for maintenance of learned behaviors, for increasing the production of those behaviors once learned, and for making reinforcement more natural

35. Token Economies • Useful for moving from a continuous reinforcement schedule, where the individual is rewarded after each correct/appropriate response, to a schedule where the individual must make several appropriate responses before being reinforced. • Good for building the ability to delay gratification, extending an individual’s attention span, increasing the amount of work produced in a given time period

36. Token Economies • Provides a TANGIBLE marker of progress • Can be effective with cognitively compromised individuals

37. Teaching Complex Behaviors • Shaping: the process by which successively closer approximations of a behavior are reinforced. Allows reasonable goals to be set and gives an individual many chances for success on the way to learning a new behavior or extinguishing an old, inappropriate behavior • Step Analysis: breaking down of a target behavior into smaller, more manageable steps which bring a person successively closer to that target behavior • Goal: Complete the first step, get reinforced, master it, the next step becomes the new goal, etc.

38. Teaching Complex Behaviors • Chaining: the linking of component behaviors into more complex, composite behavior • Useful for teaching those behaviors that occur in essentially the same order each time, and is especially useful for teaching self-help skills • Task Analysis: breaking down of a behavior into its component parts/behaviors • Example: Brushing teeth, morning ADLs

39. Techniques Used in Behavioral Programs • Behavioral momentum: a procedure in which before asking a patient to do something he/she is unlikely to do, staff first ask him/her to perform two simple tasks he/she is likely to do • Modeling: a procedure whereby a sample of a given behavior is presented to an individual to induce that individual to engage in a similar behavior

40. Techniques Used in Behavioral Programs • Redirection: a procedure whereby a patient who exhibits an inappropriate behavior is prompted to engage in a more appropriate alternative behavior

41. Staff Assistance to Maintain Consistency • Planned conflict resolution – a designated time to channel questions, grievances, and reinforce skills with specific staff • Modeling – a procedure whereby a sample of a given behavior is presented to an individual to induce that individual to engage in a similar behavior

42. Generalization of the Behavior • Generalization: the application of a behavior or sill across a number of environments or to a number of related behaviors • This can be very difficulty for individuals with TBI • Therefore, instructions must be designed to change over time, in content, and in context, to help increase generalizability of program

43. Data Collection 3 Keys to Success with Data: • 1. Make the Data Useful • Helps shape the program, assess the efficacy, look for trends in behavior • 2. Make the Data Relevant to the Goals • Must be appropriate for the behavior being documented and for the goals associated with that behavior • 3. Make the Data as Painless as Possible • Find style of data collection that works for you

44. Data Collection – What to track? • Frequency: How often does the behavior occur over a specific period of time? • Pd of time chosen depends on behavior being tracked • Best used when the goal for a plan is to increase or decrease the occurrences of a behavior • Example: Mary will decrease the number of times she approaches the nurses station from 10 to 2 times per shift.

45. Data Collection – What to track? • Proportion: In what percentage of available opportunities did the behavior occur? • # of target behaviors that occur in a given # of opportunities • Best used when the goal for a plan is to increase the quality of a behavior • Example: Josh will increase his use of his memory book from approximately 10% of available occasions to approximately 75% of occasions.

46. Data Collection – What to track? • Duration: For how long did the behavior occur? • Track for open-ended behaviors that you are trying to increase • Example: Susie will increase the time she can attend during work without a prompt from 10 seconds to 3 minutes). • Can also be used for behaviors one is hoping to decrease or eliminate, through differential reinforcement of lesser degrees of behavior (i.e., anger management strategies – how long before he uses one effectively). • Example: Mark will use the counting technique to calm himself when someone tells him he can’t go off the unit, reducing the length of his tantrums from 3 minutes to 30 seconds.

47. Data Collection – What to track? • Intensity: To what degree was the behavior present? • Can be very subjective; best if some degree of objectivity and specificity can be accomplished • Rating Scales often used; can be developed: • 1: Bill shows some aversion to the request but complies within 10 secs. • 2. Bill shows significant reluctance, is arguing, and has not complied within 10 secs. • 3: Bill attempts to leave the area. • 4: Bill knocks over a chair or throws something. • 5: Bill makes physical contact with staff or peers.

48. Evaluation of the Results • Feedback from those implementing plan, and the individual • Have we decreased undesirable behaviors? • Have we increased desirable behaviors, or replaced undesirable behaviors with more acceptable behaviors? • HOW MUCH less frequently, intensely? • Can the individual apply these behaviors, strategies in more than one situation?

49. Evaluation of the Results • Evaluate, evaluate, evaluate • Tweak, tweak, tweak • Increase reinforcement intervals

50. STRATEGIES FOR HELPING INDIVDUALS WITH COGNITVE IMPAIRMENTS