Understanding Challenging Behavior & Function-based Interventions. Katie & Blaire

Transcription

1 Understanding Challenging Behavior & Function-based Interventions Katie Al Jenaibi, M.S., BCBA Blaire Luebkeman, MSEd, BCBA June 4, 2013 Katie & Blaire

2 Behavior Analysis in Your Home Learning to change how others act, to be aware of the things you do, the way things occur in order to change the behavior of your child Manipulating events to decrease challenging behavior and increase functional/adaptive behaviors to increase their successfulness Takes time and dedication on top of everything else you do! HARD TO DO! EXHIBIT 1

3 EXHIBIT 2 EXHIBIT 3

4 Goals Look at challenging behavior (that you choose to target) from a different lens than the day-to-day way you may be used to Examine what you know about your child and apply it to behavioral concepts How behaviors are related to contextual conditions; functions of behavior Preventative strategies and ways to teach skills to decrease challenging behaviors Ways to apply intervention strategies to decrease challenging behaviors Why problem behaviors develop? Diagnostic Criteria ( autism triad ) Language/Communication Impairments Social Skill Impairments Presence of stereotyped behaviors; Maladaptive behavior development

5 Delays with COMMUNICATION development: Receptive/expressive delays Speech delays Stereotypic vocal behavior: scripting, repetitive noises, repeated questions, phrases Echolalia: non-functional repeating words either immediately or delayed Delays in SOCIAL SKILL development: Poor eye contact Inappropriate emotional expression/recognition Unaware of others feelings Prefers isolated, repetitive play

6 Delays in BEHAVIOR Development: Repetitive, non-functional movements hand-flapping, rocking, tapping, spinning humming, groans, mouth clicking Unusual response to sensory stimuli Rigidity Given their delays in development, problem behaviors emerge as solutions! We assume: if they knew a better way (had the skills) then they WOULD behave better. They WANT to be successful.

7 How Does Behavior Work For Us? Behavior does NOT develop due to a personality trait Deficits in skill development lead to presentation of challenging behaviors Behavior serves a function It gains us access to objects, activities, events or people we like It gets us out of or away from objects, activities, events or people we don t like To obtain something desirable To avoid or escape something undesirable Manage our emotions

8 Assumptions about Behavior Behavior is functional; student engages in patterns of behavior that work in some way; there is a logic to the behavior, and we need to understand that logic Their challenging behavior is efficient for them because of their skill deficits; behaviors emerge as solutions to those deficits Need to look at relationships between behavior and environment; it is as much analysis of environment (e.g., schedules, activity patterns, adults, physical settings) as it is of student s behavior Before we can fix it, we need to look at the big picture Consider all variables that may affect the behavior Consider events or changes to environment that may make the behavior more/less likely to occur

9 The ABC s of Behavior Antecedents (events and behaviors) Occur before target behavior Triggers or patterns Behavior The action of student (e.g., frequency, duration, intensity) What does the behavior look like Consequences Occur after behavior What is bring presented or removed? Considerations Be a Detective! (you already are.) Medical/Physical Problems Sleep Cycles Eating Routines/Diets Medications Time of Day Schedule of tasks (preferred/non-preferred) Physical Setting Activity Adult Patterns/ Family interactions

10 Think about A-B-C relations -Timing of events around behavior -Behavior is does not occur in a bubble -Identifying the PATTERNS is the first step in identifying the function of the behavior What are they getting out of it? How are others responding? Consistency across settings? Share these observations with school team connect the dots! Antecedent Behavior Consequence Hitting Kicking Non-compliance Yelling Swearing Toileting accident Trashing things...

11 ADD LOTS HERE to decrease likelihood of behavior happening (teaching opportunities) MANIPULATE events/actions here to eliminate reinforcing the problem behavior; function-based interventions Manipulating the Consequences The consequences or events that happen immediately after the behavior (contingent upon the behavior) and lead to patterns of continued behavior are known as Function of behavior Maintaining variables The things that reinforce the behavior, making it more likely to happen again in the future

12 Reasons for Behavior Attention/Social: student wants attention (any kinds of attn) from others Escape: student wants to escape from certain task, individual or environment Tangible: student wants to get access to a preferred thing (item, activity, etc.) that is not available at the moment Sensory: behavior fills a sensory need (access sensory input, ignore other input, remain alone) REINFORCEMENT What is reinforcement?? Positive reinforcement= adding something preferred to make the behavior MORE likely to occur in the future Negative reinforcement= removing something aversive to make the behavior MORE likely to occur in the future

13 Positive Reinforcement: When/If is provided, then challenging behavior increases or becomes MORE likely to occur in the future Attention is provided Tangible item/activity Preferred sensory input Negative Reinforcement: When/If is removed/delayed, then challenging behavior increases or becomes MORE likely to occur in the future Task/Demand goes away or is delayed Non-desired attention goes away (alone)

14 Examples of Attention-based Reactions Attention can be accidentally presented in various forms Physical touch/proximity to others Praise Sighs Talking about the child s behavior Emotional reaction Agitated tone to voice Reaction from/presence of others Attention is very powerful Strengthen the right behaviors Worsen the wrong behaviors Positive or negative attention (child may see them as the same) Examples of Escape-based Reactions Immediately after behavior occurs: Give in, not follow through with demand Demand/expectation changes or goes away Remove the unwanted demand/situation Arrival from bus, asked to put bag away/carry bag inside, child refuses and swears parent puts bag away Told to brush teeth, flops/tantrums on floor, parent decides child can go to bed without doing it

15 Examples of Tangible-based Reactions Giving them access to the item Giving in to the thing they want, even if you said no before Unlimited access to food/toys to prevent them becoming frustrated Examples of Sensory-based Reactions Typically these are internal consequences feedback or sensations that they enjoy may also be input they experience when given access to sensory equipment Sensation of head-hit or bite Ocular movements of eyes Flapping movement of hands, fingers Sound/vibration of own voice Rocking back and forth Sensation of swinging, pressure from hug/swing, etc. Digging/rubbing hands against surfaces

16 Clarifying Sensory Maintained Behavior Once you identify that sensory input maintains behavior still have to investigate (often through trial and error and sensory sampling) What particular type of input the behavior gets? What are they seeking? What other input Auditory Kinesthetic Tactile/touch, pressure Sight Vocal (sounds or taste) Smell Distinguish Between Proactive and Reactive Use of Sensory Integration IF.. Providing it as a CONSEQUENCE contingent on the behavior... Access to sensory input is PROACTIVE (planned access, sensory diet, when they are free of problem behavior, etc.) Then.. Outcome may be worse, it reinforces the challenging behavior, making it more likely to occur in the future This could prevent the bx if they get access to it at other times to decrease their motivation to seek it through behaviors

17 Finding the Function? Same behavior for different students can serve different functions Same behavior for same student can serve different functions Different behaviors for same student can serve same function Therefore effective behavior plans are developed around function-based interventions withholding the reinforcement for challenging behavior and giving reinforcement for other positive behaviors Remember Individuals with autism don t learn from typical consequences (e.g., saying no, frowning) they may be getting something different out of it We have to manipulate consequences so that we plan to NOT reinforce the negative behavior They need repetitions of the right consequence events over and over again to learn Positive behavior/skills gets them what they want Challenging behavior NO LONGER gets them what they want

18 What do you do in the moment? What do you do in the moment?

19 What makes the behavior stop NOW? What makes the behavior decrease over time? Reacting to Behaviors Life Happens. accidentally providing reinforcement to the problem behavior happens Tired Busy in public dealing with other kids You want to soothe them quickly! (attention, tangible, sensory) Not ready to fight the battle.easier to give in, give them what they want (escape, tangible) Look at the patterns and ABC relations How we react can dictate whether we STRENTHEN the challenging behavior or WEAKEN it s future probability

20 Rule of Human Behavior #1 IF IT WORKS, WE DO IT AGAIN Therefore, important for us to not accidentally make behavior worse by providing a reaction that will increase the challenging behavior Basic rule of thumb for responding to challenging behaviors No reaction is better than some reaction. Ignore and Redirect. Prevents accidentally strengthening the wrong behavior (Then figure out a more effective plan)

21 Stages of Behavior Support: ALL BEHAVIORS Problem Definition (consistent definition) Problem Analysis (understand ABCs and function of behavior) Development of Support Plan Monitor Progress Behavior Support Plan Components Consistent/clear definitions of challenging behavior Antecedent/Predictor Strategies (identify triggers/patterns) Setting Event Strategies (things to be modified to reduce e the likelihood) Teaching Strategies: positive/replacement behaviors to TEACH Consequence Strategies Reinforcement Responses to Behaviors (Reactive procedures, eliminating reinforcement of problem behaviors)

22 Antecedent Behavior Consequence Hitting Kicking Non-compliance Yelling Swearing Toileting accident Trashing things... The bulk of the plan, the most important part is within the PREVENTATIVE MEASURES Teach new skills to replace challenging behaviors! Visuals Reinforcement systems (effective ones!) Schedule Wording, tone, etc. Environment Motor/Sensory breaks And more.

23 Teaching New Skills Because of their delays in development We teach new ways to: get what they want/avoid what they don t want We teach new ways to FUNCTION (with team support/guidance) Functional Communication Responses FCRs replace and reduce the occurrence of challenging behaviors Can be word/phrase to access same outcome as behavior Can be a coping mechanism/strategy to minimize likelihood of behavior occurring We teach FCRs, therefore teaching a new adaptive skill (ethically appropriate) FCRs make you and the individual more likely to be successful Examples of behaviors that we d like to replace/reduce

24 you!, Stupid head, Poo-poo You wicked witch Hitting Throwing objects Spitting Refusals/non-compliance Crawling, running away Tantrums If he/she had a better way to access what they want they would If he/she knew how to be more functional they would (remember triad of deficits) New/appropriate skills are not likely to spontaneously develop We have to TEACH appropriate replacement behaviors

25 Examples of FCRs I want a break I need space No thank you/ I don t want to I want a quiet place to work I want to be alone Can I have more time? I need help I choose to do X instead I need to take a deep breath What (reward) does the challenging behavior get them? Escape/avoidance of demand Access to attention Access to tangible item (preferred items) Opportunity to be alone Internal sensory input The FCRs we choose to teach should offer them the same reward

26 What makes it FUNCTIONAL? FUNCTIONAL Communication Response The response we want to teach has to replace the purpose the challenging behavior serves The FCR needs to provide the same function, access the same outcome Individuals engage in challenging behavior because it is the most efficient way to access what they want (or they don t have better skill) We need to make the FCR just as efficient and easy to use, over time Getting what they want in appropriate ways will not emerge on it s own unless we teach it Teaching Alternative Behaviors Antecedent Problem Behavior Maintaining Consequence Told to turn off computer Non-compliance Yell/Tantrum X Given Access Allowed more time Appropriate, Replacement Behavior Asks for one more Minute Given Access Allowed more time Told to turn off computer Demonstrates compliance Praise (and/or reward?)

27 Use of FCRs will not emerge spontaneously PRACTICE TEACHING BY THE THREE P S: PRACTICE PROMPT PRAISE FOUR essential parts to this approach: PROMPT PRAISE 1. Discuss using the skill before a problem begins. 2. Practice sessions (model & help demonstrate how to use it). Praise their work during practice. 3. Prompt the alternative behavior as early as possible in the moment 4. Praise/reward successes and partial successes. PRAISE How do they communicate this new skill? Use visuals to increase comprehension of behavioral expectations or ways to access FCR Teaching alternative communication requires that a COMMUNCIATION SYSTEM BE IN PLACE AT HOME Communication must be 24/7 School/home Community, in the car, on the go Back up for technology-based systems Expectation that child MUST communicate to gain access to things Everyone in family has to support/encourage the communication system (full sentences, use of device, tapping on shoulder to gain attention before request, etc.) Seek team support to make this happen

28 When to use FCRs Goal is to be preventative Proactively give support Pre-teach and give opportunity to practice INTERVENE EARLY (before full crisis point, before target behavior occurs) Intervene and Prompt the FCR when. You observe common triggers in the setting/environment (antecedent events) You observe known pre-cursor/low-level behaviors (antecedent behaviors) Create & Use Visual Supports Use of visual cues objects, photos, pictures, icons, written language to prepare, preview, prompt, and review; these will assist with increasing student independence * Provides concrete/permanent cue (aids with skill deficits)»cue cards; Task cards; To-do lists»social scripts»social stories»comic strips»rules»schedules & Mini-activity schedules»relaxation cues; Strategy lists»many other examples exist

29 Available Used Function of behaviors= escape & access preferred activity (prolong access) Teaching skill: coping, mood-regulation

30 Getting Revved Up Signs: loud speaking jumbled words slamming fist on table What to do to Slow Down: Take space (a break, a walk) Ask for help Talk to an adult Review schedule Antecedent That s it! I ve had it! Behavior Throwing materials, noncompliance, yelling Function of behavior = escape hard tasks, avoid over-stimulating environments

31 Antecedent Increased vocals, increase motor activity Behavior Yelling, loud repeating of adult directive Say it in a quiet voice No Thank you Function of behavior = escape/protest non-preferred tasks, express dislike Variations can be age appropriate

32 Modify our interactions & environment Be proactive Teach a new skill & reduce challenging behaviors at the same time! More Preventative Strategies What can we do to increase the likelihood of success? Communication Tips Monitor Tone (reinforcing vs. directive) Avoid complex directives Less is more Make sure what you re saying is content that they can comprehend Gramma s rule Short & simple: First X-Then Y Allow for a delay in response Give them reminders (helps w/ rigidity & tolerance) Transition warnings - review schedule & expectations

33 Be alert for initial signs of agitation become proactive - Lessen potential triggers - Minimize language - Avoid over-stimulation - Upon intervals of appropriate behavior, increase praise and positive attention - Provide clear and simple reminders of expectations - Review reinforcement contingencies - Review schedule Be aware of what kind of attention you are providing Avoid negative attention Brief neutral reminders for every 1-3 minutes of continued problem behaviors. First X then Y State directions for the positive behavior you want to see.not what you don t want

34 Provide opportunity to communicate when they show low-levels of agitation when they re ready use your words what do you want Gesture to communication device How can I help you I see that you are, (choose a strategy) Practice Prompt Praise use of FCRs Catch being good & ignore when they re not Help them distinguish between right/wrong, good choice/bad choice by dimming the cues for negative behavior and increasing cues that they did something right/good Keep you own emotions in check Do not take it personally Remember that they will need repetitions of the experience to be able to learn how to apply an appropriate skill

35 Setting Events for Success Environmental Modifications Place highly preferred things in a place where communication is needed in order to gain access Have designated areas for calming space Have designated safety space (for everyone) Consider sensory needs (noise level, lights, other people coming/going, etc.) Proactive safety measures: door/window alarms, cabinet locks (allow you to respond with less attention/reaction and prevent safety risk Managerial Strategies Consistent plan/approach to help with transitions (countdowns, signals, visuals, etc.) Planned things to keep them happy and engaged during travel or known difficult tasks Bin o fun for car, for difficult community outings Doctor visits Crowded family gatherings Waiting at restaurants Music, headphones, isolated preferred items, etc.

36 Preventative Strategies Approach We modify the environment, our interactions and use of proactive strategies to reduce the chance that problem behavior will occur We provide explicit reinforcement for desired behaviors, non-problem behaviors or new skills tip the scales highlight the good stuff, dim the cues on the negative behaviors We give them additional cues so they can LEARN new ways to behave Applying Positive Reinforcement Tell student about plan before starting Reinforce immediately following desired behavior (gradually fade out frequency/immediacy of reinforcer) Describe desired behavior to student while reinforcer is being given Use lots of praise, physical contact (if appropriate), exaggerate facial expression when dispensing reinforcers (increase cues for non-verbal students) Noticeable reinforcement for the absence of challenging behavior (even if brief amount of time) gain momentum (DRA)

37 Things to consider: Deprivation and Satiation Immediate Delivery Contingency Control of Access Feedback Brief 'Consumption' Time Reinforcer Variety/Layers Reinforcement What s going to rock their world? What is going to make a difference/change the behavior If it doesn t after trying for a while, it s not a reinforcer Reinforcement Contingencies Remember that it is only a reinforcer/reward if it makes the (positive) behavior INCREASE Ask Student, ask school team what works in that setting Ask for guidance about setting up reinforcement contingencies (If you X then you get Y) Long-term goal is always to fade reinforcement to natural, non-contrived events

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39 Behavior Checklist with Reward Program

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41 FIRST THEN

42 Behavioral Contract Kind words and safe body with brother/sister Daily Reward Behavioral Contract II Be Responsible for belongings Be kind and respectful to mom Do homework End of Month Reward Disclaimer: Only offer what you feel comfortable following through with and confident that you will follow through

43 Clean up when asked MY RULES Use a quiet voice

44 Morning Afternoon Evening Nice Words Nice Hands Follow Directions 3 = Antecedent Behavior Consequence Hitting Kicking Non-compliance Yelling Swearing Toileting accident Trashing things... Plan of action for the moments in the learning curve

45 Reactive Strategies to Decrease Behaviors Prevention Strategies Reinforcement for less/absence of behaviors Reactive Procedures Extinction Ignoring/withholding reinforcement Punishment Time out Reduced privileges Think CAREFULLY about any use of physical intervention *Knowing what type of intervention to use requires team consult Extinction (Planned Ignoring) Principle of extinction states: withhold reinforcement for the problem behavior 1) If, in a given situation, individual engages in previously reinforced behavior and behavior is not followed by reinforcing consequence, then: 2) Individual is less likely to do same thing again when next encounters similar situation

46 Function-based Extinction: Behavior-specific Interventions Attention-maintained behavior=? Escape-maintained behavior=? Tangible-maintained behavior=? Sensory-maintained behavior Can t externally withhold this reinforcement Interventions often focus on finding competing input 3) In order for extinction to occur, must withhold reinforcement with consistency, across time, setting and people *whole family buy-in * when reacting, be mindful of long-term outcomes on behavior 4) Be mindful of extinction burst (gets worse before it gets better)

47 5) By avoiding presenting reinforcement for the problem behavior you will (over time) help reduce the frequency & make it less likely to occur seek guidance about data on the progress to help you stay committed to the intervention plan Possible Intervention Strategies Attention-maintained behavior: Ignore (do not comment) Increase attention for desired behaviors (even brief instances after negative behaviors) Time Out *(void of reinforcing environment, seek guidance at implementing)

48 Possible Intervention Strategies Escape-maintained behavior: Maintain demand, wait them out ( ride the wave and then when ready, re-introduce previous task) Continue to present low-level demands until initial task can be reintroduced Ok to modify extent of original demand but expect some performance (to catch them being successful; shaping) Follow through with expectation First-then contingencies Possible Intervention Strategies Tangible-maintained behavior: Tangible is given ONLY for appropriate behavior and WITHHELD after problem behavior Establish reinforcement goals If you do + behavior, then you get Redirect them to what they CAN have in the moment (do say you can have book or ipad, don t say you can t have pool

49 Possible Intervention Strategies Sensory-maintained behavior: Identify competing or a matched way to provide input Proactive strategies to provide access before behavior occurs (decrease their motivation to access it through inappropriate measures) Teach FCRs to request sensory input, praise/reward use of communication Utilize info from A-B-C patterns to: Implement preventative strategies to reduce triggers (decrease opportunity for challenging behavior) Identify function of behavior/maintaining variables Avoid delivering reinforcing variable contingent upon challenging behavior (think long-term gains to decrease target behavior) Use reinforcement for alternative behaviors Applied Behavior Analysis exhausts REINFORCEMENT-based procedures, before considering other interventions

50 Punishment Punisher - An event, when presented or removed immediately following behavior, causes behavior to decrease 1) If, in given situation, a student does something that is immediately followed by punisher, then 2) student is less likely to do same thing again when next encounters situation again IMPORTANT: consequence is only a punisher if the behavior decreases!!! (examples: sent to their room with favorite toys, being away from others and unlimited access to favorite things may be a reward!) Disadvantages of Punishment Cannot be depended on to produce longlasting suppression May provoke escape and aggression Emotional reactions (from student and staff) Does not teach appropriate behaviors Other behavior reducing strategies

51 Timeout Transferring a student from a more reinforcing situation to a less reinforcing situation Exclusionary timeout completely removing child from reinforcing situation Non-exclusionary timeout removing immediate access & participation in reinforcing situation, but still able to observe others benefitting ( time away ) Time OUT condition must be noticeably different than time IN conditions Timeout Adult directed Absent of reinforcement Child should not be released unless engaging in appropriate behavior Length should be short (if not, change your plan) Child should return to previous activity Precautions: Use a space that can be reliably used as void of reinforcement Consider challenge in getting child to the space/stay in space Evaluate physical measures carefully with team

52 Response Cost Removal of specified amount of reinforcer following particular behavior They start out with access to reinforcer, if non-desired behavior occurs, loses access to all or part of the reward (examples: trip to pool gets cancelled, no extra time withipad, 2 stories instead of 5, etc.) Focus Your Energy & Time for Success Prioritize what s important to change Be consistent with the plan you decide to implement Be patient.if we had a magic wand, we would give it to you! Progress can be slow ( the engine that could ) Your goal is to help your child become a more functioning part of your family Load up the proactive strategies Manipulate function-based reactive strategies

53 Katie Al Jenaibi Blaire Luebkeman *handouts available online