1. Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS HCQU)
October 2011 bjl

2. Disclaimer
Information or education provided by the HCQU is not intended to replace medical advice from the consumer’s personal care physician, existing facility policy or federal, state and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.
Certificates for training hours will only be awarded to those who attend a training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.
Standard APS disclaimers 2

3. Note of Clarification
While mental retardation (MR) is still recognized as a clinical diagnosis, in an effort to support the work of self-advocates, the APS SW PA HCQU will be using the terms intellectual and/or developmental disability (ID/DD) to replace mental retardation (MR) when feasible.

4. Objectives
Recall strategies for understanding and responding to challenging behaviors
Describe basic premises about mental illness in relation to challenging behaviors
List the important assumptions about challenging behaviors
Summarize ways to report challenging behaviors accurately
Recite methods of de-escalation
Objectives need to be measurable. These are wording examples. 4

5. Understanding Challenging Behaviors
Why might it be necessary to understand challenging behaviors?
Pose this question to the audience and gauge responses.

6. Why is it Necessary to Understand Challenging Behaviors?
To understand needs and wants
To prevent crisis situations
To improve relationships between professionals and individuals
To reduce need for hospitalizations and/or restrictive behavior plans

7. Meeting Needs and Wants
Challenging behaviors and aggression are coping mechanisms
‘Strategies’ to meet needs and wants
Challenging behaviors are NOT results of mental illness or ID/DD

8. Meeting Needs and Wants
EXERCISE
Meeting Needs and Wants
Two volunteers will come to the front of the room. One will read the story about Sally on the slide out loud while the other volunteer talks into his/her ear. The volunteer will then try to answer the questions on the following slide.

9. Meeting Needs and Wants
Sally likes to go for car rides on sunny days. She has a blue convertible and will often put the top down when she takes it out for a spin.
One day, Sally decided to go for a ride around the city. When she pulled out of her garage she put the top of her convertible down and started off, not noticing the grey clouds gathering in the western sky behind her. As she drove, the sun disappeared behind the clouds and everything appeared grey.
Sally drove on, listening to her radio at full blast. Suddenly, she felt her face getting wet. She looked at her hands and noticed that they were covered in beads of water… and so was the interior of her convertible!
What color was Sally’s car?
What happened as she drove?
In what part of the sky were the clouds gathering?
Did Sally have her radio on or off as she drove?
What happened to Sally at the end of the story?

10. Basic Premises About Mental Illness
Symptoms never occur alone.
Symptoms can be observed behaviorally.
The key in identifying possible symptoms is to notice, describe, and capture changes in a person over time.
The cluster of symptoms is a significant change in how the person acts and can have an impact on his or her ability to function.
To understand the significance of a change in someone, caregivers need to understand how the person is when functioning at a normal, healthy level.

11. Basic Premises About Mental Illness
Symptoms never occur alone
Cluster of symptoms must be present
Cluster of symptoms occur over time

12. Basic Premises About Mental Illness
Example of symptom cluster for depression
Depressed mood most of the day, nearly every day
Diminished pleasure or interest in previously enjoyed activities
Significant weight loss or gain
Insomnia or Hypersomnia (sleeping too much)
Psychomotor agitation (restlessness) or retardation (moving about slower than normal for the person)
Fatigue or loss of energy every day
Feelings of worthlessness or excessive / inappropriate guilt
Diminished ability to think or concentrate 4
Recurrent thoughts of death / suicide

13. Basic Premises About Mental Illness
Symptoms can be observed behaviorally
How could depressed mood be described behaviorally?
How could hallucinations be described behaviorally?
How could obsessive-compulsive disorder be described behaviorally?
How could manic mood be described behaviorally?
Ask audience for examples of how these symptoms/disorders could be described in a behavioral sense.

14. Basic Premises About Mental Illness
The key in identifying possible symptoms is to notice, describe and capture changes in a person over time.
Onset
Increase / Decrease
Intensity
Noticeable patterns, episodes, or cycles of behavior

15. Basic Premises About Mental Illness
The cluster of symptoms is a significant change in how the person acts and can have an impact on his or her ability to function.
Not just a ‘bad day’
Goes on for extended periods of time
Makes day to day living difficult
Impacts relationships, work / school, self-care

16. Basic Premises About Mental Illness
To understand the significance of a change in someone, staff needs to understand how the person is when she is functioning at her normal, healthy level.
Know what a person is capable of / usually enjoys doing
Talk with other staff, family members, doctors, etc.

17. Describing What is Seen and Heard
How are a person’s behaviors typically described:
in a chart?
during a shift report?
after an incident / crisis situation?
during a typical and uneventful day?

18. Describing What is Seen and Heard
Don’t interpret
No “suitcase” words
Avoid terms like ‘aggressive’, ‘isolative’, or ‘defiant’
Take one symptom at a time
Capture behaviors at the person’s best (healthiest) and worst (most ill)
Don’t argue or decide if something is a symptom or not

19. Describing What is Seen and Heard
EXERCISE
Describing What is Seen and Heard
Read report 1 on Bob & ask questions about it from manual; read report 2 and do the same. Have audience compare and contrast reports. Do the same for the reports on Kenny in manual.

20. Challenging Behavior – Basic Assumptions
There is an unmet need or want.
Challenging behavior is meaningful.
People have good reasons to do what they do.
People do the best they can with what they have at that time and in that context.

21. Challenging Behavior – Basic Assumptions
Challenging behaviors interfere with an individual’s daily life.
Challenging behaviors may result from differences in culture and limitations in abstract thinking
Challenging behaviors threaten the safety of the person or others
Challenging behaviors are likely to limit or deny the person access to the use of various facilities

22. Challenging Behavior – Basic Assumptions
“All behavior is meaningful and can be understood. It is purposeful, seeking feelings of satisfaction and security, and this is especially true of psychiatric patients” – Dr. Hildegard Peplau (1952)
Ask audience to provide their interpretations of this quote and how it applies to the work that they do.

23. EXERCISE The Amy Scenario
Read the Amy scenario in manual with audience. Ask the questions listed after each part of the scenario. Explore with audience how the answers changed or evolved as more information was discovered about Amy.

24. Challenging Behavior – Basic Assumptions
Intellectual / developmental disabilities do not cause challenging behaviors.
The only behavior that can be attributed directly to intellectual and/or developmental disability is slow learning of new academic information (Ryan 1993).

25. Challenging Behavior – Triggers
People, places or things that remind someone of an event, feeling or experience
Are different for everyone
Triggers can evoke good and bad memories
Depends on individual
Depends on experiences

26. EXERCISE
Triggers
Ask the audience to describe one behavior that they know irritates/annoys/puzzles others – then have the audience think about what might trigger those behaviors? Finally discuss how audience members deal with their own triggers.

27. Challenging Behavior – Triggers
Staff responses to challenging behaviors can be triggers
Pay attention to person’s voice tone, what he/she says, his/her actions and requests
Staff responses to challenging behaviors can be triggers
Typically inadvertent
Staff means to help
Person interprets actions differently
Pay attention to person’s voice tone, what he/she says, his/her actions and requests
Can help determine if actions of staff are triggers

28. EXERCISE
Joe’s Story
Read the story about Joe from the manual with the audience. Talk about how staff’s reactions and interventions may have been triggers for his behaviors. Then discuss ways that staff could help him without inadvertently triggering behaviors.

29. Challenging Behavior – Things to Consider
Communication
Environment
Emotions
Unaddressed Medical / Physical Needs
Trauma

30. Challenging Behavior – Communication
“The 18 Second Rule”
Give direct attention to the person
“Communication Partners”
Communication Tools
Communication Board
Social Stories
Liberator

31. Challenging Behavior – Environment
A person’s immediate surroundings
Includes who is with the person

32. Challenging Behavior – Environment
Questions to ask:
Is the person feeling too hot / cold?
Is the person hungry / thirsty?
Is the person tired / fatigued?
Is the environment too stimulating / not stimulating enough for the person?
Does the person need to exercise / move around?
Does the person need to use the restroom (may be embarrassed or unable to ask)
Are the person’s privacy / boundaries respected?
Does the person like the people he/she is interacting with?
Ask – how do you act when you are with family at home? With friends at a party? With co-workers on the job? How does the environment change in each situation? Why does it affect your behavior?

33. Challenging Behavior – Emotions
One’s feelings / experiences directly impact one’s perception of stress and coping skills
What is fun / difficult / boring / sad for one person is totally the opposite for another
Pay attention to person’s communication to gauge his/her feelings
This helps the person cope with stress
Strengthens relationship between person and staff

34. Challenging Behavior – Emotions
Safety
Key aspect of emotional wellness
Fear leads to:
Anxiety
Irritability
Defiance
Aggression
Depression

35. Challenging Behavior – Emotions
People must feel safe to feel well emotionally
Lack of safety may result in behaviors like:
Clinginess
Always wanting a preferred person present
Asking the same questions repeatedly
Refusing medications and/or treatments
Eloping from group home

36. Challenging Behavior – Emotions
Stability can be reassuring
Structure provides an expectation of what will happen from day to day
Stability can be reassuring
Especially if person experienced trauma in life
Structure provides an expectation of what will happen from day to day
Fewer ‘surprises’ equals less anxiety

37. Challenging Behavior - Unaddressed Physical/Medical Needs
Illnesses affect people with ID/DD as they do anyone else
Many individuals have multiple illnesses / conditions
Symptoms may bring about challenging behaviors

38. Challenging Behavior – Unaddressed Physical/Medical Needs
Common conditions and physical symptoms
Migraines – chronic headaches
Constipation, diarrhea – GI conditions
Degenerative joint disease, pain, inflammation – arthritis
Premenstrual Syndrome
Immobility (being unable to move around as one likes)
Cardiovascular disease (heart conditions, circulation problems)
Neurological conditions (dementia, memory loss)

39. Challenging Behavior – Unaddressed Physical/Medical Needs
Common indicators of pain
Guarded/altered body position
Moaning
Sighing
Grimacing
Withdrawal
Crying
Muscle twitching
Restlessness
Elevated/decreased blood pressure
Quietness
Diaphoresis (excessive sweating)
Muscle tension
Nausea/vomiting
Weakness
Dizziness
Unconsciousness
Lethargy
Fever
Hitting a painful area
Staring
Dilated (large) pupils
Ask if behaviors are typical for the person
Ask if behaviors are sudden changes and/or unexpected changes in person

40. Challenging Behavior – Trauma
Sobsey & Doe – “Individuals who have some level of intellectual impairment are at the highest risk of abuse”
ID/DD population most traumatized of all
90% have experienced some kind of trauma
Trauma – an experience that the person didn’t ask for and can’t stop or escape; perceived as life threatening and involves intense fear and helplessness

41. Challenging Behavior – Trauma
Signs of trauma
Mood swings/instability
Unexplained outbursts of anger
Depression
Nightmares
Flashbacks
Hypervigilance
Anxiety/panic attacks
Avoidance
Inability to experience pleasure
Unexplained physical pain
Sexual problems
Unexplained grief reactions
Hopelessness
Poor concentration
Eating too much or too little
Self abusive behaviors
Poor self-esteem, shame, guilt
Headache, stomach ache, dizziness

42. Challenging Behavior – Trauma
Basic needs of traumatized person
To feel relatively safe
To know others will respect his/her boundaries
To feel accepted, validated and listened to
To talk and be listened to
To have their feelings paid attention to

43. Mental Health First Aid Action Plan
ALGEE
A Assess for risk of suicide or harm
L Listen non-judgmentally
G Give reassurance and information
E Encourage appropriate professional help
E Encourage self-help and support strategies
Plan developed by Professor Anthony Jorm and Nurse Betty Kitchener
Gives staff/caregivers & others ideas for how to help person in crisis
Esp. crisis involving worsening symptoms of mental illness

44. Recognizing Signs of Escalating Behavior
What signs might indicate that someone is becoming:
frustrated?
anxious?
scared?
angry?
Ask audience to give their thoughts/observations on what signs may tip others off that someone’s behavior may be escalating.

45. Signs of Escalating Behavior
Observable signs of escalating behavior:
Faster breathing
Talking louder
Stiff, rigid movements
Quick movements
No eye contact
Reddening in the face
Person may not show all of these signs – may show a cluster of 3 or 4

46. De-escalation: What Is It?
Helps staff manage challenging behaviors before they become a crisis situation (escalate)
Helps person return to baseline / normal functioning

47. Techniques for De-escalation
Proximity
Be out of arm’s reach
Pace
Move and speak slowly / calmly
Purpose
Mean what you say
Do not make promises that cannot be kept
Process
Be flexible; adapt to individual and situation
Plan
Have a plan in place
Think about what worked in the past

48. Techniques for De-escalation (continued)
Practice
Use techniques that work for the person often, even when not in crisis
Presentation
Be aware of body language and voice tone
Pivot
Know escape routes and be ready to use them quickly
Persuasion
Let person talk
Remind person that you want to help
Pre-empt
Know person’s triggers
Try to avoid / limit exposure to them

49. Techniques for De-escalation - Restraints
Restraints may be necessary at times
Once restraint started, goal is to discontinue it as soon as possible
Restraint is not the end of a crisis
Does not solve problems that led to crisis
Can damage trust and relationship between person and staff

50. Techniques for De-escalation – What To Do and Say During a Restraint
Prevention of physical harm
Asking what the person needs
Assist in relaxation
Ending the restraint

51. Techniques for De-escalation – A Note About Restraints
Restraints should be a last resort
They can cause physical and psychological harm
Can re-traumatize person
Can induce fear and powerlessness
Do not teach person how to control self
Can damage trust between person and staff

52. EXERCISE
Bob’s Story
Read the story about Bob from the manual. Ask the audience to think & talk about the questions asked.

53. Debriefing
Process that helps one make use of personal experiences for learning and development
Explores why something happened, how it happened and what can be learned
Formalized way to evaluate one’s actions, interactions during and after an event

54. Debriefing Who should debrief? Clinical staff Administrative staff
Treatment team members
Participants
The individual

55. Debriefing - Steps Reflect on the experience. Analyze the experience.
Make sense of the experience.
Communicate about the experience.
Learn from the experience.
Reflect on the experience
Ask who was there, what happened during, before and after the event
Analyze the experience
Consider possible triggers
Ask who needed to be present, who did not
What needs/wants were not met for the person
What did everyone’s body language communicate
Make sense of the experience
Create a story of the event; include lead-up, the event itself, and aftermath
Include best & respectful guesses as to person’s needs/wants during event
How might person have interpreted your actions?
Communicate about the experience
Talk to others who were there about the event
Discuss what everyone’s thoughts & guesses are about why event occurred and what person needed/wanted
Offer praise for what worked & suggestions for more effective strategies
Learn from the experience
Review everything about event
Think about what went well and what did not
Devise strategies that may help in future

56. Debriefing with Individuals
I ESCAPE Formula
I – Isolate
E – Explore
S – Share
C – Connect
A – Alternative
P – Plan
E – Enter
I – isolate: change environment, reduce stimulation
E – Explore: get person’s thoughts on what happened, what he/she needed or wanted, and his/her feelings
S – Share: tell person your thoughts & feelings about event – remain respectful of person’s experiences
C – Connect: put yourself in person’s place; talk with person about how you would have felt if you were in their place
A – Alternative: ask person to help with problem solving to avoid future crises
P – Plan: ask person to help create a plan
E – Enter: ask if person can/will go back to place where crisis happened (with staff)
Use this time to review strategies & plan
Do not push person to do this

57. Caring for the Caregiver
Try not to take challenging behaviors personally
Acknowledge what causes your own anxiety.
It is okay to ask for help.
1. Try not to take challenging behaviors personally. Remember that this person is trying to communicate a want or need through the challenging behavior. It is not being done to frighten, annoy or insult you. Think about your own experience – do you wake up in the morning planning to make someone else’s day difficult? Probably not – and neither do the individuals you work with. Being mindful of this fact can help reduce your own anxieties and maintain your professional composure.
2. Acknowledge what causes your own anxiety. Think about how you can identify and address the things that cause you stress. Talk with your co-workers, friends, family or anyone that you feel comfortable with; rely on your social network to help you through tough situations. It is important to be proactive because anxiety left unattended will only continue to grow. Taking initiative in working on your anxiety will help to model better strategies for dealing with stress to the individuals in your care.
3. It is okay to ask for help. People with ID/DD sometimes require extra care and attention, adding to an already busy workload. Don’t hesitate to ask for help when you need it and be willing to help others when asked. Take care of yourself so that you can provide the best quality of care.

58. Caring for the Caregiver – Stress Reduction Tools
Breathing Exercises
Take a Break
Make time for yourself when possible
A ‘Stress Ball’
Any small, portable item
Can help reduce physical and mental tension

59. Caring for the Caregiver – Stress Reduction Tools
Share techniques with individuals
Can prevent build-ups of stress
And potential crisis situations
Remember: Everyone needs an outlet

60. Objectives Review
Recall strategies for understanding and responding to challenging behaviors
Describe basic premises about mental illness in relation to challenging behaviors
List the important assumptions about challenging behaviors
Summarize ways to report challenging behaviors accurately
Recite methods of de-escalation
Ask audience if they think these objectives were covered during the course of the training. 60

61. Final Words
“The more creativity that staff and individuals are given in coming up with strategies, the greater the chance of those strategies being effective; remember that each person is an individual and will respond in unique ways to a variety of experiences, feelings, events, and situations.”

62. References
Author unknown. (n.d.) Liberator 2. Retrieved from (April 12, 2011)
Casey,T. (May 1, 2006). Elimination of restraints through positive practices. Mental Retardation Bulletin.
Charlot, L., and Shedlack, K. (2002). Masquerade: Uncovering and treating the many causes of aggression in individuals with developmental disabilities. The NADD Bulletin, Vol. V, No. 4.
Citrome, L. (2010). Aggression. Retrieved from (April 28, 2011)
The Gray Center for Social Learning and Understanding. (n.d.) What are social stories? Retrieved from (April 28, 2011)

63. References
Kitchener, B.A., Jorm, A.F., and Kelly, C.M. Maryland Department of Health and Mental Hygiene, Missouri Department of Mental Health, and National Council for Community Behavioral Healthcare (2009). Mental health first aid usa. Annapolis, MD. Anne Arundel County Mental Health Agency, Inc.
Lovett, H. (1996) Learning to listen: Positive approaches and people with difficult behavior. Baltimore, MD. Paul H. Brooks Publishing Co.
Legare, G. (2003) Positive approaches: Learning to listen and understand someone we find challenging to support. OMR Statewide Training and Technical Assistance Initiative. Pennsylvania.
Ogier,T. Restraints: a review of literature. Tasmanian School of Nursing, Nuritinga Issue 1, June 1998.

64. References
PMT Associates, Inc. (2009). Top ten list of de-escalation techniques: The p’s of de-escalation. Retrieved from (April 29, 2011)
Sturmey, P. (n.d.). Treatment interventions for people with aggressive behaviour and intellectual disability. Retrieved from (April 28, 2011)

65. To register for future trainings, or for more information on this or any other physical or behavioral health topic, please visit our website at
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67. Test Review There will be a test review after all tests have been
completed and turned in to the Instructor.

68. Evaluation Please take a few moments to complete the evaluation form found in the back of your packets. Thank You!