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Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS.

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Presentation on theme: "Behavior Is Communication: Strategies for Understanding Challenging Behaviors Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS."— Presentation transcript:

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 © 2009 APS Healthcare, Inc. 2 Disclaimer Information or education provided by the HCQU is not intended to replace medical advice from the consumers 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.

3 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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

5 © 2009 APS Healthcare, Inc. 5 Understanding Challenging Behaviors Why might it be necessary to understand challenging behaviors?

6 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 EXERCISE Meeting Needs and Wants

9 © 2009 APS Healthcare, Inc. 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!

10 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 11 Basic Premises About Mental Illness Symptoms never occur alone –Cluster of symptoms must be present –Cluster of symptoms occur over time

12 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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?

14 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 17 Describing What is Seen and Heard How are a persons behaviors typically described: –in a chart? –during a shift report? –after an incident / crisis situation? –during a typical and uneventful day?

18 © 2009 APS Healthcare, Inc. 18 Describing What is Seen and Heard Dont interpret No suitcase words –Avoid terms like aggressive, isolative, or defiant Take one symptom at a time Capture behaviors at the persons best (healthiest) and worst (most ill) Dont argue or decide if something is a symptom or not

19 EXERCISE Describing What is Seen and Heard

20 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 21 Challenging Behavior – Basic Assumptions Challenging behaviors interfere with an individuals 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 © 2009 APS Healthcare, Inc. 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)

23 EXERCISE The Amy Scenario

24 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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

27 © 2009 APS Healthcare, Inc. 27 Challenging Behavior – Triggers Staff responses to challenging behaviors can be triggers Pay attention to persons voice tone, what he/she says, his/her actions and requests

28 EXERCISE Joes Story

29 © 2009 APS Healthcare, Inc. 29 Challenging Behavior – Things to Consider Communication Environment Emotions Unaddressed Medical / Physical Needs Trauma

30 © 2009 APS Healthcare, Inc. 30 Challenging Behavior – Communication The 18 Second Rule Give direct attention to the person Communication Partners Communication Tools –Communication Board –Social Stories –Liberator

31 © 2009 APS Healthcare, Inc. 31 Challenging Behavior – Environment A persons immediate surroundings Includes who is with the person

32 © 2009 APS Healthcare, Inc. 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 persons privacy / boundaries respected? –Does the person like the people he/she is interacting with?

33 © 2009 APS Healthcare, Inc. 33 Challenging Behavior – Emotions Ones feelings / experiences directly impact ones perception of stress and coping skills What is fun / difficult / boring / sad for one person is totally the opposite for another Pay attention to persons communication to gauge his/her feelings –This helps the person cope with stress –Strengthens relationship between person and staff

34 © 2009 APS Healthcare, Inc. 34 Challenging Behavior – Emotions Safety –Key aspect of emotional wellness Fear leads to: –Anxiety –Irritability –Defiance –Aggression –Depression

35 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 36 Challenging Behavior – Emotions Stability can be reassuring Structure provides an expectation of what will happen from day to day

37 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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

40 © 2009 APS Healthcare, Inc. 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 didnt ask for and cant stop or escape; perceived as life threatening and involves intense fear and helplessness

41 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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

44 © 2009 APS Healthcare, Inc. 44 Recognizing Signs of Escalating Behavior What signs might indicate that someone is becoming: –frustrated? –anxious? –scared? –angry?

45 © 2009 APS Healthcare, Inc. 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

46 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 47 Techniques for De-escalation Proximity –Be out of arms 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 © 2009 APS Healthcare, Inc. 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 persons triggers –Try to avoid / limit exposure to them

49 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 Bobs Story

53 © 2009 APS Healthcare, Inc. 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 ones actions, interactions during and after an event

54 © 2009 APS Healthcare, Inc. 54 Debriefing Who should debrief? –Clinical staff –Administrative staff –Treatment team members –Participants –The individual

55 © 2009 APS Healthcare, Inc. 55 Debriefing - Steps Reflect on the experience. Analyze the experience. Make sense of the experience. Communicate about the experience. Learn from the experience.

56 © 2009 APS Healthcare, Inc. 56 Debriefing with Individuals I ESCAPE Formula –I – Isolate –E – Explore –S – Share –C – Connect –A – Alternative –P – Plan –E – Enter

57 © 2009 APS Healthcare, Inc. 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.

58 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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

61 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 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 stories/what-are-social-stories (April 28, 2011)http://www.thegraycenter.org/social- stories/what-are-social-stories

63 © 2009 APS Healthcare, Inc. 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 © 2009 APS Healthcare, Inc. 64 References PMT Associates, Inc. (2009). Top ten list of de-escalation techniques: The ps of de-escalation. Retrieved from (April 29, 2011) Sturmey, P. (n.d.). Treatment interventions for people with aggressive behaviour and intellectual disability. Retrieved from autism-part4.pdf (April 28, 2011) autism-part4.pdf

65 © 2009 APS Healthcare, Inc. 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

66 © 2009 APS Healthcare, Inc. 66

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!


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