Understanding and Treating Problem Behavior

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Understanding and Treating Problem Behavior

• Edward G. Carr, PhD, BCBA, FAAMR
• State University of New York at Stony Brook

Dr. Ted Carr Leading Professor Dept. of
Psychology S.U.N.Y. Stony Brook, NY
11794-2500 Edward.Carr_at_sunsysb.edu www.sunysb.edu
/autism
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Conceptual Framework For Context-Based Model of
Problem Behavior
Context
Systems factors
Setting events
Trigger stimuli
Problem behavior
Consequences
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Elements of a Model for Systems Change to Promote
Sustainability of Effective Practices

• Vision
• Skills
• Incentives
• Resources
• Action plan

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Conceptual Framework For Context-Based Model of
Problem Behavior
Context
Systems factors
Setting events
Trigger stimuli
Problem behavior
Consequences
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Common Classes of Setting Events

• Affective state (e.g., mood)
• Behavior state Quality of social relationships
  (e.g., rapport)
• Physiological state (e.g., fatigue, pain)

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Conceptual Framework For Context-Based Model of
Problem Behavior
Context
Setting events
Trigger stimuli (Sd)
Response
Consequences
Take a bath
Sometimes Gets out of taking
Aggression a bath Sometimes
takes a bath Parent praise
Fatigue Take a bath
Aggression Gets out of taking a bath
No Fatigue Take a bath
Takes a bath Parent praise
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Critical Concept

• Problem Problem
• Contexts Behavior
• If you want to do something about the problem
  behavior you need to do something about the
  problem contexts.

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Rapport and Problem Behavior

• Poor rapport much problem behavior
• Good rapport little problem behavior

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Please circle the number that best represents the
overall quality of the relationship between you
and as of today.Unsatisfying

Satisfying  0--------------------1-
---------------------2--------------------3-------
----------4---------------------5
Rapport Scale Rating
The majority of my interactions with this person
are awkward, unpleasant, and stressful. I do not
feel particularly close to this person, and often
times, it is difficult for us to find any common
ground. (Score 0 or 1, depending on the extent
to which you find the relationship unsatisfying).
The majority of my interactions with this person
are neutral, that is, not particularly good or
bad. While I like this person, I do not feel
particularly close or connected to this person
in any meaningful way. (Score 2 or 3, depending
on perceived level of connectedness).
The majority of my interactions with this person
are enjoyable, satisfying, and interesting.
Together, we share a warm, open, and balanced
relationship. I find that we have a lot in
common, and enjoy each others company. (Score 4
or 5, depending on the extent to which you find
the relationship satisfying).
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Functional Analysis of Rapport and Problem
Behavior
Joan Eating a meal
Time (in minutes)
High Rapport and No Demand
Low Rapport and Demand
Low Rapport and No Demand
High Rapport and Demand
Sessions
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Functional Analysis of Rapport and Problem
Behavior
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Pain and Problem Behavior

• Hi pain much problem
  behavior
• Low pain little problem behavior

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Judy menses/demand
Frequency of Problem Behavior
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Judy, Kara, Mary, Penny menses/demand
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Fatigue and Problem Behavior

• Hi fatigue much problem
  behavior
• Low fatigue little problem
  behavior

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Rating scale and interview used to assess fatigue
prior to conducting a session
Please rate ___________________'s level of
fatigue by circling the number that best
describes his/her level of fatigue in the last
half hour NO FATIGUE

FATIGUE
0----------------1---------------
---2---------------3---------------4-------------5
Appears rested, alert, awake. (Score 0 or 1
depending on level of alertness) Does not appear
to be fully tired or awake. May yawn or appear
energetic at times but, overall, seems rather
neutral. (Score 2 or 3 depending on level of
tiredness) Appears tired, sleepy, exhausted
seems to be having difficulty staying alert or
awake. (Score 4 or 5 depending on level of
fatigue) Interview Questions 1. What is it that
______________ did or said that led you to give
him/her a (fatigue/no fatigue)
rating? Describe the person's appearance or
symptoms and behavior. 2. What (if anything)
might have "brought on" this level of fatigue? 3.
If you described _______________ as being
fatigued, what strategies would you use if you
had to help him/her overcome the fatigue?
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Latency to problem behavior or successful
completion of the task for each participant
during the phase 2 functional analysis
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Mood and Problem Behavior

• Bad mood much problem
  behavior
• Good mood little problem
  behavior

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Mood scale
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Sessions Terminated Abe, Mary, etc.
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Critical Concept

• Problem Problem
• Contexts Behavior
• If you want to do something about the problem
  behavior you need to do something about the
  problem contexts.

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Context-based Intervention

• Once you know the specific context events that
  are associated with problem behavior, what can
  you do?
• Avoid
• Avoid the context
• Mitigate
• Change the context
• Cope
• Teach the individual skills to cope with the
  context

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Altering Social Relationships Building Rapport

• Generalized reinforcement (Mitigate)
• Responsivity (Mitigate)
• Reciprocity (Cope)

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Measures of task performance (intervention phase)
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Addressing Pain and Discomfort

• Provide ancillary medical intervention (Mitigate)
• Noncontingent reinforcement (Mitigate)
• Provide choices (Mitigate)
• Redistribute demands (Mitigate)
• Embedding/behavioral momentum (Mitigate)
• Functional communication training (Cope)

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Judy, Kara, Mary Problem Behavior baseline
intervention
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Addressing Fatigue Must be individualized
according to cause

• Alter sleep schedule (Avoid)
• Alter medication (Avoid)
• Rehydrate (Mitigate)
• Redistribute demands (Mitigate)
• Embedding/behavioral momentum (Mitigate)
• Preferred activities (Mitigate)
• Functional communication training (Cope)
• Relaxation/naps (Cope)
• Physical excercise (Cope)

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Percent of task steps completed during baseline
and intervention for each participant
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Addressing Mood

• Identify, rate, select, and deliver stimuli
  associated with good mood

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(No Transcript)
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Many Contexts, Many Possibilities
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Social Contexts

• Disagreement with or among family members or
  peers
• Recently disciplined or reprimanded
• Teased
• Hurried or rushed
• Not enough attention from parents, peers, or
  others
• Frustrated because s/he has trouble communicating
• Denied access to what he or she wants
• Bad day at school or other daytime activity

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Activity and Routine Contexts

• A preferred activity ends
• Activities that are difficult, frustrating,
  disliked, or boring
• Activities that are long
• Activities that are noisy and/or crowded
• Having to wait
• Medical appointments
• Changes in routine new and unfamiliar situations
• Transitions

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Biological, Affective, Cognitive Contexts

• Side effects of medication or changes in
  medication
• Illness or pain
• Fatigue
• Hunger / Thirst
• Feeling hot and uncomfortable
• Sexual frustration
• Temperament
• Feeling frightened, worried, anxious, or agitated
• Feeling sad or depressed
• Cognitive processing deficits

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Assessment of Context Events Contextual
Assessment Inventory for Families (CAI)

• Please rate how likely it is that the person will
  show problem behavior in the situations
  described.
• SOCIAL CONTEXTS
• Not Somewhat Very
  Dont Not Likely
  Likely Likely Know Applicable
• 1. Disagreement or argument
• with or among family members,
• Peers, or other people 1 2 3 4
  5 DK NA
• 2. Was recently disciplined 1 2 3
  4 5 DK NA
• or reprimanded

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Parent Ratings of Social Context
Events N 60 mothers, 46 fathers
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Parent Ratings of Activity Context EventsN 60
mothers, 46 fathers
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Parent Ratings of Biological Context EventsN
60 mothers, 46 fathers
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Follow-up Assessment

• After the broad contexts that are associated with
  problem behavior are identified on the CAI, a
  follow-up assessment must be conducted to
  identify the specific situations that set off
  problem behavior.
• Example Having to wait
• What specific activity (within the identified
  context) is most/least likely to cause problem
  behavior?
• Example Having to wait in line at the grocery
  store.
• With whom is the problem behavior most/least
  likely to occur?
• Example Having to wait in line at the grocery
  store with his father.
• In what setting is the problem behavior
  most/least likely to occur?
• Example Having to wait in line at Trader Joes.

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Follow-up Assessment

• During what time of day is the problem behavior
  most/least likely to occur?
• Example Having to wait in line at the grocery
  store after school.
• How do you respond to the problem behavior?
• Example Leave the grocery store.
• What is your childs reaction to your response?
• Example He calms down after leaving the store.
• Functional hypothesis Problem behavior is
  likely escape motivated.

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Context-based Intervention

• Now that you know the specific context events
  that are associated with your childs problem
  behavior, what can you do?
• Avoid
• Avoid the context
• Mitigate
• Change the context
• Cope
• Teach the individual skills to cope with the
  context
• Lets do some examples together..

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Social Context Event Lack of attention from
others

• Avoid
• Give your child undivided attention for periods
  of time throughout the day.
• Mitigate
• When it is not possible to give your child
  attention, involve him/her in a preferred
  activity, such as listening to music or arts and
  crafts.
• Cope
• Teach your child to ask you for attention.

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Activity Context Event Difficult or Disliked
Tasks

• Avoid
• Provide an alternative task that makes use of the
  same skill. For example, during a reading task,
  allow your child to choose the book.
• Mitigate
• Modify the task to incorporate your childs
  interests. For example, ask your child to draw a
  picture after reading each page.
• Cope
• Teach your child to ask for help with the reading
  activity.

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Biological Context Event Fatigue

• Avoid
• Arrange for adequate amounts of sleep for your
  child.
• Mitigate
• Allow your child to take a nap, or modify her/his
  schedule to include more pleasant activities,
  when s/he does not get adequate amounts of sleep.
• Cope
• Teach your child to ask for a break from disliked
  activities. Encourage the child to use this
  communication skill when s/he is tired.

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Multi-Component Intervention

• The three general strategies described (avoid,
  mitigate, cope) are most effective when they are
  combined to treat problem behavior.
• Example A child displays problem behavior
  waiting in line at the grocery store.
• Intervention The family can shop during slow
  times when the lines are likely to be short
  (avoid). When the situation cannot be avoided,
  the child can be given a toy or activity to do
  while in line (mitigate). When the situation
  cannot be mitigated, the child can be taught to
  self-regulate by placing a check or token on a
  piece of paper for every 30 sec. of good behavior
  and receive a reward proportional to the number
  of check marks (cope).

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Conclusion

• A five-term contingency highlights many
  opportunities for creating new assessment tools
  relevant to the many contexts associated with
  problem behavior. In turn, the assessment data
  that is generated from the use of these tools
  suggest multiple types of new interventions that
  help improve quality of life as well as
  minimizing problem behavior.