10/4/2018. Kelly Vinquist, PhD, BCBA Clinical Assistant Professor Co Director, ID MI program

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1 Kelly Vinquist, PhD, BCBA Clinical Assistant Professor Co Director, ID MI program Mike Lind, PhD Clinical Assistant Professor Child Psychiatry Define challenging behaviors Understand the etiology of challenging behaviors and an interdisciplinary approach Understand non medical approaches to managing disruptive behaviors. More than 50% of people with ASD have a psychiatric disorder 0 50% with a mood disorder 5 35% with a Generalized Anxiety Disorder 10 64% with Phobias 1 37% with Obsessive Compulsive Disorder 0 26% with Psychotic Disorders Matson & Neberl Schwaim (2007) 1

2 Challenging Behaviors Behaviors that disrupt an individual s ability to engage in daily activities Behaviors that can cause injury to self or others Examples: Repetitive behaviors Physical Aggression Property Destruction Self injury Developmentally appropriate Mental Illness Skill deficits Challenging Behavior Behavioral Phenotype Environmental Function Medical Illness/Pain Side effects Psychiatric Diagnosis Avoid: It s just Autism Mood Disorders Agitation Isolation Anxiety Restless Difficulty tolerating changes OCD Obvious routines that are difficult to redirect Beyond typical repetitive movements in ASD such as rocking, flapping, jumping, pacing 2

3 Resources for psychiatric diagnoses DM ID 2 Provides guidance on identifying psychiatric symptoms for people diagnosed with ID. Based on DSM V criteria NADD Association for persons with developmental disabilities and mental health needs. Common medical causes for challenging behaviors Constipation Infection Dental Problems Pain Acid Reflux Delirium Complete routine labs/ imaging and screening Table 1: Current recommendations for gender and age appropriate screening in adults with ID (PMID: ). 3

4 EPS: akathisia, stiffness and pain Drooling Sedation and irritability Constipation, difficulty with urination Fragile X PKU/HA (metabolic disorder) Down Syndrome Prader Willi Syndrome Chromosome 15q Duplication Rubinstein Taybi Smith Magenis 22q Deletion syndrome Angelman Syndrome Fetal Alcohol Spectrum Disorder (FASD) Tuberous Sclerosis Complex Williams Syndrome Is the behavior developmentally appropriate? Is there a specific skill that is needed to help the person be more successful (e.g., communication, relationships) Routine or expectations are not clear Comprehension is a barrier 4

5 What does the person gain? Positive reinforcement: social attention, items or activities What does the person escape from? Negative reinforcement: work, self care, staff, difficult situations Client engages in problem behavior to get attention from staff or peers What can we do? Don t give attention to problem behavior, monitor but be neutral Teach an alternative skill (e.g., how to ask for help) Schedule frequent opportunities for person to get attention for positive behaviors (e.g., social skills, playing a game, community involvement) Don t wait until behavior occurs to respond OfmmRaqs Child tantrum 5

6 Client engages in problem behavior to get items, food, or activities What can we do? Help them communicate using a communication system Schedule times when these items/activities are available Ensure they don t get items/activities for challenging behaviors WHk Big bang 2:35 6

7 Client engages in problem behavior to get away from something or someone. What can we do? Give frequent breaks before they are frustrated Recognize how effortful small tasks can be (e.g., selfcare, cooking) Teach a way to communicate for a break or alone time Developing a plan Clarity: Information about the plan, expectations and procedures should be clear to the individual, family, staff and other team members Consistency: Team and family members are on the same page with interventions and approaches and strive to apply the same expectations and rewards Simplicity: Supports are simple, practical and accessible so that everyone on the team, including the family can be successful in making it happen. Continuation: Even as behavior improves, it is important to keep the teaching and the positive supports in place. 7

8 Visual Cues Visual schedules Timers Pointing Gestures Model (show them) Consistent routines Use specific and brief prompts Developing a plan Clarity: Information about the plan, expectations and procedures should be clear to the individual, family, staff and other team members Consistency: Team and family members are on the same page with interventions and approaches and strive to apply the same expectations and rewards Simplicity: Supports are simple, practical and accessible so that everyone on the team, including the family can be successful in making it happen. Continuation: Even as behavior improves, it is important to keep the teaching and the positive supports in place. We just have to do a few things before you can have your laptop. 8:00 Medication 8:15 Vitals 8:30 Breakfast 9:00 Meet with doctors 9:30 Laptop 8

9 Developing a plan Clarity: Information about the plan, expectations and procedures should be clear to the individual, family, staff and other team members Consistency: Team and family members are on the same page with interventions and approaches and strive to apply the same expectations and rewards Simplicity: Supports are simple, practical and accessible so that everyone on the team, including the family can be successful in making it happen. Continuation: Even as behavior improves, it is important to keep the teaching and the positive supports in place. Common issues with expectations and when they are presented After we see the person doing something that may be unsafe People only state what shouldn t happen instead of teaching alternatives Too many steps and the person: Gets confused Frustrated by number of requests or things to learn Expectations take too long 9

10 I will check with you in a little bit Later Developing a plan Clarity: Information about the plan, expectations and procedures should be clear to the individual, family, staff and other team members Consistency: Team and family members are on the same page with interventions and approaches and strive to apply the same expectations and rewards Simplicity: Supports are simple, practical and accessible so that everyone on the team, including the family can be successful in making it happen. Continuation: Even as behavior improves, it is important to keep the teaching and the positive supports in place. 2 TYPES OF BEHAVIOR PLANS Although both plans are designed to reduce unsafe behaviors (e.g., self injury, aggression, property destruction, yelling or screaming) and develop better alternative behaviors (e.g., following instructions, doing things independently, sharing, waiting, accepting changes), there are some key differences, including: SAFETY & MAINTENANCE CONSISTENCY & FOLLOW THROUGH TEACHING & EXPERIMENTAL Maintain consistent expectations. That is, follow through to the degree it is reasonable and safe. Encourage appropriate ( replacement ) behaviors. For example, remind him of behaviors you want to see, and when they happen, acknowledge and reinforce them. This works for behaviors he can do but doesn t do as much as you d like. But, it s less effective for teaching new skills. Enforce rules and contingencies. That is, you must follow through with any expectation that is set. Teach appropriate ( replacement ) behaviors. For example, create teachable moments, or situations to require that or test if he will show a safer behavior to get what he wants. This is especially important when teaching new skills or routines, when unsafe behaviors can be very intense, or if they happen a lot more than replacement behaviors. Limit reinforcement of inappropriate behaviors. That is, try to avoid responding to the client in ways suggesting there are advantages to behaving inappropriately, since this will make his behaviors worse in the long run. Appropriate for ongoing use. That is, if you do these things all the time, things are not likely to get worse, and should get better in the long run. Eliminate reinforcement of inappropriate behaviors. That is, ensure the client is not shown the benefits of behaving inappropriately, and instead, show him it is clearly better to do replacement behaviors. More appropriate to use briefly or conditionally. Because these strategies are riskier and require more effort and precision, they are usually designed to be use only at certain times (e.g., mornings before school) or in certain situations (e.g., brushing teeth). 10

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