judy reaven, ph.d. associate professor of psychiatry and ......judy reaven, ph.d. associate...

Judy Reaven, Ph.D. Associate Professor of Psychiatry and Pediatrics JFK Partners/University of Colorado School of Medicine Judy.reaven@ucdenver.edu October 2011

• Aggression • Temper tantrums • Self-injurious behavior • Non-compliance or defiance • Property destruction • Pica • Stereotyped movements and/or repetitive

behaviors • Feeding problems • Sleeping problems • Others?

• Problem behaviors are pervasive in youth with ASD • Challenging behaviors related to increased

parenting stress, especially for mothers • Marked impact on educational, social, and

community opportunities • Without intervention, problem behaviors likely

persist • In addition to skill building, focus on positive

behavioral approaches to challenging behaviors essential!!

Impaired social, communication and play behaviors are risk factors

Behavioral theories (i.e. classical conditioning, social learning, operant models)

Setting variables – biological/environmental events

Increased vulnerability No one single etiology Utilize biopsychosocial model (Griffiths, Gardner, & Nugent,

1999; Szymanski, 1994)

• Broad emphasis – Focus on lifestyle concerns – friends, social

outings, independence

– Primary focus is not just challenging behavior • Long term goals – Consider long-term goals/outcomes, rather than

just short-term behavioral outcomes • Functional assessment – Determine the function of the behavior and

develop behavioral plan

• Individuality and effectiveness • Teach functional skills

– Emphasis on useful, functionally equivalent skills to replace challenging behaviors

• Positive reinforcing • Antecedents

– Focus on antecedent procedures, rather than consequences

• Multi-component interventions – Antecedent interventions – Consequences – skill building

Critical Assumptions

Every problem serves a function

Most effective interventions are proactive

Measures of intervention effectiveness must be long-term as well as short-term – interventions should lead to more durable changes; enhance quality of life

(Bambara & Mitchell-Kvacky, 1994); O’Neill et al., 1990; Emerson, 1998)

Determine the most effective treatment approach

To understand the nature and function of the problem behavior

To determine the ongoing efficacy of treatment To identify the variables that elicit or predict

problem behavior

Setting Events & Primary Functions: S = Setting events E = Escape A = Attention T = Tangible S = Sensory

Biological Events Sleeping, eating/diet, medication, heat in the

room, toileting, physical and mental health Environmental Events Staffing changes, earlier fight, forgot favorite

toy, number of people in room, noise level, changes in schedule

Escape – work demands, chores, transitions to non-preferred activities

Attention – parent/teacher attention, peers, reprimands and praise

Tangible – preferred activities, toys, books and snacks

Sensory – deep pressure, visual stimulation, auditory stimulation, and rocking

Informant methods Direct observation

Functional analysis

Describe behaviors Define potential ecological events that affect

behavior Define events and situations that predict occurrence

of behavior Ask about perceived function Define the efficiency of the undesirable behavior Ask about primary method of communication

What events, action and objects are considered positive by the individual

What functional alternatives are known by the person

Previously tried strategies Assess for setting events Consider whether the challenging behavior

could be manifestation of a psychiatric condition

Observe across settings, time of day, etc. Obtain a minimum of 10-15 occurrences Charting can be simple or complex Keep charting user friendly Historical information helpful if behavior is

high impact, but low frequency

Time of

Day/Activity

Antecedent Behavior Consequences Intensity/Duration

(H, M, L)

Possible

Function

8-10AM

10-12PM

12-2PM

2-4PM

4-6PM

6-8PM

Interventions Need to be Data Driven Stimulus-based procedures (altering antecedent events) –

i.e. curriculum, schedules, physical setting Instruction-based procedures – direct instruction Extinction-based procedures – withhold presumed

reinforcers following problem behaviors Reinforcement based procedures – increasing desired

behavior through contingent delivery of positive rewards Punishment-based procedures – time out System change – change in staffing patterns Pharmacological based procedures – medications

Proactive interventions Skill based/functional alternatives

Environmental adaptations

Improve quality of interpersonal interactions

Provide opportunity for choice and control

Look at chain of behavior

Establish communication with families to identify setting events and treat when possible

Reduce expectations when setting event is present

Consider multiple antecedent modifications

Reactive plans

Extinction (ignore-redirect)

Mild punishment (verbal reprimands, loss of privileges, time out)

Crisis management/safety plans

4 year old boy with Autism Nonverbal Overall developmental functioning – (2 ½

yr old) Lives with parents and older brother, age 6 Attending preschool Presenting problem – SIB (head banging)

Increased head banging over the past 2 months, at times high intensity, varying frequency

Unpredictable – “out of the blue”; better or worse? Begins with agitation, crying, then head banging Previously tried - telling him to stop, protecting his

head, holding him No new family stressors, major environmental changes,

or health changes Perceived function – social attention?

Time of

Day/Activity

Antecedent Behavior Consequences Intensity/Duration

(H, M, L)

Possible

Function

8-10AM Breakfast –

making a

choice

Crying,

HB

Gave him both

foods

L

1x

??

10-12PM Watching TV,

asked to put

toys away

Crying,

HB

Time out H

8x

Avoidance

12-1PM

1-2PM

2-3PM Asked to hang

up coat and

put on shoes

Crying,

HB

Physical

prompts to

follow

directions

M

2x

Avoidance

3-4PM Brother comes

home from

school

Crying,

HB

Telling him no,

hugging

M-H

7x

Attention?

Clear bi-modal picture of SIB over the week Two levels of analysis – behavioral and

setting variables – Perceived function (s) – social attention from

brother, and avoidance (task demands) Setting variables - hunger

More frequent snacks, especially close to lunch time Directly teach him to follow simple directions such as “put

your toys away” or “hang up coat”, using task analysis, shaping behavior using physical prompts and then fading, combined with positive rewards

Directly teach him play skills for interaction with brother Directly teach appropriate attention-getting behaviors –

i.e. tap on the arm, offering a toy Use visual strategies to illustrate daily schedule,

especially when brother comes home

Safety plan Planned ignoring/extinction

Setting

Events

Antecedent

Triggers

Problem

Behavior

Maintaining

Consequences

Alternative

Replacement

Behavior

Always be on the look out to praise or reinforce good attention, effort, participation, waiting, tolerance, acceptance of change, coping, etc.

Link rewards to effort and participation but provide intermittently and not with a formalized contract ahead of time

Anticipate challenging situations Share written rules/guidelines with student

for specific situations Be explicit, rule-governed, clear, consistent Pick and choose battles

Avoid phrases like “behave yourself” – not specific enough

Tell the student exactly what is expected and for how long: “You need to be sitting quietly and reading your science book until 11:15.”

Emphasize words that indicate when – “now”, “later”, etc. and gently redirect if student acts before it is time

Autonomy is often very important for these students; use it to prevent problems and reinforce effort

Help the individual identify how choices are perceived by other people

Label the misbehavior in a calm, neutral manner

Whenever possible, allow natural consequences to arise

Do not process/discuss problem behavior in the moment

Wait for a calm time to discuss what the individual could have done differently

Help individuals to identify situations that are particularly challenging for them

Help individuals to create a list of options for responding to these situations in the future

Use self-reflection to strengthen self-esteem Demonstrate differences between individual’s

perspective and others’ perspective

Challenging behaviors (and mental health symptoms) are common in persons with ASD

Without intervention negative behaviors and mental health symptoms may persist

Positive behavior supports (and specific mental health interventions) can be effective in managing symptoms

Functional assessment is an essential component of positive behavior supports

Most effective approaches are proactive