How to support people with repetitive and “stuck” behavior
Nathan E. Ory, M.A.
Ful Lives Conference
24 April 2009
Anchorage, Alaska
Questions to ask about
Persistent, repetitive behavior
P What is just something to do?
< Time-filling activity. Sensory self-stimulation.
P What is behavioral?
< Learned habits and rituals. Somehow functional.
PWhat is neurological?
< Brain-based. Person may not be able to selfinitiate a shift of attention, or start/stop a
behavioral sequence.
P What is psychiatric?
< Obsessive-compulsive, anxiety controlling.
Different functions of persistent, repetitive behavior
P Overcoming insecurity/uncertainty through ritual.
< Comforted by familiar, well rehearsed rituals.
< Repeatedly asks questions till answered! < Emotional-behavioral.
< Exaggerated by anxiety.
Different functions of persistent, repetitive behavior
P Overcoming lack of internal boundaries.
< Constant “limit testing,” looking for predictability.
< With clear, external limits, no testing. < Emotional-behavioral.
< Exaggerated by anxiety.
Different functions of Persistent, repetitive behavior
P Obsessive thoughts - compulsive behavior
< Can’t move on, even with prompts. < Resists interruption.
< Stuck in thought-action. < Overwhelmed by thoughts that produce anxiety.
< Psychiatric.
< Exaggerated by anxiety.
Different functions of persistent, repetitive behavior
PMaintaining personal continuity.
< Linking our actions in space and time.
POvercoming “discontinuity”, inability to sequence.
< Repeating acts keep one’s place in time and space.
< With external structure, moves on.
< Cognitive-neurological-behavioral.
< Exaggerated by anxiety
Functional-”continuity” behaviors
Self-anchoring rituals
P - sensory-tactile:
< smelling, touching, licking, spitting, masturbating,
eating, self-injurious acts (e.g., scratching.)
P - kinesthetic:
< rocking, flapping, jumping
P - visual-spatial:
< ordering objects, alphabatizing, making lists,
cataloguing, word search
Functional “continuity” behaviors
Self-anchoring rituals
P - social:
< attacking wrong doers,
– keeping the "rules."
P verbal:
< repetitive speech, sing-song,
– echoing, vocalizing
– asking questions.
Functional “continuity” behaviors
Self-anchoring rituals
P - cognitive/mental:
< - replays of videotapes, rereading stories, copying
“old” schoolwork.
< - verbal rehearsal of the activity of the day
< - verbal rehearsal of the "rules", < - single minded pursuit of questions to end.
P - emotional:
< - mental rehearsal of confusions-wrongs
< -"obsessive" talking about anxiety evoking topics
< - just for fun
Behavioral characteristics of Perseverative Responding
Behaviors are persistent, and repetitive, but
reflecting neurological disorder, and/or without
any apparent functional value.
"Perseverative responding" reflects deficits in
a person's ability to self-initiate, self-organize,
self-sequence and regulate his/her own
actions and thoughts.
Different functions of perseverative behavior
NONE
P Actions have no “functional” value.
< Person is “stuck” in action, thought, sensation.
< With prompt, can move on. Cue dependent to shift.
< Neurological.
< Exaggerated by anxiety.
Some diagnostic categories showing
perseverative responding
P Developmental brain dysfunctions
< Fetal alcohol spectrum disorders
< Anoxia at birth, cerebral palsy, seizures, tuberous
sclerosis, arrested hydrocephaly
P Acquired Traumatic Brain Injury
P Genetic Syndromes:
< Fragile X, Prader-Willie, Williams Syndrome
P Pervasive Developmental Disorders
< Autistic spectrum disorders
P Dementias
P Psychiatric disorders
Indicators that persistent, repetitive behaviors are
Perseverative responding
P Person appears to have no self-control over
repetitive behaviors. Person gets "stuck in a
rut" and can not shift activity on his own
initiative.
P Person is dependent upon a caregiver to
assist him to mediate his experiences.
P Something reliably “works” to bring repetitive
behavior to an abrupt halt.
< “Stops on a dime” “Switches channels”
Some methods for assisting people to transition out of perseverative actions
P Direct or redirect with a rule
P Pre-correct
P Bring in a new face to break the pattern
P Rescue methods
< Use humour
< Displace to own sensory-motor ritual
< Take off the emotional hook
P Disappear
< Out of sight = out of mind
P “Read their mind”
Behavioral examples of
perseverative behavior
P Sensory perseveration
P Motor perseveration
– Persistent movement patterns
P Verbal perseveration
P Mental perseveration
– Single-track mind, mental inflexibility
– Perseverative thought
– Once in mind = impulsive action.
Behavioral examples of
perseverative behavior
P Emotional perseveration
< Leading to motor accelleration
< Leading to motor inhibition
Emotional perseveration and disinhibition
Person can become “stuck” in any of these
sensory-emotional reactions.
P Emotional mirror--magnifying glass
P Emotional radar: Imprinting on prior emotion
P Limited self-modulation of emotion
Emotional perseveration and disinhibition
Person can become “stuck” in
sensory-emotional reactions.
Limited self-modulation of emotion
Perseverative disorder in "starting" actions:
PPerson knows what to do, but is dependent
upon step-by-step-prompting.
PPerson knows what to do, but is dependent
upon prompt to initiate act.
–Can't tell what to do now
–
Can't tell what's most important
–Can't tell (what to do next)
– Can’t
tell when to start
Perseverative disorder in "stopping" actions:
P - Can not stop perseveration until directed.
P - Can not stop perseveration until completed.
P - "Captured" by perseveration, can not stop
until "rescued".
Perseverative disorder in
"shifting" actions:
P -"Stuck", but responds to "come", "do", "start" next
action.
– Reactive to "no", "don't", "stop"
P -"Stuck", but able to shift when "completed" action.
– Reactive to interruption before "all done"
P -"Trapped" in escalating emotional arousal.
– "Rescue" with "prop", "rule", and "role"
P -"Trapped" in sensory state.
– "Rescue" by causing to get "cognitive"
– "Rescue" by "capturing" with alternate stimulus
Structured methods for supporting individuals
who show
perseverative responding
PPrevent perseveration by protecting individual from
situations that will predictably lead to them
becoming “stuck”.
PGive prompts to transition person into what comes
“next”
< Body language (specific gestures)
< Verbal direction (specific phrases)
< Numbered lists
< Picture lists (cartoon sequences)
< Time schedules (dayplanner, calendar)
To assist transitions
get person “ready to be ready”
P Constant visual reminders
P “Finished” or “All done” and “Ready-Next”
Structured methods for supporting individuals
who show
perseverative responding
P Mediate transitions
< Physically assist person to complete
what they are doing.
< Talk them through (give the “answer key”)
so they can be certain their action will be
“correct”.
< Act as a “sensory anchor” throughout the
transition.
Use of a “Prop”, a “Rule” and a “Role”
to assist transitions
P Give prop “here & now” to transition to “then”
P Props signal “beginning” of “next” and “end” of
current action. Act as “brackets for behavior.”
P For each “prop”, have a “rule” that defines a
meaningful social “role”.
The use of “structure”
to overcome resistance to and to assist transitions
Anchor in their own familiar repertoire
P Sensory-tactile
< Solitary or social
P Auditory-visual
The use of “structure”
to overcome resistance to and to assist transitions
Anchor in their own familiar repertoire
P Cognitive
< Solitary or social
P Emotional-social
Use of a “Prop”, a “Rule” and a “Role”
to assist transitions
P Give rule in terms of single action
P Give role of being needed and useful
Guidelines for caregivers
P Transitions: have a plan or a map for each day.
P Provide continuity to person you are supporting.
P Giving advance notice: CAUTION
Nathan E. Ory, M.A. © 2008
Challenging Behavior Analysis and Consultation, Ltd.
543 Marine View, Cobble Hill, BC
V0R 1L1, Canada
phone: (250) 743-1667
www.psychologists.bc.ca/pro/nathanory
[email protected]
“Working with people with challenging behaviors:
A guide for maintaining positive relationships”
2nd edition 2007
www.fasdconnections.ca
www.autismtodayory.com