Presentation on theme: "Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit."— Presentation transcript:
1Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS HCQU)October 2011 bjl
2DisclaimerInformation 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 disclaimers2
3Note of ClarificationWhile 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.
4ObjectivesRecall strategies for understanding and responding to challenging behaviorsDescribe basic premises about mental illness in relation to challenging behaviorsList the important assumptions about challenging behaviorsSummarize ways to report challenging behaviors accuratelyRecite methods of de-escalationObjectives need to be measurable. These are wording examples.4
5Understanding Challenging Behaviors Why might it be necessary to understand challenging behaviors?Pose this question to the audience and gauge responses.
6Why is it Necessary to Understand Challenging Behaviors? To understand needs and wantsTo prevent crisis situationsTo improve relationships between professionals and individualsTo reduce need for hospitalizations and/or restrictive behavior plans
7Meeting Needs and Wants Challenging behaviors and aggression are coping mechanisms‘Strategies’ to meet needs and wantsChallenging behaviors are NOT results of mental illness or ID/DD
8Meeting Needs and Wants EXERCISEMeeting Needs and WantsTwo 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.
9Meeting 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?
10Basic 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.
11Basic Premises About Mental Illness Symptoms never occur aloneCluster of symptoms must be presentCluster of symptoms occur over time
12Basic Premises About Mental Illness Example of symptom cluster for depressionDepressed mood most of the day, nearly every dayDiminished pleasure or interest in previously enjoyed activitiesSignificant weight loss or gainInsomnia or Hypersomnia (sleeping too much)Psychomotor agitation (restlessness) or retardation (moving about slower than normal for the person)Fatigue or loss of energy every dayFeelings of worthlessness or excessive / inappropriate guiltDiminished ability to think or concentrate4Recurrent thoughts of death / suicide
13Basic Premises About Mental Illness Symptoms can be observed behaviorallyHow 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.
14Basic Premises About Mental Illness The key in identifying possible symptoms is to notice, describe and capture changes in a person over time.OnsetIncrease / DecreaseIntensityNoticeable patterns, episodes, or cycles of behavior
15Basic 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 timeMakes day to day living difficultImpacts relationships, work / school, self-care
16Basic 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 doingTalk with other staff, family members, doctors, etc.
17Describing 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?
18Describing What is Seen and Heard Don’t interpretNo “suitcase” wordsAvoid terms like ‘aggressive’, ‘isolative’, or ‘defiant’Take one symptom at a timeCapture behaviors at the person’s best (healthiest) and worst (most ill)Don’t argue or decide if something is a symptom or not
19Describing What is Seen and Heard EXERCISEDescribing What is Seen and HeardRead 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.
20Challenging 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.
21Challenging Behavior – Basic Assumptions Challenging behaviors interfere with an individual’s daily life.Challenging behaviors may result from differences in culture and limitations in abstract thinkingChallenging behaviors threaten the safety of the person or othersChallenging behaviors are likely to limit or deny the person access to the use of various facilities
22Challenging 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.
23EXERCISE 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.
24Challenging 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).
25Challenging Behavior – Triggers People, places or things that remind someone of an event, feeling or experienceAre different for everyoneTriggers can evoke good and bad memoriesDepends on individualDepends on experiences
26EXERCISETriggersAsk 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.
27Challenging Behavior – Triggers Staff responses to challenging behaviors can be triggersPay attention to person’s voice tone, what he/she says, his/her actions and requestsStaff responses to challenging behaviors can be triggersTypically inadvertentStaff means to helpPerson interprets actions differentlyPay attention to person’s voice tone, what he/she says, his/her actions and requestsCan help determine if actions of staff are triggers
28EXERCISEJoe’s StoryRead 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.
29Challenging Behavior – Things to Consider CommunicationEnvironmentEmotionsUnaddressed Medical / Physical NeedsTrauma
30Challenging Behavior – Communication “The 18 Second Rule”Give direct attention to the person“Communication Partners”Communication ToolsCommunication BoardSocial StoriesLiberator
31Challenging Behavior – Environment A person’s immediate surroundingsIncludes who is with the person
32Challenging 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?
33Challenging Behavior – Emotions One’s feelings / experiences directly impact one’s perception of stress and coping skillsWhat is fun / difficult / boring / sad for one person is totally the opposite for anotherPay attention to person’s communication to gauge his/her feelingsThis helps the person cope with stressStrengthens relationship between person and staff
35Challenging Behavior – Emotions People must feel safe to feel well emotionallyLack of safety may result in behaviors like:ClinginessAlways wanting a preferred person presentAsking the same questions repeatedlyRefusing medications and/or treatmentsEloping from group home
36Challenging Behavior – Emotions Stability can be reassuringStructure provides an expectation of what will happen from day to dayStability can be reassuringEspecially if person experienced trauma in lifeStructure provides an expectation of what will happen from day to dayFewer ‘surprises’ equals less anxiety
37Challenging Behavior - Unaddressed Physical/Medical Needs Illnesses affect people with ID/DD as they do anyone elseMany individuals have multiple illnesses / conditionsSymptoms may bring about challenging behaviors
38Challenging Behavior – Unaddressed Physical/Medical Needs Common conditions and physical symptomsMigraines – chronic headachesConstipation, diarrhea – GI conditionsDegenerative joint disease, pain, inflammation – arthritisPremenstrual SyndromeImmobility (being unable to move around as one likes)Cardiovascular disease (heart conditions, circulation problems)Neurological conditions (dementia, memory loss)
39Challenging Behavior – Unaddressed Physical/Medical Needs Common indicators of painGuarded/altered body positionMoaningSighingGrimacingWithdrawalCryingMuscle twitchingRestlessnessElevated/decreased blood pressureQuietnessDiaphoresis (excessive sweating)Muscle tensionNausea/vomitingWeaknessDizzinessUnconsciousnessLethargyFeverHitting a painful areaStaringDilated (large) pupilsAsk if behaviors are typical for the personAsk if behaviors are sudden changes and/or unexpected changes in person
40Challenging 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 all90% have experienced some kind of traumaTrauma – 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
41Challenging Behavior – Trauma Signs of traumaMood swings/instabilityUnexplained outbursts of angerDepressionNightmaresFlashbacksHypervigilanceAnxiety/panic attacksAvoidanceInability to experience pleasureUnexplained physical painSexual problemsUnexplained grief reactionsHopelessnessPoor concentrationEating too much or too littleSelf abusive behaviorsPoor self-esteem, shame, guiltHeadache, stomach ache, dizziness
42Challenging Behavior – Trauma Basic needs of traumatized personTo feel relatively safeTo know others will respect his/her boundariesTo feel accepted, validated and listened toTo talk and be listened toTo have their feelings paid attention to
43Mental Health First Aid Action Plan ALGEEA Assess for risk of suicide or harmL Listen non-judgmentallyG Give reassurance and informationE Encourage appropriate professional helpE Encourage self-help and support strategiesPlan developed by Professor Anthony Jorm and Nurse Betty KitchenerGives staff/caregivers & others ideas for how to help person in crisisEsp. crisis involving worsening symptoms of mental illness
44Recognizing 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.
45Signs of Escalating Behavior Observable signs of escalating behavior:Faster breathingTalking louderStiff, rigid movementsQuick movementsNo eye contactReddening in the facePerson may not show all of these signs – may show a cluster of 3 or 4
46De-escalation: What Is It? Helps staff manage challenging behaviors before they become a crisis situation (escalate)Helps person return to baseline / normal functioning
47Techniques for De-escalation ProximityBe out of arm’s reachPaceMove and speak slowly / calmlyPurposeMean what you sayDo not make promises that cannot be keptProcessBe flexible; adapt to individual and situationPlanHave a plan in placeThink about what worked in the past
48Techniques for De-escalation (continued) PracticeUse techniques that work for the person often, even when not in crisisPresentationBe aware of body language and voice tonePivotKnow escape routes and be ready to use them quicklyPersuasionLet person talkRemind person that you want to helpPre-emptKnow person’s triggersTry to avoid / limit exposure to them
49Techniques for De-escalation - Restraints Restraints may be necessary at timesOnce restraint started, goal is to discontinue it as soon as possibleRestraint is not the end of a crisisDoes not solve problems that led to crisisCan damage trust and relationship between person and staff
50Techniques for De-escalation – What To Do and Say During a Restraint Prevention of physical harmAsking what the person needsAssist in relaxationEnding the restraint
51Techniques for De-escalation – A Note About Restraints Restraints should be a last resortThey can cause physical and psychological harmCan re-traumatize personCan induce fear and powerlessnessDo not teach person how to control selfCan damage trust between person and staff
52EXERCISEBob’s StoryRead the story about Bob from the manual. Ask the audience to think & talk about the questions asked.
53DebriefingProcess that helps one make use of personal experiences for learning and developmentExplores why something happened, how it happened and what can be learnedFormalized way to evaluate one’s actions, interactions during and after an event
54Debriefing Who should debrief? Clinical staff Administrative staff Treatment team membersParticipantsThe individual
55Debriefing - Steps Reflect on the experience. Analyze the experience. Make sense of the experience.Communicate about the experience.Learn from the experience.Reflect on the experienceAsk who was there, what happened during, before and after the eventAnalyze the experienceConsider possible triggersAsk who needed to be present, who did notWhat needs/wants were not met for the personWhat did everyone’s body language communicateMake sense of the experienceCreate a story of the event; include lead-up, the event itself, and aftermathInclude best & respectful guesses as to person’s needs/wants during eventHow might person have interpreted your actions?Communicate about the experienceTalk to others who were there about the eventDiscuss what everyone’s thoughts & guesses are about why event occurred and what person needed/wantedOffer praise for what worked & suggestions for more effective strategiesLearn from the experienceReview everything about eventThink about what went well and what did notDevise strategies that may help in future
56Debriefing with Individuals I ESCAPE FormulaI – IsolateE – ExploreS – ShareC – ConnectA – AlternativeP – PlanE – EnterI – isolate: change environment, reduce stimulationE – Explore: get person’s thoughts on what happened, what he/she needed or wanted, and his/her feelingsS – Share: tell person your thoughts & feelings about event – remain respectful of person’s experiencesC – Connect: put yourself in person’s place; talk with person about how you would have felt if you were in their placeA – Alternative: ask person to help with problem solving to avoid future crisesP – Plan: ask person to help create a planE – Enter: ask if person can/will go back to place where crisis happened (with staff)Use this time to review strategies & planDo not push person to do this
57Caring for the Caregiver Try not to take challenging behaviors personallyAcknowledge 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.
58Caring for the Caregiver – Stress Reduction Tools Breathing ExercisesTake a BreakMake time for yourself when possibleA ‘Stress Ball’Any small, portable itemCan help reduce physical and mental tension
59Caring for the Caregiver – Stress Reduction Tools Share techniques with individualsCan prevent build-ups of stressAnd potential crisis situationsRemember: Everyone needs an outlet
60Objectives ReviewRecall strategies for understanding and responding to challenging behaviorsDescribe basic premises about mental illness in relation to challenging behaviorsList the important assumptions about challenging behaviorsSummarize ways to report challenging behaviors accuratelyRecite methods of de-escalationAsk audience if they think these objectives were covered during the course of the training.60
61Final 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.”
62ReferencesAuthor 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)
63ReferencesKitchener, 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.
64ReferencesPMT 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)
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