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Understanding and Managing
Challenging Behaviors
Nicole Baumer, M.D., M.Ed.
March 8, 2014
Down Syndrome Program,
Developmental Medicine Center
Department of Neurology
Objectives
• To Identify Behavior Challenges
• Background, Risk Factors, Why Intervene
• To Understand the Purpose of Behaviors
• To Develop Proactive, Positive Behavioral
Strategies
• To Discuss Evaluation and Intervention for
Severe, Persistent Behavioral Challenges
FCSN Baumer, 2014
Setting the stage…
• Behavioral problems are common in all
children, but especially in children with
neurodevelopmental disabilities.
• Prioritize relationships.
• There are effective strategies and
resources.
FCSN Baumer, 2014
Common Behavioral Challenges
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Defiance
Aggression
Non-compliance
Agitation
Restlessness
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Hyperactivity
Disruptive
Inattentive
Destructive Behavior
Tantrums
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Why Intervene?
•Unsafe, self-injurious behaviors
•Behaviors that interfere with socialization,
learning, daily living
Act Now!
Without intervention, behavioral problems in
childhood persist, and predict the same in
adulthood
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Behaviors result from a complex
interaction of child characteristics and
environment
Neurodevelopmental
Profile
Environmental Challenges
Skill level
Social/Emotional Stress
How does the child regulate their behavior in the face of
frustration, and social / emotional challenges?
FCSN Baumer, 2014
Child Characteristics:
Temperament
• Unique characteristics of a child that contribute to
their behaviors
• Difficult temperament traits predict degree of
behavioral challenges
• Intense reactions, low sensory threshold,
irregular cycles, negative mood, withdrawal
Thomas, Chess, Birch 1968
FCSN Baumer, 2014
Child Characteristics:
Neurodevelopmental Profile
• Neurodevelopmental Disabilities / Biology
– Affect learning, memory, emotional regulation
• Intellectual Disability, Communication Disorder,
Autism Spectrum Disorder, ADHD, Neuromotor
Disorder, Specific Learning Disorder
-DSM 5
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Environmental Factors
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Family functioning / stress
Parent-child relationships
Educational setting
Appropriateness of curriculum
Fit with teacher
Level of consistency / predictability
Strength of social networks and support
systems
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The Brain Controls Behavior
Parietal
•Visual attention
•Integration of senses
Frontal
•Motivation
•Expressive language
Executive Functioning:
•Attention
•Problem solving
•Impulse Control
•Organization / Planning
•Judgement
Temporal
•Hearing
•Receptive Language
•Memory
•Emotion
Occipital
•Vision / Visual
Processing
Brainstem
•Alertness
•Sleep
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Cerebellum
•Balance
•Motor memory /
planning
•Learning
Overview of Behavioral Management:
The Big Picture
• Understand Purpose / Motivation of Behavioral
Problems
• Proactive, Positive Behavioral Strategies
• Prevention:
• Set Expectations, Teach Skills and Adapt Environment
• Planned Responses:
• Behavioral Principles: Operant conditioning
• Reinforcement and Punishment
• Evaluation and Intervention Plan for Severe,
Persistent Behavioral Challenges
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Caveat: This is NOT Easy!
The Goal: Small Meaningful Changes Over
Time
BEHAVIOR
TIME
• Expect variable results over
time
• There are no quick fixes.
• Trial and error may be
required
Aim for Improvement,
Not Perfection!
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-Dave Stein
Prioritize!
• Dangerous behaviors, safety concerns
• Teaching fundamental skills to make improvements
across several scenarios
• The relationship
– Parent-child, teacher-child
Choose your battles!
Challenging tasks  high energy demand  frustration
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Understanding Behavioral Problems
“Kids do well if they can.”
Challenging behaviors result from
“lagging skills” and “unmet needs”
-Dr. Ross Greene, The Explosive Child
When kids have persistent behaviors,
it is often because the behaviors are
working for them.
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All Behavior Has a Purpose:
Understand the Motivation Driving
the Behavior
• Communication
– Get needs met!
– Express emotion
• Avoid / Escape
– Difficult task
– Anxiety/fear
– Limited motivation
• Attention seeking
– Even negative attention can
be highly rewarding
• Sensory / Self-Stimulatory
– Not socially-motivated
– Results in a feeling the
person likes
– Rocking, twirling, flapping
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Communication
• Difficulty understanding instructions / tasks
• Difficulty expressing thoughts, needs, emotions
Frustration!
Functional Communication is Key!
– Use simple, short sentences
– Language instruction, pictures/symbols, signs/gestures,
communication devices
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Be a Detective.
Gather the Facts.
• Assess medical, cognitive, emotional factors
• Observe details about potential triggers:
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Where? (Particular environment?)
When? (Particular time?)
How? (Sudden? Escalating?)
Who? (Certain people?)
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Consider What is Getting
in the Way of Success
• Lack of skills
– Functional communication
– Social / interpersonal
• Mood, fear, anxiety, physiological states
(hungry, tired)
• Environmental factors
– Schedule, curriculum, no routine
– Distractions: audio, visual
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Proactive, Positive Behavioral Strategies:
Key Components
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Identify child’s strengths
Identify the concerning behaviors
Consider what the behaviors represent
Decide what environmental changes can be made
Identify new skills that should be taught
Develop a reinforcement plan for positive behaviors
and new skills.
• Develop an intervention plan / planned responses to
challenging behaviors
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Identify the Child’s
Strengths and Weaknesses
• Try:
• Visual cues / reinforcers
• Social reward – earn play time
with friends
• Predictable, consistent routine
• Teach self-regulation, calming,
de-escalation
Stein, 2013
• Avoid:
• Complex language
• Over-explanation
• Curveballs
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Proactive NOT Reactive
1) Prevention
•Set expectations and stick to them
•Adapt the environment
•Teach important skills
2) Planned Responses
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Anticipate Difficult Situations
Prepare for change
Make things predictable
• NEW situations
– Social Stories:
• Simple, shows sequence of events
• Shows desired behaviors
• Adds structure, visuals, and repetition
Social Stories, Carol Gray “The New Social Stories Book: Illustrated Edition”
• Transitions
– Visual timers
– Visual Interactive Schedules
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Visual Schedules / Routines
• Help children:
•Process verbally delivered information
•Shift focus between one activity and the next
•Complete every step within a task
•Initiate activities
Less Nagging!
•Stay focused
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Visual Representations of
Expectations
Story of what happens when actions are followed through
correctly and when they are not…
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If a Child is Having Behavior
Problems…Teach Skills!
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Social Skills
Emotional processing / coping skills
Self-regulation / de-escalation skills
Problem solving
– Asking for help, cooperation, negotiation
• Language / Communication skills
– Emphasize functional communication
Show what you want with visual aides, photos, video models
Autism Speaks, 2012; NDSC; NDSS
FCSN Baumer, 2014
Reward Patience and Flexibility
• Jimmy wants the iPad RIGHT NOW. Instead of an automatic
“No” which might lead to a tantrum… TEACH him to WAIT.
Ipad only:
– After a task (start easy and build to longer/harder)
– After adult completes task (Yes, after I finish making lunch)
– After specific amount of time
• “I know you were disappointed because the store was closed.
Since you stayed calm and were flexible, let’s go get ice cream
instead.”
Social Thinking Curriculum:
http://www.socialthinking.com
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When Challenging Behaviors Do
Arise…
Planned Response
Different Responses for Different
Behaviors
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Planned Response:
Consider the nature of the behavior
• Basket 1: Safety issue
cannot ignore
• Basket 2: Not a safety issue, but potentially
problematic MAY ignore or respond
• Basket 3: Not a safety issue, not that big of a deal
consider letting it go.
-The Explosive Child, By Ross Greene, PhD
FCSN Baumer, 2014
Planned Response:
Consider the motivation behind the
behavior
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Attention Seeking
Task Avoidance
Sensory
Means of Communication
Impulsivity
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The Goal: INCREASE Desirable
Behaviors and DECREASE
Undesirable Behaviors
Behavioral Principles: Operant Conditioning
Reinforce what you want to see more of
Do NOT reinforce what you want to see less of
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http://syarafina-teach-science.blogspot.com/2011/03/behaviourism-classical-and-operant.html
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Punishment
• Works Immediately
• Decreases likelihood of behavior
BUT not effective for long-term behavioral change
Limitations:
• Causes intense, emotional responses
• Model for aggressive behavior
• Teaches what NOT TO DO
• Does not build skills or
knowledge about what TO DO.
• Strains relationships
Reserve for rare, well-defined behaviors
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Reinforcement
• Stimuli that increase likelihood of behavior
• Most effective in creating long-term behavioral change
Natural
Social
Token
Tangible
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In General, Children Respond Better
to POSITIVE Behavior Supports than
to Punishment
• Give positive feedback much more frequently than
corrections / negative feedback
• Fosters sense of competence, interest, motivation
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Planned Responses
Reinforcement Strategies / Rewards
• Use simple, consistent reward systems
Its not a bribe…
We are all motivated by rewards!
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Example: Attention Seeking
• Bobby turns off the lights in the doctor’s office
• Katie pinches Julie on the playground
• Joshua jumps on the bed…
Pay attention to GOOD behavior.
IGNORE the PROBLEM behavior!
• Extinction Burst is normal  Stay the Course!
• No strong reactions: eye contact, touch, yell, overtalk…
– FUN and INTERESTING: Reinforcement
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Example: Escape / Avoidance
– I don’t want to leave the party, so I’m going to flop
on to the floor and refuse to move.
– Math is hard, so I’m going to run out of the
classroom to avoid it.
Strategies:
– Choose “Just Right” Tasks
– Provide choices / control (within parameters)
– Take advantage of good mood and momentum
– Break up tasks into small steps
– Teach how to request breaks
– Teach new skills / make modifications
FCSN Baumer, 2014
Example: Self-Stimulation /
Sensory Seeking
• Rocking, flapping, twirling, teeth grinding
• Problematic when interfering and consuming
Goal: Slowly Restrict in Time and Place
Strategies:
– Increase range of interests
– Occupy time
– Replacement, substitute behaviors
– Do not reinforce
– Sometimes, ignore and accept
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Dangerous / Aggressive Behaviors
• May require our last resort method: Discipline.
• Consider whether planned or reactive / impulsive
– Planned aggression:
• Cognitive Behavioral Strategies / Therapy
• Clear limits / consequences
– Reactive aggression:
• Address self-control, replacement behaviors
• Breaks, calming activities
FCSN Baumer, 2014
Time-outs
• Try to use as a time away from reinforcing behaviors
or as a preventative strategy, instead of punishment
• Remove only from a desirable situation
– Or it may become escape/avoid tactic
• Boring or neutral setting
• No attention
• Use as a break!
FCSN Baumer, 2014
Professional Evaluation and Systematic
Intervention For Severe, Persistent
Challenging Behaviors
• Medical assessment
• Close collaboration among parents, caregivers,
educators, medical providers
• Consider potential psychiatric,
neurodevelopmental, or behavioral disorders
• Consider medication trials
FCSN Baumer, 2014
Assessing New / Persistent
Behavioral Concerns
• Medical / Behavioral History:
– Family history of psychiatric / behavioral problems
– Assessment of stressors
• student/teacher fit, major environmental change, loss,
transition
– Assessment of skills
• cognitive, adaptive, expressive communication, receptive
language / comprehension
• Physical examination
• Behavior checklists
• Collaborate with child’s team
FCSN Baumer, 2014
Potential Medical Causes of
Challenging Behaviors
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Pain
Infection
Sleep Problems
Nutrition
Hearing or Vision concerns
Celiac disease
Thyroid disease
Gastrointestinal problems: constipation, reflux, abdominal
pain
• Depression, Anxiety, Psychosis
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Functional Behavioral Analysis
Should tell you: A,B,Cs
• Antecedent: what happens BEFORE the
behavior (trigger)
• Behavior: what the target behavior looks
like
– How often, how long does it occur
• Consequence: what happens AFTER the
behavior (outcome)
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Behavioral Intervention Plan
• Goal:
– Reduce problem behavior
– Increase appropriate behavior
– Improve quality of life
• Systematic data collection
– Target behaviors, measure specific goals
• Evaluate and revise plan regularly
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Some Children Require Medication
in Addition to Behavior Strategies
Medications can be used to target:
– Impulsivity
– Hyperactivity
– Inattention
– Mood – depression, mood swings
– Anxiety
– Obsessive-compulsive behavior
– Aggression
– Self-Injurious behavior
FCSN Baumer, 2014
Closing Points
• The goal is improvement, not perfection
• Focusing on your relationship, the positives, and the
child’s strengths will help you choose the best
behavior strategies.
• The hope is that we can limit behavior problems over
time, so that the individual can live a fulfilling
adulthood
– The “endpoint” is not tomorrow or next month.
– Celebrate the small successes along the way.
FCSN Baumer, 2014
Resources / Further Reading
• Association for Behavior Support
– www.apbs.org
• National Dissemination Center for Children with Disabilities
– http://nichcy.org/schoolage/behavior/behavassess
• Center on Positive Behavioral Intervention and Supports
– http://www.pbis.org
• Federation for Children with Special Needs
– http://fcsn.org
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Many Resources Available
Positive Strategies for Supporting Behavior Improvement.
Autism Speaks 2012
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Thank you!
Thank you to my team:
• Partner in Crime: Dr. David Stein (Psychology, DMC)
• My team at Boston Children’s Hospital
• My family
• The children and families with whom I work
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